The Dr Scrooge Chronicles

THE DR SCROOGE CHRONICLES

BOOK ONE

A PRIMARY CARE CHRISTMAS CAROL

Stave Onein which Scrooge reveals how burnt out he is

Old Dr Marley was dead. As dead as the NHS would be within a couple of years if things didn’t start to improve soon. And, as far as Dr Ebenezer Scrooge was concerned, Jacob Marley was better off out of it. Scrooge and Marley had been long term partners and Scrooge greatly missed his former colleague who had died several years earlier. This was not the result of any affection he had had for the man, that was not in Scrooge’s nature, but rather on account of the fact that, due to the national shortage of GPs, he had been unable to find a replacement, and his workload had consequently increased beyond the point of being manageable.

It was Christmas Eve and Scrooge was sat at the desk in his consulting room. It was nearly three in the afternoon. Morning surgery had only just finished and this was now what was laughably called his ‘lunch break’. An email flashed up on his computer screen. It was from the CCG wishing him a merry Christmas.

‘Bah!’ muttered Scrooge to himself. ‘Humbug! If they really wanted my Christmas to be merry, then perhaps they and NHS England could have agreed that I didn’t have to make up the Advanced Access hours, lost from not opening the surgery on Christmas Day, later in the week. Every idiot’, he continued, ‘who goes about with ‘Merry Christmas’ on his lips should be submitted to unnecessary colonoscopic examination and be forced to reflect on the experience for the purposes of revalidation.’

Dr Scrooge was not one to enjoy Christmas, and being encouraged to be merry served only to darken his already black mood still further. The situation was not helped by the arrival of a receptionist who announced her presence with a knock on his already open door.

‘Sorry to trouble you Dr Scrooge, but the Salvation Army band are playing Christmas carols in the car park and are asking if you would like to make a donation.’ She handed him a leaflet informing him that this Christmas many people would not have anywhere to sleep due to the lack of hospital beds resulting from years of chronic NHS underfunding. Scrooge sighed – this was nothing he didn’t already know. Only that morning he had been asked to arrange a review over the holiday period of a patient that was about to be discharged, a little earlier than was ideal, from the local, desperately overworked, hospital. Though he regretted being unable to promise that level of care, his refusal then had been unequivocal and he was no more minded now, at his own personal expense, to start financially propping up a system left destitute by the establishment. As far as he was concerned, he was already paying quite enough tax and, given that he had just learnt that the security of his pension was now somewhat precarious, he felt it was unlikely that he would change his mind on the matter. He stood up and slammed the door in his informant’s face. Sensibly, the receptionist interpreted that as a ‘No’ and scuttled back to where her colleagues were celebrating Christmas with a box of mince pies and a tube of Prosecco and pink peppercorn Pringles – the latter, notwithstanding the alliteration, surely an ill advised flavour choice, regardless of the season.

Scrooge had been invited to share in the festivities but he had no desire to do so. Nor did he have time. Instead he returned to his computer screen and started the never ending task of clearing his inbox of lab results, hospital letters, and prescription requests. He’d barely started when there was another knock at the door. Scrooge barked out a ‘What is it?’ and the door swung open to reveal the ST3 who had been with the practice since August. Dr Robert Cratchit was a highly capable doctor though one who lacked confidence in his own ability. To Scooge’s dismay he was wearing a Christmas jumper.

‘What do you want? Can’t you see I’m busy?

These words were not unfamiliar to Dr Cratchit, who, over the previous five months, had heard them frequently from the man who purported to be his trainer. In fact, so frequently had he heard them that, for a time, he had used them to start all consultations with patients, imagining them to be the profession’s approved opening words for all doctor/patient interactions. A failed attempt at the CSA and the associated considerable expense of applying to sit the exam again had indeed taught him much. Familiarity however did not make it any easier for Dr Cratchit to approach a man who never offered advice without showing contempt for the one who asked for it. For although Scrooge had received training on giving feedback, he had, much to the dismay of his appraiser, consistently failed to demonstrate any change in his behaviour as a result of such practice improving activity.

‘I was j-just wondering if it would be convenient if I were to g-go’ Cratchit stammered. ‘I’m only supposed to do one clinical session today and, though the planned patch t-tutorial for this afternoon has been cancelled, I thought that, since you allocated me all the visits, you m-might let me skip off a little early this afternoon. It is Christmas after all and I would so appreciate having the extra time to be with m-my family.’

Scrooge glowered. ‘Of course it’s not convenient. And I don’t suppose you’ll be offering to work a couple of extra Saturday mornings in lieu of the day you’ll no doubt be taking off tomorrow. That’s the trouble with young doctors these days. No commitment’

The ST3 smiled faintly and waited nervously. ‘Go on then, leave’ Scrooge eventually conceded, ‘But if anything goes amiss this afternoon and I’m compelled to reflect on some significant event or another, I know where my reflections will lay the blame. Just make sure you’re in early on Thursday.’ Cratchit thanked Scrooge and slipped away, leaving the burnt out old clinician alone with his thoughts and the prospect of a three hour afternoon surgery.

As things turned out the rest of the day was mercifully quiet with Christmas Eve being the one afternoon of the year which provided the general population with something more interesting to do than seek medical advice regarding their minor health concerns. As a result, Scrooge locked up the practice early and arrived home before nine. He’d stopped on the way to pick up a bite to eat but, having consumed it en route, the only thing he had to look forward to on arriving back was, as most evenings, the prospect of going to bed.

As he got out of his car, a fog hung about the driveway of the old house, that he’d bought some years before. Scrooge approached the front door, the fog seeming to cling to him as he walked. It was then that he noticed, in place of the ancient door knocker, what was clearly the face of his old partner, Dr Marley. The apparition lasted but a moment before Scrooge, unsettled by the sighting, hurried on, unlocking the door and subsequently forcing a pile of unsolicited medical periodicals to one side as he entered the house. He locked the door behind him and climbed the stairs to his bedroom.

Scrooge undressed and put on his night attire. As he sat gazing into the middle distance, contemplating once more the strange appearance of the door knocker, there came an unexpected ringing sound that filled him with inexplicable dread. Scrooge scrambled in his pocket for his phone. However, as the caller’s number was withheld, he, as was his custom, ignored what was almost certainly a nuisance call and continued his preparations for bed. And then he saw it. A sight that caused him to be more horrified than he’d ever been before – even more horrified than that morning when his appointments had included seven heart sink patients and three more complaining of being ‘Tired all the time’. Before him, as unwelcome as critical emails from the head of Medicines Management, stood the ghost of Dr Jacob Marley.

Scrooge, nothing if not a man of reason, rose up and spoke to the spectre in an accusatory tone.

‘I don’t believe in you’ he said.

‘You don’t believe in most NICE guidelines and yet they exist’ countered the phantom.

‘That’s true’, Scrooge was forced to concede and with that he sat back down in his chair. He paused a moment then, looking the ghost full in the face and acknowledging his existence, asked the reason for his visit.

‘I have come to warn you Ebenezer. There is yet a chance that you may escape what has become my fate. I am condemned to walk the earth for all eternity burdened by these chains – chains composed of nonsensical bureaucratic demands imposed on me by those who understand nothing of medicine and seek to use the profession for their own political ends. You have forgotten, Ebenezer, what being a doctor is really all about. You have forgotten the joy that your work once brought you and now you practice as a mere shadow of the clinician you once longed to be. You’re burnt out Ebenezer. Something needs to change.’

‘Blimey!’ said Scrooge, ‘like that’s going to happen’.

‘You will be haunted by three spirits,’ continued the ghost, ignoring Scrooge’s cynicism. ‘They will teach you all that you need to know. Without them you cannot hope to shun the path I now tread. Expect the first when the clock strikes one’.

And with that the ghost of Jacob Marley departed, groaning incoherent sounds of lamentation and dragging the weight of his chains behind him. Scrooge stood motionless for he knew not how long. Then, mindful of his need for rest, he climbed into bed. Picking up a copy of the BJGP, he fell asleep upon an instant.

Stave Twoin which Scrooge fondly remembers

Dr Scrooge woke in a cold sweat and sat bolt upright in his bed. This was not unusual for, in recent weeks, the stress associated with an impending visit by the CQC had frequently disturbed his sleep. Moments later, however, his thoughts were diverted from the need to get on and write those mandatory protocols on the secure overnight storage of hand towels and the safe use of the stairs, when, at one o’clock precisely, his bedroom door creaked open and a strange looking fellow crept into the room. Over a woollen cardigan he wore a tweed jacket complete with leather patches on the elbows; on the end of his nose was perched a pair of pince nez glasses; and in his hand he carried a battered black Gladstone bag.

‘Are you the spirit, sir, whose coming was foretold me?” asked Scrooge.

‘Indeed I am’ the apparition replied. ‘I am the Ghost of General Practice Past. I’ve come straight from a meeting of my celestial Balint Group. And my, what catharsis we enjoyed there this evening. Your former partner, Jacob, was in attendance. He’s a good chap, a jolly fine fellow. But enough of that. Come along with me – he has sent me to show you what General Practice once was.’

The spirit held out his hand and Scrooge instinctively took it. As he did so, Scrooge felt himself being lifted, as if weightless, from his bed. The spirit led him to, and then through, the wall of the bedroom and out into the night air. They journeyed until they found themselves in the oak panelled surroundings of what appeared to be a gentleman’s club. A number of elderly men sat together in high backed leather chairs. All were doctors, enjoying a glass of port after a drug sponsored Christmas meal. With them was a medical student who was attached to one of their number.

