A tale of four cities

Most inner-city GPs think their practices are much the same - but they are not. As a final-year medical student I recently spent four weeks in four different cities: Liverpool, Belfast, Glasgow and London. While all the practices were in areas of deprivation, I was surprised by the variation in health service provision, practice organisation and the medicine prescribed. These factors directly affected the GPs' workloads.

I visited two practices in Liverpool. The first was in a post-war housing estate built for slum clearance in south Liverpool. It is geographically isolated, with few car owners among the residents. People are very poor. Unemployment is 40 per cent in this part of Liverpool and the stresses of job insecurity are obvious.

The female GP I was with was concerned about a 45-year-old patient who had discharged himself from hospital following a heart attack. He had gone straight back to work because he was terrified he would lose his job. The main employer in the area was making people redundant, and those with high rates of sick leave were the first to go.

The female GP had recently joined this practice, run by a single-handed male GP, who had operated out of a lock-up shop until he was burnt out. Her energy has revolutionised the practice, which is now in new purpose-built premises and computerised.

Since her arrival several women, too embarrassed to approach a male doctor, have presented with gynaecological problems. The GP says she has seen the worst womb prolapses and stress incontinence cases in her career. She is concerned that some women have been living with these problems for years.

The more successful people from this community have moved on, leaving relatively less funding for a higher proportion of sick and immobile people.

Liverpool's drug problems were evident in the next practice I visited, in Toxteth. Heroin swamped the city in the 1980s, but the heroin users are now looked down on by Liverpool's youth. The addicts are mainly 25- 35 years old, and lead chaotic and desperate lives. They have many health problems and tend to be time-consuming and disruptive patients. I met two in the first hour of a surgery. Patients with multiple problems were not unusual.

A GP had been asked to write a court report on a patient who recently joined the surgery and for whom he had no notes. He invited her to a surgery. Her children had been taken from her, she had a long history of depression and had been hospitalised on numerous occasions.

She had a history of self-harm and had recently cut her arms and face. She looked young and vulnerable and was living in an isolated bedsit. She was distressed and began to cry.

The GP arranged psychiatric support. The consultation lasted 30 minutes and the GP was stressed because he was running late and patients waiting to be seen were becoming agitated.

To cope with demand, the practice has been forced to reduce its list size. The GP earns significantly less than his colleagues in the suburbs. Because of the stress of the job he wants to cut his sessions, but cannot afford to.

One lunchtime I visited the local shops. They were barricaded inside and out. This part of Liverpool felt as if it were under siege, yet house calls are far more relaxed than in London. There is less traffic to contend with and parking is not a problem.

In Belfast I visited a practice in the Catholic area with two surgeries in central Belfast and in the Falls district. It is a city of contradictions.

There is no GP recruitment crisis. With the low crime rate, good education and high standard of living, no one wants to leave. Would-be GPs are forced to be locums for several years, and there are a number of family practices.

This practice is part of a multifund and was the best organised I visited. All the GPs were in suits and the receptionists in uniform. The staff were well trained and had specific areas of responsibility. Despite being a large inner-city practice, the approach was friendly and personal.

There is no ethnic minority community in this part of Belfast. As a consequence, the medicine is less varied and stressful. Patients from ethnic minority groups tend to present with a variety of social, psychological and medical problems, and the use of advocates can double the length of a consultation.

But the impact of 'the troubles' on the mental health of people in this area was evident. Despite the ceasefire in operation while I was there, trouble hot-spots continued to flare up.

One woman cried hysterically in the surgery. Rioting near her home had brought back painful memories of the time her daughter and husband were shot dead in cold blood.

I met patients who had received death threats. One man was suffering from anxiety problems following an attack on his house. At the time he was working in a Protestant bakery; he has not worked since. Another young man had a messed-up elbow from a recent punishment beating.

There is no heroin problem in this part of Belfast. Any new dealers who arrive on the scene are dealt with harshly by paramilitary groups. The GP I was with has only ever seen two heroin addicts in his career, and the few addicts are managed by a drug dependency unit.

The practice has a low call-out rate. The GPs have worked hard to educate patients. They are flexible and will make time in a surgery for those who need to be seen.

My next week was in Easterhouse, a deprived housing estate on the edge of Glasgow, built to house people from a post-war slum clearance. It has a population of 40,000, which is declining, and a reputation for drug and alcohol problems. It felt very deprived and is Glasgow's 'East End'. I noticed that there were few people over 65 in the surgery. Like Belfast, there is no ethnic minority community. Alcohol misuse is a common problem, and there were people who misused alcohol in every surgery.

A local taxi service has just begun a cheap alcohol home-delivery service aimed at housebound people receiving disability living allowance. Women, men and some younger people are beginning to present to social services with alcohol-related dementia. The service input these people require can be enormously expensive.

The surgery runs a busy weekly drug clinic which aims to maintain addicts on methadone. I met a number of people who are now leading stable lives as a result.

I visited an excellent community initiative where local people have set up a credit union and youth clubs and bought a holiday caravan. They have a nappy co-op and hope to set up a food co-op since most local people have to rely on mobile vans that sell a limited range of food at vastly inflated prices. They receive no help from the council.

They resent the way Easterhouse is portrayed in the media: most residents here are ordinary people trying to lead ordinary lives. I was impressed by their creative thinking. They have achieved a great deal. No bureaucratic public sector organisation could ever have managed this.

I spent my last week in north-east London, the most deprived part of the UK and home to large ethnic minority populations, including many refugee groups. It is said that 90 different languages are spoken in Hackney. I was in a practice in the heart of the third-largest Hassidic Orthodox Jewish community in the world, after Israel and New York. A few thousand families live within a square mile, and people have settled here from different parts of the world.

All the GPs in the practice are Orthodox Jews and live within the community. It is close-knit and tends to keep to itself. A significant number of patients do not speak English, so about half the consultations are conducted in Yiddish. The first patient I met was an elderly woman who cares for a husband who is largely housebound with Parkinson's disease. She has an Auschwitz tattoo on her forearm.

I learned that Calpol, the children's syrup preparation of paracetamol, is not kosher, and that the doctors referred frequently to a special kosher medicine directory.

The community provides good support for its sick and elderly people. It has also set up its own mothers' home to provide postnatal convalescence. Families are large, and it is not unusual to meet women over 40 who are pregnant with their 10th child. The community also has its own rapid-response unit and recently purchased a defibrillator, which frequently arrives on the scene before the London ambulance service.

Interestingly, there is no hospice provision. The community does not accept the principle of palliative care since the preservation of life is an important guiding principle in Judaism.

The community is prone to certain medical problems such as Tay-Sachs disease, a genetic disorder, and Crohn's, a type of inflammatory bowel disease. Due to frequent travel to Israel and overcrowding, the community is also prone to outbreaks of hepatitis A.

The public health department has worked hard to persuade the community that babies need BCG vaccination. Tuberculosis is back with a vengeance in this part of London. However the community is so insular that it feels it is not at risk.

In the entire week I did not see one alcohol- or drug-related problem.

While the four cities were very different, most of the issues faced by all the GPs related to community and mental health matters. It was encouraging to see the creativity of local initiatives which depend largely on the enthusiasm and vision of individuals not tied by boundaries.

To date, GPs' involvement in purchasing has largely been via fundholding, which has focused disproportionately on access to acute services.

The New NHS white paper offers an impetus for change. The combined effort of primary healthcare teams and public health departments adopting evidence- based medicine and liaising closely with their communities is a powerful force and has great potential to achieve more sensitive, community-led solutions to common problems.