Variation in surgery postponement rates in the NHS in England

Abstract

Introduction

Postponement of surgery at preoperative assessment in the days or weeks before the patient is admitted for surgery, as distinct from cancellation on the planned day of surgery, can be devastating for patients and an inefficient use of finite resources. However, postponements are often poorly recorded. The primary aim of this pilot study was to investigate elective surgical postponement rates during or after preoperative assessment across England, and the reasons for postponement for patients on an elective surgical pathway.

Methods

A retrospective analysis of clinical audit data from 16 National Health Service (NHS) trusts in England was undertaken. Data were collected during a two-week period in March 2024 on all postponements within a service. The primary outcome of interest was the postponement rate.

Results

Some 8000 case notes were reviewed. There were 583 (7.3%) postponements. Postponement rates across trusts varied from 31.9% to 1.0%. Significantly shorter time from referral to preoperative assessment was observed for day-case patients, urgent patients, patients without early screening and patients without a ‘to come in’ date in place. Of the 342 routine patients, 293 (85.7%) had postponements for medical rather than pathways or process reasons. Half of all routine patients waited over 94 days and a quarter of patients waited 198 days from being added to a patient tracking list to preoperative assessment.

Conclusions

Minimizing postponements and improving preoperative assessment efficiency should be part of wider initiatives to streamline perioperative pathways.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on global healthcare systems. This is particularly true for elective surgical services with increasing demand for care, resource scarcity, and the need for rapid service reconfiguration to meet these new challenges¹. This has resulted in the cancellation and postponement of many procedures, with short- and long-term consequences for surgical care and patient outcomes.

In England, National Health Service (NHS) waiting lists have increased significantly since the start of the COVID-19 pandemic, with 7.5 million patients waiting for consultant-led care by the end of July 2024². Referral to treatment times have increased as demand has outpaced supply, meaning that the preoperative pathway has had to adapt to cater for patients who have a significant wait for surgery. Patients having surgery are normally required to undergo preoperative assessment. Preoperative assessment before elective surgery provides an opportunity to optimize the treatment of existing disease and to formulate a detailed perioperative care plan. Optimized preoperative assessment promotes multiple patient benefits, supports efficiency (productivity) of operating lists and prevents cancellations on the day of surgery³.

Cancellation on the day of surgery can be extremely disappointing for patients and represents an inefficient use of finite resources^4–6. A seven-day audit from March 2017 looking at reasons for on-day cancellations across 245 NHS providers and 26 717 patients in the UK identified that 13.9% of operations were cancelled on the day of surgery⁷. Although most (56.7%) of the cancellation reasons were not appropriately documented, 27.6% of the cancellations were for clinical reasons and 10.1% were due to insufficient bed capacity.

In addition to cancellations on the day of surgery, a further challenge for the preoperative assessment process is to reduce the rates of surgical postponements in the days or weeks before the patient is admitted for surgery. This will have a beneficial impact on organization of theatre lists and limit the need for rescheduled appointments, thereby reducing administrative burden. Postponement of surgery can be defined as a situation where a date is scheduled for surgery, but surgery is postponed before the planned day of surgery either for a medical reason or a failure of the pathways or process. Postponements often take place during or after a preoperative assessment clinic review finds a problem in continuing with the planned surgery. In England’s NHS, this concept is relatively new, and postponements are often poorly recorded.

In England, the Getting It Right First Time (GIRFT) programme is a quality improvement programme within NHS England. GIRFT has a remit to improve patient outcomes, experience and service efficiency by reducing variation in how services are provided across NHS providers. Reducing rates of surgical postponements falls within this remit⁸. Anecdotally, the importance of preoperative assessment patient postponement has been emphasized through provider feedback during GIRFT programme system reviews and non-medical preoperative assessment network meetings.