‘Listen to these chaps’, the spirit said to Ebenezer, ‘Each and every one is a fine fellow – a jolly good chap. You could learn a thing or two from what decent sorts like these have to say.’

The men were taking it in turns in regaling the medical student with tales of their working life.

‘Of course, these days, the youngsters have it easy. They only work a mere seventy two hours a week you know. In my day it was eighty one’

‘Eighty one hours? You had it easy. It was all internal cover when I did my house jobs. In real terms, I did a hundred hours a week’

‘Only a hundred hours a week? Luxury. I was running a GP practice single handedly by the time I was 23.. On call every hour of every day.’

‘That’s right. We had it tough as GPs. One hundred and sixty eight hours a week we worked – and, of course, we had to provide all the obstetric care – home deliveries every day’

‘And most of those were C.Sections – we had do the operations with only kitchen utensils for surgical instruments and a bottle of brandy for an anaesthetic’

‘Aye – and if you tell that to the medical students of today, they’ll not believe you.’

The spirit indicated that it was time to move on and Ebenezer readily agreed. He’d heard it all before. The walls of the room blurred and faded and gradually, as things came back into focus, Scrooge realised that they were now high above rolling hills. Passing over snow covered fields and lanes, they travelled until they came at last to a small town and stopped by a house that Scrooge recognised as his childhood home. Outside the dwelling, a car pulled up. The familiar figure of his family GP clambered out of the vehicle and made her way up the garden path to the front door. A woman was waiting anxiously for her arrival. They exchanged a warm greeting after which the woman led the doctor up the stairs to a room in which a boy lay, pale and in obvious distress.

‘Thank you for coming doctor, I know you’re busy but I didn’t know what to do. Ebenezer’s usually such a healthy child but he seems now to be struggling with his breathing.’

‘It’s no trouble Mrs Scrooge – let’s take a look at him.’

The doctor knelt down by the bedside and smiled at the boy who managed to smile weakly back. Ebenezer liked the doctor. He’d visited her a number of times over the years but this was the first time she’d ever visited him. The doctor asked a few questions and then carefully examined the boy, paying particularly careful attention to his chest. When she was done, she turned back to his mother and gave her the diagnosis.

‘I’m afraid it looks like we’ve a case of pneumonia on our hands. He’s really quite poorly and will be needing the help of my colleagues at the hospital. We best get him there as soon as possible.’

Scrooge looked on and wondered how she could say such a thing without a computer and a pulse oximeter to enable her to assess the risk of sepsis. She hadn’t appeared to even consider a CURB-65 score. None the less, a few phone calls were made and the doctor, placing her hand on Mrs Scrooge’s shoulder as if to say that everything would be alright, made her goodbyes,having given an assurance that an ambulance would soon arrive, an expectation Scrooge thought fanciful in the extreme,

‘Do you remember that day Ebenezer?’ asked the Ghost of General Practice Past.

‘I do,’ Ebenezer whispered, taken aback at how emotional he was now feeling. The spirit smiled to himself as he sensed that Scrooge was close to tears. He loved catharsis – catharsis was good. ‘She was such a lovely doctor’, Scrooge continued. ‘Always so kind and reassuring. She’d become almost a part of the family having visited so frequently during the last days of my father’ final illness. She always seemed to have time. It was because of her that I decided to become a doctor. The way she practiced medicine caused me to realised that being a doctor was a wonderful job to have. She seemed to me to be a fortunate woman.”

‘A fortunate woman indeed’ agreed the spirit. ‘A fortunate women and…’ he paused, thrown for a moment, ‘…a good chap’. The spirit hesitated again and then added, as if to try and reassure himself, ‘She was a jolly fine fellow.’

With that the ghost again took Scrooge’s hand and soon they were once more travelling through the night sky. On and on they flew, until they came to a village hall decorated brightly with all manner of coloured lights. A Christmas tree strewn with tinsel and still more lights stood by the entrance. Inside, Scrooge recognised the staff of his GP training practice. Some talked, others laughed and a number danced enthusiastically to music provided by a band. All were clearly enjoying the opportunity to relax and have fun together. A portly man then stood up and called for a bit of hush. It was Dr Fezziwig, the senior partner of the practice and Ebenezer’s one time trainer.

‘A moment’s silence if you please everybody. If I might say a few words, thank you all so much for coming this evening. I hope you’re having a good time.’ He paused a moment and then, with a feigned suggestion of doubt in his voice, questioned the crowd, ‘You are having a good time, aren’t you?’ Those gathered gave the desired response with cheers and roars that left nobody in any doubt that indeed they were. Fezziwig continued. ‘I want to thank you all for your help this past year. The partners appreciate your hard work, doing what can be a very difficult job. We couldn’t manage without you.’ More cheers followed together with a few calls for a pay rise. Fezziwig then concluded by wishing everyone a very Merry Christmas and insisting that everyone took advantage of the free bar that he and the partners were glad to provide. ‘Only keep an eye on young Dr Scrooge. He’s a fine young doctor but Ebenezer’s not as experienced as we older GPs and I’m not sure he can take his drink! We don’t want a repeat of last months incident when he woke up naked on the delicatessen counter at Sainsbury’s!’

‘Now he does seem like a good chap – a jolly fine fellow’ declared the spirit, beaming as if the natural order had been restored to where chaos had once threatened to reign. ‘He’s a good, fine, decent, jolly chap of a fellowy sort if ever I saw one.’

The Ghost of General Practice Past turned to Scrooge and looked him straight in the eye. ‘But what of him?’ the spirit asked drawing his companion’s attention to a young man who was accepting the gentle ribbing at the hands of the senior colleague he respected so highly. He was sat laughing alongside various members of staff with whom he was sharing a table.

‘I was so happy then’ Scrooge told the ghost. ‘He was such a wise man and so willing to share what he had learnt. And we were such a great team, all so eager to support one another. Back then, there seemed to be so much more time. Why did everything change? And how did I become so resentful of the job I used to love?’

‘Something certainly changed – something that shouldn’t have’ replied the ghost. ‘At least, not in the way it has. Perhaps something needs to change again. Perhaps something needs to be recovered. But it is for you to decide what and how. As for me, my time is up. We must return. You have other guests to welcome tonight.’

And in less time than it takes for EMIS to crash on a busy Monday morning, Scrooge was back in his room, alone with his thoughts. It was nearly two in the morning.

Stave Threein which our tale takes (trigger warning) a darker turn

In the few minutes he had to think before the next ghostly visitor was due to arrive, Scrooge reflected on the events of the evening so far and wondered if he should try to claim a few hours of CPD. However, anxious as to how his appraiser might respond to such revelations and fearful that his reflections may be used against him, he concluded, as many before him, that it would be best not to put his thoughts down in writing.

He then realised that it was almost half past two. Was he not to be visited again tonight after all? But within a moment of his beginning to wonder this, he was woken from his reverie by the sound of his bedroom door bursting open and the arrival of a rather flustered looking figure entering the room. She was carrying a pile of papers in one hand whilst tapping into the mobile phone she held with the other.

‘I’m sorry to keep you waiting’, the spectre began. ‘I’ve been so busy tonight and the last chap I visited had several issues that he wanted me to provide spiritual insight on. Blow me if he didn’t have a list! Now what seems to be the problem? I am the Ghost of General Practice Present. Did you have any ideas, concerns or expectations as to how I might haunt you?’

Scrooge looked back at the apparition somewhat non-plussed. He hadn’t asked for the visit and, other than his previous encounters that night, had no experience of consulting with individuals from beyond the grave. Though highly concerned by the present turn of events and expecting to find the whole thing highly disagreeable, he had very little idea as to quite how the encounter should progress. Consequently, Scrooge said nothing.

‘Oh dear,’ said the ghost, unnerved by Scrooge’s silence, ‘This is awkward. I told Marley that there was little point in my visiting you without you being willing to see me. You see it’s so hard to help somebody unless they realise they have a problem and want to be helped.’ Still Scrooge found himself lost for words.

Rather than using the silence as a technique for therapeutic communication, the ghost laid the papers that she had been carrying down upon Scrooge’s bed and started flipping through the pages. ‘I’m sure there is a guideline for this situation somewhere. Give me a minute and I’ll be with you as soon as I find it. I don’t want to get this wrong.’ A few minutes passed, at the end of which the ghost seemed to have found what it was that she was looking for. ‘Ah yes, that’s it – come with me. I’m to show you how Christmas is being spent by others this year. Only I’m running short of time so we’ll have to make it quick’.

Once again, Scrooge was taken by the hand but, somewhat to his disappointment, she led him down the stairs in the conventional fashion before continuing through the front door and out into the night. ‘I’m afraid that these days we don’t employ the use of magic flight’, the spirit explained, ‘There’s no evidence for it, you see. It’s all evidence based hauntings these days’.

The fog had thickened making it difficult to see where they were going but the ghost still had hold of her phone and had entered the post code of their destination into Google maps. Before long they reached a block of flats and proceeded to climb the communal stairs. On the second floor, they passed through the wall into the home of a young family, the spirit assuring Scrooge as they did so, that the Celestial Institute for Ethereal Excellence had approved, in highly selected cases, what was known in the profession as quantum tunnelling, provided said cases met stringent eligibility criteria.

