In reply: I thank Mountain and colleagues from the Australasian College for Emergency Medicine for their letter.1 Despite their interpretation of our article,2 I think we share many points of agreement.

Having worked extensively as a clinician, I agree that patient harm is occurring because of insufficient capacity to treat, and that patients will benefit from more capacity to treat. I also agree that this is an important issue and that approaches to dealing with it should not be subverted. Most importantly, I would also agree that the number of available hospital beds is critical — the unanswered questions are about how many beds, and where they should be provided.

I also thank the authors for their acknowledgement that “clinical modelling” is a fundamental driver for their position. Our industry would do well to take its direction in the use of queuing theory from internationally recognised experts in the area, rather than from within the ranks of my fellow doctors.

In response to Mountain et al’s call for an 85% bed-occupancy limit as a solution, my call is for more detail about the practicalities of how we would implement this limit, which could start with the provision of clear answers to the following questions:

• How would compliance with the 85% occupancy limit be monitored?

• What are the practical measures that bed managers, nurse unit managers, executives and others could use to ensure that compliance occurs?

• If patient throughput in acute inpatient areas increased, what downstream effects could we expect?

• How would the application of resources in fixing “access block” compare with the application of the same resources in fixing “exit block”? (And an obvious sub-question: what is the relationship between the two phenomena?)

• Has a consensus been reached with all specialist groups as to which clinical units in hospitals should have access to extra beds when they become available? Or is it intended that an 85% limit would be applied across the board, irrespective of the differences between patient care needs, lengths of stay, rates of arrival and staffing mixes in different wards?

• How and when would the effectiveness of such an initiative be assessed? Perhaps another occupancy figure would appear even more efficacious through the lessons learned.

I believe these are reasonable questions that ought to be answered by anyone calling for this change. I repeat my group’s call for more, and more informed, investment in health system capacity given this huge problem and the solution being proffered.