Long waiting lists for surgery remain a major challenge for public healthcare systems, particularly in countries where patients must wait months for non-emergency procedures.
One approach attracting increasing attention is the use of centralized surgeon lists, also known as single-entry or central intake systems. Instead of directing every patient to a particular surgeon's individual waiting list, referrals are placed into a shared queue.
Patients can then be matched with an appropriately qualified surgeon who has the capacity to provide treatment sooner.
The model is intended to reduce uneven waiting times, improve coordination between medical providers and make better use of available surgical resources.
Research suggests that centralized systems can improve access and make referral processes more efficient. However, their success depends on sufficient hospital capacity, cooperation between surgeons, reliable information systems and public confidence in the process.
Patient choice is another important issue. Some people are willing to see the next available qualified surgeon if it means receiving treatment sooner, while others prefer to remain with a particular specialist.
What Are Centralized Surgeon Lists?
A centralized surgeon list is a system that combines referrals for a particular surgical procedure into a shared waiting list.
Under the traditional model, a family doctor or primary care physician usually refers a patient directly to a surgeon.
The patient then joins that surgeon's individual consultation or surgical waiting list.
This arrangement can create substantial differences between surgeons. One specialist may have a relatively short queue, while another performing the same procedure may have a much longer backlog.
A centralized intake system changes this process by directing referrals to a common entry point.
Patients are assessed and prioritized using agreed clinical criteria. They can then be allocated to an appropriate surgeon based on availability, expertise and the urgency of their condition.
The approach is also known as a single-entry model, pooled referral system or central intake system.
How Does a Single-Entry Surgical System Work?
The process begins when a primary care physician refers a patient for a particular surgical procedure.
Instead of sending the referral directly to an individual surgeon, the referral enters a centralized system.
A clinical team or intake service reviews the information and determines whether the patient meets the requirements for the relevant surgical pathway.
Patients are then prioritized according to factors such as medical urgency, symptoms, clinical suitability and waiting time.
The system identifies an appropriately qualified surgeon with available consultation or operating capacity.
The patient is offered an appointment with that provider, subject to the applicable consent and choice arrangements.
This allows hospitals and surgical teams to distribute new referrals more evenly rather than allowing individual waiting lists to become excessively unequal.
Why Are Traditional Surgical Waiting Lists a Problem?
Traditional referral systems often depend on the relationship between primary care physicians and individual specialists.
Doctors may refer patients based on familiarity, professional relationships, geographical convenience or a surgeon's reputation.
Although these factors can support continuity of care, they can also produce uneven demand.
Some surgeons receive substantially more referrals than they can accommodate, while other qualified specialists may have available capacity.
Patients may therefore experience different waiting times for similar procedures depending on which surgeon receives their referral.
A large Ontario population-based study published in 2024 examined 942,605 surgical procedures performed by 1,834 surgeons across 107 healthcare facilities.
Researchers identified substantial differences in waiting times between individual surgeons and hospitals.
For some procedures, the median waiting time differed dramatically between providers. The study reported variations ranging from 17-fold for cataract surgery to 216-fold for non-cancer uterine surgery.
These findings demonstrate how uneven referral patterns and differences in provider capacity can contribute to surgical access problems.
How Centralized Lists Could Reduce Waiting Times
The main advantage of a centralized system is its ability to distribute referrals according to available capacity.
Patients are no longer automatically tied to the waiting list of the first surgeon selected by their referring physician.
Instead, referrals can be allocated across a network of qualified providers.
When one surgeon has a long waiting list, another specialist with suitable expertise may be able to assess and treat the patient sooner.
This can reduce unnecessary delays, particularly for common procedures that can be performed safely by multiple qualified surgeons.
Centralized systems can also improve referral screening by ensuring that patients receive consistent assessments before being placed on a surgical pathway.
For healthcare administrators, a shared waiting list provides a clearer overview of demand and available capacity across participating providers.
