I think about medical matters lots, and not just because I am a hypochondriac. My sole scientific qualification is an A level in biology (my degree was in philosophy and literature) but in my twenties I worked for a charity fighting for compensation for those with industrial diseases such as asbestosis.
Around that time, one of my best friends contracted HIV. Reluctantly, I had a front row seat as that tragic epidemic unfolded and I visited many people who were losing their fight against the disease in hospital.
For the last twenty years most of my paid work has been about creating concepts and copy to be read by medical professionals and patients who are facing disease and illness.
A year before the pandemic, I spent a day in a series of waiting rooms with the late Dr Janet Summerton, a dear friend and mentor who became seriously ill not long after. Together we had hours to talk about the impact of waiting.
I’d like to stress that the following is absolutely not intended as an attack on the NHS. The hospital we were visiting was enduring a difficult day of staff shortages combined with an unusually inundated A&E department. But the experience of waiting is replicated around the country — and has only been exacerbated as we continue to deal with the aftermath of the covid pandemic.
In a nutshell… I think we need to rethink waiting, and focus on what happens in waiting rooms.
‘High noon,’ Janet says, arriving for her appointment.
I can tell she is scared, so I am pleased I turned up in good time to support her. A nurse takes us to a windowless examination room, with an adjustable couch, two or three chairs and blank beige walls. The registrar enters. I notice his blade-like trouser creases.
He begins firing questions.
‘Is your appetite poor?’
Janet provides context. She says said she had called her GP in the first place because she felt panicky after her sister’s death. Her husband’s dementia means she feels isolated. There is no one to talk to—
‘Is your appetite poor?’ repeats the registrar. He is treating Janet as if she were confused. I bristle. Janet, my mentor for years, is 79 and remains one of the smartest people I have ever met.
He examines her briskly. Yes, he can feel a lump on her liver. He orders an immediate CT scan and blood test.
We wait again. This time in the corridor.
I tell Janet how much I disliked the registrar’s manner. But then he proves me wrong, reemerging from his office to kindly lead us to the waiting room of the Emergency Ambulatory Care Unit (EACU).
So what’s the big problem with waiting?
‘Nothing to be done.’ The first line of Samuel Beckett’s Waiting for Godot encapsulates the problem.
The play’s aimless, shambolic characters, Estragon and Vladimir, wait forever for the mysterious Godot, a figure whose arrival will somehow change everything. Famously, of course, Godot never arrives.
The big problem with waiting is that it puts our lives on hold — there is nothing to be done. At its worst a waiting room can be a limbo of boredom and anxiety. Janet has no control, no power over when she will be called. But, after all, she is waiting to be helped, so why does it feel like torture?
Hospitals units, particularly A&E and EAC, must adapt to dynamic demand, epidemics, RTAs, even boozy nights in seaside towns can all cause a surge in cases.
Post Covid-19, the NHS faces many challenges: an aging population, difficulty hiring staff post-Brexit, and so on. Waiting room congestion is still commonplace.
For patients, powerless in the face of often-unexplained delays, boredom and anxiety are rife and feelings of frustration can boil over into arguments and violence.
As for the staff… The busier waiting rooms become, the more they feel besieged by escalating numbers of queries and interruptions.
Not just healthcare
Being compelled to wait is a fact of life. Listening to music while you’re waiting to speak to someone at the bank or utility company. Waiting for planes or trains. Waiting for bureaucratic wheels to turn, waiting to get a job or have an invoice paid… Waiting is built into society.
Some people, who tend to be wealthier, are able to reduce waiting in their lives: think private medicine, private jets, even tables in restaurants and so on.
But all of us know what it is to wait. In certain contexts – such as in hospitals – the negative effects of waiting are particularly detrimental.
The waiting room as a ‘non-place’
A waiting room is an example of a ‘non-place’ where social interactions are fleeting, and people have no emotional attachment to the physical space around them.
According to philosopher Marc Augé (b. 1935) in his 1995 publication, Non-Places – An Introduction to Supermodernity, people spend increasing amounts of time in non-places such as supermarkets, airports, train terminals, waiting rooms and so on. Places we pass through without wanting to stop.
Augé suggested that the new kind of alienated solitude these non-places create in people should be studied.
