Nobody likes waiting. We don’t like it in trivial situations like traffic jams and we certainly don’t like it when it involves potentially serious consequences like waiting for surgery.

Lengthy waiting lists for elective surgery are a headache for hospital management and a daily struggle for patients.

The impact of elective surgery delays

About 57,000 Australians waited more than a year for their elective surgery in 2020-21. That number represents 7.6% of public hospital patients, up from 2.8% in 2019-20, according to the AIHW. That’s a nearly three-fold increase.

Longer waiting times are happening across a range of different surgical categories and health conditions. Those needing a knee replacement endured the greatest increase in waiting times with 32% now waiting longer than a year. Wait times for elective surgery also underscore health inequalities with Indigenous Australians waiting longer than others.

This kind of waiting has serious consequences for health and wellbeing. Waiting too long for a:

  • Total hip or knee replacement can lead to chronic pain, medication dependency and lost productivity.
  • Hysterectomy can mean many more months of living in pain
  • Gall bladder removal can result in increased complications and a longer hospital stay.

Hospital leaders dislike waiting lists almost as much as patients do. Waiting lists are a key performance indicator for many hospitals. Long lists represent pressure and expose the hospital to negative judgements and dissatisfied patients.

Exploring options for reducing waitlists

A recent report by Macquarie University entitled Reducing Surgical Waitlist Times in Australia noted that,

The COVID-19 pandemic has constrained the health system’s capacity to handle normal patient loads and has reduced the numbers of patients coming to hospitals for various reasons, creating considerable unmet or latent demand. Much of this is surgical care. Various names have been given to this phenomenon, including ‘expanded waitlists’, ‘the surgical bulge’, and ‘the surgical backlog’. Regardless of whether the pandemic is resolved quickly or not, additional care will need to be provided to the patients who have not been treated.

No single strategy will fix a long waiting list. Rather, it is necessary to examine each stage of the patient journey and consider how to streamline the process.

1.     Develop robust referral guidelines

A patient usually joins a surgical waiting list after a referral from a GP.

One way to ease pressure on a waiting list is to ensure that only the right people are on it.

The hospital could establish a steering group of surgeons, GPs and allied health professionals in a particular surgical discipline to agree on standardised referral guidelines.

Rathnayake and Clarke conducted a systematic review of the effectiveness of different patient referral systems to shorten waiting times for elective surgeries. They found that,

Streamlining the triage of patients during referrals with standardized referral templates and resources enhances timely access to surgical services. Good cooperation between primary care practitioners and surgeons is important for a good referral system. A substantial proportion of referrals could be dealt with through simple communication between the general practitioner and the consultant surgeon and, in some settings, general practitioners and specialists have worked together to produce guidelines for the types of patients that should be referred. Not limiting to that, higher quality referral communications has instigated improved cost-effectiveness in surgical care.

2.     Review the waiting list

The Macquarie report recommends auditing the waiting list to:

  1. Prioritise those in greatest need (the RACS suggests it is time to review the current clinical priorities categories to better reflect patients’ needs)
  2. Reconsider low-value, high-cost surgeries where conservative treatment may offer an alternative and effective treatment option.

Surgery is not always the answer to a patient’s health concerns. Indeed, many patients may actually experience greater benefits and fewer risks from conservative treatments rather than invasive procedures.

Such surgeries lengthen waiting lists and waste resources while failing to deliver the improved health that patients seek. The Macquarie study notes that,

In NSW alone, surgery that provides no or low value to patients is estimated to cost between AU$49.9 and AU$99.3 million in NSW public facilities and accounts for 14,348 to 29,705 bed days per year. These are likely to be conservative estimates…

The forced pause in elective surgery due to COVID-19 infections is a unique opportunity to plan and reset the system to provide more high-value care, increased equity, and improved sustainability.

Achieving that may involve stronger multidisciplinary teams of medical, surgical and allied health professionals, the normalisation of a second opinion before surgery and adherence to clinical guidelines governing who is or is not a viable surgical candidate.

Various Royal Colleges or government regulatory agencies around the world have already developed relevant ‘do-not-do’ guidelines for low-value surgeries including:

  • Spinal surgery
  • Knee arthroscopy
  • Total hip and knee replacements
  • Hysterectomy
  • Colonoscopy and endoscopy
  • Carotid endarterectomy
  • Abdominal aortic aneurysm repair
  • Hernia repair.

