Dr. David Gibney:

A question was asked about socioeconomic background and whether putting in place structures helps. In Ballymun we were lucky enough to have a purpose-built health centre put in place where the primary care team and some secondary care services moved in. The arrangement has been very successful from the point of view of having everything in one building. Quite often, the public health nurses are our eyes and ears. They can tell us that they have been to a particular house and a certain person is not doing well and needs a visit. A lot of integration of care takes place, which does not happen without co-location. This is particularly useful in deprived areas. The problem in Ballymun is that we have now grown so big.

The whole health centre can only manage to have about 10,000 patients. The population of Ballymun is bigger so there is a need for another health centre.

Having an infrastructure and all the services in the one building in deprived areas can make a big difference to the lives of patients. Unfortunately, they still have chronic diseases but such infrastructure allows us to deal with patients better. We can deal with patients in the community as opposed to dealing with them in the hospitals.

The real problem that we all have is access to diagnostics and secondary care. In terms of the diagnostics that I would have difficulty accessing, a chest X-ray is fine but it would take six months to access an ultrasound. A six month wait is the best that one will get. We do not have access to MRI and CT scans. If somebody comes to me suffering a persistent headache, and no red flags to indicate he or she must go to hospital, a standard investigation would be either a CT scan or an MRI scan but we would have to refer him or her to a neurology department. The waiting time for an appointment in a neurology unit ranges between 18 months and two years. If the person manages to remember to avail of an appointment two years down the line, which I certainly would not, he or she then must wait another year to get an MRI scan. It means people fall out of the system. The problem for him or her is uncertainty. One may have a headache that one thinks is serious. Unfortunately, one must await an MRI scan but see a neurologist so it is very hard to get rid of and treat that headache. In other countries there is protocol-driven access to those diagnostics that are useful. Such a system works. We are not saying there should be open access to everything but protocol-driven access would be helpful.

In terms of outpatients, every day we receive letters in the post that are either validation letters or state someone has missed his or her appointment. The system does not work for our patients. There is a high level of functioning illiteracy and it is hard to get our patients to make hospital appointments. Also, their phone numbers change. One of the questions we ask every time a person comes to our practice is "What is your phone number?" because patients change their phone numbers all the time so one cannot use a phone number to contact hospitals without checking. Therefore, more time is required to co-ordinate getting people into hospitals. There is a major barrier to getting people into secondary care so we are left keeping people with more chronic diseases in the community. That is a real difficulty, but having a building and the primary care team co-located makes a huge difference.