the great conjunction

Saturn and Jupiter are lining up.

Apparently it’s a thing that happens every twenty years, but a great conjunction, where the two planets get so close they look like a single bright star – well, that only happens every four hundred years or so. Kepler, the seventeenth century astronomer, pointed out that a great conjunction happened in 7 BCE, and may account for the Star of Bethlehem in The Nativity.

Today we’ve had nothing but thick fog and a cruel variety of fine, saturating rain that makes walking forwards feel like swimming up. It was just as well the weather was kinder all those years ago in Bethlehem, otherwise the Birth of Christ would have featured a comedy moment where three bedraggled kings holding fancy boxes over their heads high-step three hours late into an empty stable where an innkeeper is sweeping up.

Two thousand years back in the CE, though, Saturn and Jupiter aren’t the only things lining up.

Karen, the physio, is waiting for us under the porch outside Mr and Mrs Billingham’s house. She’s brought a walking stick. Jack the carer is here for a lunchtime call. I’ve turned up to deliver and fit a shower stool and a toilet frame, and to do some obs. There’s not much room under the porch, so I’m at the bottom of the steps leaning in.
‘I’ve rung the bell but nothing’s happening,’ says Karen, her eyes smiling above her mask. ‘I’m not even sure it’s working.’
‘Shall I knock?’ says Jack. He goes up to the door – an iron-bounded oak affair, with a door knocker so huge it wouldn’t look out of place on a quayside with a ship tied up to it – and flips it three times.
‘It’s like Jack and the Beanstalk,’ I say. ‘When he goes up to the castle and knocks.’
‘Have you met Mr Billingham?’ says Jack. ‘I don’t think ogre is far off, as it goes.’
We wait.
The house is silent.
‘Are they in?’
‘They don’t go out.’
‘Do you think they’re in?’
‘Hang on…’ says Karen, leaning into the door. We all listen.
‘No. Sorry,’ she says, straightening up again. ‘I thought I heard something.’
Jack sighs.
‘This is ridiculous,’ he says. ‘We keep coming back, and the same thing keeps happening.’
‘He’d better hurry up,’ I say. ‘I’m worried about this shower stool getting wet.’
They both laugh.
‘Actually – aren’t they designed to get wet?’ says Karen.
Jack gets his phone out.
‘I’ll ring him.’
Amazingly, Mrs Billingham picks up almost immediately. Karen and I only hear half of the conversation, but this is roughly how it goes.
‘… we’ve come to see how you are, Joan…. because the doctor asked us to…. you had that fall, didn’t you? And people were worried… well… Joan… actually it isn’t that early. It’s lunchtime, Joan… that’s why I’m here, to help you get something to eat and whatnot… and I’ve got some other people here to see you, too… colleagues of mine… well, there’s Karen, the physio, she’s here to help you get back on your feet… and there’s Jim, the nursing assistant to make sure you’re okay, and to put in some equipment to help with this and that… we talked about it the other day, d’you remember?…. yep… yep… but Joan… yep… yep… Joan?… the thing is, we really need to see you today… no, the phone doesn’t really count… we need to clap eyes on you, to make sure everything’s okay… yep… sure, put him on….’
Jack widens his eyes at us and breathes out heavily, which immediately steams up his glasses. Then Mr Billingham comes to the phone and Jack starts up again:
‘…hello ….Mr Billingham? …. it’s Jack, the carer. Hi! We met the other day? How are you?… yep… and I’m sorry to disturb you… well – I did phone ahead, but the phone cut out… no, a few times…. yep… I appreciate that… yep… I know you’re in bed… but the thing is, Mr Billingham, we really need to see Joan… because the GP asked us to… he’s worried, Mr Billingham… yep… yep… I understand that… but the thing is, Mr Billingham – with the greatest respect – Joan is our patient. She’s our responsibility. And that’s why we need to see her for ourselves….’

The conversation carries on like this for some time. He persists long after I would’ve given up, and I’m impressed with Jack’s patience. He doesn’t raise his voice or start to sound hectoring or patronising at all. Instead, like some accomplished hostage negotiator, he makes subtle changes of argument, trying to coax Mr Billingham downstairs to unlock the front door and let us in.

Meanwhile, more people have started to arrive. Two representatives of the care agency who’ve come to do their initial assessment. They’re bulky, approximate figures, swathed in enormous parka coats, the furry hoods up, tightly clutching blue folders to them like aliens holding manuals to life on Earth. Next is another figure in a smaller but still pretty substantial shiny black puffa jacket, with some kind of Norwegian hat pulled hard down over her head, the ear flaps resting on her shoulders. When I nod and smile at her she just sways a little from side to side and bobs at the knee. I get the impression she’s a social worker. Last to join the line is a postman. He’s like the Royal Mail version of Lear on the heath, his long grey hair completely soaked and bedraggled, his beard, too. All he has on are a lightweight jacket and cargo shorts, none of which would be any good on a summer’s evening, let alone the current horror show. He’s weighed down by an enormous mail sack, of course – but he seems remarkably chipper.
‘What’s up?’ he says from the back of the queue. ‘Are they having a sale or something?’
Before anyone can answer he taps the social worker on the back.
‘Here ya go, Pingu,’ he says. ‘Pass these along and stuff ‘em in the box, would ya?’
Then he waves and marches off.
The letters make their way forward. I hand them to Karen, she hands them to Jack, who – still talking on the phone and cradling it to his ear – pushes them through the letterbox.
‘Mr Billingham! Your mail’s arrived!’ he says as he does it. ‘Some exciting looking envelopes… cards and all sorts … why don’t you nip down and have a look…?’

return of the pedalo kid

I’ve been coordinating all day. Which isn’t a plea for special consideration, more just a recognition of a physical fact, like admitting the Atlantic is pretty big, or yes, on balance, it’s probably true, the Himalayas can be bumpy. I’ve been shackled to the galley of this desk, working the keyboard and the phones, from half past seven in the morning, with everyone breezing in bright and fresh and grabbing coffee, to seven in the evening, most of the crew gone, the dishwasher churning in the background, the motion sensitive lights starting to click off, and a radio playing Christmas songs on a loop in the background Twas Christmas Eve babe…in the drunk tank…. There are only a few of us left now, the stragglers, the no-hopers, the hangers-on, the lost. One of the latter, Will, is a new physio, struggling to finish his paperwork. I’ve helped him out with bits and pieces, but he still has a way to go. He keeps coming up to the desk, holding his laptop in the flat of his hands like he’s offering up a bird with a broken wing that he doesn’t think can be saved.

