The waiting lists for public patients are the most visible and persistent symptom of the disarray in the health service. They got worse due to the health cutbacks of the 1980s but they are also a consequence of the way the Irish health service is run.
To address them, spending increases and reform must go hand in hand.
Where Ireland's health system differs most from other countries' is in the intimate intermingling of public and private care. The same consultants treat both categories of patient, very often in the same hospitals.
Successive governments have gone through contortions to try to ensure that there is equity in treatment for public and private patients, but every report reveals deep concerns that doctors favour those who will bring them more income.
The Government's White Paper on private health insurance, published last year, acknowledged that this "mixed model of care delivery" had drawbacks.
Since consultants received a fixed salary for treating public patients and an individual fee for each private patient, "rational economic behaviour would suggest that a stronger incentive exists for those consultants who are significantly involved in private practice to concentrate a disproportionate amount of personal time on these private patients.
"The situation is exacerbated by the fact that the private hospitals employ relatively few consultants or other medical staff of their own, relying to a great degree on the availability of doctors who also hold public contracts."
Dr Sean Conroy, a regional manager with the Western Health Board, summed it up pithily: "If a publican paid her barman by the hour for covering the bar and by the drink for covering the lounge, it would be hard to get served in the bar."
Over 80 per cent of Irish hospital consultants are engaged in both public and private practice. Many consultants, in Dublin in particular, treat patients in private hospitals which are distant from the hospital where they have their public contract, inevitably making them less available for public patients.
A consultant at Beaumont Hospital in north Dublin, for example, may be seeing private patients at the Blackrock Clinic in south Co Dublin. Many hours of highly-trained medical expertise must be wasted in traffic.
The White Paper described the growth of private health insurance as "a potential threat regarding access to the facilities and services available to public patients in the public hospital system".
The Department of Health has tried to control queue jumping by private patients by limiting the number of private beds in hospitals.
However, it would appear that consultants are finding a way around this, since there has been a massive increase in the number of day cases in hospitals.
The Department commented in the White Paper that this might result in the favouring of private patients. Sources suggest evidence is emerging that this is indeed the case.
These concerns were echoed in a report by a Government-appointed review group - including five consultants among its 12 members - which examined the waiting list problem two years ago. It commented: "Some hospitals or consultants may find it attractive to maintain a public waiting list because a proportion of those waiting may opt to be treated privately."
Under our mixed public-private system, hospitals have an incentive to attract more private patients as a source of additional income.
The review group described waiting lists as "a phenomenon of public rather than private health services", and said there was "a particular onus on managers to ensure there is equity of access for all patients, both public and private".
Waiting-list money - the response of successive governments to this deep-seated problem - was only "a stopgap," the review group said. If the root causes of waiting lists were to be addressed, there needed to be long-term measures such as investment in extra beds in geriatric hospitals and community services to take pressure off acute hospitals.
The group recommended the development of stand-alone day surgery units and, specifically, "given that waiting lists are essentially peculiar to the public health system . . . a very high proportion of activity in day service units should be devoted to public patients."
In the opinion of the review group, accident and emergency departments were admitting many patients who might not need admission because of the absence of trained senior doctors to see them. To reduce pressure on hospital beds, consultants rather than doctors in training needed to be available to see patients.
The review group did not question the Irish mixed-care model in principle. The Government is committed to mixed-care but has promised "targeted initiatives" to improve public patients' access to care.
Critical among these is the initiative by the Department of Health in the Medical Manpower Forum to change the working practices of hospital consultants.