Implementation of a “minor surgery program in primary care”: Impact on the reduction of the surgical waiting list in a healthcare area

Abstract

Introduction

This study analyzes the implementation of a Minor Surgery programme in Primary Care within a healthcare area and its impact on hospital activity indicators.

Materials and methods

A clinical training programme was designed for Primary Care professionals. The number of minor procedures performed in Primary Care and in the General Surgery Department was assessed, along with the evolution of hospital activity indicators: average waiting time, mean accumulated delay, and the number of patients on the surgical waiting list.

Results

The number of minor procedures in Primary Care increased from 95 in 2022 to 945 in 2024, resulting in a 43.8% reduction in hospital-based minor surgery and a decrease in average waiting time, total delay, and number of patients on the surgical waiting list.

Conclusions

The implementation of minor surgery in Primary Care has improved healthcare delivery by increasing its problem-solving capacity and reducing the hospital workload.

Resumen

Introducción

Este estudio analiza la implementación de un programa de Cirugía Menor en Atención Primaria en un área de salud y su impacto en los indicadores de actividad hospitalaria.

Material y métodos

Se diseñó un programa de formación para profesionales de atención primaria. Se evaluó el número de intervenciones cirugía menor en primaria y en el Servicio de Cirugía General, así como la evolución de los indicadores de actividad hospitalaria: tiempo medio de espera, demora total y número de pacientes en lista de espera quirúrgica.

Resultados

El número de intervenciones menores en Atención Primaria aumentó de 95 en 2022 a 945 en 2024, reduciéndose en un 43,8 % la cirugía menor hospitalaria y disminuyendo los tiempos de espera, la demora total y el número de pacientes en la lista de espera hospitalaria.

Conclusiones

La implementación de cirugía menor en atención primaria ha mejorado la atención asistencial, aumentando su capacidad resolutiva y reduciendo la carga hospitalaria.

Introduction

Minor surgery (MS) refers to short surgical procedures performed on superficial tissue or easily accessible structures under local anaesthesia. These procedures pose little risk to patients and no intra- or post-operative complications are expected that cannot be managed in a primary care centre.

Integrating MS into routine PC expands the skills of medical staff, improves the responsiveness of primary care, and provides direct benefits to patients. Having the procedure performed in a familiar environment, such as a health centre, reduces anxiety. In addition, the waiting time between diagnosis and treatment is shorter,¹ and unnecessary trips to hospitals are avoided, which is particularly important in sparsely populated areas.

Although Royal Decree 63/1995 of 20 January recognises minor surgery as part of the primary care (PC) service portfolio, its implementation varies between autonomous communities depending on factors such as professional training, resource availability, and the existence of specific protocols.

Various national and international studies,^2–9 have published models for integrating minor surgery into primary care, exploring its benefits and the associated difficulties. These studies have analysed aspects such as the number of procedures performed, the types of injuries treated, the training of those involved, and patient perception.

From a specialised care perspective, implementing MS in PC could help optimise waiting times by freeing up resources for managing more complex pathologies, thereby reducing hospital surgical waiting lists (SWLs). This study aims to describe the implementation of a MS programme in a healthcare setting and its subsequent impact on SWLs.

Material and methods

The health area

The study was conducted in the Department of Health of Valencia – Arnau de Vilanova – Llíria in the province of Valencia. The department oversees the Arnau de Vilanova Hospital and the Llíria Hospital, as well as a network of integrated health centres, conventional health centres, clinics, and support units distributed across 52 municipalities. Together, these services serve a population of over 340,000.

The training process

In order to implement the MS programme in primary care, three courses were organised for interested PC medical and nursing staff. The training covered organisational aspects and theoretical knowledge about the injuries to be treated, as well as the necessary surgical techniques. The courses were taught by experienced MS professionals specialising in general surgery, dermatology, and family medicine. This project aims to enable the simplest MS procedures to be performed in primary care. In cases involving more complex anatomical locations (the anterior cervical region, the axillae and the inguinal region, and the perineum), or where there are diagnostic doubts about the type of lesion or its excessive size, patients would be referred for specialist assessment.

