key: cord-1016787-kgyaj2tc
authors: Singleton, G.; Dowrick, A.; Manby, L.; Fillmore, H.; Syversen, A.; Lewis-Jackson, S.; Uddin, I.; Sumray, K.; Bautista, E.; Johnson, G.; Vindrola-Padros, C.
title: UK Health Care Workers' Experiences of Major System Change in Elective Surgery during the COVID-19 Pandemic: Reflections on Rapid Service Adaptation
date: 2021-04-20
journal: nan
DOI: 10.1101/2021.04.14.21255415
sha: 9df84b8032290fd0145b4e94a0c0b30ee9317258
doc_id: 1016787
cord_uid: kgyaj2tc

Background The COVID-19 pandemic disrupted the delivery of elective surgery in the UK. 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 UK, with the aim of developing lessons for future major systems change. Methods Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. We also carried out a policy review of the guidance developed for those delivering surgical services in pandemic conditions. We used framework analysis to organise and interpret findings. Results 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. Conclusion 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 decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of major systems change is essential for the sustainability of change processes.

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world. In the UK, rapid reorganisation of care delivery was required due to the National Health Service's (NHS) inability to cope with patient demand in the context of limited critical care capacity. One of the strategies used to increase capacity was the cancellation and postponement of elective surgery. This enabled a number of other changes.

Hospitals were able to use operating theatres and recovery areas as "surge areas" where intensive care units (ICUs) could expand, theatre staff were liberated for redeployment and anaesthetic machines were made available for ventilation. Moreover, the flow of patients who did not require urgent care in hospitals was limited, thereby reducing the incidence of intrahospital infection.

The reorganisation of care delivery at a national scale and within short timeframes provides an opportunity to examine the factors that can act as barriers and enablers of major system change (MSC) in healthcare systems. MSC involves the planning and implementation of new pathways of care 1 and shifts in ways of working across multiple healthcare organisations 2 .

Existing research in this field has emphasised that a significant contributor to MSC success is the ability of actors involved in implementing change to make adaptations in line with the opportunities and constraints of their local context 3 .

While there has been substantial description of the overall changes to elective surgery that took place during the pandemic [4] [5] [6] , there is less understanding of healthcare workers' (HCWs) experiences of implementing these service adaptations. Understanding how HCWs navigated and enacted challenging decisions regarding the redesign of elective surgical services during the pandemic will provide lessons for the planning for future MSC, particularly during pandemic conditions.

In this paper, we analyse the experiences of staff involved in adapting the delivery of elective surgery in three UK hospitals during the first wave of the COVID-19 pandemic. In the first part of the paper, we report on the policy context of surgical care during the pandemic. In the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ;  https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint second, we provide insights into the positive and negative experiences of reorganisation as perceived by those involved in service delivery during this period of rapid change.

Delivering an effective surgical service in the UK NHS was challenging even before the pandemic. A decade of austerity in national spending 7, 8 had led to the lengthening of waiting times for elective surgery 9 and growing incidence of cancellation 10 . The "UK Influenza Pandemic Preparedness Strategy" 11 identified the need to model the full impact of service closures to inform decision-making as well as the need to develop plans to support the communication of such decisions 14 .

These strategies were put to the test by an unexpectedly severe epidemic of seasonal flu in the winter of 2017/2018. In order to cope with this, all elective surgeries were cancelled, which included all planned, routine non-cancer surgeries from December 2017 to January 2018, leading to a large backlog of surgical procedures 7 . The advice provided by the NHS stated that each hospital could decide exactly how to manage the reorganisation of services at this time 15 . In August 2018, this backlog led the NHS to develop an urgent plan to redirect "significantly more" patients to private healthcare providers for their routine procedures 16 . While this preparation and experience gave some insight into pandemic conditions, further detailed preparations for a pandemic response were not undertaken in UK hospitals.

