MOST PEOPLE DON’T read scientific journals. For many of them, if you took away the editor and the author (and possibly the author’s mum), I’m not sure you’d have many readers left.

An exception to this is The Lancet, which is one of the most impactful and widely-read medical journals worldwide. If something features in The Lancet, people notice. From penicillin in the 1940s to HIV in the 1980s and the Covid vaccines in 2021, much of its research has represented significant milestones in public health.

That is why this month’s editorial in The Lancet Regional Health attracted attention, with the headline, “Ireland – Europe’s outlier in primary healthcare“.

In it, the authors note that, despite our wealth, Ireland remains the only country in Europe without universal primary healthcare. What this means in plain English is that, in Ireland, most people – fifty-eight per cent of us – pay in full, out of pocket, to see a GP; there is nowhere else in Europe where this happens. Why can’t we deliver the same level of care our neighbours take for granted?

To do so, we must understand why it hasn’t happened before now. This historical and political context is inextricable from our wider failure as a society to uphold healthcare as a fundamental right of all people. Decisions not made, paths not taken – these are the roots of the system we have today.

A rocky evolution

Our culture of paying to see a doctor has deep roots indeed. Two hundred years ago, when The Lancet was founded, health was fragile and medicine was primitive: no antibiotics, no pain relief and no real understanding of the basis of disease. Hospitals and workhouses were, in the words of historian Ruth Barrington, “less places of cure than refuges of last resort”. The workhouse was a stigmatised place, while those who could afford to, paid their doctors directly.

This arrangement was formalised in 1838 by the Irish Poor Law Act. Dispensaries were set up, each with a salaried doctor paid by the local authority. To access a dispensary, people had to be means-tested by a Poor Law Guardian, who was generally a local landowner or merchant. If deemed sufficiently destitute, you were issued a medical relief ticket, granting eligibility for dispensary care, without charge. Middle- and upper-class patients saw a family doctor privately.

There is a concept in economics known as path dependency theory. It says that historical decisions explain the present culture and determine future outcomes, particularly in complex systems and institutions. There were key moments in our history that today explain the health system we have: moments of divergence from our neighbours on the path to universal healthcare.

For example, Germany has universal healthcare, based on national insurance: you have to have health insurance, and insurers have to sell it to you. You pay your premium, adjusted to your income, meaning that seeing a doctor is free or nearly free when you visit. The State regulates and acts as a referee. These schemes developed out of nineteenth-century ‘sickness funds’, where groups of workers in a coal plant or mining town pooled together to pay medical bills. The principles of solidarity and risk-sharing were upscaled to a national level, and represent one of the main routes to universal healthcare today. In Ireland, however, we remained mostly agrarian until recently, and we did not have mines or factories; the conditions weren’t right.

Our path also diverged from that of the United Kingdom. For one thing, the UK entered World War Two, while we stayed out. During the war, families huddled in bomb shelters, soldiers and pilots fought Nazism, and factory workers made the munitions needed to do so. Out of this, the power of labour unions increased; so too did people’s expectations from the State. The Beveridge Report in 1942, by the economist William Beveridge, laid the foundation for the modern welfare state, targeting the ‘evils’ of want and disease. In 1948, the NHS was born under Attlee’s Labour government, and seeing a doctor has been free ever since.

Ireland’s neutrality during the war, our lack of strong labour unions, and the predominant influence of the Catholic Church on healthcare are key factors explaining why we took a different path.

In 1953 and 1970, Health Acts were passed, phasing out our Poor Law-era ticketing system in place of means-tested medical cards. Access to care was tiered. If you had a medical card, GP care was free – but harder to access. If you didn’t, GP care was faster – but more expensive.

Rights of access to GP care

The key principle was not rights or solidarity, but eligibility. We do not have Poor Law Guardians any more, but on some deep level, the dynamic remains the same. ‘Free’ healthcare is something one must be deemed eligible to receive. In the words of Fintan O’Toole, “we came as supplicants, not citizens”. And there is still that whiff of stigma about public healthcare.

The fact we are used to this does not make it normal. Paying €50 or €70 to see a GP is a bad deal, especially as many people doing so already pay high taxes as well as rising insurance premiums. We are paying for the same thing two or three times over.

To be clear, many GPs hold strong objections, in good faith, to expanding medical cards to everybody. They point out the workforce crisis in primary care: GPs are retiring faster than we can replace them, practices cannot cope with rising population numbers, and our I.T. systems can’t talk to each other. To GPs running on empty, giving more people ‘free’ care may seem like the last thing we need.

However, issues of resources are different to issues of strategy. We have a leaky bucket, which also isn’t big enough. These are different problems. We need more resources, but we also need to sort out the inefficiency and unfairness in the system – or else the bucket will never be full.

It is also argued that making healthcare free at the point of use encourages inappropriate usage. Evidence does suggest that removing financial barriers somewhat increases visits – but, for several reasons, this is to be welcomed, not judged.

Firstly, if visits go up when coverage is expanded, this likely reflects unmet medical needs, rather than people going to the GP for the craic. Second, there is strong evidence that removing fees actually encourages more appropriate care, such as with regard to judicious antibiotic usage. And third, if somebody goes to the GP with a seemingly minor problem, that’s a good thing. Minor problems become major problems when they are ignored. When people are excluded from care on the basis of means, they get sicker and hospitals absorb the fall-out.

So, where are we now?

Sláintecare set out a ten-year vision to achieve universal healthcare – eight years ago. Some progress has been made, for example with the public-only consultant contract in hospitals and the provision of GP visit cards up to the age of eight.

However, universal healthcare remains a long way off. Sláintecare will expire during the lifetime of this government, and it is unclear what comes next. We have a new Minister for Health – Jennifer Carroll MacNeill – as well as a Taoiseach and Tánaiste who have both previously occupied the role.

Now is our chance to achieve universal healthcare for once and for all. We have the means; the question is one of priorities. It is humbling and telling that one of the world’s leading medical journals should have to point this out. In the words of the Lancet’s editors:

“The real question is not whether the country can afford it, but whether its leaders have the political will to make it happen. It is time for decisive action to create a healthcare system that serves all citizens equally.”

Dr Domhnall McGlacken-Byrne is a doctor specialising in public health and paediatrics.