The flat bore witness to the fact that it was Christmas Day. The mantelpiece and sideboard were covered with Christmas cards and coloured paper chains were hanging from the ceiling. In the corner was a Christmas tree under which a three year old boy was happily making good use of the colouring set he had recently unwrapped. He stood up and walked into the kitchen where his parents were preparing dinner. They turned to him and noticed that he was covered in red spots. Immediately his mother emptied the pint glass of Prosecco she was drinking and used it to perform the ‘tumbler test’, her anxiety being heightened all the more when the rash failed to disappear. She pressed the speed dial button on her phone and called ‘111’.

‘I’m worried about my son – he’s covered in spots’ she exclaimed to the call handler. ‘No – he seems well in himself…No – no vomiting or fever…No – no headache or tummy pain…No – no catastrophic loss of blood and No – he has just the one head’. The list of negatives continued until the questioner focused in on the rash. ‘Well it’s almost as if he’s been marking himself with a red felt tip pen!’ The women listened to the call handler for a few moments longer before ending the call.

‘What did they say?’ her partner asked.

‘Something about a non-blanching rash being possible meningitis and that it’s better to be safe than sorry. They’re sending an ambulance.’

‘Bloomin’ right too. Now let me refill your glass, we can’t have you sober when it arrives!’

The Ghost of Christmas Present indicated to Scrooge that it was time to move on. Their next stop was just across the stairwell. Passing once more through the walls of the property, Scrooge recognised Mrs Gray, the frail elderly lady who lived there, as one of his patients. She was nearing the end of her life due to her having advanced metastatic disease. A single Christmas card lay face down on the dining room table, alongside of which was a box of chocolates she had bought for herself in an attempt to make Christmas Day, the fifth she’d have spent alone since the death of her husband, at least a little special. She knew it would probably be her last. As Scrooge looked on, the woman picked up the chocolates and shuffled slowly across the room and then, for want of anyone else to give them to, placed them in the kitchen bin.

‘What’s she doing?’ Scrooge asked the spirit.

‘She doesn’t think you’d approve if she ate them’ replied the ghost, who then proceeded to point to a letter held to the fridge door by a magnet commemorating the Queen’s Silver Jubilee. It was from Scrooge’s medical practice informing her that her recent routine blood tests had revealed that she had a slightly elevated HBA1c and that she was therefore classified as ‘pre diabetic’. Included with the letter was a leaflet giving helpful advice on healthy eating.

Scrooge stood staring at the woman. He realised that, though if asked to relay the ins and outs of all her most recent blood tests he would have been up to the task, in recent years at least, he’d not really known her at all.

The spirit had left the flat and Scrooge hurried to catch her up. They walked together without talking until they came to a house that Scrooge had never visited before. Here they stopped and stood outside the window of a dimly lit room. Peering in through the poorly drawn curtains they could see the figure of Bob Cratchit. He was sat, his head in his hands, surrounded by various medical text books. To his left was a half empty bottle of scotch and a packet of antidepressants. He was writing a note.

Scrooge turned to the Ghost of General Practice. ‘What’s he doing?’ he asked.

‘Struggling’ she replied.

‘But why? He’s such a good doctor’.

‘He is indeed. But he doesn’t know it. He has come to believe that he has to be perfect – that every guideline must be followed and a failure to do so will result in legal action being taken against him. He’s taken on the burden that comes from believing that medicine has the answer to every problem experienced by a broken society. He thinks it’s all down to him. He has been worn down by the constant demand from both society and the profession that he must perform better – that good enough is not good enough. He’s exhausted by the never ending assessment of his performance and crushed by the weight of the responsibility he feels. He lives in the constant fear that it’ll all be his fault if anything bad ever happens. He too feels all alone this Christmas.’

‘But this afternoon? He asked to leave early to spend some time with his family’

‘Indeed he did but the truth is that he hasn’t much in the way of a family – just a couple of friends he thinks of as family. In reality he had hoped to meet those friends for a drink but things didn’t quite work out the way they were planned. When he left the surgery late yesterday he went back to check on one of the patients he’d visited. Their condition had deteriorated and he arranged an admission but he was left feeling guilty and anxious. As a result he didn’t think he’d make very good company. And besides, he was worried about his CSA exam and thought the time would be better spent preparing for that.’

‘But he’ll pass the exam easily’ Scrooge exclaimed. ‘He’s come on leaps and bounds since that unfortunate misunderstanding the first time round. The patients love him – and the staff. He’ll make a great GP’.

‘Have you ever told him that?’

Scrooge fell silent. Perhaps he could have been a bit more supportive, encouraged a little more. Perhaps he could have helped him steer a course through the mass of expectation and enabled him to distinguish between what was genuinely important and what could appropriately be ignored. Perhaps he could have been the kind of trainer Fezziwig had been to him – one who, despite the changes enforced on the profession, could still see the joy of working in general practice and convey a little of that to the next generation – one who would fight for what was worth fighting for rather than retreating into cynicism, bitterness, and resentment.

‘I never knew he felt so alone. I never knew he was finding it so hard.’

‘Did you ever ask?’

Scrooge’s head fell. ‘Can I speak to him now?’

‘I’m afraid not. He won’t be able hear you, and what’s more our time is up. We must go.’

‘But I must do something’

‘That’s as maybe – but you have another appointment to keep. You must meet the Ghost of General Practice Yet To Come.’

The ghost started back towards Scrooge’s home. Scrooge himself lingered a little longer at the window in the hope that Cratchit would see him and appreciate his concern. Finally he turned his back on the scene and trudged slowly after the ghost who was now some yards ahead of him. Behind him, Cratchit slipped silently into the deepest of deep sleeps.

The spirit accompanied Scrooge back to his room but, before she left, she had one small request.

‘I’d be most grateful if you could fill in this form by way of giving feedback on my performance this evening. And it would be very helpful if you could indicate whether you’d feel able to recommend me to your friends and family…’

Regretting the choice of words even as she spoke them, an awkward silence arose between them. The spirit looked at Scrooge – Scrooge looked back

‘…or perhaps just an acquaintance…a passer by even?’

Sensing that now was clearly not the time, the Spirit said a hurried goodbye and left, leaving Scrooge alone with his thoughts. He couldn’t stop thinking about what he’d seen. He tried to convince himself it was all a dream, that none of it was real. Had things really become this bad? And could the future be worse? He had a feeling he was about to find out.

Stave Four – in which the future appears far from bright.

Alone again, Scrooge, out of force of habit, checked his phone for notifications. No red circle had appeared in the corner of the Facebook icon to indicate that someone, somewhere cared about what was on his mind. This was not unexpected as it had been a long time since anyone had ‘liked’ him – still longer since he’d been loved. It was a surprise to him, therefore, when the phone vibrated alerting him to the arrival of a text message.

‘This is to remind you that your appointment with the Ghost of General Practice Yet To Come is scheduled for now. Please access your Babylon Wealth account and prepare to speak to somebody with no soul’

Scrooge noticed a new app had appeared on his phone’s home screen. It glowed menacingly, demanding to be tapped. Scrooge couldn’t help thinking that ‘Babylon’ was a curious name for a company to chose to call itself, recalling, as he did from his days in Sunday School, how Babylon represented all that was evil, ‘the mother of earth’s abominations’ and a ‘dwelling place for demons’. Perhaps, he concluded, it was strangely fitting after all.

Against his better judgement, Scrooge opened the application and was greeted by a disclaimer making it clear that any advice given was only valid for minor, self limiting medical conditions and any harm that resulted from Babylon clinicians failing to appreciate a more serious underlying problem was not their responsibility. Those experiencing more complex health concerns were directed to approach less forward thinking health providers. Scrooge was requested to indicate his acceptance of these conditions and, having complied, the screen gave out a burst of light and there then appeared what looked for all the world to be a businessman dressed in an executive suit.

‘Welcome to Babylon Wealth,’ the man announced. ‘where your health needs are our business opportunity’. He smiled a self-satisfied smile, which Scrooge did not find reassuring.

‘Are you the Spirit of General Practice Yet To Come?’ Scrooge enquired.

The spirit’s smile wavered a little. ‘Is that what The Ghost of Christmas Present called me? She is so yesterday. I’ve been rebranded and, from now on, I am to be known simply as ‘The Future’. Exciting isn’t it? Now, how can I profit from you?’

‘I believe you’re supposed to show me my future’

‘Yes of course, but I don’t have time to talk to you about that in any depth. So, in the interests of efficiency, I’d like to request that you utilise this corporate video feed. If you’ve any further questions you’ll be required to make a further appointment. You will receive an invoice for the services I have provided today and your account will be automatically debited the requisite amount. Thank you for using Babylon Wealth. Have a nice day.’

Lost for words, Scrooge tapped the link that had appeared on his phone and continued to gaze at the screen at what seemed to be, if such a thing was possible, a broadcast from the future. It began with an aerial view of a huge featureless building over which an audio commentary played. “Welcome to the world’s first fast health outlet. – Where health is cheap and time is short”. A notice board at the entrance of the building came into focus revealing that ‘The National Wellbeing Centre’ was open 24 hours a day, 365 days of the year. Two enormous panels straddled the entrance bearing images of the Secretary of State for Health and the President of the National Pharmaceutical Board. They were pictured smiling benignly down upon the multitude who were milling around a large reception area.

