Oh why are we waiting?

Perfect 20/20 vision has no need to rely on research but it is gratifying to discover evidence for an imperfect vision. Peter Scher appreciates well-designed waiting areas but as he says, he still hates waiting.

NO HEALTH FACILITY IS WITHOUT at least one waiting area; most have several, the largest have many. Patients and visitors expect to have to wait on arrival and at further points thereafter. There are well understood reasons why instant service for every user is not feasible but waiting times measured in hours, days, weeks or months are routine currency in the NHS. Waiting is built into "the system" and so is never seen as a disagreeable experience.

One outcome of this 'system1 is the need for waiting areas. They shine out from every accommodation schedule and operational flow system, sometimes as fully fledged waiting rooms but frequently mated with other areas - "Reception and Waiting", "Children's Waiting and Play Area", "Waiting bays" (off circulation areas) and of course "Subwaiting." Waiting is not a complex function - users simply sit and wait - and it places few constraints on design. The freedom this gives to the designer is a blessed relief from the strict and detailed requirements of the clinical spaces where patients actually receive healthcare.

It is a cliché that all NHS waiting areas are dreary, ill-furnished, neglected and have depressing finishes and décor. Providing design-rich, colourful waiting areas in new and refurbished health facilities is thus the easy response. Indeed they appear almost as frequently as atriums and dramatic stairways in photographs supplied by designers, as if these represented our best efforts in health care architecture. On the other hand illustrations of clinical area - the raison d'etre of the facilities feature rather less in the publicity.

The assumption that making waiting areas pleasant also makes waiting itself acceptable is never questioned. This is as implausible as the belief that "good" architecture somehow improves clinical outcomes for patients (but in this matter I know my vision is imperfect). Unpleasant as many NHS waiting areas certainly are, it seems obvious to me that it is not the waiting environment that is most detested, it is the WAITING. In frustrated crowds we chant "Oh why are we waiting?" and as individual patients, in NHS waiting areas, we say it in our heads and sometimes to each other. It is never a comment on the design of the waiting area.

Ignoring the obvious, 'the system' relentlessly pursues a drive to enrich the experience of waiting. While waiting we may now enjoy the benefits of musak, TV screens permanently on a fixed channel, vending machines, racks of leaflets about healthcare and state benefits as well as old magazines. But if timed appointments are not scrupulously honoured by 'the system' or if patients are given no definite estimate of how long their waiting will extend then the uncertainty is stress-inducing and corrosive. It is uncertainty, not the décor that makes us want to scream.

"Aha," say the modernisers "we have a simple solution, using available technology!" At reception patients are each given a personal pager. Then if the waiting area is not sufficiently exciting for them they can go off to the cafe, to shop at the trust's income-generating retail outlets, or to see hospital arts displays in circulation areas. They can walk into the gardens and courtyards (if accessible and weather permitting), to a more secluded spot to read or just to sit, to the toilets or to the car park - as long as they stay within range for paging. When their turn comes a bleep will summon them to the appointed place.

Thus the modernisers eliminate waiting! Of course it will do nothing to remove uncertainty. After a short time new worries will beset the patient as she/he tries to concentrate on the crossword or the new sculptures. Is my pager still working? Is another patient jumping my place in the queue? Are pagers issued because the wait is to be indefinitely long? Shall I return to reception and just check? Oh why am I waiting?

The experience of uncertainty and the additional stress imposed by waiting (for the patient, by definition, is already under significant stress) ought to be reduced if not eliminated. Yet waiting is built into every part of "the system".

Some recent architectural research illuminates our subjective experience with objective observation and measurement. Professor Yasushi Nagasawa of Tokyo University's Department of Architecture made a series often studies of "The Geography of Hospitals". From the many extremely interesting results that Yasushi's team obtained, this quote is to the point:

In OPD.. .Frequent voice announcements were recorded i.e. every 1.9 minutes on average.. .during survey hours. Patients tried to listen to every announcement, wondering if they were relevant to them.

Surveys showed that, though patients often napped, read and watched TV, most of their waiting time was spent collecting information on their waiting situation, eg looking into reception and subwaiting areas, enquiring at reception desks or to passing hospital staff, asking nearby patients, listening to other patients' conversations, looking at watches and clocks on the wall, watching patients who stood after being called.