My first home visit of the day was to a 97-year-old woman who just ‘wasn’t right’. Her daughter had phoned around ten, while I was still doing the morning clinic. Between patients I’d noticed her name pop up on the screen. ‘What do you mean, “not right”?’ I asked Pearl, the receptionist, on my way to call someone from the waiting room. ‘Just that,’ she shrugged, ‘“not right”.’
I visit Betty Cruikshank every month or so. She lives with her disabled daughter, Norma, in a two-up two-down, and spends most of her day on a bed in the back room. There are crash mats around the bed wired to alarms, because Betty is in the habit of climbing over the high rails fitted to her bedframe. The last time she managed it, a couple of months ago, she lay for an hour before she was found, her ankle tangled in the rails. She has dementia and has had a couple of strokes, but she manages to eat the food that the council’s carers or Norma put in front of her, and she co-operates, for the most part, with their attempts to keep her clean.
It was true – she wasn’t right. ‘Hello, Mrs Cruikshank,’ I bellowed in her ear, and she took a long time to reply. When she did speak her words were slurred, and she seemed to look over my shoulder rather than straight at me. She wouldn’t lift her arm or show me her tongue when I asked her to, and I heard an ominous rattling sound when I put my stethoscope to her chest. She was breathing faster than usual.
‘She’s spluttering when she drinks,’ her daughter said. She used to work as a carer. ‘Could she have had another stroke?’
‘She might have,’ I said, ‘or she might just be more confused with the chest infection.’
Betty has had a ‘Do Not Attempt Resuscitation’ order in place for years. She has been in and out of hospital with chest infections, and once with kidney failure. ‘We could take her for a scan,’ I said, ‘to see if she’s had a stroke, but …’ I paused to gauge Norma’s expression. ‘But to be honest, I think she’d be happier if we kept her here, and tried treating the infection with antibiotics.’ Norma nodded, obviously relieved. ‘We can see how she gets on. Ring me if you’ve any worries, and I’ll get back in touch.’ If Norma weren’t at home she would have had to be admitted to hospital; carers from the council come in for just a few minutes at a time, at most four times a day.
I had just strapped my briefcase to the rack on my bicycle when the phone went off in my pocket. It was Pearl: ‘Are you still out?’ she asked. ‘Mary Robertson’s just phoned, she says she can’t breathe.’ Another visit now meant I’d be at least half an hour late starting my afternoon clinic. I put the angry patients in the waiting room out of my mind and focused on Mary Robertson. I knew her less well than Mrs Cruikshank, but I recalled a fit 92-year-old widow who lived alone in a sheltered housing complex, still managed her own shopping and had a carer she paid for, who came once a day. I knew there had been bladder problems, hip pain, but couldn’t summon much else.
Her voice sounded breathless and panicked on the entryphone as she buzzed me into the complex. Inside, pastel walls hung with innocuous prints, hard-wearing carpets and stairs edged with metal footplates. Her door was open and I pushed my way into a meticulously clean apartment, red alarm cords hanging from the ceilings, each wired to a central office with a telephonist on duty. Mary wore an alarm button on a pendant around her neck; she sat perched on the edge of her sofa, breathing hard, dread in her eyes.
She said she’d been getting more and more breathless for the last two days. No, she hadn’t had any chest pain; no, her ankles hadn’t been swelling. She had low oxygen saturation of 92 per cent, her breathing rate was too fast and her pulse rate was well over a hundred. On the left side of her chest I heard air moving normally, but the right side was practically silent. When I tapped her chest it sounded hollow on the left, but on the right it was like tapping a stone.
‘I think you’ve got water on one lung,’ I said, sitting down beside her. She was using her hands to push against her thighs, the better to lift her shoulders into each breath.
‘What can … you do … for that?’ she asked, every couple of words punctuated by a breath.
‘We can drain it off,’ I said, ‘but you’d need to go to the hospital.’
‘If you say so, son,’ she replied. I didn’t know for sure the reason for the fluid: it could be the first sign of a tumour in the lung; it could be infection; it could be any number of other disturbances of her 92-year-old equilibrium. But without active treatment she’d be dead in a day or two.
An ambulance would have had oxygen, but calling one would have caused a delay, so after weighing up the options we decided to call a taxi. I wrote her a referral letter, and the taxi was at the door before I’d finished. She gathered her pills and a few possessions into a bag. I held her arm as she walked. ‘Wait a minute,’ she said at the door, flustered. She went to the alarm system and pushed a wall button that would connect her to the office. The duty worker’s voice boomed out through unseen speakers into the living room:
‘Yes Mrs Robertson, are you all right?’
‘Doctor’s here’ – breath – ‘I’m going’ – breath – ‘to hospital’ – breath – ‘can you tell’ – breath – ‘my daughter?’
Her daughter lives in London and helps when she can, which isn’t all that often.
‘No problem Mrs Robertson, I’ll do that,’ said the speaker.
I assisted her down the stairs and into the taxi. The step up into the car was too high for her, and when I asked the driver if he’d get out the ramp he rolled his eyes and sighed.
