From Socialist Voice, September 2008

Discrimination and the health service

Over the years Ireland has introduced anti-discrimination legislation, and Irish people generally feel that they do not discriminate against other people or groups in society. Discrimination on racial grounds or against immigrants has been documented and publicised, and active schemes have been implemented to eliminate it, which is only what should be expected.
     However, when it comes to discrimination on grounds of poverty, somehow it doesn’t appear to most people that this is also discrimination against a section of society that is just as terrible and damaging and may be an issue of life or death, either in the short run or the long run.
     Holders of medical cards are discriminated against by doctors, dentists and hospital administrators and by the apathy of a society that says, “I’ll look after myself,” and allows such discrimination to continue.
     When a doctor or consultant distinguishes between what can be offered to the holder of a medical card and someone who has the ability to pay, that is discrimination. Everyone knows from a relative or friend, or perhaps from their own experience, of instances when a choice was offered of having an appointment or an X-ray sooner if they wanted to go the private route.
     To stop a general outcry against this, in the last few years we have had the transferring of medical-card patients and other public patients to private clinics and hospitals after a certain amount of time waiting on a public waiting-list.
     But that is just the point: why should they have to wait an excessive amount of time before being placed on another list?
     And waiting-lists are deceptive measures of the time left waiting, as they are often closed for months before reopening for new applicants, who consequently do not appear on the published reports until they appear on a list.
     The dispute between dentists and the Health Service Executive is a shocking example of discriminatory practices by the dental profession. Dentists have been in dispute with the Department of Health for years over the fees to be paid for doing work for holders of medical cards. They say they are not being paid enough: the Government—whose real aim is to privatise all medicine, in keeping with EU policy—offers a fee that is not adequate, according to the dentists, who in fact charge excessively, as is evidenced by the number of people going abroad for dental treatment.
     This problem could be solved by having a public dental system with dentists in clinics paid by the state, enough to satisfy the whole population and not the pathetic skeleton clinic system now in operation.
     When a spokesperson for the HSE was asked why they could not reach agreement with the dentists they said they could not negotiate with a cartel, which they consider the Irish Dental Association to be, as this is forbidden by the Competition Act (2002). This act was introduced on the instructions of the European Union, which wants to do away with all public services.
     So where does this leave the medical-card patient? A phone call to practically any dentist’s surgery will get the response that they are not taking on any new medical-card holders at the moment; but this has been going on for so long that in effect they are hardly covering medical-card patients at all.
     This is particularly so in urban areas, whereas in smaller towns and rural areas they need the mix of patients to fill their surgeries. But if there is pressure, it is no secret who is not taken on as a patient.
     Even worse, what is offered to medical-card patients is by no means what a private patient is offered, and this is not merely with regard to cosmetic treatment. Very limited options are offered: extraction rather than root canal work; dentures instead of preserving teeth that would require bridging work, or just ignoring work that could be done to preserve the teeth; a cursory cleaning by the dentist rather than a thorough cleaning by the dental hygienist.
     In one recent case an appointment was made for a general cleaning, as advised by a consultant in the Dublin Dental Hospital. The patient, on ringing their local dentist, was asked whether they wanted the dentist or the dental hygienist. Having a medical card, the patient thought it would be more appropriate to ask for the dental hygienist, as they imagined the dentist to be a very busy person. When they arrived for the appointment they were told it would cost €74, and that they should not have asked for the dental hygienist, as this is not covered by the medical card. On enquiring why one was covered and the other not, they were told that the hygienist option was more extensive and time-consuming than the general cleaning done by the dentist.
     This is not a trivial matter, as dental hygiene is vital to preventing tooth decay and may even prevent stomach and heart problems in the future.
     Prescription drugs are another area of discrimination. Certain drugs offered to private patients are not available at all to medical-card patients, and may not be allowed to them even if a doctor prescribes them. These are drugs not covered by the drugs repayment scheme, or that were once allowed and have been removed. Drugs are being removed from this list at an alarming rate, according to information obtained from several pharmacists.
     To a person who has money to spare, some of these may not appear to be significant, or even very expensive; but to a person living on an unemployment or disability pension and earning so little that they qualify for a medical card, such “small” sums might mean that food has to be cut, or other essential services, or even that the person does not buy the drug at all but may be ashamed to admit it, possibly leading to misdiagnosis and anxiety for the patient.
     And when they do get a prescription from some hospitals and consultants they can’t just go to the pharmacist like everyone else: they have to take the prescription to their own GP and have the prescription copied onto a special form (a procedure that is a nuisance for the doctor as well as for the patient). This means coming from a hospital, often late in the evening, having to go to the GP’s office, which is perhaps closed, dropping it in, and having to enquire the next day; they then have to come back again to collect the new prescription and bring it to the pharmacy. Such a person may be quite ill, and considerable time and probably walking is involved.
     The pharmacist may inform the patient that they can have a seven-day emergency supply of their medicine on the strength of the original prescription, as if that solves the problem of all that calling, walking, and needless time spent.
     This procedure has nothing to do with efficiency but has everything to do with making a distinction between private and public patients.
     In England recently the National Health Service removed a drug for the treatment of kidney cancer from the list of treatments available to public patients. The leading oncologists in the country wrote a public letter of protest at this disgraceful decision, but the reply was that the drug was too expensive, and that the administrators had to look at the cost of the health service as a whole, even though it meant certain death for these people.
     This raises the ethical question of the cost to society of prolonging life, as well as enhancing the general health of a country’s population. Who is entitled to what? Of course there are limits to expenditure on health in any country’s budget. Health care is expensive—this is the mantra of all governments pursuing a policy of privatisation. But where non-profit medicine and equality of treatment are the policy, people will accept what is possible as genuine and fair to all.
     As long as we have a two-tier system, the medical-card patient is in real danger, as they are at the bottom of the pile, and they may not be in a position to borrow or to sell anything to pay for treatment, as many people are now doing.
     How we treat our medical-card patients is a true measure of equality as well as of the quality of our health system. When we look back to previous centuries, or at poorer countries today, and see the appalling conditions that the working class and peasants had to endure, or are enduring now, we say, “How shocking!—but that was then, or that is there.” Well, here in our country today we allow medical-card patients to be discriminated against in a society that is increasingly individualistic and indifferent.
     It is time for everyone, especially trade unionists, to make their voice heard and to move faster and more decisively on this issue to save thousands of people from discrimination.
[DUB]

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