please welcome on stage

Thomas is alert but strangely neutral, propped up on the ambulance trolley, his white hair wild on the pillow, his mouth slack. He’s put on so much weight it’s taken a team of four to wheel him off the ambulance, up the drive, through the portico and into the house. Jenny the OT and I have arrived just in time to help, although there’s not much for us to do other than carry in all the bags of personal possessions, drugs and so on. The patient transport crew are a loud and pleasant bunch, eyes smiling over their masks, plenty of to you / to me banter as they patslide Thomas into bed, make things good, get ready to go. One of them nods for me to follow her back out to the truck, though.

‘I don’t know what help you can give them,’ she says. ‘But I gotta tell ya – I’m worried about the daughter. She’s a donkey on the edge. See what you think. Personally – I don’t know – I wouldn’t put money on it.’

The story is that Thomas went into hospital after a fall, stayed a month, then got transferred to a nursing home for a few weeks’ rehabilitation. Meanwhile, the hospital OTs visited the house, put in a hospital bed, stand aid, commode and so on, and then referred him to us for more therapy and nursing support, along with bridging care until a full time agency can take over. All in all it’s about as much as anyone can do short of adoption, or residential care, of course. But we’ve been tasked to visit for the initial assessment, to see how it all looks, and if the plan is workable.

The house is like a spacious, somewhat incongruous pink Spanish villa, set back on a rise at the head of the close. Thomas’ hospital bed has been set up in the L of the vast, low-ceilinged living area, with bare stone walls, a heavily-timbered fireplace, brasses hanging here and there, a hunting horn, a few framed portraits. Even though it’s hot and bright outside, the late summer morning doesn’t penetrate overmuch; what light there is only makes it so far through the patio glass at the far end, lying like a glossy green sweat on the backs of the clubby sofas and chairs.

In fact, the scale of the place is a little overwhelming. It’s the details that make you dizzy. On the wall behind the head-end of Thomas’ bed is a giant oil-painting of a horse’s head; at the foot of the bed, on a granite pedestal, a fish tank filled with tiny silver fish.

Thomas’ daughter, Helen brings in a giant mug, filled almost to the brim with tea.
‘Don’t spill it!’ she says to him, putting it on the overbed table.
He glances down, shakily jerks his hands, the tea slops.
‘Look what you’re doing!’ she says.
I take the cup from him, move the table to one side, hand the cup back to Helen.
‘He really needs one of those spill-free mugs – you know – the ones with the spout.’
‘What – like kids use? For kids?’
I nod.
‘That’s it!’
‘Have you got any?’
‘We don’t carry them. But you can get them anywhere. The supermarket, pharmacy…’
‘A beaker for kids? You mean Tommy Tippee?’
‘A lot of people use them.’
She looks horrified, takes the tea back into the kitchen.

Whilst Jenny starts doing the paperwork and an audit of the equipment we’ll need to check, I run some basic obs. It’s immediately obvious things aren’t right.
‘I think this is looking like a failed discharge,’ I say, looping the steth back over my neck.

Alice and Frank, two of our most experienced carers, turn up for the lunchtime call. It’s good to see them – they’re so cheerful and grounded, it immediately makes any situation a hundred times better. Between us we set about sorting Thomas out, log-rolling him, tearing off his pads, cleaning him up, putting on fresh pads, changing the sheets, sitting him up again. Thomas coughs throughout. Frank raises his eyebrows at me.
‘Tested for Covid?’
‘A month ago.’
‘Oh-kay…’

Helen appears in the doorway. She stands watching us, her arms folded, staring at the pile of sheets on the floor.
‘What’s that?’ she says. ‘Why’s that there?’

Jenny goes over to her to explain the situation whilst we finish up.
‘They’ve just had to clean your dad up and make him comfortable. Have you got a washing machine?’
‘What do you mean? I’m not doing any washing.’
‘It’s not too bad, Helen. It just needs tossing in the machine with a tab of something.’
‘Well you can do that because I’m not. Isn’t that what you’re supposed to do?’
‘No, I’m afraid not. We’re effectively an emergency service. The carers will be coming in four times a day for bed washes, pad changes, and then simple meal prep and medication if that’s needed, too. But everything else – things like washing, cleaning, shopping – well, they’re all classed as domestic chores. You’ll need to find someone to cover that if you can’t.’
‘Well I’m certainly not doing it,’ she says. ‘Why should I? I’m not touching anything soiled.’
‘You can put gloves on.’
‘Gloves? Gloves? I’m not putting gloves on. Look – you do what you have to do, but I can’t … I just can’t… I’ll go and stay at a friend’s if that’s what you think’s going to happen.’
Jenny looks over to me.
‘It might all be a little academic…’ I say, feeling Thomas’ pulse again. He sits propped up on the pillows, the focus of everyone’s attention, his mouth bouncing up and down, mute as a ventriloquist’s dummy who still has a whole bunch of things to say – important things, mad things, funny things – but the hand some time ago let go of the lever, and left him on stage to carry the show alone.

