Geoffrey is watching a creepy black and white film. There’s a corpse on a gurney covered in a white cloth, two scientists bunched up excitedly on one side with an enormous syringe.
‘How are you feeling, Geoffrey?’ I ask him, putting down my bag.
It’s difficult to concentrate, what with the corpse about to sit up, and, unbeknownst to the scientists (unbeknownst?) a car-load of policemen bristling with Tommy guns rolling quietly up the drive.
‘Terrible,’ he says, wobbling back towards his chair. ‘Absolutely bloody awful.’
‘I’m sorry to hear that.’
‘I’m sorry, too.’
‘Have a seat and tell me all about it.’
‘Ah!’
He shoots the TV with the remote, lowers himself into his recliner, and starts a long and impenetrable story that I try to supplement on the sly with info from the folder.
‘So what are you going to do about it?’ he says when he’s finished.
‘I don’t know. It must be very frustrating, living with such a long-term condition. But I’m not sure what I can add, other than to follow up the last referral and make sure it goes through okay.’
‘I get so fed up,’ he says. ‘People say they’re going to do something, and they never do. And anyway – it’s not as if they’re really interested. I don’t get any help. Just a minute. There’s someone at the door.’
‘No, no! I’ll get it.’
Unbeknownst to the Rapid Response Team, Ray, a nurse from a different department, has been sent round to take blood.
‘I could’ve done that!’ I tell him.
‘Never mind.’
Ray sets his stuff out.
Geoffrey laughs.
‘I don’t mind the company. It’s the waste I can’t abide. No wonder the NHS is on its knees. They sent me a box of catheter supplies through the other day. I haven’t had one of them in since Christmas.’
‘Oh. Well, I’ll let them know to take it back.’
‘You do that.’
Ray starts tapping up a vein.
‘Shall I make you some tea?’ I say.
‘That’d be grand!’ says Geoffrey. ‘Nice n’strong. Two sweeteners.’ He hands me his mug – a vase-sized affair with two faded Hula Hula girls dancing round the side of it.
In the kitchen I hear him talking to Ray.
‘No – no family. Just me, on my Jack Jones. The wife died last year. The second wife, I mean. Although the first wife died as well. Then I married the second. Then she died. I had two wives and they both died. And here we are!’ He sighs loudly and heavily, a conversational re-boot. ‘What I don’t get, Ray, is – what I just don’t understand – for years I volunteered, helping out with the old folk who lived near me. Making them dinners. Taking them shopping. Taking them places. And now it’s my turn, suddenly there’s no-one….’
I bring the tea through.
‘There you go!’ I say.
The mug is so heavy I’m worried about putting it on his side-table.  The table is piled with junk, and leans at a precarious angle.
‘Will it be all right on there, Geoffrey?’
‘This old thing?’ he says, tapping it lightly. ‘I think so. It’s made it this far. I don’t suppose one more mug of tea will make a difference.’

Gloria Ellery welcomes me like a son, even though we’ve never met.
‘Richard! Look who’s here!’ she cries, clapping her hands together, her eyes shining. ‘Come in! Come in! He’s upstairs, if you’d like to follow me…’
She turns and starts to climb, pulling herself forwards on the handrail, cheating the swing of her arthritic left hip as much as the stairs will allow, her support stockings swishing and creaking like someone in a wet suit.
‘I’m afraid he’s not the easiest of patients,’ she wheezes. ‘We’re all finding it a bit much. That bloomin’ cast – it makes everything so damned awkward.’
‘Language..’ says a voice above us.
‘Well it does,’ she says.
I get the story on the way up. How Richard fell in the supermarket a few days ago. (He slipped on a grape. There was a kid riding in a trolley tucking into a bag of them. Gloria wondered whether it was one of hers. Not that it mattered, of course. These things happen). Richard fell onto his outstretched hand. They knew straightaway he’d broken his arm.
‘You could see the dip,’ she says, stopping just long enough to describe an elegant swoosh in the air.
‘Oh dear.’

