Gertrude comes in, fresh-faced and smiling.
‘Dr Hamlet, I need some advice.’
‘Take a pew then,’ I say as though I am her vicar and this might be a confession.
This is meant to be tutorial time and here I was doing discretionary stuff — checking test results, trying to work out what is wrong with the sick. I’m disappointed at the interruption but not wanting to show it. My eyes glance up in brief welcome then return to linger on the screen. She sits with a cheery sigh.
‘Nurse is ill, I’ve been asked to give a contraceptive depot injection in a while,’ she reveals, ‘but I’ve never given one before.’
‘Oh!’ I was expecting something more difficult. ‘You’ve never injected a bottom at all?’
‘No, never.’
She’s just recently started the training programme and nurses only ever give those in hospital: it was the answer I expected. In all my career it has never been different. I finally give up what I was doing and turn to face her. Mrs Ophelia and her errant results will have to wait: everybody dies in the end but knowing why helps make it easier to take. Indeed, whatever the problem, it seems what lies behind always matters most.
‘Well, how about we give the injection together?’ I offer Gertrude comfortingly. She’s still smiling, full of goodwill and enthusiasm. ‘That would be great! Yes, thank you!’
I nod in acknowledgement of all that I have already achieved here. ‘Was there anything else?’
She leans forward. ‘Yes, I was hoping you might help me understand the National Audit Office report on the rollout of the COVID-19 vaccination programme in England. And why the government wants a salaried GP service. And why nice Mr Laertes did not seem to want to accept that his diabetes is a problem even though you advised treatment.’1,2
I tilt my head in recognition of the challenging questions she raises and steal a glance at the clock just beyond her head, hoping she doesn’t notice. ‘Interesting,’ I murmur, giving myself time to think.
I straighten up. Normal voice. ‘So you’re confused as to how GPs and pharmacies managed to give over 3 times as many doses for £10 less per dose?’1
She nods. ‘Yes, it doesn’t make sense.’
‘Well,’ back to my vicar voice, ‘you must understand that it is embarrassing to have flagship government developments — PPE purchasing, Nightingale hospitals, mass vaccination sites — turn out to be inefficient use of resource.’
Her smile falters as the penny drops. ‘So making GPs salaried would stop them behaving entrepreneurially, creating efficiencies and solutions that big organisations and even the government cannot match?’ ‘That’s their hope.’ I raise my eyebrows. ‘Salaried means no skin in the game. I hope not to be around by the time it happens.’3
‘Skin in the game?’ she asks, unsure.
‘As things are, my decisions affect my pay. For better or worse.’
She nods, her mouth a silent oh. ‘Nice Mr Laertes then, how does he fit in?’
I sigh, wondering where to start. ‘Well,’ I begin, ‘he’s Mrs Ophelia’s brother. She thinks I made a mistake that killed their father. Both him and their friend Mr Claudius have rather taken her side.’
She looks shocked. ‘That’s awful!’
‘Yes,’ I agree. ‘I’ve told both men they now have diabetes but neither accepts it.’
I stand up. ‘Come on, I’ll give them insulin later. We’re not salaried yet so I can still teach you to do that depot injection the old-fashioned way.’
‘What way’s that?’
‘Both hide behind the patient, I point and mime, you stab.’
She laughs, as though that was a joke. So I laugh too. ‘Let’s have a drink first — what’s your poison?’
- © British Journal of General Practice 2022
