I sat riveted through Kenneth Branagh’s perceptive portrayal of Ivanov in Chekhov’s eponymous play. Witnessing the desperate depression of the protagonist unfold I couldn’t help thinking how many points he would score on a Patient Health Questionnaire (PHQ-9), a common screening tool for depression in primary care and a burdensome necessity for accurate clinical coding (and payment). Would I dump a diagnosis of depression on the shoulders of this melancholy Russian on our first encounter or would I confine him to the computerised purgatory of low-mood?
Ivanov’s absolute hopelessness was matched in intensity by the grating self-righteousness of the young doctor caring for Ivanov’s wife. The doctor deals only in certainty even if that certainty is created by his own conjecture. This is a doctor in desperate need of a crash course in narrative-based medicine. Maybe he blew his study leave budget on an immodestly priced College exam ‘non-crammer’ course instead.
Similar degrees of despair were to be seen in a recent practice meeting. The decimation of the borough’s district nursing team took place before our very eyes as people were replaced with proformas. The powers that be ensure that district nursing services are spread thin and far. This came under the forensic glare of my headlamps as I drove to an elderly patient’s home whilst duty doctor to administer his low-molecular weight heparin jab as the single duty district nurse, covering the 22 square kilometres and estimated 227,500 residents of the whole borough, was absent (with leave) and the family had been pointed in my direction by the out of hours service.
My mum used to be a district nurse. I remember the navy blue anorak and black brief case that would disappear through the front door as she headed out for another twilight shift. It wasn’t glamorous nor did she expect it to be. District nursing still isn’t glamorous but now it seems people expect it to be. This translates into a real recruitment and retention dilemma. The lure of advanced practitioner status and maybe even a clipboard means experienced nurses continue to leave the frontline in the community for more managerial positions. The delivery of care in patients’ own homes is inevitably compromised. It came as a surprise to me to learn that the district nursing team consisted of only one qualified district nurse, supported by community staff nurses and healthcare assistants. The whole problem is exacerbated by a multi-layered bureaucracy that would bring a knowing smile to former KGB officials’ faces.
However, within a fortnight of this foreboding catastrophe, the tables have turned once again. A new local coordinator has been crowned and we can talk to district nurses again rather than communicate via the medium of fax. We also have our very own community matron now. My scepticism has served me well in the past: I now carry wound dressing packs in my duty doctor bag.
Tauseef Mehrali (GP Registrar)