In the first of an occasional series on the development of primary care groups in the north London boroughs of Enfield and Haringey, Kaye McIntosh reports that settling the size of units in this diverse catchment area has not been easy

Patients speak at least 56 different languages in the north London boroughs of Enfield and Haringey. And the health service is as diverse as the population, making the development of primary care groups a real challenge.

General practice varies from large total purchasing practices in the suburbs of northern Enfield to single-handed doctors in the inner-city area of Tottenham.

Deprivation scores vary wildly across the borough. Within one of the five PCGs, Enfield Southgate, scores on the Jarman index vary from the well-off minus13.8 to the poverty of plus 26.9.

Enfield and Haringey health authority chief executive Christine Outram describes the process of managing change in such a diverse area as 'taxing, to say the least'.

Last week almost all the 60 board members of the five PCGs met for the first time. And it was quickly apparent that they are as various as their patients.

Enfield North PCG represents former total purchasers and wants to go towards primary care trust status 'as soon as possible', according to chair Peter Barnes.

The PCG is due to agree an outline business plan this week and is likely to register an interest in becoming a primary care trust well before the national deadline of January next year.

Meanwhile Enfield Southgate still hasn't agreed a chair in a stand-off between two GPs, and is due to ballot all PCG members to reach a final decision.

Right from the start no decision was straightforward. Ms Outram says deciding where the groups would be 'wasn't obvious - but we couldn't just do what the HA thought'.

A workshop involving all stakeholders from GPs to nurses and HA managers boiled the options down to three 'although we had been hoping for just two so it would be a straightforward choice'.

After consultation, setting up one group in each of the two local authority areas was rejected for producing over-large units - Haringey would have covered around 215,000 residents and Enfield 265,000.

Geographical factors such as the Great Cambridge Road which divides the area were rejected for the same reason, leaving option three - the five parliamentary constituencies.

Two are fairly small - Enfield Southgate has a PCG representing 70,000 people.

Edmonton PCG covers a younger, generally deprived population of 89,000.

Enfield North includes the former New River total purchasing pilot, covering five practices with a budget of£33m. It comes in just 5,000 over the 100,000 population guidelines.

Tottenham is the most obviously inner-city area with a high proportion of single-handed practices and the highest level of ethnic minority patients at 38 per cent.

For a long time it seemed likely there would be two PCGs but after what one GP describes as 'nearly civil war' the combatants declared a ceasefire and set up a single group covering 136,000 people. The chair, Julian Chadwick, was decided just a week ago.

Hornsey and Wood Green, the largest PCG, covers a population of 161,000 and is the only group headed by a woman, Jackie Mansfield.

The HA 'held the ring' for elections to the boards, completed last month.

The GPs in each group have taken advantage of their right to be in the majority and choose the chair - each group has seven GP members and a GP chair.

The HA also interviewed would-be nurse members to create a shortlist for a ballot of all nurses in each PCG area. Lay members responded to adverts in local newspapers.

Ms Outram says the HA took a 'facilitatory' approach. 'The HA has a delicate balance to achieve, offering support but not dictating the agenda.' The 'inclusive process', starting each stage with a workshop, consulting widely and trying to achieve consensus has taken its toll on her staff.

'I get very concerned about the level of workload that some people are carrying. We are being stretched to the limit with all the primary care group development as well as all the routine work of the health authority.'

But stakeholders of all professional backgrounds agree that, so far, it has worked.

Hornsey and Wood Green lay member Maria Duggan said: 'The relationship between the HA and PCGs is cautious. But I don't get the impression that anyone in this neck of the woods is out to shaft the HA and the HA is bending over backwards to explain its role.'

Local medical committee chair Laurence Knott was warmer: 'The majority of people are very happy with the HA approach and saw them as facilitating the process, particularly over the elections.

'Maybe they weren't moving fast enough for some leading-edge practices but we have to recognise that different areas have different levels of expertise and the HA has to support them all.'

Newly-appointed HA chair Peter Dixon - who is having to resign as a member of Edmonton PCG board following his appointment - said developments to date were the least important stage of the process.

'So far it has all been about structures. We are re-arranging the deck chairs for the umpteenth time but the important thing is to get on with the task and start the work on the ground.'

Major issues facing the PCGs include building relationships with local trusts - particularly Chase Farm Hospitals trust, which is in the process of merging with Wellhouse trust in the neighbouring borough of Barnet.

Liz Heyer, former chief executive of Chase Farm trust, is now project director overseeing the merger.

'We are looking at how we sustain clinical services and we have to involve PCGS in that.'

The merger talks between the two medium-sized DGHs are well advanced: 'By the time PCTS are up and running we will be wanting to engage them into locking into our services.'

But Ms Heyer is keen to stress that negotiations will not be 'just about replacing contracts with HAs and fundholders with contacts with PCGs.' She wants to provide 'new kinds of services', for example taking diabetic services out into the community.

Managers at North Middlesex Hospital in Edmonton are more cautious, perhaps reflecting the reaction of larger, teaching hospitals. Finance director Julian Groves said: 'Our initial concern is making sure we can move ahead for the first year by setting fairly modest aims. We have to move at a pace the health service can support with no change to acute services in the first year.'

But the PCGs may not want to wait for trusts to catch up - members are keen to get started.

Ron Singer, a keen exponent of commissioning through the NHS Alliance and board member in Edmonton said his PCG was keen to co-ordinate primary, community and social care.

'We get some services from Enfield Community trust and some from Haringey Healthcare. We use social services in Enfield and in Haringey so we tend to fall through the gaps. There has never been an opportunity to address these problems before.'

Hornsey and Wood Green PCG is determined to improve services for the most neglected groups of patients. Ms Duggan said: ' PCGs have the potential to address health inequalities on a local basis.'

One of the issues most of the five PCGs want to tackle is breaking down the language barrier with asylum seekers.

In Tottenham, PCG members want to set up a refugee resource centre to help patients such as a recent influx of Kosovan refugees.

PCG chair Julian Chadwick said: 'We have got no funding for it at the moment but it is a central problem here.'

The PCGs also have their sights set on different levels. The former total purchasers of Enfield North are keen to reach trust status and are seen by HA director of development Carol Duncan as a 'PCT trailblazer'. But Ms Duncan told board members: 'We are clear that most PCGs want to work at level two.'

Dr Raj Raithatha of Enfield Southgate agreed: 'Obviously I think we need to aim for level two and then pause to consider what we need to achieve and how to take it forward.'

Whatever level the PCGs start at, Ms Outram recognises that the HA will get leaner as the PCGs take on more power. 'Ultimately we will merge with another HA.'