Where there's a Will...

Peggy was in today. She’s well into her eighth decade and in pretty good shape. She survived a cancer diagnosis – going through surgery then chemo and radiotherapy and follow-on operative procedures all over ten years past, and has never looked back. The surgeons have told her she’s cured and she hasn’t needed follow up in more than three years.

Today she’s in to talk about a minor injury, sustained a week or so ago, and healing nicely, so no need to worry. And yet... worried she is.

How do I know? She tells me so—though she did look far more apprehensive that the minor injury warranted so I had already guessed as much.

And why? Not through the injury, and not from her past health scares. No today she is worried because last week she and Jack visited their solicitor and made their Wills. As she put it “We’d never made a Will before, and now I have I’ve got to face up to the fact that I’m going to die.” It’s as though the simple act of making a testamentary disposition has opened wide the door to the Grim Reaper, The Fourth Horseman, The Pale Rider (no not Clint—the real one*). In short she has had to formally acknowledge her mortality.

What impresses me most is that after everything she went through ten years past it hadn’t even entered her consciousness that cancer was something she might not survive. Her faith in the undeniably excellent care and support she was given then, and for the years after, had allowed her not to have to do so. She’s a little surprised that she feels this way now, but I can reassure her it’s something I’ve seen many times before and so, far from cracking up, she’s displaying a normal if utterly irrational response to the feelings generated by this simple act of forethought.

I’ve tried to calm her fears by telling her that to the best of my knowledge there is no hotline from Hades to the offices of the legions of probate solicitors worldwide, and especially none here in Borsetshire. At least I hope not.

*That said, these days Clint is looking his venerable age, and might pass in a dim light for the Bony Fingered Wielder of the Scythe.

Re-Assura-nce ?

O.k. I know I’ve not been around much lately—or indeed at all, for months. I know there’s a lot to say right now, and not having a voice with which to say it has been a huge frustration, but sometimes words just elude me. So I’m grateful for an email from a friend that gave me a prod to try again.

I fear it’s polemic time, but since I imagine so many of you have drifted quietly away in the long silence perhaps I won’t end up boring too many people. I should also point out that the email came over two weeks ago, so I fear this is not the best place to come for an answer to any queries you may have. Certainly it’s unlikely to be the speediest :-(

So on to the email. My friend was talking with a consultant who revealed the following;

“Apparently the PCT are refusing to fund all 3 monthly hospital reviews, and have been for some time (ie before Coalition took over) The hospital are still arguing about this, to get the PCT to accept those patients they put on pathways exempted from the GP's…”

I have to say the same is true, in some form, in our own PCT and likely in almost every PCT in the country. The reasons for this are many and complicated and though driven by finance are not purely dictated by the bottom line. What we have to bear in mind is our fractured, battered, beloved but struggling NHS has been through six decades of continual change. This change has been technical and clinical every bit as much as financial.

So, how dare a PCT dictate to a consultant when and how a patient should be reviewed? Well the first motivation right now will undoubtedly be financial. Each encounter of a patient with any hospital or “hospital-supplied” service since at least the early 1990s has carried a price tag. So the initial encounter at outpatients generates a bill. There is then a tension between hospital and PCT, both of whom have a primary statutory duty to deliver a balanced budget which overrides any other duty they may have. So more hospital outpatient reviews means more money for the hospital, and a bigger drain on PCT resources.

In the time I’ve been in family practice the level of care and expertise available in the community has gone through a quiet revolution. Pretty much everyone, including our consultant colleagues still see general practice as a sleepy medical backwater of two surgeries a day and a round of golf in between. Anyone who has had any regular dealings with their GP surgery over the past decade or more will know that things aren’t like that anymore. At least they will if they take a quick look around. First, it’s likely that their surgery has a number of doctors rather than just the one or two that was the norm in the first few decades of the NHS. Next, as well as the normal surgery appointments there are likely to be dedicated clinics for a number of conditions including diabetes, heart disease, asthma and COPD as well as “lists” for minor operations ( a rarity in 1990 and near universal by 2000) wart treatment, travel clinics, counseling, physio, and in some of the more adventurous, even “alternative” therapies like acupuncture, chiropractic and a host of others. (True in remoter and more deprived areas not all of this will be so, but even there the GP is still likely to be offering a range of services that thirty years or more ago would have been the preserve of the hospital).

All of this activity is also funded by the PCT. So if the PCT can agree diabetes reviews as an exemplar, in practices, for a fixed price well below that of the hospital, and if the practice is geared up to provide a service at least as good as that of the hospital for the vast majority of punters, why would they opt to have these patients reviewed in hospital or hospital led outpatients? Particularly when the service commissioned from General Practice is a “block contract” paid per capita and not per encounter. But there’s great deal more to this than mere finance. Any regular user of hospital services will tell you that they seldom get to see the same doctor two clinics running, because of the way hospital careers and training are organized, and because the minimum realistic interval between appointments is many months. In practice a GP will generally take a lead role in a given clinical area and will be rather more available. When patients are stabilized and well managed yearly or six monthly reviews will generally be the norm and these could be delivered in either setting, but in Practices the team doing the reviewing will de facto be smaller and longer in post, and so likely more consistent, delivering better continuity and with a greater hollistic knowledge of the patient. And when things are more complex practices can generally respond if needed in a day or two and review in a week or two, where the only option available to the consultant would be admission or “urgent” outpatients which—in this locality at any rate, could be anywhere upwards of 4 to 6 weeks.

This is not to deny that there are some, rather iller and more complex patients who genuinely need more frequent hospital care, and for them the existing system is undoubtedly flawed, to the unending frustration of Consultants and GPs alike.

There was another point raised in the email, “(h)is other interesting information was that here the GP's refer to a private company called Assura as well as the NHS. He pointed out that many of the local GP's have significant shares in Assura and therefore a clear conflict of interest…”

Here’s where things start to get complicated and not a little murky. Before I start I must declare an interest in that our locality has services provided by Assura in which every practice in our consortium are partners.

Assura was started some years ago as a commercial supplier of outpatient style services to GPs run by GPs. They have grown down the years and to the best of my knowledge now continue this model and also help practices with premises development in a model similar to PFI. They tend to develop local services as stand alone ventures—franchises if you like, in joint ownership with GPs, and often engage some of those same GPs who have developed particular expertise, alongside Consultants and other practitioners as appropriate, to provide the service. Their services can range form Physio to Dermatology to Orthopaedics to name but a few. I believe they have also been involved in tendering to offer out of hours GP services as well but cannot be sure if they presently run any.

