Here is another story about caring for a patient at a distance
On a Tuesday in July 2011 I was taking the midday phone calls. A patient who had been seen that morning by one of my colleagues rang for further advice. My colleague had diagnosed a likely pyelonephritis and prescribed antibiotics, and sent a urine specimen to our local hospital for analysis. Pyelonephritis is a serious condition which not infrequently needs hospitalisation. The patient, under thirty and otherwise a fit and healthy person, was having shivers and felt the need for further advice. I told the patient that the ‘shivers’ might be due to a temperature and what to do about that, but that it might also be due to rigors due to the infection spreading to the blood. I advised that he/she continue taking the antibiotics, and take medication to lower his/her temperature, and to ring again if the shivering persisted or if he/she became more unwell.
The next afternoon at about 3pm the patient phoned again. The patient was still quite unwell. As it happens, I had been invited to speak to a group of mainly pyschotherapists about this blog, this Protest, and I was getting ready to leave for this meeting. I could see that the patient lived 2 blocks from the surgery and I thought I could drop by on my bicycle on the way to the meeting. I told the patient that I felt he/she needed to be seen. The patient said he/she would come to the surgery; I said to come straight away.
It took the patient 45 minutes to arrive. I assessed the patient, spoke to the duty medical team at our local hospital; we would continue to manage the patient at home, but if he/she got any worse, hospital review and possible admission would be necessary. I gave the patient a letter, in case he/she needed it.
The patient then said that he/she had moved address, and now lived in Hackney, a neighbouring borough. The patient had had to come to the surgery by minicab, hence the delay in getting to the surgery. The patient said: ‘This really does not work for me. I’ve moved but did not want to change doctors, but this does not work.’ What the patient meant was that getting medical care under his/her present circumstances was difficult, due to the distance. In fact, it did not work.
I told the patient that this had been my experience: looking after patients at a distance becomes more complex, and often unworkable. It works fine for patients who are well and do not need medical attention, but does not work if the patient becomes ill. I told the patient I was about to speak to a group about this problem, and the fact that the Health Bill was seeking to abolish practice boundaries and allow patients to register with a GP of their choice, regardless of where they lived. The patient said this did not make sense. I agreed. I encouraged the patient to find a local GP.
The next day the results of the urine test came back: the patient did in fact have a urinary tract infection, and the antibiotics she had should have treated the infection. I spoke with the patient on the phone; there had been an improvement. I warned him/her that if this recurred, he/she would need further investigation.
This is a simple story. It illustrates the problem well. The patient had delayed registering with a local GP because there were problems (limited choice given his/her new address). When he/she became ill and needed to see the GP, the practical issues became evident.
A core part of our work is looking after people who are sick. Sick people are less mobile. There is no getting away from this very basic fact. That is why patients need a primary care practice which is local, not distant. Distance is a barrier to care.