“Oh, no, not again”. I looked at the email form Pentonville prison asking me for Keith’s medical history and list of medications. I filled it in: Methadone for heroin substitution, Diazepam – also for addiction and chronic anxiety, Citalopram for depression. He was in and out of prison pretty frequently for fighting or shoplifting, so I guessed I’d be seeing him out again soon.
The next letter was to let me know that Dawn hadn’t attended her hospital appointment. They, ‘assumed she no longer wanted to be seen’, and so had discharged her from their clinic. “Please don’t hesitate to refer her again if you think she needs to be seen”. The language annoys me intensely. Nobody from hospitals ever phones patients to find out why they don’t attend. One study has done exactly that and found that half the patients who didn’t attend felt too ill to come in. Other patients never receive their appointment or are too chaotic and disorganised, some make a choice that other things like caring for relatives or hanging on to their job, are more important than their health. The reason patients who do not attend are discharged is partly to reduce the waiting times for others but also because hospitals get paid more for a new referral than a follow up appointment. But can I blame them when waiting times are increasing, tariffs are being slashed and so many hospitals are in debt?
Incidentally, I’m going through letters because Dawn hasn’t turned up for a double appointment she booked with me. I tried to leave a message on her phone, but I suspect that she’s run out of credit again. I had wanted to have enough time to talk to her about her recent hospital admission with septiciaemia – a complication of her dreadfully controlled diabetes. She is only 40 years old but is already on dialysis because of the damage caused by the diabetes to her kidneys and can barely see because of the damage to her eyes. I don’t expect her to survive the year, but I cannot give up trying.
The next letter is asking me to sign a petition saying that charging patients who fail to attend GP appointments will harm patients. With what is going through my mind I cannot ignore it, so I sign it. It’s little surprise though that my colleagues are thinking the unthinkable, with over 80% of GPs saying they don’t have enough resources to provide the access and quality that patients need. We cannot continue to do more with less.
The next letter is handwritten on a scrap of paper from Brian asking for something to help him sleep. I haven’t seen him for almost a year. A few years ago I managed to help him stop drinking. He had been an alcoholic for about 20 years and would stagger into the surgery with a can of lager and start arguing with the receptionists. I used to have to call him in to my room as soon as he arrived and escort him back outside so that he wouldn’t upset the other patients. About a week after he stopped drinking he stopped going outside and hasn’t left his flat since. It was only by getting almost blind drunk that he could summon up the courage to face the world. Nothing that I could do, with the help of psychiatrists and psychologists, could get him out. I was shocked when I last saw him. He had lost a lot of weight, his hands were heavily nicotine stained and his voice was so hoarse it was hard to discern his words. His skin was covered with sores from not washing and there was the unmistakeable sickly sweet almondy smell of lice. His flat was strewn with empty cans, over-flowing ashtrays and fast-food waste bought in by a couple of his old drinking buddies. There was no point phoning him – he didn’t have a phone. I resolved to go round to see him after surgery.
The next letter – I was making good use of the unexpected gap in the middle of my surgery – was from the local A&E department telling me that Selina had attended after taking an overdose. It was her tenth A&E attendance this year and it’s only May. The summary was very brief, “overdose of antidepressants after argument with boyfriend, observed in department, self-discharged against medical advice, GP to follow up”. We’re being told that have to stop patients like Selina going to A&E – I wonder if they realise that we see her at least twice for every A&E attendance, that her brother committed suicide last year and another brother is in prison. Compared to them I think she’s doing OK. I’ve run out of ideas to stop her going to A&E.
The next letter was also from A&E. Nicola had been there with Danielle, her 18 month daughter, again the summary was brief, “cough and runny nose, slight fever for 7 days: on examination: Temp 36.9, chest clear, child happy and active, ears and throat not inflamed. Diagnosis: common cold. GP to follow up.” There was nothing about Nicola’s frequent panic attacks, a lot worse recently after a one-night stand with her violent ex-partner led to him trying to move back in with her. I had seen her with Danielle only a few hours before they went to A&E – I wondered if they had gone there because it was somewhere safe. I added her to a long list of patients to call. My patients aren’t surprised to get a call after 8pm these days.
