Sunday 26 January 2020

Dr Brendan O'Shea: 'Small sums affect key health decisions - and cost us all more in long run'

'I encounter households daily where healthy eating is not possible.'(Stock image)
'I encounter households daily where healthy eating is not possible.'(Stock image)

Dr Brendan O'Shea

'Out-of-pocket costs' sound mundane, irrelevant to people with deeper pockets, but they are increasingly damaging the greater the level of deprivation in your household. If you live in the bottom quarter, small sums really influence decisions you make regarding health.

Competition between food, accommodation and treats drive healthcare out of the equation.

When reconciling household demands, people make damaging decisions regarding health, often because of modest out-of-pocket costs. Armchair politicians see this as 'the feckless getting what they deserve' when they get sick.

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Epidemiologists tell us 'just deserts' mean higher rates of cancer, poor mental health, obesity, and more and earlier onset of heart disease and diabetes. The poor suffer more and die younger. GPs see this play out in surgeries, over years, within families.

I encounter households daily where healthy eating is not possible. Bottom quarter households buy cheap, energy-dense high-fat/high-carbohydrate discounted foods (deep-fat-fried chicken, fish, pizza) instead of more expensive/less energy-dense foods (fruit, vegetables, smaller portions of better quality meat).

Affluent households spend on fitness, active travel and education. Bottom-quarter households buy flat-screen TVs and online subscriptions, ie passive, low-quality entertainment.

I frequently see where marginalised hard-working people have unplanned pregnancies, leading to abortions. "I needed to renew my pill prescription, but put it off because of cost."

"He was going for a vasectomy, but we put it off till after Christmas - now I'm caught."

Small costs affect key decisions. Where homemakers have conflicts between food and long-term health, putting low quality dinners on the table wins.

In the dark days of 2009, I was shocked to see individuals stopping blood pressure medication due to cost. I clearly recollect a young construction worker sustain a life-altering stroke because of this.

Can this get better? Perhaps. This week we had a moderately severe asthmatic child in clinic. The child was borderline in terms of ED referral.

An alternative was to treat aggressively in practice, and review next day. This was possible, because they had an under-six medical card.

Previously, we would have worried about the cost of an extra practice visit, but now a fast revisit the next morning, taking 90 seconds, seeing the child, and re-examining, was acceptable.

The child had improved enough to avoid admission. The system was saved an emergency department visit - several hundred euro, when properly costed. Arguably, all cost-effective care should be almost freely available, especially in primary care, where earlier investment delivers big returns in downstream costs.

Discussing prescription charges with my local pharmacist, he advises they don't cause serious hardship. Instead, people advise if they have accumulated medications - to save €1.50, they advise the pharmacist they 'don't need the inhaler' on the repeat prescription.

From 2018 to 2020, the Drug Payment Scheme charge has been reduced from €144 to €114. This is a quiet move in the right direction.

Reducing it further would put Irish citizens on a par with most other EU citizens.

So what is your view on all this? Would you consider making this a kinder society where everyone needing cost-effective primary healthcare gets it, with reduction of out-of-pocket costs?

The evidence is clear on this. Best outcomes are achieved by improving access to primary medical care for the economically disadvantaged.

Ask your politicians what is their position on Sláintecare, which broadly will see improved access to primary care for more people.

My European GP colleagues are shocked by the extent we charge people in surgeries in Ireland.

Dr Brendan O'Shea is a GP in Kildare, and Adjunct Assistant Professor at Trinity College Dublin

Irish Independent

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