“…non-places are there to be passed through, they are measured in units of time. Itineraries do not work without timetables, lists of departure and arrival times in which a corner is always found for the mention of possible delays.”Marc Augé, Non-Places An introduction to supermodernity
In other words, we experience a waiting room as a place where time passes. And in waiting rooms the passage of time is glacial.
Janet is anxious and upset. I try to distract her with conversation. Attempting to joke, I remind Janet that Sartre’s hellish play No Exit, famous for the line ‘hell is other people’ has been staged with the set replicating a waiting room. I soon wish I hadn’t.
To pass the time, we people watch. I think of the kinds of specific worries people have in waiting rooms. What happens if I am called when I am in the toilet? Why is that person being seen before me? Will I be called next so I can escape?
Janet is full of dread. Not every health problem can be cured. Two hours elapse, then there is some activity.
A senior health assistant leads Janet and I off to take her blood. He says the blood results will take up to an hour and a half to arrive, but the CT scan will be done shortly.
The catheter is making Janet’s arm sore but we are buoyant. An hour and a half is a finite amount of time. We visit the counter down the corridor to buy a snack, and return to waiting room. We chat about mutual friends, about books, politics and the news. We look ironically at The star of the month, a smiling unit staff member, and smile at the Offensive Waste bin.
But other than a poster about sepsis, there is nothing else to look at. If you stand up, however, you can at least glimpse the sea through the window, a reminder of how beautiful the world is. We feel exiled from it already.
The hours drag by. Intermittently, Janet becomes distressed. I try to make her laugh, persuade her to help me invent a board game, The Waiting Room, (a.k.a. Nothing To Be Done) where the boot, scottie dog and top hat tokens of Monopoly are replaced by miniature busts of Samuel Beckett, Franz Kafka, and George Orwell. The board itself has a baffling design by Escher. You will never pass Go.
After four hours of waiting, Janet becomes furious. At the desk she demands to know what is happening about her CT scan.
‘Ten minutes,’ they say.
The philosopher Jean-Paul Sartre thought that it is only by making decisions that you can prove to yourself and others that you exist. The waiting room, of course, is a place where decision making is reduced to: Shall I risk losing my place in the queue if I get a cup of coffee and if the machine is still working? For many this inability to do anything means drifting into a state of anxiety and dread.
For Sartre, the reason we experience anxiety is to make us feel so wretched that we are forced to decide to do something about it. One problem with waiting rooms, of course, is that there are no decisions to be made and we remain in a state of anxious non-existence. In an early novel, Sartre described this feeling as a kind of ‘nausea’.
If there is a choice it is a bleak one.
Janet can only wait for the treatment she needs, however damaging this is to her mental health — or she can leave. But leaving is, of course, self-defeating and potentially harmful.
So the waiting room is a no-win situation.The longer we wait, the more powerless and anxious Janet becomes.
These are a few of the words I associate with being in waiting rooms: anger, anxiety, boredom, depression, desperation, dread, ennui, hope, need for reassurance, panic, staff-pestering, rage, resentment towards others in the room, unfairness, violence and worry.
After five hours of waiting, we fall silent. Janet is silently crying with anger. ‘Why are they lying to me?’ she says.
The staff are overstretched. She has been fobbed off. Now nobody knows how long it will be before she is called to Radiology.
Eventually, in our sixth hour of waiting, we are led to the Radiology department waiting room.
‘You should be first,’ the senior health assistant says, ‘you’ll be done in ten minutes.’
We are not first. We are not done in ten minutes, because another patient, an amiable but confused elderly man, had arrived just ahead of Janet.
Some questions about waiting rooms
- Is waiting really inevitable? Something we’re all so accustomed to accepting, that we don’t imagine there is another way?
- Shouldn’t care start in the waiting room?
- Why isn’t the management of waiting seen to be more important? I don’t just mean trying to speed the time people wait for operations, I mean thinking of waiting as an opportunity for therapy.
- What if actively reducing waiting became a goal?
- How do power imbalances relate to waiting? Why are we made to wait?
- Why don’t we directly address the cause of anxiety and help people feel in control in medical waiting rooms? When I go to see the vet with my cat, the waiting room is full of cat-soothing pheromones. That’s because feline wellbeing has been taken into consideration. So how about us humans?
Some things that appear to help the waiting room experience
- Being expected
- Friendly reception staff
- Good staff morale
- Magazines and reading material
- Natural light
- Pictures on walls
- Punctuality of appointments
- Playing on your phone
- Reading a book
- Taking a friend
- Ticketing systems
Twenty minutes pass. It seems Janet has been forgotten. I go to the office and flush out a radiologist. She agrees to talk to Janet.
