How many hysterectomies should purchasers buy?

In the reorganized British National Health Service (NHS), purchasersare supposed to assess the health care requirements of theirresident populations and contract for an appropriate volumeof services. In the case of elective surgical procedures thiscan be problematic when there is no reliable information onhealth needs and no consensus on appropriate rates of use. Anexamination of hysterectomy rates in 8 districts in 1 RegionalHealth Authority found a nearly 2-fold variation in population-basedrates, a difference which had persisted for at least 12 years.A detailed comparison of a high- and a low-rate district wasconducted to assess the extent to which the variations in therates were related to indices of data quality, resource availability,use of alternative surgical procedures, use of private hospitals,differences in gynaecologists' admission thresholds and differencesin demand. The difference was not accounted for by supply factors,but there were significant differences between the 2 districtsin levels of demand for specialist gynaecology services anddifferences in gynaecologists' admission thresholds. It seemslikely that the low-rate district contained a greater numberof general practitioners who were willing to treat patientsthemselves rather than refer them to specialists. Because ofthe sparsity of scientific evidence on which to base judgementsabout appropriateness and the lack of consensus about need,it will be impossible to specify a target figure for an optimalhysterectomy rate.