True they are a “private provider”. So are many others currently offering care and services under the NHS umbrella. And true they provide services in partnership with local GPs, and invite referrals from those same GPs. However, to be able to provide such services they are obliged to tender in an open market to the PCT who commission the service, in competition with other providers, NHS and Private Sector, and stringent attention is paid in that tendering process to cost benefits and to potential “conflicts of interest”. So much so that it can take anything upwards of 18 months to 3 years for tender to gain official sanction.

This is the shape of our modern NHS and current reforms look set to oblige commissioners to look not just to NHS-allied organizations like Assura, but also to the wider marketplace, opening the door for strictly commercial private sector providers who will not have either the tradition of engagement with the NHS nor the public service ethos that alliance with GPs who are grounded in the existing systems carry in their “DNA”. One of the consequences of these new arrangements in our locality has been an increase speed of access to specialist opinions for patients who would otherwise have had to pay personally to see a consultant privately. Under these arrangements the PCT is paying the franchise and the patient is seen as an NHS patient. I wonder if this has some bearing on my friends’ consultant’s concerns over conflict of interest?

That sinking feeling...*

I suppose it had to happen sometime. The word is out. There are times when consultations don’t go so well. Like any other human interaction a slight misread of body language, an ill chosen word or a momentary friction between personality types derails things and the express train of therapeutic discourse and discovery goes hurtling off down the wrong track, or smashes headlong into the buffers.

(Yes yes I know derailed trains don’t do either of the above in reality, but it’s my train set and it follows my rules ‘k? ‘K.)

I’ll be the first to admit to my share of disasters, but I hope that I recover most of them before any lasting harm is done to the therapeutic relationship. And though you might not believe it of us as a group, we all try our best not to put our size nines in our mouths too often, or to deliberately rub our patients up the wrong way.

After recent discussions with friends, both face to face and “virtual” (you know who you are) I’m a little worried that sometimes the poor souls of the receiving end of such consults then feel they’ve been labelled, and somehow singled out from the rest for “special” attention. So allow me to set the record straight.

There are times when the doctor-patient relationship dysfunctions, and continues to dysfunction repeatedly and serially over a sustained period. To be non-PC about it terms like “Heartsink” and “Quack” get bandied about and a rift opens between patient and the profession as a whole.

Let me be quite clear about this—though the term and the concept of the “heartsink” patient exist and I’m perfectly certain that the equal and opposite concept of the “heartsink” or “quack” doctor also exist, from where I sit the terms loose currency through overuse. In a career of over 25 years responsible for the care of upwards of 14,000 patients on a day to day basis, and with a dedicated personal list of over 2,000 patients theoretically entirely my own in that they have named me their personal physician by registering on my list, I can’t think of even a handful of patients whose name would instil in me that feeling of apprehension implied by the term. Yes I have many patients who at times test my patience, just as I’m sure there are even more patients whose patience I test from time to time. That doesn’t amount to the same.

One bad consultation, even a run of awkward encounters doesn’t amount to the same thing. Indeed often you have to negotiate a period of awkwardness until you achieve an understanding as with any other interpersonal relationship. Patients know how they feel, even if they don’t intuitively know why. Problems arise when the way they express their symptoms, feelings, fears and apprehensions isn’t heard or isn’t interpreted correctly, or appears to have been ignored and disregarded.

If we can be grown up enough to acknowledge this and back track a bit and try over mostly we can make progress and though we may not be destined to be firm friends we can work together—after all it’s the patients who do all the heavy lifting in any therapeutic process barring the most trivial. We might prescribe the meds, the lifestyle changes or perform the operations, treatments, manoeuvres needed to fix things, but the punters have to take the pills / advice and adapt to the aftermath of the procedures. If we get it wrong first go we have to have the trust of the recipient that our next effort will be better. It’s when this breaks down, and stays broken that we risk loosing an effective therapeutic relationship. At that point the majority of patients, quite sensibly decide that it’s time for them to find another doctor—who will hopefully understand them and their needs better. Sometimes it behoves the doc to suggest this perhaps by means of a personal recommendation.

Where we risk sliding into a longer term “institutional” dysfunction that ends in mutual “heartsink” is where a patient runs through a series of such dysfunctional relationships, or feels trapped within one, ongoing and without possible exit. It’s easy then for patients to feel abandoned, doc’s to feel their well intentioned advice is ignored and for both sides to give the impression either that they’ve stopped trying or are completely disinterested and merely going through the motions.

* anybody else know where I nicked the title from? EVCHN on offer as per usual.

Addendum: For the counterpoint see this from Anna. (Thanks Anna).

You can't get better...

O.K. so it's not quite the speedy revival I was hoping for. Still perhaps if I aim for a post a month for now that will do? Well it might have to. And to be honest I'm not sure you're going to like this one. Still here it is...

This week saw the publication of the Health and Social Care Bill, the road map for the much heralded changes to our health services in Blighty under the present administration. You'll notice I've omitted the word National and the capitalization. The thing is, it's hard, sitting here, to see the coming changes as anything other than the final nail in the coffin, ending the pretence that we have such a thing as a unitary "National Health Service" at all.

Ever since devolution, health in Scotland, Wales, and Northern Ireland have been devolved too (in fact the Scots had their own service even before that), but these four separate services still cannot really be regarded as truly national even within the definition of the "home nations" that make up our fractious little "United Kingdom".

Even before this the rot had started with the experiment that was "Fundholding" where GPs held a tiny proportion of the NHS budget to buy operations for their patients from hospitals. The vast majority of these operations were still performed in the NHS (soi disant) but already the "internal market" had hospitals (later "Trusts") vieing with one another for the cash. And even then a small proportion of procedures were shuffled sideways to the private sector on the basis that they could be done quicker and at no more cost to the taxpayer.

This hypocrisy was swallowed hook line and sinker by the monster that was the incoming faux "Nu" Labour administration. Competition and choice became holy writ, and so they remain. True, levels of investment in health went up, and at last we reached a level comparable to other developed economies. Sadly that increase was built on the foundations of decades long underinvestment, so although current spend might be comparable, past investment has been anything but and our infrastructure remains woefully inadequate as a result. Worse yet, dear Gordon found a splendid way of burying the cost of new infrastructure in the PFI scheme where we, the humble taxpayers, sign up to a 30 year mortgage every we time we want a new hospital / surgery / clinic, and said facility is built, operated, and owned (for gods sake) by private enterprise. So not so much mortgage as "rent" then. And at the end of the 30 year term what happens to the infrastructure? (No that's not rhetorical-- I'm pretty sure the builders will own it and our successors will be renegotiating the lease, but I'm not 100% sure).