Richard is standing waiting for us in the middle of the bedroom, his arm in a sling.
‘Wounded soldier, reporting for duty,’ he says, saluting with his good arm. ‘Pleased to meet you.’ And he holds out his hand for me to squeeze.
I tell him I’ve come to take his blood pressure and so on, and also to see if he needs any help with washing or getting ready for bed.
‘Oh, I think I can manage well enough,’ he says.
‘Now, Richard,’ says Gloria. ‘We both know that’s not true. You’ve had terrible trouble with that cast and I think it’s about time you accepted some help.’
‘Yes but – I don’t like to put anybody out.’
‘It’s no trouble, Richard. I know you might find it a bit embarrassing to begin with, but everyone needs a little help now and again. Don’t worry on my account. I’m used to it.’
‘Put him in his boxers and dressing gown for now,’ says Gloria, shaking out some fresh clothes from the laundry basket. ‘And a little shave wouldn’t go amiss.’
Richard still struggles with the idea that someone should help him dress.
‘Don’t worry,’ I say. ‘Just close your eyes and imagine you’re Louis Fourteenth of France. Or is it Sixteen? I lose count. Anyway – that guy – the Sun King – the guy who held out his arms and had everything done.’
‘We’ll go with fourteen,’ says Richard. ‘Sixteen was – you know – grrrccch…!’ He raises his cast and makes a little sawing motion in the general direction of his neck.
‘Or King Farouk!’ he says, following me into the bathroom.
‘I’ve not heard of him.’
‘Egypt,’ he says, ‘World War Two. Look him up.’
He stares at himself in the bathroom mirror whilst I run some water.
‘Equally useless,’ he says.

‘How come you fell down the stairs?’
It was a few days ago, but Hanna still looks pretty beaten up. Panda eyes, bandaged head, dressings on her left elbow and leg, and everywhere, blooms of rich and sickening bruises: blue-green, green-black, purple-black.
‘I was jet-lagged. At least, that’s what I think.’
‘So what happened?’
‘I’d been staying a couple of months with a friend in America.’
‘Very nice.’
‘It was. Just the loveliest time.  Absolute bliss. Well, when I came home, I went to bed and fell into a particularly deep sleep. I was still dreaming when I got up in the night to go to the loo. But I must’ve gotten used to the bathroom and bedroom being one way and not another. So when I turned right instead of left, I fell all the way down the stairs.’
‘The whole flight!’
‘All the way to the bottom. When I came round I was covered in blood, and – I’m ashamed to say – I’d wet myself.’
‘It sounds as if you were knocked unconscious.’
‘That’s what they reckon. Anyway, it took me quite a while to come to my senses. I behaved – quite oddly, really.’
‘How do you mean?’
‘Instead of calling 999, I dragged myself all the way up the stairs again.’
‘To go back to bed?’
‘No. To call for help. To wake my parents up. Of course – they’ve been dead twenty years. But I was confused, you see? I’d had this bang on the head. I couldn’t understand what had happened to me. I was calling out Mummy, Mummy! I’ve fallen down the stairs! But no-one was coming out to see me. So I went into their room. It’s a junk room now, I’m sorry to say. So there I was, standing in the doorway looking at all this junk and wondering where the hell they’d gone!’
‘How weird.’
‘Terrifying. So d’you know what I did next?’
‘What did you do?’
‘I went into my sister’s room and sat on her bed. Milly I said. Milly. I’ve fallen down the stairs and hurt myself, and Mummy and Daddy have disappeared. But then I realised she wasn’t there either. No-one was. Which shouldn’t have been surprising. Milly hasn’t lived here since she married in 1972 .’

The final notes on Glenda’s referral are succinct.
Non-compliant with treatment incl. meds. Self-neglect. Can be abusive.
The upshot is that the normal routes aren’t working for her  – palliative, district nurses, GP and so on. She’s a difficult customer, and as is often the case, we’re the safety net. The Co-ordinator asks for an update.