the wave

On the side of the kitchen cupboard that faces the door there are a series of lines, marking the changing heights of all the kids that lived there. It’s a steady progression, up and up and up, levelling off I’d guess in the teenage years, except for one line way above the others – a good few feet, almost at the ceiling.
‘Jesse did that’ says Ange, laughing. ‘He stood on a chair. Although – to be fair – he probably didn’t need to.’
Bill, the father to all these kids, is sitting impressively at the kitchen table, quite possibly the very chair Jesse used. He’s still and watchful, with a head of hair and beard so full and pure and white it’s like watching snow clouds gather on a craggy peak.
‘I don’t like all this,’ he says.
‘I know, pops,’ says Ange, giving him a squeeze that he tolerates stiffly. ‘I know. But it’s like we said. Remember? Things have got to change. You’re not as young as you used to be.’
She looks at me and smiles. ‘Let’s face it. None of us are.’

It’s an eerie feeling, sitting in that kitchen. At one time it must have been the centre of the house, the first and main room commanding the hallway, which itself leads off into a honeycomb of other rooms. Spilling down into the hallway is a bare, broad staircase whose handrail and boards are smoothed from decades of hands and footsteps. Everything is shadowy, now. Haunted – and quiet, too, with that deep and settled kind of quiet that makes your ears ring.

There’s a knock on the front door. Ange gets up to show in a couple of guys from the equipment department who’ve been tasked to fit a handrail up the stairs on the other side. They get straight to it, and soon the old house rattles with an intensity of drilling and shouted instruction.

Bill winces, directs his attention out into the garden, so wild it’s like the whole world is green and spilling over everything, advancing in a wave. He buries his focus somewhere out there.
Ange gives him another squeeze.
‘Mum would’ve said the same,’ she says.
He doesn’t reply.

display purposes only

Henry doesn’t come to the door so much as slowly coalesce from the shadows beyond the glass.

Henry is frail but not physically unwell. I know his story pretty well by now. He’d been living in Portugal for many years until things started to go wrong, his marriage ended, he was hit by severe financial problems, lived a while in his car, was sectioned following a suicide attempt. After a great deal of toing and froing, his daughter Diane managed to repatriate him, temporarily setting him up in a basement flat whilst she sorted out something more suitable and long-term. I’d spoken to Diane many times on the phone. She was bright and busy and supremely well-organised, but I knew she was struggling to cope with work and family as well as the traumatic fall-out of her parents’ separation. Diane knew as well as anyone that the basement flat wasn’t great. It had a set-aside feel, silent and secluded – not at all the kind of place you’d choose for someone suffering depression and anxiety. But even though it suffered from having the generic, impersonal feel of showroom flats the world over – blown-up photos of Times Square and a colourised London bus driving over Westminster Bridge in the rain; enormous, squashy leather sofas impossible to get out of once you’d sat in them; glass vases with white pebbles and a single, artificial lily; a flat screen TV; venetian blinds – at least it was warm and safe, and near enough to where she lived to make keeping a regular eye on her father vaguely feasible.

The good news is that Diane had managed to find a better, brighter place. Henry is due to move the following morning; my visit here this evening is to be the last in this place, a welfare check, to see he’s okay.

‘Hello,’ says Henry.
We’ve met a few times before, but he makes no sign he recognises me. He’s as still as a photograph, completely neutral, like it really makes no difference to him whether he shakes my hand here in the doorway or stands inside staring up through the casement window at the feet of the people walking by.

He lets me in. We relocate to the living room. Henry drifts over to the kitchen counter, next to a tall suitcase on wheels, all zippered up and ready to go. I have the eerie feeling that If I was an alien probe sent into the room to scan for life, I’d struggle to differentiate between them.

