The Deal

Ben Hoban is a GP in Exeter.

The doctor stands waiting, shivering in the July sunshine at a country crossroads a long way from home. The electric vehicle parked on the verge has managed the journey well despite all his range anxiety, and it turns out that roads outside the capital do appear on satellite navigation systems. He is wearing his second-best suit, hoping to give the impression of not trying too hard, but he is worried that after all he may be out of his depth. His partners know that he is away on a practice development activity, but he hasn’t gone into detail with them, just in case it comes to nothing. You know how these things can be.

The dog-walker is irritating. She came out of the woods a couple of minutes ago with something on a lead that frankly looks like it would be more at home in Chelsea than out in the middle of wherever-it-is-shire. The dog yaps at his car while she stands there looking totally relaxed and – no, please – as if she is about to talk to him. Maybe this was all a mistake.

“You look a little lost, if you don’t mind my saying so,” she says.

“Thank you, I’m meeting someone, it’s fine,” he replies, forcing a little confidence into his voice.

“Yes, I see, although I wonder how well you know them.”

Her comment is unexpected, and he experiences a sudden mix of confusion, annoyance and curiosity. His appraiser has encouraged him to cultivate a greater awareness of his emotional states during the consultation, and he thinks there might be something in it. He realises that despite all his preparation, he genuinely has no idea whom he is supposed to be meeting, and turns to look at this dog-walker more closely. She is casually dressed, but in a way that still oozes money, above average height, slim, must be in her fifties, although there is something older about her eyes, and a half-smile that suggests she is waiting for him to catch up, or perhaps a cat playing with a mouse. The penny drops.

“I’m so sorry, I’m Doctor -”

“I know, please don’t worry. I’m not what most people expect, am I? No horns, no tail: I hope it’s not too disappointing. You want something – everyone does – and you’re hoping to make a deal.”

“Yes, exactly! It’s all been so difficult, what with the Quality and Outcomes Framework, the pandemic, the Primary Care Networks, having to supervise all those extra clinicians, and patients just won’t look after themselves…” He realises that he has left his notes in the car and makes himself focus on his audience. She is just tying a knot in one of those disgusting plastic bags people collect dog mess in and then leave lying around anyway. She puts it into an expensive-looking tote and gives him her full attention in a way that instantly cuts him short. He registers a vague heaviness in the centre of his chest.

“Spare me the pitch. You are a failure. You find work frustrating but can’t afford to retire, you think of yourself as a businessman but don’t have the guts to push through your ideas, and you tell yourself that you want to help people, when really, you just want them to like you. You have nothing to offer me in return for saving your bacon except your cooperation. Fortunately for you, I like a little project.” As he hears this, the doctor knows that it’s all true, but can’t help thinking of himself as a rasher of bacon, and suppresses a shudder. The woman is smiling, and he notices her perfect teeth.

“Do we have a deal?”

“I have decided to devote my considerable resources to your case. We will need to start with your staff, whose attitude is recklessly unprofessional. There will be no more small-talk at reception or bending of rules for patients, who for the sake of clarity will be referred to as units. Those representing an unfavourable balance of costs and benefits will find that their relationship with the practice has irretrievably broken down and will be able to re-register elsewhere, while the rest will need to be properly motivated to ensure optimal compliance with your programme of preventive healthcare measures. A certain level of ambient fear works well: death and disease can be so ugly and I have some terrific ideas for your waiting room slide show. You will be able to grow your practice list through a proactive and robustly open-minded approach to prescribing opioids and benzodiazepines, and any units not fully engaged with the direction of travel of the business will find themselves suddenly resembling a cold turkey. Those fortunate enough to have skin tags will present themselves for quarterly minor surgery unless they want to find themselves at the back of the queue the next time HRT is hard to come by. Naturally, you will be far too busy managing this beacon of productivity to see any patients yourself, but will be in an excellent position to mentor the salaried doctors I shall be sending your way, whose unfortunate habits might make it difficult for them to secure employment elsewhere, and who will be more than happy with a minimum wage and the benefit of your discretion. I foresee a healthy practice, with excellent outcomes and optimal QOF scores. Can you feel the weight of my argument?”

The doctor is aware that the heaviness in his chest is both growing and spreading to his left arm. His head swims as he tries to keep track of a rapid succession of emotions – excitement, horror, and fear – and he knows that his discomfort must be obvious. He sees that the woman’s smile has grown too, however, and that she is showing more of those perfect teeth than seems strictly necessary. He reflects that on balance, this was not a good idea. She extends her hand.

“Do we have a deal?”

Featured photo by charlesdeluvio on Unsplash

The BJGP is the world-leading primary care journal. At BJGP Life we add multi-media comment and opinion for the primary care community.

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