The Crippen Diaries (Week 20)

Not quite Tannochbrae

Monday 15th May

There is a large comprehensive school close to the practice. At least half the children who are registered with us attend it. The headmaster has just written to all parents saying that any child who is off school with illness must have a doctor’s note confirming the illness.

This policy will mean a lot of extra work, mostly unnecessary. But that is not what makes me cross. This is an insult to parents. These decisions are a matter for parents. They should be the judge of when their children are fit to go to school. If my children have so much time off that their education is suffering, I expect the school will contact me, if I have not already contacted them. Doctors are not truant officers. It is not for us to disempower parents.

We draft a letter to the headmaster stating that we will not be issuing certificates for children who are off school. We state that if he has concerns about a child’s poor attendance due to illness, he may write to us for a medical report. Provided we have the parent’s consent, we will provide the report and we will charge a professional fee for its preparation.

I do not think this is going to be a major income stream.

Silly man.

++++++++++

Andrew is a retired architect. Used to be a great rugby player. Like so many ex-rugby players his joints are a mess. When he retired ten years ago, he and his wife bought a small house in Spain. Initially they went out just for the winter, but now they are out there for nine months a year.

He needs a hip replacement. It has been playing up for some years but he kept putting it off. He is getting rest pain, and his exercise tolerance is severely limited. Just before Christmas he gave in. He is on the waiting list to have it done.

He was all smiles today. He is going to have the operation in three weeks time. In Spain. And he is not going privately. He will have it done on the Spanish Health Service. The large British ex-pat community where he lives now have most of their medical care in Spain.

When I started, all the ex-pats came home for their medical care. Now most of them go out to Spain for it. The waiting lists are shorter. The nursing care is better. The hospitals are cleaner.

So they tell me.

It is all anecdotal, but it depresses me.


++++++++++

I saw two women with breast lumps this morning. Angela and Christine. Both in their late forties, a dangerous age for breast cancer. Angela has a family history of breast cancer. Christine has not.

Clinically, Christine’s lump is ominous. I fear it will be malignant. Angela’s is almost certainly benign. Both must be referred to the breast clinic, and both under the two week rule (TWR).

I tell Christine that I was worried about her lump, that I fear it might be malignant and that I will be getting her an urgent TWR appointment. She has a few questions, we talk it through and she is grateful for the speedy availability of the appointment.

I tell Angela that I am as sure as I can be that her lump is benign but that we have to be certain, and so I will get her an urgent appointment within two weeks. She asks if I can get her an appointment quicker than that. I cannot. She asks if I could phone the consultant’s secretary and get her squeezed in more quickly. I could make the phone call but I am not going to. It is unfair to pressurise them like that. They are already providing an excellent service.

She asks if it would be “worth going privately”. She does not have private health insurance. She might get a private appointment a day or two sooner, though that is not certain. I explain that it would not be just the cost of the consultation. There would be the mammogram. And, as it felt cystic, probably an ultrasound, and then possibly an FNA. You are up to a thousand pounds before you can say BUPA. She decided to wait for the appointment, but clearly felt it “was not good enough.”

Expectations. Expectations. Expectations.

This keeps happening. I sympathise. It is awful waiting for appointments, waiting for tests, worrying about cancer. But the NHS really delivers here, and still it is not good enough.

++++++++++


Tuesday 16th May

I have not seen Trevor for several months but he was the first patient in today. When I last saw him here in January, I wrote:

The second patient of the morning was Trevor. 32 years old. Hopeless alcoholic. Disturbed childhood. Physically and sexually abused.

He is dishevelled. He stinks of yesterday’s alcohol. He is shaking. Not yet had the first drink of the day. During the consultation he vomits and, before I can get a bowl in front of him, he catches it is cap.

He refuses admission to hospital.

“They aren’t interested, they just want to get you out as quickly as possible.”

