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<p><strong>I</strong>n December, I did my last day on call. My last ever out-of-hours session in general
practice. In a 13-hour shift on Boxing Day, I did a lot of home visits, during which I offered advice and
treatment for rashes, pains, Covid, injuries and infections. I saw newborn babies and I certified deaths. In
addition to the usual workload, the pandemic meant filling in for absent colleagues who were shielding or
infected with the virus. From 8am to 9pm, at the out-of-hours centre and on home visits, I didn’t stop. The
plastic container of leftover Christmas dinner I had brought with me remained unopened.</p>
<p>This last day was in many ways symptomatic of the changes I have seen over the course of 30 years. Today,
with advances of medicines and technology, patients are living longer, often with three or even four serious
long-term conditions, so having one patient with heart failure, chronic respiratory problems, dementia and
previous stroke is not at all unusual, whereas 30 years ago the heart failure might have carried them off in
their 60s. This makes every patient much more complex, and it can be much harder to manage them and to get
the balance of treatments right.</p>
<p><a
href="https://www.theguardian.com/news/audio/2022/mar/25/in-my-30-years-as-a-gp-the-profession-has-been-horribly-eroded-podcast"><img
src="https://i.guim.co.uk/img/media/5b44685f1761b7ca72d27cd65dd6259da5bf1819/0_345_8192_4918/master/8192.jpg?width=460&quality=85&auto=format&fit=max&s=7f594b03cc8c1d3a07d0357fa636c4d8"
alt="Dame Clare Gerada, a London-based GP (general practitioner) who is President of the Royal College of General Practitioners. Photographed in South London. Photograph by David Levene."
contenteditable="false" draggable="true"></a><img class="ProseMirror-separator"><br
class="ProseMirror-trailingBreak"></p>
<p><a
href="https://www.theguardian.com/news/audio/2022/mar/25/in-my-30-years-as-a-gp-the-profession-has-been-horribly-eroded-podcast"><strong>‘In
my 30 years as a GP, the profession has been horribly eroded’ – podcast</strong></a></p>
<p><a
href="https://www.theguardian.com/news/audio/2022/mar/25/in-my-30-years-as-a-gp-the-profession-has-been-horribly-eroded-podcast"><strong>Read
more</strong></a></p>
<p>Today, unlike 30 years ago, all patients are strangers and, as my catchment area now extends into different
London boroughs, even the places I go are unfamiliar. Gone is the relationship between my community and me.
Instead, I am part of a gig economy, as impersonal as the driver delivering a pizza. I ended the shift with
a profound sense of loss and sadness.</p>
<p>One of the patients I saw was a man in his 90s, with a history of dementia, living with his adult children
and grandchildren. The call had come in that he was not drinking or eating, and had not passed any urine for
24 hours. I wasn’t expecting to be able to offer much. I knocked loudly. By now it was raining and very
cold, and I waited shivering while someone came to let me in. The patient’s room had been taken over by the
clutter of ill-health. A hospital bed, commode, wheelchair, a table covered with medicines and surgical
dressings. Incontinence pads (unused) lay piled on the floor, and used ones in a sanitary bin in the corner
of the room contributed that unmistakable odour of old age. My patient sat sleeping in a chair. The story,
as told to the call centre that arranged the visit, was a background of dementia and infirmity, recent
Covid, previous stroke, and now not drinking.</p>
<p>Get the Guardian’s award-winning long reads sent direct to you every Saturday morning<br></p>
<p>I was puzzled as to why I had been called. What was I expected to do? This man was dying, here, now, in
front of his family. They had struggled over the Christmas period to care for him on their own – community
services had peeled away owing to holidays and pandemic-induced shortages. I offered options: get him back
to hospital, try to admit him to a hospice, or keep him at home and make him comfortable in the hospital bed
provided by social services – although an ambulance would have taken hours to arrive, and organising an
emergency palliative care bed in the middle of the holiday season would have been almost impossible.
