Those who can't go private go sick

It's Monday morning in the health centre of a deprived area of Dublin. The large, open-plan waiting area is full of people

It's Monday morning in the health centre of a deprived area of Dublin. The large, open-plan waiting area is full of people. Patients waiting for different health services mingle freely. You can vaguely discern a queuing system for the various doctors. Suddenly, a scuffle breaks out, followed by some shouting.

A wave of people back away from the protagonists. A Stanley knife flashes briefly, before security staff move in to break up the fight. The two drug addicts settle down again. However, they are now at the top of the queue, separated by a few seats from the rest of the patients. No one wants to get close to the visibly agitated pair. One lady with two young children gets up abruptly and wheels her buggy towards the exit, muttering about "not staying to have her children upset like this". An elderly man with a walking stick sits at the edge of his seat, his eyes darting anxiously in the direction of the surgery door.

Some miles away, in a well-to-do Dublin suburb, it is also a busy Monday morning at the purpose-built surgery. The car parking spaces are full. Patients are greeted at the door by a smiling receptionist who directs them to the waiting area. The children relax in a fully equipped mini-play area. Adults are soothed by background music, while a TV monitor quietly plays health education messages. The appointment system ensures that delays are kept to within 15 minutes.

The practice nurse offers a wide range of preventive medical services which are easily accessed. A physiotherapist runs a twice-weekly clinic. A clinical psychologist, specialising in the treatment of stress-related illness offers appointments on site also. Early-morning and late-evening surgeries are available, worked on a rotating basis by the four general practitioners.

These contrasting pictures of primary health care represent real practices in Dublin. Geographically separated by mere miles, they are light years away in terms of service provision. Similar contrasts could be found in any Irish city.

The doctors working in both of these situations are equally well trained. All aspire to providing the best possible care for their patients. However, in one practice they do not have to battle against endless waiting lists, cancellations, poor working conditions and, most of all, the frustrations of seeing their patients' conditions deteriorate because of the State's inability to fund and resource properly the public health sector.

And what of the patients themselves? The case histories of Pat McEntee (not his real name) and Dominic Flynn clearly illustrate the current inequalities in the Irish health system.

Flynn attends a doctor in the health centre described in the opening paragraph of this article. He is on the maximum amount of medication for his heart condition, to the point where he told me that the "rescue medication" prescribed by his GP for the times when the heart pain becomes unbearable is no longer effective. Fifteen months after being told he needed a bypass procedure, his symptoms have worsened, perhaps to the extent where the original blockages in the arteries of his heart are now worse than at the time of his heart attack.

Other aspects of his life have suffered during the delay. He has not been able to work. He has felt down at times, partly because of the continuing angina pains but also because of a lessening sense of self-worth. He is a man who enjoys his work, and so it is not surprising that not being able to get back to it has affected him psychologically. He cannot drive and his family are suffering because of a reduced income. Not usually given to fatalism, he now wonders "if I will ever get back to normal".

Last November, with the encouragement of his extended family, who offered to help him financially, he explored the option of undergoing private treatment. Access would not have been a problem, but the cost was prohibitive. The hospital costs amounted to approximately £6,000, with professional fees adding another £750. The private option perished, along with any remaining optimism of an accelerated solution to his problem.

By contrast, McEntee has never looked back since his bypass two years ago, performed within days of being admitted with chest pains to the Mater Private Hospital. He enjoys his retirement to the full. He was fit enough to travel to Italy some weeks ago and is a very active member of local committees. McEntee says he will always be thankful for membership of a private health insurance scheme, which ensured the prompt and hassle-free treatment of his heart condition.

The gulf between the health "haves" and "have-nots" is an ever-widening one. In 1980, a landmark British study called the Black Report was the first to quantify social inequalities in health care. In December 1999, researchers at the University of Bristol extended and updated its findings. These show an ever wider social class mortality gap. The difference in life expectancy between the highest and lowest socio-economic groups in Britain is now 9.5 years for men and 6.4 years for women.

And in a study which is even more relevant to the cases of McEntee and Flynn, a paper in the January edition of the British Medical Journal confirms their respective experiences. The Scottish researchers looked at more than 26,000 patients on the cardiac surgery waiting lists between January 1986 and December 1997 and compared the waiting time for surgery with a social deprivation index. Not alone were socio-economically deprived patients more likely to develop coronary heart disease but they were less likely to be offered surgery once the condition warranted it. These patients were further disadvantaged by having to wait longer for bypass procedures.

While there are no studies available for the Republic, it is reasonable to presume a similar picture here. European figures for coronary artery bypass surgery rates do place us mid-table and above Britain for the number of operations performed. However, when you adjust the figures to take account of the national death rate from coronary heart disease, our performance relative to other countries drops.

The inequalities are not confined to heart disease. MRI scanners are the most up to date, non-invasive way of diagnosing many tumours and other conditions. They are especially important in the field of neurology, which covers conditions such as Parkinson's disease, multiple sclerosis, strokes and brain cancer. An international meeting of neurologists in Dublin last week was told that of six scanners in the State, only the one in Beaumont Hospital is completely dedicated to the public health service. While some of the others do perform scans on public patients on a contract basis, they were built and are run by the private sector.

Waiting lists for eye cataract surgery have always been lengthy. Yet the Royal Victoria Eye and Ear Hospital in Dublin had the highest percentage of bed closures during 1999. On average, 25 per cent of the hospital's 90 beds were closed every month according to the Department of Health figures.

Jan O'Sullivan, a member of the Mid-Western Health Board, has said she is concerned that some elderly people in the region may be "scraping money together" to have surgery, such as cataract operations, done privately. Seventy-eight people over the age of 65 are on surgical waiting lists for two years or more, according to the board's latest statistics. Behind both these statistics and the patients' stories lies a history of unremitting cutbacks in the health services. While a reduction in services might at least have been understandable in the economic gloom of the 1980s, it is completely unacceptable in the boom times of recent years. There is an urgent need to open more hospital beds and to appoint more hospital consultants before we can even begin to address the inequalities in health care.

Case history I

Pat McEntee (68) is a retired civil servant from Co Meath. Two years ago he underwent cardiac bypass surgery after being admitted to the Mater Private Hospital with chest pain. He had an angiogram (the test where dye is passed into the arteries of the heart) which showed blockages in all three coronary arteries. Four days later he had his surgery and was discharged from hospital two weeks later.

Private health insurance covered the cost of his stay and his consultants' fees. The overall cost was in excess of £10,000. "I have never looked back," he says.

Case history II

Dominic Flynn (46) is a lorry driver with Dublin Corporation. He lives in Poppintree, north Dublin. Fifteen months ago he was admitted to the Mater Hospital with the symptoms of a heart attack. He too had an angiogram performed which showed blockages of two of the three coronary arteries. He was advised to have a bypass procedure in the form of "balloon angioplasty" and placed on a waiting list. He is still waiting to be called for admission. Mr Flynn gets daily episodes of chest pain. He is unable to drive his own car and is medically unfit to return to work. He is afraid to travel too far from home in case of worsening chest pain.

Two weeks ago he had to attend the accident and emergency department of the hospital when the pain did not settle with the usual medication. He is full of praise for both his GP and consultant who, he says, "are doing their best in difficult circumstances".

Messages can be left for Dr Houston at: 01-6707711 ext 8511, or email at: