Testing times?

A couple of weeks ago I had the pleasure of Brian’s company. He’d been at the golf club the night before at one of their legendary social functions. These functions used to be a simple excuse for a night of bacchanalian excess, but in these times of scrutiny and accountability even the hallowed portals of the Ambridge and District are not sacred and every function must serve an higher purpose. To that end the committee had invited in someone to do a bit of “health promotion” and offer “screening” before they sat down to their fifteen course banquet with attendant wine list, port and cigars to follow and brandies after the Loyal Toast.  

If you are detecting a hint of irony here I fear it was utterly lost on Brian.

In any event the screening on offer posed us a bit of a problem. It seems that Brian was informed his test (a P.S.A. allegedly) was “high”.

And that was all.

No advice about symptoms, no suggestion of what to do next, indeed no quantifiable information on what “high” might mean in “pounds shillings and ounces” *. Apparently the same was true for a few other stalwarts of the A&D, but fortunately they will be off bemusing their own medical attendants as none of them saving Brian are registered with us.

So what to do now? Well P.S.A. is a notoriously fuzzy test at the best of times. It’s undoubtedly captured the zeitgeist of those men, like Brian, of a certain age, and many attend seeking the “reassurance” of a quick test, on the assumption that a “low” result will ward off the spectre of prostate cancer. And here we run into a few difficulties.

The test measures a chemical put into the blood by an “unhappy” prostate. The problem is the source of prostatic disquiet could be anything on a spectrum from infection through inflammation to cancer. There had been hopes a few years back that it might prove useful as a test for the latter, but the test is just too imprecise to be useful and indeed the prevailing wisdom is that the potential harm of the number of unnecessary biopsies and other procedures that would arise from using it as a screen far outweigh any benefits it might provide in identifying new cases of prostate malignancy.

Needless to say, just because the medical establishment, hampered as it is by a need to evidence practice, doesn’t view the test as a good thing, doesn’t mean, now the Djinn is out of the bottle and the movers and shakers of groups like the A&D up and down the country won’t engage the services of the 21^st century equivalent of the Snake Oil salesmen of old. So it is that they end up buying in unproven services from unscrupulous predators, keen to turn a fast buck at the expense of the anxious and ill informed, all from the best of motives. But this leaves Brian with a bit of a problem. Now he’s had a “screen” and it is “high”, but he has no symptoms of prostate disease.

I’ve offered him an examination (not described here for the sake of the squeamish—fans of Billy Connoly will know what I’m talking about though) but for now he has declined. Do we repeat the test, and if so when, and what do we do if it comes back raised again.

He’s agreed to go away and think about it for a while, and knows to come back at any point if he starts developing symptoms that suggest his prostate is unhappy, but I’m not sure he won’t be back asking for a lab test at some point in any event.

*EVCHN for attribution as usual.

Brand X

Enter Jamie, from his Nike trainers to his fashionably oversized baseball cap (I’m guessing it has some other appellation, but am too unhip and disinterested to go looking—but you all know the sort) festooned with its own logo (which again I “should” know, but again can’t really be bothered enough to go looking) he is every inch (or centimetre for the younger reader) an Ad Man’s dream.

Now I know I’m old, and grumpy, and horribly uncool, but I can’t be doing with all this branding. In the good old days, when life was austere—and I mean properly austere, not the austerity-lite Dave and George are enacting, we were glad to have shoes of any sort—let alone trainers, and trousers that came to within four or five inches of the floor without having to have extra bits let in. Labels were things you cut out of the back of your jumper to stop them itching, not “accessories” to blazon every spare surface.

Well o.k. there was the year every red blooded male child hankered after a pair of hiking shoes with a compass in the heel and a “bear paw” tread, but that was essential survival gear for when you found yourself trapped behind enemy lines, a fate more common for the average eight year old back then, when the average eight year old was allowed, nay expected, to play out in all winds and weathers and states of enemy occupation… but I digress.

