To the Editor: May I suggest some explanations for the findings of Schofield and colleagues on the rate and reasons for surgery cancellations on the intended day of surgery.1

• Patients placed on a “never-never” waiting list for relatively minor surgery, such as many ear, nose and throat operations, treat the procedure with the contempt that has been shown to them. If the problem really needed the operation, most will have turned to the private sector, and, if it did not really need an operation, it has got better by itself.

• Surgeons who have many “no-shows” habitually overbook to fill their lists. In this day and age, surgeons who “underutilise” their lists are punished by losing them.

• No surgeon who has purposely overbooked their list will put a correct time estimate on the operation. We know how to add up.

• Surgeons whose lists are often shortened because of lack of beds begin to double book themselves, so that they are not left with an empty day. If the list is full, the surgeon may then be unavailable because of the other commitment.

• Surgeons who know they have a 30% chance of not getting an elective postoperative intensive-care bed for one patient book a “stand-by” patient, which becomes a cancellation if the intensive-care bed eventuates.

I suggest that, before millions of dollars are spent on management consultants, the following simple procedures be considered:

• Always give the patient a date for the operation, even if it is next year. It keeps everyone a lot more honest, and patients might even ring the hospital to change the date (if they can get through the unnecessarily tedious process of phoning the booking clerks.)

• Administrators must understand that a hospital’s load fluctuates enormously and, if elective surgery is deemed the least important activity, it will never be done. To have enough beds for elective surgery means having empty beds sometimes.

• If patients are given a date, the hospital can predict the number of beds required for elective surgery patients, and these should be treated as full beds in advance. Intensive-care beds can also be booked, as intensive-care stays after elective surgery are predictable. If the hospital has excessive emergency admissions, it should be possible to open reserve beds at short notice or to reschedule surgery by negotiating with patients.

These simple measures might cost more to the current account, but not the millions required to engineer some high-technology process driven by management consultants.

Comment: The recent articles in the Journal by Schofield and colleagues1 and Cregan2 on cancellations of surgery on the scheduled day are important, as they focus attention on the management of elective surgery in the public sector.

The number of on-the-day cancellations reported by Schofield et al could be reduced by continuing to compile these statistics. The consequent focus on the various problems at their hospital would reduce cancellations, although it might take several years for an effect. The statistics will vary between hospitals, depending on the amount of complex tertiary surgery undertaken and the demographic characteristics of the catchment population. Some of the problems are common to most hospitals, and more dialogue between them would be helpful.

Most surgeons working in the public sector experience repeated frustrations with the management of the elective surgery waiting list. The points made by Wu are valid but of course do not cover everything in a multifactorial problem. However, her suggestions for improvement are very worthy of consideration.

Giving a patient a date for an operation is sensible: both patient and staff know where they stand. If a patient had to be given a date more than 12 months in advance, then the hospital would be failing in its obligation to provide an adequate service to the community. A major reorganisation might be required. A patient who has been given a definite date can be brought into a pre-admission and pre-anaesthetic clinic (as suggested by Cregan) 3–4 weeks before the date. This would eliminate many of the reasons for cancellation listed by Schofield et al. At the pre-admission clinic, the patient could be instructed to telephone on the day before surgery to confirm arrangements (as is done at some hospitals). This does require staffing the telephone, but puts the onus back on the patient. A late cancellation could then be substituted by a “stand-by” patient, thus avoiding a vacancy on the list. Although cases of sudden illness will still occur (when 4% of staff of large hospitals are on sick leave at any one time, inevitably some patients will be sick too), only a very small number will become acutely ill after 19:00 on the previous day.

Wu’s second point, concerning administrators’ views of elective surgery, is even more important. As Cregan points out, elective surgery is the easiest service for health administrators to manipulate to meet budgetary requirements.2 It is essential that, somehow, beds (and intensive care beds) for elective surgery are effectively quarantined to give certainty to patients and staff. The 23-hour model described by Ryan and colleagues3 is a method of achieving this.

There is a shortage of surgeons — a fact recognised by the Royal Australasian College of Surgeons and by governments. The training of new surgeons relies heavily on the elective surgery lists of public hospitals. The governments of New South Wales and Victoria have been agitating for the accreditation of more surgical trainees. This becomes a nonsense when an adequate supply of elective surgical patients is denied by financial restrictions and hospital policies that deliberately restrict elective surgical beds. As elective surgery is at the heart of the training of future surgeons and surgical nurses, attention to this problem should be a top priority of all governments.