Reviews

Inever knew Jimmy when he was alive; I met him through the things he left behind. I became acquainted with him a few days after he had died as I was writing his discharge summary.

Jimmy had fallen on hard times. I pieced this much together from the notes, not that I sought it out, but I somehow dropped my guard. He had lost his job and he had lost his wife. The notes did not tell me which came first. He was actively looking for work. I knew this because his job seeker record, which had been in his pocket when he had been taken ill, was now stuffed in the back of his notes. A faltering painstaking scrawl recorded his daily round of disappointment. “Hayward's machine tools—still nothing will try again next week.” I learnt that the constant disappointment was getting him down, the admission clerking said “antidepressant, doesn't know which.” But he was still looking for work on the day that he died; the notes recorded him as collapsing in the job centre. The notes said that he was a heavy smoker and that recently he had started to have a drink most evenings. The notes said that he drank approximately 12 cans of cheap cider each week. I tried not to imagine him puffing and panting to the job centre to start his daily round.

Was Bevan thinking about people like Jimmy

I felt that I had met many men like Jimmy. Proud and independent and determined not to ask for anything that they had not earned. One of the invisible men, a man who had laboured in a factory and paid his taxes. Lacking eloquence he would never be noticed, and in his death he would not be missed. There would be no obituary in the Times.I wondered if this was the sort of chap Aneurin Bevan might have had in mind when the NHS was set up.

He was admitted in the late afternoon with respiratory failure caused by chronic obstructive pulmonary disease. The history was difficult because he was so unwell. I was a little surprised to see his problem list included, “Query alcoholic.” There had been no possibility of corroboration; he had come in alone and there was no next of kin. He drank less than I did. He had a poor man's disease and he had no advocate. He was seen later that day and seemed to be getting worse.

I understand that the night was particularly busy; most of us have had those nightmare on calls when you just do not know if you will cope. But there were only two more entries in the notes, “Fighting the mask, alcoholic, unwell, not for intensive care but for full medical therapy.” Then one more entry, “No breath sounds, no heart sounds, RIP.” And there but for the grace of God go I, no more blood gases, no one to one nursing to help with the mask, no time for further review, and no evidence of full medical therapy.

There cannot be many of us who have not met Jimmy. There cannot be many of us who have not felt empty numbness at the cold pragmatic triage of the impossibly busy on call. And how many of us who have been through this have not silently prayed, “If ever my parents get admitted please let it be quiet and please let me get to them as soon as possible so I can guarantee they get good quality care.”

This is a sort of quality of care that is not easily measurable like waiting lists. This is a difficult sort of quality. We have the tools, we can do the audit, and we can show that sometimes we have not got what we need to look after Jimmy. But then the managers ask us to give a business case, show how the improved quality of care will save money. They are happy to spend a little money to save a little money, but how do you save money when the cheapest patient is so often a dead patient.

Occasionally, as I toy with this impasse I just wonder what would have happened if Jimmy had had a daughter who just happened to be a medical negligence lawyer. I suspect a quick phone call to the trust risk manager would have led to one to one nursing in a flash. Spend a little money to save a little money.

Sadly, this winter we will see Jimmy many times; I do not think that he will often have that daughter. So good luck this winter, and if you see Jimmy give him your best, you are all he has got.