There are tissues on my desk.
They are probably the most essential part of my room and sometimes they are all I have to offer patients, along with a willingness to listen. I never considered there would be days when I use them more than my stethoscope but there are and they're becoming more frequent.
It is 8.40am. I am sat in my room with a patient with a serious mental illness. I know them well. I have seen them at their best and their worst. Today is one of the worst. Today they want to die. They look pale, exhausted, can barely speak, sit staring blankly into the air. They cannot even cry.
I have nothing to offer this patient, apart from empathy and my pathetic tissues. They need specialist care from the mental health services.
It should be simple - the local services have been streamlined. Redesigned and rearranged. Tailored to the demands of the modern NHS. Ready for action. The clue is in the name - The Crisis Team. I ring them.
They are engaged. I try again, two, three, four times, while my patient sits silently in the corner. Try again, still engaged. I know from bitter experience this may take some time. The team are permanently busy, understaffed and overrun. Trying their best with less funding and more demand. I am now 45 minutes behind with a full waiting room. Filled with trepidation, I have to let my patient leave with a relative. I promise fervently I will ring them as soon as I know more. I promise I will get them help.
I see other patients. To their eternal credit, not a single one complains that I am running late.
Finally, I get through:
"Hello, I have a patient that needs assessing urgently. History of severe mental health problems, under Consultant care, recently admitted. They are relapsing and suicidal. I am very concerned."
"I'm sorry Doctor, this patient is already known to Mental Health Services. Our criteria say we can only see new patients now; I'm really, really sorry, you'll have to go through Central referrals. Let me give you their number."
I ring Central referrals: "This patient was admitted recently weren't they? I'm really sorry Doctor, you need to contact the hospital. They are still officially under their care. We can only see them once they are fully discharged to the community".
I see other patients.
I ring the hospital: "No Doctor, I'm sorry, they have definitely been discharged. They were under Dr X's care and discharged to his team. Shall I give you his secretary's number?"
Previous encounters have taught me that if I am at this point in the dance of referrals, it's often easier to bypass the official system and speak directly to another clinician. I chide myself for wasting all this time. I should have rung him first.
I ring his secretary: "I'm very sorry Doctor, I'm afraid he's in a meeting all morning and he begins a ward round straight after. I could try and get a message to him for you if that would help? Would you like the contact details for the community team?" "Yes," I reply, "I would."
I see other patients.
I ring the Community Psychiatric Nurses: "This patient is allocated to my colleague. She's out doing her visits, but I'll get her to ring you as soon as she's back."
Please, I implore, tell her it's urgent. I am very, very concerned about this patient. They've been waiting all morning.
I see other patients.
An hour later, I finally get through to the right person. She is polite, keen to help, like the other five people I have spoken to. The team will visit as soon as they can. I ring the patient, whose family is effusive in their thanks to me. I feel a fraud.
How can this be right? How has it taken me over five hours to get through to someone who can help? I know it could easily be another five before the team are free to see them.
When I ring the patient's house the next day, I hear they were seen late that night. They have a crisis package in place short term, with daily input and a medication change. They have been referred for Psychological therapy. The current waiting list is a year.
This is the reality of a lack of funding for mental health. The over-burdened services, pared down to the bone. There are no beds left, there is little access to counselling, psychotherapy, cognitive behavioural therapy. The constant anxiety and anguish for the patient, the days off work, the long term sickness, the sleepless nights, the repeated presentations to the NHS. There are no savings here.
So the next time I see them, all I have to offer is a listening ear. That, and a tissue.