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Tailgunning, constraint theory, and the NHS-as-a-plate-of-spaghetti: an Institute of Health Services Management waiting-list conference showed this branch of management science to have generated its own rich and occasionally tiresome jargon.

Happily, outgoing waiting-list buster Dr Peter Homa had a clearly expressed sense of what waiting-list management is all about.

'View things from the patient's perspective. Do not be preoccupied with finished consultant episodes, but focus on the patient's needs,' he told the conference last week.

Dr Homa, who heads the National Patients' Access Team, will leave to become director of the Commission for Health Improvement at the end of October. He painted an optimistic picture of the future.

'There is considerable scope to improve waiting lists, just by getting the basics right,' he said.

He urged managers to take the initiative. 'Do not wait for someone to give you a target.'

It was, he said, important to show commitment to cut waiting lists despite competing priorities; to develop effective multidisciplinary teams sharing long-term objectives; to experiment 'in a disciplined way'; and not to be afraid of what he called 'noble failure'.

At one hospital, the ophthalmology outpatient service took nine months to complete, involving five separate patient visits. It was redesigned into a five-hour process, 'reducing costs with a significant improvement in patient satisfaction'.

This required an imaginative approach, and staff had to be prepared to change the way they worked. One clinician, who had redesigned his waiting- list process, had wanted to change the system for 17 years.

'When I asked why he had waited 17 years,' said Dr Homa, 'he replied: 'Because no-one asked me'. Most of us in the NHS want to do a good job and problems are often the product of a system, not of individuals. We must make improvements at the level of the system.'

David Mudd, director of the NHS Executive initiative Action on Cataracts, showed how redesigning the waiting-list process could improve access to cataract surgery - one of the biggest single areas of NHS activity with around 170,000 operations in 1998-99.

One person in 12 on waiting lists is waiting for cataract surgery. But there are wide variations, with 300 per 100,000 population being treated in some health authority areas and just 100 per 100,000 in others.

If all HAs that fall below the English average were to meet the average, said Mr Mudd, the NHS could do 15,000 more operations; if all HAs met the level of the top 5 per cent, then around 58,000 more cataract operations could be carried out.

Service design is crucial. The most successful trusts have a number of key characteristics:

they do 300-plus cases per 100,000 population annually;

their cataract services are fully integrated;

they provide good patient information;

they offer one-stop diagnosis and preoperative assessment;

they have high rates of day-case surgery.

The best performing trusts complete the process within four to six months of referral, with the second eye being treated within a further two to three months.

Best practice sees 12-13 patients treated in a three-hour session; worst practice just three to four in the same time.

Mr Mudd said it was possible to treat more patients without putting the operating team under too much pressure. But more resources need to be made available. 'If demand continues to rise at 6, 7, 8 per cent a year, we have to look at the resources we devote to cataract services.'

College of Health director Marianne Rigge said there was a popular misunderstanding about waiting lists: 'It sometimes seems that the figure is the problem. It would not matter if there were two million people on waiting lists if they were treated swiftly.'

The failure of the NHS to address waiting times means that around one person in 10 is paying for private treatment, and many more would do so if they could afford it.

'These people are paying a very high price for inefficiencies in the system which could be ironed out,' said Ms Rigge.