Janet cannot understand her.
‘Put in your hearing aids,’ I say.
‘Your blood test shows that your kidneys are not working well today,’ says the radiologist. ‘Did anyone tell you to drink water?’
‘No,’ says Janet.
‘The dye will put a strain on your kidneys so we can’t do it unless you’ve drunk half a litre at least.’
Luckily, as it is a hot day, Janet has drunk enough water.
‘Good. Just wait a bit longer, you’re next unless we get an emergency from A&E.’
In the seventh hour of waiting there is no emergency from A&E. Janet receives her scan and we return to the EACU waiting room.
Ten minutes of waiting, then Janet is — at last — discharged. We are free to go.
I believe that care can start in the waiting room in every hospital.
I am a lifelong supporter of the NHS. I think it is one of the UK’s finest achievements. But it faced unprecedented challenges during the time of covid, and has come through at enormous cost to the wellbeing of its staff. This achievement is even greater when we consider that it is being stealthily undermined by a government ideologically opposed to its continuation.
The difference money makes to the waiting process is astonishing.
Two weeks after my day with Janet in an overstretched NHS hospital I am in the reception area of the Montefiore Hospital in Hove, graced by Brian Eno’s 77 Million Paintings for Montefiore, a slowly-mutating light installation, accompanied by soothing ambient sounds.
I pick up the comments book and read, ‘you can feel your blood pressure calming by the minute. It made me think of cells and change and the beauty of life.’ I turn a page. ‘The best waiting room experience I’ve ever had.’
This waiting area is welcoming, even uplifting. It has smiling reception staff, flowers, natural light, help-yourself coffee and tea. This is definitely not a non-place. It feels human, and permanent. It could not be more different to the waiting rooms Janet and I had been in, where slow time was filled with depression, anxiety and anger.
The Montefiore Hospital is private. There is no A&E department, and no need to respond to unpredictable influxes of the patients that can cause crowded waiting rooms.
I am shown to another Eno installation downstairs. It is inspirational. The Quiet Room for Montefiore (below) is used by patients after chemotherapy. Lights softly change colour as ambient music drifts and soothes. Both installations contribute to a therapeutic, humanising tranquillity. But even if we could put an Eno installation in every waiting room in the UK, there is much more to do.
Soothing people is not enough
People feeling extremely panicky or angry are not always going to be calmed down by a picture or even a tranquil Eno installation.
Creating a calm environment helps, and changing the way the waiting room is organised. But why not address what causes the anxiety and help people process it?
Staff morale is critical. Cheerful, efficient reception staff can set the tone for the whole room. Small things like natural light, pictures, enough seats, and pleasant colours contribute too. While simple ticketing systems help people understand where they are in the queue, so they can at least decide if they have enough time for a pee or to buy a cup of tea.
We have to better manage the psychology of waiting, to alleviate patient anxiety and stop the pestering of overstretched staff.
How can we help people feel more in control when they are waiting?
I suggest one way is to give the patient a feeling of agency, and a way of taking decisions. If we accept that waiting rooms will always exist in hospitals, why not help people find a way to make some decisions?
While we were waiting, Janet and I invented an imaginary app to help people in the room. It asks people how they are feeling in the waiting room? Panicky? Then here are some techniques you can choose to take control — give them a list of mindfulness techniques. Anxious? Tell them feeling anxious is normal, let’s address what’s worrying you. Irritated? Ask what’s bugging them. Is it missing their turn? Is it the time? Tell them what can be done and why these delays are likely. Help them calm down. Bored? Here’s a game to play. Here’s something interesting to read. Happy? Have you thought about chatting to someone who looks like they need help? And so on.
Janet spent well over seven hours in hospital that day. The registrar conversation, the procedure of blood test and scan, took less than 30 minutes. This means that just over 92% of her experience was spent waiting, feeling scared about what was happening and in the dark about when she would be seen.
I’m not suggesting the simple idea for an app that Janet and I dreamed up (maybe it’s wall mural or a z-card brochure with the same information) is any kind of a silver bullet.
But addressing the problem of waiting rooms seems to me a huge opportunity to improve the patient experience.
The first step, of course, is to believe with seriousness that better is possible. Anyone want to help?