*

There’s serious work going on at Glenda’s house. A full skip in the driveway, debris spilling out and overwhelming the little front garden. Making it to the front door is like picking my way through a landfill.
I let myself in with the keysafe.
Hello? Glenda?
She’s in bed, her bony fingers laced together on the outside of the covers. With her chalky white skin and graven features, she could be the alabaster tomb to a medieval knight, except instead of a chainmail coif, she has a paisley headscarf, briskly knotted under the chin. She’s looking straight up at the ceiling, and only moves her eyes slantways to look at me as I come into the room.
‘What do you want?’ she says.
‘Jim. Rapid Response. Pleased to meet you.’
I hold out my hand; she doesn’t reciprocate. I nod instead, put my bag down and explain why I’ve come.
‘I told the last one. I don’t want you coming in.’
‘That’s fine. I understand. But I just need to go over a few things, and if you still don’t want any help, I’ll have to get you to sign this form. Just to say you’re declining. Officially, you know.’
‘I know. I know very well,’ she says.
‘So. How are you doing, Glenda? How are you bearing up?’
‘Well I’m dying, if that’s what you mean.’
‘Are you in pain?’
‘Yes, but please – don’t let’s go down that road. I’m too tired.’
‘No, no. We don’t have to. I’m just interested to see how things are.’
‘The doctor was here yesterday. No doubt he sent you.’
‘Yes. Yes, I think he did.’
‘He can’t understand why I won’t take the morphine. None of them can.’
‘Why is it that you…’
‘I control my pain in other ways.’
‘Okay. How do you mean?’
I sit down, put my bag and folder and everything else aside. She describes a course she did thirty years ago, a meditation retreat, where she learned to treat pain and physical discomfort by means of mind control.
‘I find it hard to talk about,’ she says. ‘But essentially it means holding the pain close up, not pushing it back, and accepting it for what it is. There’s no fighting, you see. No turning away. You simply let it exist, much as we all do. And after a bit of practice it stops becoming something you fear. It just is. And you start to live with it. And it either goes or changes or gets worse, but you don’t pump yourself full of drugs to stop the experience. You let it breathe, things move on, and there you are.’
‘I’m impressed.’
‘There’s nothing to be impressed about. It’s just a different way of looking at it. There’s too much running away from how things are. When I was in hospital it was the same.  The patients were crying out for more pills, more pills. There was no end to it. And the doctors and nurses were falling over themselves to give it to them.’
‘I suppose it’s a practical profession. They like to do something.’
‘Yes – and no doubt the pharmaceutical companies are very happy about that.’
‘So how did you get on in hospital?’
‘I couldn’t wait to leave. I discharged myself in the end. They treated me like I was mad. And they were so rude. There was one doctor in particular who stood at the foot of the bed with a syringe in his hand, shaking. He was saying there were ways they could force me. Getting in a psychiatrist and so on. All because I didn’t want what they’d got for me.’
She screws up her face and shields her eyes, because the sun has come round a little and the curtains aren’t keeping her in shadow anymore. I adjust the angle of them, and she relaxes again.
‘I’ll give you the name of it so you can look it up,’ she says.
‘Thanks. I will.’
I tell her about Fred, a judo teacher I used to have. He was well-known for going to the dentist and refusing anaesthetic.
‘The way he described it was he attended to the pain,’ I tell her. ‘Not that I really understood what he meant. I’m afraid I’m a bit of a wimp when it comes to the dentist. I’ll take whatever they can give me.’
‘Personal choice,’ she says. ‘That’s the key. I’d like to hear more about Fred…’
She agrees to let me do some obs. Unsurprisingly, they’re pretty poor.
‘How involved have the palliative team been?’ I ask her, completing the chart.
‘All they’ve said is Ring us when anything changes. I bet they’re glad I don’t, because none of them know what to do with me. They just want to squirt me full of morphine and be done.’
I bring her in some tea. She sits up a little to drink it.
‘I must admit I’m getting fed up with it all,’ she says. ‘But I can’t afford to go to Switzerland.’
‘That means drugs,’ I say.
She smiles, a tight, fraught thing.
‘Yes, but not in the way they mean.’

‘Ella died this morning.’
‘Ella…?’
The name sounds familiar. I flip back through my diary – and there she is, just a couple of days ago.
‘Ella! Of course! Oh no! She was pretty unwell, though…’
‘I know, but still. It’s a bit of a shock.’
To say Ella had been unwell was an understatement. An elderly palliative patient, in the closing stages of an aggressive cancer, she’d suffered a hypoxic collapse. After they’d stabilised her at hospital she’d been discharged home to die there. She’d been referred to us for bridging care whilst the palliative team struggled to find capacity. But as is often the case, things can go more quickly than anyone anticipates.
‘Poor Ella.’
There’s not much time to dwell on it, though. We’re under the clock. It’s a question of grabbing what info you can, whatever supplies you need, and getting out on the road.

