The Kingdom of Tonga is a developing country in the South Pacific. It has a population of 90,000 and is an archipelago of 170 tropical islands. As the only South Pacific country never to have been colonised, Tonga is the last remaining Polynesian kingdom. I spent a medical elective there in March and April.
By contrast, the village of Tonteg lies 10 miles north of Cardiff, at the gateway to the South Wales valleys. It was a mining village and now suffers all the problems of mass unemployment. I spent my senior GP attachment at a practice here in May.
Parc Canol Group Practice, to which I was attached, has eight partners, allied professionals and administrative staff. As well as being in charge of clinical governance for the local health group, the partners have written the formulary for Taf-Elai. One partner is involved in medical politics, and another is a Home Office adviser on drug and alcohol misuse.
Parc Canol was formerly a fundholding practice and it is now the pilot scheme in Wales for commissioning. The practice has surgeries in three villages. One has a pharmacy on-site; another houses a fully equipped physiotherapy suite. The main building in Tonteg has offices for the clerical and managerial staff, a library, a lounge and three treatment rooms where minor operations are performed. The consulting rooms are spacious and well-equipped. Each has a computer for accessing patient records.
The Tongan government provides free healthcare from three hospitals, one for each of the country's main island groups. Primary care on the main island of Tongatapu is provided by the outpatients' department of Vaiola National Hospital, where I spent my medical elective period. The department aims to function as both an accident and emergency department and a GP drop-in clinic.
Staffed 24-hours a day by two doctors and many nurses, it sees upwards of 200 patients a day. The fabric of the department is dilapidated and lacks basic equipment.
There is only one thermometer.
One advantage of primary care in a hospital setting is that patients can be sent to the pathology laboratory or to the radiology department and seen back in outpatients with their results later that day. Most investigations required in general practice are available in Vaiola, although a few blood tests (thyroid function, for example) have to be sent to laboratories in New Zealand. Patients admitted to the hospital all come via the department.
The doctors had trained in either New Zealand or in Fiji.
Most had worked as senior house officers on the various wards of Vaiola Hospital, and had spent time in the hospitals of the other island groups. The experience they gain in these small hospitals is invaluable: here the doctor deals with everything - in Caesarean sections, for example, they are anaesthetist, obstetrician and paediatrician.
Pay and conditions compare poorly with other South Pacific nations. Doctors at Vaiola have to sleep in their cars in the car park when on-call as there is no accommodation.
Many Tongan doctors are wooed abroad by the prospect of higher salaries.
The practice in Tonteg deals with a substantial amount of occupational lung disease and an exceptionally high prevalence of ischaemic heart disease. In the past, the miners of Beddau and Tonteg would be seen by doctors employed by the National Coal Board for assessment of their pulmonary fibrosis (quoted as a percentage figure).
Drug misuse, especially of street heroin, is common. One partner, who also works for the government's drugs czar, sees drug misusers in a weekly clinic. The practice manager, who has been trained by a local drugs charity, discusses pastoral issues with the patients at the same visit.
The area around Tonteg has hit the headlines repeatedly this year because of three outbreaks of meningococcal meningitis. The first, in January, caused three deaths, and a public health emergency was declared, with mass vaccination at schools in the area. Alarmed parents marched to demand blanket vaccination. The partners were swamped by patients fearing infection, resulting in exceptionally long waiting times for routine appointments.
Diabetes is the biggest health problem in Tonga. I also saw systemic viral illnesses and chronic obstructive airways disease and many cases of tuberculosis, typhoid, leprosy and acute rheumatic fever. There is no malaria, but there are periodic outbreaks of dengue fever.
The department has three ambulances, donated by the Japanese government, although I never saw these being used. Tongans often leave a medical emergency to take its natural course without seeking medical advice.
Consumer-driven General practice in Britain is becoming consumer-driven.
Clinic times at Parc Canol are convenient for the working population, repeat prescriptions can be ordered over the telephone and dispatched direct to any named local pharmacy.
Parc Canol was the first practice in Wales to provide TVs in its waiting rooms: an initiative intended to assure privacy from eavesdropping when standing at the receptionists' desk. Patients can choose which partner they wish to consult for routine appointments: the patients come to know their doctors well and vice versa.
Primary care in Tonga is provided solely by the shift working, salaried doctors. Catering for a large population, it is rare that they know any thing at all about their patients. As there is no appointment system in operation, patients are faced by long waits to see a doctor.
Privacy played little part. All consulting rooms adjoined the waiting room, which typically held 100 patients. And in order to maintain a through draught the doors between them were left open.
There was one respect in which patients' wishes were - inadvisably - respected. Despite possessing a dedicated isolation ward, patients presenting to Vaiola with suspected tuberculosis were admitted to the medical ward.
I asked why this was so and was told that TB is so stigmatised in Tonga that if the patient's family and friends found out what the doctors suspected they would never speak to the patient again (the word taboo has a Tongan origin).
The Parc Canol practice consistently achieves compliance for cervical screening in excess of the government's higher target. The practice's computer system has an important role: for example, when a patient's file is opened a warning box appears on screen if the patient is overdue for a cervical smear.
The practice holds a weekly diabetic clinic. Following diagnosis, all diabetic patients are called regularly to attend. A week before each appointment they see the practice nurse, who takes a blood sample, and they also attend the local district general hospital to be seen by the ophthalmologists. On the day of the appointment the patient is seen in turn by the practice nurse, the practice chiropodist, and finally by a partner who is responsible for all diabetics at the practice.
A diabetic clinic has recently been established at Vaiola, too. Diabetics are first seen by a nurse who weighs the patients and measures blood pressure and capillary blood glucose. They are then seen by the dietician, before returning to the nurse to have any leg-ulcer bandages changed, and to be given the next appointment. Physicians from the medical ward are summoned to see any patient where there are particular concerns.
Shortages and gratitude
Tonga is poor: the amount of aid from foreign donors each year is apparently six times the value of the Tongan gross domestic product. Although some of this money is used to improve roads and telecommunications, large amounts are spent on the Tongan health service.
It was difficult to gauge whether shortages of everyday supplies were due to lack of money or poor management .
Royal Tongan Airline was refusing to fly blood samples to New Zealand on the grounds that it had not been paid. For two weeks there were no surgeons in the whole of Tonga because both had taken leave at the same time, leaving the radiologist to perform all major operations.
But my experiences left me grateful for much that I previously took for granted, including dependable supplies of water and electricity and reliable laboratory results, and a conviction that the British system of primary care must be defended.
Geraint Lewis is a final year medical student at Cambridge University.