Doctor bashing (4) - Dr Meanswell and The Shrink

One of the joys of returning to the medical blogosphere after a long break is catching up on new blogs, and blogs I had missed. The tantalisingly named Lake Cocytus is in fact the hiding place of The Shrink, a consultant psychiatrist who clearly enjoys his job and sees patients personally. By reading the small print of a statute he has found a way to get free home care for at-risk patients. Brilliant. Sadly, The Shrink does not like GPs. Well, each to his own. He tells a worrying story of neglect and incompetence by a GP who he portrays as failing to provide proper care for a patient.

The Shrink’s article is short and the inference is that the GP he describes is a generic representative of the whole profession. But, as the script writer might say, is there a back story? There usually is. So let me tell a back story, a real story. Every GP in Britain will identify with it as will anyone who is caring for an elderly relative.

All GPs have a large number of frail elderly patients, usually female, who live alone and who are struggling. The subprime minister has deemed these people to be in need of "social" care, not medical care. Hospital policy and government targets mean that medical admissions are geared to achieving "completed events". The hospital scores points when a patient is discharged. There are no points for follow-ups. Elderly patients with multiple medical problems never have "completed events." One problem leads on to another. But forget that Nye Bevan “cradle to grave” nonsense. The elderly only need “social” care and the NHS does not cover that.

CCF : Congestive Cardiac Failure

Poor old Mrs Boggins has osteroporotic fractures, a bit of CCF, a bit of COPD, a bit of faecal incontinence, a bit of urinary incontinence and a lot of loneliness (daughter lives 60 miles away and rarely visits). She used to come down to the Health Centre but has not been able to for six months. Her GP, Dr Meanswell, has asked the district nurses to go in, and they have. They say this is not a “nursing “problem and refer her to social services. Dr Meanswell asked them to get some incontinence pads, but they are not allowed to. Only the incontinence nurse quacktitioner can do that. She visits but before she can have some pads, Mrs B has to do some homework. She has to fill in a fluid chart for a week and try to rate her poo with the help of the Bristol Stool Chart. (See "Defining the Euroturd") If she passes the test, she may get some pads. In the meantime, well, it’s a bit smelly but that is not a nursing problem and the incontinence nurse quacktitioner does not “do” hands on nursing.

One day Mrs Boggins' has a fall. A neighbour asks Dr Meanswell to call. "She should be in hospital, doctor". Mrs B has indeed had a fall. Nothing broken, but she has been on the floor for two hours. So Dr Meanswell sends her in. He phones the hospital and a gloriously inexperienced F1 gives him the third degree about WHY he needs to send her in. "This sounds like a social admission". Bloody right, but Dr Meanswell can't say that because if he does they will not take her. So he picks a medical problem at random and says she has CCF. Always a good one. Anyone can see her ankles are swollen. Acutally, Dr Meanswell knows that her ankle oedema is due to stasis and veins more than her well controlled CCF but it will fool the HCPs. Mrs B is kept in A/E for three hours and fifty-nine minutes and then moved to a New Labour pretend ward. The F1 changes her furosemide to bumetanide and sends her home with a note saying "GP to check E & U in two weeks. Please refer to the falls team."

The "Falls Team" is a collection of HCPs who duly see Mrs B and say "Is she depressed? Suggest psychiatric assessment." Mrs B is not psychiatrically ill, she is lonely. Dr Meanswell knows that a psychiatric assessment is unnecessary but, once it has been suggested, albeit only by some over promoted quacktitioners, if he does not ask for one, he could later be in difficulties defending his decision not to refer.

Four weeks later Mrs B gets to the Psycho-geriatric Clinic. Go into any medical school and say to the students “Hands up those who want to be a psycho-geriatrician”. It is not a popular speciality and there are not enough consultants. So Mrs B sees the locum consultant who does not speak much English and after a brief consultation inappropriately puts her on mirtazepine giving her two weeks supply. He does not offer her any follow up but does send a letter in bad English saying “GP to monitor mirtazepine.” Two nights later (long before the letter has even got to New Delhi for typing never mind to Dr Meanswell) an unnecessarily medicated Mrs B falls out of bed. The call-centre summons an ambulance. The wise and learned paramedics put her back to bed and leave a note saying "patient declined admission - GP please assess."

Mrs B did not decline admission. She was not really given the choice. The neighbour tells Dr Meanswell that the paramedics told Mrs B that there was no point in going into hospital. These days they are right. Dr Meanswell checks her over again. Nothing has changed except she has lost more weight and is frail and at risk. He dreads another tongue lashing from some pompous F1 but nonetheless suggests hospital. “Oh not again, please” says Mrs B “last time I was left on a trolley, and I needed to go to the loo, and there was no one to help and so....”

A care package

Dr Meanswell goes back to the health centre and phones social services. He is bad tempered and shouts at them. Why has the social care not started? “Ah," says the social worker, "we are sending in someone next week to assess her to see what care package she needs”. Dr Meanswell has already assessed her many times. But that does not count.

Mrs B. now stops eating. She does not drink much either. She gets dehydrated. So Dr Meanswell has to send her in again. This time she is kept for 36 hours, rehydrated, and sent home with a note saying "GP to check E & U in two weeks". No follow up.

And so it goes on. And on. Backwards and forwards. In and out. Lots of “completed events” for the three star, foundation trust hospital. Lots of "assessments" but still no care for Mrs Boggins.

Finally, in extremis, Dr Meanswell, desperate to get some help, decides to see if he can wangle a psychiatric admission. Where Dr Meanswell works, you can't refer directly to a psychiatrist, you have to refer to the CMHT, a load of well meaning amateurs. Fortunately, on this occasion, a good psychiatrist gets involved. Like Dr Meanswell, he is a real doctor not a “falls team quacktitioner" and so, like Dr Meanswell, he can tell that Mrs B is not mentally ill.

With some difficulty he persuades Mrs B to go into hospital again. Three days later, she dies. It might have been last time, or next time, it just happens to be this time.

Was it really like this with The Shrink’s GP? Who knows? But it does not matter. There are some bad architects in this country and some bad solicitors and, believe me, there are some bad GPs too. That is not the point. There are also thousands of Dr Meanswells, and tens of thousands of frail, elderly men and women who are not getting the care they so desperately need.

The only thing reminiscent of a care package here is the pass the parcel game everyone plays in the NHS. Try not to be holding the patient when the music stops or you will have to do something. Instead, do your "assessment", then pass on the patient as quickly as possible for yet another meaningless "assessment". Each assessment scores points and hits targets. This proves to the government that all is well in the NHS.