Poor Ella, though.

*

That day is particularly bright. I’m wearing sunglasses and I’ve left my jacket off. All the trees are starting to fill; daffodils and primroses blazing along the verges; everywhere a sense of the sun moving in, drawing up life and colour and warmth.
Ella’s daughter Rose answers the door.
‘You’ve just caught me washing my hair,’ she says, towelling it into a mad frizz and laughing. ‘Mum’s just through here. Mum! A visitor!’
The front room has been rearranged to accommodate Ella’s hospital bed, commode and a large oxygen dispenser that whirs and clicks in the corner.
Ella is sitting upright, clear plastic nasal specs looped round her ears and under her nose. She waves an emaciated hand in the air. Even that small movement exhausts her.
I introduce myself and explain what I’ve been sent to do.
‘I’m wearing two hats today,’ I say. ‘The first is clinical. They want me to run a set of obs, your blood pressure and the rest…’
Again, the waving hand.
‘Don’t bother,’ she says. ‘I can … save you … the trouble… they’re terrible.’
‘I won’t do them if you don’t want me to.’
‘We’ll see.’
‘The other is a carer’s hat. So depending what you’d like – a wash maybe? Help with the toilet? Something to eat?’
She shakes her head.
‘I can’t … eat,’ she gasps. ‘I feel too… sick. But a … flannel wash … might be nice.’
‘Let’s do that, then.’
I get together everything I might need, a bowl of soapy water, flannels and towels, then set up shop next to the bed. Ella wants to wash her own face.
‘I’m a … fussy so-and-so…’
She unhooks the nasal specs and puts the tubing down beside her. Her lips are a dusky blue, but she doesn’t have to be told.
‘Don’t worry,’ she says. ‘It won’t … take long.’
Half way through the wash she has a dreadful fit of nausea and can’t carry on. I help her through the worst of the retching. When it subsides, I do my best to make her comfortable again. She lays her head back on the pillow and closes her eyes, the skin in all the hollows of her cachectic frame sinking in with each snatched breath.
On a low shelf in her line of sight is a large, silver photo frame. In it, a black and white picture of a young man and woman lying under a tree, the woman with her head in the man’s lap, looking up and laughing as the man tickles her nose with a piece of straw.
‘What a beautiful photograph,’ I say to her.
‘That’s Ben,’ she says. ‘My husband. I’m glad… you like … that photo. I’m rather … attached to it … myself.’
By the time I’ve taken the bowl away, sluiced it, wrung out the flannels, hung them up to dry and come back into the room, Ella seems to have made something of a recovery. The duskiness has eased from her face, and she manages to talk a little more easily.
‘Ben was such a lovely man,’ she says. ‘Very determined.’
‘Like you.’
‘Like me! He had a stroke when he was fifty. Out of the blue. But he insisted on having… a handrail on a rope…. hung above the bed… so he could do pull-ups. What on earth… are you doing? I said to him. Getting fit he said. And a year later… there he was … hanging upside down from a helicopter… chasing the next shot.’
‘What was he? A hunter?’
She laughs, a low-down rattle.
‘Cameraman!’ she says. ‘But I tell you something…. between you and me… he may have been rough and tough… but he was actually as soft as butter…anytime there was something… you know, something silly… like a spider in the bath… guess who he came running to.’

There’s a life-size model of a Jack Russell facing the door as I go in.
‘Wow! He’s realistic!’ I say to Babs, patting the dog on the head.
‘That’s the point,’ she says. ‘To scare people off.’
‘He’s very well behaved, though,’ I say, bending down to pat him on the head. ‘Good boy.’
‘It’s plastic,’ she says, then hobbles at top speed back along the empty corridor, suddenly lurching to the left into her living room. I follow her, wondering what information might have been left off the referral.

