Patients languishing on waiting lists are being let down by hospitals engaging in "queue-jumping" and other weaknesses in managing appointments, a report reveals.
A majority of hospitals are failing to treat all those who are longest on public waiting lists first, despite the "next in line" policy ordered by the Department of Health.
The startling findings are revealed in an unpublished briefing document from the National Treatment Purchase Fund (NTPF), and seen by the Irish Independent.
It also shows a failure to be strict with people who do not turn up for an outpatient appointment despite getting reminders. Nearly 40,000 people are "no shows" every month.
And it found weaknesses in a range of areas, including a lack of planning to try to ensure capacity meets demand
The NTPF, which used to arrange for public patients waiting longest to be treated privately until its role was changed by former Health Minister James Reilly, has audited how 22 hospitals manage waiting lists and will examine another 18 this year.
Hospitals should be operating a booking system whereby, except for urgent cases, patients who have faced the longest delays get treated chronologically.
But this is not always happening, the internal briefing document from the NTPF has revealed.
The most recently published waiting list figures by the NTPF for April showed nearly 10,000 waiting over a year for operations - these are in the category who should be seen first.
The focus will again turn to waiting lists this month, as Health Minister Leo Varadkar and Social Care Minister Kathleen Lynch said that nobody should be waiting more than 18 months for an operation or outpatient appointment by end of June. The strict instruction was to target patients waiting the longest.
Mr Varadkar admitted in the Dáil only last week: "Quite frankly, waiting lists sometimes are badly managed. One has to drill down into them to really understand them."
He found that some patients who were waiting three months for surgery were seen quicker than somebody "at the tail end".
And he admitted that "people were being put on the long finger for longer. That is a particular problem".
Waiting lists have soared in the past year, forcing the Government to return to some outsourcing. About 1,500 patients on public waiting lists will be outsourced to private hospitals, with the HSE picking up the bill.
The document calls on the Department of Health to provide clarity on the future role of the NTPF, which arranged for the outsourced treatment of more than 217,000 public patients between 2002 and 2011 when it was downgraded.
Up to 2011 its average annual grant was €63m but it is now around €5m. Its functions include negotiating prices with nursing homes under the Fair Deal scheme and compiling waiting list data.
In response to accusations that hospitals are not following the chronological rule, a number of hospital doctors have insisted that all cases must be judged on merit - and the system is not always practical.
For instance, a patient may need access to a particular form of preparation before undergoing an operation.
Patients may not be fit for surgery, and others who have not been waiting as long may be deemed more in need of an operation first.