Study underlines need for better implementation of patient care ahead of surgery across the NHS

Today the first national overview covering NHS hospitals across England sheds new light on the extent and causes of surgical postponements and cancellations. 

The clinical investigation, published in the British Journal of Anaesthesia, is a 7-day snapshot evaluation of 91 participating NHS Trusts, conducted from 11th to 18th November 2024. 

The project was a collaboration by the National Institute of Health Research (NIHR) Central London Patient Safety Research Collaboration, NHS England, University College London and the Royal College of Anaesthetists. 

It’s estimated that over 6 million patients are on a waiting list for elective care in England, with NHS Trusts still struggling to tackle the vast backlog caused by the COVID-19 pandemic. 

England’s programmes to reduce waiting times for planned surgery have not met their goals and in late 2025 the Public Accounts Committee reported that progress in reducing waiting times appeared to have stalled, with “too many people still waiting too long for diagnostic tests and treatment.” 

For individual patients, the wait for procedures such as hip or knee replacements can be many months. So, when surgery is either postponed at the point of their preoperative assessment appointment, or cancelled within 24 hours of surgery, the result is not only anxiety and frustration for the patient, but may result in deteriorating health and worse clinical outcomes. 

FINDINGS 

Cancellations 

• Data from 91 NHS Trusts finds 9% of operations postponed at preoperative assessment clinic.
• The study found national cancellation rate of 10% within 24 hours of planned surgery.
• Nearly 40% of last moment cancellations were deemed to be potentially avoidable.
• Almost a quarter were due to acute medical conditions, meaning with earlier recognition, the problems could have potentially been resolved and the procedure gone ahead.
• Alternatively, with robust systems to identify such patients before the day of surgery, they could have been replaced with patients deemed ready to proceed - thereby avoiding wasted theatre time and staff deployment. 

Postponements

• The study found that 9% of pre-operative assessment appointments resulted in postponement. 

Most postponements occurred because patients had not been adequately prepared and were not in the best medical condition for an anaesthetic or surgery by the time of their pre-operative assessment. 

• Over half of postponements (61%) were due to patients needing further tests or specialist anaesthetic or medical review, often as a result of the patient’s other medical conditions. 

The authors highlight the need for earlier, robust processes to ensure underlying health issues are identified at the time patients are added to the waiting list. This would enable them to be treated and where possible their health issues resolved before surgery.

 Operating List Inefficiencies 

• 25% of operating lists were reported as running inefficiently. Reasons included scheduling, organisational issues, delays in patients arriving and staffing issues. 

A mandate for change

In a linked BJA editorial, Professor Scarlett McNally OBE, Consultant Orthopaedic Surgeon writes ‘the findings underscore the scale of systemic inefficiencies, unacceptable waste of public money and emotional toll experienced by patients’.

She sees a compelling mandate for change and also comments: ‘NHS England has spent billions building new surgical hubs, but such stand alone units do not operate on patients at greater risk of complications, those who are older, or living with underlying health conditions and in need of the additional backup of an NHS hospital. Without a different approach that focuses on supporting and preparing these patients, waiting lists will remain unacceptably high, as procedures are too frequently postponed or cancelled.’

Commenting on the study findings, Dr James Bedford, University College London and Lead Author of the investigation said: “This detailed clinical investigation underlines the need for better implementation of patient care ahead of surgery, across the NHS. In particular - and in keeping with standards issued by NHS England - we need to ensure we identify health problems, which put patients at risk of postoperative complications, as early as possible, so that these can be improved while they are waiting for their operation. 

“The process of early screening also helps to identify patients who are low risk, who can potentially be called to have surgery at short notice, therefore reducing their waiting time, and improving service efficiency.” 

Dr Claire Shannon, President of the Royal College of Anaesthetists said: “This study shows why strengthening perioperative care must be a priority. Delivering joined-up, patient-centred care before, during and after surgery leads to better outcomes for patients and is more efficient and cost effective for the NHS.” 

Dr Denny Levett, Director of the Centre for Perioperative Care said: “As demonstrated by this study, so many last-minute cancellations in elective surgery could be avoided by earlier screening and better preparation before surgery. We will continue to work closely with policymakers and the NHS to transform surgical pathways and embed early optimisation to improve patient outcomes.”  

Professor Hugh Hemmings, Editor in Chief of the British Journal of Anaesthesia said: “This important study presents a one-week snapshot from Nov 2024 of postponements and cancellations of elective surgery in NHS England.  The data highlight avoidable systemic issues that should be addressed to improve efficiencies and lower waiting times for elective surgery in the NHS.”