Oh but then there was even worse to come. ISTCs anybody? Well some of you might have been treated in one. Most PCTs have one. Remember our old friends choice and competition? Well to enshrine them in our hearts PCTs were compelled to establish Independent Sector Treatment Centres. Yes Independent Sector-- "Private" to you and me. Set up by the NHS and awarded fat contracts for surgical procedures and outpatients. They bussed in Consultants from far and wide. Mostly from the expanded EU and Scandinavia, all thoroughly decent chaps and impeccably qualified, but with no grounding in the workings of the NHS. They were guaranteed income for operations and creamed off all the "easy" cases. They did good work, but on fitter, younger, less complicated patients. Anyone who crossed their threshold with a sniff of a raised blood pressure, wheezy chest or high blood sugar was politely declined and sent back to wait for the NHS "proper" to sort them out. And remember the "guaranteed contracts"? Well they meant that in a year when they didn't perform the required number of procedures contracted, they got to keep the money anyway. And all paid for by the PCT and therefore the NHS. And if, and when one of their patients did become more complicated, they were shipped out of the ISTC and back to the local hospital to be sorted by the NHS consultants who had been denied the opportunity to treat their initial problem by the establishment of the ISTC.

Add to that the lunacy of ever more micro-management of contracts and setting of targets as Nu Lab imploded and our poor PCT colleagues have spent much of the last five years running around in ever decreasing circles. And now we get the Health and Social Care bill. Where once we had fundholding, now we get GP Commissioning, and instead of 10% of the NHS budget we get something approaching 60-70%. We're still mortgaged to the hilt with hospitals we don't own, and now every "provider" of NHS services is going to be compelled to become, or to join, a "Foundadtion Trust". Where prices for specific treatments were set nationally now these trusts will be at each others throats striving to win contracts, and now we get the added imperative to consider, when contracting, "Any Willing Provider". Until now the assumption in contracting has been that the NHS family is the "Preferred Provider" and so when bidding for contracts for NHS services, Trusts could presume their bids would be considered ahead of any other. Now that protection is gone and not only will thrusts be at one anothers throats, they will do so with wolves circling the fold ready and waiting to pick off the choicest prey.

And the best bit, the absolute best bit... PCTs (the health service managers we've all derided for all these years, but who have done the best they could to shield us from the twin madnesses of the Department of Health and the Foundation Trusts) have been told that they must continue to run the show for the next year or so whilst GPs gear up to becoming managers themselves, knowing that at the end of their term, they will vanish. Some will doubtless be reabsorbed into the new commissioning bodies or the overseer NHS Commissioning Board which will be there to insure the Commissioning consortia are working properly. But with massive cuts in funding for NHS management demanded throughout the restructuring, many more will be looking for jobs elsewhere, just at the time the Private Sector "wolves" are seeking a foot in the door.

The NHS I joined in the early 1980s gave me freedom to refer patients anywhere in the system, based on their need as that system was bought and paid for in its entirety as a monolithic state run enterprise. Since the foundation of the PCT my freedom to refer has been constrained, in large part, to the county I work in, and to the two or three Trusts my PCT contracts with and preferably to the hospitals we are shackled to by PFI contracts. With commissioning, all the early evidence suggests my freedom to refer will be constrained still further. "National" no longer applies. Even "Local" is beginning to look dicey. True for most of my patients, most of the time, this won't mean a lot. Right up to the point it means their hip replacement will be done by Kwik-fit as the cheapest willing provider!

16.ii.11 Addendum.
In a similar vein just seen this which you might like to read. Not sure I agree 100% but there's some honest to goodness venting going on and much truth. (Thanks to BG for tweeting the link).

Resurgam?

Looking back 2010 hasn't really been a vintage year has it?

Well, no matter. 2011 is just around the corner, full of promise. Even in this new found age of austerity there's much to look forward to, both personally and professionally. New challenges to be met, places to go, people to see.

It's easy to look to the year ahead with trepidation, and I've spent most of the last three days doing just that. this arbitrary date on the calendar looms large for the bereaved, the anxious, the dispossessed, but hope is there to be had, and sometimes we need someone else to point that out for us.

As a political ploy Dave's "Big Society" is a bit of a non-starter-- as a friend of mine quipped yesterday, the difference between the Big Society and the Big Issue is that nobody buys the Big Society-- but the fundamental decency of our fellow men that would underpin it is still there and will, I fervently hope and expect, come to the fore in the months to come. *

So, wherever you are, and whatever your plans for tonight, I hope you give Oh-Ten a splendid send off and Oh-Eleven a roaring welcome. I hope to be back rather more next year, and I look forward to hearing all your news as time unfolds.

We shall, as ever be firmly installed in front of the Hootenanny, and we'll be raising a glass to you and yours, and us and ours.

Cheers to you all, and Happy New Year.

*Woohoo. "Big Society" three times in one sentence! Thesaurus- Schmesaurus say I.

Not only... but also....

So-ho. You all though last post would be a flash in the pan didn’t you. Go on, admit it, you know you did. Well to be honest so did I a bit. You see you, well I, make these resolutions to try to do better, to stay more engaged, to put down just a few words each day until you get to something postable... and then real life chucks great dollops of stuff at you, well me, or your tiny little butterfly mind flits onto something else and here we are three weeks on and nothing to show.

Anyhow, in the flurry of quite unexpected, and stunningly over generous comments to my last outing, my friend Bendy Girl set me a sort of a challenge, which I shall now attempt to answer. If you’ve not met her before you owe it to yourselves to do so now. Go ahead, click the link and have a browse, I’ll still be here when you get back.

It seems our heroine has started a “revolution from her bed” as she says. And there follows a small contribution from your humble interlocutor about two friends of mine. As regular readers will know whilst the following stories are “true” they are composites of more than one individual’s experience in each case and reflect the “patient experience” rather than identifying an individual.

