Table 2 Irish primary care context

To access primary care in Ireland a patient must attend a GP and, if required, be referred to relevant members of the PCT. Patients are required to pay out of pocket to see the GP (cost up to €60 per visit) unless they have a medical card. Applications for this medical card are means tested and the onus is on the patient to find a GP to sign the application form, thereby agreeing to provide care for that patient and to add them to their patient list. This implies that accessing healthcare in the community for low income patients is dependent mainly on a GP accepting a patient’s application. Patients who have been unable to find a GP can apply to the HSE to be assigned to a GP. This medical card covers the cost of visiting the GP and most of the cost of prescription medications. Certain homeless services have access to an ‘emergency medical card’ which allows staff to procure medical care for clients in urgent situations. When a patient with a medical card requires investigations or consultant clinics in public hospitals, there is usually a long waiting time [86]. Patients who pay out of pocket or who have health insurance will often have these appointments arranged much more quickly; this is commonly known as the two-tier health system (for further details see [21]). Government spending on health in Ireland, and other European countries, was reduced during the recession. As O’Donnell et al. [21] have reported in relation to migrant health services, in times of austerity cuts are often made to services targeted at marginalised groups. In 2010 the government in Ireland introduced a ‘prescription charge’ on all medications dispensed from pharmacies to patients with a medical card as a way of saving money in the health service. This levy is currently set at €2.50 per item that the pharmacist must collect on dispensing, i.e. if a patient is prescribed four separate medications for a month they must pay €10 (€2.50 × 4) to the pharmacist. This is an example of an out of pocket payment that seems to disproportionately affect marginalised groups.