I’ve been wearing a mask all day, too, which doesn’t help. It’s like having your head under the duvet, which – after eleven hours of coordinating – is a dangerous state of affairs.
‘That last call took me way longer than I expected,’ says Will, approaching the desk with his laptop again.
‘It’s tricky, to begin with. There’s a lot to think about. You’ll get quicker.’
‘Yeah. Also….the family were quite challenging.’
‘Were they? In what way?’
‘Oh – he was alright. It was his wife. Mrs Tuttle. She was quite hostile. I don’t think she wanted me there.’
‘Let’s take a look…’
I call the patient’s records up.
‘Hmm. It says here the last time he was on our books, about six months ago, we had trouble getting access. Looks like she didn’t want anyone coming in the house. Concerns about Mr T. Social workers … dah, dah … yep, definitely sounds tricky. We’ll have to go carefully. I think you did an amazing job to get as far as you did, Will.’
‘Thanks,’ he says. ‘I took it slow. Which I had to do anyway. It’s just…’
‘Go on..’
‘You couldn’t call her, could you?’
‘Who? Mrs Tuttle. Of course! What for?’
‘Well – I had to get out of there pretty sharpish in the end, and I wasn’t sure she really understood about the way it works with the carers.’
‘I can explain it to her. No worries.’
‘Thanks. lt’s things like letting her know that they can’t ring before they turn up. Also that they’ll be respectful about waiting before entering the house. And the kind of things they’ll do when they go in.’
‘Absolutely. I can do that.’
‘Thanks!’ he says, looking relieved. ‘I don’t think I could face talking to her again.’
‘How bad could she be?’
He smiles at me, then slowly backs away.

I have to admit, helping Will like this feels good. It makes me feel like an old hand. I’ve visited so many patients now, in the ambulance and in the hospital avoidance team. I’ve seen it all, good and bad. I see myself as Will no doubt sees me – one of those helpful, easy-going, thoroughly competent colleagues who’ll always be there to pour oil on troubled waters. I sigh, lean back in the chair. Pick the phone up. Hang the mask off my ear like a marine. Check the number. Punch it out.
When the phone picks up I introduce myself.
‘Why are you ringing?’ says Mrs Tuttle. ‘The other man was only here five minutes ago.’
There’s a formidable clip to her voice that immediately registers. I feel like I’ve put to sea drunk in a swan-shaped pedalo and woken up five miles offshore. In the rain.
‘Yes. I know. That was Will. The Occupational Therapist.’
‘Oh! Well. He told me he was a Physiotherapist.’
‘Yes! You’re right! Sorry. That’s what I meant. Physiotherapist.’
I want to tell her that he’s only just started here and I was momentarily confused, but the words burn away just as surely and instantaneously as my sang froid.
‘It’s just like the hospital,’ she carries on. ‘They tell you one thing and do something completely different. They say my husband won’t be coming out for a week and then five minutes later I’m called by the ambulance to say he’s on his way. They promise the earth and give you nothing. And now you.’
‘Well. Yes. It must be frustrating.’
‘Frustrating?’ she says. ‘Would you mind waiting there a second?’
‘Of course.’
‘I’m just going to put on the recording device.’
Recording device.
‘There!’ she says. ‘Now. Start again please. Tell me your name, your job description, and the purpose of your call.’

read my lips

Mr Blatchford is a double-up for two reasons. The first is manual-handling: he’s a bed-bound, double-amputee, so he needs two people to log-roll in situ for personal care and wound dressing, and for repositioning in the bed. The other reason is he’s aggressive.
‘It sounds like a suit of armour job,’ says Rosa, the coordinator today. ‘Long sleeved gown, mask and visor, gloves of course. Shoe covers, probably.’
‘Because he’s aggressive?’
‘No. Because he spits.’
‘Yes. Spits. Intentionally. Not just when he’s talking.’
‘Has he got dementia or something?’
‘No. He’s just spitty. And sweary. Sorry.’
‘You’re not selling him.’
‘I’m not, am I? Still – he shouldn’t be with us long.’
‘Let’s hope not.’
‘You’ll have to double-up with his usual carer, Mandy this morning. When she’s not there we’ll have to find another pair of hands.’

I know the block well – a warden-controlled place on the outskirts of town. The kind of prefabricated, glass and red-brick building you could throw up in an afternoon if you knew your way round a box of Lego. Mandy meets me at the front door. She seems thoroughly pleasant, which is encouraging.
‘Dickie’s so happy to be home,’ she says, showing me up the main stairs. ‘He’s got all the equipment he needs, so we’re pretty well set-up.’
She gives me a hesitant, backwards glance over her shoulder.
‘What have they … said about him?’
‘They said he was a bit of a handful,’ I tell her. ‘They said he spits.’
She stops on the landing with one hand on the fire door.
‘They’ve said a lot of things about Dickie,’ she says. ‘To be honest with you, I don’t know where it’s come from. I mean – it’s true – he can be plain-spoken. He’s always been a bit fruity with his language. And I think it’s true his mental state has taken a bit of a dip. But this spitting business? I’ve not seen it. Treat him as you find him, of course, but don’t worry about the spitting too much. I think it might’ve got a bit blown out of proportion.’
‘I’ll still gown-up in the corridor, though, if that’s okay.’
‘You do what you have to,’ she says. ‘I’ll go on in and tell him you’re here.’