Afternoon clinic was 12 patients allotted just ten minutes each, a satisfying assortment of fevers, injuries, anxieties, aches and despondencies. At its best, general practice is about kindness as much as it is about medical science. I was half an hour late in starting and I didn’t make up the time. When I’d written up the last consultation, and was just about to start on the hospital correspondence and results, there was a knock at the door – Pearl again. ‘I’m really sorry Gavin, there’s another visit. Ellen MacIvor’s carer has phoned, says she’s confused.’
I knew Ellen MacIvor a little better than Mary Robertson. She was 95 years old – born in 1922 – and somehow was still managing to live alone on the second floor of an old tenement. She had never married and had no children, but a niece dropped by three times a week. Council carers visited three times a day to help her with meals, but Ellen was able to wash and dress herself and even prepare some of the food. When I first met her, seven years earlier, she had managed the stairs with ease, but I suspected that for the last year or so she’d hardly been out.
The keys to the house were held in a lockbox screwed to the wall at the entrance. I punched in the code and two keys dropped out. I let myself into the stairwell, negotiated the baby buggies and bicycles padlocked to the landings, and used the second key to get into the flat. Ellen’s used to be a poor area, but successive house price booms and waves of gentrification have transformed it; her neighbours are now all young professionals or students. ‘Miss MacIvor?’ I shouted from the door, but there was no answer. Worn carpets, food stains on the skirting boards, a stale urine smell. I went through to the living room: she was sleeping on an easy chair in front of an electric fire and had spilled tea down her apron. A sandwich left by the lunchtime carers was untouched and a note from them said they’d tried to get her up to the toilet, but she couldn’t walk. I once worked with a hospital physician who called this ‘acopia’: an inability to cope. I worked with another who called it ‘de-pedism’: the patient has ‘gone off their feet’.
‘Miss MacIvor!’ I shouted a bit more loudly. Her eyes opened slowly; like Mrs Cruikshank she looked absently over my shoulder. Also like Mrs Cruikshank, her chest sounded terrible – full of phlegm, and whistling. When I pushed her forward in the chair, in order to listen to her lungs at the back, I saw she’d wet herself – the cushion was sodden. She was able to give me her name and date of birth, but got her age and her address wrong, and couldn’t tell me what year it was. She too had a chest infection, perhaps after or coincident with a stroke or transient ischaemic attack. There was no hoisting equipment in the flat to move her, no diagnostic equipment aside from my stethoscope, and it was now nearly 7 p.m. There was no mechanism that would allow me to arrange carers to come in overnight. If I’d had some help, I could have cleaned her up and got her into bed.
I tried phoning her niece, but there was no answer. The empty sofa was piled high with social work papers, care plans, blister packs of drugs and TV listings magazines. I rifled through them and eventually found a care plan with a different number for the niece. This time I got through. ‘She needs some antibiotics and some tests,’ I told her. Nervous, pained, she asked: ‘In the hospital?’
‘Not necessarily,’ I replied. ‘Are you nearby?’
‘No – not back for another couple of days,’ she said.
‘I could try to get the carers doubled up,’ I said, though that couldn’t happen until the following morning. ‘And if we get four visits a day instead of three, we might be able to keep her here.’
‘I’d worry about that, doctor,’ she replied. ‘She’ll try to get up, and she’ll fall. I don’t think we can take the risk.’
‘Don’t worry, I’ll sort it out,’ I said after a pause. I phoned the hospital, arranged for an ambulance, wrote a referral letter and left it propped near the door, on top of a little pile of papers and blister packs, where the ambulance crew would see it as soon as they came in. ‘You’re going to the hospital,’ I said to Miss MacIvor. Her eyes opened: ‘Oh no, oh no,’ she murmured, before nodding back to sleep.
The ambulance service said they’d be there within four hours. I pulled the door closed and replaced the keys in the lockbox.
The following afternoon there was a meeting of doctors from all the GP practices in my sector – or ‘cluster’ – of the city. We don’t get together very often: we’re far too busy with clinical work, and the out-of-hours service has to cover our practices while we’re away. Many practices in the area are folding, some because they can’t recruit replacement staff, others because the antiquated system that requires GPs to provide their own premises doesn’t work any more. When GPs get together there’s a lot of grousing about patients’ high expectations and the relentless demands from government. But most doctors still love the job and want to find ways of making the system more sustainable.
Cluster groups are Scotland’s answer to the CCGs or Clinical Commissioning Groups in England: assemblies of doctors who are given the opportunity to get together and plan services for their area. None of us has any experience handling the colossal budgets wielded by the 21st-century NHS – we’re clinicians, not managers. You’d have thought that having spent ten, often twenty years training in clinical medicine, we’d done enough to suggest we weren’t interested in managing budgets, but that is what government both north and south believes we should aspire to do. There are monthly advertisements in the GP press for ‘leadership training’ and ‘resilience training’, as well as workshops on ‘managing change’. I’m not sure who is expected to see patients while we take on these new roles.
