Loneliness

In a drive to be ever more organised when it comes to completing our QOF tasks by April, this week has been a 'Vulnerable Elderly' review week. These reviews involve long consultations with endless questions about hearing problems, mobility, hygiene problems (I never quite know how to ask about this one?) and to finish, the dreaded mini mental state examination.

As a quick aside, can I just say how much I loathe the mini mental test. If the patient is completely coherent, asking what year it is, what country we're in and to follow ridiculous commands involving fingers, ears and nose is just embarrassing. Many are offended, many just think you're wasting their time. If on the other hand the patient suffers from a degree of dementia and can't answer the questions, watching their embarrassment is even worse. All in all a hideous experience.

There is however, one question that I dread asking even more than I dread the mini mental test. It's this:

"During the last month, have you often been bothered by feeling down, depressed, or hopeless"

It's part of the depression screening, and the tragically high number of positive responses provides the basis of many a disheartening conversation. For some, these feelings stem from financial problems, family disagreements or the loss of a loved one. For the majority they are simply due to loneliness. Those without local friends or family, too frail now to make the journeys they once used to.

One patient told me that he insisted on going to the supermarket every single day, because so often the brief conversations with checkout staff provided his only human interaction. Another mused that she had simply lived too long, her husband and all of her friends having died before her. She could only give me her cleaner's name as her next of kin.

So they score a positive on my depression screening, but what of that? Should I give them antidepressants? I can't see how that would help. Psychological therapy? Somehow I don't think so. I've tried to get patients such as these involved in day centres or community activities, but I find that many are simply unable and some too proud.

It's hard to know how I can help and now I too am feeling down, depressed and hopeless...

The QOF Express

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.