A NEW REPORT on the experiences of GPs working in economically deprived areas of Northern Ireland has found that the legacy of the Troubles provides “additional complexity” to their caseload.
In one case, a GP recalled two instances in which a patient requested diazepam in anticipation of paramilitary beatings.
The study in the British Journal of General Practice involved interviews with GP working in the ‘Deep End’ – general practices where more than half the patient list live in the most socioeconomically deprived quintile.
The report noted that within the UK context, “Northern Ireland can be seen as the Deep End of the Deep End”.
At the time of the report’s publication, Northern Ireland had the longest secondary care waiting list and the highest suicide rate in the UK.
The study aimed to understand the challenges facing Deep End GPs, why GPs work in these areas, and offer suggestions and solutions to improve patient care and GP experience in the Deep End.
Nine GPs, representing nine of the 45 Deep End practices, were interviewed as part of the study.
Two have practices in the Derry and Strabane area, while one has a practice in the Newry area.
The other six have practices in Belfast (four in north Belfast and two in west Belfast).
Most of the GPs raised the intergenerational trauma in the lives of their patients linked to the Troubles.
The report noted that for the younger generation, this trauma takes the form of substance misuse and mental health problems, and there is also the influence and intimidation by active paramilitary groups.
One GP in west Belfast told the study: “I can think of two patients in the past year who received paramilitary beatings and they rang to speak to the GP before… asking for diazepam in anticipation of these organised beatings, which is definitely a shock to me.”
The GP suggested that these people go to the police, but was informed “that’s not an option for them”.
“Or they perceive it’s not,” added the GP.
“I’m not really sure how I manage it, but I know that I don’t need to ask about paramilitary involvement because patients will just tell me.”
Figures released by the PSNI last November revealed that 19 people were victims of paramilitary-style shootings between 1 November 2022 and 31 October 2023.
In the previous 12 months there were only seven victims.
A separate GP in west Belfast told the study that when they first started working in the area, “somebody phoned and said they’re under death threats and I got anxious and worried”.
But they said they no longer get anxious or worried by such calls because “really badly, it’s become normalised… all these bad things suddenly become normalised”.
They added: “I suppose as a GP it’s just part and parcel of what I do every single day and it’s [the Troubles legacy] still very prevalent and prominent.”
Another GP said of the younger generation: “I think there’s a lot more we’re seeing now of the next generation, who maybe haven’t directly witnessed anything … and we’re seeing more of the consequences of them growing up in an unstable childhood environment.
“And I think that brings a different mental illness that we’re definitely seeing a lot more now through the use of street drugs and alcohol.”
Other challenges reported by GPs in these areas are “experiences of the insurmountable workload, leading to feelings of burnout”.
Another issue raised by GPs was patients in Deep End areas underusing or overusing services.
“Deprived people either overuse the service or don’t use it at all,” said one GP in Derry and Strabane.
GPs also warned that some people in these areas “have an expectation of poor health”.
“I think people in areas of social deprivation tend to have a lower expectation of their own health, and so just accept chronic disease a lot more and expect chronic disease in their lives,” said a north Belfast GP.
When asked why they work in Deep End areas despite the challenges, GPs expressed feelings of “duty, responsibility, and belonging to an area”.
Some identified with their patient population and expressed a commitment to serve the communities they themselves came from.
“This is where I grew up, these are my people,” said one GP.
Another said: “We were born and raised in the area, so that’s why we came back here.”
Others described feelings of justice and a desire to meet the needs of those who need it most.
“I trained for this very reason,” said one west Belfast GP.
“These are the patients that need us most. And I wouldn’t want to work anywhere else.”
The GPs interviewed called for increased mental health provision given the volume of mental health presentations.
GPs added that increasing mental health service provision and access in areas of socioeconomic deprivation would improve patient care and GP experience.
It was also suggested that increased community and social support to tackle societal issues could improve health and wellbeing.
“Rather than invest money in diabetes or COPD [chronic obstructive pulmonary disease], that for me is not the prevention,” said one west Belfast GP.
“It’s actually education, the health literacy, and obviously they all need better housing and better education.”
Meanwhile, some GPs said a rethinking of booking systems and creating extra capacity and flexibility in daily access would allow practices to respond when someone engages with healthcare services in an “ad-hoc” way.
“I do think patients find it difficult to engage with what’s offered in the way it’s offered, so I think they would be able to engage far more in a drop-in whenever suits … as opposed to multiple DNA [did not attend] appointments,” said a north Belfast GP.
The report’s authors said that GP policy or initiatives need to consider the specific challenges faced by colleagues in Deep End areas, as “not doing so will likely increase disillusionment, burnout, and negatively impact morale within the Deep End workforce”.
They added that measures should be taken to increase GP registrars’ exposure to Deep End areas and that “at least one placement on their training journey seems feasible”.
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