Dickie is an elderly guy in the last weeks of his life. He’s lying on his back in a hospital bed, the covers tucked neatly up to his chin. The flesh has fallen away from his nose and cheeks and his grey hair is combed back in gelled lines. A pair of enormous steel-rimmed glasses are balanced on the ridge of his nose which magnify his eyes and – with his mouth half-open – give him the appearance of an ancient fish, unexpectedly landed, salted away in a box.
‘It’s the nurse, Dickie,’ says Mandy, gently laying a hand on the covers. ‘Come to see how you are.’
He moves his lips up and down in an approximate way. Mandy smiles up at me.
‘Dickie has trouble speaking,’ she says. ‘But he does make sense if you concentrate.’
I move closer to the bed and lean over, my apron rustling, my visor fogging up.
‘Hello, Dickie,’ I say, speaking loudly to be heard through everything. ‘My name’s Jim. I’m a nursing assistant. Welcome home!’
He turns his head to look at me, and his mouth waggles.
‘What’s that?’ I say. ‘I can’t quite get it.’
‘He says Can you lip read?’ says Mandy. ‘It’s okay. I’ve known him a long time. I’m quite good at it.’
‘I’ll have a go!’ I say, leaning in a bit closer.
He waggles his mouth again.
‘Nope. Sorry. Can you say it again?’
‘Oh, Dickie…’ says Mandy.
‘Once more…?’ I say, leaning in even more closely, frowning, staring at his mouth. The bottom teeth biting the upper lip and then releasing in a tired flick; the lips dropping into something of an O; the bottom teeth touching the upper lip again, releasing more softly.
‘Oh. Okay. Yep. Got it that time.’
Fuck off.
‘He doesn’t mean it,’ says Mandy. ‘Do you, Dickie?’
Dickie slowly turns his head to look at her, and his gnarly old eyebrows quiver – as best they can – into the up position.

about george

I’d met George a few times in the past, so I had my doubts.

‘You have to take him,’ said Lyra, the manager of the rehab unit. ‘He’s been here six weeks and it was only supposed to be a couple of days.’
‘But you say he’s hoist only now?’
‘In that house?’
‘And it’s been cleared? It was so tiny and cluttered. You’ve actually managed to fit a hoist and a commode in there?’
There’s an ominous pause.
‘Yes,’ she says. ‘I wouldn’t be sending him home, otherwise. Would I?’

The conversation hadn’t started well.

George had been referred to us for an initial assessment. I’d phoned the unit to clear a couple of things up. When the first person answered I went through the usual spiel: Hello. My name’s Jim. I’m a nursing assistant from the Rapid Response team. I’m just calling to find out about George’s discharge today.
‘Oh. Hold on. You need to talk to another nurse.’
She put the phone down on the desk without muting it, so I could hear her calling out (although the other person was too far away to hear): I don’t know. Some guy asking about George…. I don’t know what he wants…. Why don’t you speak to him?…. Well where IS she?…..
Then some general clattering, muttering, background noise. Laughter. Eventually someone else picked the phone up from the desk.
‘Hell-oo?’ she said, in that drawn-out, slightly hesitant voice you might use for a sales call or worse.
‘Oh – yes – hello! My name’s Jim. I’m a nursing assistant from the Rapid Response team. Sorry to bother you. I’m just calling to find out about George’s discharge today.’
‘George Masters.’
‘No. Who are you?’
‘Me? I’m Jim. Nursing assistant. Rapid Response Team.’
‘Just a minute…’
She puts the phone back down on the desk, again – without pushing the mute button.
I don’t know. He says he’s a nursing assistant called Jim. Asking about George.
There’s some toing and froing between the two, then she picks the phone up again.
‘What is it you want exactly?’
‘Well – two things. One is that on the discharge summary they give an address that’s different to the one we’ve got. So we need to clear that up. And the other thing is to find out what time he’ll be home.’
‘Just a minute…’
She does the same thing. This time, I’m waiting for five minutes, hanging on the phone, listening to all the traffic and fuss of the unit. Just as I’m about to hang up and call again later, the phone gets picked up by someone else.
‘Hello. Erm. Yep. My name’s Jim. I’m a nursing assistant from the Rapid Response Team. Erm.. can I ask who I’m talking to?’
‘My name’s Sheila. How can I help?’
‘Are you a nurse, or …’
‘Yes – I’m a nurse.’
‘Great! Do you know about George Masters?’
‘What about him?’
I take a breath, then go into the two things I need to know about George so we can be there to do the initial assessment.
‘You need to speak to Lyra,’ she says.
‘Who’s Lyra?’
‘The unit manager… LYRA…!’ she shouts, so loudly I have to lean away from the receiver. She slams the unmuted phone back down on the desk.
Another five minutes.
Eventually the phone gets picked up again.
‘Hello? Lyra speaking?’
‘Hi Lyra. Can I just say, before I go on – I’m not all that happy with the way this phone call has gone. I’ve spoken to three different people. They’ve all put the phone down without even muting it, so I can hear them shouting across the unit…’
‘Don’t get clippy with me,’ says Lyra.
‘I’m not clippy, I’m just saying…’
‘I don’t appreciate your tone…’
‘All I’m saying is that it’s been really frustrating ringing your unit today….’
‘We’re busy. What d’you expect?’
‘Everyone’s busy.’
‘I think you need to look at the way you speak to people. Who did you say you were?’

We struggled on with the conversation, but by the time I hung up I was sweating more than a pilot who’d spent half an hour fighting to stop a plane crash.

‘So – when’s he home?’ said Anna, who was due to handle the initial assessment with me.
‘She’ll call me,’ I said. ‘Maybe.’

To be fair, from that point on Lyra was more amenable. I think it was because she was desperate to discharge George, who’d been a disruptive presence on the unit, constantly ringing his button, throwing tissues everywhere, generally playing up. I’d met George before, of course, and I knew he could be difficult. But when I’d known him he was still at home – a tiny, cluttered house with a kitchen whose ceiling was halfway down and whose downstairs toilet was so unspeakable you wanted to clean it up with a flamethrower. He had a cute dog, though – a perky little brown and white Jack Russell called Lily, so it would be nice to see her again.
‘I’m sorry about the way the phone call went,’ said Lyra. ‘We’re completely rammed here, as you can imagine. And I’m having to get by with agency nurses, and they don’t know the routine.’
‘That’s okay. I’m sorry if you thought I was clippy.’
We laugh about it.
End the call.

Later that day I’m sitting in George’s front room. We’ve just hoisted George from the wheelchair onto the hospital bed, but already he’s talking about putting himself on the floor because ‘it’s too early for bed,’ even though he couldn’t sit in a chair without three feet of rope and a crash mat. The neighbour who we were told would be coming round with shopping and generally keeping an eye on things is actually self-isolating and not leaving his house. To add to the woeful picture, we’ve just found out the boiler doesn’t work. Our team have been asked to provide bridging care four times a day, but even so you couldn’t say with any confidence that George would be safe between calls. He really needs some kind of residential facility. Still – at least Lily the dog has been rehomed.

