The economy is booming. But not so you'd notice if you need a new hip or you're an elderly parent seeking residential care for your handicapped child. A trip to casualty usually results in an interminable wait and if you're admitted to hospital you could spend up to a week on a trolley or even in an armchair. Some of those in need of heart by-passes have been waiting for six years, others have died on the waiting list.

At the end of this year more than £70 million will have been spent on waiting list initiatives since 1993. But despite this, people are still languishing on lengthening lists for considerable periods of time. A review group to examine hospital waiting lists and waiting times has been announced by Minister for Health, Brian Cowen. It is a necessary move. At the last count more than 32,000 people were waiting for hospital treatment.

Since 1980, Ireland has reduced its number of hospital beds per 1,000 of population by more than 40 per cent. It is the biggest reduction in a table of 16 OECD countries, and may be compared to a 4 per cent reduction in Germany over the same period. Lengths of stay in Irish hospitals have reduced by 29 per cent.

But following these reductions the Republic is considered "standard" according to Dr Miriam Wiley, head of the ESRI's Health Policy Research Centre. "We look very modern."

With such a high level of spending on the health services, the question must be asked why the initiative has not had more success. The waiting list problem highlights two key areas in the health services which need to be addressed: planning and evaluating success.

According to Dr Neil Brennan, former president of the Irish Medical Organisation (IMO), the Irish health services lack an overall plan. Attempting to solve a problem such as the waiting lists in isolation, simply creates problems elsewhere. "There does not seem to be a vision of the future. Where are the health services heading?"

Secretary-General of the Irish Hospital Consultants Association (IHCA), Finbarr Fitzpatrick, says the central problem is the underfunding of the health services. Waiting lists, he says, are being used as a way of controlling expenditure in the health services. "They are deferring admission from one year to another and thus deferring the cost."

According to the ESRI's Dr Wiley, the Republic is experiencing an economic boom, but looking to the future the Department of Health must "make sure the building blocks are laid in very secure foundations so we can adapt to the change which will inevitably come.

"The 1980s were a huge lesson. We had dramatic change over a short time but there was no alternative. What we need to do now is to ensure that what we are putting in place can be supported and that it is flexible and adaptable. We need to look at multi-skilling. Just because a clinic closes at 5 p.m. does not mean the building cannot be used for something else."

However, she points out, while doing so, health service administrators must work to retain what is best about the Irish system: "That sick people, regardless of circumstances, can get access to good quality care, efficient care, safe care."

The costliness of the acute hospital sector, says Dr Wiley, is of critical importance to the demands of the health service as a whole. "Many developed countries are currently confronting the problems posed by ever-increasing demands on both health and hospital expenditure and are attempting to increase efficiency within the health system as a whole. The functioning of the hospital sector will have a critical effect on the overall success of these efforts."

Increasingly, the question needs to be asked whether we are getting a return on the investments that are being made within the health services. "There are many areas where we cannot say what we are achieving with specific investments. There is difficulty getting this information because we do not have the tools to do it. It is generally recognised that we need to measure quality."

A number of very good strategies have been produced for different sectors within the health services. However Dr Wiley is critical of the "reactive, rather than pro-active" method of managing the health services.

"Right now we have a service which is demand driven. People turn up at the door. In the Dublin area, the majority of admissions are through casualty. But are these the people who should get priority? Everybody should recognise the need for more strategic thinking."

Strategic thinking is a message that Dr Neil Brennan pushed during his year as IMO president. "There is no blueprint and if there is, nobody in the Department of Health is telling us what it is."

As an example of short-sightedness he cites the imminent move of the Adelaide and Meath hospitals to Tallaght and the effect it will have on health services in Dublin's inner-city area. "It was a good plan 10 years ago and is still necessary for Tallaght but it will leave Dublin's inner-city with a number of problems. There is a large elderly population and increasing numbers buying city centre apartments. But no plans appear to be in place to cope with this."

Mr Finbarr Fitzpatrick says Irish doctors and nurses are under increasing pressure to maintain standards. "Up to 98 per cent of admissions to hospitals can be emergencies. It is very hard when you are running a hospital that is virtually totally taken up with emergencies. How can you plan properly? Elective admissions are put on the long finger."

The IHCA is also concerned that some hospitals are built and equipped but not maintained afterwards. The Cork University Hospital is a perfect example, he says. "This hospital is comparable in size with the main Dublin hospitals. When it opened almost 20 years ago it was known as the `Wilton Hilton' but it is far from that now, as it has never got any worthwhile capital expenditure since. It is also grossly understaffed."