With the onset of the COVID-19 pandemic, NHS England requested that staff suspend nonurgent elective operations in preparation for the predicted rise in demand for beds, resources and staff availability 17 . The Royal College of Surgeons (RCS) published guidance on the 20th . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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March 2020, which recognised the need for the surgical workforce to adapt during the COVID-19 pandemic 18 .

This approach for managing hospital capacity was similar to that taken in the US and Italy, where hospitals reduced operation room schedules and removed patients planned for nonessential procedures from operating lists 19, 20 . Other countries, such as South Korea and Singapore 21 , continued with elective work during the pandemic by adding new control and monitoring measures, such as screening and testing patients before admission and reorganising surgical work into 'hot teams' managing acute surgical admissions and 'cold teams' continuing with elective surgical work.

The RCS recognised the difficult decisions the surgical workforce had to make with regards to prioritising surgical procedures and released further guidance on the 11th April 2020 to aid with the decision-making process 4 . They allocated priority levels to various forms of surgical procedures to help guide the allocation of finite numbers of resources and staff. It was advised that patients needing urgent surgery (such as emergency admissions or cancer treatment), patients who had previously had their procedure delayed, and children should be prioritised 4, 17 .

In an attempt to increase labour, resources and facilities to allow the continuation of essential services such as cancer and clinically urgent surgeries, the NHS gained extra capacity from independent, private hospital providers. Private-to-public hospital conversion for surgical care was operational in the UK from the 23rd March 2020. This enabled the NHS to transform independent hospitals into 'COVID-19 light sites' 22 . These sites were specific units or hospitals that provided elective surgical care for non-COVID-19 patients.

Estimates suggest that just over 43,300 surgeries were cancelled each week during the 12week period in which elective surgical procedures were suspended during the first wave of the pandemic in the UK 21 . With the mounting backlog of procedures that this created, the UK set out to restart elective surgeries on 18 June 2020 23 . Public Health England (PHE) published infection and prevention control guidance which outlined that patients undergoing planned/elective surgical procedures should follow a low-risk COVID-19 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint pathway 24 . This meant that patients would need to test and isolate prior to their surgery as well as undergo a clinical assessment of symptoms before their procedure. In addition, emergency rotas were developed and new roles were advertised to reduce the burden of current staff workload and maintain the quality of patient care 25 .

As elective surgeries restarted in the UK, NHS England set targets that aimed to achieve 80% of the previous year's surgical activity by the end of September and 90% by the end of October 2020 5 . However, even with established COVID-safe pathways and outsourcing to COVID-light sites, a report published on 6 October by the RCS indicated that surgeons were struggling to reach these targets 26 . A lack of theatre capacity and sub-optimal levels of staff were major contributing factors. Later in October, several Trusts across the UK reviewed their position and made the decision to re-suspend non-urgent elective procedures in order to cope with the increasing number of COVID patients during the UK's second wave of the pandemic 27 . The policy timeline of decisions about suspending and restarting surgery is summarised in figure 1.

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We frame the rapid change in the delivery of elective surgery in the UK during the first wave of the pandemic as an example of major systems change (MSC). MSC involves introducing specific, targeted changes to the organisation of work within systems which affect a wide number of staff, often framed around the concept of re-designing 'pathways' of care for patients 2 . Jones et al 28 define these processes as: "Policies, strategies or interventions that aim to transform the way multiple care services are coordinated at the inter-and intra-organisational level to address a single service area (e.g. stroke) or integrated service domain (e.g. primary care)."

The MSC field to date has focused on examples of planned system changes, such as centralising service provision 1, 29, 30 , integrating different forms of public service 31 , and introducing new technologies into health systems 32 . The case study of changes to elective surgery provision during the pandemic enables investigation of the enablers and consequences of unanticipated, rapid change.

While there are a number of characteristics identified as enablers of MSC -unified leadership, locally driven decisions, rapid monitoring and feedback to enable adaptation, and engagement of staff and patients 33 -it is how these characteristics dynamically manifest in a specific local context that is of particular importance to the success of change processes 34 .

