Sheila is 82 years old. She has lived in the same house, in the same village all her life. She never married, has one distant relative she doesn't speak to, and rarely comes to the surgery. She always drives herself to her appointments. She never forgets to come. In the last few years, Sheila's health has become more complicated. She had raised blood pressure on a routine check. The blood tests showed she was diabetic. Her blood sugar control was erratic. A concerned neighbour rang the surgery a month ago - Sheila was unwell. She had a cough which hadn't gone, and now looked ill. They brought her into the surgery, and she was admitted straight away. The diagnosis was bronchopneumonia, complicated by poor diabetic control. She stayed in hospital for 10 days; a long time in an era of rapid discharges and bed pressures. She was discharged home on insulin to improve her diabetic control. A fax was sent to the district nurses to go and deliver the necessary equipment the next day.
When the district nurses rang and asked for an urgent home visit, I went out. Sheila's village is 20 minutes' drive from the nearest town. Her garden was overgrown, a challenge to reach the door. The nurse opened it to my knock.
"Come in" she said. "Don't sit down anywhere".
The house was filthy. Thick with dirt on the floors and windows. There was no food in the kitchen. The air was thick with cigarette smoke. No central heating. No phone. The carpets, threadbare. The drawers, full of packets of untaken diabetic medication. In the middle of it all sat Sheila. She was bemused more than anything when I explained I'd come to see how she was getting on after her discharge. How were her blood sugars? Was she eating regularly? Who was doing her shopping? Did she know she wasn't meant to drive? Where was her toilet? Could she wash on her own?
It was a mess. The decisions about her treatment and discharge had been made with no knowledge of her home situation. While medically correct, they were never going to work for Sheila. She had never asked for a home visit before, as she had never needed one. We, and the hospital team, had no clue she was living like this. She refused all offers of help. No she didn't want respite care. She didn't want carers from social services. She wouldn't consider going into a home. She didn't want her relatives to be contacted.
Sheila doesn't care about seven-day opening. What she needs is time. She needs continuity, to build a relationship with a GP, with a district nurse, who can gradually try and help her understand that she needs some help. She needs a weekly visit from me, and at least twice weekly from the nurses. She needs our time. And this is the one thing I can't offer her. We are all stretched too thinly for me to spend the 45 minutes once a week that this patient needs. She will only see us if she has an acute deterioration in her medical condition. The best I can manage is to ask the district nurses to see her when they can, and let us know if they need GP input. But they are stretched just as thinly as we are. The days of visiting because a patient was high risk and needed a long term approach are gone. We respond to one crisis after the next. If we had some breathing space, we could do so much more for our patients.
David is 75 years old. He has dementia. He is one of the few who was suitable for medication, and for the last five years, has managed well. Another patient who rarely attends, he comes in to tell me he's tired. He has managed to make the appointment himself, and come on time, so whatever symptoms he has are enough to prompt this change to his established routine.
Unfortunately, because of his dementia, I cannot find out anything else about David's tiredness. He lives alone, has no family, no help. He manages fine. But his memory is such that when I ask about every symptom I can think of: "No problem there doctor" is his reply.
I examine him head to toe. There is nothing to find. I arrange some blood tests, and ask him to come back in a few days time. I write it down, hoping he will remember.
I need to see him at home. To spend some time trying to solve this. Is he tired because of an undiagnosed medical condition - cancer? Is he simply ageing? I can only judge what is in front of me, and my detective skills are letting me down. We are taught at medical school that 90% of the diagnosis is the history. When I don't know my patient, and I don't have the time to get to know them, what can I do?
David doesn't need to know how much his dementia medication costs each month. It won't make a difference to him. His dementia may mean he won't understand when £ signs appear on his boxes of tablets. He might think he needs to pay someone for them, or that he is spending his own money to buy them. He needs my time. He needs me to get the chance to know him, so I can do a better job as his GP.
Amy is 19. She was put into care at a young age due to abuse and neglect. She developed mental health problems and has been on medication since she was 14. She has three children by different fathers, and has been in a string of abusive relationships. During her last pregnancy, her depression worsened. Social services have placed her children with a foster carer, while Amy tries to put herself back together. She has spent the first 9 months of her baby's life seeing another woman becoming Mummy. She is desperate to have her kids home, but we go one step forward, two steps back. I've lost count of the overdoses she has taken. The number of time she has been taken to A&E after cutting herself. She has fallen through the gaping holes in mental health care. She doesn't qualify for the specialist care for post-natal depression because her problems pre-dated her pregnancy. If her children lived with her, she would be getting intensive support to ensure they were being cared for. She is penalised because they aren't; relying on the insufficient support that every other mental health patient faces now. Her days are plagued with guilt about not being there for her children. She cries herself to sleep every night. She can't see a way out, and every time she starts to make progress, the guilt overwhelms her and she overdoses again. She still doesn't have an allocated psychiatric nurse, as she moves between the hospital and community crisis teams, never reaching longer term follow up.
As a mother, my heart goes out to her every time we meet. I cannot imagine how she feels, but can see the despair etched on her face. All I can do in our appointments is to listen; to try and reassure her that her children are being well cared for, and to try and be optimistic, that maybe the latest change in her tablets will make a difference. I want to spend half an hour with her. To try and offer her the consistency and support she needs. I can't even offer her this. We don't have enough appointments for her to book in advance, demand is too high. We can only control it by making everything bookable on the day, so she has to ring at 8am like everyone else. If she's having a bad day, she may not turn up.
Fining Amy for missing her appointment will achieve nothing. It will simply heap misery on a patient who can really sink no lower. I won't be the one to make that decision. I won't make it my responsibility to chase and penalise someone who is suffering so much already. What Amy needs is an individual, tailored approach to her heart-breaking situation. The "one-size fits all" world of Mr Hunt's metropolitan life, with seven-day access to a GP or nurse you've never met, to treat the minor self-limiting illness that has been irritating you since that morning, will not help these patients. They need to see professionals who are experienced, highly skilled, with the time and resources to care for them. To take the longer term view than simply the 10-minute appointment slot, and so reduce the burden on both the NHS but also social care.
It is patients like these, and our inability to do the best we can for them, that is making doctors leave general practice. The government's vision of medical care in this country is not going to help these patients. They are the ones who will suffer from the cuts, the fines, the charges, the agenda of convenience. When I rant about the problems in general practice, it is these patients I am thinking of. Not myself, and the stress of doing a challenging job. I genuinely believe that if the proposed changes to primary care continue, it is patients like these who will be the silent, forgotten casualties. They won't make headlines, but they will be suffering. Whose conscience should that be on, I wonder Mr Hunt?