Perhaps I should have declared my interest at the outset. I have a close personal friend who suffers from a disabling condition which requires surgery, for which she has waited for four years. I have seen her unable to lift and comfort her younger child, unable to work, in constant pain, most recently beginning to experience vertigo.

I have seen her through the years of her trips across the city to visit outpatients, of her six-month waits for MRI (Magnetic Resonance Imaging) scans. I know she has lived all this time with the knowledge - communicated by a junior doctor - that the operation, if it ever comes, could leave her in a wheelchair but that the odds of that are greater without surgery.

I remember well how last year she fought hard to get to see her consultant to discuss her options - her second sighting of him, 3 1/2 years after her first.

He told her: "For £3,000 to £3,500 or thereabouts (ask my secretary for details) I can operate on you in two weeks' time in a private hospital."

She thought about going to the credit union and decided against. You don't face into possibly permanently disabling surgery by going into debt. And if something went wrong, how would she fund a protracted stay in a private hospital?

An acquaintance with the same condition received surgery within a week and was back at work within six weeks. I am ashamed when I think of my friend's situation and the tens of thousands like her. I am a VHI member and she and I know I would never share her experience.

That in a nutshell is the kind of health system we have developed in Ireland. In the series An Unhealthy State, with other writers I attempted to explore why and what we might do to change it.

Two fundamental reasons emerged. The health system is underfunded. The savage cutbacks of the 1980s had by 1989 reduced public health spending on each person to little over half the EU average.

Today, public health spending is 80 to 85 per cent of the EU average but with rapid population growth, continued substantial spending increases are necessary to bring our health spending up to EU level.

The second explanation for my friend's experiences, of equal if not greater importance, is that the health system is structured inequitably, unusually so by modern European standards. People on low incomes must count the cost every time they or their children need to consult a family doctor.

In hospitals public and private practice are so enmeshed that public patients' interests suffer. Private patients in effect jump queues and are subsidised by the State to do so. Most recent evidence of this was published last week in the ESRI's new study of private practice in public hospitals.

From this poorly funded, inequitable system consequences flow, not least that Irish life expectancy is low by European standards and that mortality rates differ by social class and area of residence.

Critics of the series included a former Minister for Health, the medical organisations and many consultants. Those who see the health system differently - public patients - less frequently read The Irish Times (although one correspondent did indeed write eloquently after a week in a public ward).

Those who are seeking to implement change - public servants - are not permitted to engage in public controversy. The comments of highly trained and experienced officials with decades of insight into the healthcare system have been dismissed by some correspondents because they are "nameless and faceless".

The series portrayed the problems of the health service as multifaceted, requiring change not only from consultants but also from politicians and indeed the electorate in confronting the issue of rural hospital rationalisation. Yet Finnbar Fitzpatrick, chief executive of the Irish Hospital Consultants' Association, engages in the hyperbole that the series "excoriates consultants as the root of all evil in the health services".

No dispassionate reading of the series can support this statement. But what the series did do, and what Mr Fitzpatrick in truth dislikes, is that it questioned how hospital consultants work. And it did so supported by very good authority. Mr Fitzpatrick discerned innuendo. The series was a great deal less subtle and better supported than that.

Consultants' traditional work practices are an important issue in the reform of the health services because they contribute to the twotier nature of the system and leave much public patient care in the hands of poorly supervised doctors in training, a reality disputed by some correspondents but extensi vely documented in the 1993 Tierney Report on medical manpower. Today's shortages in junior doctor staffing are a direct consequence of many Irish medical graduates' refusal to stay in this unreformed system.

The Department of Health and others in health administration are determined to address this and have been attempting to do so against the resistance of the Irish Medical Organisation and IHCA in the Medical Manpower Forum, an understanding supported by participants in the forum and by its draft report, a copy of which has been seen by The Irish Times.

The Department has stated its willingness to appoint many more consultants if it achieves changed work practices. So far, the medical organisations have offered "flexibility". The Department wants a different kind of consultant, the organisations essentially want more of the same.

THUS, much of the rhetoric in articles by Mr Fitzpatrick and Dr Peter Kelly of the IHCA and Mr George McNeice, chief executive of the IMO, is best understood when they are viewed as competing trade unionists engaged in the early skirmishes of critical negotiations who must justify themselves to their memberships.

This is the subtext of much hostile reaction to the series. The Minister for Health, Mr Martin, addressing the IHCA conference last weekend, spoke on this theme when he told the assembled consultants that "maintaining the status quo is not an option".

