Saturday, November 28, 2009

Mothers and Daughters.

Friday was an odd day. It's the long run up to Christmas that starts in earnest this weekend with German Markets seemingly springing up all across the land and traffic into all our major town centres gridlocked as we flock to see how our continental cousins do Festive. (More sausage and gluhwein than turkey or beer and a lot of carved wood apparently).

Then there's the flu jabs-- not only the "normal" ones this year, but also the added thrill of pandemic jabs, which pretty much everybody seems to want but for which the target population is at variance to some degree with the other jab. Still in our neck of the woods it's proving popular. We gave 500 last week, and filled another 500 clinic appointments within 2 hours of opening them up. It's almost as though we were offering tickets to see Robbie Williams.

But this Friday was mainly odd because of a couple of encounters that made it plain that the rules of normal behaviour had been suspended for the day. and this weeks before the Lord of Misrule has his annual outing.

Exhibit One: Jocasta.

A precocious young lady of ten. She has eczema, and a month ago kindly young Dr Neighbour decided it looked a bit nasty, and needed treating for infection as well as the more normal inflammation of the eczema itself. This isn't uncommon. Eczema itches. When it itches we scratch. When we scratch we break the skin, bugs get in and a low grade infection adds itself to the misery of the eczema. Mixing an antibiotic into the cream is a far more effective way to tackle this than to opt for "systemic" antibiotics (that's the ones you take by mouth -- or sometimes in a drip) which might eventually work, but are far more likely to fuel resistance and generate side effects.

Sadly Jocasta's eczema looked every bit as nasty on Friday morning as it did a month ago. "How could this be?" I wanted to know-- "Didn't the cream work then?"

"Well we didn't use it" says Mum. "Jocasta said it made her legs sting!"

"Oh dear, so how long did you try it for before you sopped it then?" a reasonable question I felt, but both Mummy and Jocasta gave me that look that suggested I had suggested they go drown sackfulls of puppies.

"Well we only tried it the once. After all she said it stung!"

So we've agreed that poor Jocasta is going to try to be brave, in the hope (firm expectation on my part) that the cream will not only stop singing very soon, but might even do as intended as clear the infection. a;;owing the eczema to settle in its wake.

Exhibit 2: Cissie.

An urgent request for a home visit mid afternoon. Cissie's daughter has been to stay for the last 3 weeks. Cissie will be 90 in a couple of years, and has been left all alone after her husband's passing many years ago. Her daughter lives a long way off the patch, but came to stay when Cissie, normally fiercely independent, got a bit confused, as often happens when folks beyond "a certain age" develop a urinary tract infection. Antibiotics and three weeks of regular meals have worked wonders for her and she's fitter and better nourished now than she's been for a year or two. Daughter has a pressing engagement elsewhere this weekend, but brother is on his way and will be arriving before bedtime.

Daughter has also managed to arrange carers to call twice a day to help Cissie with getting up and going back to bed. She even tried to get her to consider meals on wheels, but after trying one Cissie was less persuaded on that front and would prefer to keep making her own arrangements, which she is in fact now quite capable of doing again. Still for over a week Cissie has been independent and Daughter has simply been helping her sort out the arrangements. And the Friday lunchtime Cissie refuses to eat, starts leaning heavily on the walking frame, takes herself off to the back parlour and refuses to speak to her daughter at all.

When I visit there's no apparent cause for this sudden "turn for the worse". Indeed Cissie is quite polite with me and wonders rather what all the fuss has been about. She does in the end allow me to gently check her out and confirm that she has neither water infection, flu, or any other cause of acute ill health. Neither has she suffered a stroke or any other insult to her frame as can occur in old age. The simple fact is that Cissie would far rather be cared for by Daughter then Son and wanted to make this plain without saying so. I'm pretty sure she's got the message.

Monday, November 23, 2009

Pretzel logic.

Once every couple of months or so there's a boffin or a group on Radio 4 shouting the odds about how they can save the NHS pots of cash but keeping folks out of hospital. Last week it was the turn of the Alzheimer's Society. I'll admit to only having caught a small part of the piece, but these things are fairly predictable in their content, intensely well meaning, and woefully wrong in their assumptions, and the thing that really strikes me is, received entirely uncritically by reporters who are otherwise presented as amongst the most enquiring minds of their own or any other generation.

If I have the figures slightly wrong I apologize, but the thrust of the argument is unaffected. It seems the Alzheimer's Society had done a piece of work which suggested that at any given time a large number of hospital beds were occupied by dementia sufferers who might be better cared for at home. the number might have been as high as 1 in 4 but certainly at least 1 in 10. Now it's true that in a number of disciplines, notably general medicine, a great many inpatients are taken on to the ward and then kept longer than is medically necessary because of complex social factors, and dementia would be one of the most common of these. This means that dementia sufferers cannot be discharged as easily, needing as they often do, more community care and support, which is seldom available freely and on demand. Such discharges require planning. Planning is seemingly impossible across a weekend, and is seldom practicable on a Friday, and so these poor "long-stay" patients often stay a week or more longer than is needed simply to accommodate "Social Care".