Involvement of those who will be responsible for implementing MSC in decisions about adapting local practices has been identified as crucial to successful implementation 35, 36 , as reorganising service delivery is ultimately achieved by multiple groups of staff collectively adapting their locally established working practices and relationships 28 . With regard to changes in the provision of surgical services, there has to date been limited investigation of the experiences of staff who implemented these changes. There is growing emphasis on the importance of learning from the adaptations of staff involved in delivering new practices 1,3,37 , which we seek to build on and contribute to through this research.

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In this paper, we will contribute to MSC scholarship through an examination of UK HCWs' experiences of reorganising and adapting elective surgical services in response to the COVID-19 pandemic. We focus our analysis on staff's reflections about the positive and negative aspects of rapid service organisation, drawing attention to the perceived barriers and enablers of adapting to pandemic conditions. We provide practical lessons for policy-makers and insights about the challenges of implementing MSC in pandemic conditions.

Adopting a theoretical perspective that MSC is enacted through social practice 38 , we aimed to develop insights from the perspective of HCWs involved in enacting changes in surgical services during the pandemic. We argue that understanding the enablers of rapid change and reorganisation during the pandemic from the perspective of those delivering it contributes broader insights for how policy can guide the effective and safe delivery of elective surgery throughout the duration of the pandemic and beyond.

This study was part of a larger, ongoing programme of research investigating the perceptions and experiences of HCWs during the COVID-19 pandemic. The wider study utilises a rapid appraisal methodology integrating data from three research streams: telephone interviews with frontline HCWs, UK policy review and media analysis 39 .

For this paper, we conducted a policy review and drew on in-depth, semi-structured interviews with frontline staff.

The aim of the healthcare policy review was to understand how surgical service delivery has been reorganised as a result of the COVID-19 pandemic in the UK, exploring the advice given during the first wave of the pandemic and subsequent reflections as the UK entered a second wave. We followed the framework set out by Tricco et al 40 for rapid evidence synthesis. We searched for government policies on public NHS databases using the following search strategy:

Search strategy for UK policy review:

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The copyright holder for this preprint this version posted April 20, 2021. 2) Aimed at surgical healthcare delivery 3) Related to the COVID-19 pandemic.

CVP selected the policies that met these criteria. SLJ, GS, LM and IU reviewed the policies and extracted data regarding the type of policy, professional group it was aimed at, the type of changes in service delivery it proposed and the duration of these changes. Data were crosschecked across reviewers. The policy review informed the background section of this paper.

The aim of the in-depth interviews was to capture the experiences and perceptions of frontline surgical staff in relation to the impact of COVID-19 on the delivery of surgical procedures. Semi-structured interviews were carried out from 28 March 2020 to 26 June 2020 using a semi-structured topic guide (see Appendix A) which focused on the impact of COVID-19 on elective and emergency surgery delivery, the decision to cancel elective surgeries and the preparedness strategies in place to guide this process as well as the concerns or fears related to the restarting of elective surgeries.

Interviews were conducted via telephone with a purposive sample of 25 frontline staff across 3 London trusts which were involved in the wider research programme 41 . Potential participants were identified by local hospital leads. A sampling framework was developed in order to guide recruitment which included different professional groups, levels of seniority and gender. The final sample included anaesthetists (11), surgeons (5), nurses (4), surgical trainees (2), surgical assistants (2) and a service manager (1) . Over half of the sample was female, with the majority of participants in middle or senior management positions.

Years in practice ranged from less than a year to thirty-two years in service.

These individuals were provided with a participant information sheet and were asked whether they were interested in being contacted by a member of the research team. Where individuals expressed an interest in participating, they were contacted by a . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint researcher asking if they had any questions about the study. When HCWs agreed to take part in the study, they were asked to sign a consent form. Participants were reminded that their participation was voluntary and that they could withdraw from the study at any time and maintain anonymity. Interviews were audio-recorded and transcribed using an authorised transcription service.

