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Today's GPs are being shamed into keeping patients out of hospital

Kay seemed seriously unwell. These days, however, GPs are expected to discuss potential admissions first.

Kay was not a frequent attender, and she’d only come that day because her two grown-up daughters had forced her to. “It’s just a cough,” she told me as she sat down. She gave her children a withering look. “I’m sure there’s nothing you can do.”

That’s true for the vast majority of respiratory illnesses: most are viral infections that antibiotics won’t cure. But every now and then, lurking among the legions of self-limiting coughs and wheezes, there’s a pitfall for the unwary – someone who turns out to have pneumonia, say; or a patient with something else seriously wrong.

Kay had a modest fever, her heart rate was slightly raised, and there was infection throughout her airways. But I see patients like this most days in winter. There was something else – a sallowness to her complexion, a subtle indrawing of her features – that made me think she might be more unwell than she appeared.

She looked decidedly nonplussed when I said that her daughters had been right to bring her. I prescribed antibiotics, took blood tests for urgent analysis, and instructed her to return the following day. I pulled the results off the system the next morning. Elevated counts of infection-fighting cells as anticipated, but also an unexplained anaemia – and, most worrying of all, a sudden deterioration in her kidney function.

Once upon a time, I would have sent her to hospital without a second thought. These days, however, GPs are expected to discuss potential admissions first. We’ve been supplied with mobile-phone numbers for consultants in every department. The idea is, if we have instant access to specialist advice, we might be able to keep some people out of hospital. I rang the on-call consultant physician. That day it was a guy called Mark.

“Can I tell you about this lady?” I said. As I talked him through Kay’s case, I grew increasingly embarrassed: there was really only one course of action. When I finished, Mark simply said, “She’s got to come in, hasn’t she?”

He sounded puzzled that I’d even rung, and I felt foolish for having done so. I explained how, day after day, we GPs get distress emails from the hospitals saying they’re on continuing “black alert” – which is every bit as grim as it sounds – and pleading with us to do anything we can to stem the patient flow. And how we’re supplied with constant feedback on how our admission rates compare with those of our peers, the agenda being to shame those who might be considered profligate into “better” behaviour. Mark hadn’t appreciated the barrage of inhibition we’re under in primary care, and expressed regret on behalf of the hospital that it was so. For my part, it caused me to reflect on how my clinical decision-making is being distorted by the constant stream of bad news.

Kay was reluctant to be admitted because she, too, had seen countless news reports likening our hospitals to humanitarian disaster zones. But her daughters looked relieved; family members often sense when there’s serious trouble.

In hospital, Kay was treated aggressively for her chest infection, but a swift succession of tests to investigate the other abnormalities showed her to be riddled with unsuspected disseminated cancer. Her bronchopneumonia was, very sadly, the result of her system finally being overwhelmed. There was nothing that could be done; she never made it back home.

She became yet another statistic that would be fed back for me to evaluate my practice: a patient who had died within a few days of admission, the inference being that I shouldn’t have involved the hospital in futile end-of-life heroics. The bean-counters who’ve decided on this particular black mark against a GP’s name have no understanding of what it’s like in the real world, where patients sometimes turn up very sick with undiagnosed illness, as Kay did, and need urgent hospital care to find out if they have any chance at all.

This article first appeared in the 16 March 2017 issue of the New Statesman, Brexit and the break-up of Britain

Photo: Getty
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The rise of the green mayor – Sadiq Khan and the politics of clean energy

At an event at Tate Modern, Sadiq Khan pledged to clean up London's act.

On Thursday night, deep in the bowls of Tate Modern’s turbine hall, London Mayor Sadiq Khan renewed his promise to make the capital a world leader in clean energy and air. Yet his focus was as much on people as power plants – in particular, the need for local authorities to lead where central governments will not.

Khan was there to introduce the screening of a new documentary, From the Ashes, about the demise of the American coal industry. As he noted, Britain continues to battle against the legacy of fossil fuels: “In London today we burn very little coal but we are facing new air pollution challenges brought about for different reasons." 

At a time when the world's leaders are struggling to keep international agreements on climate change afloat, what can mayors do? Khan has pledged to buy only hybrid and zero-emissions buses from next year, and is working towards London becoming a zero carbon city.

Khan has, of course, also gained heroic status for being a bête noire of climate-change-denier-in-chief Donald Trump. On the US president's withdrawal from the Paris Agreement, Khan quipped: “If only he had withdrawn from Twitter.” He had more favourable things to say about the former mayor of New York and climate change activist Michael Bloomberg, who Khan said hailed from “the second greatest city in the world.”

Yet behind his humour was a serious point. Local authorities are having to pick up where both countries' central governments are leaving a void – in improving our air and supporting renewable technology and jobs. Most concerning of all, perhaps, is the way that interest groups representing business are slashing away at the regulations which protect public health, and claiming it as a virtue.

In the UK, documents leaked to Greenpeace’s energy desk show that a government-backed initiative considered proposals for reducing EU rules on fire-safety on the very day of the Grenfell Tower fire. The director of this Red Tape Initiative, Nick Tyrone, told the Guardian that these proposals were rejected. Yet government attempts to water down other EU regulations, such as the energy efficiency directive, still stand.

In America, this blame-game is even more highly charged. Republicans have sworn to replace what they describe as Obama’s “war on coal” with a war on regulation. “I am taking historic steps to lift the restrictions on American energy, to reverse government intrusion, and to cancel job-killing regulations,” Trump announced in March. While he has vowed “to promote clean air and clear water,” he has almost simultaneously signed an order to unravel the Clean Water Rule.

This rhetoric is hurting the very people it claims to protect: miners. From the Ashes shows the many ways that the industry harms wider public health, from water contamination, to air pollution. It also makes a strong case that the American coal industry is in terminal decline, regardless of possibile interventions from government or carbon capture.

Charities like Bloomberg can only do so much to pick up the pieces. The foundation, which helped fund the film, now not only helps support job training programs in coal communities after the Trump administration pulled their funding, but in recent weeks it also promised $15m to UN efforts to tackle climate change – again to help cover Trump's withdrawal from Paris Agreement. “I'm a bit worried about how many cards we're going to have to keep adding to the end of the film”, joked Antha Williams, a Bloomberg representative at the screening, with gallows humour.

Hope also lies with local governments and mayors. The publication of the mayor’s own environment strategy is coming “soon”. Speaking in panel discussion after the film, his deputy mayor for environment and energy, Shirley Rodrigues, described the move to a cleaner future as "an inevitable transition".

Confronting the troubled legacies of our fossil fuel past will not be easy. "We have our own experiences here of our coal mining communities being devastated by the closure of their mines," said Khan. But clean air begins with clean politics; maintaining old ways at the price of health is not one any government must pay. 

'From The Ashes' will premiere on National Geograhpic in the United Kingdom at 9pm on Tuesday, June 27th.

India Bourke is an environment writer and editorial assistant at the New Statesman.

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