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Panoramic Views

Friday 7 June 2019

Panorama: Crisis in Care was a difficult watch. BBC cameras followed the Somerset adult social care team and selected clients/patients over a ten-month period and the results broadcast on the past two Wednesdays. It was a brave decision to allow the cameras in without any editorial control, but Stephen Chandler (Director of Adult Services) was clear that this was a story that needed to be told and has received many plaudits for doing so. The hope was that this would trigger a wider debate.

The dedication of the social care staff and the strain on relatives was clear for all to see, as was the stark contrast between the budgetary arrangements for social care and health, despite all the talk in recent years, and indeed decades, of bringing the two sectors together. I’ve been at many briefings where the leaders of the local authority organisations have discussed budgetary decisions with their health counterparts; it is writ in stone that the County Council can’t carry a deficit, and there are no smoke and mirrors in the finance department at County Hall. Compare and contrast this with the NHS, where there are agreed ‘control figures’ (aka overdrafts), and the potential to carry deficits over to following years, or sometimes to shunt it around the system. Once the level of care had exceeded what was appropriate for social care, we saw social care staff arrive at the CCG to apply for continuing healthcare (CHC) funding. We didn’t get to see the discussions that followed inside, but the implication was that once the healthcare criteria were met, the pressure was off. Obviously, we know that’s not the case, and yet the false division between social and health care was starkly obvious. The problem then can become one of ‘flip-flopping’ back and forth between health and social care. Reviewing a CHC decision and then withdrawing ‘health’ funding because the patient has improved after three months of increased care input, despite their underlying condition remaining stable or even progressing, seems perverse and causes consternation and distress to families.

Last weekend’s Parkrun was highlighted nationally as the ‘GP Parkrun pledge day’ with GPs and practice staff from around the country running and volunteering for their local Parkrun. Saturday morning was warm and sunny, and following last year’s record numbers taking part in the NHS event, it was clear from the massed hordes on Taunton’s Longrun meadow that this was going to be another large turnout. Particularly conspicuous was a sea of blue running vests huddled near the start, with closer inspection revealing a stupendous turn-out from St James Medical Centre in Taunton. There was a discrete surgery logo on the front, and a significantly larger one on the back celebrating their sponsor of choice, a (very) local hostelry. It was an impressive sight, and I trust their sponsor rewarded them appropriately later in the day. It’s worth signing up for Parkrun, if only for the £100 discount Mrs. Chair and I have each received off our next Exodus holiday.

Last week I found myself in the Maternity Seminar Room at Musgrove to meet with the gynaecology consultants. I’d last been there when I was an SHO to one of the (then) three Obs and Gynae consultants. How many did they have now, I wondered? The four gathered before me looked at one another and there was a bit of discussion before they agreed there were now twelve of them. TWELVE?!? That apparently included two gynae-oncologists. We were meeting to discuss the unilateral decision by the gynae department at Musgrove to only accept acute admissions via Consultant Connect, for calls arriving between 9am and 5pm. Colleagues who’ve used the service for any speciality will know the joy/surprise/relief when successfully connected via the system, but it’s by no means flawless. Generally, connection rates across the piece run higher at YDH (approximately 80%) than at MPH, where the rates vary from 50-74% depending on speciality. Before the meeting I’d checked the rates for gynaecology at MPH with my contact at Consultant Connect HQ. Since launch, the rate had been 67%, although they had managed 100% in the previous two weeks.

Neither Consultant Connect nor the commissioners at the CCG agree with the service being used as the main route for acute admissions. The consultants’ view was that it was far better for GPs to be able to talk directly to a consultant, who would then be able to either accept the admission or refer to an acute clinic if appropriate. Natürlich. But what happens in the 33% of cases where contact isn’t made? I did my best to paint the picture of a GP, possibly working alone, and certainly without the back-up of a junior team (or 11 consultant colleagues) worried about a sick patient who they wanted to admit. Patients would be piling in at 10-minute intervals, along with phone calls and the other detritus that thrills us through the day. There needs to be a fallback available almost instantly if no consultant is available. The consultants are working on what this might look like, but in the meantime do let us know if you have problems admitting gynae patients, particularly to Musgrove. As specialities go, they have relatively few admissions and so it should be manageable.

