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BMJ. 2007 July 28; 335(7612): 210–211.
PMCID: PMC1934471

Liste d'attente? Pourquoi?

Reviewed by John Petri, orthopaedic specialist, John Paget NHS Foundation Trust

Doctor, when can I have my operation?”

“Well, my dear, in a few weeks I suppose.” I was learning fast.

I walked into my first UK consultant job from a similar job in France 13 years ago. At first my patients were easy to please, because there was no waiting list in my orthopaedic firm. But I can take no credit for this, because mine was a newly created job, and at first I had to steal patients from colleagues to have something to do. Otherwise, however, waiting lists were omnipresent and, apparently, an unavoidable fact of life. Still, how unavoidable could they be? I had had no waiting list in France. In fact I had to translate from English to explain to my French wife what it meant: “Liste d'attente.” She knew you could get stuck on a liste d'attente while desperately trying to reach a representative of the French bureaucracy over the phone, but a surgical liste d'attente? She was horrified.

I was determined not to allow a waiting list to form. I thought, “I'll show them how I can organise an efficient service and get operations done at the same rate as I see patients in clinic.” How naive I was. Within two years I was operating on people who had been on the list for a year. It was shocking and frustrating—it felt like being impotent. The operating sessions were short and few, only three and a half hours twice a week. Then half of that time was taken up with “sending for the patient,” anaesthetising, positioning, and cleaning the theatre between operations. Sometimes something would get in the way of even this slow routine, and the reasons to cancel operations were innumerable: unavailable instruments, unavailable porter, lack of beds, and unexpected medical problems. I spent more time in the coffee room than in theatre.

The most amazing aspect of all this was that nobody was talking about the causes of waiting lists. If I asked, people looked at me condescendingly as if I were deluded. If pressed, they would mention “lack of surgeons” as the cause. How could it be “lack of surgeons” if I was doing half as many operations as when I was in France?

Early on during my time in the NHS I met a more experienced orthopaedic consultant who had moved to the NHS from Belgium. I asked how he could stand such slow and inefficient surgical activity. “I tried to change the system but I gave up,” he said. “I was just making enemies.”

Well, I did not care about making enemies. Firstly I had to show that we did too few operations. I collected data to compare my hospital with one of similar size and activity that I knew well in France. I presented the results at an audit meeting. In the NHS we had twice as many surgeons, anaesthetists, and theatre staff as in France and were doing less than half as many operations. Then I wrote a short paper in which I showed that, by introducing a few changes and adding another operating theatre to the two we were already using in orthopaedics, we could increase the number of operations by 73%. I was so excited that I sent my plan to all the surgeons in the hospital and to Frank Dobson, health secretary at the time. The reply came from his office after three months. It was long and articulate and sounded like a political party broadcast. It could be summarised by the sentence, “Thank you for your interest, we are already doing all that is necessary.”

My colleagues had not even replied, except one who was convinced that it would not work. There was no point in trying to convince anybody. Fortunately the management supported me, and we went through the many steps that it takes to build a new theatre. Just before that I was allowed to run a pilot scheme, hijacking a second theatre for my Thursday morning list. I would operate in one theatre while the next patient was being prepared in the second theatre. In six months my waiting time fell from one year to a few weeks.

It took another three years before I could finally run regular “dual lists.” Finally I was operating in the way I wanted to. Bliss! We measured the “surgeon's utilisation” going up from 50% to 95%.

In 2005 I had no waiting list and I started operating on my colleagues' patients. In November I won a Medical Futures award, and finally my story could become public, for any other UK hospital to observe and emulate. Television crews came to our theatres, which became temporarily known as “studio 1” and “studio 2.” I never had so many senior house officers assisting me. We were also visited by a television = crew from TF1, a national French channel. When I asked why they were interested they said that they often reported on the NHS but that it was usually bad news; for once they wanted to report good news.

In January 2006 I was invited to meet the then prime minister, Tony Blair, who, asking, “Do they pay you more than other surgeons?” was surprised that I wasn't.

The flocks of surgeons who were supposed to come and see how you can more than double the number of operations did not materialise. But my trust remained delighted with the results and, at the beginning of 2007, half of the patients in my operating sessions were drawn from other surgeons' waiting lists. One thing did happen. I did not pay much attention to it because I expected it but later came to realise how important it was: my income from private practice was halved.

I do not blame my colleagues for not showing much interest in my work, although I could do without the reputation of being one who does “conveyor belt surgery.” Why should they work harder for less money? Perhaps the government should try to create incentives to get rid of the widespread inefficiency in the NHS. Any health system can work only if the health professionals want to make it work. It's the job of politicians to make them want it.

As for me, all I wanted was to give the NHS good value for money and to prove a point. Next week I am moving to Switzerland. I shall certainly have a job explaining to the Swiss what surgical waiting lists are.

I had to translate from English to explain to my French wife what “waiting list” meant. “Liste d'attente.” She was horrified.


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