"Waiting-lists have emerged as a highly potent symbol of failings in the acute system."
The Government must recognise its "ethical responsibility" to ensure "timely universal access to the acute system on the basis of clinical need". And it must stop issuing waiting list "targets" of three, six or 12 months which are "indicative, arbitrary and lack any substantive clinical meaning".
So advises the Harvard Association, whose analysis of the Irish health service has culminated in the paper, Waiting lists: Analysis, Evaluation and Recommendations, by Prof Ray Kinsella, director of the Centre for Insurance Studies in the UCD Graduate School of Business.
The paper is the result of a Harvard case study analysis of the Irish acute hospital service, which it describes as "flawed, unequitable and in need of reengineering".
Today there are 30,000 people on waiting lists, about the same level as in 1993, although over the past seven years the Department of Health and Children has thrown £124.57 million at the problem. Seven Government policy reviews have attempted to come to grips with this complex issue, which "far transcends the issue of funding", the research concludes.
The official wait starts when a senior consultant declares that a patient requires admission to "Acute Systems", it notes. "At the heart of management at this point is the simple issue: does the patient have private health insurance?"
If he or she does, then the patient is usually given a date to come in for surgery and/or in some cases at the location of his or her choice. If not they may, depending on their categorisation, get locked into the public waiting-list system.
When a patient needs surgery, the consultant categorises the patient as "urgent", "routine" or "soon". Being "urgent" gives the best chance of an early date. "Routine" may be "left waiting indefinitely for years without a realistic expectation of treatment", the team finds.
Some patients and their families continually contact the admissions office which, while it cannot change a person's priority status, can refer them back to the outpatients department. "In effect, he/she who shouts the loudest may gain faster access while a less vocal person may be disadvantaged; there is, at the same time, a very real risk of a person deteriorating while they are on the list," the Harvard study notes.
Why are there chronic delays in the system? Sometimes the nursing shortage is to blame. Or beds may be taken up by emergency cases, particularly in winter. So if you have been waiting two years for your hip transplant, you could lose your bed to someone with pneumonia.
The solution? Ring-fence elective surgical beds, the paper argues. And give the private hospitals more incentive to conduct more public work.
Or you may turn up for surgery only to be told you are not ready for it. That means you are keeping someone who is ready for surgery on the waiting list. The solution? Create preadmission facilities where people who are ready for surgery are streamlined to theatre, while those who are not have their problems sorted out, instead of wasting a surgical bed, the Harvard team suggests.
At the core of the issue is the fact that waiting-list data are unreliable. "You cannot manage what you cannot measure," says Prof Kinsella. There are actually several "waiting lists", by hospital, by speciality, by consultant and by grade of severity. There is also the issue of double counting, with the same individual on several lists.
The report recommends that each patient get an identification number that would avoid such duplication.
The research team advises that the requirements for surgery become more open and transparent. For example, the Mid-Western Health Board has shown the value of giving orthopaedic patients a "needs-based" assessment, so that those most in need get their surgery first.
The reality is very different. "In any one day, there can be several surgeons attempting to have their patients admitted, and it is generally left between the surgeons to agree whose patient is admitted. In principle, a private patient cannot be brought into a public bed, but this is not always an elective case in practice," according to the paper.
"Ownership" of the lists must also be addressed. "There have been situations where, despite the option of a patient going to another doctor (who might be free to treat them earlier), the consultants have been reluctant to transfer the patient," it says.
While there are waiting lists, there are no waiting times, it says. The Harvard team believes the CSO should have a key role in maintaining a reliable waiting-list to which doctors can refer to give patients a realistic expectation of when they will have surgery. Hospitals would input their figures directly to the CSO so that the whole issue would be transparent, depoliticised and better managed.
"There should be a mandatory requirement to inform patients as to the length of waiting lists with the option to go elsewhere," the team advises.
Using the total capacity of the system, public and private, would be more efficient than divvying up waiting lists between hospitals, they recommend.
Most waiting patients are in the Eastern region, but this does not mean they could not have surgery elsewhere. This concept of total management should encompass the public and private sectors. It is beginning to happen with the contracting out of public waiting-list patients to private hospitals.
"It needs to be developed in a much more comprehensive manner, not alone because it is an important part of the overall solution, but also because for most people there are not two systems: there is one `universal' system funded by taxation and a second private health insurance sector to which people perceive they have to have recourse in order to gain timely access to needed facilities: in effect, to jump the public queue, within which they are afraid of being `stranded'," the report says.
It concludes: "There is a need to reconsider whether or not it would be technically more efficient for the patient, in terms of the waiting list, if the universal entitlement funded through the Exchequer should be delivered to a much greater extent through the private sector."
This could be done if the system were funded through compulsory private health insurance. A greater reliance on the private sector to deliver innovative service would produce outcomes in the best interests of all citizens, it concludes.