Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Tackling a huge surgical waiting list needs a different approach

BMJ 2023; 380 doi: (Published 25 January 2023) Cite this as: BMJ 2023;380:p162
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on Twitter @scarlettmcnally

The number of elective operations performed in the UK decreased enormously during the covid-19 pandemic, adding to the millions of patients already on waiting lists. The main focus of politicians and policy makers has been to cherry pick the “high volume, low complexity” cases into “surgical hubs” to reduce waiting lists. We should now consider the people waiting for surgery who may be excluded by this approach.

In the UK, 46% of adults who have elective surgery that requires an anaesthetist are over 65.1 At age 65, 50% of the population already have multiple comorbidities.2 Patients with complex conditions have more complications. A minority of patients are hugely resource intensive owing to complications—requiring expertise, critical care, repeat operations, and lengthy hospital stays, with increased care and financial costs. This means that 45% of healthcare costs are expended on 3% of patients.3 Standalone units, such as surgical hubs, don’t operate on people who might need additional back-up. Some 10-15% of operations have a complication,4 and this is four times more likely if a patient is frail5 or physically inactive.6

The good news is that interventions work. Stopping smoking can reduce complications by 50%.7 Increased physical activity, such as going for a daily brisk walk, reduces complications by 30-80%.8 Patients need to be supported in making active choices. Since optimisation for surgery involves simple measures, the waiting list should be thought of as a preparation list.9 Using this “teachable moment”10 may also help people with their future health.

Around 10% of operations are cancelled at very short notice,11 often for administrative or medical reasons that could have been mitigated. Staff work in silos. Sharing skills across the whole perioperative pathway is shown to reduce complications by 50% and to shorten hospital stays by 1-2 days, reducing the need for postoperative critical care as well as short notice cancellations, healthcare costs, and patient dissatisfaction.8

Preparation for surgery must start early in the care pathway. NHS England is working to retro-fit optimisation for surgery for millions of people already on waiting lists,12 but this needs buy-in from healthcare staff or it will become a bureaucratic exercise.

And let’s not shy away from questioning whether surgery is the best option in all cases: 14% of patients express regret about having had it.13 Shared decision making is a concept that should be normalised. Senior clinicians must have honest, two way discussions with patients about BRAN—“Benefits, Risks, Alternatives, and what if we do Nothing.”14 When older people have a discussion with a geriatrician led service, 15% of them decide against surgery.15

Let’s improve perioperative care to get the excellent results from surgery that our patients deserve.


  • Competing interests: Scarlett McNally is deputy director of the Centre for Perioperative Care ( The centre pays her NHS trust 1 PA (one half-day a week) for her time.

  • Provenance and peer review: Commissioned, not externally peer reviewed.