In July 2023, GIRFT published specific operational guidance that promoted the use of standardized preoperative assessment pathways to ensure preoperative assessment occurred before a confirmed ‘to come in’ date was issued for non-urgent surgery. The uptake of these recommendations has been variable and there remain multiple preoperative assessment services that are unable to provide an appointment for preoperative assessment before a ‘to come in’ date is confirmed due to growing demand. To our knowledge, there has been no previous data collection on either the incidence or reasons for early surgical postponements within preoperative assessment.

The primary aim of this pilot study was to investigate the surgical postponement rate at or after preoperative assessment and the objective reasons for postponement for patients on an elective surgical pathway.

Methods

Study design

This was a retrospective analysis of clinical audit data collected by the GIRFT programme.

Ethics

Individualized consent was not required for this analysis of audit data. No patient-identifiable data were collected as part of the audit. Reporting follows current guidelines for observational studies⁹.

Setting, timing and data collection

All NHS hospitals in England are run by trusts. Each trust covers a geographically defined catchment area of varying physical size and population, but typically a trust will run between one and four acute hospitals providing secondary and tertiary care. Data were collected for surgical postponements at 16 NHS hospital trusts in England during a two-week (10 working days, Monday–Friday) period in March 2024. The two-week window varied for each trust depending on when they could complete the pilot study.

Trusts were invited to take part in the pilot study by means of an expression of interest communicated through a number of clinical networks, mainly the national non-medical network which is attended by approximately 75% of NHS trusts within England and has representation from every English region. For the pilot, we aimed to gain participation from 15–20 NHS trusts.

Each trust was issued with data collection sheets to collate any postponements that happened during the study period. Some providers had multiple preoperative assessment units, and all were included where possible. Data sheets were given to both non-medical and medical teams dependent on who made the clinical decision to postpone the patient (for example, postponement may have been a medical decision after initial non-medical preoperative assessment review). The date of the postponement did not have to be the date the patient was seen for preoperative assessment (for example, if a patient was seen for preoperative assessment outside of the study dates but the decision to postpone was at a later date within the data collection period, this was captured).

The data captured included the total number of case notes reviewed and the number of postponements. For patients with a postponement, the following details were also collected on the nature of the postponement:

1. Date referred into the trust for consideration of surgery, date of preoperative assessment and date added to a patient tracking list. The patient tracking list date is assumed to be the date the surgical team became aware that the patient was listed for surgery.

2. Whether a ‘to come in’ date was given to the patient prior to the preoperative assessment and, if it was, what this date was.

3. Priority—urgent or routine.

4. Planned day-case or in-patient stay.

5. Use of early screening, risk assessment (or other triage methods) and optimization pathways prior to preoperative assessment¹⁰. Early screening is defined as a standardized approach to identifying long-term conditions or risk factors for poor health outcomes, such as a questionnaire or specific investigations. Risk assessment is defined as the process of assessing a person’s risk from undergoing a surgical procedure or anaesthesia. Optimization is the process of supporting and working with a patient to get their health in as good a state as possible before surgery. This includes both supporting people with the management of any long-term conditions and supporting people with any behaviour changes required to improve their health.

6. Reason for postponement. A list of possible preoperative assessment reasons is given in Table 3. ‘Other’ was an option. More than one reason for postponement could be given. The reasons for postponement were dichotomized as either medical-related or pathway-related. Where this dichotomy was used to present data, the medical reasons were assumed to be the dominant reason.

7. Person making the postponement decision—surgeon, nurse/allied healthcare professional, anaesthetist, patient.

8. List of the included specialties within each preoperative assessment unit.

Inclusion and exclusion criteria

Only adults (as defined by the trust) undergoing elective surgery were included. Patients were excluded where:

1. Local anaesthetic (without sedation) was planned for the procedure.

2. The patient did not attend preoperative assessment clinic because they are unable to (for example, acutely unwell).

3. The clinic appointment was cancelled due to staffing/resource/capacity issues.

4. ‘To come in' date moved due to non–patient-specific issues (for example, hospital pressures).