Research Shows Potential Benefits for Patients and Surgeons
A systematic review published in BMJ Open in September 2025 examined patient and surgeon perspectives on central intake systems for surgical waiting-list management.
The researchers identified 2,805 studies during their initial search. After screening and assessment, nine studies were included in the final review.
The selected research covered healthcare systems in Canada, the United Kingdom, Sweden, Norway, New Zealand, Australia, Italy and the United States.
The review identified four major themes from patient perspectives and five themes from surgeons, alongside two broader themes shared by both groups.
Patients generally valued the possibility of fairer referrals, clearer waiting-time expectations and improved access to treatment.
Surgeons recognized potential improvements in referral efficiency, teamwork and the distribution of clinical workloads.
However, both groups raised concerns about how centralized systems could affect individual choice, communication, professional responsibility and the quality of care.
The researchers concluded that successful implementation requires a careful balance between system-wide efficiency and patient-centred healthcare.
Patients Want Faster Treatment Without Losing Their Choice
One of the strongest concerns identified in the systematic review involved patient autonomy.
Some patients welcomed the opportunity to receive treatment from the next available qualified surgeon rather than waiting for a specific specialist.
Others wanted to retain the right to choose their surgeon, particularly when they had already established a relationship with a particular doctor.
Patients also wanted reliable information about the experience, qualifications and quality of the surgeon receiving their referral.
Simply telling patients that another doctor is available sooner may not be sufficient to establish trust.
They need to understand why the alternative surgeon is appropriate and how the proposed arrangement could affect their treatment.
A well-designed system should therefore provide transparent information and allow meaningful patient participation in decisions about their care.
Surgeons Recognize Efficiency but Have Their Own Concerns
Surgeons participating in the research generally recognized the operational benefits of centralized referrals.
They identified improved referral management, better distribution of patient demand and opportunities for more collaborative clinical practice.
However, they also raised concerns about staffing, operating room availability, infrastructure and the administrative resources required to operate a centralized system.
Some specialists worried that a centralized model could reduce their professional autonomy or weaken established relationships with referring physicians and patients.
Others emphasized that surgeons should remain involved in decisions about clinical suitability and the allocation of complex cases.
The review highlighted the importance of strong leadership and active participation from clinicians throughout the implementation process.
Why Patient Choice and Trust Matter
Centralized referrals can create a more consistent allocation process, but patients must remain confident that the system is working in their interests.
One concern is that patients may not know enough about the surgeon they are offered.
Differences in experience, surgical specialization and clinical outcomes can influence whether a particular provider is appropriate.
For that reason, centralized systems need transparent standards for surgeon eligibility and clinical matching.
Patients should receive understandable information about their options, including the potential advantages and disadvantages of accepting an earlier appointment with another specialist.
Where clinically appropriate, patients should also have a clear way to decline an alternative referral and discuss their options with their healthcare provider.
Complex Operations Cannot Always Be Pooled
Not every surgical procedure is suitable for a centralized waiting-list model.
Common, high-volume procedures with relatively standardized treatment pathways are generally more suitable for pooled referrals.
Examples may include selected hernia repairs, cataract operations, tonsil removals and joint replacement procedures.
More complicated operations may require highly specialized expertise, particular equipment or multidisciplinary treatment teams.
In these cases, allocating patients purely according to the next available appointment could be inappropriate.
The BMJ Open review highlighted concerns about complex and specialized procedures that do not fit easily into a standardized referral process.
Centralized systems therefore need clinical exceptions and clear referral pathways for patients whose conditions require a specific specialist or treatment centre.
Centralized Waiting Lists Cannot Solve Every Capacity Problem
One important limitation is that redistributing referrals does not automatically create additional surgical capacity.
If all participating surgeons are already working at full capacity, placing patients in a shared queue may improve visibility without substantially increasing the number of operations that can be performed.
Hospitals still need sufficient operating rooms, nurses, anesthesiologists, surgical equipment, recovery beds and postoperative support.
Staff shortages can also restrict the number of procedures that hospitals are able to schedule.
