Wait…did you say he’s unconscious?

A few weeks ago, on Remembrance Day, Keith our close friend of more than 25 years died peacefully at home surrounded by a bunch of us who loved him and were loved by him. Although too soon at the age of 65, his death was a good death. Painless, nursed to the end by his husband Neil, with light input from the local hospice. He’d had a glioblastoma of his midbrain for nearly three years, and although the last months were difficult, most of his time post-diagnosis was good quality.

On the day he died he’d taken a definite turn for the worse. Semi-conscious, difficulty swallowing, entirely bed bound and a little more distress from his headaches. We were worried that the morphine solution he needed to keep the pain away was going to run out over the weekend. Unfortunately the hospice is unable to supply medication at home (I suspect something to do with budgets), it all has to go through the GP service, and so we rang NHS111.

Neil was really in no fit state to do the negotiations at this point and admitted he would probably get annoyed and frustrated, so I took it on myself to do it as the “professional” in the room. After a short time negotiating the “if you need this please press two” section of the service, followed by a wait on hold for about fifteen minutes I got through to a person. I explained the situation, then had to explain it again bit by bit as she was clearly working through the algorithm on her computer screen.

“So is Keith conscious”?

“No, he’s unconscious, he has a brain cancer and is terminally ill”

“Wait, did you say he’s unconscious? Are you sure? What happens if you try to wake him”?

“Yes, I’m sure. I’m a doctor, his Glasgow Coma Scale is about six if you want the medical version”.

“I just need to speak to my supervisor…please hold”

…

… <elevator music>

“Hi, if you try to rouse him what happens? Does he speak to you?”

“No, he’s unconscious, he has a brain cancer and is dying, he doesn’t need hospital, and don’t worry, this is entirely expected. I suspect he would react to a painful stimulus but I’m not going to do that because he’s dying and it’s not necessary.  I just need the prescription please”.

“Please hold”

….

…<elevator music>

“So is he under the care of a hospice?”

“Yes, but we need to go through the GP service for all medication”.

“Ok, hold on”

…

…<elevator music>

“Hi, ok we will refer through to one of the local doctors , is it ok for them to ring you back on this number?”

The doctor rang back about ten minutes later and sorted the problem out within a few minutes. Not only that but she anticipated other issues that would arise and made the referrals necessary.

Doctors are expensive. We are highly trained, go through a rigorous assessment process well into our mid-thirties and set ourselves extremely high standards both in our professional and personal lives. Through decades of poor workforce planning, not just in the UK but worldwide, we are in short supply and the onus has been to stop our time being wasted, filter out demand and distribute tasks traditionally done by doctors to others whose training is focused on those particular areas.

Fair enough, that makes sense. However this has led to unintended consequences. If I hadn’t been medically qualified with a strong sense of what should happen Keith could well have ended up in the emergency department with inappropriate interventions and investigations, dying in a place his absolutely did not want to die in, because the algorithm says if they’re unconscious they should get an ambulance. It’s not the fault of the telephone operator I spoke to, she’s not medically qualified and is following what her computer screen tells her to do. She escalated where she was supposed to, but someone less sure of themselves, less au fait with what was going on, would have agreed to getting an ambulance.

Our patients deserve to have access to doctors on the frontline. Yes, we are more expensive than a telephone operator, but we are efficient decision makers trained to see a bigger picture, to look after the whole patient and use our skills to anticipate other issues that might come up. We are good value.

I want to emphasise here that I’m not advocating against other roles such as experienced nurses and other allied health professionals - or indeed medical associate professionals - taking up an extended scope of practice and doing some of the work traditionally reserved for doctors. What I am advocating against is putting up barriers between patients and doctors. There need to be firm supervisory frameworks and we doctors must be present at the frontline, even when that frontline is at 2pm on a Saturday afternoon.

Keith died peacefully at 5pm. He wasn’t certified dead until 3am because the referral from the hospice to NHS111 service never reached the intended destination. Neil had been told to expect the doctor about 11pm, but he had to negotiate the algorithm again at midnight when the doctor hadn’t arrived. His death was entirely expected, yet Keith has been referred to the coroner because he had not been seen by a doctor in the month before his death. In the meanwhile his funeral is on hold, but it’s given Neil - an accomplished artist - time to decorate Keith’s coffin.

Keith, rest in peace, you were much loved, but as a service the NHS could have served you so much better.