On this occasion Jamie (who’s closer to sixteen than eight by the way) was accompanied by a worried looking Cathy (his mum) and after a cheery Jesterly “What ho!” she prompted him to roll up a letter strewn sleeve to reveal the forearm underneath. It transpires Jamie’s forearm has a hole in it. Well more a crater than a hole—it has a base. A mainly greeny-grey rather septic looking base, with angry looking red edges all around. It’s around 2-3 millimetres deep, and self inflicted. A few nights before, Jamie and some mates had been out braving the Biblical floods getting out of their heads on scrumpy and howling at the moon (traditional country pursuits in these parts). For some reason they then decided to do a spot of branding of their own, and one by one heated a lighter to a glowing white heat before jabbing it, now unlit at least, onto their own forearm!

On the plus side, in the modern era of antibiotics the resulting sepsis can be easily treated, and the circle is no bigger than the blunt end of a pencil. On the minus side it looks deep enough that it can’t but heal with a substantial and rather ugly looking scar. Unlike the brands he’s wearing now, but will be too cool for himself in a year or two, this one will be for keeps. He says he’s not unhappy, he wasn’t “self harming” in that sense, and that it was just a “lark”, and for now I think I believe him, but I hope this isn’t the start of some new and scary trend. Somehow it feels far nastier that the present dual fetishes for piercings and ink.

Nice Weather....

April has been an odd month in Ambridge. For odd, read wet. Indeed were I of a superstitious nature I’d be laying in biblical quantities of wood right now, and assembling a binary menagerie. You see the Am has burst it’s banks and roams abroad the flood plains of Borsetshire like an invading army and the denizens of the quaint Am-side villages are stockpiling tinned goods and filling sand bags “just in case”.

In consequence the roads of the customary drive to work have become waterways, especially those approaching the foot of the Ambridge Escarpment. Last week I sloshed up behind a Clio that was crawling along at a sedate pace in the middle of the canal… er, road, seemingly oblivious to the tailback that was forming in short order behind me.

It transpired as they approached the rise to the aforementioned escarpment, that there was a tailback of their own in front. Or at least a tail attached to the back of a young lady mallard who had, not unreasonably, taken this particular part of the Queen’s Highway for a new tributary to our mighty river, through which she was paddling and plashing along, oblivious to the chain of four wheeled watercraft arrayed in line astern. I can’t help wondering what went through her mind as she encountered the uphill gradient of this particular watercourse though.

There have been benefits to the “wettest-April-on-record”. The lawns at Jest Acres now, at last, have a greenish hue and no longer resemble blasted and windblown tundra. Admittedly most of this greening is of mossy origin, but as you all know I’m never one to complain. And the wizened and stunted trees of the soon to be legendary Jest Orchard have finally seen fit to sprout a few green shoots and varicoloured pink and white blossoms which cling desperately to their branches for a few moments before being lashed away by the battering rains.

Just now it looks for all the world as though May is destined to continue the aquatic trend, though we are told it would need to keep up like this for months ahead if we are not to regard present conditions as a drought still. (It seems the spirit of Michael Fish is alive and well at the Met Office). Be that as it may, imagine my delight when, on approaching the escarpment this morning I espied a hastily hand painted sign reading simply, “Caution! Ducks!”

Roll on the 23rd Century

What follows is perhaps not for the squeamish, or for reading too close to mealtimes...

It is an inconvenient truth, but there are some things we are called on to do that are just plain awkward and embarrassing to have done. Until Dr McCoy’s hand held “Wibbly” scanner is invented we have to make do with more archaic and difficult methods, and en route to that same Star Trek tech we are developing methods that though better than the traditional, are still plain odd at first blush. (Blush being very much the operative word here).

There, how very English of me. I’ve spent an entire paragraph skirting around a difficult topic without saying anything meaningful or illuminating. And I’m risking spending another doing just the same, so time to bite the metaphorical bullet and get on with it. There’s an old surgical aphorism that’s as true today as it’s always been, and it simply states “If you don’t put your finger in, you put your foot in it!”