Interview notes were imported into rapid assessment procedures (RAP) sheets, which were used to synthesise findings on an ongoing basis 41 . Researchers (KS, AD, AS, HF, LM, EBG) collectively read transcripts and developed an analytical coding framework based on a preliminary scan of the data using a framework analysis approach 42 . The coding framework focused on identifying HCW's positive and negative reflections on MSC during the pandemic. These codes were inputted into a Microsoft Excel matrix, with the emerging codes in the columns and interviews entered as individual cases in the rows. The framework was refined during team discussions and all researchers were asked to apply the same framework across their assigned interview transcripts. KS, AD and GS cross-checked the data during the coding process to ensure consistency across researchers.

The study was reviewed and approved by the Health Research Authority (HRA) (IRAS: 282069) and the R&D offices of the hospitals where the study took place. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

P o s i t i v e r e f l e c t i o n s o n r a p i d a d a p t i o n C l i n i c i a n - l e d r e o r g a n i s a t i o n S t a f f a n d t e a m f l e x i b i l i t y I n n o v a t i o n i n s e r v i

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint Decisions about how to effectively suspend surgeries and reallocate resources were made at trust and regional levels, as opposed to nationally. This was facilitated by 'heavy clinical leadership during the pandemic, with teams collaborating together across sites, across hospitals, across specialties' (COV97: Surgeon). This approach enabled consideration of local context, in relation to the surgical infrastructure available and the impact of COVID-19 in a given area at a particular time. For example, some hospitals involved in this study collaborated with other regional hospitals to transform some services into cancer hubs which maintained urgent cancer care.

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The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint Surrounding hospitals would redirect their patients to us, because we were supposed to be COVID free, and we somehow became a cancer hub basically for the north of the city.

A major contributor to rapid adaptation was the ability of staff to collectively draw on their clinical and professional experience to redesign service delivery, collaborating across departments and hospitals to reallocate resources.

Teams displayed agility in adapting to rapid restructuring, with roles, teams and rotas all regularly changing. Some surgical staff were redeployed to support ICU services while others worked to maintain the provision of emergency care, with regular adjustments to reflect the loss of staff due to illness or requirements for self-isolation.

it keeps some of the workforce separate, so we would always have a core workforce who weren't ill.

Senior staff in particular were more active in supporting colleagues, with more consultants present overnight to oversee services -'we used to have no consultant anaesthetist resident overnight, we now have 10 resident in the hospital doing various things' (COV24: Anaesthetist). In some instances, this meant taking responsibility away from junior team members in order to increase efficiency, for example suspending training for junior surgical staff.

We decided that we would be operating ourselves, between consultants, in order to minimise the risk of complications and in order to speed up the operations.

Delivering change quickly was facilitated by improved communication within and between teams -'there was a chain of communication from, from the top, several times a day, every . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint day' (COV94: Anaesthetist). Rapidly understanding the needs of different teams enabled staff to identify where there were gaps in training or equipment and to reallocate resources accordingly.

There was lots of efforts in grassroots. I was involved in training of airways, in the end I just did it myself because we couldn't wait any longer, for the collective benefit of our colleagues and patients. Management have been very supportive but it is clinicians who have been coming knocking on the door saying we need to prepare and perform these trainings.

Identifying and responding to local needs regarding the provision of resources, support and training meant that teams could rapidly restructure themselves to adapt to pandemic conditions.

Despite the challenges of reorganising services, staff felt the way hospitals had been able to react was 'very interesting and exciting' (COV37: Service Manager). A great deal of improvements were thought to stem from the redesign and adaptation of services carried out during the peak of the COVID-19 pandemic.

Even after the pandemic we definitely want to keep the good things, all the changes we've implemented, because we've seen tangible results in our everyday practice...in terms of time-saving, resource-saving, increasing efficiency, more appropriate managing of resources, managing of staff, all that.

This was felt particularly in relation to the flexibility and collaboration between teams and sites, as discussed above, but also with regard to new approaches to caring for patients remotely. Efforts to reduce flow of patients through hospitals meant that staff introduced remote consulting to deliver pre-operative care.