The living room is even more startling than the hallway. It’s like being on the set of a trippy psychological thriller. The wallpaper doesn’t help – broad red vertical stripes on a candy yellow background. All the furniture is duplicated, as perfectly as if someone had slid a mirror down the centre of the room. There are two toy collie dogs sitting to attention right and left of the fireplace; two Chinese saucers, right and left of the low coffee table (one with a set of teeth); two rattan chairs with identical cushions in opposite corners of the room; two bookcases, each set with four ornamental unicorn heads.
Babs picks one up and holds it out to me.
‘I’m going up town to get a couple more tomorrow,’ she says. ‘Look!’
I turn it round and round in my hands. The unicorn has a disappointed look, like someone ran up to a horse and rammed an ice cream cone on its head.
I know how it feels.
‘Lovely’ I say.
Babs puts it back on the bookshelf and begins pacing around.
‘Who sent you?’ she says.
‘Doctor Jones.’
‘Doctor Jones? I’ll kill him. I’ll go down the surgery and string him up. Interfering… Why d’he send you?’
‘I think he just wants to make sure you’re okay. After your recent hospital stay and everything.’
‘I’ll show him okay!’
In an effort to mollify Babs and get her on side, I explain clearly and calmly who the Rapid Response Team are and what we do.
‘Maybe there are ways we can help,’ I say, self-consciously adopting a neutral posture in the chair.
‘How?’
‘Well I don’t know. Bits of equipment. Shopping. Someone to help with your meds. Whatever! Some physiotherapy…’
‘Physiotherapy? Why would I want that?’
‘You know – to help you get better.’
‘Doctor Jones!’ she says again. ‘What’s he like? I’m going to ring him up and tell him what I think…’
She grabs at the phone, picks it up and for a horrible moment I think she’s dialled 999.
‘Are you all right?’ I ask her.
She hangs up.
‘I’ll tell him later,’ she says. ‘Now then. What are you going to do?’
She stares at me, her eyes fixed and dark, like someone made a quick sketch of an anxious face and scribbled worry lines either side of the nose.
‘Can I do your blood pressure, temperature, that kind of thing? But I won’t do anything you don’t want to do…’
‘That’s all right,’ she says, throwing herself down into one of the chairs and bunching up her sleeve. ‘If Doctor Jones wants you to do it, I suppose you’d better.’
She carries on talking whilst I take her blood pressure.
‘I want to do something for him,’ she says. ‘I want to show him how grateful I am. So I think what I’ll do is get a card made. Special, like.’
‘Where?’
She stares at me.
‘At a card shop. One of them ones that plays music.’
‘Yeah?’ I say, slinging the steth round my neck and writing down the reading. ‘Lovely. What sort of music?’
‘I don’t know. What do you think?’
‘How about Thank you for the music?’  I sing a couple of bars.
‘Thank you for the music?’ she says. ‘He’s a doctor.’
‘It’s the first thing that came to mind.’
‘Really?’
She pulls down her sleeve and folds her arms.
‘I was thinking more of the death march.’

For someone starving themselves to death, Rita has a remarkably healthy appetite.
‘I fancy some porridge. Do you know how to make it?’ she says.
‘I normally use a saucepan, but I can follow instructions.’
‘Good man,’ she says. ‘Not too hot,’ and settles back in the chair to sip her tea.
‘Sorry about the mess in the front garden,’ she says, nodding at the patio doors, ‘but I’m having some people in to do it up. It’s going to be a terraced affair. Two levels, one for sitting, one for planting. It’s quite a sunny spot. Think Mediterranean.’
‘Lovely.’
I tear open a sachet of two minute oatmeal porridge, empty it into a bowl, fill the sachet to the line with milk, give it a stir and put it in the microwave for two minutes. The microwave hums and turns, and an aroma of warming milk and golden syrup fills the little kitchen.
‘How often do you see your family?’ I ask her over my shoulder, washing up the few things on the sideboard.
‘Hardly at all. One’s in Australia and the other’s in Canada.’
‘Oh. Any grandchildren nearby?’
‘Michael’s in London, but he’s so busy, poor chap. I don’t think he’s got time for himself, let alone an old fool like me.’
The microwave dings ready. I take out the bowl, give it a stir, put it on a tray with a spoon and take it through.
‘Set it down there, would you?’ she says, waggling a finger at the kitchen trolley. ‘It’ll need to cool for a bit.’
She adjusts her position in the chair and then immediately sinks down again in a movement that’s more deflationary than anything else.
‘I’m done,’ she says.
‘What d’you mean, done?’
‘Finished. Kapput. What’s the point?’
‘I’m sorry you’re feeling a bit low. Have you spoken to anyone about it?’
‘Like who?’
‘I don’t know. The doctor?’
She laughs.
‘They’ll just put me on funny pills. No – I know exactly what the problem is. Old age! That’s why I won’t eat, you see. I simply don’t want to carry on.’
‘But look at your lovely garden, Rita. Think how great it’ll be when it’s done and you can sit outside in the sunshine and eat your porridge.’
‘Is it cool enough, d’you think?’
I move it around with the spoon.
‘Give it a go and see.’
I pass it to her. She takes a speculative mouthful.
‘Mmm!’ she says. ‘Just right!’

