`I'm afraid the doctor won't see you now'

I'VE BEEN an NHS GP for nearly 15 years, and my rough calculation is that I've seen more than 60,000 patients in that time. That's a lot of sore throats, discharges from one orifice or another, and personal crises. But there's always some new twist, as I discovered last Friday at the end of evening surgery.

The patient was an elderly Greek Cypriot man who looked like he had been sent straight from central casting to fill the part of someone who spent his afternoons drinking coffee out of small cups and fiddling with worry beads. He turned up at the reception desk without an appointment, saying only that he felt very unwell and that it was urgent.

He intuitively knew the first rule of access to a doctor in our health centre: "Say it is an emergency and make it clear with your body language that you are not leaving until you are seen." In my capacity as the practice's "duty doctor", I was just about to go out on an urgent visit. "Don't worry," the Greek man told me as I purposefully dashed through the waiting- room, "I'll wait for you." On my return he looked a lonely but contented figure. Lonely, because it was 6pm and everyone else had left. Contented, because I now had plenty of time to see him.

He came into my consulting-room and sat down, looking like he intended to stay for a good long while. Half an hour passed while I heard about the intricacies of his relationships with the Department of Social Security (which is still sending his pension to Cyprus even though he is now living in England), a steamship company (which still has possession of all his belongings somewhere between Cyprus and London), and a rapacious landlord ("you wouldn't keep an animal in that flat"). Several times I tried to interrupt, but he carried on with all the skill of an on-message Labour politician. It was late, and I tried to discover what had brought him to me.

He was getting short of breath at night, and the only thing that made it better was a fan that allowed him to get more air into his lungs. Unfortunately, however, his own fan was on the steamship somewhere between Cyprus and London. And he couldn't afford to buy a new one because he had no money. The reason he had no money was that he had paid an exorbitant amount to the landlord and the DSS hadn't yet sorted out his pension. It all fitted together with a logic that couldn't be faulted.

As it was now 6:40 pm, I did my best to determine if there was some medical cause - lung disease, heart failure - for his breathing problem. There didn't seem to be, so I racked my brain about what I could do to help him. Part of my job, after all, is to give patients the feeling that I am on their side. Out of the corner of my eye I spotted the small, electric fan that I use on hot afternoons when the sun beats into my west-facing consulting room.

"I can lend you my fan," I heard myself saying. "You can return it when your belongings arrive from Cyprus. I won't be needing it at this time of year." He rose from his chair, and departed, a walking stick in his right hand and an electric fan in his left. No prescription, no expensive tests, no detrimental effect on hospital waiting lists.

There are not many professionals in this world who are contracted to provide an open-access service 24 hours a day, 365 days a year, without any money changing hands. Every doctor uses a variety of techniques to make life more manageable. Some of the techniques have become accepted parts of medical practice -- joining up with other doctors to form duty rotas, providing advice by phone, using deputising services and doctors' co-ops at nights and weekends.

The latest flavour of the month is NHS Direct, the call centre run by nurses and computers that gives freephone advice to patients and protects doctors from being called unnecessarily. And there are also an increasing number of private solutions to the problem of getting to see a doctor where and when you want to. It is now possible, for example, to pop into a private surgery on Euston station on your way to or from work. For pounds 36 you can see a doctor, no appointment necessary, and come away with advice or a prescription. But, as one of my patients (who didn't want to wait until I had a free appointment) discovered to his cost, the prescription will not be a subsidised NHS prescription and he had to pay a whopping fee to Boot's for his course of antibiotics.

The great British doctor's receptionist, low-paid, hard-working, and a curious mixture of kindly and vicious, is probably the highest hurdle to jump if you want to see a GP. Receptionists are directly employed by GPs as their first line of defence. For commercial enterprises, receptionists are the public face of the organisation, which is always keen to attract more business. For NHS GPs, receptionists are like military early warning systems, making sure patients get what they need (but not necessarily what they want), protecting doctors from some of the more outrageous demands, and keeping an eye on the waiting room.

A second line of defence, the triage nurse, is now fairly commonplace in casualty departments and becoming more accepted into general practice. Triage is originally a military term which describes the distribution of war casualties into three groups: those who needed immediate attention in order to survive; those who could wait for medical treatment; and those that didn't have any chance of surviving.

The trouble with all these barriers to seeing a doctor is that they often weed out just the people who should be getting in. A classic example is the teenage girl who comes in on a Monday morning asking to see a doctor. The conversation goes something like this:

Receptionist (well-trained and friendly): "Good morning, how can I help you?"

Girl (shy and self-conscious): "I need to see a doctor."

Receptionist (consulting computer screen): "The first available appointment is on Thursday at 3.20."

Girl (ill at ease): No reply.

Receptionist: "Is it an emergency?"

Girl (slinking away): "No, I suppose not."

Receptionist (to next person in queue): "Good morning, how can I help you?"

The next time we see this patient she is 18 weeks pregnant. Whose fault is it that she didn't take the morning-after pill (which sadly requires a doctor's prescription)?

Even when everything works according to plan, and the right patients get to see the right doctors at the most convenient times, doctors are still faced with the problem of how to prevent a consultation going on for too long. The NHS average is about seven minutes per patient.

The old technique of handing over a prescription, as if to say "Here is your party bag, it's time to leave," is effective, but not always clinically appropriate. Moving towards the door is another way of saying goodbye, but can be interpreted as uncaring and even insulting.

As a last resort, I have occasionally had to play the trump card of saying goodbye to the patient by leaving the room myself, with the patient still seated by my desk. This has never failed to work, but I occasionally find myself loitering at the back of reception, peeping out to see if the patient has emerged from the inner sanctum of the surgery.