Surgery may come with an infection budget

The waiting room would look exactly the same. Under a draft protocol now being discussed by a group of clinical directors, what would change is the letter. A planned hip replacement would be scheduled not only against theatre time and a surgeon's list, but against the hospital's remaining infection budget for the year.

The budget would work like any other allocation. Each institution would receive a quantity of the antibiotics still reliably effective against the organisms that turn up in surgical wounds, and every elective procedure that depends on prophylaxis would draw on it. Emergency work would sit outside the budget, as emergency work always does. Everything that can wait would be asked to prove, in advance, that it is worth a dose.

A woman of seventy-one, on the list since spring, would be told her operation had moved. The letter would not say the ward was full, because it would not be. It would say the procedure had been rescheduled for reasons of stewardship capacity, a phrase explained on the reverse in a paragraph she would read four times and then take to her daughter.

“Nobody would be denied treatment,” a spokesperson for the drafting group would say. “Treatment would be sequenced according to the resource it consumes. The resource here is not money and it is not a bed. It is the continued ability of an antibiotic to work, which is the only item on our inventory that we cannot reorder.”

Clinicians would object that the budget does not create the rationing, it merely prints it. That is the strongest argument for it and the hardest to say out loud. The counter-argument would be quietly arithmetical: a hip deferred by a year is a year of reduced mobility in a person of seventy-one, and reduced mobility at seventy-one has its own outcomes, none of which appear in the stewardship column.

The awkward economics sit further upstream. A good new antibiotic is one that is kept in reserve and sold as little as possible, which makes it the only product in modern medicine whose commercial success is measured by how rarely it is used. Health systems have begun paying for such drugs by subscription rather than by the box, precisely so that a company can be rewarded for a medicine nobody is allowed to prescribe.

None of this is protocol. There is no infection budget and no letter. But the surgical safety checklist already contains a line for the antibiotic given in the hour before the first incision, and every part of this scenario follows from the day that line cannot be ticked.