‘I’m so sorry to disturb you, Jeffrey. My name’s Jim. I’m with the Rapid Response Team and I’ve been sent in to see how you are.’
‘That’s all right, mate,’ he says. ‘You do what you have to.’ Then he closes his eyes and falls immediately back to sleep.
Jeffrey is a hundred and one years old. He’s lying in the foetal position in bed, his left hand crooked under his head, his right hand resting on the outside of the duvet up near his face, like his thumb just slipped out of his mouth. Jeffrey was discharged from hospital this evening after investigations for a GI bleed. He’s been in a fair bit recently, what with one thing and another. They’re still not sure about the bleed. They’ve booked him in for more tests. For now, he was discharged back to his warden controlled flat earlier this evening, carers four times a day, one late at night.
He’s been referred to us to keep an eye on things.
‘Do you have any pain, Jeffrey?’
He opens his eyes again.
‘Only you,’ he says. ‘I’m kidding, mate. I’m grateful for all you’re doing.’
‘Any more vomiting?’
‘Nah. They jabbed me in the arm with somink. It seems to have done the trick.’
‘Great. I’ll be as quick as I can so you can rest.’
‘You carry on,’ he says, and falls asleep again whilst I feel his pulse.
All his obs are south of where they should be, and it’s frustrating not to have a record of his baseline. I’d guess he’s probably stable, but it’s tricky when I’m the last clinician to see him. When I’ve finished the examination I write up the results and wake him up one last time.
‘I’m a bit worried about you, Jeffrey.’
‘Me? I’m all right.’
‘Your oxygen levels and your blood pressure are a little on the low side….’
‘I just want to rest. That’s it.’
‘I know, but – would you mind if I called the out of hours nurse to come in and see you later?’
‘Nah. I’m all right. I’ve got the carers at ten. If anything happens in the meantime I’ll press my button. Just let me sleep now.’
‘Okay, Jeffrey. I’ll have to let my boss know what’s what, but I’ll clear off now and let you rest.’
‘Thank you. Could you put that light out when you go?’
I close the door quietly.

Back out in the car I phone the Co-ordinator and tell them what I’ve found.
‘He’s worn out,’ I say. ‘He doesn’t want anyone else going in. He just wants to rest.’
‘I don’t think so. Not with obs like that. We’ll have to get the out of hours in.’
‘He’s got a DNACPR,’ I add, hopelessly.
She makes a note. A DNACPR is specifically about resuscitation, of course, and has no bearing on whether or not he receives treatment for anything other than cardiac arrest. She doesn’t suggest a night sitter because they’re in huge demand and mainly for falls risks. Jeffrey won’t be getting out of bed, so at least he’s safe in that respect. It’s a shame, though. I don’t know what the OOH will do when they go in. With obs as poor as Jeffrey’s, it’s touch and go whether he’ll simply be readmitted. Not because the hospital will necessarily do anything, but because the OOH won’t feel able to leave him at home. I don’t know why he’s been discharged knowing all this – but then, of course, I really do. The relentless squeeze on bed space at the hospital means something has to give. In this case, it’s Jeffrey.

I don’t know what his family situation is. Coming in cold like this, it’s difficult to get much more than a snapshot of his care provision, family circumstance. I have no idea who might be available to come and sit with him in a chair by the bed, to hold his hand, or smile at him when he opens his eyes, another human being to be with him in the small hours of the morning. I don’t have the space, the time or the wherewithal to do anything other than report the bare, clinical facts of his observations. And all the Co-ordinator can do is pass them on to the OOH. And so it goes on, the dance of Clinical Responsibility, Stripping the Willow in a particularly fraught and exhausting Ceilidh, where you don’t link arms but swap obs sheets, person to person to person, all the way to the hospital and back again, with no-one able to break the chain, to step aside and sit down next to Jeffery and say ‘All right, mate? Let’s sit this one out.’