As the camera roamed around, the audio commentary explained how no appointment was necessary but that, on arrival, patients were required to utilise electronic panels positioned in the foyer to answer a series of questions by way of ‘Yes’ or ‘No’ answers only. As a result of the responses that were given, each individual would then be assigned to a wellbeing advisor. If, and only if, it was deemed necessary that face to face contact should ensue, they would then wait outside one of the 666 consulting rooms housed within the complex until their allocated interaction was scheduled. Patients were advised that only objective quantifiable, symptoms could be dealt with and that treatment options would be determined solely on the basis of the medico-economic considerations pertinent to each individual case. Reassurances were offered that a number of payment options were available.

Around the foyer, electronic panels displayed information for consumers alongside a number of company disclaimers:

“Due to many drugs now being of limited availability, if medication is advised, the sourcing of that medication is entirely the responsibility of the customer.”

“Please be assured that we respect your anonymity and consider it of paramount importance to maintain the highest levels of confidentiality. In order to guarantee this, no wellbeing advisor will consult with the same client on more than one occasion and no personal communication is permitted between clinicians. A mask can be worn over the face if desired.”

“The National Wellbeing Centre cannot accept responsibility”

“Strict quality control measures are in place to guarantee the optimal outcome of each clinical interaction. Each consultation is electronically monitored and any deviation from company protocols will result in disciplinary action being taken against the clinician concerned.”

The announcements seemed endless, each, it appeared to Scrooge, alienating the individual in need still further from the connection they craved with somebody who just might care enough to show a little concern. Patients were managed without any warmth or compassion – processed by a system that existed solely for the benefit the state that had created it.

As Scrooge continued to watch, the announcements kept flashing across the screens, hypnotising those whose eyes were drawn lifelessly to their incessant messages. Dehumanised, everyone became the same – And that same was nothing more than a reservoir of data.

“Please be aware that displays of emotion are not encouraged in consultations and tissues are therefore not provided in the consultation rooms.”

“Customers will not be permitted to leave the centre until the requisite post interaction forms are completed. Not only does the filling of these forms provide the essential feedback necessary to identify suboptimal clinician performance, the personal data requested allows us to identify those agencies from whom we will profit most by our facilitating their communication with you.”

“Everybody here at the National Welfare Centre wishes you, and your purchases, a very merry Consumertide.”

And then, finally, before the cycle of messages started once more, one last announcement:

“Turmeric is available from the kiosk in the foyer”

The camera returned to a view of the outside of the building and Scrooge caught a glimpse of a small panel attached to the wall next to the main entrance. He paused the video and expanded the image to take a closer look. He could just make out the words that were inscribed on the ill maintained copper plate.

‘This facility was erected on the derelict site of what was once known as a GP medical centre. Drs J. Marley and E. Scrooge worked here for many years providing a form of medical provision which today is only of historical interest. The medical centre operated with the quaint intent to provide medical care that was responsive to patient needs. Dr Marley’s untimely death left Dr Scrooge struggling as he found it impossible to replace his former partner. He continued for a time supported by a series of doctors in training, but, after a personal tragedy struck the medical centre, it was no longer considered fit to remain a training practice. Dr Scrooge continued alone for a brief time, but the pressure of working in such an inefficient manner soon proved too much and he himself succumbed to a stress related illness. Happily, his demise proved the catalyst for the development of the progressive wellbeing centre that we benefit from today.’

Scrooge could not believe what he had witnessed. It struck him that there had at no point been any mention of there being any doctors present in the running of the well-being centre. It was almost as if there was now nobody providing a professional opinion, nobody making a judgement, nobody applying a bit of wisdom and that clinical algorithms were being used to make each and every decision. Were there, he wondered, any doctors still in existence at all? Perhaps, in the future, nobody wanted to be one. The questions kept coming. Was this really the future of the health service that once, years previously, he had been so proud to be a part? What about Cratchit? What did the ‘personal tragedy’ refer to? And what of his own future? Could any of this be changed?

Scrooge tapped frantically on his phone seeking a further appointment with the Ghost of General Practice Yet To Come. Fortunately, for all the faults of Babylon Wealth, having made the appropriate additional payment, an appointment was easy to come by, and soon, the business-like figure of the spectre, who had been so brusque with him earlier, appeared on the screen once more.

‘Good Spirit’ Scrooge implored, ‘Assure me that I may yet change these shadows you have shown me by an altered life’

The spirit laughed. ‘It’ll take more than one doctor changing to alter the future of the health service. That’s the trouble with you people. Too often you think it’s all down to you’. The spirit made a poor attempt at a Clint Eastwood impersonation, ‘A doctor’s got to know his limitations.’

‘And besides, what’s your problem? What we’re doing merely reflects the ideology of the nation – that everything comes down to money. We measure and record data because data sells. What we understand at Babylon Wealth is that people are commodities. For example, we record an elevated cholesterol solely because we know there is somebody out there who is selling a product to reduce lipid levels and is willing to pay for the information we collect. We don’t care about people, only the wealth that they generate for us.’

‘But it’s not all about money’, Scrooge insisted.

‘Isn’t it?’ countered the spirit. ‘It seems to me that everyone has a price Dr Scrooge. Are you really the exception?’

‘Well maybe I do have a price, but if I have, it’s at least partly because, in recent years, with so much of the joy having been sucked out of the job, the only way that I’ve been in any way rewarded for my efforts is financially. There’s no appreciation from those who call the tune, no recognition of how difficult the job has become and nothing but constant demands that I must do better. Take appraisal – if a requirement to show year on year improvement doesn’t amount to saying that we’re not good enough as we are, I don’t know what is. Something has to change’.

‘Well good luck to you with that, Scrooge. I concede that, as a profession, challenging the status quo rather than capitulating to the spirit of the age whilst all the while laudably endeavouring to deliver its impossible demands would be a step in the right direction. But I can’t see it ever happening – you’re all too busy just trying to keep your head above water to organise a concerted campaign for change.’

‘But let me try, spirit. Let us try. I have learned my lesson well this night. Perhaps things need not turn out the way you have shown me”.

And with that, Scrooge deleted the Babylon Wealth app from his phone, never to be installed again. He got back into bed. He’d seen and heard quite enough.

Stave Five in which we are given cause for hope

It was early morning when Scrooge woke. He sat up in bed and looked around the room. Everything appeared as normal and yet, within himself, he felt changed. Perhaps he was being naive but he felt a sense of optimism that he hadn’t known for years, daring to hope that things could get better.

It was then he remembered it was Christmas Day. ‘At least I think it is,’ he said to himself excitedly, ‘assuming that all three Spirits did indeed visit me last night and that I haven’t missed the great day completely’. He ran to the window and looked out. A light layer of snow coated the ground which heightened his excitement still further. And yes, a young lad was trying out a brand new bicycle, no doubt a freshly unwrapped Christmas present. Add to that the fact that one or two folk were making their way towards a church whose bells were ringing joyfully in the distance, it was, with the utmost certainty, Christmas morning.

But there was no time to lose. He had to check on Bob Cratchit. He dressed hurriedly and ran down the stairs and out into the crisp morning sunlight which reflected off the snow-covered ground. Scrooge got into his car and within a few minutes he was outside the house of his trainee. He knocked loudly on the door but there was no answer. He knocked again and, when there was no response, shouted through the letter box. Still there was only silence. Scrooge moved round to the side of the house and looked through the same window he had the previous evening, its curtains still only partly drawn. Cratchit was sat there, just as he had been when Scrooge and the Ghost of Christmas Present had left him earlier. Scrooge hammered on the window until, at last, he saw movement and a wave of relief surged through him. Slowly Cratchit stood up.

‘Open up Bob. Open up this instant. Do you hear?’ Scrooge shouted at him though the glass. ‘Open up. It’s Christmas Day!’

Cratchit, clearly half asleep and still the worse for the half bottle of whisky he’d drunk the night before, gradually stood up and made his way to the front door. Scrooge had never been one for outward displays of affection, but now, as Cratchit opened the door, Scrooge greeted him with a hug that was as welcome as it was unexpected.

‘How are you Bob? Are you alright?’

‘I’ve a bit of a headache if I’m honest. And not one that’s improved any by all your hollering. But why are you here? Has something happened? Have I done something wrong?’

‘On the contrary. If anyone is at fault it’s me, for not appreciating you more. And to show you that I mean it, what do you say to a partnership come August when you’ve completed your training? I’d be proud to call you my partner’

‘You must be desperate!’

‘Desperate? Of course I’m desperate! Have you seen the state of the health service? But that’s not the reason for my offering you a partnership. I would like you to help me change the way we do General Practice. It’s a conditional offer of course – conditional that is on you seeing some change. There’s no way I’d want you to commit to a lifetime of working the way we have of late.’

‘Well I guess I’ll have to think about it. But thank you. I didn’t realise that you thought I was up to the job’.

‘Of courses you’re up to the job. We all worry sometimes that we’re not though, so don’t be surprised if you find yourself questioning the fact – that’s normal! The trouble is that we’re all so anxious imaging that we have to be perfect. We’re not God you know – even though both the government and our patients sometimes expect us to act as though we were.’

‘Well I guess you’re right there’

‘Of course I’m right, I’m your trainer! Now, what’s with the whisky and the packet of antidepressants?’

