Surgical Hubs and Elective Recovery: Why Sustainable Throughput Depends on More Than Additional Capacity

Surgical hubs have become one of the defining features of elective recovery strategies across the NHS. Designed to protect planned care from emergency pressures, hubs aim to increase surgical throughput, reduce cancellations and support recovery of long waiting lists through more focused and standardised elective pathways.

The rationale is clear. Dedicated elective environments can create the operational stability needed to improve scheduling reliability, increase procedural repetition and reduce disruption from wider system pressures. NHS England has positioned surgical hubs as a central component of wider elective reform and productivity improvement programmes, particularly for high-volume, lower-complexity procedures.[1]

Emerging evidence also suggests that hubs can improve activity delivery when the surrounding operational conditions are supportive. A recent national evaluation examining newly established elective surgical hubs in England found that organisations implementing hubs experienced a 21.9% increase in high-volume low-complexity surgical activity during the first year of operation.[2] Importantly, the study did not simply conclude that “more theatres increase activity”. Rather, the findings suggested that dedicated elective pathways, improved separation from emergency pressures and greater operational focus may help organisations create more stable delivery environments for selected procedures. However, whilst the strategic opportunity is significant, the operational reality is often more complex than increasing theatre capacity alone.

“Surgical hub” is frequently used as though it describes a single model. In practice, hubs can operate through several fundamentally different configurations, each with distinct opportunities, limitations and implementation challenges. More importantly, hub performance is rarely determined by theatre space alone. Sustainable throughput depends on the reliability of the wider operational system supporting it.

Different Surgical Hub Models Create Different Operational Challenges

Standalone Elective Hubs

Standalone hubs are typically physically separated from acute emergency pressures and designed to deliver high-volume elective activity through dedicated facilities and ringfenced pathways. The advantages can be substantial:

• Reduced disruption from emergency demand

• Improved list stability

• Greater pathway standardisation

• Lower cancellation risk

• More predictable patient flow

• Increased opportunity for procedural repetition and productivity gains

However, separation from the acute site also introduces operational complexities:

• Workforce duplication requirements

• Anaesthetic cover sustainability

• Escalation and transfer pathways

• Maintaining utilisation across fluctuating demand

• Reliance on sufficient case volume concentration

• Limited flexibility during periods of operational pressure

Importantly, scheduled capacity does not always translate into functional capacity. Sessions may exist on paper, but throughput can still become constrained by staffing availability, patient readiness, diagnostics or downstream flow limitations.

Ringfenced Hubs Within Acute Sites

Many organisations operate ringfenced elective hubs within existing acute hospital estates. This model can provide easier access to shared infrastructure, diagnostics, workforce and critical care support without requiring full site separation. This can improve mobilisation speed and operational flexibility. However, maintaining genuinely protected elective capacity within pressured acute systems is often operationally challenging. Common pressures include:

• Emergency pathway encroachment

• Competition for beds

• Shared staffing pools

• Workforce redeployment during escalation

• Increased fragility during winter pressures or high occupancy periods

Protected elective capacity becomes difficult to sustain when theatres, wards and staffing remain interconnected with the wider operational pressures affecting the organisation.

Specialty-Specific Hubs

Some hubs focus on specific specialties such as orthopaedics, ophthalmology, urology or endoscopy. These models often aim to improve throughput through pathway standardisation and concentrated expertise. Potential advantages include:

• Reduced pathway variation

• Improved procedural familiarity

• Standardised equipment and workflows

• Higher-volume operating models

• More predictable scheduling

• Enhanced training opportunities

However, specialty hubs remain highly dependent on the reliability of surrounding pathways. Throughput can still become constrained by:

• Referral variability

• Patient optimisation requirements

• Diagnostics access

• Outpatient conversion rates

• Rehabilitation capacity

• Discharge pathways

• Case-mix complexity

High-performing hubs are therefore not simply efficient operating environments. They are systems capable of reliably coordinating multiple interconnected operational processes.

Regional and Networked Hub Models

Increasingly, systems are exploring regional elective networks and shared hub models across multiple organisations. These approaches can create significant opportunities:

• Pooled waiting lists

• Better utilisation across organisations

• Concentrated expertise

• Economies of scale

• Improved regional elective coordination

However, they also increase operational coordination complexity:

• Cross-organisational governance

• Workforce alignment

• Referral management

• Scheduling ownership

• Financial accountability

• Data interoperability

• Patient travel considerations

• Pathway standardisation between organisations

Regional hubs may improve theoretical flexibility whilst simultaneously increasing the complexity required to coordinate delivery successfully.

Throughput Is a Systems Problem, Not Simply a Theatre Problem

Across all hub models, one principle remains consistent: Elective throughput is determined by the reliability of the wider operational system supporting the hub. Increasing theatre availability alone does not automatically increase completed surgical activity if other parts of the pathway remain constrained.