Sandra, one of the District Nurses phones to see if we have capacity.
‘Don’t worry! It’s not a full-on referral,’ she says. ‘More of a favour, really. I’ve just been round to see Harry, one of our palliative patients. A lovely gentleman, stubbornly independent, you know the sort. Coping remarkably well up to now. No carers, just friends helping out now and again. Anyway, he’d had an episode of incontinence, probably food related more than anything. I cleaned him up, changed his bed things and put them in the wash. Medically he’s stable. It’s just he cried when I was there and it was a bit of a shock to be honest. We’re all a bit worried about him. It’s too late to sort out a proper care package tonight, if that’s what he needs. I just wondered if you could send someone round last thing to see he’s okay for tonight.’

Harry is eighty something, fifty years at sea, twenty of those a captain, the beard and the bearing to prove it.
‘Can I see some identification, please?’ he says at the door. I show him my badge.
‘Thank you,’ he says, hands it back and shows me in.
He walks uncertainly, like a man in a dream, running his hands over the walls and the furniture not for balance but to reassure himself they’re real. I follow him into the sitting room. He eases himself down into a sculpted leather armchair, a TV showing Twenty20 cricket, the sound off.
‘Sandra asked if I’d drop by to see how you are,’ I tell him.
‘Sandra. Yes.’
‘How are you feeling?’
He stares at me. There’s a delay before he replies each time, no doubt a symptom of his cancer.
‘I’m fine,’ he says. ‘I had a little setback, but everyone’s been so kind.’
I take my coat off and drape it over my bag.
‘What can I do to help?’ I ask him. ‘What about a cup of tea?’
He considers that.
Eventually he says: ‘Thank you. Tea. Yes.’
‘How do you have it?’
Another long pause. He wets his lips a couple of times.
It’s a physical thing. You can almost see the images passing in front of him: the kettle, the cup, the milk.
‘No sugar,’ he says. ‘Thank you.’

Often, when you go into people’s houses, there’s a slight confusion. Where do they keep their tea things? Which is the cutlery drawer? Where’s the bin? You spend a minute or two opening and closing cupboards, expecting one thing, finding another. Harry’s kitchen is different. Everything is just where you might expect it, neatly stowed. I get the impression if the house unexpectedly put to sea, you could still make breakfast quickly, and nothing would fall on the floor. The draining board is a work of art, all the cutlery standing handles down, forks and knives on one side, spoons and teaspoons opposite, plates in size order. There’s a tray over by the kettle with caddies for tea and coffee. Tea-towels hanging from hooks. I’m the untidiest thing there.
‘Here we are!’ I say, bringing him a cup of tea. ‘How about something to eat?’
‘I couldn’t,’ he says after a while. ‘I’m afraid I’ve lost my appetite. But thank you.’
‘You’re welcome. Sandra asked me if I’d empty the washing machine and hang it all out to dry. Is that okay?’
‘Please,’ he says. ‘I don’t feel quite up to it.’

There’s a clothes rack in the utility room, full of pyjamas, shirts, pants, socks, handkerchiefs and jumpers. I fold them all up as neatly as I can, put them in a pile on the sideboard, then take out the washing. I shake out the sheets, duvet cover, pillow slips and towels, space them out as much as possible, then go back into the lounge.

‘Shall I put the dry things away for you?’
He looks over at me, then nods.

I take the pile of laundry and go into his bedroom. Again, it couldn’t be easier. There are specific drawers for each item, and I square everything away, everything except the towels. I check the bathroom and the hallway, but I can’t find an airing or linen cupboard, or any place else that might double for that. So I go back into the lounge.
‘What about these?’ I say, holding up the little pile of towels.
He stares at me, at them. After a while he says:
‘Lay them on the chest, could you? In the bedroom.’
I want to say Aye Aye, but I just smile and turn about.