For this reason, centralized intake should be considered one part of a broader surgical improvement strategy rather than a complete solution to waiting lists.
The Difference Between Referral Waiting Times and Surgery Waiting Times
Surgical delays generally involve two distinct stages.
The first is the period between a referral from a primary care physician and the patient's initial consultation with a surgeon.
The second is the period between the consultation and the actual operation.
Single-entry referral models primarily target the first stage by distributing consultations more evenly among available surgeons.
However, patients may still face long delays after their consultation if operating room capacity, hospital beds or specialist staffing are insufficient.
Research published on selective centralized booking has emphasized that improving referral management alone may not resolve delays between consultation and surgery.
Healthcare systems therefore need to measure both stages separately to understand whether a new referral model is genuinely improving access.
Funding and Operating Room Resources Remain Major Obstacles
Implementing a centralized surgical system requires administrative, technological and clinical resources.
Hospitals need personnel to review referrals, maintain waiting lists, coordinate appointments and communicate with patients and surgeons.
They also need reliable digital systems capable of tracking patient status and identifying available clinical capacity.
Without adequate funding, centralized intake can become another administrative layer rather than a meaningful improvement.
Operating room scheduling must also be coordinated across participating specialists.
Additional funding may be needed to expand surgical sessions, recruit healthcare workers and increase postoperative capacity.
These requirements are particularly challenging in regions where specialist shortages and hospital infrastructure limitations are already severe.
Leadership and Cooperation Are Essential
Centralized systems require cooperation between surgeons, hospital administrators, primary care physicians and healthcare authorities.
Surgeons must trust that referrals will be allocated fairly and that clinical standards will be maintained.
Hospital administrators need to establish clear governance arrangements and ensure that participating providers understand their responsibilities.
Patients and referring physicians must also receive clear explanations about how the system operates.
The 2025 systematic review emphasized that strong leadership, stakeholder engagement and organizational culture changes are important for successful implementation.
Without these elements, disagreements over autonomy, workload distribution and clinical responsibility can undermine the entire program.
Canada's Experience With Centralized Surgical Referrals
Canada has experimented with different centralized referral arrangements in several provinces.
Examples include the Winnipeg Central Intake System, British Columbia's surgical initiatives, Nova Scotia's Hip and Knee Action Plan and the Saskatchewan Surgical Initiative.
These programs demonstrate how centralized intake can be adapted to different healthcare environments and surgical specialties.
However, the structure and effectiveness of each model depend on local workforce capacity, hospital resources, governance and the procedures included.
Canada's experience also illustrates that centralizing referrals is not necessarily the same as centralizing all surgical services.
Patients may still receive care at different hospitals or by different specialists within a coordinated network.
New Research Highlights the Importance of Surgeon Perspectives
A separate qualitative study published in 2025 examined how surgeons viewed the single-entry model in a large Canadian community hospital.
The researchers interviewed 10 surgeons from different specialties and administrative roles.
Participants described frustration with inefficient referral processes, overwhelming workloads and limited operating room availability.
Many considered a single-entry system a promising way to improve equitable access to care.
However, concerns included depersonalized treatment, reduced professional autonomy and the risk of assigning cases to providers without sufficient attention to their particular expertise.
The researchers also warned that changes to referral arrangements would need to be considered alongside existing physician compensation models.
Without financial and organizational reforms, a new system could unintentionally reinforce some existing inequalities.
A New Ethical Argument for Single-Entry Models
In December 2025, a commentary published in the Canadian Medical Association Journal examined whether single-entry referral models could be ethically justified.
The authors argued that patient autonomy is important, but it is not the only ethical principle healthcare systems must consider.
Fair access, timely treatment and the responsible use of limited public resources are also important considerations.
They noted that traditional referral systems do not necessarily provide meaningful patient choice.
Patients may be directed to surgeons based on a referring doctor's habits, personal relationships or reputation rather than transparent information about waiting times and clinical outcomes.
Geographical barriers can also limit access to specialists, particularly for people living in rural and remote communities.