Cratchit looked down at the ground. ‘I didn’t take any, just thought about it. I guess I was just feeling a little overwhelmed. I was being stupid”

‘It’s not stupid to feel overwhelmed. There’s no shame in being asked to do more than you can cope with. The only foolish thing is to not realise you need to say ‘No’ sometimes – that sometimes you need help and have to ask for it. I’ll try and make that easier for you from now on. Promise me though that you’ll not let your thoughts travel in such a dark direction again without letting me know.’

‘I’ll try not to – I promise.’

‘Excellent. Remember, we’re in this together.

Cratchit couldn’t quite believe what he was hearing and couldn’t stop himself voicing the question that was on his mind.’

‘Dr Scrooge,’ Cratchit began

‘It’s Ebenezer. Call me Ebenezer’.

Cratchit hesitated and then tried again. ‘Ebenezer.’ It seemed strange to hear the name spoken aloud, ‘I hope you don’t mind me saying this, but something seems different about you today. Has something happened?’

‘I rather think it has,’ said Scrooge. ‘As a profession we’re convinced everything’s wrong. A lot is of course, but I see now that if we can see what the problems are, then surely we stand a chance of making changes.’

‘But how?’

‘To be honest, I’m not quite sure. One thing would be our need to challenge the idea that medicine has all the answers. We need to say ‘No’ to the over medicalisation of life and be honest with both ourselves and our patients as to what we can and can’t do. Another thing would be that we have to be allowed to behave as the professionals we were trained to be. Once we were seen as people who could be trusted to make judgments in the best interests of patients. Now it seems we are seen as mere service providers, required to unquestionably follow guidelines regardless of how appropriate or otherwise that might be. It’s as if we’re not considered competent to try to decide what is best for our own individual patients. But one size doesn’t fit all. And so we need to fight to retain the doctor patient relationship that underpins good general practice and not allow it to be lost in the rush to conveyer belt medicine. We have to take back control over our work, make our own decisions as to how to apply medical knowledge to each individual situation and have the courage to resist the inappropriate demand to behave in ways that are imposed on us by government, pharmaceutical companies and society as a whole. That would mean better health for our patients and happier working lives for ourselves. That’s something I can aspire too, and knowing what it is I’m aiming for might just give me a chance of fathoming out how I might go about working towards it. At least, that’s my hope.”

Scrooge, in his excitement, had been pacing around the room. Now, pausing for breath, he sat down.

‘But that’s enough of all that for now. We can get together tomorrow and plan then just how exactly we’re going to do things differently. We’ll call it a practice away day. Just think of all the CPD hours we can claim! So, what are your plans for today?’

‘Well I had planned on a spot of revising for the CSA.’

‘Revising for the CSA. What nonsense – you’d pass that tomorrow with your eyes closed. Like it or not, you’re spending the day with me! We’ll have dinner at my house. I ordered a lorry load of food from Waitrose last week and there’s no way I can manage it all on my own. In fact there’s more than enough for two. Quick, go and get yourself sorted out. I’ve got an idea – one that might, for the first time in my career, satisfy my appraiser that my reflections have altered my practice!”

It wasn’t long before Cratchit was sat in the passenger seat of Scrooge’s car wondering where Scrooge might be taking him. A few minutes later they pulled up outside a block of flats and Scrooge led the way up the steps to the second floor. He knocked on a door.

“Who lives here?” asked Cratchit.

“Mrs Gray. She’s lived here alone since her husband, Timothy, died a few years ago. He was a short man. He had some kind of growth hormone deficiency I believe.’

Eventually, the door opened, and Mrs Gray stood there, evidently astonished to see her GP.

‘Good morning Mrs Gray. And a very merry Christmas to you.’

‘Well a very merry Christmas to you too Dr Scrooge. But what brings you here? Is it about the chocolates?’

‘Certainly not. We, that’s Dr Cratchit and I, have come to pick you up and take you off to my house for Christmas Day. What do you say? Will you come?’ Mrs Gray hesitated, uncertain if she should.

‘Please come, Mrs Gray. It would mean a lot to me’

‘But I’ve nothing to bring’.

Scrooge looked over her shoulder and saw the box of chocolates on the kitchen table. ‘What about those?’ Scrooge asked, ‘You don’t have to bring anything, but if you’d like to make a contribution…’

‘But I’m pre diabetic Dr Scrooge, I need to be careful what I eat’

‘Who told you that?’ said Scrooge, a broad grin forming on his face. ‘Not a doctor I hope. Believe me Mrs Gray, you shouldn’t believe everything we doctors tell you!’

With that, Mrs Gray tottered to the kitchen, picked up the chocolates and made her way back to the front door. Then, together with Scrooge and Cratchit, she made her way slowly down the stairs. Half way down, Scrooge stopped.

‘You go on Bob, I’ll catch you up in a moment. It’s just that I have a feeling that, as a GP, I am, for once, ideally positioned to reduce hospital admissions’

He ran back up the stairs and knocked on the door of the flat opposite that of Mrs Gray. A man opened the door.

‘I don’t want to appear interfering,’ Scrooge began, ‘but your son will develop a rash later this morning. When he does, try wiping it off with a damp cloth. Trust me, I’m a doctor!’

With that Scrooge turned and headed off back down the stairs leaving the man speechless behind him.

…………………………………

A couple of hours later, the two doctors and their elderly patient sat around a dining table enjoying Waitrose’s finest. As the meal drew to a close, Cratchit turned to Scrooge

‘I think I’ve made my decision’ he said.

‘What decision is that?’

‘I’d like to accept your offer of a partnership, if I pass the CSA that is’

‘That’s wonderful Bob, simply wonderful!’ Scrooge stood up and shook Crachit warmly by the hand and then, for the second time in the day, embraced him warmly. ‘This is excellent news – for me and for the practice. We should organise a party!’

Scrooge dashed out of the room and returned with a sheet of paper on which were listed all the practice staff, their names and telephone numbers.

‘And a party we shall have,’ declared Scrooge handing the list to Cratchit. ‘Start ringing round and invite anyone who’s free to join us here this evening. Perhaps someone will bring some of those Prosecco and pink peppercorn Pringles – are they really a thing? Only don’t let me drink too much. The last time I did that there was an incident at a local supermarket, the details of which you don’t want to know!’

‘Can I say something Dr Scrooge?’ Scrooge turned around and saw that Mrs Gray had got to her feet. With one hand she steadied herself by holding onto the table and with the other she was holding a glass of wine. ‘I’ve had a lovely time today and I want to thank you for all your kindness. I’d like to propose a toast, to both of you, the practice, and the NHS as a whole. It’s something my late husband used to say.’ She raised her glass higher. ‘God bless us, every one’, she said.

‘God bless us, every one’, repeated Scrooge and Cratchit, smiling as they raised and carefully tapped their glasses together.

…………………………………

In time, Cratchit passed his CSA and joined Scrooge in partnership and when Scrooge came to retirement he did so reluctantly. He considered himself to have been a fortunate man to have had the career he did. Cratchit continued on, the practice grew and new partners were appointed. Though their processes and procedures didn’t always meet with the full approval of the CQC, the partners always enjoyed strong support from their practice population. Scrooge’s experiences that night may not have changed the state of the NHS as a whole, but they did change how the NHS was manifested in one small corner of that great organisation. Scrooge never had any further encounters with spirits – he had no need of them. Afterwards it was always said of him that he was a doctor who cared for his patients more than he cared how he was thought of by people in power and that he knew how to support others and how he needed the support of others himself. May that be truly said of us all.

And so, as Mr Gray observed, ‘God bless us, Every One!’

BOOK TWO

A TALE OF TWO PATIENTS

In which Dr Ebenezer Scrooge finds some meaning in the seemingly meaningless and determines to keep on keeping on – at least for a little longer yet.

Almost three years have passed since Scrooge was visited by the three spirits and the world is in the grip of a global pandemic.

It was a little after eight in the morning and Dr Ebenezer Scrooge was sitting at his desk, looking at his computer screen. He watched as, with every passing minute, the list of patients he had to call lengthened. He was the only doctor in the practice that morning as his partner, Dr Robert Cratchit, had phoned in earlier to report that, since his six month old son had developed a fever overnight, he’d have to self isolate and work from home pending the result of the Covid swab that he’d organise to have taken later that day. Though frustrated, Scrooge didn’t blame Bob. He knew his colleague wasn’t one to avoid work and understood that the practice had to be seen to comply with government guidance on limiting the potential spread of the coronavirus, even if the actual risk from his partner coming in to work was small and far less than that posed to patients as a result of their care being compromised by his not being at work.

Scrooge reflected on how he’d never been so dissatisfied with his working life as he was now, more dissatisfied even than he had been, three years previously, when the spirits of General Practice Past, Present and Yet to Come had made their life changing nocturnal visits to him. A lot had happened since then. Bob, who had been a registrar at the time, had completed his training, joined the practice as a partner and even found time to marry one of the admin staff and have a child. But then Covid-19 had arrived on the scene and, as well as all the suffering and death it had caused, it had also had a significant effect on the provision of primary care.