I don’t say anything. It’s true. Most of the medical profession avert their eyes, literally and metaphorically, when an alcoholic turns up. The local psychiatrists are not much help. They will not take a direct referral. Instead, they write to the patient telling them that if they want to be seen, they must contact the department themselves. A test of “commitment” they call it. It’s a hurdle. A lot fall at it. Trevor always has.

I cannot not believe it. Trevor looks well. He is coherent. He is reasonably clean. As he chats I flick through the computer screen. Three weeks ago he presented to one of my partners, desperately ill, dehydrated, vomiting and shaking. My partner sent him in. He was so ill that they had to keep him. Drips, antibiotics, vitamins, food and nursing care. Despite his history, the psychiatrist did not see him.

A member of the CMHT did.

“Not depressed. Can go home. Refer back to GP.”

Great. I need to stop getting angry about this but I keep thinking, “What do you have to do, how ill do you have to be, for the psychiatrist to see you?”

Trevor has been out of hospital for nine days and he has not had a drink. He has not gone as long as this ever before. He has split up with his long-standing partner. She is also an alcoholic and is still drinking heavily. Vodka for breakfast. They are good and bad for each other in equal measures. They fight like cat and dog half the time and prop each other up, literally and metaphorically, the other half.

For the last nine days, Trevor has been living in his car. He parks it on some rough land near the canal. He has been to social services and they have given him an information pack and sent him to the housing department. The housing department referred him to social services. The housing department say there is no one in our precious home county who needs housing. And, anyway, he is an alcoholic.

I spend a long time talking with Trevor. Sober Trevor is intelligent and articulate. Bleeding heart liberals would say his problems are all due to his bad childhood. Wat Tyler would say “pull your socks up or I will put you on a bonfire”. I think it is his bad childhood.

I will start badgering social services and housing. There is an excellent CPN locally who helps alcoholics. She will see him.

If the housing department and social services would do something immediately, Trevor might survive. I fear they will not. He will return to his partner and the cycle will start again.

It is frustrating.

++++++++++

Yesterday, I had to order some domicillary oxygen for a patient. I have mentioned this before. In the old days, I wrote a prescription and the local chemist fixed it up within 24 hours. It took five minutes to arrange. Then the goverment took control of the system, centralised it and "simplified it." Now we cannot issue a prescription. Instead we have HOOF. We have talked about this before.

I feel a slogan coming on. This is no longer about ordering oxygen. It is about “Working for healthier lungs.”

Hmmm… I like that.

The business of supplying oxygen has generated so much new work that there is now a HOC newsletter which I found here. Sadly, that site is being re-designed, so I referred to and re-read the updated protocol here and having done that was able to fill in the HOOF form (as seen here ) . I faxed it through yesterday afternoon and went home.

The patient had about six hours oxygen left which I knew would last twenty four hours. I told her I would phone today and if here was no oxygen, I would get her into hospital. I phoned her with no expectations. Joy. She had the oxygen. It arrived yesterday. It arrived four hours after I sent the fax.

What can I say?

Clearly, all my critical remarks about Patricia Hewitt and protocols are unfounded. The system has worked.

Good old Patricia.

Good old new Labour.


++++++++++


Thursday 18th March

British Rail announced in December 2005 that they were going to stop running trains for four months whilst they reviewed the service. You may have missed the announcement. Fortunately the service started again today. From now on, applications for train tickets will only be accepted from people who want to travel. Putative passengers who had tickets in December will be offered a restricted service of short journeys to destinations not of their choosing. Those who bought tickets after December will have to buy another one.

Too silly for words. Of course it is.

Today I received a letter from Debbie, the specialist nurse for children with learning disabilities.

Anytown Park Health Centre
Coventry Road
Anytown

14 May 2006

Dear Colleague,

Re : Community Nursing Team for Children with Learning Disabilities

As you are aware, a decision was taken to freeze our waiting list in December 2005, to enable a review of the Learning Disability service to be carried out.