Some patients do not need these procedures and may experience better outcomes through other treatment modalities. Some patients desperately do need these procedures and will benefit from shorter waiting times on a lighter list.

3.     Practise active waiting

Being on a waiting list does not have to mean a long period of passively waiting for surgery. Waiting can provide a valuable window of opportunity that can enhance treatment outcomes.

Patients waiting for joint repairs or heart surgery, for example, should be encouraged to enrol in a program of prehabilitation in the hospital’s physiotherapy department or through a private provider in the community.

Prehabilitation enables patients to go into surgery in better physical and psychological condition, equipping them to withstand surgery, recover well and avoid readmittance.

You may also be able to develop stronger local networks to care for patients on the waiting list, such as patient-centred medical homes.

4.     Prioritise screening

Australia runs three national screening programs for breast, cervical and bowel cancer.

Cancer screening aims to detect cancers while they are still small and more easily treatable. This means many patients may avoid the need for surgery, managing their cancer through other therapies.

COVID has disrupted some screening services and caused patients to be preoccupied with a range of other concerns that seem more pressing than presenting for screening. It is time to encourage patients to re-engage with screening programs. It is also time for hospitals to create capacity for diagnostic procedures after positive screening tests.

5.     Improve efficiency

You could review the whole operating room (OR) process to find out how to improve efficiency. Common problems include:

  • A late start to the first case of the day – the whole list runs late after that
  • Equipment malfunctioning – rigorous maintenance and timely replacement is essential
  • Some surgeons underusing their scheduled surgery time while others overrun
  • Slow turnover of the OR between procedures – faster cleaning and preparation of the OR for the next patient can enable more surgeries per day
  • No bed available in post-op recovery, meaning that a patient cannot leave the OR on time – you may need more post-op beds or a better way of predicting how long each patient will need to be there after a particular procedure.

6.     Increase capacity

The biggest dent in the waiting list is likely to come from simply performing more surgeries.

But how do you create more capacity? You could extend elective surgery into the night to make greater use of the operating rooms. That can be done but it has been shown to worsen patient outcomes.

You could commission new capital works to create an extensive suite of operating rooms and post-op recovery wards. Again, it can be done…but it involves wrangling the hospital bureaucracy and, even if you get the green light, it’ll be years before those new facilities are ready for use.

Another option is to increase capacity by using mobile and modular healthcare facilities. Think of these as an extension to your hospital, a purpose-built facility that complies with all relevant standards but can be installed in just a few months to create additional surgical capacity.

Mobile and modular healthcare facilities are widely used in the UK and have formed part of that nation’s COVID-safe healthcare planning.

COVID-light sites were created to separate elective surgery patients from emergency admissions. This is a new model of care that is not centred around the local hospital (which is often treating COVID patients) but instead built around a dedicated surgical hub that only admits COVID-screened elective surgery patients. This model enables the continuation of elective surgery while reducing the risk of patients contracting COVID-19.

The Victorian government’s COVID catch-up plan includes the creation of Rapid Access Hubs across metropolitan public hospitals to streamline surgical theatres, equipment and staffing. These Hubs will exclusively perform specific surgeries such as hernia repairs, cataract surgeries and joint replacements.

Hospitals in Australia are beginning to adopt flexible mobile and modular solutions to increase their capacity. That includes tertiary referral centres like The Alfred (to perform open-heart surgery) and The Prince Charles Hospital (to increase capacity for colonoscopies).

Introducing such solutions has many benefits, including:

  • Clearing a backlog of surgeries
  • Contributing to greater patient satisfaction
  • Updating the hospital estate in a cost-effective and sustainable manner
  • Providing staff with the opportunity to work in a more modern environment equipped with the latest technology (which may assist with staff recruitment and retention).

Demand for surgery may remain high for some time to come, as the impact of delayed screening tests and suspended surgeries continues to be felt. A number of different strategies may be used to ease the waitlist pressure. Among the most effective is the creation of additional onsite capacity using mobile and modular healthcare facilities.


If you would like to explore how we could help relieve your waiting list pressures, please contact Q-bital Healthcare Solutions.