There’s nothing else for it.
I ring Lyra.
She answers.
I tell her the situation.
There’s an ominous pause…

The nightlife of Berlin

‘How are you getting on, Jorge?’
‘Fine. I’m just finding somewhere to park. I won’t be a minute.’
‘See you in a bit, then.’
I put the phone back in my pocket.
Take a breath.
Lean against the railings.
Look around.
I can’t see Jorge’s car, though, which is odd. There’s a clear view up and down the road, and of the D-shaped green just opposite.
I wonder if I’ve got the right address.
I have a sudden feeling of dislocation. Everything seems unnaturally still, like I’ve wandered into an old plate photograph in the short walk from my car to these railings. But instead of a frozen horse and cart, a geezer in a bowler hat, a woman in a hooped skirt and bonnet, there’s a guy in a T-shirt sitting in his van staring at the front door where he dropped his tray of groceries, and across the road, a man in white surgical gloves staring at a rack of rentable bikes.
I wait.
Re-shoulder my bag.
Look around some more.
I can’t see Jorge’s car anywhere. Maybe I have got the wrong address.
I ring him again.
‘Yes, yes. I’m just coming. Look! I can see you…’
But I can’t see him!
It’s peculiar – then, suddenly, bursting through the paper of the photograph, there he is, waving his phone in the air from the centre of the grassy D, and everything comes back to life. The delivery driver slams his door and moves off. The guy begins wiping down the saddles of the bikes.
‘Have you been here long?’ says Jorge.
‘Hardly any time.’
‘Come on. Let’s see if he’s in this time.’

We’ve teamed up for the assessment because there’s a safety caution both for Gary and the address. Gary had suffered an injury to his leg and gone to A and E, but it was obvious from all the collateral noise around the referral – emails between the hospital, surgery and social services – that no-one knew what to do with him or felt able to take responsibility. Gary had such a long history of non-attendance, non-compliance, non-cooperation, non-everything, you’d think it would be easy just to type NON in big red caps on his notes and leave it at that. Except Gary wasn’t quite so definitively NON that he wouldn’t stop presenting at the hospital complaining he couldn’t cope. As a last resort he’d been referred to us. We’d tried over the last few days to get in touch with him, but he didn’t answer the phone, didn’t reply to messages. Then his phone was switched off. None of his other contact numbers worked, or the people who did answer either knew where he was and didn’t want to say, or didn’t know, or didn’t care, or all of the above. A couple of days ago a therapist had let themselves into his flat with the keysafe, but there was no-one in. The next day there was no key in the keysafe.
Today’s visit from Jorge and me is the last throw of the dice.
I ring the intercom.
And again.
And we’re just about to turn round and leave when it crackles into life.
Come up he says. Make sure you put your masks on.

Gary looks a bit like Eddie Vedder from Pearl Jam – or would do, if Eddie Vedder had spent the last thirty years shooting up, smoking crack and eating chips. He stands unsteadily at the flat door, an unlit joint clamped in the corner of his mouth, his puffy eyes squeezed shut like a sick and denuded mole coming up for air. He’s naked, except for a threadbare dressing gown and a velcro support boot.
He waves his hand in the air.
‘Come on in,’ he says.
We rustle after him, stand hopelessly in the middle of the room as Gary waddles to the sofa and eases himself down into it.

These days we have to gown and mask up for every patient – to protect them as much as us. And normally I hate it. Not only is it uncomfortably hot, but it also acts as a barrier to that open, human interaction you depend on so much to get things done, move things on. Now I’m glad of it. The room is as fetid and unkempt as Gary, ropes of old spider web hanging down so thickly you could jump up and swing from one side of the room to the other. There’s a case of beer on the kitchen counter, scatterings of pill packets, smoking gear, not much else. The TV looks like it’s been punched off.
‘Hello Gary,’ says Jorge. ‘You know – everybody’s been trying to get hold of you.’
‘Before you start,’ says Gary, shakily hooking his lank hair to one side. ‘Before you have a go, I’ve just got to do this. Alright? I’m breathless. I need to do my puffer. Okay? Is that okay?’
‘That’s fine,’ says Jorge. ‘You need to take your medication. We can wait a minute.’
‘Thank you,’ he says.

There’s a glass coffee table in front of him. On it is a spacer device with an aerosol of beclomethasone in one end, a glass of water, a mug of tea and a DVD of a guide to the nightlife of Berlin. Gary picks up the spacer device, gives it a shake, squirts the aerosol, puts the business end of the device in his mouth, and starts breathing through it, slowly and deeply, for five goes. Then he lowers the device. Gives it another shake. Another squirt. Puts it to his lips, repeats. When that’s all done, he gently and reverently puts the device back on the table.
‘Good. Well done,’ says Jorge.
Gary holds a finger up.
‘Just a minute,’ he croaks.
He picks up the water, takes a mouthful, puts the glass back down, leans back on the sofa, tips his head, and begins to gargle – a long, deep sound, like a lumpy old British motorbike. It seems to go on forever. Me and Jorge exchange looks over the line of our surgical masks. Gary takes another sip of water. Repeats the gargle. Swallows loudly.
‘Better?’ says Jorge.
‘Just a minute. Please. Just a minute,’ says Gary.
He takes the tea – very slowly – and takes a sip of that. Then he takes the DVD of Berlin and places it on top, to keep the tea warm.

A man appears from a room just behind us. He’s as grey and ruined-looking as Gary, except longer in the body, more stooped.
‘I’ll keep outta your way,’ he says, and ducks back inside.

‘So – Gary!’ says Jorge, clapping his blue gloved hands together. ‘You’re a difficult man to get hold of. Why didn’t you answer your phone when we’ve been calling?’
‘I was in too much pain.’
‘Yes – but – you see, if you don’t answer your phone, we start to get worried. One day you weren’t even in the flat.’
‘I’d gone out.’
‘Of course. But then the next day there was no key in the safe.’
‘I told you. I was in too much pain.’
‘But when we can’t see you we start to worry. And then we think about calling the police.’
Gary opens his eyes and looks straight at us – but then lets it pass with a shrug.

