It can take months of waiting to be put on an official waiting list, but that's not counted as part of the official waiting time.
From the day a public patient is referred to a consultant by his or her GP, it will be three months or even longer before the patient is seen by a senior decision-making consultant in a hospital outpatients department (OPD).
"It's somewhat akin to telling someone waiting for the 46 bus that they are not `really' waiting, or impeded, by the failure of the bus to appear for three months after they have taken up the station," says the report, Waiting Lists: Analysis, Evaluation and Recommendations.
According to the Harvard case study, many of the patients blocking the waiting lists don't need to see a hospital consultant at all.
Those who do need the care of a specialist are too often seen by staff who are not senior enough to make decisions about their care. They end up as return patients in the "waiting-list loop". And these return patients prevent new, possibly more deserving, patients from entering the loop.
"The `engineering' of A&E in terms of `best practice' in service industries needs to be urgently addressed: this should encompass enhanced diagnostics within A&E together with process management benchmarked against `Best of World' (as is done with rating airports) flow-through systems," the paper says.
It was Prof Leslie Daly of UCD whose innovative work first highlighted the impact of poor management of OPDs on waiting times. He advised on the need for strict protocols and the importance of a constant presence of senior medical decision-makers in OPD, ensuring appropriate care and prudent management of patients, who could be efficiently processed on to a waiting list or discharged from the system.
The GP, the "gatekeeper" of the acute hospital system, may be unaware of the length of waiting lists for first appointments for individual consultants, since no official lists of this kind are kept. The Harvard team recommend that GPs should have access to a central waiting list on a website kept by the Central Statistics Office.
A minority with appointments to see consultants is actually going to need surgery. But whether they need it or not, people are automatically expecting their GPs to refer them to specialists.
As the Harvard report states: "Patients are increasingly well educated and often arrive at a GP surgery armed with the latest medical developments from the Internet." Increasing litigation is also a factor in encouraging GPs to refer.
On average, GPs refer 6 per cent of patients to acute hospitals. A "minor variation in GP referral will have a major impact on the hospital system", according to the study. The Harvard team recommends that GPs be encouraged to keep to "best case" referral rates.
It also believes GP group practices should be established with sufficiently large capacity to directly provide or "outsource" a wide range of the treatments which at present "clog up" the acute hospital system and keep sick people in the purgatory of "the loop".