Men of a certain age, and ladies of pretty much any age will now be cringing and looking away squeamishly. The awkward reality is that there are some bits of us that can go spectacularly wrong, that we can’t actually see, and so, to gain a better understanding of certain symptoms of alarm we have to rely on other methods. These begin with the simple (?) “digital exam”. No, not some clever electro replacement for “analog exam” just the humble expedient of placing a gloved finger into an orifice and “rummaging” (it’s actually a bit more technical than that at the operators end, but I fear further explanation would put us all off our cornflakes). This method remains the gold standard for initial assessment for enlargement of the prostate and early examination of some suspected ovarian problems and can help differentiate the likely causes of some abdominal pains or “funny bleeding”.

Moving along we have an array of other bodily intrusions on offer from the now antique barium studies through scopes for use from either end (though separate scopes for each you’ll be glad to hear), there are also scopes that go up the hooter (or schnozz for American clinicians). The latest innovation in our neck of the woods is an ultrasound probe designed to bypass the bones of the pelvis to generate ultrasound images of the uterus and ovaries internally. All of these would fit nicely into the folklore attending those lurid tales of alien abduction so beloved of Midwestern agrarian types and hairy, wild eyed, science geek conspiracy theorists.

So why am I mentioning all this now, I hear you ask. You did ask didn’t you? You’ve not just read a couple of lines at random and run away screaming?

Good.

So why indeed.

On a handful of occasions down the years patients, including one of mine right now, resist the suggestion that we intrude on their “personal space” to such an extreme degree. Despite careful explanation they find the concept of an invasive examination too personally challenging. Mostly, with some gentle persuasion they can be won round, or alternative methods can be found to garner the necessary information, but every doctor carries with them a few cases where this has not been possible, and for the want of a timely smear, or prostate exam, or colonoscopy or other such “space invader” examination, an aggressive disease has taken hold where it need not have.

For these patients, as Dr Neighbour so elegantly put it a few weeks ago, it’s as though they are “dying of embarrassment.”

It's all Greek...

Two weeks ago, in mid-afternoon surgery, there was a soft “plink” noise. Only a quiet noise, but such a noise as comes laden with evil portent. Accompanying the “plink” was a flash of the screen, followed by an evanescent appearance of the fabled BSOD* then nothing. Like a heavyweight boxer smacked on the chin by Ali in his pomp, my computer folded at the knees, collapsed to the canvas and tiny cartoon bluebirds started flitting around its brow to the accompaniment of a tweety whistle.

The gremlins had struck with perfect timing, late on the Wednesday before the Easter weekend. So Maundy Thursday morning we called IT. They promised and engineer on next working day (i.e. Tuesday). No big problem as one of our learners was off on hols and her broom cupboard --- er *room* (ahem) was free to consult in. **

After a tranquil and relaxing Easter (yeah right… but that’s another whole set of stories involving fire and sacrifice and tedious little distractions of a similar sort, not for here and now) your humble interlocutor was out of surgery on Tuesday morning touring the Nursing Homes of the district—part of a new initiative to enhance our care of the elderly-- and so fully expected to be back after lunch to find a shiny new terminal humming away right as nine-pence.

No such luck!

Happily we were a nurse down so had a treatment room spare, with a computer in, so 3 days 3 rooms and on with the motley. Except none of the punters could get used to the idea of me consulting in the nurses room and all and sundry developed a compelling need to rummage in the treatment room cupboards for this dressing or that blood tube as I was trying to work. Still we got through. But by close of play still no sign of IT.

Wednesday and Dr Neighbour was out all morning—day 4 room 4 and by now it wasn’t just the punters that didn’t know where they were going. All my diagnostic kit was liberally distributed through the other three rooms, all of which were now in occupation, so whenever I needed to check an ear, dip a urine or test a BP I was off wandering the corridors like a lost soul looking for my kit. Oh and Wednesday we had a student in for tuition with yours truly. The poor thing didn’t know what on earth was going on, but gamely took to entertaining the punters whilst I roamed chuntering through the building questing for this or that.