So with all of that said, first let’s meet Dud. Dud has worked in light industry all his life. Of course by light industry we only mean not building steam engines or other very very heavy things. He’s worked with metal in heat and dust and smoke for years. He’s also been partial to the odd fag, to be sure (American readers take note: Fag = cigarette in “proper” English like wot is spoke in Ambridge), and as a result of all of these factors he’s developed that persistent shortness of breath that is COPD. He needs three inhalers several times a day to get by. That hasn’t stopped him working well past retirement age, his skills being too valuable to the company to loose. A few months ago his chest took a bit of a nosedive, he started coughing a lot more and he ended up in hospital. While he was in the nice docs did a chest x ray and found a nasty looking “shadow” at the top of one lung. Dud put two and two together, decided he wasn’t liking the arithmetic and quickly persuaded them to let him home without a lot more testing and probing. He’s on oxygen, is comfy, and is looking forward to sitting up for nights on end to watch the test matches from Down Under. We haven’t talked about his diagnosis, because we don’t need to. In the end the only thing he’s worrying about now is how much his treatment is costing and whether he deserves it!

Pete lives in Penny Hasset, a stones-throw from Ambridge. He’s been barman, cleaner and general factotum to the Penny Hasset Working Men’s club for decades. Though never a smoker he’s worked around smokers for most of his working life. From quite an early age he was identified as having bronchiectasis. This, for the uninitiated, is a poorly understood condition of susceptibility to recurring destructive chest infections that slowly but surely erode the normal architecture of the lung, leaving in their wake cavities which fill with phlegm which in turn render the sufferer more susceptible to infection. Three years or so back Pete had a really bad infection—bad enough to warrant admission to hospital with pneumonia. While he was there he developed respiratory failure and came home with both oxygen and night time ventilation. Against advice he went back to work. He lasted six months before I prevailed on him to be signed off. He was gasping, and the lifting his job entailed was patently far too much for him. Three months after signing him off the benefit docs asked him in for a medical, where they asked him a few questions, got him to do a few trivial physical jerks, and passed him fit to return to work. This despite me filling in a form explaining his need for long term oxygen therapy and night time ventilation.

So Pete gamely struggled back to work. At least by now there was a smoking ban so his working conditions were a little better, but come the following winter he had another exacerbation, a long spell off work, and finally lost his job. Thus far I’ve been able to persuade him he really ought not be looking for another, and again thus far, the B.A. docs appear to have seen sense and have accepted my latest report and stopped hassling him.

So there you have it. Neither Pete nor Dud would have chosen to be where they are now, and neither has asked not to work when they were capable. Indeed both have rather struggled on when reason would have suggested they ought not. And I could name you a dozen others in a similar position. All present talk of making it more profitable to work than rely on benefit may sound very noble and high minded in the marbled halls of power, where hard graft means having a lot to read and a few late meetings to go to. It completely misses the enormous efforts made by the likes of Pete and Dud to keep going against the odds, and any move to impoverish them is little short of scandalous and should be relentlessly pointed out for the evil narrow minded bigotry it is. I sincerely hope this is not what Dave and his cronies are about to do, but somehow I'm expecting to be disappointed.

Crikey _ _ *

Well, blow me down, here we all are in November. We are all here, right? I mean it's not like I've neglected you at all is it? Well not *really* neglected. Well I didn't *mean* to. Er...

Perhaps I'd better stop digging now eh?

Would it help if I said I'm sorry to have been away for so long and that I never meant to. There were lots of times when I sat down to put finger to keyboard, but the words just wouldn't come. There were even a few when the words just wouldn't stay away, but there was no time to tap them out-- rather fewer to be sure, but a few. Anyhoo-- if there's anybody still out there just let me say again, and for the record, I'm sorry for not keeping in better touch.

So there you have it.

Now what was I going to say....


Oh, yes, crikey!

~Er, that's where we came in-- why doesn't he just get on with it? ~

~Don't ask me. I only stopped by to water the plants!~

~Shhh shhh shhh shhh, it looks like he's going to say something in a minute...~

~well it's about blooming time if you ask me...~

Sooo Mondays...

~What does he mean Mondays-- it's Wednesday isn't it?~

~Shhh, don't scare him off he's only just come back!~

... well perhaps more this past Monday, but in GP land Mondays are funny days. People save stuff up for Monday, or get sent up by the nice out of hours docs after an encounter at the weekend, or wake up at the start of a working / school week feeling a but the worse for wear, and need to be seen stat...

~ooh hark at him going all E.R. on us~

.. just in case it's the killer lurghi, or Green Monkey Disease or whatever. In a nutshell Mondays always loom that bit larger on the GP calendar, unless they are Bank Holidays, in which case the immediately succeeding Tuesday gets promoted to honorary "Monday-with-knobs-on" status.

And so it was two days ago the the gods of Mondayness struck and blighted the surgery with a cloud of despondency. The whole day was a catalogue of grief and woe. I should have known it was going to go ill when the first three patients all moaned bitterly about having their blood pressure checked. Now it's never entirely comfortable having your pressure checked in the vice like grip of the sphygmomanometer (500 points in Scrabble if you can position it right) but on Monday apparently not only was the cuff extra squeezy, it was also "too cold"!

Like the rest of the building.

No heat on over the weekend means it takes till Wednesday duty surgery for the building to thaw, and last weekend was a tad "Parky" as they say. (And yes this is a Wednesday duty surgery and I'm feeling far more toasty thanks for asking). In the end though parkiness was going to be the least of the problems presented.

After coffee a couple came in to talk about the death of their son. it was sudden and unexpected, and there is nothing to say in such a consultation that isn't, however well intended, a platitude. The best you can do is to make sure the bewildered, bereaved and struggling couple in front of you know that you really mean it when you tell them you'll be here for whatever, and whenever they need you. Not an easy sell now we're closed weekends and evenings.

We spent a half an hour going round the houses, with me trying-- vainly, and inevitably so-- to persuade them they have nothing to blame themselves for. In reality this is true, of course, but in the messed up milieu of "feeling" and "emotion" it is anything but. There are always a thousand "what ifs", easy to ask and impossible to answer. We covered a few, and we'll cover some more as time passes, but sometimes, even when it's inadequate "stuff happens" is the only response.

From here it's how you pick up the pieces that matters. We'll help as best we can, and they have family and a phone number to call that will open up the doors to more and better support that I can provide. And my door will remain open for them for as long as it takes, but it all feels so woefully inadequate.

The rest of the day plods on with a succession of intractable depressives, horrid sore throats and one comedy ailment-- a poor chap who pulled his back when he was jolted by the shock of poking himself too hard in the ear with a cotton bud. Now he knows why the ENT boys say never put anything in your ear that's smaller than your elbow (go on try it, you know you want to try putting your elbow in your ear-- not you Bendy Girl if you're still out there, you just might make it and then I'd feel terrible).