Please don't get the impression here that I'm disparaging the organizers or providers of social care either. I know first hand how hard their job is, squeezing a quarts worth of service from a pints worth of resource is not easy at the best of times. To expect them to do so at short notice, particularly at weekends when office support has evaporated, would be plainly unreasonable.

The upshot, patients with complex care needs tend to stay longer in hospitals. This is an eternal verity. Now the Alzheimer's Society quite reasonably argue that with better input in the home admissions could be prevented, and discharges facilitated. But those resources are currently sadly lacking, and if we think the health budget is poorly funded, our social services colleagues gaze in envy from the"blasted heath" of close on a decade of "efficiency savings".

Lets assume for a minute, that some Fairy God-Social Worker were to wave a wand and overturn this to provide the network of carers and support staff we need. Let's then assume that the service they supply can kick in at the first hint of a crisis and prevent all unnecessary admissions. Let's further assume the 1 in 10 figure (which I still believe is an overestimate across the entire UK hospital population, but that's an argument for another day perhaps) is correct.

So, if every one of those patients who was in hospital could instead be cared for at home, we could reduce the hospital population by 10% overnight. If we allow that there is no-one else in line to occupy those vacated beds then we could have a whole load of spare capacity in the NHS hospitals estate. That being the case it would be a simple arithmetical exercise to close 1 in every 10 hospitals, thus saving the NHS pots of lovely cash.

To paraphrase a currently very popular Meerkat-- "Simples!"

Thursday, November 12, 2009

I don't know much about art....

We've a very genteel nursing home on the patch. It's taken over an Edwardian era Vicarage and converted it to accommodate the residents in the rooms formerly devoted to staff and family, using the larger reception rooms for dining and lounging very much as you'd expect. It's a good one. You can tell because your never greeted by an unsavoury aroma when you cross the threshold-- regular visitors to such establishments will know exactly what I mean, there are always staff on hand to greet you, and always with a smile, and none of the residents is left to wander wraith like through the halls and stairwells.

It's also apparently run by people of quite unsound mind. They commissioned a local artist (also a patient of mine as it happens) to bedeck their common areas with what our family has always referred to as "Muriels". Vasty paintings of trellised vines and frolicking Putti interspersed with little snippets of inspirational text . All very tasteful, but neither Vicarly nor especially Homey, but not without it's own idiosyncratic charm. But this is far from the limit of their artistic pretensions.

Being an Edwardian era property the home has grounds which though obviously landscaped ab initio, had been let go a bit before the present occupiers took root. So they decided to do them up a bit and have a sculpture park. You know the sort, all concrete Lions and Dishevelled and Deshabillee Nymphs and Graces. Indeed the portals to the establishment are guarded by two resplendent sprawling "marbled" Lions of fierce and noble mien who look like they've been there since time immemorial.

Now I've not visited for a few months-- they're good enough that I seldom have to except to welcome new residents who have opted to join our list, or to review the med's of those of our patients who have been lucky enough to fetch up there-- yes Dr Field et al, some of us really do go out and review our patients med's you know (sorry just a bit of a snit about today's Radio 4 News coverage, if you've not heard it it really doesn't warrant repeating now-- forgive the intrusion). So today I was especially pleased to see they've installed a new sculpture pride of place in the centre of their lawn.

There, atop a noble plinth stands a life size "bronze" of a sheepdog. Fair enough I hear you say. Nothing wrong with a statue of dear old Shep surely? And you're quite right, except....

This dog has his forepaws planted foresquare on the rump of a rather startled looking sheep, his hind legs splayed wide in classic leap-frog pose as he vaults over his ovine charge, ears flapping away behind him.

After spotting this I chuckled all the way back to the surgery, and I only hope, when my time comes, they find me someplace just as quirky to spend my dotage.

Friday, November 06, 2009

Speaking truth unto power.

Never an easy thing to do for sure, but lately it would seem it has become near impossible. For residents of these fair isles the story of poor Professor Nutt will likely be familiar, but for the rest of you Auntie will fill in the blanks.

It seems the Prof. has been a bit fed up with his political masters apparently failing to hear anything he has had to say on his specific area of expertise, so he has made one public comment too many for them and has been given the push. Now I agree that advisors must advise but politicains must finally decide. That's what a representative democracy is all about, but when political and evidential approaches to an area of public policy diverge as radically as they now appear to in the "difficult" area of drugs there comes a point where the advisors become superfluous and we end up with an approach based on "public opinion". It seems Mr Mackie really is setting HMG's current drugs policy and reasoned advice is deemed unnecessary and inadvisable.

In the long run this damages the credibility of the policy as presently voiced, and calls the judgement of our political representatives into question. If the policy is determined not on the evidence of actual risk, but on some otehr grounds, those grounds need to be far better and more clearly articulated to have credence. If the present classification system is more moralistic than scientific then so be it, but at least let's acknowledge that and move on.

I'm told the Grauniad has suggested that we have moved from "evidence led policy" to "policy led evidence" in this area, and this seems to have been an increasing trend across government for at least two decades, and not just here in Dear Old Blighty or on this lone issue. So perhaps it's time we dropped the figleaf the "advisory" committees lend to policy formulation and let the whole shooting match be determined by focus group and the "Court of Public Opinion".

After all things worked so much better when we had hanging, flogging and transportation to fall back on.