Waiting lists have become the barometer of health service well-being. For the ordinary person, they give a feel for how difficult access to hospital services will be. To the healthcare commentator, the quarterly analysis of figures allows a finger to be kept on the pulse of hospital functioning.
And for the Minister and his mandarins, waiting-list initiatives have become the bottomless pit into which millions of pounds have disappeared, often without any sustainable benefit.
Prof Ray Kinsella's paper Waiting Lists: Analysis, Evaluation and Recommendations is a timely addition to the growing health service debate. As he points out in his introduction, it raises fundamental issues of equity and the effective use of scarce healthcare resources. For the 30,000 or so people currently waiting for hospital treatment, the paper highlights some unpalatable truths about inefficiency and inequality.
A key message from the analysis, which was overseen by Prof Kinsella, is how waiting lists are totally skewed towards the eastern region. More than 85 per cent of people waiting for acute cardiac care live within the area of the Eastern Regional Health Authority.
This reflects the lopsided population distribution in the Republic but also raises issues such as the need for the present number of health boards and the top-heavy structure of health administration.
He advocates a "lean-but-mean" structure of fewer health boards, more developed regional hospitals and the creation of "super-clinics" in the community which would provide a wide range of procedures which currently clog up the acute hospital sector.
The paper also highlights the plight of a significant rump of people who do not qualify for medical cards and who cannot afford private health insurance. This growing section of society pays a toll at every junction in our health service, when accessing primary care, paying for medication or forced to borrow money to fund urgent private medical care.
Such individuals, as well as those public patients at the tail end of lengthy waiting lists, are truly disadvantaged; their plight represents a serious ethical issue and an especially iniquitous form of State-run social discrimination.
Prof Kinsella makes a cogent case for the development of pretreatment facilities as a means of increasing the efficiency of the hospital sector. By properly preparing a patient in advance of surgery, the present nonsense of provisional admission dates could be eradicated. Combined with ring-fenced elective beds, people on public hospital waiting lists could be guaranteed a firm admission date for surgery or in-patient investigation.
The waiting-list paper has found that, on average, GPs refer 7 per cent of patients to the hospital system. Prof Kinsella notes that there is considerable variation among family doctors in their referral rates and that, as gatekeepers to the hospital system, even a small reduction in referral rates would impact positively on acute-hospital congestion.
However, he appears not to be aware of research which shows that "high-cost" doctors - whether in terms of prescribing or their use of the hospital system - adopt a more proactive and preventive approach to the health of their patients.
Prof Kinsella correctly notes the clogging up of the outpatient system by "return" patients who are inappropriately recalled to the hospital by inexperienced junior doctors. This problem will be addressed only with a large increase in the number of hospital consultants, so that a decision on a patient is always made by a senior medical decision-maker.
Accessing outpatient appointments also takes up a disproportionate amount of a GP's time. Because he or she lacks up-to-date information on individual consultants' waiting times, the GP is forced to telephone in person when a patient with an urgent problem presents at his practice.
At present, the only way to ensure that such a patient does not fall through the many gaps in the system is to speak directly with the consultant. Relying on well-meaning hospital administrative staff to "telephone back" with a cancellation simply does not work and could be a recipe for patient harm or even death.
In these circumstances, Prof Kinsella's call for the immediate supply of "real-time" waiting-time information for GPs should be urgently listened to.
His evaluation of current waiting-list data is quite damning: it refers only to inpatients; it is incomplete, with no private-sector figures included. If a patient is waiting less than three months he does not officially exist within the public system; and the data make no reference to waiting times, the parameter of most immediate relevance to doctors and patients alike.
Of four key recommendations in the Harvard group study, the following is the most important: "Recognition of the ethical responsibility of Government to ensure timely, universal access to the acute system on the basis of clinical need." The critical question remains: will this recommendation be implemented in the forthcoming health strategy?