And then with grim inevitability, in comes a girl to talk about the death of her mum. Of course you have to bear in mind that in this context a girl is anyone more that five years younger than me-- what with me still being so youthful and all, but here even at forty-mumble she's still her mum's little girl and always will be, even with mum suddenly no longer here. The perspective is different, but the consultation is very much the same. Mum had been ill for some time, and her end was not perhaps quite so unexpected, but that hardly makes a difference as anyone who's been through this will tell you.

There are days when I feel barely adequate to the task. And somehow they are mostly Mondays.

* fill in the missing letters for a fabulous virtual prize.

Does you does or does you don't...*

So we hover on the threshold of a brave new world, of which doubtless much more later—unless of course that nice Mr Lansley ponies up my share of the £70Bn all in one go, in which case I might soon be blogging from the Cayman’s. Somehow I think not though so you might all be putting up with me for a bit yet.

One thing we’ll not be missing from the old regime is the ceaseless buggering about with targets they like to call “micro management”. One of the weirdest of these was something they liked to call “Access” where the Holy Grail was that punters in need could get to see a doc within 48 hours. This was for us a nonsense, since punters that need to see a doc get fitted into a duty surgery appointment same day. Bit of an un-missable target then, or so one would like to think. Still we spent a happy year or three making monthly submissions to the PCT to prove that this was what we were doing, boxes duly got ticked and we all carried on our merry ways rejoicing.

Or so I thought until last week. For last week in walked a very shaky Susan. She’d not been to see us in over a year, so I was a bit surprised when she said she had come for a repeat of her anti-depressants, also not issued in over a year. I gently inquired as to the reason for the gap in treatment. It transpired that Susan had been seeing Dr Neighbour regularly for her combined anxiety and depression symptoms up until a year ago. Then the Cllr Dan Archer Memorial Car Park and Pizza Franchise just over the road from the surgery was closed “for maintenance”. This meant Susan having to park on the far side of town and walk through. Given the agoraphobia that was a large part of her presentation, this proved physically impossible for her, so she just stopped coming, and waited, indoors, for a year, for the CDAMCP&PF to reopen, so she could start attending again.

Of course no amount of measuring “access targets” can spot a patient like Susan falling through the cracks. I’m not sure anything else in our current armamentarium will either. You see we’re very good at pulling up people we think are over-using their meds, but we tend to the view that punters who stop filling scripts and coming to see us are either better or have moved on to other avenues for help. In common parlance it’s “a bit of a bugger”, and it rather puts all that silly target nonsense in the shade. Access indeed.

* I know it's unfair to readers in other juristictions, but an EVCHN to the Blighty based reader who can spot both the inane reference, and the sublime progenitor (the original song that is) for today's title.

Yesterday*

Spike came in this week for a chat. Nothing special in that really. We meet four or five times a year now to tweak his meds, catch up with the doings of the clever doctors in his various clinics, and the not so clever apparatchiks in the DWP.

Mostly what he needs me for is certificates to verify his status and the odd re-jig of his painkillers. The interesting bit is his status. You see Spike is a Revenant.
O.K. not the sort you need to fend off with garlic. Indeed Spike can walk quite happily abroad in the daylight. He can do it in Blighty too, and does, mostly, though not without a constant reminder of his if not unique then certainly uncommon circumstance. Oh and you can see him in mirrors too, in case you were wondering.

The difference between Spike and those other more spooky returners from beyond the veil is how he got here. Some time ago he was working in a factory. Having worked there pretty much all his adult life he reckoned he knew what he was doing, so when colleagues needed a hand unloading something big and hefty and made out of steel (sorry my grip of the technicalities here is perhaps a tad fuzzier than would be ideal), he stepped up, like always, and lent them a hand—in fact both hands and the whole rest of himself—as he had countless times before. This last time things went a little less than well, and in no time Spike found about half of himself pinioned under the hefty thing. In took something over an hour, cranes and such, and expert paramedics to extricate him.

In that time Spike drifted away for a while, and when he came too he was hooked up to all sorts of exciting contraptions which were re-expanding the lung that his rib fractures had collapsed, holding his leg back together, and supplying the pain relief he was going to need pots and pots of before he would be ready to try to move at all. Nobody said much at the time, but for a little while he had been what,in less technically gifted times might reasonably be called a bit dead.

It’s taken a while, but he’s now back on his feet and this week we got to discuss the various absurdities of his current position. Like anybody left disabled, either by health or injury, Spike has had to be assessed, and has become, like Schroedinger’s celebrated cat before him, a thing of percentages. Apparently, to the DWP he’s now only roughly 33% of his former self and in a bizarre twist, according to his employer’s solicitors he’s responsible for being so in a roughly similar proportion, since it wasn’t in his job description to help out his mates, and he wasn’t wearing the approved safety kit.

All Spike knows is it hurts him to walk now. Not much, but enough to stop him getting out and about like he used to. He can walk the dog, a bit, and do the garden, sometimes, but as for getting back to work, he’s still a long way off. Then there's sleep. Between nightmares he’s fine, and no he wouldn’t like sleeping pills and no the counsellor lady hasn’t helped a lot. And as to the hospital, a nice sister in ITU who had seen him through the worst asked him last month if he realized how lucky he was to have cheated death, like this was something to be instantly and unhesitatingly grateful for, despite loss of livelihood, and severe limitation of many of the functions he suffers that we all take for granted.

Spike knows, in a sense, he has been lucky, or at least luckier than he might have been, but her well intentioned comment really hasn’t helped. He now feels guilty about the bitterness and the sheer panic that sometimes overwhelm him when he’s transported back to his time on ITU or worse to the day it all happened and his old life ended.

So I tell him that’s o.k. and that for 1/3 of a Spike he’s doing pretty well and day by painful day he’s getting better. Who knows, soon he might even make a 1/2 Spike, and even now in his diminished and revenant state he’s still more of a man than some I look after who are notionally whole. And so we decide that this afterlife isn’t so bad after all, but he’s quite right when he says we should all be so lucky...

* I know this is a bit of a reach, but Virtual Hob Nob on offer if you link post and title-- you all know the drill by now I hope;-)

Of coffee and Hob Nobs.

So, I managed to keep this blog entirely free from politics all through the election... admittedly by the simple expedient of failing to comment on anything at all for the duration, and all through the tawdry aftermath for good measure. In all honesty things are a bit grim in Ambridge right now, so there’s not been a whole lot worth sharing, and really no time for sharing it all with you poor long suffering souls.

