The research has arisen from operational experience of the clinical provision of surgical services. This has led to the main research question "How can efficiency be improved in an Operating Theatre environment?" The research question involves a thorough investigation of the clinical flow process for surgical patients within the perioperative setting. It is hoped that the results of the research will produce recommendations on how to increase clinical productivity across the surgical pathway. Although there is a body of literature on efficiency in Theatres there are few reports on the whole clinical pathway involving all the stakeholders responsible for the service. The research is case study focused and as such it is set in one of the largest teaching hospitals in Europe. Queen Elizabeth Hospital Birmingham, part of University Hospitals Birmingham NHS Foundation Trust in the United Kingdom has gained recognition as one of the leading hospitals in Europe and has an international reputation for quality of care, informatics, clinical training and research. The hospital provides direct clinical services to well in excess of one million patients per annum. It has over 1200 beds, 42 operating theatres and procedure rooms and a 100 bed critical care unit, the largest co-located critical care unit in the world. The comprehensive nature of the hospital’s clinical service provision has provided a very suitable environment to undertake this research programme. The clinical data requested from the Trust offered the researcher eighteen months of surgery time performance from the Theatre suites. All the data in this research is anonymised. Three intermediate procedures that averaged a one hour duration were selected for review as it was felt that this type of high volume low variety activity would be most suitable for the introduction of a clinical intervention trial. The performance data revealed regular late starts, delayed turnaround between patients and unplanned, unfunded overruns. This preliminary data set confirmed the impetus for this study. The stakeholder interviews and the structured observation of the patient flow from the surgical wards to the Theatre suite provided further evidence of the challenges faced in a busy environment to undertake the scheduled work. Stakeholder interviews provided perspectives on the recurring issues from different positions along the patient pathway. The structured observations provided evidence that there are common inertias that impact on the timely transportation of patients to the Theatre suite. These inertias can lead to repercussions for the rest of the scheduled work. Common themes extracted from the interviews and observations through a coding process include incomplete patient preparation, patients not admitted onto the digital health record system, unsigned consent forms, incomplete patient notes, unavailable test results, late arriving staff and unavailability of staff for patient escort duties. These operational constraints influencing patient flow are experienced throughout the global healthcare sector as borne out in the literature review. Most studies have aimed at one particular area to improve performance. This study adopts an over-arching position for ‘system led’ working. Promoting cohesive working from all the stakeholders responsible for delivering surgical services will shift away from the ‘silo’ working practices that is evident in healthcare. These constraints impact on time, efficiency, process and performance. In this thesis an exploratory case study methodology is employed to examine the constraints affecting patient flow. This study contributes at three levels. Firstly the identification of the gap in the literature around surgical teams working in cohesion. Secondly the confirmation from the clinical data, the stakeholder interviews and the structured observations that the completion of the planned clinical activity is affected by common inertias. Lastly the researcher offers recommendations for clinical interventions for trial and audit. Recommendations for Clinical Intervention 1. Link Practitioner 2. Introduction of Turnaround Teams The recommendations for future trial and evaluation include :- ● The introduction of a link practitioner to work between the surgical wards and the Theatre suite. The link practitioner would be responsible for ensuring that the patients were prepared and ready for transportation to the Theatre suite at the allotted time and that all their documentation and notes were in order. ●The introduction of turnaround teams in the Theatre suite would allow the Theatre staff involved in the surgery to focus on preparing the instrument sets for the next case rather than having to clean and prepare the room and furniture for the next case as well. The idea of the turnaround teams undertaking the cleaning of the room and the preparation of the equipment and furniture is to reduce the time taken between the end of one procedure and the beginning of the next. These recommendations are intended to overcome some of the recurring operational difficulties experienced in the surgical services setting and are offered for future integration and for further research.