5. Cancellation on the planned day of surgery.

Outcome of interest

The outcome of interest was postponement of surgery (yes/no) at preoperative assessment. Some NHS hospital trusts give the patient a ‘to come in’ date before preoperative assessment, whereas others wait until after the preoperative assessment to give the ‘to come in’ date. As such, postponement was defined as:

1. For patients with a ‘to come in’ date at preoperative assessment, anything that prevented surgery taking place on the first provided ‘to come in’ date was defined as a postponement.

2. For patients without a ‘to come in’ date at preoperative assessment, anything that prevented the preoperative assessment being completed within two weeks of the first preoperative assessment date. Two weeks was chosen as a cut-off based on provider feedback that review of initial preoperative tests (for example, bloods and infection prevention and control screening requirements, inclusive of a review of their clinical history) was routinely performed within this time period.

Data management and statistical analysis

Data were held within a secure server controlled by NHS England. Analysis was supported by standard statistical software including Microsoft Excel (Microsoft Corp, Redmond, WA, USA) and Stata (Stata Corp LLC, College Station, TX, USA).

Standard descriptive statistics were used depending on the nature of the data. Trusts were categorized as those with a high and low postponement rate based on being above or below the average postponement rate for the entire data set. Chi-squared tests were used to compare outcomes for categorical data. Mann–Whitney U test were used to compare two groups for time to event data, which were non-parametric. Confidence intervals for postponement rates for each trust were calculated using the assumptions of a binomial distribution.

Results

Some 8000 case notes were reviewed across 16 NHS hospital trusts in England. There were 583 (7.3%) postponements across all patients. Postponement rates across trusts varied from 31.9% to 1.0% (see Fig. 1). Detailed data on patients who were postponed were available from 12 of the 16 trusts, covering 482 (82.7%) patients. The coverage of clinical specialties across these 12 trusts is summarized in Table 1.

Data on the characteristics of postponed patients at the 12 included trusts are presented in Table 2 categorized into trusts with a postponement rate above (high postponement rate, seven trusts) and below (low postponement rate, five trusts) 7.3%. Trusts with a low postponement rate had a significantly higher proportion of patients on a day-case pathway and more postponement decisions made by surgeons or more than one person. Low postponement rate trusts also had a higher proportion of patients undergoing routine surgery, postponement for a pathway or process reason rather than a medical reason, early screening in place and a ‘to come in’ date in place at preoperative assessment, although none of these differences were significant.

Nurses and anaesthetists alone made the decision to postpone in 52.9% and 40.9% of cases respectively. Recording of joint decision-making was rare. Of the 255 postponement decisions made by nurses, 65 (25.5%) were for urgent patients and of the 197 postponement decisions made by anaesthetists, 66 (33.5%) were for urgent patients.

Waiting times for preoperative assessment

Data on timing of the preoperative assessment relative to referral date, the patient tracking list date and the ‘to come in' date are also presented in Table 2. The referral to preoperative assessment date was significantly shorter in low postponement rate trusts.

Table 3 presents data on time from referral date to preoperative assessment date and time from patient tracking list date to preoperative assessment date for the various categories of patients. Significantly shorter time from referral to preoperative assessment was observed for day-case patients, urgent patients, patients without early screening and patients without a ‘to come in’ date in place. Significantly shorter time from patient tracking list date to preoperative assessment date was observed for urgent patients. Although longer waits from patient tracking list date to preoperative assessment might be expected for routine care, over half of all routine patients waited over three months (median 94 days) and a quarter of patients waited nearly 200 days (upper quartile 198 days) from patient tracking list addition date to preoperative assessment. Of the 342 routine patients, 293 (85.7%) had postponements for medical reasons. Each of the 17 possible reasons for postponement according to whether the procedures was urgent or routine are shown in Table 4. Reasons for postponement were similar between the two groups, with medical reasons dominating. Many of the medical reasons for postponement related to chronic medical conditions.

