The 4am Question

The 4am Question

This Christmas I spent until 1am on Christmas morning putting up a trampoline in the garden. I had started the process that morning, but ran out of time as we were out all afternoon and evening. Getting home at around 11pm meant working by torchlight to finish the job.


As I came back inside, I could hear running water. Stepping into the kitchen the noise increased, and I was confronted by water pouring through the ceiling via a light fitting.


Our boiler had burst. At 1am on Christmas morning.


As you can imagine there was a short period of panic until we managed to turn the water off and drain the system. Our children slept on, despite the boiler being in a cupboard in our 9-year-old’s room, but my wife and I were up until about 2am.


We were lucky though. We were at home and awake when it happened. We realised what it was, acted quickly and with the exception of the boiler itself (which I suspect needs replacing) there was no significant damage. Together, we worked out what to do, and made the house safe quickly.


I recently heard it said that just one simple question reveals all you need to know about how vulnerable someone is:


“If something went wrong at 4am, is there anyone you could call?”


Think about that for a moment – who could you call? I know I have friends and relations who I could call. I would hesitate to wake them, but I know they would want me to if I really needed them. In fact, I see it happening on social media – I see friends posting problems they have faced and people replying “you should have called me”. When I posted that our boiler had burst onto FaceBook I had several offers of meals and showers and even accommodation for my whole family. I am truly grateful and it was very humbling.


If you have that kind of network, it makes you more resilient. You are less likely to have a crisis, and when you do, you can get through it. You are less likely to need to call upon emergency services, who are there to help when needed but who will inevitably not know you or your family, who will be more likely to escalate if they can’t sort things out, and from this you are more likely to end up in hospital or some other place of safety.


We need to identify the people who respond with a “No” to the question above. We need to know who they are and what additional services they need to help them. To do this we need to work across multiple agencies. We potentially need information from GPs, hospitals, social services, police and more. Some will be known to third sector or faith organisations. Some will be known to none. And once identified, we need to work together to help.


This is the core work of Integrated Community Teams, of Primary Care Home and of Accountable Care. It is about identification and holistic multi-agency working and support. It is about putting the individual at the centre and doing all that we can to minimize the risks and plan for the unexpected. It is not enough for the doctor to decide that the health care needs are met and leave the rest to the social worker. We have to accept that people do not differentiate between health and social care needs, they just know that they have a problem. Life is too messy for us to separate things out like that. We need to integrate and look at all problems together.


I suspect that health and social care systems up and down the country are looking at doing just this. It is not easy. It requires the breaking down of barriers between organisations and the moving of resource around the system. To achieve it we need to move out of our organisational silos and work together.


I believe it is achievable though. We just need to work at it.


We didn’t need to call anyone when our boiler burst in the middle of the night of the one bank holiday of the year where pretty much everything closes down. There are people I know I could have called though.


And if you ever need me in the middle of the night, and have my number – please just call.



Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group


Follow Dr Jonathan on Twitter @DrJonGriffiths


A Christmas Story

A Christmas Story

Do you know the Nativity story? How confident are you that you could retell it? Maybe you could, maybe you couldn’t. Either way, I wonder what kind of a story you are imagining. Do you have the ‘Gentle Jesus Meek and Mild’ story in your head with a nice clean stable, a white-skinned Jesus, jovial shepherds enjoying the starry skies and three bearded wise men on well-behaved camels? We like to remember the story like this don’t we? It is comforting and non-threatening, it does not offend white middle-England and you can accept the story without having to properly engage with it.


This is not the story that I have in my head.


Let’s think about it a bit more. We have a Jewish, unmarried (at the time of conception at least) pregnant teenager homeless in Bethlehem about to give birth. We have the birth taking place in a place where the animals were kept (stable or cave, who knows) – I doubt it was clean, I doubt it was pleasant, I suspect it was frightening, chaotic and messy. We have shepherds coming in from the hills (I understand shepherds were not the most trustworthy of people in those times) and ‘wise men’ traveling from afar – essentially foreigners appearing from nowhere with extremely bizarre gifts. Following all of this we have infanticide from King Herod and a flee to Egypt.


This is about as far removed from modern maternity care as you can imagine.


If you go to Church over the Christmas period you will hear the story told in a variety of ways, possibly even as I have just summarised it. You will probably hear the key message of the belief that this was God incarnate. That this is God come to us in the mess and in the chaos. To the outcast and the misunderstood, to all people regardless of any protected characteristic.


I want to move this from a sermon into a blog about healthcare. I want to talk about General Practice and community care. I want to point out that this is also where we work with our patients – in the chaos and the mess, in their homes (if they have them) and in their communities. That we see people regardless of who they are.


This is the beating heart of the NHS. When I talk to GPs about what they value most about the job they talk passionately about working with individuals over periods of time, about understanding them and their families and communities, about relationships, and about being there for them. Over 2 years ago I blogged about my ‘frontline work’ and it’s worth reading the first few paragraphs of that blog again now. This is what we do.


And it is hard work. Hard, but incredibly valuable. Right now this work is being threatened. The financial challenges of the NHS are hitting GPs. As demand increases on hospital services, Payment By Results Tariffs result in money moving into hospitals, and as there is only single pot of money there is correspondingly less for community, general practice and mental health services.


2017 is going to bring huge challenges for commissioners and the health care systems they are responsible for. I would challenge us all to consider how we get the balance right between resourcing the various parts of those systems. We need community based care just as much as hospital based care, although it frequently seems as though the system set up to commission favours the hospital elements.


When you are thinking about the Christmas Story this year, I would encourage you to really think about it and what the story is saying. Not the sanitised, anglicised version, but the messy, challenging version. And when you do, then think about all those who are also choosing to work to help others through their chaos and mess, and let’s all look to ensure that these services are considered as we commission in 2017.


I’d like to wish you all a very Merry Christmas. I wonder if there are many clergy who will start their Christmas sermons talking about healthcare before moving onto discussing a warts and all nativity? Let me know if you hear one that does!




Dr Jonathan is a GP at Swanlow Practice in Winsford and Chair of NHS Vale Royal Clinical Commissioning Group


Follow Jonathan on Twitter @DrJonGriffiths


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