A document was drawn up to implement MS in PC in the area. It established key aspects such as infrastructure and equipment provision, MS team organisation, surgical session dress and hygiene rules, care process steps, the documentation system and recording in medical records.

Following the theoretical phase, participants observed and performed MS procedures under the supervision of experienced professionals in the operating theatres of Arnau de Vilanova Hospital and Llíria Hospital, before moving on to health centres. This practical stage was carried out in collaboration with specialists from General Surgery and Primary Care Services, enabling participants to develop the skills and confidence required to perform these procedures.

MS had already been implemented in one of the health centres in the area since 2002 before the programme began. From 2022 onwards, it was gradually extended to a total of eight health centres in the department, depending on staff training and the provision of necessary resources. Patients were distributed by geographical area, with each centre assigned the MS of its municipality and nearby localities. Currently, each basic health zone has a MS reference professional who assesses all candidate patients and decides whether they should be treated in PC or hospital.

Infrastructure and materials

The selected centres were equipped with an advanced treatment room or procedure room, complete with the necessary infrastructure. These rooms have a minimum size of 16–20 m², with controlled ventilation and temperature, light sockets, a sink, and essential furniture, (stretcher and adjustable bench, mobile lamp, May table, and side table, among other items). They also have an electric scalpel and the necessary surgical equipment, as well as containers and preservatives for sending samples for pathological analysis.

Each centre also has cardiopulmonary resuscitation equipment located near the procedure room. A set of documents was prepared for patients, including an informed consent form, a surgical report, a pathological analysis request form, and treatment recommendations.

Descriptive analysis

To assess the programme's impact, the number of MS interventions performed in PC centres and in the General Surgery department of the hospital was considered throughout the years of implementation. Prior to the start of the programme, hospital MS data from 2019 were collected as a baseline, before the onset of the pandemic. The evolution of various indicators of hospital activity was also analysed, including average waiting time, total delay, and the number of patients on the waiting list for MS procedures in General Surgery. Average waiting time is defined as the average number of days that patients have waited from their inclusion on the SWL to the date of the procedure. Total delay is defined as the average number of days that patients have been waiting on the SWL since their inclusion without having yet undergone surgery, as of a specific date.

We compared these data descriptively using graphical representations, which allowed us to visualise trends in surgical activity and their potential impact on reducing SWL. To analyse the evolution of the number of interventions in both primary and specialised care over time, we used a non-parametric Friedman test, which is suitable for analysing paired data in small samples. This is because a normal distribution of the data could not be assumed due to the small number of observations available. The level of statistical significance was set at p < .05

Results

In the eight centres with MS rooms, the number of procedures increased progressively following the implementation of the training programme. In 2022, the first year of the initiative, 95 procedures were performed in PC. This figure quadrupled in 2023 to reach 386 procedures. By 2024, this figure had risen to 945, more than doubling that of the previous year. In the first quarter of 2025, 390 MS procedures were performed. Fig. 1 shows this evolution over time.

Figure 1.

Minor surgical procedures (MS) performed in primary care per year.

By contrast, the number of MS procedures performed at the hospital decreased progressively following the introduction of the programme. While 1691 MS procedures were performed in General Surgery in 2019, this figure fell to 952 in 2024, representing a 43.8% decrease. This downward trend continued in 2025, with only 193 procedures recorded to date, Fig. 2. Fig. 3 shows the correlation between the evolution of MS in PC and that performed in hospital. Applying the Friedman test shows a significant statistical correlation (p = .04) in the evolution of the number of procedures performed in primary and specialised care over time.

Figure 2.

Minor surgical procedures performed in the hospital per year.

Friedman test: p = .04.

Figure 3.

Evolution of the number of minor surgical procedures performed primary care and in hospitals, compared using the Friedman test. MS: minor surgery; PC: primary care.

The average waiting time for MS in hospital was reduced to less than 50 days after the programme was implemented, and the total delay also decreased, as shown in Fig. 4.

Figure 4.

Evolution of the average wait and total delay on the surgical waiting list for minor surgery in hospital, recorded in days.

The number of patients in SWL over the years of the study is shown in Fig. 5.

Figure 5.

Number of patients on the waiting list for minor surgery in hospital.