IT phoned late on Wednesday and announced they would definitely be in on Thursday. Probably.

Thursday we had a problem. Everybody was back in and consulting, so I had a room (my own) with no computer, and there was a computer in the office space behind reception with no privacy. Solution, print out contact sheets for the whole surgery (recent history, significant problem lists, current meds and any up to date bloods) and consult without the “one eyed monster” writing scripts by hand and updating the computer record afterwards. Simples!***

So sure enough two patients in, IT guy arrives to install a new box and take the old one away to be sealed in carbonite and buried in a vault on the Death Star. Brilliant news, except that he needed an hour and a half to twiddle knobs and adjust dials to get the thing working properly. And it’s a one time now or never offer ‘cos he’s got to be elsewhere working for a godlike NHS manager by 13.00 and he’s off to a stag do in Amsterdam after that (you’re thinking TMI right? So was I). So send all the punters home or try to consult in the car park? As I ask the question of our chief receptionist we both look to the vacant practice manager’s office for inspiration. P.M. off for the week getting drowned in the balmy post Easter rains so no help forthcoming from that quarter.

Now I know you’re all already ahead of me here. Office, vacant, and with computer linked to clinical system. There followed what the younger generation would call a face-palm moment.

Day 5 room 5 and by lunch surgery sorted and back, at last to normality. I’m back in my Tardis and all’s right with the multiverse. Excepting the trivial matter of a loss of data slowly gleaned over ten or so years of consulting and only partially and fitfully backed up. And the abiding impression of a few dozen punters and a final year student of my Alma Mater that I’m a bumbling fool who suffers with terminal “olecrano-gluteal dysgnosia”****.

*Blue Screen Of Death

** Yes the Ambridge surgery treats its learners rather like Hogwarts does. Only without the pointy hats and wands and such.

*** In joke in Blighty about a talking meerkat. In all honesty if you need to ask you're better off not knowing, trust me. (Though You Tube will probably oblige, but you’ll really wish you hadn’t bothered. Honest.)

**** EVCHN for first correct translation. (There's a tiny clue in the title)

A good walk

Ray’s been back in a couple of times recently. When he arrives the front of house team find him and his dopey black lab a quiet seat out on the maelstrom that is our waiting room, and instead of the usual summoning by bells I actually get up and prowl the corridors to fetch them. Only the time before last there he was on his own.

The last time that happened it was because “Rockstar-dog” his first and dare I say prettier guide dog had succumbed to a coronary at the relatively spry age of ten. Since then he’s had “Dopey-dog”, who has been a faithful, if far more docile companion. So, with grim inevitability, I plant a size nine boot firmly in mouth by enquiring “What, no Rockstar-dog today?” Ray is of course far too much the gentleman to pull me up on my alarming faux pas, but gently says “No, Dopey-dog is out with my neighbour for a run...”

Our consultation runs its course, he’s actually looking better now than last summer when he was experiencing problems with his meds, and as we finish and I’m walking him back to the pharmacy, we return to the subject of the absent Dopey. Apparently the neighbour purloins him now and again to prowl the perimeter of the local golf course, seeking out strays. Stray golf balls that is. It turns out the neighbour is a devotee of the “good walk spoiled”.

Happily the quote stays firmly in my head, as Ray inquires if I play myself. I have to sheepishly admit I do not. I know it’s something of a cardinal sin for a chap of my tender years and noble profession not to play, but I never really saw the point. At my admission Rays face lights up in recollection—“You really should you know, it’s a great game. I used to love it, back before the arthritis got me.”

Now Ray is almost to the day ten years my senior, and the arthritis well and truly got him a good three and a tad decades ago. Anything that sparks such an evidently joyful reaction on reminiscence can’t be all bad, can it? So now I’m beginning to wonder if I’m missing out on something. Not that I’m sure I’ve got the time for a new pursuit just now, but that’s another story.

