Waiting-list buster Peter Homa is keen to point out that tackling waiting lists is only part of a wider endeavour to improve access to high- quality care. Kaye McIntosh listened in on an HSJ masterclass

Waiting-list buster Peter Homa turned the tables last week to give an audience of NHS managers the chance to pass judgement on his own performance.

Speaking at an HSJ masterclass sponsored by Glaxo Wellcome, he said the task of his patient access team was to 'provide support' for health authorities and trusts, to 'identify and disseminate good practice', and to 'help redesign elective patient processes'.

At at the end of two years, said Dr Homa, 'our progress might reasonably be measured against those targets'.

He told the audience that waiting lists were an 'absolutely central subject'.

'We cannot consider waiting lists as a hermetically sealed initiative disconnected from all the other issues on our agendas.'

Reducing the number of patients waiting for admission to hospital on its own was not enough, he said.

Instead his task was a 'genuine endeavour to improve access to high-quality care'. It was also 'a long-term endeavour', not just 'one of those jagged- edge changes on the chart that beleaguer the NHS'.

A member of the audience asked Dr Homa whether it was 'simply an issue of supply and demand', with increasing elective activity linked to increasing waiting lists.

Dr Homa admitted that 'clearly our capacity to provide new services or important supplementary procedures' opened up new waiting lists.

But, he said: 'There is a huge amount of progress to be made to provide patients who are waiting with better services.' There was still 'much to do to improve the overall level of care'.

Another questioner was concerned that 'we need to attack the waiting list at both ends'. Attempts were needed to reduce the number of

patients joining the list as well as speeding up the number leaving it.

Dr Homa agreed, saying it was 'insufficient to exclusively focus attention on secondary care'. The 'long-term endeavour' had to look at the whole range of care, from primary and community to secondary levels.

Responding to the point that there was an issue of clinical severity in terms of long waiting lists for cardiology services, Dr Homa said there had been recognition of the need for resources to deal with highly complex cases.

Dr Homa was tackled about surveying GPs to find the extent of patients who were not put on waiting lists because GPs knew that referring these patients would do no good.

He replied that public health doctors had a role in 'surveying the level of health needs in the community'.

Attempts to 'improve access to high-quality care' should involve more than just hospital leaders, he said. It required co-operation between clinical and managerial staff from HAs, primary care groups, trusts, GPs, social services, voluntary organisations and patients.'It is no longer adequate for hospitals to steam along assuming they can achieve a reduction in waiting lists without involving other players,' he said. And that meant 'shared governance between clinicians and managers'.

He added: 'Unless that exists the prospect of improving the high quality delivery of care is illusory.'

The type of leadership required 'in something as complex as the health service' was 'distinguished by behaviour not practice'. The issue was how to 'inspire others' so that staff eventually became leaders themselves. The patient was at the centre of this process. One of the long-term aims would be 'to have a patient-sensible test of the provision of elective care', he said.

'Patients don't know what a finished consultant episode is.'

Clear accountability was important 'so we can ask who is responsible' and 'to ensure that the individual has the necessary management support', including 'appropriate training in waiting list management'.

When the national patient access team visited hospitals and asked staff whether such training had been offered, 'very often the answer is yes but sometimes the answer is no'.

One hospital visited by the team kept records of patients who had agreed to come in at short notice for procedures - but 88 per cent of the records did not have telephone numbers and 10 per cent had only home contact numbers.

Dr Homa praised the technique of 'tail-gunning' - ensuring 'we don't have patients waiting longer than the Patient's Charter target by sending letters to come in after 16 months' wait'.

An annual consultant planning programme was important. 'Organisations don't improve their performance unless the individuals within are encouraged to improve their performance,' he said.

One audience member asked if Dr Homa's team was talking to the Royal College of Nursing about staff shortages.

Dr Homa said nurse shortages were 'among the most frequently encountered complaints we come across', and pointed out that Kate Harmond, nursing director for South Thames region, was joining his team in the new year.

Another delegate warned that some trusts were 'looking at a short-term fix' for waiting lists, purely to meet the government's pledge.

Dr Homa said: 'Unless there is a long-term plan agreed with stakeholders the achievements will dissipate.'

He added: 'Unless we are clear where we are going we may end up somewhere else.'

He said the team was working on 24 pilot sites for booked admissions projects.

This was about a 'more patient-centred and courteous way of providing care', rather than reducing waiting list figures.

Booked admissions were not 'about the provider imposing a date' and could reduce the number of patients who fail to attend an appointment.

But the quality of delivery was vital as well as the quality of care itself, he reminded delegates. 'Good care badly delivered is diminished.

'It is no good having effective care delivered in a bad way.'

It was 'no good' importing experts from outside the organisation. 'The people concerned with redesigning care and implementing it should include the people responsible for delivering it.'

Finally, Dr Homa warned delegates that they did not have to succeed in order to make activity valuable. 'Noble failure is very important,'

he said. 'Unsuccessful endeavour' gave 'much more opportunity to learn' than successful projects.