Scrooge was alarmed by how fast the vision brought to him by the Ghost of General Practice Yet to Come was now becoming a reality. More and more consultations were being undertaken remotely, a trend that, though perhaps necessary for a time, had been welcomed by much of the profession and was one that seemed set to remain. Scrooge though, a man so old fashioned he’d yet to switch to a height adjustable desk, was less enthusiastic. To some this contactless life might be considered to be ‘the new normal’ but, in Scrooge’s eyes at least, whilst new, it was in no way normal.

Furthermore Scrooge found himself constantly asking if the response to the coronavirus might not, in the long term, do more harm than good. He understood, of course, that steps had needed to be taken to control the spread of the virus, but wondered if perhaps the right balance hadn’t quite been struck.

In the early days of the pandemic he had been informed that, as a GP, he’d be responsible for providing end of life care to patients with the coronavirus. He’d been told it was likely he would have to explain to many of them that, due to a lack of ventilators, it would not be possible for them all to be admitted to hospital and that a good number would, instead, have no option but to take their chances at home.

Scrooge had of course found all this deeply concerning, but when he started being asked to contact all his vulnerable patients and discuss with them their end of life preferences he sensed something wasn’t quite right. This feeling grew when he did a few calculations and realised that, were there to be 50,000 deaths in the country, a figure the government had suggested as a worse case scenario, he himself could expect to lose just one or possibly two of the 1800 patients on his own list. And though it would be no less sad for those who grieved their passing, those most likely to succumb to Covid-19 would be those who were already drawing to the end of their lives and might, therefore, not unreasonably be expected to die this year even if Covid-19 had never existed.

What Scrooge knew for sure though was that nearly six months on not one of his patients had actually died, only two or three had been hospitalised and he hadn’t seen anyone remotely unwell with coronavirus for months.

And in addition to all this Scrooge kept hearing about all the consequences of the measures taken to tackle the pandemic: the tens of thousands of non-Covid related deaths due to patients not receiving sufficiently timely treatment for their conditions, the hundreds of thousands of additional deaths that were likely to occur as a consequence of the lockdown having so badly damaged the economy, and the millions of people who would find themselves joining the queue of those unemployed or those waiting for NHS treatment.

It was, thought Scrooge to himself, the worst of times, an age of foolishness and an epoch of incredulity – with absolutely no positive side to it. Still, his was not to reason why, his was but to do and, almost certainly, not die. And with that Scrooge realised that he’d better stop wondering how long he could continue working as a doctor and start instead phoning the numerous patients who’d already requested urgent contact with him that morning.

He quickly dealt with the first couple of calls which involved patients seeking advice about minor upper respiratory tract infections. He hated himself both for prescribing antibiotics (‘just in case’ due to his not being able to see and assess them properly) to patients who almost certainly didn’t need them, and for then going on to advise them that the whole household would now have to self isolate pending the symptomatic family member having a Covid swab. He knew that the former went against all he had tried to teach patients regarding how antibiotics were unnecessary for self limiting viral infections and that the latter would threaten the livelihoods of families but was nonetheless deemed essential even though, ever since patients with possible Covid symptoms could have a swab taken, not one had come back showing a positive result.

The morning continued in similar fashion though soon, amongst the physical problems that were being presented, a number of cases relating to the mental health of patients required triaging. The isolation of lockdown was now getting a lot of people down and many more were experiencing high levels of anxiety. For many the concern was about catching the coronavirus, even amongst those for whom there was very little risk of their coming to any harm were they to do so – for others it was the threat to their livelihood that was causing them to lose sleep. Scrooge tried to support them as best he could but knew he’d be able to do it so much better if he could see a few of these folk face to face. Even then, however, the requisite plastic apron, latex gloves and face mask would make meaningful conversation on sensitive matters difficult.

At mid morning there was a knock on the door announcing the arrival of one of the reception staff with a cup of coffee and a selection of biscuits. Scrooge accepted them gratefully and munched on a custard cream whilst signing the prescription handed to him by the receptionist. It had been requested urgently by a patient who was currently waiting for it in reception.

Brushing the crumbs from his lips, Scrooge looked back at his computer screen and noticed another call had come in from an elderly man who’s problem had been flagged simply as ‘back pain’. Pleased to have such a straight forward call to deal with, Scrooge picked up the phone and dialled the patients number. Within a few rings the patient answered.

‘Hello, is that Mr Carton? It’s Dr Scrooge, how can I help?’

‘That was quick doctor, I hadn’t expected you to ring back so quickly, I know how busy you all are, what with this virus and all. But don’t worry about that with me, it’s just my back that’s the problem. It’s kept me awake all night it has – I’ve never before experienced anything like it.’

Scrooge asked a few more questions and didn’t sense that anything particularly concerning was going on other than the fact that Mr Carton, a man not prone to call for help unnecessarily, seemed quite agitated by the pain and that he’d not had any relief from even his wife’s reasonably strong painkillers. Scrooge decided that he had perhaps better see his elderly patient after all. He felt guilty for doing so since the guidance was so insistent that all patients should be managed remotely wherever possible.

‘I’d like to see you Mr Carton, but before I do I need to ask a few more questions. Have you developed a new persistent cough lately?’

‘No doctor, it’s just my back, it’s like …”

‘Or a fever?’

‘No doctor, as I was…’

‘And have you lost your sense of smell at all’

There was a pause on the end of the line as Mr Carton clearly struggled to understand the relevance of such a question to his clearly stated problem of back pain. Eventually he answered in the negative and Scrooge asked him to come down to the surgery but to wait in the car park until he was ready to see him. He’d ring in 15 minutes and say when it was safe for him to enter the building.

Whilst he was waiting Scrooge dealt with a few more telephone calls including one from Enid Gray. Mrs Gray was terminally ill and had been so for some while. She had survived longer than had been expected despite, on Scrooge’s advice, repeatedly ignoring the letters sent out under his name inviting her to have a repeat blood test to determine if she were still pre-diabetic. But now she was undoubtedly losing her battle with cancer and was very definitely going rapidly downhill. He picked up the phone and was soon speaking to the patient he’d become very fond of ever since he’d invited her to share Christmas Day with Cratchit and himself a few years previously.

‘Hello Mrs Gray, how are you? How can I help?’

‘Oh I am sorry to bother you Dr Scrooge. It’s just that I feel so tired at the moment. Since I came out of hospital I’ve simply no energy at all’.

Mrs Gray had been admitted the week before having taken a fall at home. She had been discharged precipitously under the guise of it being too dangerous for her to stay in hospital in the middle of a global pandemic. Little thought seemed to have been given, however, to the risk of her living alone without an adequate package of care. Mrs Gray did not have a smart phone so there was no possibility of Scrooge doing a video consultation with her. Despite this, and though he hated himself for even thinking it, were Mrs Gray to die, since she’d been seen so recently in hospital, Scrooge knew he wouldn’t have the unnecessary nuisance of having to liaise with the coroner about her death, not under the new guidance that had come out on the issuing of death certificates during the pandemic. Even so, Scrooge looked up the results of the tests taken during Mrs Gray’s hospital stay. He noticed that she’d been found to be a little anaemic and so Scrooge suggested that he write Mrs Gray a prescription for some iron tablets and arrange for the district nurses to check a further blood test later in the week. Mrs Gray seemed happy enough with this plan but Scrooge nonetheless stressed that, should she feel any worse, she could call him again at any time.

By the time he’d done this he noticed that it was time to see if Mr Carton had arrived. He called him on his mobile and learnt that he was indeed waiting in the carpark. Scrooge invited him in saying he’d meet him in the waiting room. He then donned his PPE being careful to tie the plastic apron about his waist before putting on his gloves, experience having taught him that with gloves on it was nigh on impossible to tie the apron effectively. Mask applied Scrooge then went to the empty waiting room pending Mr Carton’s arrival. As he sat there, perched on the radiator, he surveyed the carefully spaced seats that so few people these days sat on. It saddened him that this was no longer a place where people gathered waiting to be seen, somewhere one might bump into an old acquaintance that one hadn’t seen for years and with whom one might catch up on each other’s news.

A few minutes later Mr Carton arrived accompanied by an obviously very anxious Mrs Carton. It was becoming something of a trend now but once again Scrooge found himself hating what he was doing as he asked Mrs Carton if she wouldn’t mind waiting outside. ‘Because of the Coronavirus’, he added by way of explanation. Walking together toward his consulting room Scrooge paused by the waste bin in the corner of the waiting area and, by holding his apron close to the container, indicated to Mr Carton how that which was now supposedly protecting him from a deadly virus, was made of the the exact same material as that which now lined the bin. It always amused Scrooge to point this out to patients even if by doing so it served only to make him feel even more rubbish about himself.

Back in his consulting room, and having run over the symptoms again, Scrooge asked Mr Carton to pop up on the couch. Scrooge had noticed that the agitation that he had sensed in his patient on the phone was apparent speaking to him in the flesh, Mr Carton was finding it difficult to stay still. Up on the couch Scrooge noticed something else – a pulsatile mass in his abdomen which could be nothing other than an abdominal aortic aneurysm.

After explaining the seriousness of the situation and calling for an ambulance, it wasn’t long before Mr Carton was being led away by two paramedics to the emergency vehicle that was now parked outside the front doors of the medical centre. Scrooge walked out with them and caught site of his patient’s increasing worried wife. Stepping over towards her, Scrooge explained what was happening to the man she’d been married to for more than fifty years.

‘I’m afraid you won’t be allowed to go with him, Mrs Carton. The hospital aren’t allowing any visitors at the moment you see.’

