Northern Ireland’s newly-appointed ‘waiting list tsar’, Derry-born surgeon Professor Mark Taylor, brandished a saw at a conference in Belfast last week to illustrate his commitment to slashing waiting times.
We may wish him all the best. However, it will be impossible for any individual patient to judge how well he is succeeding because nobody is ever told exactly where they are on a waiting list.
GP telephone booking systems may be much maligned but at least most play a message saying “You are at position x in the queue”.
Try finding out where you on a waiting list and you will be directed to websites giving the average waiting time for your procedure. The NHS app, not available in Northern Ireland, does the same.
This information is meaningless when the average can be of a range spanning months to years and you have no idea where you are on that range.
Advice this useless could be considered deliberate obfuscation - even if it is accurate, which is frequently debatable.
Waiting lists are not made public for two broad reasons. First, it is a significant practical challenge: the information is generally unavailable in a centralised, shareable form.
Northern Ireland’s new health IT system, Encompass, should make this easier but tellingly that is not one of the improvements it promises. Its portal for individual patients only provides average times, like the NHS app.
This reticence points to the second reason waiting lists are not made public. Clinicians, managers, officials and politicians have good reason to fear it would make their professional lives a nightmare.
Waiting lists are not simple first-come, first-served queues. Clinicians use their judgement to move patients up by need, or to match needs to resources. A complex case, even if urgent, might have to wait for particular staff and equipment to be available.
Managers and officials are juggling resources and arranging initiatives. Partnerships between health trusts or with the private sector can move large groups of patients up the list, with the effect of moving others down.
Politicians are ultimately answerable for it all. If the 102,000 patients on hospital waiting lists in Northern Ireland could track their positions in real time, it would almost certainly generate a tsunami of complaints from people demanding to know why they are not moving forwards or slipping backwards. This could inhibit clinical judgement, management initiative and political courage.
A limited illustration of this may already have occurred with the new regional breast cancer referral system.
This centrally-managed list is supposed to equalise red-flag referral times across all trust areas in Northern Ireland and reduce waits for everyone. Instead, it has sharply increased waits for most patients.
Some clinicians believe this is largely because the new system makes it harder for them to use their judgement to move patients up the list.
Other experts think clinicians flatter themselves and the problem is more complicated, although managers and officials are hardly rushing to offer alternative explanations for what has gone wrong.
The countervailing view is that transparency would incentivise everyone to do better and to explain their professional judgements.
Politicians might come under meaningful pressure to take the difficult decisions they have ducked for so long over reform and revenue-raising.
Some experts worry about consultants, who have a key role in managing waiting lists and usually have a second list for their private practice. The vast majority may be doing the best for all their patients but nobody else has enough information to be certain.
Patients are not only kept in the dark about their exact position. They are left with the convenient impression that their list is almost a queue, nearly treating them on a first-come, first-served basis.
More clarity on how lists are managed might ease the feeling of abandonment people have as they languish for years without communication.
One of Prof Taylor’s concerns is patients missing appointments. That might be less common if appointments did not arrive out of the blue.
The points-based system for social housing prioritises need over time spent on the list. Not everyone agrees with this, but everyone knows how it works and can debate its pros and cons. We are not trusted with even that much insight into our own healthcare.
Transparency should always be the default assumption in a public service, as a general principle and as a practical way to improve performance by holding staff, officials and ministers to account.
It could be a transformative change. Why is it not even being discussed?