Five years since his last visit to Ballymun Health Centre, Dr Muiris Houston finds problems still abound
It is five years since I walked through the doors of Ballymun Health Centre. On the outside, little has changed: the nondescript brick has become even greyer than I remembered. The graffiti on the windows has been updated, however, with the result that light is having difficulty penetrating the many layers of artwork and "greetings" inscribed on the window panes.
Inside, lots of people are milling around the cramped ground floor, where the general practices are located. Upstairs is home to public health nurses, dentists and psychiatrists. Here, the offices are even more crammed with additional desks and filing cabinets. Generally, the building has the appearance of one that is well past its sell-by date.
Knowing how my former patients hate to see outsiders skip the queue for the receptionist, I wait dutifully in line.
Then, a woman in front of me turns round and double-takes, unsure if her eyes are playing tricks on her. "Dr Houston. How are you?" she asks. I tell her I'm fine and that I have returned with a view to writing about the health centre.
Have there been any improvements? Absolutely none, she says, except a feeling that the place is getting more overcrowded than ever.
Like everyone else I meet, she bemoans the fact that a brand new replacement building is sitting across the road, closed because of a drawn-out disagreement between the Northern Area Health Board, the Department of Health and Ballymun Regeneration Ltd.
Compared with my near decade as a GP in Ballymun - practising in the most primitive conditions to the apparent oblivion of the Eastern Health Board - what has changed?
Do the doctors still have to deal with a lack of privacy for their patients? Does the lack of locks on doors still mean the person undressing for examination runs the risk of someone bursting in on top of them?
Do their harassed receptionists have to deal with high levels of emotion and occasional violence borne out of patients' frustrations with the poor facilities and a second-class health service?
Dr David Gibney recalls arriving to a markedly dirty building. "I remember being told we could not have a key to access the practice and our charts out of hours and being told we could only use certain rooms in the afternoons," he says.
His colleague, Dr Bríd Hollywood, describes the difference in five years for her as the "sea change in the attitude of the Northern Area Heath Board to the Health Centre in Ballymun. "I feel they share our sense of frustration at the situation here."
Dr Mary Jennings feels the practice uses the facility to the absolute maximum of its limited capacity. "But it is disheartening to work in," she says. Dr Hollywood is certain people don't come to Ballymun Health Centre because of its perception as a down-at-heel clinic.
But looking around, there is no doubt the five-doctor practice has changed things for the better. Patient charts are now computerised. An effort has been made to promote preventive medicine. The receptionists are busy, but are not the subject of abuse.
A number of part-time practice nurses offer direct access for patients, as well as driving immunisation, asthma and diabetes clinics. A practice manager has an office in the adjacent shopping centre.
And the Department of Health's primary care strategy has ensured that the practice patients have access to physiotherapy, speech and occupational therapy.
A dietician and councillor are also accessible on a part-time basis. However, in a classic example of un-joined-up government, the Department of Finance's employment ceiling prevented the filling of some paramedical positions for more than two years, in direct contrast to the stated aims of the primary care strategy.
No matter how utopian the practice is in comparison to the early 1990s, the fact remains that the current building represents a health and safety risk.
In March, the health centre was closed because of power and heating breakdowns, leaving patients without access to family doctors and public health nurses. The trade union IMPACT has formally asked for the health and safety issues to be addressed.
Meanwhile, the ideal solution - a move across the road to a purpose-planned and finished health centre - is bogged down in a funding dispute.
If this was a more up-market area of Dublin, the dispute would not have been allowed drag on so long. Even the recent local elections did not generate movement on the issue - a reflection of Ballymun being home to those in the lower socio-economic groups and the unemployed, with a traditionally low turnout in elections
It is a well-established fact that people resident in areas such as Ballymun suffer much greater ill health that the residents of more affluent parts of the capital.
In my time as a GP there, patients often presented late in their illnesses, even with the most severe pathology.
Even now, my successors say they still see extreme forms of disease.
It is hard to put preventive health on people's agenda when they spend so much of their lives reacting to the vicissitudes of life.
But there is no doubt that a more spacious and purpose-built health centre would change people's attitude to their health.
And at a different level, providing greater access to third-level education for young people and improving infrastructure, such as transport links, have been shown to indirectly improve people's health status.
If we are serious about reversing health inequity in the Republic, it is time for deprived urban areas to be prioritised.