Building an initial programme theory to explain how and why on-the-day surgery cancellations occur and how they might be reduced

Samarasinghe et al. BMC Health Services Research https://doi.org/10.1186/s12913-025-13592-x (2025) 25:1445 BMC Health Services Research Open Access RESEARCH Building an initial programme theory to explain how and why on-the-day surgery cancellations occur and how they might be reduced Buddhika S. W. Samarasinghe1*, Ross Millar1, Mark Exworthy1 and Justin Aunger2 Abstract Background On-the-day surgery cancellations (OTDSCs) have been a longstanding global problem, bringing significant suffering to patients and carers, and substantial waste across healthcare systems. Any cancellation of a surgery that occurs for any reason on the day of the scheduled surgery is defined as an OTDSC. Despite the high prevalence of OTDSCs, little is known about why they happen and how to minimise them. This study aimed to develop Initial Program Theories (IPTs) and share valuable insights that can form the basis for future evaluation of OTDSCs. Method We conducted a study to address the questions, “How do OTDSCs occur, and in what contexts can they be minimised?“. We used a qualitative and multi-stage approach to developing IPTs. Data collection included OTDSC literature (n = 35) identified from a systematic search, including feedback sessions with administrators (n = 10) from eight NHS trusts, two feedback events with patient expert advisers (n = 6), and expert practitioners (n = 8). Results The iterative analysis found that OTDSCs are a complex undesired outcome, influenced by many interconnected “variables” at macro-level (e.g., waiting-list policies, austerity measures and workforce shortages) and meso-level (e.g., workload, high emergency admissions and interruptions), as well as healthcare professionals’ (HCPs) and patients’ perceptions and behaviours. The study identified that failures in various aspects of individualised care (such as care planning, communication and resource allocation) in preparing for surgery before admission could also contribute to different types of OTDSCs. Conclusion As a result of the complex and interconnected nature of OTDSCs and the wide variety of causes, it can be hard to reduce their occurrence. OTDSCs can be minimised by carefully considering various aspects of individualisation of care, such as clinical care planning, communication and resource allocation and delivery when preparing patients to undergo surgery. Providing favourable working conditions and creating effective knowledge transfer between the stakeholders initiating OTDSCs and HCPs who prepare patients for surgery can be critical *Correspondence: Buddhika S. W. Samarasinghe Full list of author information is available at the end of the article © Crown 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Samarasinghe et al. BMC Health Services Research (2025) 25:1445 Page 2 of 14 to minimising most OTDSCs. The study developed a taxonomy and novel IPTs that have practical implications for policymakers and practitioners when designing interventions to minimise OTDSCs. Keywords Surgery cancellations, Realist evaluation, Realist theory building, Multi-methods Background Evidence suggests that On-the-day surgery cancellations (OTDSCs) are a significant and longstanding problem faced by healthcare providers, policymakers, patients and HCPs. Most surgeries are completed using scheduled surgical care systems (SSCSs) that manage surgical care from patient preparation into surgery, and to recovery [1]. OTDSCs are an unintended outcome of SSCSs, which include various conditions, including cancer, and the prevalence of these is quite high. OTDSCs are an unintended outcome of scheduled SSCSs, which include various conditions, including cancer, and the prevalence of these is quite high. For example, the global prevalence of case cancellation on the intended day of surgery has been found to be 18%, according to a meta-analysis [1]. The economic and psychological burden of OTDSCs for patients and families is well documented and emotionally harmful to patients, with a series of negative effects, including anxiety, anger, rejection and physical/psychosomatic symptoms in the extended waiting period [2]. To improve the efficiency and experience of scheduled care waiting lists, policymakers have increasingly relied on standardised interventions such as performance targets, care pathways, protocols, standard operating procedures and checklists to manage patients and resources. Yet in recent years, the UK National Health Service (NHS) has exemplified how policy decisions such as austerity measures, staffing shortages, increasing emergency admissions and inadequate social care resources, have created problems for hospitals in delivering effective and safe surgical care. Furthermore, NHS hospitals are government-funded systems where patients with varying clinical complications, multiple co-morbidities and diverse socio-economic needs (i.e., among people of different income groups and ethnicities) undergo scheduled care surgery. There are also inequalities in those who experience OTDSCs. Patients undergoing surgery with few clinical complications are less likely to experience OTDSCs for clinical reasons [3–5]. Evidence from the UK [6], the US [7] and Singapore [8] suggests that OTDSCs are common among patients from disadvantaged communities (e.g., low-income groups and homeless people). Similarly, a wide range of evidence highlights that patients who undergo surgery with high levels of clinical complications are more likely to report OTDSCs [7, 9]. As a result, OTDSCs have been a significant problem in the English NHS [6, 10, 11]. A large cohort study found that 13.9% of patients attending inpatient operations were cancelled on the day of surgery. The biggest reason for OTDSCs is that patients are unfit for surgery, accounting for 33.3% of OTDSCs [12] Reported loss of income from OTDSCs in hospitals can be substantial, and, in the English NHS, the cost of lost operating theatre (OT) time because of surgery cancellation is as high as £400 million per year [13]. Delivering safe and efficient surgery has become a significant global health challenge [14]. Surgery is a high-risk invasive procedure completed under loca (...truncated)