UK Healthcare Workers’ Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

Document Type : Original Article


1 Department of Targeted Intervention, University College London, London, UK

2 Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK

3 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

4 Institute of Epidemiology and Healthcare, University College London, London, UK

5 Department of Anthropology, University College London, London, UK


The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.
Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.
Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decisionmaking and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.


Main Subjects

  1. Turner S, Botero-Tovar N, Herrera MA, et al. Systematic review of experiences and perceptions of key actors and organisations at multiple levels within health systems internationally in responding to COVID-19. Implement Sci. 2021;16(1):50. doi:1186/s13012-021-01114-2
  2. Fulop NJ, Ramsay AI, Perry C, et al. Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England. Implement Sci. 2016;11(1):80. doi:1186/s13012-016-0445-z
  3. Allen D. From boundary concept to boundary object: the practice and politics of care pathway development. Soc Sci Med. 2009;69(3):354-361. doi:1016/j.socscimed.2009.05.002
  4. May CR, Johnson M, Finch T. Implementation, context and complexity. Implement Sci. 2016;11(1):141. doi:1186/s13012-016-0506-3
  5. Royal College of Surgeons of England. Clinical Guide to Surgical Prioritisation during the Coronavirus Pandemic — Royal College of Surgeons. Accessed March 15, 2021. Published 2020.
  6. Royal College of Surgeons of England. Recovery of Surgical Services during and after COVID-19 — Royal College of Surgeons. Accessed March 15, 2021. Published May 26, 2020.
  7. Department of Health. Resource Shortage, Escalation and National Loan Programme for COVID-19 in England. Accessed March 15, 2021. Published April 7, 2020.
  8. Kerasidou A, Kingori P. Austerity measures and the transforming role of A&E professionals in a weakening welfare system. PLoS One. 2019;14(2):e0212314. doi:1371/journal.pone.0212314
  9. NHS England. Consultant-Led Referral to Treatment Waiting Times Data 2019-2020. Accessed March 15, 2021. Published 2020.
  10. NHS England. Statistics on Cancelled Elective Operations. Accessed March 15, 2021. Published 2020.
  11. Department of Health. UK Influenza Pandemic Preparedness Strategy 2011. Accessed March 15, 2021. Published 2011.
  12. NHS England. Operating Framework for Managing the Response to Pandemic Influenza. Accessed March 15, 2021. Published 2017.
  13. Kent Resilience Forum. Pandemic Influenza Contingency Plan. Kent Resilience Forum; 2009.
  14. Herrod PJJ, Adiamah A, Boyd-Carson H, et al. Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact. BMJ Open. 2019;9(9):e028753. doi:1136/bmjopen-2018-028753
  15. Public Health England. Exercise Cygnus Report: Tier One Command Post Exercise Pandemic Influenza. Accessed March 15, 2021. Published 2016.
  16. North Tees and Hartlepool NHS Foundation Trust. Outpatient Appointments and Elective Surgery Cancellations; 2018. Accessed April 9, 2021.
  17. Illman J. More patients could be sent private as waiting list spirals. Health Service Journal website. Accessed April 9, 2021. Published August 30, 2018.
  18. Simon Stevens, Amanda Pritchard. Next Steps on NHS Response to COVID-19. Accessed March 15, 2021. Published 2020.
  19. Royal College of Surgeons of England. Guidance for Surgeons Working during the COVID-19 Pandemic. Accessed March 15, 2021. Published March 20, 2020.
  20. Lancaster EM, Sosa JA, Sammann A, et al. Rapid response of an academic surgical department to the COVID-19 pandemic: implications for patients, surgeons, and the community. J Am Coll Surg. 2020;230(6):1064-1073. doi:1016/j.jamcollsurg.2020.04.007
  21. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. Br J Surg. 2020;107(7):785-787. doi:1002/bjs.11627
  22. Nepogodiev D, Omar OM, Glasbey JC, et al. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:1002/bjs.11746
  23. McCabe R, Schmit N, Christen P, et al. Adapting hospital capacity to meet changing demands during the COVID-19 pandemic. BMC Med. 2020;18(1):329. doi:1186/s12916-020-01781-w
  24. Macdonald N, Clements C, Sobti A, Rossiter D, Unnithan A, Bosanquet N. Tackling the elective case backlog generated by COVID-19: the scale of the problem and solutions. J Public Health (Oxf). 2020;42(4):712-716. doi:1093/pubmed/fdaa155
  25. Public Health England. COVID-19: Guidance for Maintaining Services within Health and Care Settings. Accessed March 15, 2021. Published 2020.
  26. Chapman R. COVID-19: impacting the acute surgical assessment. Br J Surg. 2020;107(11):e515. doi:1002/bjs.11984
  27. Royal College of Surgeons. Protecting Surgery through a Second Wave. Accessed March 15, 2021. Published October 1, 2020.
  28. NHS Restart: Briefing Document. Accessed March 15, 2021. Published 2020.
  29. Bresadola V, Biddau C, Puggioni A, et al. General surgery and COVID-19: review of practical recommendations in the first pandemic phase. Surg Today. 2020;50(10):1159-1167. doi:1007/s00595-020-02086-4
  30. Shanthanna H, Uppal V. Surgery during the COVID-19 pandemic. Lancet. 2020;396(10261):e74. doi:1016/s0140-6736(20)32279-0
  31. Wielogórska NL, Ekwobi CC. COVID-19: what are the challenges for NHS surgery? Curr Probl Surg. 2020;57(9):100856. doi:1016/j.cpsurg.2020.100856