So colour me astonished when I received, through the comments of this shambling mess of a “journal”, a request from a publisher to review a book about my craft, written by an esteemed colleague known to probably nearly the entirety of the UK GP community. Consider the foregoing a declaration of interest. What follows is not exactly a paid endorsement, but I did receive, and am thoroughly grateful for, a copy of the said volume. All that said, I took this assignment with more than a little trepidation.

The thing is the author, one Dr Tony Copperfield (actually a collaboration of two practising GPs) is well known for his bi-weekly column on the back page of our Trade Paper “Pulse” where his worldly wise musings on the absurdities of the job, the relentless push for “evidence based medicine”, the inanities of the Contract, the Departmental Diktats and the lunacies of the PCTs (our immediate managers) never fail to raise a wry smile and a sardonic chuckle. But to let him loose on an unsuspecting public—would this be wise? I had my doubts.

I suppose at this point I should mention the book in question, “Sick Notes. True stories from the front lines of medicine.” It’s published by Monday Books and you can find it here.

Having received and devoured my copy I’m happy to say that this collection of Dr Copperfield’s writings strikes just the right note. The wit and the sardony (I know it’s not a proper word but it definitely should be) are still there, but leavened with stories of old friends and worthy adversaries in the form of Airfix Man (I defy you to read this snippet without at least the beginnings of a lump in the throat) Mr Nickleby (guess where Dr C goes for many of his pseudonyms), and Rebecca Bagnet, along with snipes at the political dimensions of health care, the PCT, the profusion of forms and hoops and brain dead rituals that seem solely intended to stop us doing the job. Along the way you will discover the central role of coffee and Hob Nobs to the functioning of any well regulated family practice and you’ll learn a lot about how UK General Practice operates... er, consults.

If you read this book you’ll discover why your GP adopts that strange far away look when you take him or her a little list, or begin with “I don’t see you often...” or end with “While I’m here....” . Dr C is indeed divulging some trade secrets, but he’s giving you a user’s guide to your GP into the bargain. Or at least he is if you live in this sceptered isle. Because Dr C practices here in Dear Old Blighty his descriptions of our working environment and the challenges it presents are very time and place specific, but the stories he tells of his patients and their woes are universal. And though the style is tongue in cheek the book is billed as a work of non fiction, and so it is. Not all of the events portrayed may have happened exactly as presented, but however much they stretch the credibility, believe me when I tell they happened, and they’ve almost certainly happened to your GP too. (I would have dearly loved to have been at the meeting where he and his partner presented the PCT with their newly “imagineered” Universal Referral Form.)

I suspect this book will be regarded as something of a niche market publication, but I hope it manages a wider circulation, and if I have one wish it is to make it compulsory reading for all PCT managers and Chief Executives. Indeed I’m thinking of passing my copy on to our own Beloved Leader, assuming it’s still in a fit state when my partners have done with it. I get the feeling there is a real gulf of understanding between our two disciplines, and I think Tony Copperfield might have give us a means of bridging the divide. So if you’re an NHS administrator, a politician in or aiming for the Health Department, or if you’re remotely interested in the workings of our shared profession, you owe it to yourself to read this book.

And the next time you’re in the surgery why not take along a packet of Hob Nobs for the troops? Tell them Tony sent you.

They’ll understand.

The Judgment Call

This post comes with a spoiler. There follows a replay a scenario I encounter five or six times a year. It's one of the very few (I hope) red rags that I can't help but charge when they are waved in front of me. I'm disappointed that after twenty years behind this desk I'm no better at handling them, and I know that what follows might well provoke an "equal and opposite" reaction in some readers. Please just take this as a glimpse into the darker workings of the Jesterly mind and not as implied criticism of anyone else.

If having read it you then have insights to share I'll happily receive them, and if you feel moved to "flame" then vent away by all means-- just don't expect a very sympathetic hearing if you do. On the other hand I promise I'll sit on my hands and not bite back.

So, now that's out of the way;

Monday 10.00 Request received to visit to Mrs Grundy.

Monday 13.00 Visit to Mrs Grundy, a lady well past retirement age. She requests visits roughly once, sometimes twice, every month or so. I find her, as I always now find her, seated in her living room, watching TV and with her lunch, three parts eaten, on a tray on top of her trolley / walking aid. Today she's feeling a bit chesty, and as is also often the case, her chest is essentially clear, but she has a nagging catarrhal cough that's been hanging on since New Year. We agree that it's a nuisance, but that she's not unwell, and there's nothing in her presentation that would indicate antibiotics are likely to help at all, and that the linctus she swears by is still possibly her best choice for symptom control. As is now her norm she sits barefoot with slightly puffy ankles and with an arcade of tiny thread veins and capillaries running the length of the outside edges of both feet. She frequently comments on them, but does not do so today. I decide to let this particular sleeping dog lie.

Tuesday 09.35 Request for visit to Mrs Grundy. Carers noted "Swollen legs and blue feet".

Tuesday 12.25 Telephone call to Mrs Grundy. She's aware of the carer's request, but agrees her feet are no different than they have been for the past year or two, and that she would not welcome compression (the only sensible "treatment" option here) even if I were to offer it to her, which she's sure I won't because she's made it very plain how she feels about this before. We talk about her trying to elevate her legs a bit more (something we both know she's unlikely to do-- but feel we have to discuss for form's sake). She thanks me for the call and agrees there's no need for a home visit.

Tuesday 14.40 Telephone call from Mr Grundy Jr complaining that "the Doc refused to visit my mum".

Tuesday 14.47 Mr Grundy unavailable on mobile number given to staff when I try to call back.

Tuesday 15.50 Mr Grundy finally answers mobile and staff put him through. We discuss the fact that his mum's feet have been as they are now for years and were fine in that context as recently as yesterday, and that she herself says they are no different today. "But the carer says she thinks mum's got a thrombosis so you've got to see her". "You know. For peace of mind." I remind Mr Grundy that if he or his mother are unhappy with the service we offer they are at liberty to register her elsewhere. He tells me he thinks he will.

Tuesday 19.00 Visit to Mrs Grundy. Her feet are as they always are and ever are likely to be. There is no evidence of thrombosis, but at least now Mr Grundy can sleep easy in his bed.