‘Have you eaten anything this evening?’ I ask, glancing around for clues.
He shakes his head.
‘Aren’t you hungry?’
‘No.’
‘Do you mind if I have a look and see if there’s something I can get you?’
He shrugs.
I go into the galley kitchen area, so pristine you can smell the caulking gun.
The fridge has nothing in it. I open the overhead cupboards, and I can’t help thinking of the old nursery rhyme: …but when she got there, the cupboard was bare, and so the poor dog had none.
The only food I can see anywhere are five Kilner jars of pasta lined up on a shelf, each one holding different shapes and colours.
‘I could do you some pasta…’ I say, wondering what on earth I’d use for a sauce.
He shakes his head again.
‘Display purposes only,’ he says.

smoko

There’s a small enclosed porch at the front of the house, and that’s where Karen goes to smoke, a bit like an air-lock in reverse. The porch only has three things in it (not including Karen): an ashtray, a pack of cigarettes and an enormous plastic pipette. Quite what that’s for I don’t know, but I don’t hang around to ask.

‘Dad’s in the kitchen having his porridge,’ says Karen, taking another deep drag and nodding behind her as she blows out.

Her father Keith is sitting at the kitchen table. A tall, lean man in his seventies, he struggles to his feet to shake my hand and thank me for coming. He’s had a long spell in hospital, discharged home with a summary of his complex health problems and a request to sort out equipment and therapy. His handshake is warm and firm, and despite his illness he still has an air of quiet competency about him.

‘Sorry about Karen’ he says. ‘She’s adopted the porch as her smoko and we can’t persuade her to stop. She’s got learning difficulties,’ he adds. ‘She’s a good girl.’

I set up shop at the table and we go over how things are and what Keith might need.

‘You wouldn’t think to look at me now but I used to be so fit,’ he says. ‘I played football, tennis. Swam in the sea. Built this house, worked full time. There weren’t enough hours in the day. And if you’d have said to me after all that I’d have ended up like this I’d never have believed you.’ He works the porridge around in his bowl a while then adds: ‘Never smoked. Not a one. Mind you – I think Karen’s taking care of that side of things all by herself.’
And as if summoned by her father, Karen strides into the kitchen, bringing with her a palpable cloak of smoke.

‘All right?’ she says.

and so to bed

Community Health encompasses so much, from the acute to the chronic, the social to the medical, from the replacement of a single worn ferrule on a walking stick to the installation of a gantry hoist and a small army of carers; from a three day course of antibiotics to months of gruelling IV therapy. Work in it long enough and you’ll see countless variations, each situation particular to the individual patient and their family.

But if I was forced to nominate the one thing that caused the most problems out in the Community, I would say it was a Resistance to Change.

It’s been said before that the only constant in the world – the one thing you can be absolutely sure of – is that things change. And ultimately it’s not the specifics that matter so much as the way you embrace them. Hanging on to things that cannot possibly last, however much you’d like them to, inevitably leads to friction and unhappiness. A hard lesson to learn, of course, and one that needs constant practice and reinforcement, but no less important for all that.

Take Janice and Henry, for example.

Henry is a hundred. A simple expression of fact – impressive enough in itself, were it not for the fact that every night he goes up three flights of stairs to bed.

Janice goes up behind him, of course. Janice is Henry’s daughter. They’ve been living together a good many years, now, and they’ve got their routines. Latterly Janice has taken over the role of principal carer, a guy coming in every morning to help with washing and dressing. Janice is doing a great job in difficult circumstances, changing Henry’s pads, keeping him fed and entertained. They have a lovely relationship.

We’d been called in by paramedics, who attended a non-injury fall here the other day. Apparently Henry slipped out of his leather armchair downstairs, and Janice couldn’t get him up.
‘The footstool slid forward and he sort of jacknifed’ says Janice. ‘It was too early in the morning to do what I normally do, so I had to call 999.’
‘What do you normally do?’
‘I go out in the street and ask someone if they’d be so good as to come in and help.’
‘Isn’t that a bit risky?’
‘Oh no! People are good, you know. And I only ever ask the burly ones.’
‘Has Henry fallen a lot, then?’
‘Half a dozen times. Not falls so much as a gentle collapse. This one was different because he was in a funny position. Generally it happens on the stairs.’
‘The stairs?’
‘About half way. Occasionally his legs just give out. So he’ll sit on a step a while. And if he can’t get back up again, I’ll nip outside and fetch someone in.’

