People just haven't got the money to pay doctors' fees and are prepared to gamble with their health, writes JUNE SHANNON
THANKS TO the crippling recession, some people are really struggling to look after their most precious asset – their health.
For those not covered by a GP visit or full medical card, attending the doctor is an expense which, for some, must now be incurred only after other essentials such as mortgage repayments, food and heat.
While people who make these decisions are not being wilfully neglectful of their health, deferring a GP visit can sometimes mean the initial health problem develops into a more serious condition.
According to a recent report on health inequalities in Ireland by the independent think tank TASC, “regressive budgetary measures over the last three years have had a disproportionate impact on low-income groups. These measures will contribute directly to higher levels of poverty and deprivation – and thus to increased health inequalities.”
The report, Eliminating Health Inequalities – A Matter of Life and Death, also stated: “Reducing the incomes of those who are already struggling to meet their basic needs has a direct impact on their health and wellbeing in the short and long term”.
The negative impact of the economic recession on people’s mental health has been well documented, but little has been reported on its impact on people’s physical health.
While there is a dearth of research in this area, reports from GPs around the country reveal a worrying trend – that the recession is having a major effect on the physical health of the nation.
There are those who put off GP visits because they simply do not have the fee and there are those who are returning to work too early after illness. In addition, doctors also report that the high costs of medicines are forcing some patients to take risks in borrowing them from other people or buying them online, while those with chronic conditions such as diabetes are not attending for regular check-ups and, as a result, are storing up health problems further down the line.
Dr John Latham is one of a number of GPs who report an increase in the number of patients inhibited from attending for “very necessary follow-up” as a result of their financial position.
While Latham makes provisions for these patients such as waiving the fee for a second visit, his worry is that people with chronic illnesses such as diabetes are not going to receive adequate follow-up or that some people, particularly men, are going to leave symptoms “until it is really almost too late”.
According to Cork GP and president of the Irish Medical Organisation, Dr Ronan Boland, Ireland has “a unique and most unsatisfactory system of semi-private care”.
“We are one of the few countries in the developed world where going to the GP is an out-of-pocket expense for two-thirds of the population they effectively have no means of recovering.”
Boland says that people on the margins of medical card eligibility tend to present late and are poorly compliant in taking medicines, particularly the more expensive drugs.
“All of those things have got a lot worse over the last three years in that a lot of those patients are simply not coming in,” he says.
“We are just not seeing them and when we are, we are seeing them in terms of the problems being stored up over six months or a year.”
Boland says he has also noticed an increased trend of patients purchasing medicines abroad where they are cheaper and he suspects that some may be ordering drugs online.
“I have most certainly noticed over the past two or three years an increased tendency for patients to claim to been taking their medicines without having seen me or seeking a prescription from me.
“In some cases, they are clearly buying them when they are overseas on holidays . . . whether some of them are ordering drugs online or not I don’t know, but I would certainly suspect so.
“Somebody who has got COPD or asthma really should be under regular review by their doctor because the medication they require this month may not be the medication they require in three months’ time or six months’ time.
“The reason a lot of these medicines are prescription only is precisely to ensure that . . . somebody is under regular medical supervision and, in some cases, that situation is not happening.”
GPs are also reporting that patients are under increasing pressure to return to work far too early after an illness and this is also impacting negatively on their health.
This is often driven by a fear that in the current climate where jobs are scarce, their absence could be used against them, while those who are self-employed are reporting that they simply cannot afford to get sick.
Doctors are also seeing an increase in people’s intolerance for being sick, with some demanding inappropriate medicines such as an antibiotic for viral illnesses in the vain hope of getting better quicker so they can return to work.
Dublin GP Dr Gerry Mansfield has seen this in his practice in Dún Laoghaire. “Stress and pressure reduces your immune system – that is well proven . . . the intolerance of being unwell, the expectations of being able to get back quicker than maybe they should, and potentially bringing infections back into the workplace, it is all reducing productivity and is a false economy,” he says.
Doctors have also noticed an increase in stress-related physical conditions such as stomach problems, irritable bowel syndrome and exacerbations of asthma.
While stress can have a hugely negative effect on mental health, studies have also shown that, left untreated, chronic stress can increase the risk of heart disease.
As a GP who has cared for patients through the tough financial times of the 1980s, Dr Eamonn Shanahan says there is “a different quality” to the stress described by patients this time around, and a much greater fear for the future.
“What we need to do is to help people cope better with their stress so that when they do come to us that is part of the brief,” he says.
“It is beyond just looking after the immediate physical problem that they have and helping them to cope better with stress,” he explained.
A recent report by the Irish Patients Association (IPA), A Review of the General Medical Scheme – Increased Work Load and Future Costs, further highlights the impact on health arising from the recession.
In the report, Prof Ray Kinsella of UCD says the data suggests that Ireland is slipping into a new “health/poverty trap”.
“This new ‘healthcare/poverty trap’ is characterised by, on the one hand, a rise in unemployment and an associated fall in disposable incomes and, on the other hand, by significant pressures in healthcare funding, including expenditure on GP services, which are of particular importance since they are the ‘gatekeepers’ into the already stressed acute system.”
Stephen McMahon, chief executive of the IPA, said anecdotal evidence suggests people are more cautious about visiting the GP because of the high costs involved.
“We haven’t seen much evidence of . . . GPs actually reducing their costs. We know that they have been hit for their medical card fees – the HSE has reduced those – but we haven’t seen that reflected in the private fees either for GPs or hospital consultants,” he says.
Like many GPs around the country, Dr Mary Favier in Cork does a lot of pro bono work such as waiving fees or discounting costs for patients who find themselves in financial difficulty.
“We just discount our patients right left and centre. We just don’t charge them because all the people who have got jobs here and there, or part-time work, just don’t have it anymore.”
However, Favier also warns that in the future Ireland would reap the problem of deferred presentations to doctors and poor care of chronic illness.
“We will have more complicated diabetics who will have more side-effects, will need more interventions, will have more heart attacks and need more laser eye surgery because of what we are putting off today, and it is incredibly short-sighted,” she said.