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We weren't doing many telephone consultations before but I think we've realised that there are certainly some patients in the future who will be suitable for telephone follow-ups after this which we would have taken a while to realise otherwise.

While there were frustrating experiences, such as problems with technology, several HCWs stated that the push into digitalisation during COVID-19 may be beneficial to the wider acceptance of remote care across the perioperative pathway:

it now, but certainly use some of those aspects that keep the health service more efficient.

Learning from this experience was also seen as beneficial for preparations for a second peak or a future pandemic. For ongoing uptake of new approaches to be successful, staff suggested that training in innovative practices should continue even when COVID-19 cases are few, informed not only by the UK response but also by insights from other countries.

Throughout the COVID-19 pandemic, professional societies and national organisations in the UK offered guidance about delivering elective procedures. This guidance was not felt to be sufficiently clear about how to maintain safety during the surgeries that did proceed.

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The copyright holder for this preprint this version posted April 20, 2021. Inconsistent guidance made staff feel in conflict with national bodies. At times they felt they had to fight to protect themselves, for instance in having to negotiate access to PPE for surgical procedures they deemed to be risky but were not recognised in formal guidance as such. Beyond safety as teams, some participants also felt that they were left to risk-assess their individual risk of COVID-19 exposure.

While staff attributed success in service reorganisation to clinician-led decisions about adapting service delivery, they sought more guidance about delivering surgery safely.

There should be clear guidance from NHS and Government running down to Trust level rather than having to wait for clinicians to change things themselves.

Staff argued that local decisions would have been easier within the context of consistent national guidance providing the underlying principles of safe care during the pandemic.

The overall decision to postpone non-urgent surgery was considered by the majority of participants to be a 'top-down' decision, with little involvement from frontline clinicians.

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While the decision to change the model of elective surgery delivery during the pandemic was not contentious among participants in this study, there was ambivalence about the exact way in which services were reorganised. Some staff felt that the decision to stop all elective surgery was 'the right one' (COV85: Surgeon) because of the uncertainty around the risks of surgery at the outset of the pandemic. Equally, other participants reflected that there may have been other approaches for managing risk while continuing to provide surgical services.

We may not have shut down the whole service in the way that we did. I think we could have had a more strategic plan.

This uncertainty was motivated by concern about the future consequences. Some feared that the NHS was 'stretching a different problem further down the road' (COV38: Surgeon), with a growing backlog of support needed for patients whose procedures were postponed. Some of the challenge related to the speed at which the decisions were made. Staff noted in particular the delay between awareness of the impact of COVID-19 in Europe and subsequent decisions made about the UK response:

We could have had a more strategic plan if, as a group we decided to say 'we're going to need to model what's happened in Italy across London but we're going to need to keep elective surgery going', rather than holding off, holding off and then doing a kind of crisis response within a four to six week period.

HCWs in this study shared a commitment to adapting elective surgery service delivery in light of the pandemic, but displayed considerable doubt in their reflection on both the decision by NHS England and the Royal College of Surgeons to cancel all but essential surgical services and its timing.

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While staff redeployment was considered key to the pandemic response, it was noted to cause anxiety, confusion and stress. Starting work in ICU without appropriate skills for their role was difficult for redeployed surgical staff. While formal training was made available, there was not always time to undertake it.

There's a lot of anxiety amongst the theatre staff and the operating staff and they're all feeling a bit overwhelmed by their experiences in the make-shift ITU that we created. They're all not feeling great.

Moreover, redeployment was felt to reflect service needs rather than staff skills.

They redistributed nurses every day. Respiratory trained nurses which would have a better understanding of respiratory problems than a surgical nurse, but those nurses aren't being redeployed to ICU. They were not looking at skill sets, treating each nurse as a number rather than looking at the skills of nurses.

The changing composition of teams, with 'new faces within the department every day' (COV94: Anaesthetist), also made it difficult to establish working practices as a group.

Keeping track of rapidly changing processes was also a challenge: 'it was really exhausting just trying to work out what we were doing with different things coming up in different places all the time' (COV45: Anaesthetist).

