The NHS is facing an unprecedented level of future pressure due to impending challenges driven by an ageing population, increase in long-term conditions, and rising costs and public expectations. In particular, rising health care demand, rising costs and flat real funding mean that the NHS could face an estimated £30 billion financial shortfall by 2021. If these challenges are not addressed there is a risk that many service providers may become financially unsustainable, and the safety and quality of patient care decline. In response Monitor (the regulator of NHS Foundation Trusts) working with NHS England, the NHS Trust Development Authority and the Local Government Association has instituted a new five year joint planning regime. The intention of this regime is to focus on the robustness of Foundation Trusts' strategies to deliver high quality patient care on a sustainable basis. Foundation Trusts will have to present five year financial projections, develop realistic transformational schemes and align their plans with those of other actors within the Local Health Economy (LHE). Planning on a five year basis and in conjunction with other healthcare providers is a new discipline and differs distinctly from the approach taken nationally to planning during the regime of Foundation Trusts (since 2004) when a more market oriented focus has dominated. Against this complex background, and as part of the new five year planning regime one of the areas that UK Trusts plan to review is elective care, which mainly involves planned surgery. This project aims to develop ideas for service innovation in the orthopaedic surgery domain using a design-engineering led approach. This approach enhances design thinking through the use of system thinking, human factors and engineering analysis. This research will develop and evaluate a patient-centric and system-wide solution for sustainable delivery of surgery services.