The authors suggested that single-entry networks could be organized around groups of surgeons rather than individual specialists.
Within these groups, surgeons could agree on collaborative rules for allocating procedures according to expertise and clinical suitability.
This approach could help maintain professional standards while reducing unnecessary differences in waiting times.
New South Wales Audit Shows the Implementation Challenges
The challenges of implementing pooled surgical waiting lists are also evident in Australia.
A 2026 report by the Audit Office of New South Wales examined access to planned surgery and the use of more efficient service-delivery models.
The audit found that NSW Health had trialled initiatives including surgical hubs, pooled waiting lists and efforts to reduce unnecessary procedures.
However, these approaches had not been implemented consistently across the state.
In January 2026, Hunter New England and South Western Sydney Local Health Districts reported operating only one or two routine pooled waiting lists each.
The arrangements covered only a small proportion of their overall surgical lists.
The audit identified pooled waiting lists as particularly suitable for selected high-volume procedures, including hernia repairs, tonsil removals and lower joint replacements.
It also identified reluctance among some clinical staff as a significant barrier to expanding the approach.
Workforce shortages in regional areas made implementation more difficult because hospitals had limited flexibility in recruiting and distributing specialist services.
The findings demonstrate that a policy can appear effective in principle while still encountering substantial organizational resistance in practice.
What Must Happen for Centralized Lists to Succeed?
Successful implementation requires more than creating a shared electronic waiting list.
Healthcare systems need clear clinical criteria for prioritizing patients and matching them with appropriate surgeons.
Patients must receive transparent information about their treatment options and the reasons behind referral decisions.
Hospitals need sufficient staffing, operating room capacity and administrative support to process referrals efficiently.
Surgeons should participate in the design of the system, including decisions about which procedures are suitable for pooled allocation.
Strong governance is also necessary to monitor performance, resolve disagreements and maintain accountability.
Finally, healthcare authorities should evaluate both the benefits and possible unintended consequences of the model.
How Should the Success of a Centralized Surgical System Be Measured?
Reducing the size of a waiting list is not enough to establish that a centralized system is successful.
Healthcare administrators should measure the entire patient journey, from initial referral to consultation, surgery and postoperative recovery.
Important indicators include:
- Median and maximum waiting times for consultation and surgery.
- Number of patients waiting beyond clinically recommended time frames.
- Number of operations completed and cancelled.
- Distribution of referrals and workloads among surgeons.
- Patient satisfaction and acceptance of alternative surgeons.
- Clinical outcomes, complications and readmission rates.
- Differences in access between urban, rural and underserved communities.
- Administrative costs and long-term program sustainability.
Measuring these outcomes helps determine whether the model is improving access without compromising quality, safety or fairness.
Can Centralized Surgeon Lists Solve the Surgical Waiting List Crisis?
Centralized surgeon lists offer a promising way to improve the organization of elective surgical care.
They can reduce uneven referral patterns, make better use of available specialist capacity and provide patients with more transparent access to treatment.
However, they cannot independently solve shortages of surgeons, operating rooms, anesthesiologists or hospital beds.
They also require careful attention to patient autonomy, clinical suitability and the quality of communication between healthcare providers.
Evidence from systematic reviews, Canadian surgical research and the New South Wales audit suggests that implementation is just as important as the underlying concept.
The most effective approach is likely to combine centralized referrals with adequate funding, collaborative clinical governance, transparent patient information and expanded surgical capacity.
Conclusion
Centralized surgeon lists could become an important tool for healthcare systems struggling with long surgical waiting times.
By combining referrals into shared queues, hospitals can distribute demand more fairly and connect patients with qualified surgeons who have earlier availability.
Research indicates that both patients and surgeons recognize the potential benefits, but successful implementation requires trust, professional cooperation and adequate resources.
Ultimately, the goal should not simply be to move patients through a waiting list more quickly. It should be to provide timely, safe, appropriate and equitable surgical care without sacrificing the quality of the patient experience.
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