‘But he will be OK?’, she asked, ‘I will see him again won’t I?

Scrooge wanted to look her the eye but found himself unable to meet her gaze. ‘I’m sure he’ll be fine’ he said, trying to sound confident before adding, more honestly, ‘At least, I hope he will’. With that Scrooge went back inside, removed his PPE and placed it in the bin. Along with all that was being used both by him and the rest of the practice staff, he pondered how long it would take for all of it to biodegrade. He thought how insignificant his previous use of the odd plastic straw now seemed in comparison to environmental impact of all this discarded PPE.

The day continued in similar vein and when he eventually finished the days work shortly after 7.30 he noted that he’d completed 86 individual patient contacts made up of telephone calls and face to face consultations. In addition there had been the day’s post to read and act on, blood results to deal with and many, many repeat prescriptions, requests for sick notes and sundry other administrative jobs. It hadn’t been the busiest of days but it was somewhere close to it. And yet he thought to himself, if the posts he had seen on social media were anything to go by, many people out there felt that GPs had reneged on their duty throughout the coronavirus crisis.

As he logged off from his computer he noticed the four cold cups of coffee sitting undrunk on his desk, together testifying to how busy his day had been. What he couldn’t understand however was why there was never an accompanying pile of uneaten biscuits! ‘Another medical mystery’ he said to himself as he stood up, ‘but one that will have to remain unsolved for the time being. I’m off home.’

Scrooge locked up the building, got into his car, and set off for home. He tried to turn his thoughts away from the day, but as he drove the radio was playing Solomon Burke’s ‘Cry to me’. Hearing of how loneliness was such a waste of time, of how it made you want to cry, Scrooge couldn’t help but think again of Mrs Gray and so, having deviated from his usual route home, he soon found himself parked up outside her home instead.

Walking to the door to the stairwell of the block of flats in which she lived, Scrooge noticed a now faded rainbow that someone had painted on the adjacent wall. Underneath were written the ubiquitous words ‘Thank you NHS’. Scrooge averted his eyes, uneasy at what seemed to him as yet another shrine erected to an organisation that, whilst wonderful, was being deified in ways that weren’t helpful, by a population that was putting all its hope in an NHS that could not possibly deliver all that was being asked of it. He didn’t consider himself a hero of the pandemic, that particular label he felt, would surely be better applied to those who would lose their jobs and livelihood over all of this.

Scrooge pulled opened the door and climbed the steps to Mrs Gray’s flat. As he donned yet more PPE he noticed the piles of bottles filling the recycling box of the flat opposite that of Mrs Gray. Somebody was clearly doing their bit to support the local off-licence in these difficult times. Scrooge wondered if the young Mum who lived there, and who had called him several times this week regarding various minor problems, might be better served by a face to face consultation. Perhaps she’d feel freer to talk when she wasn’t being overheard by her partner, given how he was known to have problems ‘managing his anger’. He made a mental note to call her in the morning before turning back to Mrs Gray’s flat and ringing her doorbell.

Nobody came to the door and so Scrooge rang it again. Again there was no response. Trying the door and finding it unlocked, he gently pushed it open and entered the flat.

‘Hello? Mrs Gray? It’s Dr Scrooge – is anybody here?’

Scrooge made his way in the direction of the feeble voice that called out from the back room and found there Mrs Gray, laid uncomfortably on her bed, desperately pale, weak and laboured in her breathing.

‘Dr Scrooge, what are you doing here?’ Mrs Gray asked, barely able to voice the words. ‘I wasn’t expecting you to call round, I know how busy you all are at the moment. And aren’t you supposed to avoid visiting people like me?’

Scrooge looked down at his feet and felt ashamed at the thoughts he’d had when he’d spoken to her earlier that day.

‘Some would say so, Mrs Gray, some would say so’, he replied and, realising that Mrs Gray’s time was near, Scrooge did something else that he wasn’t supposed to do. He pulled off his mask and apron and, after slipping off his gloves, took Mrs Gray’s hand as he sat down next to her on the chair that stood by her bed

‘Enid’, he added, thinking to himself how nobody should be allowed to die without a friend present, no matter what anyone says, ‘I suspect that what I am now doing is a far far better thing than I have ever done. Of course I should be visiting you.’

Mrs Gray smiled at Scrooge, and Scrooge smiled gently back.

Thirty five minutes later, after a call to the local funeral director, Scrooge was back in his car. Picking up his phone he dialed the number for the hospital and was informed that Mr Carton had had his aneurysm repaired and, all being well, would be allowed home the following day. The vascular team had apparently had little else to do and so had wasted no time in dealing with what was the most interesting case they had had in weeks.

Scrooge smiled again, this time to himself. Perhaps his actions today hadn’t changed the world, but they had made a world of difference to at least one or two people he’d had the privilege of helping. Perhaps he thought, he would continue in General Practice, at least for a little while longer. And that, he decided, was cause for celebration. After all, as one whose income had not been threatened by the events of the last six months, he had much to be grateful for, not to mention a civic duty to support the local economy.

And besides, he’d had nothing to drink all day.

BOOK THREE

IT’S A WONDERFUL GP LIFE

In which Dr Scrooge is visited one final time.

It was a little after 6.30pm on Christmas Eve and Dr Ebenezer Scrooge had just finished the final telephone consultation of the day. A receptionist appeared at his open door holding a plate on which sat two sorry looking mince pies. Careful to keep her distance, she placed it carefully on the end of the examination couch that was positioned just inside Dr Scrooge’s room.

‘Is there anything else you need Dr Scrooge?’, she asked from behind her mask. ‘Only, if it’s OK with you, I’d like to get off promptly this evening. Will you be all right to lock up?’

‘Yes of course Alice, you head off’, Scrooge replied, ‘Thanks for all your help today. And have a very Merry Christmas.’

But Scrooge himself was in no mood for merriment. It had been a long hard year which had seen the job he loved change beyond all recognition. So great had those changes been that at times he felt as if he was working in a glorified call centre. And he wasn’t enjoying it. The work had remained just as difficult with on call days being busier than ever but, disappointingly, there had been little recognition of this from some quarters, with many seeming to think that GPs had shirked their responsibility during the pandemic, imagining perhaps that they’d spent the whole of the summer on the golf course.

This was certainly not the case for Dr Scrooge who, apart from that incident involving a lemon, a stained glass window and the irate members of the parochial church council, hadn’t picked up a golf club for many years. But still the profession had been on the wrong end of much criticism and had even, on at least one occasion, been branded a national disgrace in the papers. Though he knew it wasn’t true, such allegations hurt.

‘Sometimes’, Scrooge muttered to himself, ‘I don’t know why I bother.’

At least now he had a few days off work but, with no family of his own, spending that time alone wasn’t something he was particularly looking forward to. Furthermore a letter of complaint had arrived that morning that had only served to dampen his spirits still further. He’d been expecting it for a while and, as one who in recent years had found it easy to be overly self critical, he couldn’t help feeling the claims made against him were wholly justified.

‘I could have managed things better’ he thought to himself. ‘If only I was a better doctor. It just wouldn’t have happened if I’d done my job properly.’

Slowly he stood up from his desk and, ignoring the mince pies, made his way out of his consulting room. He stopped as he passed the waiting area, empty now as it had been most of the year. He missed interacting with a full waiting room. He liked to greet those he knew and, on occasions, in the hope of lightening the mood a little, sharing a joke with those anxiously waiting their turn to be seen. It must have been at least nine months now since he’d bent down low to look under the chairs when the person he was calling hadn’t been present, as if somehow they might be hiding from him there. He must have done this hundreds of times over the years but it always seemed to make someone smile, even if that someone was only Scrooge himself.

There were now only two chairs left in the waiting room. Scrooge walked over to one of them and sat down. He starred at the screen mounted on the wall. Used to convey information to those gathered, he mused to himself that, like the current TV schedules, it only ever showed repeats. Still in a melancholy mood, Scrooge sat down and considered the past year.

It had been one in which he had been urged, not without good reason, to distance himself from those who had sought to come to him for help. But, he feared, this had, as a consequence, resulted in his seeing the needs of his patients in isolation and that the care he offered them had inevitably become less personal as a result. This he felt had been as detrimental for him as it undoubtedly had been for his patients. Understandably focused on the coronavirus the world had sometimes failed to see the bigger picture. Lost in the woods that could could no longer be seen, and confused by the trees that had crowded its view, the world had, he sensed, in its desperation to keep on living, forgotten the meaning of what it was to be alive.

And it wasn’t only at work that things had changed.

Last week he’d been shopping. First he’d parked in a multi-storey car park where, ‘due to Covid restrictions’, the top three storeys had been closed off. But to his mind at least, such action had only succeeded in forcing people to crowd into the two remaining lower levels. Then, outside a department store, he’d heard a father reassuring his little boy that his mother wasn’t dead but had simply popped into a shop. It’d have been funny if it hadn’t been so sad, evidence of the crippling and excessive anxiety some, including children, were experiencing. And then, to top it all, he’d visited his local branch of Waitrose and bought fennel, dill and some apparently ‘essential’ orzo, three items that a few years previously he’d never heard of let alone considered buying. What, he wondered, was the world, and he, coming to.