High levels of staff sickness, which were felt to be 'decimating our service' (COV10: Surgeon) resulted in higher intensity working patterns for those who remained at work. This impacted on the perceived quality and efficiency of surgical teamwork.

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The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint We used to be a really slick oiled team, we'd have everything ready, but you can see they're all worn out.

The concern among all participants was how to manage both surgical activities and COVID-19 care, as it was felt that the hospitals did not have enough staff to 'provide a full set of normal services alongside COVID services' (COV7: Anaesthetist). Staff felt they were being asked to deliver two parallel health systems without sufficient resources: one for COVID-19

and one for non-COVID-19 care. 

Similarly, HCWs were aware of the potential risks of continuing with procedures, for patients and for themselves, particularly during aerosol generating surgeries which were 'highly contagious' (COV74: Anaesthetist). For patients who attended in-person appointments, HCWs described higher risk during procedures and higher levels of distress for patients pre-. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint and post-operatively. Some HCWs attributed this to not being allowed someone to accompany them to the hospital and was likely exacerbated by the impersonal nature of being attended to by staff wearing full PPE.

Post-operatively then they're not allowed any visitors and I think that definitely impacts on their mental health.

Deciding whose surgeries would continue involved complex judgment of what discomfort could and should be tolerated by patients, as well as a reflection on the risk of proceeding for both patients and staff.

HCWs restarted elective surgery following the reduction in COVID-19 cases after the first national lockdown. This represented another major change to service delivery, with staff reporting that it was 'harder to restart elective work than it was to stop and create a new ITU' (COV95: Anaesthetist).

Healthcare staff were widely concerned about the backlog of surgeries and waiting times for patients following the reintroduction of elective and non-urgent surgical procedures. While staff had been able to categorise cases as 'urgent' in the early stages of the pandemic based on immediate threat to life, they faced a significant challenge in deciding where to start among those patients whose surgeries had been postponed: 'we don't really understand how to prioritise' (COV26: Anaesthetist).

Staff were faced with a number of concurrent challenges. As well as patients whose care had been delayed, other patients needed surgical interventions as a result of their conditions worsening after avoiding hospitals during the pandemic. Decisions about prioritising 'who goes on the waiting list first' (COV45: Surgeon) were taxing. Staff had to weigh up factors that had no clear equivalence, such as whether to prioritise patients based on their risk of further complications, how long they had been waiting, or their current level of pain:

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The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint So, for example, many patients will be on a list for orthopaedic surgery, so all the patients who … who you know, who have two new hip replacements and knee replacements, things like that, which are debilitating conditions, which aren't necessarily big and life threatening, aren't getting done. But yet they'll still be at home, in their sort of pain or whatever, having to deal with it. This case study demonstrates the productive potential of giving staff agency to develop workarounds for problems based on their local knowledge and experience 43, 44 . We join other . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint voices in emphasising the importance of involving those who will deliver change in decisions about how it should be done 28, 36 Rapid change was possible because staff were given the autonomy to decide how to adapt existing working practices. However, we have identified a number of important nuances to this claim.

First, staff were not involved in all decisions about service adaptation. There was minimal consultation of staff involved in service delivery regarding key decisions about cancelling and re-starting elective surgery, despite pre-pandemic policy guidance placing emphasis on hospitals making local decisions about service reorganisation [11] [12] [13] [14] . Pressure from COVID-19 was not the same in different Trusts, and staff were frustrated by top-down decisions to cancel non-urgent elective surgery in the absence of critical reflection on alternative service models, as had been done in other countries 21 . Our findings build upon those of a recent scoping review on the immediate and long-term impact of COVID-19 on the delivery of surgical services, which has argued that contingency plans for continuing with surgical care during the pandemic were missing at a global level and this had a negative impact on patient prognoses, outcomes and experience 45 .