To make the case for additional investment in health and to solve medical staffing problems, he said the agenda of the forum must be delivered, an agenda which included "redrawing professional boundaries, organising care and service delivery around the patient rather than vice versa".

It is curious that, while the central proposal at issue in the forum is the creation of a new form of consultant or specialist post to ensure the rostered and monitored availability of trained doctors for public patients, only Dr Kelly has expressed a view on this in response to the series.

As chairman of the IHCA's manpower and common contract committees, albeit not a member of the forum, Dr Kelly offers insights into his association's conservative stance. He quotes a survey in which a majority of his members rejected the introduction of a new category of consultant because, he said, they could be "exploited by hospital managers and other consultants" and would do all the difficult work at anti-social hours. "This would lead to discontent and strife," Dr Kelly wrote.

At the moment, the people in that position are low-paid junior doctors in training who deliver much of the care to public patients. Were Dr Kelly to survey public patients, he might discover they would rather that the person who sees them during anti-social hours or indeed at other times is a wellpaid, fully trained consultant.

He does not mention that his association has also rejected the Department's proposal that all consultants would be rostered to work on-site shifts, a situation in which they could not exploit one another. He maintains that, despite rejecting all proposals from the Department for rostered shift working, consultants are prepared to be available on site out of hours and will provide "some form of shift cover", the form to be decided in negotiations rather than agreed on at the forum.

Some participants (yes, nameless and faceless) in the medical manpower forum have stated their belief to this writer that what the IHCA fears is control of consultants' working conditions by hospital management, who would monitor their attendance and availability to every category of patient.

Prof Muiris FitzGerald, whom the series quoted, is "a lone voice" in his support for change, Dr Kelly asserts. Yet the new generation of younger doctors is supportive of the idea of a rostered consultant/ specialist post, as the series reported. Indeed, a recent letter to the IMO's Irish Medical Journal reported on a postal survey of 104 trainee paediatricians which found 85 per cent of them expressing interest in a new nonconsultant specialist grade. A reading of the draft report makes it clear that the IMO does not represent this view at the forum.

Many individual hospital consultants, who have written letters in response to the series, have echoed their organisations in rejecting criticism of their work practices but have offered no view on the forum's proposals for change.

They have written in hurt and angry tones about their dedication and their commitment to their public patients. Quoting from personal experience, they have appeared unfamiliar with published reports on the medical system's shortcomings, which the series had quoted extensively. (see right)

In private conversation with this writer a number of consultants have been highly critical of traditional medical working practices. Consultants in rural areas, for instance, question the manner of working of their big-earning Dublin colleagues. None, however, will risk his colleagues' ire by saying so publicly. They permit themselves to be represented by conservative organisations dominated by the agenda of the big earners and thus perpetuate the view of the medical profession as a monolith.

In their letters, consultants have in general argued for more spending and more consultant posts - both stances which the series supported. However, with a few exceptions they have chosen to ignore its central conclusion: that while health spending must rise as a national priority, the organisation and funding of the health system must be reformed to ensure equitable access. In contrast, a number of general practitioners, family doctors who see the impact of inequitable access on people's lives, have corresponded on this issue.

It is hard for well-motivated, perhaps altruistic consultants, to acknowledge that they are beneficiaries of the two-tier system. Even the very best of them who actively fights cutbacks, when he or she is engaged in private practice, benefits from the fear of public patient status which has driven 45 per cent of the population into private health insurance and generated a boom in private medicine. Harder still is it for consultants to concede that this two-tier system has its roots in their predecessors' opposition to the introduction of a free, comprehensive healthcare system.

The former Chief Justice, Mr Tom O'Higgins who, as Minister for Health in the 1954-57 Inter-Party Government, was responsible for the establishment of the VHI, disputed in a letter that the motivation for this was to provide private income for doctors. It was instead a response to the "unjust" exclusion of half a million people from access to health services available to the rest of the population under the 1953 Health Act, he said.

What Mr O'Higgins omitted to mention was how this exclusion of top income earners had come about.

Since the 1940s the Department of Health and a succession of governments had attempted to extend free medical care to the entire population in the manner of Britain's NHS. As documented in Dr Ruth Barrington's scholarly history, Health, Medicine and Politics in Ireland 1900-1970, they failed chiefly because of the opposition of doctors and the Catholic Church. Doctors wanted to keep a proportion of the population paying fees because this protected their private income. The establishment of the VHI achieved their objective.

If consultants today want to break the historical link with their counterparts in the 1940s and 1950s, they have a golden opportunity. Let them fill the letters pages with their proposals for ending the two-tier system.

An Unhealthy State described a range of ways in which this might be achieved.