Common limiting factors include:

• Workforce rigidity

• Pre-operative assessment bottlenecks

• Booking horizon limitations

• Diagnostics capacity

• Inpatient bed availability

• Recovery and critical care dependency

• Late cancellations

• Scheduling inefficiencies

• Variation in consultant practice

• Staff sickness and rota fragility

• Patient optimisation delays

• Discharge constraints

In many organisations, these operational constraints are distributed across multiple departments and processes rather than sitting neatly within a single performance metric. This can make them difficult to identify using traditional reporting approaches alone. The result is often a gap between theoretical capacity and functional delivery. This broader operational challenge is reflected in national elective recovery performance. A 2025 National Audit Office review examining NHS England’s elective recovery transformation programme found that, across 44 NHS trusts receiving surgical hub funding, additional elective activity delivery was on average 48% lower than originally planned.[3] Importantly, this does not demonstrate that hubs are ineffective. Rather, it highlights the difficulty organisations can face translating planned elective capacity into sustained operational throughput within highly constrained healthcare systems.

The same report also identified wider delivery pressures including workforce constraints, construction delays, operational dependencies and difficulties maintaining protected elective pathways during periods of system pressure.[3]

The Risk of Relocating Bottlenecks Rather Than Removing Them

One of the most common operational challenges within elective transformation is solving one constraint whilst unintentionally creating pressure elsewhere. For example:

• Increased theatre throughput may expose pre-operative assessment bottlenecks

• Faster surgical flow may increase discharge or rehabilitation pressure

• Additional elective lists may intensify diagnostics demand

• Separate hub models may fragment already stretched workforce pools

• Regional coordination may increase scheduling complexity

This is why elective improvement programmes frequently behave as complex systems rather than isolated operational interventions. Improving one part of the pathway does not automatically improve the performance of the whole system.

Evidence examining elective cancellations and postponements across NHS organisations further illustrates this operational variability. A recent review identified postponement rates ranging from 1.0% to 31.9% between organisations, with same-day surgical cancellation rates reported between 5% and 17.6%.[4] The contributing factors were rarely isolated to a single issue. Instead, the evidence consistently identified interacting pressures including bed shortages, workforce availability, theatre scheduling challenges and downstream flow constraints.[4]

This variation is important because it demonstrates that elective performance is often shaped less by individual interventions alone and more by the reliability and resilience of the wider operational system surrounding them.

Sustainable Elective Recovery Requires Operational Visibility

Surgical hubs remain one of the most important opportunities within elective recovery. The potential benefits are real and significant when supported by the right operational conditions. However, successful implementation depends less on creating additional capacity alone and more on understanding whether the wider system can reliably support that capacity at scale. This challenge sits within a broader national productivity context. NHS England’s current productivity framework requires annual productivity improvements of approximately 2% over coming years, substantially above the NHS’s historic long-term productivity growth rate of approximately 0.6% per year.[5] Achieving this level of sustained improvement is unlikely to depend on infrastructure expansion alone. It requires organisations to understand how workforce, operational processes, patient flow and pathway coordination interact across the wider system. This requires organisations to understand:

• Functional rather than theoretical capacity

• The interaction between workforce, estates and patient flow

• The operational impact of variability across pathways

• Downstream consequences of increased throughput

• Whether improvements are operationally sustainable rather than temporarily supported through escalation measures

This is increasingly why organisations are looking beyond traditional reporting and static demand-capacity approaches alone towards more dynamic forms of operational modelling and scenario analysis. Understanding how workforce, estates, patient flow and pathway constraints interact before major service changes are implemented may become increasingly important in determining whether additional elective capacity translates into sustainable throughput gains in practice.

FLOORPLAN® is designed to support this type of whole-system operational visibility by helping organisations understand how demand, workforce, estates, scheduling, patient flow and pathway constraints interact within complex elective care environments before major service changes are implemented.

The organisations most likely to achieve sustainable productivity gains are therefore not necessarily those creating the most additional theatre space, but those best able to understand and coordinate the wider operational system surrounding it. Surgical hubs are not simply estate solutions. They are operational systems whose success depends on the reliability, resilience and coordination of the pathways supporting them.

References

1. NHS England. Reforming Elective Care for Patients. NHS England; 2025.

2. Fowler AJ, Dobbs TD, Abbott TEF, et al. Elective Surgical Hubs and High-Volume Low-Complexity Surgery Activity in England: National Evaluation Study; 2025.

3. National Audit Office. NHS England’s Management of the Elective Care Transformation Programme. London: National Audit Office; 2025.

4. Minto G, Cowley A, Mahmood S, et al. Elective Surgery Postponements and Cancellations Across NHS Organisations: A Review of Operational Causes and Variation. British Journal of Anaesthesia; 2026.

5. NHS England. Productivity Plan Update. NHS England; 2026.