The chest is a vast sailor’s trunk, made of dark African woods, intricate marquetry ships with masts and sails, riveted, braced with copper bands. I place the towels on top of it, then go back into the lounge.
‘Is there anything else I can help you with tonight?’
‘No. I’ll be fine,’ he says. ‘I’ve got friends popping round later.’
‘Sandra’s back in the morning. Maybe you can have a think about what kind of help you might want from now on.’
‘I’m a cussed old thing,’ he says. ‘I like to be as independent as I can.’
I stand to go.
‘If there’s nothing else…’
‘There is one thing,’ he says, and points to the table in front of him. To a tea spoon resting on a woven Jute coaster, the handle aligned with the edge of it, both of them parallel with the remote control.
‘That’s the culprit,’ he says. ‘The bad spoon. I’m sure of it. You couldn’t wash it up for me, could  you?’
‘Of course.’
I take it into the kitchen, give it a good scrubbing, then place it, handle first, with the others.

Mr  Smith’s diagnosis came six years ago – inoperable brain tumour, prognosis of anything up to ten years – but it wasn’t until the CVA  a few years later that he became so incapacitated.
The Smith family are coping with his illness as well as any family could. They have all the equipment their small terraced house can take: a hospital bed with a dynamic mattress, pressure relieving equipment, a commode on wheels, bath boards, perching stools and anything else the OTs can think of. Mrs Smith has steadfastly refused any care support. She has three sons, all of whom take turns helping  their father in and out of bed. Mr Smith was referred by his GP to the Rapid Response as an NCH – Not Coping at Home – but no doubt if there was an acronym for In Need of Respite from the Physical and Emotional Strain of Caring for the Terminally Ill, the GP would have used that instead.
‘He just needs to see something other than these four walls,’ says Mrs Smith, catching the loose strands of her hair and tying them back in place. ‘Me too, probably.’

I finish the health screen and tell them I’ll be in touch with the palliative team to see what can be done.

I shake hands and leave.

*

I’ve been working in community health for almost a year now, but I still struggle to understand how all the different agencies interact. No doubt it’s simply a matter of funding. Who lives where, under what medical centre jurisdiction, which Commissioning Care Group and so on. What makes it even harder to figure out is that so much of what we do overlaps. There are specialties, of course – Palliative care being one – but people are sick for the same reasons, and often need the same treatment, regardless of the provider.
Still, Mr Smith is a palliative patient. It seems fair to assume that all aspects of his treatment would now fall to the Palliative team. So I make the call.
Eventually I get to speak to Wendy, one of the senior nurses. She’s a little abrupt to begin with – Who am I? Where am I calling from? – a friable quality to her voice that suggests things are as stressful there as they are here.
‘Yes, we’re aware of Mr Smith,’ she says. ‘Why have you become involved?’
I explain the situation, the fact that the GP referred them to us because they weren’t coping at home. I tell her that Mr Smith seems stable. His obs are okay. The family don’t want more care, as such. They just want a break.
‘A break? What exactly do you mean? Respite care? An In-Patient bed? I don’t think he’s there yet. Do you?’
‘I just think they’re all pretty exhausted and need a break.’
She sighs.
‘I don’t think you understand the situation,’ she says. ‘We’re bursting at the seams here. If his symptoms haven’t deteriorated there’s nothing we can do. I’ll talk to the District Nurses to see if they have any capacity to go round, but really, I’m sorry. We can barely cope with the patients who are actively dying, let alone those that are tired and need a break.’
‘I know you must be busy…’
‘Busy? About as busy as you, I should think! No-one’s got capacity for anything. I wish I could tell you differently.’
There’s a sense of her moving away from the phone to gather herself.
‘Hello?’ I say, after a pause.
‘Look,’ she says, coming back. ‘Leave it with me. I’ll speak to the DNs and figure something out. I’m not promising anything. Certainly not a bed. But we’ll talk to the family and find out what’s going on.’
‘Thanks for that.’
‘What did you say your name was?’
‘Jim.’
‘Thank you, Jim. I’m sorry I can’t be more positive.’
‘That’s okay. I know how it is.’

I think about the Smith family, how brilliantly they’re doing together, taking on so much of the burden of Mr Smith’s care. How much they’re saving the NHS in doing that. How they could just use a break.

Still.

I write out the bones of the conversation, and file the notes away.