This has now taken place and as a result, the revised criteria for accessing the service is as follows:

Referrals

Referrals to the service will be accepted directly from Consultant Paediatricians and GPs, or from other healthcare professionals, with the GPs support for the referral. This is in line with practice based commissioning.

Criteria

1. Under Fives

• The child must have a learning disability
  
• A specific reason for referral must be given.

2. Over Fives

• The child must have a learning disability
  
• A specific reason for referral must be given.

The revised criteria will apply to all new referrals to the team from 15th May when the list is reopened.

Children already on the waiting list, who are no longer eligible for a service, will be offered short-term support.

Referrals sent to the team during the period of time the list was closed, will need to re-refer, via the appropriate referral pathway.

Please find enclosed the new referral form together with a copy of the new referral pathway. Please note this team will no longer accept old referral forms.

A further review of the service will take place in November 2006. In the meantime, if you have any queries, please do not hesitate to contact me.

Yours sincerely,




Debbie Jones
Specialist Nurse for Children with Learning Disabilities

Enc: the referral pathway


I think I have got that. They stopped taking referrals for five months whilst they thought about the kind of service they wanted to offer. They concluded that the learning disabilities service would in future only accept children with learning disabilities.

Well done, girls.

Now there is a five month back log. But at least we have a referral “pathway”.

What does this mean?

Why is working in a nationalised industry jeopardising my sanity?

++++++++++

What happens to children with learning difficulties? They become adults with learning difficulties. Because they are grown up, people do not realise and are less tolerant.

Patrick is 42 and has learning difficulties. I met him for the first time today. Patrick has worked as a shelf-stacker and a lorry driver’s mate, and as a labourer. At the moment he is not working at all. He came today because he is feeling tired all the time. TATT as it is called in the trade. This is a heartsink symptom. If you are feeling TATT, find some different words or the doctor’s eyes will glaze over.

Patrick was theoretically on lofepramine and olanzepine. Because he keeps losing his temper, he was put on olanzepine by the locum psychiatrist for people with learning disabilities. When Patrick gets cross he hits people. Usually his long suffering girl friend. He was put on lofepramine, an anti-depressant, by the CMHT who were seeing him until someone noticed the expression “learning difficulties” in his notes and turfed him out. Ordinary psychiatrists do not see people with learning difficulties.

He is not depressed and does not need lofepramine. He is not psychotic and is unlikely to benefit from olanzepine. Both these prescriptions were “get you out of the door” prescriptions. He realised that too. He threw them away.

The learning difficulty locum psychiatrist thinks Patrick may be a BPD. This is a non-diagnosis for difficult patients they do not want to see anymore. It means "I can't help you and I don't like you." Patrick says he would like some counselling but there is no one who will provide it. He asks me if I have some tablets to stop him feeling TATT. I do not.

Patrick is a big man. I am glad he is not cross with me. I chat with him for half an hour. He has a remarkably good sense of humour. He says he is bouncing around the system like a pin ball.

He is.

When he goes I write a letter to all the psychiatrists and CMHT team members who have seen him saying “you are all playing pass the parcel with this man. I think there is a grave danger that one day he will kill someone. Can no one take ownership of the problem?”

In a different life, when I was a lawyer, I went into Strangeways prison in Manchester.

There were a lot of Patricks in there. It is cheaper than a psychiatric ward.

Half an hour behind. Again. And stressed. Again.

+++++++++++



Friday 19th May

Duty day today, and it is busy, but everything is eclipsed by Andrea.

Andrea is 24 and is South African. She finished her degree there and is doing the “world tour” before she returns home to settle down to work, career, life and all those things. She has been in the UK for eight months. She is working as a sailing instructor in a local inland reservoir. I met her for the first time this morning.

She sat down, glanced at me, looked at the floor and said, “I’m not coping.” She sat silently for a long time. Then she said “It’s not worth it.”

