Single-entry models as an ethical approach to decreasing surgical wait times

Key points

• Direct physician-to-physician referral contributes to prolonged surgical wait times in Canadian referral markets; long waits for surgery carry negative consequences for patients.

• Wait times can be decreased by using a single-entry referral system, which pools patients requiring a specific surgery into a single queue and matches them with the next available qualified surgeon; however, such models have been criticized as unethical for limiting patient choice.

• Single-entry models are consistent with principles of health systems ethics, as autonomy is just one of many values that must be balanced in the pursuit of access, fairness, and efficiency in the face of limited resources.

• Structuring single-entry referral networks so that the receiver of referrals is a group and not an individual surgeon — with groups establishing collaborative rules for which surgeons handle which kinds of cases — can alleviate concerns that surgeon skill and expertise varies.

Few issues generate more public concern in Canadian health care than long wait times for surgical procedures. Delays in care are associated with physical pain, psychological distress, long-term disability, or even death. Fortunately, wait times can be decreased substantially — up to 60%¹ — by using a single-entry referral system for common surgeries such as hip and knee total joint replacement. A single-entry referral system pools all patients requiring a specific surgery into a single queue and matches them with the next available qualified surgeon, rather than surgeon selection being driven by the referring physician or patient. Some critics have raised concerns that single-entry referral compromises the critical ethical principles of patient choice and autonomy.² We argue that real choice rarely occurs in existing referral markets in Canada — we use the term “market” rather than “system” to describe the exchange of services between providers, consumers, and their agents in health networks without central coordination — and that a well-designed single-entry system can preserve meaningful choice while delivering improved and more equitable access to care.

Although Canada’s surgical wait times are among the longest in high-resource countries,³ not every patient waits a long time for surgery. Using the current direct physician-to-physician referral system, patients face very different wait times depending on which surgeon they are referred to.⁴ Referring physicians make their referrals with minimal information about capacity, wait times, or clinical outcomes. Surgeons are independent practitioners with their own offices and booking systems; they typically face high demand for their services, with limited ability to triage patients, manage capacity, or align with system-level goals such as reducing inequities in access to care for populations and balancing clinical loads.

Long wait times for health services in uncoordinated referral markets undermine public trust, exacerbate socioeconomic and geographic disparities, and are susceptible to gender bias: For example, female surgeons typically receive fewer and less professionally rewarding referrals.⁵

Single-entry models have been criticized for limiting choice compared with physician-to-physician referrals.² However, meaningful choice requires more than a menu of options — it requires accurate and relevant information on which to base decisions and the agency to act on those decisions, neither of which is reliably present in current Canadian surgery referral markets. Family physicians often refer patients to surgeons according to habit, proximity, reputation, or personal relationships.⁶ Public reporting of surgical outcomes is minimal, and rarely accessible or actionable for patients.⁷ Report cards have limited impact on patient behaviour in Canada, largely because they are neither sufficiently detailed nor trusted.⁸

Geographic barriers further limit choice, particularly in rural and remote areas. Surgeons with very long wait times are effectively inaccessible to patients with an urgent need. And even when patients request a specific surgeon, there is no obligation for that surgeon to accept the referral. Existing referral markets offer a nominal choice — technically possible, but rarely attainable.

Can single-entry referral systems be reconciled with the principle of autonomy — supporting patients to make informed, voluntary decisions about their care? In clinical bioethics, autonomy is not absolute. In public health and health systems ethics, the focus shifts even more from individual decision-making to the health of populations:⁹ Autonomy is just one of many values that must be balanced in the pursuit of access, fairness, and efficiency in the face of limited resources.^10,11

If constraining choice by means of single-entry referral does not violate health care ethics principles, how can these models inspire trust among patients and physicians?

Surgeons vary in their expertise and skills, and patients must be confident that they will receive competent care regardless of who provides that care. Single-entry referral systems require quality and accountability across all participating professionals. Surgeons can achieve this goal by structuring single-entry referral networks so that the receiver of referrals is a group — within a hospital or a geographic area — and not an individual surgeon’s office. Each receiver group would then create its own collaborative rules about which surgeons in the group will provide care for which type of patient or condition, with participatory governance (e.g., a weekly rotation of triage oversight) and transparent processes (e.g., monthly reports of referral distribution). This ensures not only that all surgeons have equitable access to new patient referrals, but also that each patient is connected with a surgeon who has the skill and knowledge to manage their clinical problem, and further spares referring providers the frustration of receiving rejected referral requests because the consultant does not provide the requested service. Existing referral markets, in contrast, do not protect patients from being referred to inappropriate providers. Creation of coordinated surgical groups as the receivers of referrals would reduce the risk of patients being treated by unsuitable surgeons, freeing patients and their referring physicians from the obligation of navigating a complex and often confusing referral marketplace on their own.

Beyond ensuring that every patient is connected with the most appropriate surgeon in their referral region who can see them soonest, central intake models can also provide legitimate and actionable alterative choices, such as referral to an appropriate specialist with the shortest wait time in the province, the closest appropriate physician regardless of wait time, or to any surgeon with special characteristics that are important to some patients, such as a common language or cultural competency.

Prioritizing patient and referring physician choice of a specific surgeon in central intake referral models, albeit well intentioned, fails to enhance autonomy and would perpetuate the harms to patients and populations that are caused by direct physician-to-physician referral. Single-entry models are consistent with principles of health systems ethics and, properly designed, provide genuinely meaningful choices to patients who require surgical care. Designers of central intake referral models in Canadian health systems can use the concepts described in this article to ensure that their efforts serve to solve health care problems and not reinforce them. Moreover, it is important that health system leaders and surgeons explain the rationale for single-entry referral systems to patients and the public, emphasizing that direct physician-to-physician referral leads to prolonged surgical wait times, with important negative consequences for patients.