Discussion

Postponement rates varied markedly for each of the NHS hospital trusts included in the study, with around 1 in 14 patients having a postponement across the 16 sites. The vast majority of reasons for postponement were medical and for chronic conditions, with many amenable to optimization prior to surgery. As median waiting times from referral and patient tracking list date to preoperative assessment date were lengthy, particularly for routine patients, the opportunity to optimize patients prior to preoperative assessment was being missed in many cases.

Fewer than 6% of patients who were postponed in this study had been through an early screen, risk assessment or optimization process prior to preoperative assessment despite it being mandated for in-patient pathways (almost half of all patients in our study). It is notable that trusts with low postponement rates had a higher proportion of patients undergoing early screening and risk assessment.

Including the additional step of early screening, risk assessment and optimization at the point of consideration for surgery, in addition to a later preoperative assessment, is undoubtably challenging for providers in terms of capacity and demand. However, our findings suggest that it is an important step if postponement rates at preoperative assessment are to be reduced. It is a change that will improve patient care and experience, reduce financial costs, and improve public health¹¹. Furthermore, patients who are medically optimized for surgery are likely to have less need for critical care beds, have a shorter stay and be suitable for surgery in specialist elective surgical hubs^12,13. This will support the post–COVID-19 recovery of elective surgery in England.

The median time from referral to preoperative assessment was over 200 days, and over 250 days for routine patients who were postponed, allowing sufficient time for optimization prior to surgery. However, just over 5% of postponed patients had access to early screening, risk assessment and optimization. Delays to offer initial screening, early risk assessment and intervention for modifiable risk factors means that for many patients, preoperative assessment services are the first contact to review a patient’s health status. This includes a large number of patients already given a ‘to come in’ date prior to any assessment.

Interestingly, over half of patients were postponed by the nursing teams at preoperative assessment and a quarter of these were for urgent surgery. Multidisciplinary decision-making appeared to be rare, with only 1% of postponements recording more than one professional group making the decision to postpone. It is important that when patients are postponed, particularly for urgent surgery, there are a range of senior decision-makers involved to discuss with the patient and their carers the risk of proceeding to surgery and the time to delay for optimization. As clinical guidelines emerge for the management of patients on a perioperative pathway, there needs to be robust training and education, competency assessment and escalation policies to support staff with clinical decision-making. A key part of this is patient-centred, shared, multidisciplinary decision-making conversations and a formalized explanation of risk, for both modifiable and unmodifiable disease^14–16.

The vast majority of postponements (88%) were for medical reasons and often for chronic conditions that are amenable to optimization. In trusts with low postponement rates, pathway and process reasons for postponement were more common, suggesting that this group of trusts had achieved low postponement rates, in part, due to minimizing medical postponements. Medical optimization pathways are well established in specific patient cohorts in England such as anaemia and diabetes management with multiple national guidelines to support implementation in perioperative care^17–21. However, the evaluation and interpretation of these pathways and guidelines could be a source of variability in surgical postponement rates across England. Use of a perioperative passport and dedicated diabetes specialist nurse support has been shown to improve patient outcomes and reduce length of stay for patients with diabetes undergoing surgery¹⁴.

We believe that highlighting surgical postponements from preoperative assessment and the reason for them will support delivery and implementation of robust perioperative pathways for patients on surgical waiting lists. Surgical postponement rate is an additional metric that should be considered when evaluating opportunities to improve patient care and contribute to overall productivity gains within the NHS. In England, such pathways are needed to support recovery of surgical waiting lists following the COVID-19 pandemic and are part of a drive to increase the efficiency of service delivery through initiatives such as increased use of enhanced recovery and day-case surgery pathways and streamlining out-patient pathways^22–29.