The next letter was from the district nurses asking me to see Ray because they were worried that he was becoming depressed and not eating. Ray is 87, he is very breathless because of COPD and hasn’t been out for years. He’s also very lonely and isolated. I visit him 3 or 4 times a year, and other than a carer and the district nurses I’ve been his only social contact for the last decade. He’s never been interested in a befriending service or lunch clubs, insisting that he prefers his own company. I’ve little doubt that he was happier when he was in prison – where he spent 40 years before being released shortly after his 75th birthday. He’s not an easy man to like, even now.
Ray was in prison for child sexual abuse. All of the patients I described before Ray were abused as children. An enormous part of my work as a GP, and I have little doubt, a significant and often unrecognised part of the work of A&E, mental health and paediatric services in particular is the care of adults who were abused as children. I doubt that any part of the NHS is unaffected. The damage is lifelong and extends through generations. The anger, anxiety and self-loathing that victims feel creates huge challenges for healthcare professionals who are torn between the deepest compassion and the most intense frustration.
The only thing that I have found to be consistently helpful is continuity of care. For people who have never been able to trust others because of what happened in childhood, a long-term relationship with a stable adult who knows them is literally life-saving. As many of my patients have told me, “Doc, you’re the only normal person I know”
This post is dedicated to all the patients who can identify themselves in any way. It’s based on 14 years of general practice and nearly 20 years working as a Doctor. All the descriptions are intended to be authentic, but to represent no single person.
Jonathon
Psychosocial complexity in multimorbidity: the legacy of adverse childhood experiences. Sinott et al. 2015
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Joshua Children’s Foundation for victims of child sexual abuse.
A Better NHS 
Hi
Thank you for such a wonderfully and carefully thought out post, I must admit the term “DNA / Did Not Attend”, assumptions, and beliefs around this from hospitals frustrates and infuriates me, the way same way racist and bigoted behaviour does.
The labelling and derision of patients who do not attend, only helps to further the issue. I long for the day, where healthcare professionals ignore the organisational silo thinking behaviour and instead focus on the patient, and begin to ask what caused them to miss this appointment, and start with a curiosity to understand.
Reblogged this on Flip It Right Side Up.
What an excellent blog. The myths about being a GP are about as fabulous as those we hear about hospitals (standing on street corners dragging patients in!) Describing life as a GP by telling stories to bring colour and life to the issues is really effective. We try to do something similar in acute hospitals. What can we do together to create mutual appreciation and support and reduce the mistrust that exists between us?
This is marvellous, tragic, tear jerking. It is the absolute best of Mellojohnny , East End of London GP, the spirit of general practice there and everywhere, the unique and major spirit of the National Health Service – why we need it, and why we need it to do the job Mello J does. And why we need GPs like him to remind us they do it not blaming the patients, not expecting patients to pay for the extra appointments they impose as a burden on their well paid doctors and ….reflecting why our politicians and why our institutions never help make things better for the lives of these people…SOME LIVES! go Dr mello .
Great stuff Dr MJ – have FBed and RTed, this, as one does in this day and age -keep up the great work. How can you be so Mello?
First time reader directed here by Roy Lilley from his excellent NHS managers blog. I work in MH services and worry seriously about those people with long term, complex mental health problems and the determination to create capacity by referring people back to their GP when they have made a ‘recovery’. In the best of worlds working in partnership with primary care colleagues does provide excellent care for people suffering from mental illness. However the misuse of the concept of recovery in mental health will lead to many more ‘don’t hesitate to re-refer’ or ‘discharging back to the care of GP’ letters. Continuity of care is almost never talked about and in order to create capacity we are beginning to deny the significant disability faced by many.
“but also because hospitals get paid more for a new referral than a follow up appointment.”
Whilst the difference in payment is correct (firsts take longer), the perceived motivation for discharging back to the GP isn’t quite right IIUC.
The first/follow-up attribute is based on it being their first *attendance*, not their first *appointment* – so discharging back to the GP makes no odds to the income. It’s all about the demand management you accurately identify.