Hospital managers must work with clinicians to ensure that patients are treated according to clinical need, rather than just to trying to reduce waiting lists and times, according to a National Audit Office report released today.

The report says one in five consultants questioned had frequently treated patients in a different order to their clinical priority, simply to meet government targets to reduce waiting lists or to ensure patients waited less than 18 months.

The report includes examples of distortions in clinical priority lists, including routine reverse vasectomies performed in preference to patients waiting for bladder tumour surgery.

'It is inappropriate to operate on routine patients in preference to those who require relatively more urgent treatment solely to meet waiting-list targets, ' it says.

The report also suggests the maximum inpatient waiting time of six months promised by 2005 will be extremely difficult to achieve. Although it points out that waiting time is more important to patients than their place on the waiting list, the NAO argues that total waiting time is not usually measured.

It recommends that the Department of Health consider whether trusts should monitor the total time patients wait from seeing their GP rather than the first outpatient appointment, as is the case with cancer services. It also recommends that trusts should validate their inpatient and outpatient lists at least every six months. It points to a number of cases in which trusts had adjusted waiting-list figures 'inappropriately'. These included Redbridge primary care trust, Guy's and St Thomas' Hospital trust, University College London Hospitals trust, Plymouth Hospitals trust, South Warwickshire General Hospitals trust, and Stoke Mandeville Hospital trust. The NAO is undertaking further work on these cases.

The report highlights major inconsistencies between trusts in which patients they include on waiting lists, which means the lists cannot be verified.

However, it says that published figures are likely to be overstated because significant numbers of people continue to be included on lists who should not.

The report says the information provided to the DoH from patient administration systems varied widely, with two out of 50 trusts studied simply providing estimates, one because of a computer crash.

To spread good practice to improve the management of waiting lists and times, the NAO identifies five key areas: appropriate GP referrals; outpatient clinics to be operated at optimal capacity;

the use of operating threatres during evenings and weekends; effective discharge arrangements;

commitment of senior managers to achieving change.