Fortunately, they chose to keep him where he was.</p>
<p>The next visit was to a nursing home, the fourth that day. Each had different Covid requirements. One
allowed me straight in after asking if I had had a negative lateral flow test that day (I had); one had
asked if I had recently visited a known Covid-infected person (of course I had). This one asked to see my
vaccine certificate and took my temperature, then ushered me straight in.</p>
<p>This patient was another elderly man, but there was nothing I could do for him. He had died earlier in the
day, and my role was to confirm this. It was what was called an “expected death”. I was led into his
darkened room. The curtains were drawn, and a paper sheet had been placed over his body. Over the years I
have been present at the bedside of patients at that moment of transition from life to death. It is an
extraordinary moment that has never stopped amazing me.</p>
<p>Being invited by family members to be present at that most intimate time represents the culmination of my
role, which is caring for the patient from cradle to grave. But this death was different. This man had died
alone, with no friends or relatives at his side, all long since dead. I checked for signs of breathing or a
heartbeat. I examined his eyes for fixed dilated pupils. I stroked his hand, not as part of any examination,
but just to pay my respects to his passing. I signed the necessary paperwork, made a note of the time that I
pronounced life extinct, and offered my condolences to the care home workers.</p>
<p>My last patient of the day lived with her adult relatives. Terminally ill and recently discharged from
hospital, she was restless and clearly in pain. She needed pain relief, something to ease her passage from
life to death. I looked helplessly at her family. What could I do? My doctor’s bag provided by the
out-of-hours service contained nothing that could ameliorate her suffering.</p>
<p>She needed a syringe driver – a pump that allows for small quantities of powerful medicines to be given via
a small needle placed just under the skin. This isn’t something that GPs carry, and even if we did, we
wouldn’t have the medicines to put into it. When I started out as a GP, my doctor’s bag contained ampules of
morphine, pethidine and other painkillers I might need on my visits. But the days of carrying strong
medication are long gone, since the restrictions imposed after the murderous actions of <a
href="https://www.theguardian.com/society/2005/aug/25/health.shipman" title="">Harold Shipman</a>.</p>
<p>I felt angry. Why had the hospital not arranged care before discharging her? Covid had meant that many
patients were discharged as quickly as possible to clear beds for the expected surge but without, it seems,
a thought as to what provision they needed in the coming days. That evening, I was all there was. My only
option was to suggest a transfer back to hospital, to a busy accident and emergency department. I, but more
importantly the system, had failed her in her final hours of need. My deep shame was hidden behind my mask.
</p>
<p>I do not know what happened to this patient. Each patient I saw that day was a stranger, and each contact
an isolated encounter. We would never meet again. They were single episodes and, unless I made an error
resulting in a complaint (and this is a constant anxiety), I would never know the outcome of my actions.</p>
<p>Driving home at the end of the evening, I shed tears of exhaustion, and helplessness. It wasn’t that I had
done a bad job. I had attended as best as I could, had consulted where needed with relatives, care workers
and even hospital practitioners to seek additional advice. My sadness came from how things had changed, how
different this day was, compared to my first day on call – and how much more personal my job had been in the
past.</p>
<hr contenteditable="false">
<p><strong>B</strong>ack then, in 1991, in my first trimester of pregnancy, and armed only with an A to Z,
coins for the public phone box and my Gladstone bag, I raced around my “parish” in south London seeing
patients whose lives I would still be involved with decades later.</p>
<p>I learned the rules of home visiting very early in my career. Even with the invention of Google Maps and
mobile phones, they haven’t changed substantially.</p>
<p>The first rule is that the home you are looking for is always the hardest to find. Door numbers stop being
sequential; 15 Maple Street is never between 13 and 17. Instead, it is to the left, along a bit, up a flight
of stairs and next to number 55. Before mobile phones, the only possible help, if I was really lost, was a
detour to the local police station. Today, we have an <a
href="https://www.theguardian.com/society/nhs">NHS</a> driver, but back then we had no one to help
navigate, or to mitigate the fear of going into the unknown, of wandering around at the dead of night,
carrying the doctor’s bag.</p>
<p>The second rule of home visiting: treat each home visit as if you are a guest. Even though you’ve been
invited to cross your patient’s threshold, remember that it is a privilege to do so. At patients’ homes, we
learn more about the social aspects of their ill health than the snippets we glean when they attend the
clinic. Even after 30 years, I feel a surge of excitement as I enter the home of another. I’d like to think
this is evidence of my compassion, but it’s probably just my natural nosiness.</p>
<p><img
src="https://i.guim.co.uk/img/media/560d2d24dee4df1eeb50711014bb927ace5910a6/152_508_6111_3666/master/6111.jpg?width=445&quality=45&auto=format&fit=max&dpr=2&s=b3b57eebd6b1d859e98903532fcf086d"
alt="Clare Gerada in 1992." contenteditable="false" draggable="true"><img
class="ProseMirror-separator"><br class="ProseMirror-trailingBreak"></p>
<p>Clare Gerada as a recently qualified GP in 1992. Photograph: David Levene/The Guardian</p>
<p>There is nothing more humbling, especially when coming from the privileged position of a well-paid doctor,
than to see how others live: in overcrowded spaces with parents and children sharing a bedroom; without
heating, because they can’t afford it; or in a mess, more preoccupied with surviving day to day than keeping
a tidy home. I have had my fill of shocks: having to navigate my way through rooms cluttered with the
paraphernalia of drug misuse, or seeing a patient, recently deceased, sitting on the lavatory (it is not
uncommon when having a fatal cardiac event or clot in the lung to have an overwhelming urge to open one’s
bowels).</p>
<p>My third rule: don’t rush. Practically the only tool we have when we visit a patient in their home is time.