Second, a crucial issue was that the solutions created by staff were temporary, emergency responses. Workarounds, such as those employed by participants in this study, are usually time-limited responses to ongoing structural issues 43 .While staff lauded their freedom to innovate and the increased investment of organisational resources, they faced a significant challenge in trying to safely and sustainably design and deliver two parallel systems of care for COVID-19 and non-COVID-19 services. Simultaneously delivering both systems within the resources available to them was felt to be untenable. While staff could draw on their clinical knowledge and experience to adapt services, they had limited practical experience regarding the specific requirements of service delivery under pandemic conditions. There was a perceived absence of organisational knowledge and preparedness in this respect.

Finally, staff were placed in a position where they had to choose which surgeries were urgent and which could wait. These were not simple clinical decisions, but complex ethical choices that had to be contextualised within the lives of their patients 46, 47 . The guidance available from national bodies, such as the Royal College of Surgeons 4 , did not sufficiently support staff to engage in these ethical dimensions of care. Struggles to prioritise and cancel surgeries impacted the mental health of HCWs, many who felt overwhelmed and stressed with the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint backlog of procedures 48 . Furthermore, conflicting or absent guidance from national bodies about safe delivery of surgery during the pandemic led to ongoing anxiety about infection control for themselves and for patients 49 .

The inconsistent or contradictory guidance shared with hospital teams created confusion when redesigning service delivery models. Few institutions had organisational knowledge in the form of pandemic preparedness strategies in place. National bodies producing future guidance should ensure that lessons learnt from this and other pandemics are clearly and effectively communicated. This should consider both the ethical and practical dimensions of care-delivery during a pandemic.

The absence of staff voices in key strategic decisions about the pandemic response had significant consequences for staff experience and patient care. Previous pandemic response guidance advocated for greater autonomy of decision-making at Trust level. Involving staff in ongoing planning should be a priority, enabling staff to contribute their knowledge and experience to decisions about how to sustainably change service provision.

Policy and guidelines now focus on maintaining non-urgent elective operations through subsequent waves of the pandemic 5 . However, clearing the backlog of surgical procedures is dependent on the ability of staff to safely deliver surgical care. Measures needed to maintain consistent delivery of elective surgical services include safe staffing levels, effective testing of staff and patients and sufficient resources of PPE, drug stocks, theatres and recovery units 50

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 20, 2021. ;  The creative response of staff redesigning services led to a number of valuable innovations, such as improved collaboration within and across surgical units and greater uptake of remote pre-and post-operative care. Ensuring that systems and resources are in place that support the sustainable continued uptake of innovation should be prioritised.

The findings offered in this paper should be viewed in light the limitations of the study. First, although data were collected during the height of the first wave of the COVID-19 pandemic from a range of staff involved in delivery of surgical services, our respondent pool was mostly comprised of senior staff and was not ethnically diverse. The experiences of more junior staff may have shed light on different issues. Moreover, we only recruited staff from NHS hospitals in London, excluding private hospitals that took on additional NHS surgical work.

Despite these limitations we maintain that the overall lessons taken from the case study provide useful insights into sustainable MSC that can be applied throughout the UK and across other nations with a comparable health care system. Their relevance will be amplified by further research exploring how healthcare service delivery has changed in subsequent waves of the pandemic and in other countries. Moreover, it will be important to examine the sustainability of changes over time to see if those that were identified as positive remain in place.

In this paper, we argue that both the successes and challenges in the reorganisation of surgical care during the pandemic are related to the involvement of HCWs in decisionmaking. Our analysis revealed important contradictions in their experiences. On the one hand, staff were empowered to lead decisions about the practicalities of service reorganisation, enabling creative service adaptations in line with local constraints and opportunities. On the other, there was an absence of involvement of staff in wider systemlevel pandemic decision-making and unclear guidance about how to continue safely . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint delivering surgery and prioritising who needed it. Limited preparedness and lack of staff involvement ultimately led to short-term gains in terms of infection control but a longterm impact on the delivery of certain services Ensuring sustainable MSC requires effective engagement and involvement of those delivering change. 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 20, 2021. ; https://doi.org/10.1101/2021.04.14.21255415 doi: medRxiv preprint

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