She came over to the UK with her boyfriend, but they split up three months ago. After another long pause I asked her when she had last been happy. She laughed and said about three years ago. I have bulimia. I am on these – she took out a packet of Paroxetine and put them on the table. They don’t help. She is not vomiting anymore, but she still does laxatives. Lots of them. All her family are in South Africa. We talk a little more. She is not sleeping well. She never cries. Never. She says she is not suicidal.

Another long silence. Then, “I was raped on New Years Eve.”

Another long silence. I ask if she went to the police. She did. He was arrested and prosecuted. It went to the Crown Court, but then the CPS decided to offer no evidence and the case was dropped. “I was drunk at the time” she said. They told me they would never get a conviction. “I kept saying no, but I was drunk.”

I ask, “What brings you today, rather than in January, or next week or next month?”

She says that yesterday she stood in the supermarket holding a packet of paracetamol in her hand for so long that someone came over and asked if she was all right.

“Do you want to harm yourself?”

She shakes her head. Then she rolls up her sleeves and without a word shows me superficial lacerations on both forearms.

I ask if she has told anyone. Everyone at work knows. He used to work there as well but they sacked him. They are supportive and protective. I ask if she has told her parents. She looks at me for a long time and shakes her head.

++++++++++

Jobbing general practice.

I fantasize.

After Andrea goes, I wander down the corridor and grab our onsite counsellor. She agrees to see Andrea on Monday. I pick up the phone and track down Tessa, the local consultant psychiatrist. She is always supportive. We have a natter. Then she says, OK, what have you got? A disturbed, self-harming, socially isolated bulimic with low self-esteem who has been raped. Right, I’d better see her. Is she all right for the weekend? Yes, she is, and I have fixed up support for the rape, but I need help juggling the bulimia, the paroxetine and the possible depression. Tessa agrees to send her an early appointment and she will liaise with me and our counsellor.

Back to reality, Crippen.

The only think I have got is the CMHT.

I could phone them. But I am not prepared to discuss this girl with a “senior” mental health worker or the like. I have tried it before. I know what they will say.

First, the fob off. “Ah, she has an eating disorder so she should go to the eating disorder unit.” Our eating disorder “unit” is run by nurses and dieticians.

Then the self-help groups. They will offer to fax me a list of the various organisations who “help” women who have been raped. I have the list myself and I am a dab hand with Google. There is nothing wrong with these organisations but they tend to be (oh! dear, I feel the flak approaching) a bit “right on” for Andrea. Andrea is not “right on.” She needs a hug. I cannot provide that. She needs her mother. I cannot provide that either. She will not tell her mother what has happened over the phone. She probably will not tell her mother at all.

Finally, if I say it is urgent, they will offer a “risk assessment” by the protocol laden nurse specialist. I have already done a risk assessment, and a lot more than that. But I am not in the CMHT. I do not have a protocol. I have not ticked any boxes. So that does not count. Urgent referrals to the CMHT automatically generate a “risk assessment”. This is nothing to do with a psychiatric assessment or a diagnosis.

Patricia Hewitt says I am clogging up the system with unnecessary referrals.

The referral “pathway” to the CMHT is a protocol based form that has to be faxed through. I have to grade the seriousness of the problem. Does she need to be seen “same day” or within “two working days”, or within “five working days”? The CMHT does not work weekends.

I hate writing words like “raped” on forms to be faxed off into the ether. But that is what I do. I go for “two working days”. Four would do. Anything reasonable would do if I could discuss it with a sentient human being.

She will be seen by someone next week. They will refer her to the eating disorder unit. And that will be it. I know. Been there before.

Andrea is a highly intelligent university graduate with low-self esteem and bulimia who is self-harming and has been raped. She is not potty. I do not thing she is suicidal. She needs help. She needs sympathy. She needs support. She will get none of it.

Give me an hour a week for six months and I could provide most of what she needs. I do not have that time.

Part of my problem is that I am a relatively high-emotive doctor. This is not a good thing.