Janice has already given me a tour of the place. One of those rickety old town houses, compressed by its neighbours into a vertiginous, three-storey affair, two rooms per floor, Henry’s bedroom at the very top, the stairs leading up and up and up so relentlessly you don’t need a handrail so much as crampons and a bottle of oxygen.
‘I’m puffed and I’m half his age’ I said to her.
‘You shouldn’t be,’ she said.
We’d skated over the possibility of changing things around a bit. Maybe moving the bed downstairs. Janice was indignant.
‘Where would I sleep?’ she said.
‘I don’t know. Upstairs?’
‘Out of the question!’
‘He’d be safer.’
‘Yes – but… where on earth would I put everything?’

a loss of balance

‘My psychiatrist is worried what effect all this is having on me,’ says Angela. For a moment I think she’s going to illustrate by pointing to her brain, but uses her finger to push her glasses back up her nose instead. She makes as if to fold her arms, then changes her mind at the last minute, puts them in her lap – and then changes her mind again, and folds them after all, leaning forwards with her shoulders hunched, rocking imperceptibly.

I’ve only been in the same room with Angela five minutes and I have to say, I’m as worried as the psychiatrist. Angela’s face is so intensely anxious, it’s as if someone had taken a cup, drawn round it with a crayon to get the circle, roughed in two permanently arched eyebrows, a pair of thick glasses, a flared nose, a downward pointing mouth, and then below it, as an afterthought, adding an incised groove like a second mouth, to amplify the sadness of the first.

‘You’ve got a lot on your plate,’ I say. ‘Anyone would be anxious.’
‘I am anxious,’ she says. ‘I’m very anxious.’
‘It’s understandable.’

Staring at us from the armchair opposite is the source of Angela’s anxiety: her father, William – an imposing figure, despite his extreme age. William is fastidiously dressed in a buttoned-up shirt and tie, bottle green cardigan, corduroy trousers with a sharp crease down the centre of each leg, his velcro-shoes box-fresh, correctly fastened. He’s so tall and gaunt, with so many edges and angles to him, you’d hardly think he was real at all. I imagine when he gets up at the end of the evening, he simply unfolds, flap by flap, like a complicated origami figure, cushion fold, chair fold, reverse-squash fold – and shuffles away to sleep in an envelope.

He must have some mass, though. He fell on the patio a week ago, taking his wife Rose with him, landing on her and fracturing her hip. Rose ended up in hospital, of course, with the prospect of a long convalescence. The only other sibling, Angela’s brother Tommy, works away from home a great deal and can’t spare the time. And as Angela is off on long-term sickness due to her anxiety, they decided – or at least, I would think, Tommy decided – that Angela should be the one who stays with William until Rose makes it home again.

‘I just can’t keep an eye on him every single hour of every single day,’ says Angela, hopelessly.
‘Hmm,’ I say. ‘What do you think, William?’
William slowly unlaces his fingers and then holds his hands apart in a sad, what-will-be-will-be kind of way.
‘It’s difficult,’ he says. ‘I don’t want to worry anyone. But it is unfortunately the case that – for whatever reason – I have something of an issue with balance.’

I turn to Angela again, who’s staring at me with such terror it’s like we’ve been dragged to the edge of a precipice.

‘You see?’ she says.

rachel’s song in waltz time (with hens)

daddy was a / publican who / drank more than he / sold
wrestled with the / licence board who / finally took / hold
mummy did the / best she could but / struggled with the / pain
many were the / arguments and / nothing ever / changed

now you’re gone / it’s just my mum / she’s living on a / farm
with free-range hens / that scratch around / the yard and house / and barn
they follow you / or perch on drums / or watch you from / the shade
it’s wonderful, how / hens can be / so perfectly / behaved

here’s a picture / that I took, when / I was last at / home
a single egg / a socket set / the white against / the chrome
I don’t know why / it means so much / maybe I’m just / blue
Looking back at / everything, the / thoughtless things we / do

daddy was a / publican who / drank more than he / sold
wrestled with the / licence board who / finally took / hold
mummy did the / best she could but / struggled with the / pain
many were the / arguments and / nothing ever / changed

