Ballymun Family Practice:
Dr Fiona Bradley's and Dr David Gibney's practice is on the lower floor of the Ballymun Health Centre. This 1970s-style concrete building is in the car park of Ballymun Shopping Centre. There is an unwelcoming open-plan waiting area, with rooms opening along each wall.
A recently added internal conservatory serves as an office and is an indication of chronic space problems in the centre.
Dr Bradley and Dr Gibney work closely with another GP. Between them they provide 2-1/2 full-time "equivalent doctors" and look after about 4,000 patients, using the shared office and three consulting rooms.
Due to space restrictions they can employ a nurse for two days a week only.
The Ballymun population is about 20,000, split between high-rise flats and corporation town houses. Although there are no official deprivation statistics for the State, Ballymun is recognised as one of the most socially deprived areas of Dublin.
Bryson Street Surgery: Situated at the junction of Lower Newtownards Road and the Short Strand, it marks the border between Protestant and Catholic east Belfast and has served the health needs of both communities for many years.
A two-storey, red-bricked house on a corner site, the surgery is compact. The waiting room is small but has a friendly air. However, with five GPs, three nurses, seven receptionists, a practice manager and other staff, one of the partners, Dr Christine Hunter, admits they are crying out for more space.
The practice looks after 8,000 patients who live in densely packed streets of old terraced and new Housing Executive housing. Three storeys are as high as the houses rise, but the area is still heavily populated. It ranks as the 14th most socially deprived electoral ward in the North.
With such a high level of deprivation, the patients of the Bryson Street practice have health needs typical of an innercity population. There is a high rate of cardiovascular disease, with approximately one in 24 patients having a heart or circulatory problem.
The practices - how they compare
Staff:
For 4,000 patients in Ballymun - 2-1/2 GPs; one parttime nurse, one receptionist.
For 8,000 patients in Bryson Street - Five GPs, three parttime nurses, one practice manager, one secretary, seven receptionists (some part-time).
Facilities:
The health board provided premises in Ballymun, including three consulting rooms and a shared office.
The privately owned premises in Bryson Street has five consulting rooms; one practice manager's office, one nurses' room, one doctors' office, one computer room, one administration office and one staff room.
Preventative Care:
The Belfast practice runs specific asthma, diabetes, "wellman", immunisation and health promotion clinics. In contrast, the doctors in Ballymun run an immunisation clinic and a dedicated methadone/addicts clinic. They feel frustrated at not being able to provide more proactive care but are severely hampered by space.
Team Work:
In Bryson Street, the district nurse has coffee with the doctors most working days. The "attached health visitor", a nurse who specialises in preventative care [there is no direct equivalent in the Republic], runs an immunisation clinic in conjunction with the doctors. There is a community psychiatric nurse, occupational therapist and physiotherapist attached to the practice also.
In Ballymun, GPs have a good informal working relationship with public health nurses, who work on a sectoral basis. The psychiatric nurses run a community psychiatric clinic on the second floor of the clinic and are highly accessible, also on an informal basis. There is a monthly meeting with child psychiatry services, held off-site. Both Dr Gibney and Dr Bradley would like to formalise these relationships but cite the lack of a meeting area as a barrier.
Intravenous Drug Users/Heroin Addicts:
The most obvious difference between these practices is the absence of heroin addicts in the Bryson Street practice. The Ballymun doctors are kept busy running preventative methadone clinics to the maximum level possible in general practice. When I expressed surprise to Dr Hunter in Belfast, she explained that heroin is kept out of the community by the paramilitaries. This creates its own morbidity, with young men heavily intimidated, resulting in both physical injury (so-called punishment shooting and beatings) and psychiatric illness. The Bryson practice has one of the highest prescribing rates of anti-depressant drugs in the North.
Cardiovascular Disease:
The practices are mirror images of each other where heart disease is concerned. With heavy smoking and drinking rates and poor nutrition, both have up to three times the cardiovascular mortality found elsewhere on the island. Dr Gibney, who moved to Ballymun from a practice in Templeogue, is horrified at how young his patients develop heart disease. A patient of his recently described his mother's death from heart disease as "at least she was old". The woman was 59. Dr Gibney would like to have the time and space to address preventative heart disease measures in their practice population.
Respiratory Disease:
Patients of both practices develop chronic bronchitis at a relatively young age. Smoking rates are high and environmental pollution is another factor of city life.
Waiting Times for Hospital Services:
The time patients must wait for hospital services for four different specialities is outlined below. Access to private medicine is a non-starter for both practice populations. Patients must wait, in some instances for a worryingly long time. In Ballymun, the wait for routine cardiac bypass surgery is 24 months. In Bryson Street it is 12 to 18 months.
Innovations/The Future:
The Ballymun practice recently participated in a pilot scheme that gave its patients direct access to a dietician. It worked extremely well but the service has now gone. The GPs are hopeful the facility will be reactivated. The Northern Area Health Board is aware of the practice's infrastructural needs. There are plans for a new health centre in two to four years.
Bryson Street also needs space, but this would involve buying a neighbouring house or shop. The partners can do this provided they shoulder the financial risk. A recent innovation that has helped the GPs manage patients in the community is the Rapid Response Service. This is a high-intensity nursing service provided by the local community trust which means oxygen treatment, intravenous drug therapy and catheterisation (placing a tube into the bladder to drain urine) can all be performed with the help of intensive nursing care. It is available to each patient for up to seven days, long enough to keep an elderly person with heart or respiratory failure out of hospital.