And yes, Dopey-dog was back next visit, and still in need of guiding, by me, to my room, the room he’s been coming to four or five times a year for most of his adult life while he’s been “guiding” Ray. But it seems the both of them know their way around a golf course better than I’m ever likely to.

Something something Dark Side....

I can’t quite believe I’ve done this, but after a small discussion piece courtesy of Aunty this morning (Radio 4 Today programme to be exact—where else?) I’ve just toddled over to the dark side for a peek at “Conservative Home”. It’s a scary place for a dyed in the wool pinko liberal like myself, but Tim (the proprietor of same—apparently that’s how his punters like to name him) has woken up far too late in the game, to the unpopularity of the Health and Social Care Bill. Well done Timbo. Trouble is you’re a couple of years late and a tad more than a dollar short (roughly £20 Billion in modern nomenclature).

The reality is, whether Dave ditches Nutter Lansley (the Fred Dibnah of NHS restructuring) or no, the damage is already done. The changes our esteemed Health Secretary wanted made have been enacted by fiat, un-trialled and unchallenged and there’s no turning the clock back now, Bill or no Bill the NHS must restructure because he’s already blown to tiny pieces the bodies that were running the fractured health economies that made up the hopelessly balkanized soi-disant “National” Health Service. With PCTs de facto abolished and Commissioning Groups champing at the bit to take over (but still in our locale hopelessly ill equipped and un-resourced), Dave and the soaraway success that is our coalition can fiddle all they like. Rome is well and truly ablaze and we can only await the Phoenix that will arise from her ashes.

Tim’s article and the opinions of his various commenters just go to show how utterly our political class fails to grasp “health” as an issue. They can’t resist tinkering and faffing. As I’ve argued before it would be impossible for them. It’s not their fault, and it’s not particularly different under this administration if I’m honest, except in outcome. Lansley has been more radical that some, less than others in his stated intent, but worryingly, he has been let loose to run amok BEFORE fully framing the legislation and establishing the structures that would allow his reforms to take shape. The last time this happened, in 1997, it took us a while to sort, but thanks to the dedication and professionalism of countless much derided NHS managers, and the care and devotion of all the NHS professions, it got sorted.

My worry is that we’re not now the service we were then, and that the dedication and devotion has been severely eroded by over a decade of being on the sharp end of loony initiatives and make-work restructuring, plus struggling to hit unattainable targets, like performing seals honking air horns for fish. And this erosion is far from the fault this administration alone. Indeed though the seeds for our present difficulties were sown by dear Margaret Hilda and her barmy army, they were seized on wholeheartedly by Tone and Gordon and driven further and harder under them than I suspect any right of centre government would have dared.

So if this is all sounding rather like a counsel of despair, you’re probably right to see it as such. It is far from clear what our battered health services will look like when and if the dust settles. Locally our own health economists are looking at a “once in a lifetime opportunity” to reshape services for the future, but I fear even before their plans have been drafted we’ll be moving on to the next initiative— and scrapping the bill will make very little difference one way or the other. Sadly health in real life isn’t like health in the popular imagination—fuelled as that is by dramas that wrap up a complex case in sixty minutes (forty five on independent channels to allow space for adverts for things almost calculated to make you ill). And politicians, as again I think I’ve said before, are taught to think in terms of balance sheets and changes to be delivered in their entirety within eighteen months or at least ahead of the next reshuffle. So Tim, if you’re listening—and I can’t see any reason you would be-- say what you like about the bill and its prospects for Dave’s re-election chances, but please, please spare a thought for the poor bastards on the receiving end* of your masters' extravagant insanities, and try to persuade them to think in terms of generations and not reshuffles.

* Oh and by the way that’s all of us—assuming you’re ever unfortunate to suffer a long term ailment that the private sector won’t insure—like diabetes, arthritis, heart disease, chronic lung disease, any occupational ailment..... well pretty much anything except a boob job** if I’m honest. Oh and especially NHS managers—those we have left.