a change to the routine

Ralph has two explosive tufts of silvery white hair springing out either side of his head. That, along with his downcast mouth and rapt expression make him look like a giant marmoset monkey – one that’s been in the wars a little lately, with a plaster cast on one arm and a dressing across the bridge of his nose.
‘I don’t remember nothing about it’ he says. ‘Mind you, I probably wouldn’t, would I?’
Ralph’s routine has been the same for the last twenty years: up at six, cup of tea and a slice of toast, off to the newsagent for the paper, back for another cup of tea and a study of the racing meets that day, off to the bookies for an hour or two, back for a nap and a bite to eat. The only variation yesterday was the bus that knocked him over.
‘It weren’t nothing to get excited about,’ says Ralph. ‘Just a glancing blow, like. So they tell me.’
It was enough for an overnight stay in hospital for observations, though, and a referral to us, post-discharge.
‘I’m fine. Honest. I can still get about. What time is it?’
‘Half-past five.’
‘Is it? Blimey! Where’d the day go?’
His daughter Janet is there, too. You can tell she’s his daughter. Not the hair, obviously, but the frank and warmly open way she looks at the whole situation. Despite her broad good humour and the obvious affection that exists between them, I can see it’s been a stressful few years.
‘I was at work,’ she says. ‘I knew nothing about it till I got a call from the hospital. Lucky he had his bookie’s loyalty card on him so they could do a bit of detective work. They scanned his head and everything, so it was just his arm and a few nicks and bumps. I think the bus come off worse, didn’t it, father?’
‘Hey?’ he says.
‘I said I think the bus come off worse.’
‘What bus?’ he says.

the gambler & the ranger

‘I’m so sorry about Radar’ says Gill. ‘He barks at everything.’
‘I don’t mind. Our last dog Buzz was a bit like that. Anyone came to the door, it was rah rah rah. We tried everything. We even invited the postman in once, so they could be properly introduced. And that was fine and everything. Smiles all round. But as soon as we shut the door and the postman knocked again, Buzz started. He used to rip the letters up, too.’
‘Who? The postman?’
‘Buzz. I wouldn’t blame him if he did, though. It must have been annoying.’
‘Ahh – they’re used to it.’
‘We did get worried about his fingers, so we put the letterbox on the outside.’
‘Funnily enough, postmen are the one thing Radar doesn’t bark at.’
‘I wonder why?’
‘No idea. There’s no telling with dogs. Certainly not this one.’

You’d expect a dog called Radar to be particularly alert. Something wired and small and spiky, with luminescent, revolving eyes (although I’d no doubt scream if I saw a dog like that). This Radar must have been named after the prototype version, made of Bakelite and valves, more like a radiogram.

He sniffs my trousers to see whether more barking was needed, and then waddles back to his rug in front of the fire, falling so loudly, if you shut your eyes at the moment of contact you’d think someone was dropping off a sack of potatoes.
Radar licks his chops, and stares back at me with a look of heavy jowled disapproval.

‘Dad’s through here,’ says Gill. ‘He’s just having a nap.’

Edward has been set-up with an extemporary bedroom in the lean-to out back. It’s perfectly warm and comfortable, though, just a short hobble with the zimmer to the ensuite, plenty of room for his equipment, misty views over the valley. He’s lying on his left side with his legs crooked up and his hands up by his face – such a foetal position you can almost see the umbilical cord, ninety years long, snaking back out to him.
‘Seems a shame to wake him’ I say, gently putting my bag down.
‘He won’t mind,’ says Gill, touching his shoulder. ‘Dad? Dad! Someone to see you.’
It’s surprising how quickly he comes to.
‘Righto!’ he says, blinking hard a couple of times and then pushing himself into a sitting position.
‘I’ve just got a couple of things I have to do,’ says Gill. ‘Are you alright for a minute…?’
She hurries away into the kitchen, and I introduce myself.

‘I was in the middle of such a strange dream,’ says Edward as I unpack my things.
‘Oh? What was it?’
‘You don’t want to know!’
‘Try me! I like dreams.’
He presses the heels of his palms into his eyes, and sits quietly on the bed a moment longer, gathering himself.
‘It’s a western,’ he says at last. ‘There’s this man, you see – a gambler, in a big, black hat. And he’s trying to take over the town. Well the mayor doesn’t want him to. So he takes him outside, throws the gambler’s hat on the ground and puts a gun to his head. But what the mayor doesn’t know is – there’s this ranger, watching it all, from the hills. And he’s got this rifle, with a bloody great telescopic sight. And he starts shooting, all around them. Pe-ow! Pe-ow! Pe-ow! So the mayor, he jumps on his horse and he rides off. And then the ranger he comes over, and he shakes hands with the gambler. And the gambler says to him: Thank you very much. And the ranger says: You’re welcome. And the gambler says: I don’t think the mayor’s going to be very happy. And the ranger says: Tough. I’m a ranger. I can do what I like.
‘That’s brilliant! You could sell it to Hollywood!’
‘D’you think?’ sighs Edward, licking the palms of his hands and smoothing his hair flat. ‘I don’t know. I don’t think they shoot westerns anymore.’