  32. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020;21:100331. doi:1016/j.eclinm.2020.100331
  33. Nepogodiev D, Bhangu A, Glasbey JC, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. doi:1016/s0140-6736(20)31182-x
  34. Kane AD, Paterson J, Pokhrel S, et al. Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study. Anaesthesia. 2020;75(12):1596-1604. doi:1111/anae.15281
  35. Al-Jabir A, Kerwan A, Nicola M, et al. Impact of the coronavirus (COVID-19) pandemic on surgical practice - part 1. Int J Surg. 2020;79:168-179. doi:1016/j.ijsu.2020.05.022
  36. Jones L, Fraser A, Stewart E. Exploring the neglected and hidden dimensions of large-scale healthcare change. Sociol Health Illn. 2019;41(7):1221-1235. doi:1111/1467-9566.12923
  37. Fulop N, Walters R, Perri, Spurgeon P. Implementing changes to hospital services: factors influencing the process and 'results' of reconfiguration. Health Policy. 2012;104(2):128-135. doi:1016/j.healthpol.2011.05.015
  38. Vallejo-Torres L, Melnychuk M, Vindrola-Padros C, et al. Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services. Br J Surg. 2018;105(5):587-596. doi:1002/bjs.10761
  39. Maniatopoulos G, Hunter DJ, Erskine J, Hudson B. Large-scale health system transformation in the United Kingdom. J Health Organ Manag. 2020;34(3):325-344. doi:1108/jhom-05-2019-0144
  40. Greenhalgh T, Russell J, Ashcroft RE, Parsons W. Why national eHealth programs need dead philosophers: wittgensteinian reflections on policymakers' reluctance to learn from history. Milbank Q. 2011;89(4):533-563. doi:1111/j.1468-0009.2011.00642.x
  41. Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Large-system transformation in health care: a realist review. Milbank Q. 2012;90(3):421-456. doi:1111/j.1468-0009.2012.00670.x
  42. Harvey G, Kitson A. Translating evidence into healthcare policy and practice: Single versus multi-faceted implementation strategies - is there a simple answer to a complex question? Int J Health Policy Manag. 2015;4(3):123-126. doi:15171/ijhpm.2015.54
  43. Martin GP, Carter P, Dent M. Major health service transformation and the public voice: conflict, challenge or complicity? J Health Serv Res Policy. 2018;23(1):28-35. doi:1177/1355819617728530
  44. McKevitt C, Ramsay AIG, Perry C, et al. Patient, carer and public involvement in major system change in acute stroke services: the construction of value. Health Expect. 2018;21(3):685-692. doi:1111/hex.12668
  45. Willson A, Davies A. Rhetoric or reform? changing health and social care in Wales. Int J Health Policy Manag. 2021;10(6):295-298. doi:34172/ijhpm.2020.53
  46. Bate P, Robert G, Fulop N, Øvretveit J, Dixon-Woods M. Perspectives on Context: A Selection of Essays Considering the Role of Context in Successful Quality Improvement. Accessed July 15, 2018. Published 2014.
  47. May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology. 2009;43(3):535-554. doi:1177/0038038509103208
  48. Vindrola-Padros C, Andrews L, Dowrick A, et al. Perceptions and experiences of healthcare workers during the COVID-19 pandemic in the UK. BMJ Open. 2020;10(11):e040503. doi:1136/bmjopen-2020-040503
  49. Vindrola-Padros C, Chisnall G, Cooper S, et al. Carrying out rapid qualitative research during a pandemic: emerging lessons from COVID-19. Qual Health Res. 2020;30(14):2192-2204. doi:1177/1049732320951526
  50. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:1186/1471-2288-13-117
  51. Alter S. Theory of workarounds-draft manuscript. Commun Assoc Inf Syst. 2013;34(55):1-30.
  52. Zhou X, Ackerman MS, Zheng K. CPOE Workarounds, Boundary Objects, and Assemblages. Accessed March 20, 2018.
  53. Myall M, May C, Richardson A, et al. Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency. J Health Organ Manag. 2020;35(9):1-17. doi:1108/jhom-06-2020-0240
  54. Søreide K, Hallet J, Matthews JB, et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services. Br J Surg. 2020;107(10):1250-1261. doi:1002/bjs.11670
  55. Newdick C, Sheehan M, Dunn M. Tragic choices in intensive care during the COVID-19 pandemic: on fairness, consistency and community. J Med Ethics. 2020;46(10):646-651. doi:1136/medethics-2020-106487
  56. Huxtable R. COVID-19: where is the national ethical guidance? BMC Med Ethics. 2020;21(1):32. doi:1186/s12910-020-00478-2
  57. Vera San Juan N, Aceituno D, Djellouli N, et al. Mental health and well-being of healthcare workers during the COVID-19 pandemic in the UK: contrasting guidelines with experiences in practice. BJPsych Open. 2020;7(1):e15. doi:1192/bjo.2020.148
  58. Hoernke K, Djellouli N, Andrews L, et al. Frontline healthcare workers' experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ Open. 2021;11(1):e046199. doi:1136/bmjopen-2020-046199
  59. Robert G, Williams O, Lindenfalk B, et al. Applying Elinor Ostrom's Design Principles to Guide Co-Design in Health(care) Improvement: A Case Study with Citizens Returning to the Community from Jail in Los Angeles County. Int J Integr Care. 2021;21(1):7. doi:5334/ijic.5569
  60. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25(7):509-517. doi:1136/bmjqs-2015-004315
  61. Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. BMJ Qual Saf. 2016;25(9):716-725. doi:1136/bmjqs-2015-004453
  62. Royal College of Surgeons. Elective Surgery during COVID-19. Accessed April 9, 2021. Published June 26, 2020.
Volume 11, Issue 10
October 2022
Pages 2072-2082
  • Receive Date: 14 April 2021
  • Revise Date: 13 July 2021
  • Accept Date: 07 August 2021
  • First Publish Date: 01 September 2021