opinion

Veterans of earlier waiting list initiatives may be excused a certain cynicism over health secretary Frank Dobson's weekend outing for Breakfast with Frost . The NHS has seen it, and done it, all before. And no doubt a short-term cut in waiting lists can be achieved this time, too (see News, page 7).

Of course, cutting the headline figure last time was partly a genuine reduction due to sheer hard work; but it was also about distorting priorities (more money for cold surgery, less for mental health), semantic trickery (redefining 'waiting list') and downright fraud (setting up a waiting list to join the waiting list). Will it be any different this time? Health minister Alan Milburn goes to some lengths in this week's Journal to explain why it should be (See Open Space, page 20), and some of what he says will reassure managers concerned that Mr Dobson's bluster presages a return to the bad old days.

It is clear that ministers do now recognise that waiting lists cannot be cut simply by treating more patients. The NHS has done that year on year for half a century and still has waiting lists double the length it started with in 1948. Part of the problem is that GPs are encouraged by falling lists to refer more patients.

Mr Milburn hints at part of the solution to this: unified primary care budgets are a good start in the battle to convince GPs that there is no bottomless fund of cash which could be used to provide for their patients if only the machinations of wicked managers could be defeated. But they are not enough. While GPs remain independent contractors, able to refuse to co-operate, even with their own colleagues, in what Mr Milburn refers to as the task of aligning clinical and financial responsibility, it is doubtful that there can be a truly effective means of managing the supply side.

Another of the modernisation measures Mr Milburn mentions - the NHS Direct telephone advice line service - may worsen the supply-side problem by lowering the threshold at which people seek help from the health service.

More fundamentally, Mr Milburn puts the case for driving down waiting lists by arguing that it is what people want, and indeed that it is essential if people are to have faith in the health service.

There will be considerable sympathy in the NHS with his wish to rebuild public confidence. No-one - doctor, nurse, manager nor patient - will gain if more people choose to go private, and any drift away from public services would be disastrous. But people may encounter private healthcare in many ways. As ministers are aware, earlier initiatives worked precisely by using public money to send people to private hospitals. They do not intend it to happen again, but Mr Dobson may need to spell this out in his sternest tones - for the pressure on health authorities to deliver will be intense, and the temptation great.

But Mr Milburn's claim that those who argue waiting lists 'don't matter' are out of touch with patients' priorities cannot pass unchallenged. That may be true, but Mr Milburn should resist the temptation to follow public opinion slavishly on this issue. Many people want to bring back hanging or voice some other equally unacceptable view of what governments should do. On this and other matters we have a right to expect ministers to lead public opinion.

That said, Mr Dobson, Mr Milburn - and now HAs and trust boards - are prisoners of an election manifesto pledge which many may have come to regret, but which the government cannot in good faith now ignore.

The NHS will help Mr Dobson to deliver his promise. For as long as it remains his number one priority, it will seek to maintain low waiting lists come what may.

But in return, it should be down to Mr Dobson to accept that the single-minded pursuit of a policy often has unexpected consequences, and, more importantly, to explain to people why other aspirations for the health service must take a lower priority. So far, his willingness to do that has ensured that the mud thrown by his political opponents has not stuck. Telling the truth on this scale will test his Teflon coating to the full.