The first speaker at the meeting was a primary care pharmacist, who spoke about plans for dealing with the situation created by ten years of the Quality Outcomes Framework. Under the QOF, doctors are penalised for not prescribing. Everyone accrues diagnoses as they get older, and QOF mandates the addition of a prescription, or several prescriptions, for each new diagnosis. It is now quite normal for someone in their eighties to be prescribed 12 different drugs to take each day. It isn’t just that this is expensive: it also causes unintended side effects. What’s more, we are audited to ensure we prescribe the cheapest available version of any given drug: each practice receives regular chastening spreadsheets comparing their own prescribing costs to local and national averages. The QOF has now been abandoned in Scotland (it limps on in England, Wales and Northern Ireland), and so far hasn’t been replaced. The pharmacist was encouraging us to strip back all prescriptions that can’t be justified with solid evidence, even with elderly patients. This is to be welcomed, as part of a new emphasis on ‘realistic medicine’.
The second speaker was a health board manager with very shiny shoes, who, knowing he was facing a hostile crowd, told a long story about his grandparents’ health problems to reassure us that he knew the challenges and complexities of primary care. I’ve heard many such speeches before.
The third speaker was a widely respected, energetic consultant physician who has been charged with redesigning the way we manage the mounting number of frail elderly patients who shuttle back and forth between home and hospital. In my part of the city, the total number of beds available for inpatient care across all specialities dropped by about 20 per cent between 2003 and 2013. The consultant physician told us that plans were already in place to drop them by a further 10-15 per cent. ‘We can do this,’ he said. ‘Forty per cent of the patients in my ward don’t need to be there.’ He said this with a note of irritation, as if the lack of beds was somehow our fault as GPs for admitting elderly patients in the first place. ‘What are you going to do,’ he asked us, ‘when you phone to admit a patient and we refuse to take them? Because we’ve no beds. Because there isn’t enough money.’
There was a surprised silence. This was new: a senior clinician, involved at the highest level of strategic planning, stating that the current system is on the verge of collapse, and explicitly shifting responsibility for the problem back to general practice, which is itself in deep trouble. Hospital managers talk about ‘bed blockers’, and it seems they are now ready to start freeing up beds by refusing admissions. If you were to ask a plumber what to do about a blocked drain, you’d be sceptical if he asked you to stop turning on your taps. The consultant physician asked what we as GPs will do when hospitals refuse to take our patients. I have a different question: what will happen if our requests that elderly patients be admitted are refused? And my answer is: ‘They will die.’
The crisis in the NHS has many causes, and I don’t pretend to understand all of them. There’s the phenomenal success of modern medicine, which now keeps people alive (though dependent on more or less continuous care) for decades with diseases that once would have killed them in weeks. (I know a centenarian who recently had sophisticated heart surgery on the NHS, not in an emergency, but to improve her quality of life.) Advances in nutrition, housing, sanitation and public health education have all played their part in stretching life expectancy to unprecedented levels. In 1948, when the NHS was set up, men lived on average to 66 and women to 71; now both men and women live into their eighties, and the average 85-year-old costs the NHS five times more a year than the average thirty-year-old. To this you can add the atomisation of families caused by social and economic change, meaning that fewer and fewer people have relatives around to help as they get older. There are other, less material factors. Politicians live in fear of tabloid tantrums whenever a new cancer drug, say, is considered too expensive for the NHS, with the result that expensive treatments of dubious value go on being funded while less glamorous or headline-grabbing interventions are cut back.
Mrs Cruikshank was lucky: she had a daughter who could take the decision with me not to prolong her life by all means possible, and a social care package that could be tweaked to keep her at home. Mrs Robertson was the kind of nonagenarian hospital managers like: fit and independent, presenting them with a particular complaint which they could diagnose and treat before discharging her. She is at home again now, and will undergo further tests as an outpatient. It’s the Miss MacIvors that the NHS doesn’t know what to do with. She’ll be in hospital now for weeks, becoming more and more institutionalised, less and less able to manage on her own – blocking a bed. But unblocking her bed will require massive investment in social care, and the creation of a truly 24-hour service that’s able to come to her home day or night, at short notice, get her washed and into bed, arrange efficient transport for any X-rays or scans she needs, and double her provision of carers for as long as she needs them. There’s going to have to be a massive expansion in nursing home places, funded by the government, to which GPs can admit patients directly without having to go through a hospital dealing with acute cases. There’s going to have to be a dramatic investment in a new kind of primary care in the community, employing many more GPs and district nurses. District nurses already do a great deal to prevent emergency admissions, but they are woefully undervalued and many are taking early retirement; training has been scaled back, and increasingly impossible rotas are driving some to quit.
Management consultant initiatives and stealth privatisations have for years set about the NHS like termites, nibbling away at the beams and struts of a once magnificent structure. But the whole edifice is now on the brink of collapse. If the principles of the NHS are to be defended, we will have to find more money, and a new way to run things. My own view is that asking GPs to deliver a plan in their spare time isn’t merely preposterous, it’s dangerous. Yet there don’t seem to be any politicians, in Edinburgh or London, prepared to be honest with the electorate about how much it would cost to bring government spending on health even up to the EU average. France, Germany and Sweden all spend more on health than we do. The underfunding of healthcare in the UK is a political decision.