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J R Soc Med. 2004 September; 97(9): 457–458.
PMCID: PMC1079609

The well-managed waiting list

'Treatment delayed is treatment denied'

David Williams1

The editorial by Professor Black (April 2004 JRSM2) extols both the inevitability as well as the virtues of the surgical waiting list. Having practised on both sides of the Atlantic, I find his arguments hard to accept.

A surgical 'waiting list' is a queue activated by discrepancy between the need for services and the operating facilities available, such as a limited number of operating rooms and/or personnel, and at the same time, a plethora of patients in need of surgery. Such a queue may be bypassed only by the urgent nature of the existing clinical condition of some of the patients; the others will be served in the order by which they have accessed the system.

The basic characteristic of such a waiting list is that, given a stable number of the populace serviced by that particular institution and occurrence of the conditions requiring surgery, on the one hand, and the 'fixed' narrowness of the 'bottleneck', on the other, the list must grow. For example, if an average of 100 new patients per month is in need of coronary surgery, the hospital can handle only 80 and the waiting list already has 200 patients, then this list has to increase by an average of 20 patients per month and double in ten months.

Does this happen? Not necessarily. Visiting numerous institutions in Europe, I found that in most institutions the list remained steady and the time the patients had to stand in line for surgery remained the same year after year. There were several possible explanations for this. One is that the institution managed to satisfy the ongoing demand but was not able to take care of the already existing waiting list. This is possible but unlikely. Another is that it was 'self-regulating' by attrition. Some patients got tired of waiting and simply got off the list while others sought help at some other, usually private, institution. Some patients whose condition suddenly worsened died while awaiting surgical intervention. Finally, it is indeed possible that the waiting list was artificially maintained, not because of lack of resources, but because the healthcare providers had no intention to make it disappear.

Black indeed lists some of these 'commendable reasons' for the existence of such a 'well-managed' waiting list:

  • 'It maximizes efficiency by ensuring steady demand for previous resources, such as staff, theatres and beds'— true indeed
  • Enhances staff satisfaction and morale by ensuring theatre lists have an interesting mix of cases, and enable training needs to be met—a very weak argument
  • 'For some diseases... waiting for surgery provides a period of spontaneous resolution of symptoms, therefore avoidance of unnecessary surgery'—true unless it gets worse or the patient dies
  • 'And for those whose condition does not improve, it allows time to either reconsider their decision, or prepare both practically and psychologically for their operation'—for 3–6 months?

To these 'benefits' of the waiting list system we may add what is an open secret: for many underfunded health institutions the only way to obtain additional budgeting is to have its request justified by a few hundred indignant patients standing in a queue awaiting surgery.

Even if some of the above arguments are valid one cannot help noticing that none serve the interest of the patient, only the needs of caregivers. That fact is well reflected in Black's statement that the 'principal reason people opt for private care is to avoid excessive waiting'. The fact that people are willing to stand in a queue does not mean that they like it. They may accept it because they believe that it is an economic necessity. The harmful effects of surgical waiting lists are not limited to inconvenience but include psychological and physiological harm—especially in the patient population in the queue for diagnostic and therapeutic cardiac interventions. I cannot accept Black's recommendation that 'payers should focus on the number of patients treated rather than the number of patients awaiting treatment'. There is no such thing as a well-managed waiting list—only a poorly managed flow of human beings, standing in line, awaiting care.


1. Williams DO. Treatment delayed is treatment denied. Circulation 2004;109: 1806-8 [PubMed]
2. Black N. Surgical waiting lists are inevitable: time to focus on work undertaken. J R Soc Med 2004;97: 159-60 [PMC free article] [PubMed]

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