A complicated paper from which the message should be in these straightening times to consider opportunity cost and utilise theatre capacity optimally with maximal efficiency.

Efficiency of the organisation (work and facilities) is an administrative function and requires robust management but utilisation is by the anaesthetists and surgeons; using the time to best service advantage necessitates an element of control over their individual activities.  We all know that how much (theatre) time is taken up is more variable than can be accounted for by case mix and so on; what we do must be based upon best practice, we can and should learn from those with optimum utilisation.  We must be able to justify the time based upon evidence and outcomes and a balance also has to be struck between theatre time and the overall stay in hospital.

Do we need to consider ‘lean six' and ‘sigma' when it is clear that much of the problem we face when considering surgical capacity is equivalent to that which beset General Motors.  Of course patients come with all sorts of co-morbidities and complications, we can't change that.  Choice and a personalised service are important, we can both treat the patient like an antique clock and change practice, working towards fewer options in individual facilities; why 20 different implants when ‘568/20000' would suit most patients with the remainder going to another facility.   

The authors recognise that anaesthetists and surgeons are in the forefront of the delivery of operating services but more than simply being in a key position to provide hard data we can promote and accept necessary change(s).  We have to show why we can't do more as in the 75% for staff costs we're the most expensive.