Jorge starts trying to explain to Gary who we are and what we do as a service, but Gary already has firm ideas. He doesn’t want physio or nursing – he knows his own body. All he wants is a carer to come in every day to wash his good foot, and maybe give his foreskin a freshen-up with a personal wipe.
‘Excuse me? Your what?’
‘My foreskin!’ says Gary. ‘You know… down there.’
‘Well! I think you can do that for yourself, can’t you?’ says Jorge. ‘I mean – for goodness sake! You need to be as independent as possible.’
‘Where’m I gonna get the wipes?’
‘From the shops. Any of the supermarkets round here will sell them.’
‘They haven’t got any.’
‘How do you know?’
‘Because Stu does my shopping.’
‘Is that Stu in there?’
‘Yes. But he’s not there all the time.’
‘But he is there some of the time.’
‘So maybe Stu could buy enough for the week when he goes.’
‘I just told you. They haven’t got any.’
‘It’s not the sort of thing we do, I’m afraid, Gary. We’re an emergency service. We have to look after very sick and vulnerable people. People who don’t have other people around them to help. You’ve got Stu. So that’s good.’
‘What you’re saying is, basically, you can’t do nothing for me?’
‘On the physio side, maybe. Do you have a support worker?’
Gary shakes his head.
‘That’s gone, now,’ he says. ‘That’s all finished.’
‘I’m sorry to hear that.’
Gary bristles.
‘If you’re not going to help me with the things I need, then what use are you? Just get out.’
‘Okay. That’s fine, Gary. We will go. And we’ll refer you back to your GP.’

Back outside, the air is wonderfully cool and fresh.
‘What a complete waste of time,’ says Jorge. ‘I think he was playing some kind of stupid game with us. What do you think?’
‘He was using that spacer device like a crack pipe.’
‘Yes! And my God – when he started gargling like that! I didn’t know where to look!’

A young couple pass by on the pavement, both of them hugging cardboard boxes of supplies. There’s such a tangible air of competence and vitality and neighbourliness about them I can’t help smiling.
‘Where did you park?’ I ask Jorge.
‘Over there! Under that tree!’
‘Let’s walk together!’
So we do.

malcolm the robot vs. tina dreadful

Tina’s surname is Redmond but everyone calls her Tina Dreadful.

Nothing prepares you for her. Nothing. Not meditation. Not medication. Not prayer.

You’d have to say Tina is following her vocation. She’s raised nastiness to the level of art. Made rudeness a competitive sport. Transformed vileness and good ol’ fashioned meanness into a spiritual quest. She’s racist, sexist, casually abusive. She’s uncooperative, obstructive, distracting. Now and again she’s content, in the way that torturers turn off the loud television sometimes, to soften you up for the next onslaught. Mostly, though, she’s just a bully.

I defy anyone to visit Tina and keep their cool.

The Dalai Lama would stomp across the road and kick a trash can.
Mother Theresa would storm out of the front door, tear off her headdress, fling her sandals up at the window. (And then swear at you for tutting).
The Pope would hurry outside, kiss his cross, light a fag, jump in his Pope Mobile, and do a doughnut in the street in his hurry to get away.

Tina is on a slowly repeating cycle, a sine wave of sickness and degradation. On the downward phase she self-neglects to the point of ill health, gets admitted to hospital (when she’s so far gone she can’t protest); the deep-clean team goes in to steam-blast the floor, replace the bed, buy in new sheets and towels and so on; Tina gets discharged back with a package of care, and the whole cycle starts again. Over the years, Tina has left many tearful health care professionals in her wake. She’s had umpteen multi-disciplinary meetings between the council, social services, neighbourhood representatives, psychiatrists and police, but no amount of special delivery letters, no amount of signed contracts or verbal consents, have done anything to change her situation or her character. She does have mental capacity. None of this has been found to be an expression of mental illness. It’s just plain cussedness, and no-one seems able to do anything about it.

I met her daughters once. They were the loveliest, most caring women you could imagine. But they’ve lived so long in the foothills of this dark and forbidding personality they can only protect themselves as best they can, apologise, try to make amends, and wait for the next rockfall.

However, I have to say, now and for the record: Malcolm can handle Tina.
And I’ve finally figured out how he does it.

Malcolm is a robot.

Here’s what I think happened.

I think a scientist – mad or otherwise – sat in on one of the multi-disciplinary meetings. I think this scientist patiently listened to everyone moaning on about the latest awfulness, and then when things fell quiet, calmly got up, went to the door, opened it, and invited Malcolm in.

Malcolm is perfect. He’s average height, medium build. He has a hairless, wipe-clean head. He has cool, evaluating eyes and realistic hands. He speaks with great modulation, in phrases designed to advance understanding and minimise flare. He moves with economy – but there’s power there, too, on a graduated scale from 1: puncturing the film on a microwave meal or 2: kicking through a wall. His demeanour is gyroscopically monitored, one hundred and eighty degrees of equanimity and poise. And his battery is good for eight hours.

You might think it’s a bit extravagant to use a robot such as Malcolm in this banal social situation. But maybe this is a field trial. Maybe this is part of the stress-testing you’d want to put such a unit through before you send them off to recolonise Mars or something.

The fact is, he’s amazing.

And the reason I think he’s a robot? Two things.

1: When the other carers see that they’re down to visit Tina they wail and plead and do everything they can short of throwing themselves out of the window to escape having to go. Malcolm just smiles.

2: Reading his notes afterwards. He writes coolly, neutrally, with great measure. You get a sense behind his words of the vile language Tina is using, the awful tenor of the situation, but nowhere does Malcolm rise to it. He describes himself moving through the scene, relaying the facts with a detachment that borders on nervelessness.

But the biggest giveaway?
He talks about himself in the third person.

For example: The Carer suggested that Tina roll to the left a little so he might change the inco sheet. Tina declined to do this, saying that she did not want to. The carer pointed out the negative effect lying on urine soaked sheets would have on the integrity of Tina’s skin. Still, Tina declined to cooperate. The carer asked Tina whether she would like something prepared for lunch. Tina declined, saying there was nothing in the fridge. The carer suggested he look in the fridge. Tina said that he could if he liked, it was a free country. The carer looked in the fridge and discovered a microwave meal – sausage hot pot and dumplings. The carer presented this to Tina. Tina said she was sick of sausage hot pot and dumplings and she would rather starve. She then went on to describe issues she was having with her mobile phone, a Sim card problem the Carer was not able to resolve at this time. Tina made comment about this in a generally abusive manner. Tina then requested the sausage hot pot and dumplings be heated anyway, which the Carer proceeded to do. The carer made tea, which Tina declined in favour of pineapple juice. Then Tina said the tea was not sweet enough, and she required apple juice not pineapple juice, and not in that beaker. Then she spilled the tea and had to be cleaned up. The Carer then presented the sausage hot pot and dumplings in a bowl. Tina used many swear words when the Carer placed the bowl beside the bed, saying that ‘it was no good there, was it’ even though she could easily reach the bowl. The Carer took action to remedy the situation, and with nothing further to be accomplished, left the scene, all being well at that time.