Discussion

The implementation of CM in primary care in Spain has varied across the different autonomous communities. Since 1999, most regional health services have incorporated CM into their primary care portfolios, developing specific plans for its introduction and implementation at different rates and with different levels of resource allocation.

The first successful experiences of CM in primary care were initially documented in the former INSALUD territory,¹⁰ and were subsequently replicated in various autonomous communities. However, the feasibility of replicating these good results in health centres with fewer resources, or where professionals lacked specific training or motivation for surgical practice, was a recurring topic of debate in the forums where these projects were presented.

Despite these barriers, successful local experiences began to be published in different regions in the early 2000s.^4–9 For instance, Arroyo et al.⁷ described the implementation of a primary care (PC) programme in Elche, while Tarraga et al.⁸ documented a similar model in Albacete. Both programmes were met with high levels of acceptance and satisfaction among patients. However, consolidating CM in PC has faced several challenges. The main factors limiting its expansion are care overload, lack of continuing education, professional turnover, and inadequate infrastructures.¹¹ The ongoing pandemic also set back many programmes that were already underway.

From the patients' perspective, multiple studies have shown a high degree of satisfaction with MS in PC.^1,6 A recent study¹ compared the perceptions of patients treated in PC and in hospital, and highlighted that although both settings were well rated, MS in PC received better scores due to shorter waiting times and more detailed explanations from healthcare professionals.

It has been observed that performing MS in health centres, compared to referral to contracted centres, can reduce costs by up to 49%.¹² Furthermore, in a comparative analysis, Vaquero et al. found that the cost of MS performed in PC was up to 17 times lower than that of the same intervention in hospital.¹³

However, most publications on MS in PC have focused either on its impact within primary care itself or on analysing surgery performed within the programmes. Internationally, McCormack et al.² published their findings in 2021 following 133 MS procedures performed over the course of a year. They concluded that their results helped reduce hospital waiting lists. Nevertheless, to date, we have not found any studies that quantify the effect of these programmes on hospital surgical service indicators in areas where they have been implemented. Our review aims to address this knowledge gap by providing a comprehensive overview of the impact of MS programmes on the healthcare system.

In our healthcare area, MS interventions in PC have shown steady growth since the programme's implementation in 2022. The reduction in hospital demand for MS, as evidenced by the number of interventions and the average waiting time and total delay indicators on MS waiting lists, has enabled us to optimise hospital resources. This has increased the availability of outpatient consultations for other conditions and allowed us to reallocate operating theatres that were previously used for MS to those requiring general anaesthesia.

However, integrating MS into primary care creates an additional workload, and these programmes often depend on individual professionals taking the initiative. Barriers to these initiatives include lack of training, equipment, financial remuneration, and time. A Danish study published in 2023¹⁴ analysed the factors that influence family doctors' decisions to implement MS. The most decisive factors were training and the role of the family doctor as mentor.

As with any implementation process, we have also encountered challenges in our field. One of these is the need to maintain the motivation and commitment of primary care professionals, which is a key aspect for the programme's success. Therefore, in addition to providing training during working hours to encourage participation, we had to manage professionals' schedules to ensure that surgical activities did not interfere with their daily responsibilities. To this end, substitutes were offered to cover their usual schedule, and additional paid working days were provided to help maintain the teams' involvement and motivation. Raina et al.³ also included incentives for professionals in their study, such as salary increases or accreditation.

Finally, we would like to highlight the absence of qualitative indicators related to the quality of minor surgery performed as a limitation of this study. It is important to note that this article exclusively focuses on hospital-based care, and we were unable to access patient outcomes or quality data from primary care records. Within the scope of the study, we found no evidence of hospital admissions or emergency room referrals of patients who underwent minor surgery as part of the programme. Nor were we aware of any patients being referred to hospital surgery for the same reasons. Despite this limitation, we believe that the results reflect the programme's successful implementation and positive impact on healthcare systems.

Conclusion

Implementing MS in PC has improved healthcare in health centres, increasing their response capacity and reducing the number of MS interventions carried out in hospitals. Given these positive results, this model could be adopted in other areas of healthcare, establishing MS as a standard PC service and promoting the more efficient use of healthcare system resources.

Funding

No specific support from public sector agencies, commercial sector, or not-for-profit organisations was received for this research study.