Time to listen to their problems. Time to examine them, to observe them, to think and share one’s thoughts
about what needs to happen next.</p>
<p>Back then I had access to a cottage hospital where I could admit patients just because they were “off their
feet”. If this provision had still been available today, I could have admitted that last patient on Boxing
Day. She would have been placed in a single room, overlooking a well-kept garden, and she could have died in
a far more dignified manner. But successive reorganisations of the NHS and cost-cutting have removed our
small, GP-run hospitals and not replaced them with enough community services to fill the gaps.</p>
<p>Back in 1991, each on-call shift would be 24 hours long – a rota of one day in five, sharing the burden
with my partners. Our patch was a large area of south London, stretching north to the South Bank at
Waterloo, south to Brixton, to nearby Camberwell and all the way east to London Bridge. Our practice was
only a mile away from Westminster, meaning that many members of parliament lived within our catchment area,
able to make a quick dash to the House of Commons if the division bell rang, summoning them for a vote. The
surgery was in the bottom two floors of a 22-storey block of flats and backed on to the local housing
estates.</p>
<p>This was my practice, my partnership, the culmination of 10 years of training and a job that I had wanted
to do for as long as I could remember. My father had been a general practitioner and I had wanted to follow
in his footsteps since I was a little girl, witnessing him work from the front room of our family home. He
would take me on home visits to the postwar estates of Peterborough. I witnessed first-hand the care and
attention he gave to his patients and the love and respect he received back from them. He was the family
doctor: someone who could be relied on to be there, day or night; my role model and my teacher.</p>
<hr contenteditable="false">
<p><strong>M</strong>y first ever day on call, in February 1991, started with a Saturday “emergency” surgery.
About 20 people drifted in with coughs, colds, infections and the occasional serious problem needing a
referral to hospital. None of it was usually overly taxing, and by mid-morning home visits began. That first
day, I had three calls to make.</p>
<p>The first visit was not far from my home, in a block of flats at the back of the surgery. I knew from the
brief information I had received that the call came from a member of parliament who was complaining of
severe abdominal pain.</p>
<p>I had already run through my initial diagnosis. <a href="https://www.theguardian.com/society/gps">GPs</a>
work backwards, eliminating what could be the worst reason for the problem first. As I walked around the
block, I wondered whether his pain was due to a dissecting aortic aneurysm. The aorta is a massive vessel
which runs centrally down the body. In some people it can bleed and cause severe pain and, if untreated,
death.</p>
<p>My diagnostic armoury was then, much as it is today, simple dipsticks to check urine for blood or sugar or
possible infection, finger-prick testing for blood glucose levels, a blood-pressure machine, a thermometer,
an otoscope to look in the ears and an ophthalmoscope for the eyes. Today, I can add an oximeter, a simple
device that clips on the fingertip to measure the oxygen content of the blood. Otherwise, then as now, I had
to rely on my clinical acumen – clues derived from observing the patient, listening to their story and
examining them.</p>
<p><img
src="https://i.guim.co.uk/img/media/d06f571c9b9b8cbd9f1c7624899e305665af8e97/0_1138_5464_6827/master/5464.jpg?width=300&quality=45&auto=format&fit=max&dpr=2&s=bc8f2c513ded3ecfc797d9e4f5ca29dd"
alt="Clare Gerada." contenteditable="false" draggable="true"><img class="ProseMirror-separator"><br
class="ProseMirror-trailingBreak"></p>
<p>Clare Gerada today. Photograph: David Levene/The Guardian</p>
<p>I found the flat. As I knocked on the door, my assessment began. Slowly I could hear him unlocking multiple
locks. When at last the door opened, facing me was a middle-aged man in dressing gown and slippers. His face
was ashen and unshaven, and he ushered me in quickly. I noted: he was well enough to answer the door, to
stand, to give a coherent story; not confused or collapsed.</p>
<p>He began to tell me about what troubled him: pain, all night, from loin to groin; pain passing urine. A
quick check of his urine showed blood. After I examined his abdomen, I arrived at the diagnosis – renal
colic, no doubt due to a small stone passing through his renal tract. Treatment: painkillers, given as a
suppository; antibiotics to treat any underlying infection; and the instruction to drink plenty of fluid to
help flush through the stone.</p>
<p>The most likely outcome was that he passed the stone and nothing more would be required. I would follow up
the next day with a phone call. I inserted the first suppository, stayed until I was sure the pain was
subsiding and made sure he had fluid next to him. (He later sent me a thank you letter, which I have to this
day.)</p>
<p>The next visit was in an altogether different area: a hostel in Camberwell. I knew the place well, as
before I started general practice, I had run an outreach service for its residents – all men, and all
recovering intravenous drug users. It was a grubby place, smelling of disinfectant and the stale, musty