** Oh and probably boob jobs too-- at least if they were done on the cheap.

I wouldn't get too excited, but...

"Crikey, two posts in under a month-- what's he playing at? You wait months and months and nothing at all, then this..."

"Shh I think he's trying to say something!"

"Well I for one am not holding my breath so there!"

(And you're right not too. It's been a bit quiet round here of late I know, but here goes...)

As you can probably gather 2011 has hardly been a vintage year at Jest Acres. In fact we’ll none of us be too unhappy to see it go. There have been times this year when it’s been hard to string a coherent thought together, let alone get anything down on the page—virtual or literal. I miss writing hugely, but for large chunks of this year the words just wouldn’t come. There have been moments and punters worthy of anecdote, but it’s just not been possible, and for that I apologize to those of you who might have stopped by from time to time.

I’m hoping for better things in 2012, though if we’re to start looking after 25% of the inpatient population in addition to doing the day job (as one boffin seems to think we ought, to the rapturous reception of Mr Lansley among others) that might be a trifle ambitious. Whatever the case I’m determined to try harder to put virtual pen to paper as it were.

I hope ’11 was good to you all, and whether or not, I hope ’12 will be fantastic for us all. There’s a lot of doom and gloom about pretty much everywhere at the moment, but despite it all there is much to be grateful for (among many other blessings I’m especially looking forward to sampling some home made Mars Bar Vodka over the New Year holiday—if I survive I’ll report back).

So a slightly early Happy New Year one and all, and I’ll be back, soon I hope, to see you all next year.

East of Eden

Whether you take it as revealed truth or allegorical myth there’s something compelling about the argument that we live in a flawed and imperfect world. Perfection is there to be striven for, but it’s unrealistic to expect that we shall get there alone. We allow in our oral histories that transcendence *is* possible, but only to a very few very special individuals, and then generally with the help or agency of some higher power. For the rest of us East of Eden is where we are expected and expecting to remain—in this life at least.

Indeed, if anything just now it feels we’re heading further and further east, away from calm, plenty and fulfilment as each day passes. Perhaps it doesn’t help that it’s winter now for real in Ambridge, after an Autumn so mild half the bulbs at Jest Acres seem to think it’s Spring again, but the old Crystal Ball resembles more a Snow Globe than anything else looking to the next year or two.

In the midst of all this gloom and angst we get a bizarre assertion in the news today. 24,000 deaths a year could be avoided if diabetes were treated better. With a token apology for pedantry, avoided? Really? Now I know modern medicine is pretty hot stuff, but I’m not aware of any innovation potent enough to permit us to avoid death. It’s not clear from the reporting whether this is a verbatim quote of a grandiose claim or just sloppy journalese, but I fear I have to disappoint you all. The best we can attain for now is a deferral, which in the colloquial idiom “ ain’t nothin’" but I fear falls far short of the alleged outcome.

I’m also a little uncomfortable at the assertion that there’s some kind of blame to be attached in each of these 24,000 “un-avoided deaths”. It’s almost certainly true that a great many could be helped to look after their diabetes better and in so doing delay or avert death from this condition, but it is equally the case that a number of them would prefer to be let alone, not seeing a prolonged existence as desirable for any of a number of reasons, some well thought through and some, to external scrutiny apparently frivolous.

I worry that in seeking to target this group of patients for “better” care we risk trampling on their autonomy. This is an increasing trend in all areas of modern patient care, where we are pressed to treat to a target—evidence based for sure, but paying little or no regard to the individual on the receiving end.

This is in no way to suggest that trying to offer better holistic care would be a bad thing, and if by so doing patients can be engaged and encouraged to try a bit harder to reach the targets then this can only be a good thing, but where like Mme. Voizin in Chocolat there are patients who know their choices are unhealthy, but opt to continue to indulge, accepting a shortened rather than an impoverished span, who are we to deny them.

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;-)