The main thought that occurs as I drive away is that I'm being used as a form of surrogate, by a son who is unwilling to engage directly in his mother's care. This would be fair enough were Mr Grundy living and working in Kent or Aberdeen, or Spain, or Florida-- as has been the case with others I look after. But Mr Grundy lives three streets away from his mother, and yet, for all his willingness to complain about the surgery and my approach to his mother's care, she sees me far more often than ever she sees him. I'm left with the disappointing impression that she might almost be better off if he did live somewhere far far away if this is his idea of "caring".

Proper poorly

Sorry not to have been around much lately. We've been a tad busy in Ambridge, especially this past two weeks, what with the bank holidays and all. Still at least it's starting to look as though spring might at long last be sprung. I'm going to try very hard to keep this space politics free this next month, but I can't promise. It depends how much I'm provoked. For today though a little treat from last week. I'm still not sure exactly what the problem was but I creased up with internal hysterical laughter at two points in the following exchanges. Virtual Lindt Bunnies on offer if you can spot where.

"Wellit'slikethisI'venotfeltwellformonthsnow,Idon'tknowwhatitisexactlybutI'vebeenfeelingreallypoorly,everythinghurtsandI'msotiredallthetimeandIjustwanttofeelbetter,"

"O.k. Where exactly..."

"onlyyouseeit'sbeenmonthsnadIjustfeelsoillandIjustwanttofeelwellagain.Imeanit'snottoomuchtoaskandIthinkIneedsomeantibiotics..."

"Right, so what is it you think the anti..."

"OnlyMrsWotsithadsomewhenshewaspoorlyandnowshe'stonsbettersoIreallythinkyououghttogivemesomenow."

"Yes but before I can I need to know..."

"Imenait'sbeenmonthsnowandIreallyshouldn'tbeleftfeelingthisillallthetimeit'sjustnotright,"

"But..."



"Carryon"

"Well what I wanted to ask was where you thought...."

"Wellit'sjustbeensobadIcan'tbegintotellyou...."

What's so funny 'bout ...

.... peace love and understanding?*

I'm struggling to find a way into this post, but once again there's something I need to get off my chest, so for those who prefer not to have to listen to me ranting on at length about a pet peeve, I urge you to look away now.

Right. There we are. Just a few of us left now, so stand by for a little serious spleen venting.

Not long ago I heard from a friend, that they knew someone who held a faith based objection to having their daughter immunized against HPV. Apparently this God-fearing member of the community felt that doing so was giving the poor girl tacit permission to sleep around with all and sundry. I'm sorry but to me this is wrong on so many levels that I had to put finger to keyboard in rebuttal.

And before we go getting carts before horses and saying that dear old Dr J the hippie and flower-child is off on a diatribe about free love and the like, for the record, I'm not. I'll admit to a more liberal interpretation of certain strictures held to more rigidly in other quarters, but there's no such thing as free love, and never has been. Societies order themselves as they will and their mores are adapted to suit the cultural milieu in which they are nurtured, but human animals being as they are behaviour at the individual level is mediated by a whole load of other stuff so that even the most intellectually enlightened and liberal of practitioners of the art can come very easily undone when emotions like jealousy sow seeds of mistrust.

My problem with the position taken by the righteous (self-righteous?) on this is two fold. First, observable evidence tells me that fear of cervical cancer is absolutely not what determines whether a fourteen year old girl has sex. Indeed even fear of pregnancy doesn't appear to enter into the equation for many. There are a great many other drivers that will determine when and if a teenage girl will become (in that most forensically clinical of phrases) sexually active. Peer pressure, alcohol and drug use must be significant actors, as are education and family and social background, and a whole host of subliminal and indeed "liminal" messages from our mass media.

For a few months in the wake of the much publicized Jade Goodie's untimely demise the issue of cervical cancer was very prominent and a great many women sought screening who previously would not have done. I'm not aware that it had any impact on teenage sexual behaviour however.

Putting all this to one side, my second objection is that the main thrust of this argument places all onus on the poor girl, who, as we understand the pathology of cervical cancer, is only exposed to risk by her partner. Granted, more partners adds up to more risk, but outside of a closed community daughters of the most devout families will end up with partners who might not share their up-bringing, or who have come to the religious life late and after a period of youthful experimentation. It is an orthodoxy of Sexual Health practitioners that when you sleep with a new partner then you sleep with everyone that new partner has previously slept with (in a purely metaphorical sense, by and large).

So a failure to vaccinate a young lady against HPV is at best wilfully blinkered and at worst negligent. Worse, it suggests that parents have absolutely no confidence in their daughters, or indeed in their own abilities to educate them and pass on the values that they live by, and hints at attitudes more in keeping with the strictures of the Taliban that the teachings of a God of love and understanding.

* Usual VECHN for first correct attribution of this shamelessly plagiarized title.

Out!

It's finally happened. To be honest I'd half expected it, but still it's a bit of a shock to the system. Monday saw us all sitting around the table at coffee time dissecting the events of the weekend, and talk turned to Dr Neighbour's kids who are off doing the now almost compulsory world tour on a break between studies. They're able to keep in touch by mobile (sometimes) and by blog for the rest. Dr N is new to the bloggoshere and has found the whole thing a revelation, being able as she is to keep in touch with the kids adventures almost as they happen, in word and picture as well as (when monnies and signal permit) by voice.

We sometimes forget how much has changed this past decade. Even ten years ago, when a cousin of mine was doing the same thing, mobile coverage was less reliable and relatively massively more expensive, and most of us were still on good old fashioned steam powered dial up connections so the occasional email from Delhi or Addis Abbaba or wherever, was the most we could expect, and the the hard copy photo's pasted neatly into albums when processed and sorted after the prodigal's return.

So there we all were marvelling the wonders that modern tecnology and permanent web connection have brought when, from the other end of the table comes a voice-- "You've got a blog too haven't you Jesty!"

Back when I started this "stream of consciousness" rambling there were precious few medical bloggers, and especially GP blogegrs about. Not so now as a trawl through the blog rolls of some of my fellow bloggers will attest. I've always tried to keep this little corner of the net under the radar a bit, but being blogrolled by these same erudite colleagues means that inevitably one of my partners blundered across the caseblog some time ago, but till now hadn't thought to mention it.

I'm not overly surprised, but confess to being a little dismayed. It's not that I write stuff I think will upset them, it's just that from here on I'll be more directly aware of the presence peering over my shoulder. Right now I'm not sure what I think about that, but I suspect it will change the nature of our interaction in this virtual place, so I'm asking you all, regular and more recent readers, to bear with me while I figure it out.

Still it could be worse. At least I'm not a formerly cash strapped epidemiologist. Then again, I'll never be portrayed on screen by Billy Piper either.

