Season of mist and, hopefully, mellow fruitfulness

Lesley Morrison

‘Autumn wins you best by this, its mute appeal to sympathy for its decay.’

Robert Browning (1812–1889)

The last weekend of October was my last weekend being on call in the old system. The colours were glorious, the leaves were falling, and I was busy. Busy and satisfied. Perhaps forbidden fruits tasted sweetest but many of the patients I happened to see and situations I happened to find myself in made me feel glad to be a GP and somewhat thoughtful about what we might be about to lose.

The first patient was, sadly, deceased: an overnight sudden death of a member of a visiting shooting party in a farm cottage. NHS 24 passed on the message from the police with the request to attend. Having waded my way through the new central police telephone system and ignored the taped invitation to dial 999, I acquired directions to the ‘locus’. Many misty miles later, I confirmed death and, as the rest of the shooting party had gone off shooting, the two police officers and I kept each other company until the Procurator Fiscal rang back.

Back in town, the district nurse in our practice, on call for the town, asked me to visit and assess pain control for an elderly woman whom she knew well and who was dying at home of cancer. The patient, her sister, the nurse, and I all agreed that starting a pump would be the thing to do and we did. The next call was to a very elderly woman who had died somewhat of cancer but mainly of old age, in her own bed surrounded by her family. Her husband and daughter were moist eyed but not unhappy. She had been ‘very fond of her doctor’, my partner, and I felt almost sorry that it was not he who got to share the moment.

At the cottage hospital a 16-year-old arrived with his father having taken a substantial number of ibuprofen. His work was ‘stressful’, people were accusing his girlfriend of ‘doing things she's not doing’, and his parents were arguing all the time. They continued to argue about who should take him to the hospital. Just before he left he lifted his eyes and I recognised him. When I looked at his notes on Monday it fell into place. I had seen him amid major family problems 4 years previously, and I wrote inviting him to come in after he was discharged. He hasn't come yet, but at least there was recognition and continuity and he has the invitation.

A regular customer was brought by ambulance following a 999 call made by his carer. The nurse put me in the picture. ‘He vomits, goes off his legs, comes in to get sorted out, and goes home’. Fine then, who am I to interfere with tradition? Especially if the alternative would be an admission to the hospital. A call follows to a patient of mine at home who is very ill and needs to go into hospital. She does, promptly. She would have welcomed admission by anyone, as would her family, but perhaps the familiarity helped.

The following morning, the old lady with the pump died, peacefully.

Over the weekend there was, of course, the usual motley collection of coughs and novices falling off bikes and minor trauma. There was also the old man in the nursing home having a stroke and the young auxiliary, his friend, watching him and needing reassurance from a familiar face that he wasn't in horrible pain. There was the other old man in bed at home with probable renal colic requiring analgesia and follow-up who might, a day later in the new system, have been admitted to the hospital by someone unaware of his medical and social history. There was the familiar woman with cancer and a chest infection due her chemo in 5 days who was pleased that I knew who her doctor was, and there was the young woman with a nasty urinary tract infection who needed antibiotics and a letter to excuse her from a social services case conference with colleague social workers to discuss the fostering of her three kids.

So, continuity of care, sharing of knowledge and information, local admissions, trials of treatment, windows of opportunity to connect, and connections to follow up: the rich pickings of an on-call service provided by local GPs for their practice populations with fresh knowledge and insight being fed back into the local system. But such an ecosystem has been deemed unsustainable and the mulch in the new system is going to be spread more thinly and by a wider selection of gardeners. Will the soil be as fertile and will the recycling be as effective?

Undoubtedly, the last leaves always seem more intensely golden and it is easy to lapse into sentimentality about a passing time. But, for the fruit of future seasons to be good, the roots of the precious tree of general practice need to be well maintained and nourished.