Therefore, should a patient undergo elective 12 h surgery on the weekend, which, whilst negating the twilight period in our study, would potentially be associated with the worst outcomes in our cohort? Morton and Snow 1 caution against limiting the large number of operations admitted electively to intensive care out-of-officehours, because we can only measure 'those patients operated on'. It is our belief that this cohort does not reflect patients denied surgery solely based on the availability of in-office-hour surgical lists, nor do we believe that greater in-office-hour surgical completion would result in a zero-sum game (i.e. delaying elective surgery to in-office-hours will result in more adverse outcomes). 5 Our results suggest that using out-of-office-hour intensive-care facilities as a vehicle to reduce waiting lists for elective major surgery may not be the safest or most cost-effective means. There are certainly other options in reducing waiting lists for elective surgery, including expanding the number of operating theatres and the development of high dependency units. We hope that our findings stimulate further research and consideration, especially given that the timing and order of elective surgical lists, in conjunction with a patient's perioperative workup, are theoretically amenable to strategic health system planning. Whilst we believe the political, administrative, and workforce priorities will always mandate a need for out-ofoffice-hour elective procedures, the one-third of all planned cases requiring intensive care services are well above the 1e8% of planned surgical cases returning to ward-based care during out-of-office-hour periods. 6,7 We are grateful to Morton and Snow 1 for encouraging further debate in this important area of surgical, anaesthesia, and intensive care practice. Authors' contributions Morton & Snow wrote a letter to the BJA editors about our manuscript and we are responding. It will make sense when the letters are placed in order and the BJA provide a reference or doi for the Morton & Snow letter.
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