The fact that we needed the discussion at all reflects the continuing trend of colleagues in other bits of the system to alter services or roll-out new ideas that directly impact on primary care, without first consulting with the LMC, as they are statutorily required to do. The recent ‘falls pathway’ that arrived on our desktops is another such example, and we’re still trying to get to the bottom of where that’s come from.

Last month marked the 500th anniversary of Leonardo da Vinci’s death. A true polymath and the original “Renaissance man”, he made significant contributions in engineering, mathematics, sculpture and neuroanatomy- he was the first person to pith a frog- and could also paint a bit. In a recent BMJ article entitled ‘Keeping an open mind’, an ENT surgeon bemoaned the way that, historically at least, we’ve asked our youngsters to choose arts or sciences in their mid-teens, effectively closing a whole hemisphere of learning thereafter. Some medicine courses are now designed specifically for arts graduates, but traditionally aspiring medics, unless they fancied staying at uni until their late twenties, had little choice but to study sciences for A-level.

I was forced to confront my own ’sliding door’ moment recently when I popped in to my alma mater, Kings Taunton, for their Spring Fete. I rarely go back, but the weather was clement, and the promise of Petherton’s own Malcolm Pyne arriving with a truckful of roast pig carried the day. I caught up with several senior colleagues from the local health system whose children are at the school, and also bumped into my old French teacher, Mr. Ian Halford, for the first time since leaving in 1976. In previous blogs I’ve mentioned seminal moments from school or university, but few have had as significant an impact on my A-level choices, and so my path towards medicine, as the last ten minutes that Mr. Halford and I had spent talking together 45 years previously. It was my French O-level oral exam, and I suspect neither of us has been quite the same since.

I had no medical aspirations as I approached my O-levels, and was undecided whether to become a nerdy scientist, or one of the artier set who would go on to spend their sixth form years reading Keats, dissecting Proust, and illicitly smoking with the more sophisticated girls. I’d been predicted a good grade in French; we’d done lots of practice for the oral exam, and I felt confident enough as Mr. Halford sat down opposite me. Using two fingers, he started the reel-to-reel tape recorder running, and off we went.

It started well enough; he wanted us to have a conversation about an imaginary walk together on the Quantocks, and I quickly got into my stride, imagined and metaphorical. The ciel was bleu, with nuages building from the west later. Les oiseaux were chansant and it was all going smoothly. About three minutes in, however, things took a dark and sinister turn, with Mr. Halford pointing out that we were surrounded by ‘mutantes’. There were hundreds, apparently, in what I could only assume to be some sort of post-apocalyptic zombie horror show. Taking his lead, I entered into the spirit, suggesting peut-être that Hinkley Point est allé ‘critique’? He had remarkable eyebrows, and they shot upwards in what I understood at the time to be encouragement to expand further, but now recognise was a sign of deep alarm.

I ploughed on. My knowledge of radiation sickness in those days was sketchy at best, and translating ‘blistering skin’, ‘prostrated by vomiting’ and ‘bleeding from every orifice’ probably broke my flow a bit, but I wanted to add some texture and describe what these ‘mutantes’ were doing and experiencing. When the ten minutes was up, a visibly shaken Mr. Halford turned the recording off.

‘What was that, Bray?’.

It turned out to be a simple misunderstanding, and on reflection we would have been more likely to have come across ‘moutons’ than ‘mutantes’ in the verdant Somerset hills. That was the end of my career in the humanities, and so here I am.

It’s ironic that of the various bits of garnish after my name- I’m a Member of this, Diplomate of that and Bachelor of a couple of others- the only thing that I’m proclaimed to be a Master of, is the Arts. Mrs. Chair has made it clear she thinks that’s an anachronistic joke, so I’ve decided to broaden my cultural horizons.

Having survived an audio-visual thrashing from Muse in London at the weekend, I was in Plymouth on Wednesday for a spot of ballet courtesy of Matthew Bourne’s ‘Romeo and Juliet’. Possibly distracted by having a swollen throbby knee forcibly flexed to 90 degrees for two hours, I struggled to see past some liberties with the plot (the action was set in a juvenile psychiatric institute) and was amused that the villainous Tybalt appeared to be modelled, visually at least, on Ben Stokes.

Mrs. Chair is right. I am a Philistine.

Nick

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