Have you sat up with a sick child and wondered if a sore neck and rise in temperature might be the harbinger of meningitis? Have you reluctantly phoned your GP, reasoning that whatever the cost or inconvenience, the risk of waiting for an opinion may be too great?
Or have you ever concluded: "I can't afford to call the doctor"?
Many parents face this dilemma. Since only 30 per cent of the population, in effect only those on social welfare, is eligible for medical cards, poor families must pay for every doctor's visit. Workers on such low pay that they are exempt from tax have no safety net when their families are hit by illness.
"Families put off going to the doctor," John Monaghan of the St Vincent de Paul told a recent seminar. "There isn't a conference of the society which isn't paying out money for doctors' bills every day of the week."
General practitioners themselves say this is wrong. Dr James Reilly, chairman of the Irish Medical Organisation's GP committee, favours a trebling of the income threshold for medical cards "to bring it up to the average industrial wage".
Some general practitioners waive their bills and put in long hours helping the sick and the psychologically distressed, for no payment from either the patient or the State. There are some great GPs out there. But is this any way to run a health service?
For the 30 per cent of the population who are medical card patients, GPs are paid the annual sum of £39.50 for those aged under five, £23 for five- to 15-year-olds, under £30 for 16 to 44-year-olds, and so on, on a sliding scale up to £60 for the over-65s. These figures apply no matter how little or great the needs of individual patients. The consequence? In areas of Dublin with concentrations of medical card patients and the low-paid, there are three times fewer GPs than in middle-class areas, according to TCD's professor of general practice, Tom O'Dowd.
"This is how discrimination operates between public and private patients at the primarycare level. Access is a difficulty," he says.
Analysts of health systems call GPs the "gatekeepers". They are supposed to refer patients to hospitals or the appropriate specialists and to play a central role in preventive medicine.
Yet the development of this critical first layer of the health service has been largely left to GPs themselves, as a kind of private enterprise, a cottage industry, conducted from converted garages and rooms above shops. If GPs want to develop modern health centres which offer a range of services, they go into debt. The Eastern Region's fund this year for development of general practices for 588 GPs is £1.68 million, about £3,000 each.
Nationally, up to half of GPs work alone with no partner, according to Prof O'Dowd. Only one-third of GP practices employ a nurse.
GPs have no way of knowing who their patients are supposed to be. There is no register of non-GMS patients. They cannot decide, for instance, to remind every man of a certain age in their area that he ought to get his cholesterol checked. The national breast screening programme relies on the electoral register to determine who should be notified. If you haven't registered to vote, you might not get a breast check.
Given their support for more medical cards, it seems contradictory that GPs in the Irish Medical Organisation (IMO) are now threatening not to take on any new medical card patients from next month. They are "drawing a line in the sand", according to Dr Reilly, because they are carrying an underfunded system.
He argues that the current level of capitation payments does not recognise the treatment needs of chronically ill patients, who do not qualify on income grounds for medical cards but who receive them at the discretion of the health boards. GPs are also incensed at the Government's decision in the Budget to extend medical cards to all those aged over 70 when so many poorer people are ineligible.
Were the Opposition in power, GPs could expect more radical change. Labour proposes extending a free GP system to everyone. Fine Gael sees this as desirable but not immediately attainable and proposes instead a free service up to the age of 18 and for students, the over-65s, the lower 60 per cent of income groups and the chronically ill.
When Dr Noel Browne, as minister for health, proposed free GP care for children in 1951, he met formidable opposition from the medical profession. Times have changed. Dr Reilly says that "if a government wants to give everyone free medical care and can fund it", the IMO will not oppose it.
GPs today appear to accept that a government-run and funded service would offer patients better access and doctors the chance to practise real preventive medicine.
"Many GPs would be happy to be put on the salary of a consultant in full-time public practice," according to Dr Reilly.
There remain controversial issues to untangle between the medical profession and the State. The IMO would oppose State employment as a GP's only option, Dr Reilly says.
He adds that some GPs fear that, as State employees, they would lose their freedom to be "patient advocates". Consequently, he believes insurance companies should be involved in a State-funded system to avoid the State being the "sole payer". These concerns appear surmountable. Sweden and Spain, whose national health is placed by the WHO in the top five countries worldwide, have entirely salaried GPs. In France, whose system the WHO judged best in the world, 48 per cent of GPs are salaried.
Fifty years after Noel Browne's defeat, it appears that the obstacle to a primary healthcare system accessible to all is not professionals' resistance but lack of political will to achieve it.
mawren@irish-times.ie
