Little clots of blood float around the cloudy pink liquid in the jam jar Henry's placed on the desk in front of me. The medical student beside me has in mind half a dozen possible, mostly serious causes of frank haematuria (visible blood in the urine) and I can see her jotting them down. Like too many men, Henry was hoping 'things would sort themselves out' for several weeks, and only after his wife noticed the blood-stained toilet bowl could she cajole him to come in.
Nevertheless, what Henry really wants to talk about is his son, just out of prison on a methadone script and looking for rehab. I was hoping to discuss Henry's worsening renal failure - a consequence of his uncontrolled diabetes and high blood pressure. His wife wants to talk about his depression and worsening memory. The jar of bloody urine stands on the desk momentarily stalling any conversation while we sit waiting to see who will speak first and about what. Nine minutes remain of the ten-minute consultation.
General practice has developed during the past 60 years of the NHS to allow GPs a monopoly over the provision of primary healthcare. Because of this we are able to develop lasting therapeutic relationships with our patients that can extend over lifetimes and generations. It is possible for me to look after Henry and his wife for the rest of their lives, guiding Henry through what will, quite soon, be his final illness, his wife through her bereavement and their son through his drug detox and subsequent relapse.
The long-term relationships that GPs have with our patients result in continuity of care. This allows us not only to manage ongoing ill health, but also to be prepared for serious illnesses. How Henry might react to a diagnosis of prostate or bladder cancer and how we might then manage it cannot be understood without knowing about how he has managed (or failed to manage) his diabetes; how his wife aids him and helps with his medication and appointments; how his depression affects his behaviour and how the chaos and distress their son brings affects them all. A familiarity with the latest guidelines for managing haematuria is essential, but negotiation and adaptation are essential if I am able to help Henry.
I've decided to focus on the bloody urine for now, but take time to arrange to see his son 15 minutes before my Thursday afternoon surgery (I'll be glad of an excuse to miss the end of the meeting in which various imaging corporations pitch their services.) I send an email to our practice nurse to ask if she can fit him into the next diabetic clinic before bringing the conversation around to the jar in front of us. Six minutes remain.
I test the urine sample and decant some into specimen pots to check for cancer cells and infection. I ask about other symptoms and perform a physical examination. My ten minutes are up, but he still needs a referral. At the heart of the coalition government's ideology is 'patient choice', so instead of referring Henry to the local hospital, I am obliged to spend valuable time guiding him through a range of private and voluntary providers offering services for his bloody urine.
Meaningful choice needs to be informed and considered, but Henry doesn't know what most of the 14 tablets a day he takes are for, he can't recall whether his blood pressure is too high or too low and he only comes to appointments if his wife reminds him on the day. Usually when I ask him why he has come to see me, he says, 'I don't know, you're the doctor!' In so many ways he is like my own father who, despite being considerably more affluent and educated, is equally ignorant of his treatment, happy to trust his GP and my mother 'to worry about all that'.
The new commissioning organisation has made the job a little easier by restricting us to a short-list of 'approved, value-for-money providers'. The provider I believe to be in Henry's best interests - the local hospital - is not approved but may be 'negotiable'. Negotiation will involve spending valuable time writing letters trying to convince the commissioners that because of Henry's depression, diabetes, renal failure and long history of missing appointments he needs to have his care there.
Unfortunately I later discover that the urology department has been 'decommissioned' for being too 'inefficient'. The 'one-stop' heamaturia clinic has become 'two-stop' because a private company has the contract for day surgery and the cystoscopies (bladder scopes) are being done at another hospital, while the local operating theatres are concentrating on more profitable gynaecology. I no longer know what is in Henry's best interests.
What Henry wants, and more importantly needs, is to be looked after, but he's told he must 'take responsibility and choose'. As his advocate I must help him choose and also fight to keep the services he needs. As his GP my days may be numbered. More efficient providers will move in to provide convenient care for young healthy people who will choose not to spend time waiting to see a doctor whose clinics run late because of complicated patients like Henry. Instead of waiting, they will register with Virgin, or any number of competing providers who know healthcare is most profitable when the patients aren't really sick.