The smallness of our village was brought home to me last year by the response to a series of articles I wrote on the health services. Particularly revealing were the comments that got back indirectly. In a village, most things get back.

Despite the work of a few individuals, this still remains largely true. Were health economics a truly developed discipline in Ireland, as it is in the US, doctors would have become accustomed not just to journalists but to entire faculties at universities discussing how they work. In these circumstances, the Unhealthy State series in The Irish Times last October might have provoked a less intense reaction.

Reactions to the Unhealthy State series had revealed a central division in opinion between hospital consultants, who saw the problems of the health service as primarily to do with under-resourcing, coupled with poor management; and others (including some general practitioners) who accepted the series' analysis that while these problems were grave, the two-tier nature of the system and the role of consultants' work practices within it could not be ignored.

At the meeting, consultants were of course loquacious about the problems of working in an under-funded service dispersed between too many small hospitals which politicians refuse to rationalise. But they did not defend the two-tier system. They condemned it as "wrong", "embarrassing" and "shaming". They were considerably more radical than their representative on the panel, Finbarr Fitzpatrick of the Irish Hospital Consultants' Association.

With the major opposition parties proposing radical change to ensure equity of access, it appears as if the department's new health strategy may follow suit. It emerged during the evening that the department has been examining health systems in a dozen other countries.

At the prompting of one consultant, the meeting discussed which country had the ideal health system. Prof Thomas Rathwell, a Canadian expert in health administration, cautioned that while the Canadian system was centrally funded, efficient and equitable, it had flaws. To develop our own system, we must eventually look within.

The smallness of our village was brought home to me last year by the response to a series of articles I wrote on the health services. Particularly revealing were the comments that got back indirectly. In a village, most things get back. At coffee in one large Dublin hospital, it was diagnosed that I had written critically of medical work practices because I had failed pre-med. I didn't, but dissecting society began to have greater appeal than dissecting earthworms, so I transferred to history and economics.

Then there was the consultant who prescribed that I should not be invited to medical households since this evidently provoked social envy. Informed that I grew up in a tribe of doctors (grandfather, parents, uncle, sister), he declared that I was disloyal. There was also the medical dinner party which toasted me - "and they weren't drinking to your health". This would be just harmlessly amusing, even perversely flattering, were it not for the arrogance of the implicit assumption that only the envious ask questions. It is easier to rubbish unpalatable views by discerning a personal motivation, to confuse individuals with issues; it is harder to accept the challenge of meeting rational argument with rational refutation.

It was not my truancy from medicine but my application of the disciplines of history and economics to understanding the health services which produced an analysis at odds with the perceptions of some of the medical profession.

There hasn't been much systematic analysis of the Irish health service. In a study published in the 1980s, American health economist Prof Dale Tussing said it was a scandal that there were no health economists in Ireland, that a sector which could use as much as a tenth of GNP employed no one to study it systematically. Despite the work of a few individuals, this still remains largely true. Were health economics a truly developed discipline in Ireland, as it is in the US, doctors would have become accustomed not just to journalists but to entire faculties at universities discussing how they work. In these circumstances, the Unhealthy State series in The Irish Times last October might have provoked a less intense reaction.

There have, however, been more reflective responses to the series; the medical profession is not a monolith. Two weeks ago, I was invited to speak in a debate organised by the physicians' section of the Academy of Medicine, the medical specialists' academic body, and it developed into a thoughtful exchange involving the audience of health professionals, administrators and academics as much as it did the panel. Reactions to the Unhealthy State series had revealed a central division in opinion between hospital consultants, who saw the problems of the health service as primarily to do with under-resourcing, coupled with poor management; and others (including some general practitioners) who accepted the series' analysis that while these problems were grave, the two-tier nature of the system and the role of consultants' work practices within it could not be ignored.

"Lots of letters get written that should be left in a drawer for two weeks," remarked one consultant after the academy meeting. For what was striking about the meeting was that the opinions expressed there by consultants, many of them relatively young, were different from the views some consultants and their representatives had expressed in letters and articles in the aftermath of the series.

At the meeting, consultants were of course loquacious about the problems of working in an under-funded service dispersed between too many small hospitals which politicians refuse to rationalise. But they did not defend the two-tier system. They condemned it as "wrong", "embarrassing" and "shaming". They were considerably more radical than their representative on the panel, Finbarr Fitzpatrick of the Irish Hospital Consultants' Association.

There was some disingenuousness. One surgeon questioned whether there might not have been genuine medical reasons for the relative low priority accorded to a patient featured on Prime Time recently, who had waited four years for cardiac surgery in contrast to a private patient who had been treated within weeks. Medical priorities do not explain, however, why an ESRI survey uncovered not one private patient who had waited as much as one year for in-patient treatment, in contrast to the many-year waits of many public patients.

Refreshing too was the frank contribution from the floor of the newly-appointed secretary-general of the Department of Health, Michael Kelly. "We live in a low-taxation, low public spending economy by European standards. That's by choice of the Irish community," he said.

"The fact that we have an under-invested health system is no excuse for the two-tier system that's in place at the moment. The mood now is for investment, development and growth. Change must go along with that."

With the major opposition parties proposing radical change to ensure equity of access, it appears as if the department's new health strategy may follow suit. It emerged during the evening that the department has been examining health systems in a dozen other countries. Michael Kelly upbraided the gathering for dwelling too much on problems, too little on solutions. "We need a debate about moving forward. There is a great deal the medical profession can contribute to constructive debate," he said.

At the prompting of one consultant, the meeting discussed which country had the ideal health system. Prof Thomas Rathwell, a Canadian expert in health administration, cautioned that while the Canadian system was centrally funded, efficient and equitable, it had flaws. To develop our own system, we must eventually look within.

Maybe this was not a representative evening. Perhaps conservatives save their insights for coffee-breaks and their arguments for negotiations. Many consultants present were from St James's Hospital in Dublin. While St Vincent's was represented on the panel by the campaigning oncologist, John Crown, neither St Vincent's nor the Mater, each with a thriving private hospital, provided contributors from the floor.

However, if the openness to debate and change manifested by the consultants and administrators at the meeting were truly representative, it would bode well for the future of the health services.

mawren@irish-times.ie