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The authors' discussion touches on the matter of economic justification. They mention that when the project was set up the cost-effectiveness of the alteration in practice was not considered. Indeed, I recall when the Trent Regional Audit for Surgery of the Hand visited Leicester, the Orthopaedic Business Manager mentioning that no business case had ever been put forward for this alteration in clinical practice – a most unusual situation in contemporary practice.

Comment on: Nurse-led management of carpal tunnel syndrome: an audit of outcomes and impact on waiting times – Carpal tunnel syndrome