:-(

Are you Joe Public?

In a recent email a very good friend of mine asked me to describe my “average” patient in response to a typically flippant remark I’d made. Which got me to thinking—never a good idea as we shall now discover. Inhabiters of this Sceptered Isle will I hope be familiar with the work of the comic genius that is Dave Gorman, a man who, on a drunken whim, set out to find 54 like named souls and in so doing brightened my life considerably one evening a week for six weeks as he described his search with stats and graphs and all sorts. This all happened a few years back, and if you know nothing of Dave or his quest I urge you to seek him out here.

As an homage (or ommmaaaje as I believe it’s pronounced on the other side of the pond) I offer the following.

The first thing to say, is that the “average” patient comes in two distinct but similar incarnations. Let’s call them Routine and Urgent. In an ordinary week Routines outnumber Urgents by 7:1. On a busier week, like this, the ratio is 3:1, though every third Routine is in fact a Semi-Urgent, but for today they will be appearing as Routines (largely because I can’t face doing the additional maths to separate them out). Right, now that's clear on we go.

So, for this week Ms Routine has been assiduous in his attendance, though her gender identity has been perhaps a little uncertain, being as he is 55% female. She’s a pleasing mix of ethnicities being 8% East European 24% Asian and 16% Afro-Caribbean leaving him roughly 52% indigenous to Borsetshire or Expatriate Brummie.

She’s been around 32% depressed—this prolonged cold spell, the recession and pre-election tension all taking a part in this slightly high statistic. He’s also been 16% Itchy—again mainly thanks to the cold, and 24% giddy. For the rest she’s been pretty much equal parts infectious and sprained. Oh, and he’s been 8% pregnant and 40 years old. And called Paul.

Mr Urgent has been, if anything a bit more confused, being 63% female. She’s 25% East European, 6% each Afro-Caribbean and Asian and a surprising 6% Viking. He’s also only 89% here. Her religious observance is confused, being as she is 6% Moslem, 6% Rastafarian and 24% Catholic. As to diagnoses he’s been suicidally low, had a bit of a cough, a nasty stinging when she—er… you know, and he’s been 18% pregnant—and called Samantha. And she’s 37 years old.

So there you have it, Paul and Samantha, Ms and Ms average. I'm sure you all recognize them.

Margot (Four little words.)

When Jerry first got the back pain that turned out to be myeloma Margot immediately rallied round, sorted his life out for him and got him to and fro for his chemotherapy like the trouper she undeniably is. After around eighteen months the chemo' was stopped, and the myeloma was declared in remission. Jerry wasn't quite the man he had been, but with Margot's help he got back on his feet and soldiered gamely on for five years before the disease came back again.

Sadly this is exactly what myeloma does. It's the cancer that breaks pretty much all the rules, especially the one that allows chemo' to work. Normally cancers grow more rapidly that anything else in the body. the chemo drugs poison growing cells (which is why they make your hair fall out). It also means you can give doses that will poison just the cancer cells and the hair follicles-- well mainly, and leave the rest of the patient in reasonable nick. Not so myeloma. It grows way more slowly that normal cells and tissues, so to kill it completely we'd have to kill the patients other cells and organs a number of times over, so we have to use pulses of chemo' to contain rather than cure.

In the end Jerry proved unequal to the fight and slid slowly into that good night around six years ago. And poor old Margot, having been utterly solid throughout his illness, finally fell apart. The first couple of years alone were really tough, even the arrival of a couple of grandchildren did little to lift her spirits. Anti-depressants did their bit to hold back the overwhelming tides of grief, and sheer dogged determination hauled her slowly out of the pit.

A couple of weeks ago she was back after an interval of almost twelve months, during which she'd successfully taken herself off the med's and was thriving. We talked it through, and time and the gradual demands of the same growing grand children had worked their inevitable magic allowing her to reconnect with the land of the living. She was smiling, and rightfully proud of herself. Then, just before she got up to leave she innocently asked those four little words, "While I'm here Doc..."

Anyone with any medical training will tell you how freighted with menace that tiny phrase can be. And so it was. She just wanted to mention this little pain she'd been getting in her chest, just for the past few months, just when she was climbing hills or stairs, or, as it's been lately, it got a bit cold.

So now poor Margot's off to see the cardiologist, but she still managed to leave the room smiling-- for the first time in years. I hope it lasts.

The mark of Kane

In hobbles Adam, a man plainly in distress. So much so that he's had to bring Eve along, just so he can lean on her. He's bent double, and obviously struggling with severe back pain. Eve crosses the room and sits, but Adam elects to remain, standing hunched at the end of the desk, grimacing in a pantomime of pain that mimics a Greek mask of tragedy.

Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.

Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.

"Badges, badges?.... "

Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.

Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.

(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)

Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.

There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.

At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.

Twenty four hours later Mac' had died.

He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(

So where did everybody go?

Even readers far from these shores might have noticed that Dear Old Blighty in general, and Ambridge in particular, have been experiencing a little local difficulty with the weather. Here it hit on Tuesday, and shows little sign of clearing up until well in to next week. The result has been chaos on the roads, dire prognostications over our ever more fragile supply chain for simple necessities like fresh veg and gas as well as grit for the roads. Oh, and a sudden fall in demand for our services.

On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.

Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.

It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".

Another year over...

... and lest face it, '09 hasn't been all that special. This can be a miserable time of year at the best of times, as I think I might have mentioned a time or two lately, and it's been noticeably worse this year. Over the past two weeks every surgery has seen at least two or three young adults in floods of tears as the dam bursts and they finally have to admit that they might really be depressed. Mostly it's been on a background of lost employment, failed relationships, mounting debt, and for many, a looming fear of homelessness of of having to go back to living with parents. Even this morning, in my last surgery of the year there have been another handful.

At times like this I am extremely grateful to be doing the job that I do in the place that I do it, but these are problems I'm powerless to directly influence. I can suggest that my poor victims try to throw themselves into something that they used to enjoy doing, that they try finding an outlet to talk about how they're feeling, and that they take the pills I'm about to offer them. What they need is a guarantee of a job, a prince / princess charming-- or at very least a kissable frog, a sizable lottery win, and a place of their own, and none of these things are in my gift.

So today I'm counting my blessings, and hoping that for all of us 2010 will mark an up-turn.

Thank you so much to all of you who read this nonsense, and all the more to those who are moved to comment. You really do all go a long way to keeping as sane I am ever likely to be. All the very best to all of you in the year to come, and God bless us, every one!