We need more Malcolms.

the battle of don’s deep

Donald sits low in the armchair, his left leg bouncing up and down like a jackhammer, his left arm in a sling, his right hand restlessly picking at the chair fabric. However neutrally or sympathetically I try to phrase my questions to gauge what he needs since his discharge home, it’s impossible to get a straight or reasonable answer. I’m not making  progress.

I have to say I’ve never met anyone quite so burned-up with fury – or anyone whose eyebrows angled up in the middle so perfectly. It’s like his nose is the prow of a bony ship, and the eyebrows are the arms of a cantilever bridge raising to let it through. His eyes are in sync, too; closing as the eyebrows go up, as if he’s reading his diatribes back of the eyelids, like an autocue.

At least Don’s environment is fine. Potted plants. Laminate flooring. An enormous flat screen TV. Donald muted it when we came in, but the show he was watching continues to play. I think it’s one of those how things are made programmes, this episode all about buttons. Pastel buttons, tartan buttons, spotty buttons, two-holes, four-holes…. The manufacturing process is complex and fascinating. About a million buttons pouring into some kind of steaming bath, then rolling out on a conveyor belt. What for? Do we need this many buttons in the world…?

‘…all you bureaucrats, trying to reduce everything to a simple yes or no, clicking your little keys, ticking your little boxes. Life doesn’t work like that. Pain certainly doesn’t. Pain doesn’t conform to your pissy rules. If I say yes I can do that, you’ll put down yes, and you’ll say he can totally do that – he’s fine, we can leave him alone. But the fact is sometimes I can and sometimes I can’t. It costs me enormous levels of pain and suffering just to get out of the chair. You don’t know what it’s like. I used to be a bodybuilder. I used to be fifteen stone, built like a brick shithouse. I’ve got a toleration for pain your brain could never conceive of, never conceive. I’ve got an IQ that’s in the top one percent. I know what you’re talking about, so don’t try to fool me. I know what’s behind your words. I can’t be bought off like the rest of them. And just because I refuse to be bullied into accepting things that aren’t right, I get stigmatised and put down as difficult…’

I’m so glad I’m doing this assessment with Agnes. She’s so experienced and battle-hardened, I couldn’t feel better about it if I was an elf on the ramparts of Helm’s Deep watching the orcs approach with ladders, and Gandalf was holding my hand.

‘I’m sorry to have to ask you these things,’ I say to Don. ‘I know it’s a bit one size fits all. But we need to get a rough idea what we can do to help. Like physiotherapy, for example. Do you think you might benefit from some?’
The eyebrows flick up; the eyes close.
‘Oh? Yeah? Physiotherapy? You try living with the pain I’ve got. You try doing their little exercises. Me just scratching my head is like you running a marathon. Physiotherapy! And what will they do? They’ll come and they’ll sit where you are and they’ll say Oh, Donald, if you don’t do anything you’ll get this and that. You’ll get muscle wastage, deconditioning, ligament contracture…. Bullshit! They don’t know what it’s like to suffer like this. They wouldn’t last five seconds.’
‘And where was your fracture again? It’s on the system somewhere, but if you could just tell me…’
Eyebrows up.
‘What’s the point? You wouldn’t understand. I’ve got a better understanding of anatomy and physiology than the surgeons. That’s why they didn’t like me. They couldn’t get rid of me quick enough. I knew their language. I knew what they were up to.’
‘Try me. Just – you know – the basics.’
He sighs, then winces, fiercely and dramatically, as if that simple exhalation of breath was the most exquisite form of torture. And then when he’s recovered from that, and re-found the energy and the deep spiritual reserves required to continue talking, the eyebrows go up again, and the eyelids come down.
‘I have a type two coracoid process fracture distal to the coracoclavicular ligament. Yeah? Know what that is? Thought not. Just put busted shoulder. What’s the point of talking about physiotherapy if you don’t even know what it is I’ve got?’
‘The thing is, Don – I know this is difficult for you…’
‘Oh! You know, do you? How do you know? Been through it yourself, have you?’
‘What I mean is – I can see how distressed you are and from that I can guess how difficult you’re finding it…’
‘This is the problem,’ he says, eyebrows up, lids down. ‘This is the problem, right there. Everyone thinks they know but everyone in fact doesn’t know. Everyone knows precisely jack shit….’

I’m struggling to make any headway at all with this assessment. And because Don’s speech is so overwhelming and so full of invective, and because his eyes are closed and I can get away with it, I can’t help glancing at the screen again. Another batch of buttons are going through some kind of electroplating bath, in plain, out golden. They look great. A bit showy, maybe. Still. Nice to have gold buttons….

Agnes takes over. The fact that she’s Scottish seems to help. There’s a broad warmth to her voice that deflects Don’s sniping more successfully, for a while at least. But after ten minutes or so of her best attempts, even she begins to waver. In fact, I’d go as far as to say she starts to sound a little snappy – but then her phone rings.
‘Sorry!’ she says. ‘Do you mind if I take this…?’
And she ups and leaves the room.
I couldn’t feel more abandoned than if Gandalf suddenly waved a bony finger in the air, produced a phone from his cloak, and stepped back from the ramparts just as the orcs came over the top.

I turn to face Don again.

His eyebrows go up.

the community witch

To begin with, I’d had an unsettling dream. Lola, our lurcher, was stuck in mud down in a ditch, and I’d struggled with a short hose to wash her out of there. She’d accepted my help with a boneless kind of resignation, lapping at the water more to please me than anything else. I’d woken up exhausted. Found myself downstairs having coffee and toast, driving into work, parking, tapping out the code for the security door, swiping my card and passing through into the frenetic office – the whole thing so toneless and heavy-eyed I wouldn’t have been surprised to find I was still in my pyjamas.

I sat down and started to plan the day, struggling against the feeling that I was out of place, faking it. To be fair, it was a feeling I’d had before, that I was an imposter, acting out a role, and it was surely only a matter of time before I was found out. I could see it all, the sudden fall of silence, the turning of faces in my direction, the manager standing over me with her arms folded, tough detectives just visible in her office, smiling, shaking their heads, cracking their knuckles.

