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Nuffield Department of Anaesthetics; jaideep.pandit{at}dpag.ox.ac.uk (Pandit) John Radcliffe Hospital; Oxford OX3 9DU (Westbury) Department of Obstetrics and Gynaecology; Milton Keynes General Hospital; Standing Way, Milton Keynes MK6 5LD, UK (Pandit)
To the Editor:
McIntosh et al. have provided a clear explanation of the otherwise complex subject of more efficient case scheduling (1).
The solution proposed by McIntosh et al. namely to "change staffing to match the reality of the workload," seems sensible but cannot be enacted in the United Kingdom because the National Health Service (NHS) cannot, or will not, meet the necessary additional staff costs. This applies equally to surgeons and anesthesiologists who—like all hospital staff—are salaried employees on fixed hours of work (i.e., there are always higher costs in meeting a large when compared with a small workload). In some situations (e.g., United States and Australia), these extra costs can be offset by income generated from doing the work (or indeed a surplus might generate a profit).
There are clearly many other differences between the health services described. In the United States and Australia, some ORs are designated "open" and cases can be moved flexibly to utilize time. This is rare in the United Kingdom, where ORs are dedicated to a specialty and a rate-limiting step appears to be surgeon availability (2). US surgical services can claim blocks of OR time broadly proportional to the amount of work they generate. In the United Kingdom, OR allocations are determined by historical allocations, block contract estimations by health authorities, and national priorities for certain treatments as determined by central government (3). Nonetheless, we are interested to know if the McIntosh et al. feel their approach is universally applicable and equally valid for our health system.
Finally, we were surprised by the proposed formula for (in)efficiency in their article (1). This formula yields a quantity whose units are in absolute dollars. At least one problem with this approach is that it biases against larger centers: i.e., the absolute number of hours of over- or under-utilized time will almost always be greater in a large center with more ORs, when compared with a small center. Thus the proposed formula will always yield a higher absolute value for inefficiency for a larger center. We suggest this formula might be better adapted by adjusting for the total hours of OR time available: e.g., by dividing the hours of under- or over- utilized time by the hours available and expressing the result as percentage (in)efficiency.
REFERENCES
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