‘What’s the point? I’m a failing doctor, in a failing system in a failing world. Time for me to call it a day. If I write a letter of resignation and give in my notice now, by the summer I’ll be free of all of this. And the practice and the local community will be all the better for that!’

His mind made up, Scrooge started back to his room in search of some headed paper. But as he did so the TV screen burst into life and the figure of an elderly man appeared surrounded in swirling mist. He was dressed in a old duffel coat and he was sporting a trilby hat. From within its confines, he tapped on the TV screen and called Scrooge’s name.

Scrooge turned back to address the figure, less startled perhaps than some might have expected him to be on account of his previous experiences with ghostly yuletide apparitions.

‘Oh for goodness sake. Not again!’ he started. ‘Must I be haunted every Christmas? Who are you this time? The Ghost of The Christmas We Never Expected?’

The elderly figure seemed a little taken aback but nonetheless began to make his way awkwardly out of the TV. Before long he was standing in front of Scrooge, smiling broadly.

‘Well a good evening to you too, Dr Scrooge’, he replied. ‘As it happens I’m not a ghost. Far from it. My name’s Clarence, and I’m your guardian angel – allocated to you now that George has no further need of me.’

Scrooge was, momentarily, lost for words.

‘Clarence? What kind of a name is that for an angel. And who’s George when he’s a home?’

By now Clarence was removing his coat and carefully placing it on the back of a chair in that rather irritating way that patients sometimes do at the start of consultations. He was clearly planning on staying a while.

‘I’m a little surprised you don’t recognise me’, Clarence replied, ‘but then you’ve probably only ever seen me in black and white. But surely you must remember George. His was a wonderful life.’

‘Well bully for George is all I can say. I hope he’s happy’

‘Indeed he is. Very happy. But from what I’ve been hearing, that can’t be said of you. Have you thought about chatting it over with your appraiser?’

‘Not likely! I know they’re supposed to be supportive but I prefer to pretend that everything’s fine with my appraiser. Fortunately they’re not generally hard to fool. Like long haired sheep it’s easy to pull the wool over their eyes!’

‘Then perhaps I can help a little – I do have some experience in the area’.

‘How do you mean? You’re not going to suggest CBT or mindfulness are you? Only, if you are I’m not interested’.

‘Not as such. It’s just that…well it seems to me that you are questioning just how useful your life as a GP has been. You think you haven’t made a difference. But that’s not true. You’ve made a huge difference, in innumerable ways, often without you ever having realised it’.

Scrooge remained silent, though on this occasion it was not by way of employing a therapeutic tool. The truth was that he was eager to hear what Clarence had to say but was reluctant to appear as such. The angel, sensing Scrooge’s predicament, continued.

‘Well let’s start with the obvious shall we? Take Mr Carton. Surely you remember how, after your telephone consultation with him you agreed to review him face to face and were thus able to diagnose that his back pain was due to an abdominal aortic aneurysm. He’s alive this Christmas because of your actions. And then there was the kindness you showed to Mrs Gray as she lay dying. That mattered too you know? Enormously’.

Scrooge grudgingly indicated his agreement. ‘But it’s no more than any GP would have done’.

‘Perhaps, but that’s not the point. The fact of the matter is that what you did made a difference. If only ‘The Ghost of General Practice Present’ were here we could have taken you and shown you how happy so many people are this evening because of your actions over the years. I’d WhatsApp her but I know that right now she’s very busy haunting a Covid vaccination centre. It’s been a tough year for the members of BASIL too you know.’

‘BASIL?’, Scrooge interrupted, ‘I’ve heard of SAGE, but who the heck are BASIL?’

‘“Beings and Spirits in Limbo”’, Clarence replied. ‘We’ve all been meeting on Zoom this year. It’s been awful. The Ghost of General Practice Past still hasn’t learnt how to unmute himself and the oh so smug Ghost of General Practice Yet To Come can’t stop telling everyone how he correctly predicted the increase in remote consulting and the wearing of face masks during face to face reviews.’

‘Enough of that though, back to what I was saying. In addition to those positive outcomes that you know about, there are so many small actions that you have taken that, unbeknown to you have had similar wonderful consequences. Take that occasion when you reassured a couple who were worried that their child’s rash was meningitis. Because of you they didn’t call the ambulance that they had been planning to and, as a result, a man who was suffering a MI at the time was attended to promptly when he called 999. Wonderfully he was stented within an hour of the onset of his chest pain. And then there’s Dr Cratchit of course.’

‘Bob? What about him?’

‘He really was desperate that Christmas a couple of years ago you know. He didn’t tell you the half of it at the time but, back then, he really was close to the edge. It was your support that pulled him through. And don’t forget that it was you who gave a job to the young lady that is now his wife, not to mention the mother of their child. You gave Emily a chance when many wouldn’t have, not with her previous poor employment record. If you hadn’t taken her on, she and Bob would never have met. Indirectly the happiness of that young family is down to you. And I could tell you a thousand other similar stories of how you’ve influenced individual lives for good.’

‘Even so, that complaint I received today. It’s completely justified you know. I made a mistake. A big one. And people are suffering because of the error I made’.

‘So you slipped up. And that is both regrettable and so very hard to live with. But did you really ever imagine that you would go through your whole career as a doctor without ever making a mistake? Surely not even you are that stupid. Working as a doctor is a bit like pushing people out of the way of speeding trains. On occasions you’ll not be able to push someone out of harms way in time. And sometimes you might just get hit yourself. Even so, you must still try to remember all those folk you have been able to help, all those who have avoided pain and distress because of what you were able to do for them.’

As Clarence had been talking, Scrooge had been gazing at the ground but now he lifted his head and, addressing his companion, looked him in the eye.

‘But it’d be nice to be appreciated a little.’

‘Well of course it would and the truth is many people do appreciate your efforts. But be that as it may, the value of an action remains irrespective of whether any appreciation is shown for it. Pleasant though it undoubtedly is, is it really so important to be lauded for what you do? Surely happiness comes more from performing an act of kindness than from the appreciation that might follow it. Besides if you really want to be appreciated, post an amusing video of a cat on Facebook. Only don’t expect that to satisfy you for very long.’

‘If Covid has taught us anything Ebenezer, surely it’s this. That it is possible to be content with less and that, rather than striving constantly to gain more in life, we would do well to be content with and enjoy the gift of life we already have. Life is uncertain, it always has been. We are not the sole masters of our fate, nor that of those we love or those for whom we care. There is much that we do not know, much indeed that we cannot know. As such we need to learn some humility and acknowledge just how little we truly understand. We need to stop arrogantly pretending we invariably know best. Everyone makes mistakes sometimes. Even you GPs!’

Scrooge smiled and took a step towards Clarence who had got to his feet and was now putting his hat and coat back on. Scrooge hesitated as he once again became mindful of social distancing guidelines. Clarence didn’t seem too bothered though as he too was taking a step forwards. The two men exchanged a firm handshake.

‘Thank you, Clarence’ said Scrooge. ‘It was good of you to come this evening’.

‘‘Not at all, Ebenezer, not at all. It was a pleasure. And thank you for all your hard work this year. You, and all your staff, are doing a grand job in difficult circumstances. Don’t think that it’s not appreciated. And trust me, it isn’t going unnoticed, not by those who count, not by those you’ve actually cared for. Now, you’ll forgive me if I don’t stand and applaud you, and since I can’t give you a voucher entitling you to a free coffee or a discount bar of chocolate, I’m afraid this will have to do!’

And with that, and before he could undertake a detailed risk assessment regarding the merits of such behaviour, Scrooge was experiencing something he’d never experienced before. He was being hugged by an angel.

‘Don’t worry about Covid-19, Dr Scrooge,’ said Clarence, laughing as he sensed Scrooge’s unease. ‘This duffel coat and trilby hat offer complete protection. Or at least as much as those flimsy plastic aprons you’ve all been wearing these past few months. And besides, what’s the worst that could happen. Only that you die and discover what has long been joyfully known by many, that there aren’t varying degrees of danger in the place where I come from.’

As they separated, Scrooge looked somewhat bemused by the strange comment of his unexpected visitor.

‘Haven’t you heard, Ebenezer?’, said Clarence, continuing to chuckle to himself. ‘There are no tiers in heaven!’

And with that a warm glow surrounded Ebenezer. As it did so a bright light filled the waiting room. In a moment though it was gone, as indeed was Clarence. Scrooge, alone once more, stood motionless for a few seconds, trying to collect his thought. Perhaps he’d need to rethink that letter of resignation.

He walked out of the waiting room and made his way to the back entrance. He switched off all the lights and set the alarm before finally leaving the building and locking the door behind him. As he walked to his car he felt a vibration in his pocket. Pulling out his phone he noticed that he’d received a text message. It was from Bob Cratchit.

‘Where are you? We’ve been waiting for you. I trust you’ve not forgotten you’re bubbling with us over the next few days. Get over here quick or you’ll miss all the fun of putting the little one to bed. Remember we’re expecting you to do the full Father Christmas routine for us. See you soon.’

As he gazed at its screen, the phone vibrated again and another message appeared.

‘And we’re a little short of mince pies. Do you know where you could lay a hand on a couple?’

Scrooge looked back at the surgery. ‘I rather think I do!’ he said to himself smiling. Perhaps, he thought, this might be a Merry Christmas after all.

THE END


For the four part story, “Jeeves and the Hormone Deficiency”, click here

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