A disconnected, dizzying kind of feeling. I forced myself out of it by focusing on the task at hand, probably in the same way you might dampen down vertigo on a cliff face by describing in detail the tiny wildflower growing close to your face.

All this is to say I had a muzzy headache when I sorted out my list of patients for the day and went outside.

It was the perfect day for a headache. Even the pigeons were off, either comatose on the ledges or pitching forwards, gliding a little, slamming into the ground. The sky was a hard, preternatural blue, with that artificial depth you only get in cheap, 3D pictures.

My first visit didn’t go well. I’d already established – or thought I had – that I’d be visiting early today to take blood before Mr Williams had taken his digoxin. When I rang to give him the heads up I was on my way, there was no reply. I tried the mobile. Same thing. I texted the mobile to say I was coming, and headed over. They had a keysafe, so access wasn’t an issue. At least, it shouldn’t have been. Outside the block there were only two keysafes. One was so crapped up it looked like it had been salvaged from the Titanic and stuck on the wall as a talking point. The other was obviously the one I needed – pristine, the label still bright. Which was fine, except the number didn’t work. I went round the back of the block, to the courtyard parking area. The early sun was angling in, falling on a pot of large, white lilies, which seemed like a sign, although of what, I couldn’t say. There was no access, so I returned to the front and used the tradesmen button, which seemed appropriate, anyway. It worked. Two floors up, I knocked on Mr Williams’ door. I knew he couldn’t get up to answer it, but he lived with his son Nathan, so that was okay. After a while I knocked again. I heard some shouting, and I guessed Mr Williams hadn’t told his son about the visit. Still – it was nine o’clock by now, so I didn’t feel too bad. I left it a good while before I knocked again, just in case Nathan was in the shower and needed time to dry off. All in all it was probably twenty minutes. At last, the sound of movement in the hallway, latches thrown, and the door was suddenly wrenched open.
‘What?’ said Nathan, round eyed, furious, peering round the edge of the door with one hand either side of his face like a malevolent Kilroy.
‘I’ve come to take some blood,’ I said. ‘I rang and sent a text.’
He stared at me for a long second, like he was running through the consequences of tearing me to pieces – (on the run; helicopters, hounds, handcuffs; the cells; the dock; the nick; stepping out into the broad bright world with a brown paper parcel under his arm twenty-five years later with a long beard and a crooked back…).
‘On you go, mate,’ he snarled, and released the door.

I was thinking about all this when I was sitting in a slow line of traffic on my way to the next patient. It added to the fugged stew of the day. What was I doing with my life? Was it a struggle simply because I was forcing myself to do something that wasn’t a good fit? What was a good fit? How was it possible that I had got to this age, having done so much, still struggling to orientate myself in the world?

The traffic loosened a little and we all nudged forwards. I sighed, pulled on the handbrake again, glanced in the rearview mirror at the car behind me. It was a battered old Micra, the red pinking out, a line of plastic animals along the dash. The driver was a middle-aged woman, her hair in a Little My bun so high on the top of her head it flattened against the roof. She was wearing white plastic sunglasses which made her look like an owl on acid. As soon as she noticed me she spread the fingers of either hand widely with the thumbs still hooked in the wheel, like she was flaring her wings. I smiled awkwardly and looked forward again – only to find the traffic had moved on. I fumbled the gears, stalled, started again, caught up.

But then – a strange thing. I thought: what if she wasn’t annoyed with me? What if she was actually a witch, dedicated to casual acts of magic wherever she went. What if the Micra was her familiar? That flare of her fingers – maybe that was the spell being released, sparkling through the air from her to me like that beam of sunlight on the pot of lilies?

I decided that’s what it was. And strangely enough, as soon as I did, the day got better. The next patient and his family were as warm and welcoming to me as if I were the son they never had. I sat between them, sunk deep on the ludicrously comfortable sofa, taking notes, making them laugh. And the patient after that, who I’d found hanging half-in and half-out of his bed, who I’d treated as best I could till the ambulance came – well, I could see he appreciated it, too. And when the ambulance did turn up I knew them, and it was like a reunion. And it was all warm and easy and right. And I finished late but I didn’t care.

And it was all down to that witch.


character lines

Ellie is a clinician with years of experience in hospitals, hospices and the community. Everything she does comes from a simple love of humanity, in all its mess and interest. And like all people skilled in their art, she practises it with a glorious kind of flow, intuitively adapting her stance to events, almost like a dance, making it look effortless and free. I’ve never seen her lose her temper. I’ve never seen her fail.

Which is why I’m glad we’re visiting Mr Coulsdon together.

There are so many exclamations, warning triangles and block caps on Mr Coulsdon’s record, it would be tidier if they simply replaced them all with a picture of a snarling beast and the words Here be dragons. Mr Coulsdon is notoriously, emphatically, tirelessly bad-tempered – a situation exacerbated by ill health, both mental and physical, of course, and his social situation. But it has to be said the starting point was maybe never that propitious.

Mr Coulsdon’s lounge window is just to the right of the entrance to the block. He has a tatty sheet permanently taped across it, bowed down in the middle. The TV is on full volume – Formula One, by the sound of it. We ring the bell a couple of times, but nothing happens.

‘He’s definitely at risk, so we’d better go in and see he’s okay,’ says Ellie. ‘A quick in and out. I’ll do the obs, you do the typing. How’s that?’
‘Fine by me.’
We let ourselves in using the ‘tradesmen’ button. His flat door is always open – taped up, dented, the scars of many forced entries in the past.

‘Hellooo? Mr Coulsdon? It’s Ellie and Jim – from the hospital. Come to see how you are…’

Other than a plain leather sofa in the far corner, the room is surprisingly, resonantly bare. No carpet, shelves or decorations, no pictures or home comforts. Mr Coulsdon is sitting in the middle of the room in an office chair, his bandaged, ulcerated right leg up on a stool. Just beyond it is the TV, cars screaming round a track. His foot is right in the middle of the screen, and you’d think Mr Coulsdon would angle things – the telly or the foot – so he could get a better view. But it’s hard to shake the idea that like a dodgy off-peak boiler, Mr Coulsdon will find a way of keeping the needle in the red.

‘Mind that!’ he snaps. I’m not sure what he means, because there’s really nothing to mind. ‘These people!’ he says, and links his fingers across his belly.