odour of dirty clothes. The door was opened by one of the residents and he took me to Charlie, a young man
in his 20s lying in bed in his small single room.</p>
<p>He was shaking and unwell. I could see he had a high temperature. I held his hand while I took the story as
best as I could. How long had he been unwell? When was his last drink of alcohol? (This could be the effects
of withdrawal.) He was breathless. It quickly became apparent that his problems were due to pneumonia, and
when I listened to his chest there were audible crackles: unmistakable signs of infection. I wondered about
HIV infection, which was by now rampaging through intravenous drug users. I asked him about needle sharing
(no) and whether he had been tested for HIV (yes, negative).</p>
<p>I told him I would need to send him to hospital for a chest X-ray, blood tests, intravenous antibiotics and
fluids. He was fearful, convinced that he was being sent to the hospital to die. He was also worried that he
would not receive his methadone, needed to offset withdrawal symptoms from heroin. He didn’t want to leave
the sanctuary of the hostel. We agreed on an alternative plan. I gave him a double dose of oral antibiotics
and left him further doses for the following days. I filled the water jug next to his bed, put a straw in
his glass and recruited one of the residents to check on him every hour or so. I left, promising to return
later that day, and if he was no better then we needed to reconsider admission to hospital.</p>
<p>My final visit that day was to a more affluent part of town, a tree-lined square in one of the most
sought-after areas of my parish. This was for a child with earache. She had been crying all day and the
family were now concerned as they couldn’t get her temperature down. Examination confirmed an infection of
the inner ear, treated simply enough with antibiotics. I gave the mother a starter pack from my bag and a
prescription to be collected at a nearby pharmacy. They were grateful and thanked me for coming so quickly.
</p>
<hr contenteditable="false">
<p><strong>I</strong>t is hard to put my finger on the reason for my sense of sadness when comparing my shifts
in 1991 and 2021. If I’m honest, my relationship with my patients has been gradually eroded and devalued –
sacrificed on the altar of efficiency and expediency. In the later years of my career, it was no longer
possible to build an understanding of each patient’s personal context, their family and community. Even when
I was working in large GP cooperatives, sharing the out-of-hours workload, it was different, more personal,
and one felt that “something could be done”, even if it were only to offer compassion.</p>
<p>But there is nothing much I can offer to the patients I attend to nowadays. I cannot make them better, or
reverse the effects of old age or serious illness with simple painkillers or antibiotics. The problems I saw
could not be dealt with by me alone, yet gone were the support systems I could rely on in the past. Gone
were the district nurses whose names I knew.</p>
<p>Home visiting is an integral part of general practice in the UK, and should remain so. But given the
current pressures on GPs, we have to find ways of using our profession for maximum effect. The patients I
saw on Boxing Day in 2021, unlike those I attended to in 1991, needed more than I could offer. It is time to
introduce different ways of delivering out-of-hours care that better meet the needs of our patients. We need
specialist teams, with elderly care, specialist nursing and other practitioners working alongside the GP –
making sure that, wherever possible, we can keep the patients safely cared for out of hospital. We need
virtual wards, respite care, new forms of cottage hospitals where patients can be observed and cared for
over time. A home-visiting GP cannot fill these gaps. Where I am of most value is providing continuity of
care to the patients on my practice list, and we must restore this.</p>
<p><a
href="https://www.theguardian.com/news/2018/jan/26/searching-for-an-alzheimers-cure-while-my-father-slips-away"><img
src="https://i.guim.co.uk/img/media/366c69996c4b2f1e2f537314000884f28165928e/152_372_1171_703/master/1171.jpg?width=460&quality=85&auto=format&fit=max&s=9435dbf7037e58c4145ec39ad724a98b"
alt="Peter Savodnik (right) as a young man with his father and sister in a swimming pool"
contenteditable="false" draggable="true"></a><img class="ProseMirror-separator"><br
class="ProseMirror-trailingBreak"></p>
<p><a
href="https://www.theguardian.com/news/2018/jan/26/searching-for-an-alzheimers-cure-while-my-father-slips-away"><strong>Searching
for an Alzheimer’s cure while my father slips away</strong></a></p>
<p><a
href="https://www.theguardian.com/news/2018/jan/26/searching-for-an-alzheimers-cure-while-my-father-slips-away"><strong>Read
more</strong></a></p>
<p>Maybe my sadness is that an era of my professional life is now over; and my mourning for the past has
coloured my reflection. I am not hanging up my stethoscope yet (only for out-of-hours work), but my days of
being a clinician are coming slowly to an end. No matter how hard my last day of visiting was, it has been a
privilege to have worked as a GP, in clinic and out of hours, and I could not have chosen a better career.
</p>
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