In our opinion, re-engineered pathways create opportunities to prepare patients for surgery medically, physically, and psychologically by instituting measures that have been shown to improve postoperative outcomes³⁰. Shared decision-making, co-morbidity management and collaborative behavioural change across care providers, including skilled clinical teams, are likely to be key components of these pathways. Ensuring patients have timely assessment and an offer of intervention for modifiable medical conditions will help ensure that preoperative assessment services are used appropriately. It is vitally important that this is a partnership with theatre and booking teams. Surgical postponements from preoperative assessment result in a significant amount of extra administration time and ‘rework’ so preventing postponements will help to improve productivity within elective services in both primary and secondary care.

The sharing of patient data across different healthcare locations is vital for supporting transition and continuity of care³¹. Patients who are postponed often have existing results and clinical history that should be accessed through shared care records at the decision to list for surgery³². This functionality is often missing at provider level due to limited interoperability, digital maturity at provider level or processes that do not support access³¹. There is ongoing national work overseeing integration of primary and secondary care data, and a recommended standardized data set for information on co-morbidity status, lifestyle factors and test results to be made available to clinicians on referral to secondary care.

Our study has some limitations. We did not capture detailed data for patients who were not postponed. Such data would have allowed us to understand factors associated with postponement in much more detail. We accept that we may not have captured data for all participating trusts on all postponements occurring during the two-week data collection period. However, this is unlikely to have substantially biased our findings. The reasons for postponement were as detailed by each trust and in some cases will be subjective. This is particularly true when dichotomizing these data as medical or pathway/process related. Many postponements will be due to a combination of medical and pathway reasons. We did not capture data on the procedure being conducted for each patient, or the clinical specialty this fell under. Future work will look to capture these data. More broadly, despite using a standard data collection sheet, data capture methods will have varied across trusts. We did not capture how the decision to postpone was reached (for example, by following a guideline or protocol or further discussion across the multidisciplinary team). Defining the decision-making process should be explored in future studies.

There is now a national focus in the NHS in England to ensure that medical and lifestyle risk factors are identified at the earliest opportunity after contemplation of surgery and NHS England policy is mandated to reflect this for in-patients on an admitted pathway³³. On-day cancellations, with reasons for cancellation, can now be tracked through the Model Health System online platform³⁴ and the waiting list data set². Tracking postponements in a similar way will help providers to understand the reasons for postponement and put systems in place to minimize them. Minimizing postponements, and improving preoperative assessment efficiency, should be part of wider initiatives to streamline perioperative pathways. This will be important not only for surgical pathways but to support longer-term benefits in population health.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgements

We thank all staff within individual NHS trusts who collected and entered the data used in this study. We acknowledge the support of Adam Foster (NHS programme manager, perioperative programme), Nathalie Stevenson (consultant anaesthetist at Royal Free London NHS Foundation Trust) and Gayle McDonnell (preoperative assessment nurse lead, Barts Health NHS Trust) in designing the study and with data collection. Anonymized, primary data will be made available by the authors to other researchers upon reasonable request. The study was not pre-registered.

Disclosure

The authors declare that there is no conflict of interest.

Data availability

This report does not contain patient identifiable data. Data in this report are anonymized. The underlying Hospital Episode Statistics (HES) data cannot be made available directly by the authors as the data were obtained under licence/data-sharing agreement from NHS Digital. HES data are available from NHS Digital upon application.

Ethical approval

Ethical approval was not sought for the present study because it did not directly involve human participants. This study was completed in accordance with the Helsinki Declaration as revised in 2013.

Informed consent to participate

Informed consent was not sought for the present study because it was an analysis of routine clinical data.

Consent to publish

All authors consent to publication

Author contributions

Emma McCone (Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Writing—original draft, Writing—review & editing), Chris Snowden (Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Writing—original draft, Writing—review & editing), Michael Swart (Conceptualization, Methodology, Project administration, Resources, Supervision, Writing—review & editing), Tim Briggs (Conceptualization, Funding acquisition, Resources, Writing—review & editing), and William Gray (Data curation, Formal analysis, Methodology, Writing—original draft, Writing—review & editing)

References

Author notes