‘We won’t keep you long’ says Ellie, standing where he can see her, tilting her head on one side as if he’s the most fascinating thing she’s seen so far this morning. ‘How’re you feeling?’
‘How d’ya think I’m feeling?’ he says. Then he flicks me a sly glance and waggles his fingers in the air. ‘With my hands!’
‘Oh – that old chestnut’ says Ellie, putting her bag down. ‘Now then Mr Coulsdon. First things first. Can we turn the TV down a touch, please? Only I can’t hear myself think’
‘Who’s taken the bloody remote?’ he says, scratching his enormous beard as if he thinks it might feasibly be in there. He catches me watching him.
‘What’ve you done with it?’ he snaps.
‘Found it!’ says Ellie, picking it off the floor beside him and flourishing it in the air. The furious yowling of the racing cars eases up.
‘There! That’s better!’
‘For you!’ says Mr Coulsdon. ‘How long’s this nonsense going to take?’
‘Oh not long. Of course – you don’t have to have it at all if you don’t want.’
‘Well I don’t want it! All these people coming round here, messing me about. And nothing ever gets done!’
‘About what?’
‘What – the foot or your flat?’
‘The flat! The flat!’
‘What’s the matter with the flat?’
‘It’s a dump. A trash heap. I wouldn’t keep a dog here.’
‘It looks pretty tidy to me. Do you have people come round to help?’
‘If you can call them people.’
‘Well – look. That’s another matter. I can have a word with one of our social workers about it if you’d like?’
‘Social workers? Scum of the earth.’
‘I’m sorry you feel like that. I think they do a great job under difficult circumstances, Mr Coulsdon.’
‘Do you?’
‘Yes. Absolutely. But look – I’m not here for that. I’m here to do your obs and make sure your leg is okay. That’s it. I won’t if you don’t want me to, but I have to know you understand the consequences of saying no before we leave. Do you follow me?’
‘Jesus Christ! Just get on with it, will you? I haven’t got all day.’
‘All right, then. Thank you. Jim’s here to write the facts and figures down.’
‘Hi’ I say, perching on the edge of the sofa and opening the laptop.
‘I did wonder,’ he sniffs, his chair creaking dangerously as he shifts position. ‘I can see it wasn’t for his looks.’
‘No – you see? That’s what they call character lines,’ I tell him.
‘Oh is that right?’ says Mr Coulsdon. ‘I thought it just meant you were old.’

bonnets vs aliens

Like a country that declares war on its neighbours over a mountain ridge, Mrs Alderman has gone to war over her back.

It’s been the cause of a great many problems and pain for her over the years, and lots of clinicians of one sort or another have been involved. But there are some degenerative diseases that can’t be cured with medication or fixed with surgery, and the best you can do is try to ease the symptoms and find a way of organising your life in a more accommodating way. Unfortunately, Mrs Alderman’s response has been to declare war on everyone who has tried to help. Top of her list are the orthopods, who – according to Mrs Alderman – are a bunch of clowns with chainsaws. The orthopods are followed by everyone else who works in the hospital, Consultant to Cleaner, then the ambulance service, Community health teams, doctors, their reception staff, and really anyone who happens to be driving past, and then her neighbours, of course, and most of all, her family.

Her grandson Joey has been staying with her a few days since this latest discharge from hospital. His main contribution has been to restock the fridge freezer with ready meals. Much further than that he’s unwilling to go, and it’s hard to blame him, really. The flat is an absolute mess, and even if you brought in a team to straighten the place out, Mrs Alderman would have it back in its current state before they’d posed for photos and shut the door behind them.

This sprawling sense of chaos and complaint seems to attach itself to any contact with Mrs Alderman. I’d been sent in to conduct the initial assessment, which is essentially a fact-finding mission, to see how she is and what she needs from us. We’d had a frank conversation about emergency care support, what she could and couldn’t do for herself. She’d agreed that one care call in the morning might be helpful to get her washed and dressed; everything else – taking her medication, putting a ready meal in the microwave – she could do for herself. She could get out the chair by herself and take her four-wheeled walker out of the flat, down the corridor and back, so she was by no means immobile. And it was important to take regular exercise, however limited.

What happens next is that Mrs Alderman is on the phone that evening complaining that the carers hadn’t shown up, that the morning carer had done nothing but stand in front of a photograph of a dog she used to own called Rusty saying how nice ginger dogs were, for fack’s sake, and then pulled off her support stockings and took them down to the laundry room.

‘They’re in the dryer,’ she says.
‘Who put them in the dryer for you?’
‘How the fack would I know?’
‘Can’t Joey fetch them up?’
‘Why should he? He’s seventeen! And anyway, even if he did he can’t put them on for me, can he? And I can’t. Not with my back. I thought you were supposed to be facking helping…’

The carer isn’t around to ask about any of this. My suspicion is that Mrs Alderman removed her own stockings and took them to the laundry room herself, but the Coordinator is worried.

‘It might be easiest if you just go there tonight and sort her out,’ she says. ‘And try to clarify the situation whilst you’re there.’

* * *

There’s just one person in the laundry room, an ancient woman bent over a broken plastic trug, busy shovelling the contents into a machine. She looks up when I come in, supporting herself on one arm so precariously she looks in imminent danger of pitching head-first into the washing machine.
‘Hello,’ I say. ‘I’m Jim, from the community health team at the hospital. I’ve just come to pick up Mrs Alderman’s washing and take it up to her. I think she left it in the dryer.’
The woman straightens.
‘Oh! She’s got you running around now, has she?’
I smile and shrug.
‘That’s her lot, there,’ she says, nodding at another plastic trug, piled up with dressing gowns and throws and things and two blue support stockings artfully draped on top.
‘She puts too much in’ says the woman, tightening the scarf round her head, then leaning back in to her load.

* * *

When I knock and struggle through into Mrs Alderman’s flat, the TV is on full volume. She’s watching a film – marines fighting alien invaders or something. A helicopter gets blown to bits and there’s a close up of Aaron Eckhart looking worried.
‘Put it down there,’ shouts Mrs Alderman to me, as if we were under fire, too, pointing the remote at an undifferentiated heap of crap in the middle of the room.
‘Fack me, I don’t know,’ she says, muting the TV. ‘One minute it’s Sense and Sensibility, the next it’s facking aliens.’