It is an Alice in Wonderland scenario. You gain power by promising to cut the number of people waiting to go on hospital treatment waiting lists. But you massage the figures by stopping people getting an appointment to see a doctor: creating a waiting list to get on the waiting list.
That is the accusation facing prime minister Tony Blair - and it is one he is determined to knock on the head.
Official figures show that the number of patients queuing to see a consultant in order to get on the waiting list grew rapidly this summer. Up to 485,000 people were waiting at the end of June, up 29,000 on the previous quarter.
Then, just to inflame the situation, manager Ian McKay was suspended from Redbridge Healthcare trust in east London, for the 'inappropriate suspension of some patients' from the waiting list. Eighty-four patients waiting longer than the 18 months guaranteed had, it is alleged, disappeared from the stated figures.
Less than a week later, the prime minister announced a 'tough new package of measures' to combat long outpatient waits. No longer would the government concentrate solely on patients waiting for operations. Health authorities would have to monitor and identify those further back in the queue and make 'regular reports' on their progress to health secretary Frank Dobson and NHS chief executive Sir Alan Langlands.
Mr Blair launched the 'drive to improve outpatient waiting' at a Downing Street summit, where Sir Alan joined senior managers, medical directors, GPs and physiotherapists to discuss how to tackle both types of list.
Mr Blair pointed out that 75 per cent of patients get an outpatient appointment within three months of their GP's referral. But, he admitted, 'the number waiting over 13 weeks has been growing'.
'It has been alleged that this is because we are deliberately making people wait longer for an outpatient appointment, in order to slow the rate of referrals for operations and so keep down the length of inpatient waiting lists. That is just plain wrong.'
He claimed that a 'record number of outpatients, including 175,000 'new' patients, had been treated last year. But there were particular problems with outpatient waits in four clinical areas - orthopaedics, ophthalmology, ear, nose and throat, and dermatology.
Different approaches to cutting lists were detailed by managers present at the meeting. In Newcastle, a carrot and stick approach is being taken to cutting the dermatology list. Newcastle upon Tyne Hospitals trust is encouraging GPs to treat more routine conditions, such as mild acne, themselves. This is combined with the provision of a fast-track weekly clinic for suspected melanomas.
Richard Barker, trust business and development director, says: 'If GPs are going to take on some of the common skin conditions, we have to give them fast access for more serious problems.'
The fast-track clinic also helps to cut the number of patients who don't turn up for appointments; the shorter the wait, the less likely they are to forget the date, or consult privately without letting the hospital know.
One of the ideas behind the project was to tackle soaring referral rates, and reduce the knock-on effect on waiting lists. Referral rates were going sky-high, Mr Barker says. They came down under the scheme, but are now heading back up again. 'But without the project they would have been even higher.'
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The project didn't receive any special funding - it was about using existing staff more effectively and improving communication between primary and secondary care. But extending projects like this would increase costs, Mr Barker adds.
'There is no funding for the managerial side. You can't run that across 20 or 30 specialties in a large acute teaching hospital without management funding.'
Mr Barker is confident that the prime minister got the message: 'One of the things we got across was that you can't just lift these projects and put them down elsewhere. It needs careful planning and winning of hearts and minds.'
The prime minister's backing will be valuable in focusing attention, Mr Barker says. 'Outpatient work up until now has not been a high priority. This sort of change will not happen until there is total commitment across trusts and HAs.'
Waiting-list buster Dr Peter Homa adds: 'The PM wanted to receive a personal briefing on the challenges and difficulties we face.
'He emphasised the importance of all of us in the NHS giving outpatients the same level of attention as inpatient waiting lists.'
A team from South Manchester University Hospitals trust gave Mr Blair an example of that focus in action. Orthopaedic waits at the trust fell dramatically after introduction of a triage system. Patients referred by GPs were assessed to see if they were suitable to be seen by orthopaedic physiotherapists in a weekly clinic.
More than half could be taken off the consultant waiting list. And 90 per cent of those seen in the clinic needed either advice or physiotherapy. Fewer than 10 per cent were returned to the waiting list.
Gerry Lemon, orthopaedic clinical director, says the scheme was 'so successful in reducing outpatient waiting times' that it would continue after the trial ended.
Managers leaving the meeting were hopeful that a greater understanding of the issues at the top would lead to better support for their work.
Dorset HA chief executive Ian Carruthers says that Mr Blair 'wanted to hear, first-hand, from health service practitioners about what can be done to improve outpatient waiting lists'.
A group from Birmingham told him that the focus for reducing outpatient waits had to be on primary care as much as on hospitals.
Dr Martin Wilkinson, a GP working with Birmingham Heartlands and Solihull trust, described how allowing GPs to make decisions can speed up the process.'We have identified nine surgical conditions where often there is not much in the way of a decision in outpatients beyond rubber-stamping the GP's diagnosis.'
GPs taking part in the project can now book patients with conditions such as simple hernia or lumps and bumps straight on to the operating list. No outpatient appointment, no delay, no unnecessary repeat investigations.
'We have to agree to work to protocols, but GPs are more in control. We know as soon as we refer that our diagnosis has been accepted and the patient can go ahead.' The project is at an early stage, but it should cut waits and leave slots free for patients who really need a consultant opinion.
Dr Wilkinson says: 'Mr Blair wanted to hear what the barriers are to changing the way we have always done things. One of our key messages was that the problem starts at the referral, not at the hospital. You have to look at it at the PCG level and give GPs the resources they need to expand their role - from more nurse practitioners to better diagnostic support.'
Trust chief executive Robert Naylor says Mr Blair was 'concerned' about a reported increase in GP referrals, and its knock-on effect on waiting lists.
At Heartlands and Solihull, about 25 per cent of all outpatient referrals go on to have a surgical procedure, Mr Naylor adds. So any rise in the number of GP referrals is worrying.
There is 'very clear evidence' that while inpatient waits are down, the outpatient list had gone up, despite the trust treating 'more outpatients than ever before'.
Mr Naylor asked Mr Blair and his team for 'incentives for GPs to look after more patients themselves'. If the resources were in place, PCGs could build a better relationship with secondary care 'so patients can go through both in a seamless transition'.
The Heartlands team will 'wait and see if the message has got through', he adds. 'Now it is up to the government to put in place the resources needed to ensure the benefits are delivered.'
Tackling waiting lists
Health authorities must identify, target and tackle local outpatient problems.
Monitoring of outpatient performance must be stepped up.
Regular reports to the health secretary and the NHS chief executive are required.
The National Patients Access Team, charged with cutting long waits, will undertake an 'extended programme of visits' to promote best practice.