Wednesday, May 23, 2007


You know, the brown liquid, elixir of life, staple commodity of the NHS and any other large demand led service industry.

The only thing is, the word means different things to different people. Some have given it a language all its own, with carefree talk about skinny this, grande that, latte the other thing, till no sane person under the age of thirty knows what the heck they are talking about. Some folk will accept anything wet and brown as the genuine article, others (present company not necessarily excepted) get all snobby and want to know what kind of beans it was made from and have a certain qualifying threshold of taste to be worthy of the exalted name.

In the final analysis, if it’s made from beans and not leaves, and isn’t chocolate, then it’s probably coffee.

By now most of you will have glazed over completely and will be left wondering what the hell I’m talking about. Or you’ll have gone to put the kettle on….

Oh, right, that’s Java for me then, and perchance a hob nob or two?

Ok this next bit requires a bit of a stretch, but stick with it if you can…

Right at the moment my caseload is suddenly overrun with patients with end-of-life disease. Most of my visits this past fortnight have been to administer palliative care or to help with bereavement. And most of the folk I visit would claim C of E as their religious denomination. And just like their coffee their C-of-E comes in all shades and flavours from the happy-clappy-evangelical skinny lattes through the christenings-weddings-and-funerals freeze dried instants to the high-church-latin-mass bean snobbery.

I could now descend into the depths of silliness and start assigning other choices of beverage to other faiths or denominations, (for some reason I’m getting Dandelion and Burdock for Wiccans about now….) but my point is (oh yes, there actually is one folks), we routinely ask for peoples denomination when we check them in for any variety of health service pretty much, and we take their professed C-of-E-ness at face value, but unless and until we ask what that really means (as I am having to do quite a lot at the moment) it is all too easy to lump them all in as freeze dried instants, when they might be looking for a whole lot more.

Brothers and Sisters, bless you all for listening. Here endeth the lesson. Now, where’s that Java…

Tuesday, May 15, 2007

Visiting Cleopatra?

Sorry folks, another wholly unintended hiatus I'm not at liberty to discuss... I hope to back a little more regularly hereafter. Hob nobs on offer to the first to deduce the somewhat gnomic title...

And so without further ado, on with the motley.

Any GP will tell you, a request for a home visit to a patient in their eighties or beyond, where the notes are a slim folder, or latterly a near blank computer printout, with no clinical entry in over a decade, almost invariably spells bad news. Indeed generally the worst possible news.

At the other end of this domiciliary consultation there is almost always a large tumour of the breast, bowel, ovary or similar “occult” malignancy. Or rather, a patient afflicted with one of the above. A patient who has been enduring the onset of whichever it might be, silently, and for some time.

Often, though not invariably they have been living alone and untroubled by the world at large, with neighbours or other acquaintances seeing to their shopping. Being of a “self sufficient” generation they have tended to see to the cutting of their own hair, the mending of their clothes, and have their bills paid either by the same neighbours at the post office, or the bank by direct debit. Then, one day somebody turns up out of the blue, spots and odd contour in the clothing and decides it’s time to “get the doctor in”.

Of course it’s long past that time already, though there will still be things that can be done, and in the succeeding weeks a new relationship can be formed twixt doctor and patient as a package of care is built around their new found need. Almost always the patients are wholly undemanding, and would often rather have just been let alone in the first place, but again almost without exception they accept our “too little, too late” ministrations with good grace and a polite appreciation.

We tend to regard such patients as living in “denial” of their illness. I am increasingly coming round to the view that they are doing nothing of the sort. True, for some the diagnosis and prognosis come as a complete shock. But not many. Most have been well aware that “the game’s afoot” for months, if not years before coming to or attention. They have calmly taken the view that rather than be “prodded and poked” they will allow nature to take its course. Far from living in denial, they have been living in “acceptance”.

There is an art in caring for such cases that lies in laying out options, allowing fully informed choices to be made and then in stepping back and doing “just enough” to allow things to play out as they will. Caring need not always be synonymous with curing, and indeed in such cases seldom could it even if we wished it so.

Wednesday, May 02, 2007

May Day

Ok so it's a day late for reasons way to complex to explain, but it's been simmering for a while so here goes....

May Day

Labour Day. Tanks rolling through Red Square in a show of might only the most organized form of labour can deliver...

...or May Day. Mrs Snell fretting as the Loxley Barrat infants tie one another totemlike to the Ambridge maypole with pretty coloured ribbons....

...or then again M'aidez the desperate gallic imperative that signals distress to the whole world, in the desperate hope that someone, anyone, might be listening and disposed to lend a hand....

It would be all too easy to take this post as an irrelevant whinge redolent of both self importance and self pity. I only hope you will all take my word for it that such was not my intent. After all we've known one another long enough for you all to know that's not my style.

In general I would far rather laugh off the stresses of the day, lurch with all the grace of an inebriate if stately W.C.Fields from one crisis to the next and keep on gigging. Indeed after this post I intend to return to doing just that, but not today.

So, why the long face I hear you ask in your best bartender voice. Well I'll tell you.

It all started on Friday. I was at a weekend conference of GPs and other interested parties. You know the sort of thing; a short talk before a long dinner day one, full on lectures breakfast to teatime day two, lots of small group work within the sessions, lots of networking between, and, trust me on this, nobody can set the world to rights like a gathering of gps. You see, we all know we're right about everything, all the time, and even when we are patently wrong. It's one of our most endearing traits. If you don't believe me, ask the wife.

So all in all these affairs tend to be pretty jolly, where all the afflictions that assail the human frame are sqaurely batted into touch by mid morning and we are just gearing up to take on the eternal verities over the lunchtime Pinot Grigio.

Except that for some reason this time the old GP magic just wasn't working. It turned out that we weren't even on steady ground with the afflictions bit anymore, hemmed in as we were by unprecedented levels of administrative interference in our working lives. Where before we had mostly felt free to examine the evidence for or against given remedies and interventions before offering them up for the adulation of the grateful masses, we were suddenly waking up to find the administrators had parked their tanks on our lawns and hemmed us in with Nice Guidelines, backed by the financial muscle of our immediate paymasters in the PCTs who keep muttering archly about with-holding funding from us if we don't prescribe in exactly the approved* manner.

Out on the village geen the strident Mrs Hewitt has managed to strap all the fledgling doctors of tomorrow to the MTAS maypole in miles of red ribbon and by the time she has funished untying them it will be a minor miracle if at least half of them haven't fled to Canada, Australia or New Zealand just to get away from her and her barmy schemes for their career development. Ironic when you think she's an ocker sheila herself....

All in all most of us are left with the impression that the NHS we all trained to serve, and had each commited decades of our working lives to, exists no longer, save as a convenient 'Golden Arch' style logo to be appended to all the little franchises that are setting up in business to replace it. The old public service ethos has finally given up the ghost. Our clinical independence has been frittered away on a 'pocket full of mumbles' in the form of our increasingly tarnished new contract.

And if you think all that sounds gloomy, I have to tell you I was one of the more optimistic members of our gathering.

M'aidez indeed.

* O.K. hands up who thought I was going to say "prescribed" again, eh?