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RESTRICTIVE PRACTICES
Reviewed by ANDRE BEAUMONT
I used to wonder why Margaret Thatcher took so much against professions given that she had trained as a barrister and the evident harm that charlatanism can deliver but with the passage of time I could see why: restrictive practices.
When a profession make expressions of moral outrage, especially regular ones, you can be sure there is a restrictive practice being defended.
There is the story of a solicitor who had been the executor of his sister's will.
She had had the will drawn up independently and had asked that her two relatives be the only beneficiaries. The solicitor drawing up the will told her that she ought to name a charity as the residual legatee in case they both predeceased her. She demurred. He then expressed an unwillingness to draw up such an 'incorrectly drafted' will. She gave way, nominated a charity and for good measure left it a bequest anyway. She neither told the solicitor that her brother was also one nor showed her brother the will.
She did not survive her relatives. On her death her brother received a very generous offer from her neighbour for her home. He indicated a willingness to sell but the charity objected and asked for a valuation, the appointment of an estate agent to sell it and meetings of the beneficiaries. The valuation was lower whereupon the charity insisted on an expedited sale, to the distress of the relatives. In all of this the charity was within its rights. The neighbour declined to deal with the appointed agent and the property was sold for substantially less.
The solicitor drafting the will knew that the inclusion of a charity in the will was likely to occasion more legal work but did not explain this.
On anecdotal evidence, dentists, until recently, regularly prescribed long-in-the-tooth broad spectrum antibiotics like penicillins to people who had extractions or other work that caused gum and mouth bleeding but do so somewhat less now.
The argument was that bacteria could enter the bloodstream and cause damage to the heart valves or other heart tissue.
This, however, does raise the question of how many people have been saved from heart valve or heart tissue damage by fortuitously taking antibiotics from time to time and whether those who, to all intents and purposes, never take them have been at greater risk.
These long-in-the-tooth broad spectrum antibiotics are neither the last resort antibiotics nor the ones usually used in complicated cases and if resistance to them is in evidence it is of minor consequence as resistance to these old, well-used drugs is not the threat.
It also raises the question whether a small number of antibiotics should not be available over the counter in pharmacies because of their fortuitous benefit to the population. Is not the hullaballoo about restricting all antibiotics to seemingly ever rarer prescription by doctors entrenching a professional monopoly?
After all, even in wealthy countries like the U.S. there are people who cannot afford to go to the doctor who do buy over the counter drugs that can correct their ills.
The H2 antagonist drugs like Omeprazole and Zantac are a case in point. Rigorously restricted to prescription when they were on patent they suddenly found themselves over-the-counter once off patent.
Essentially they are near harmless to humanity and could have been sold over-the-counter earlier at full price. If they do not need prescription now why did they then?
Put another way, which would cause, or does cause, most harm to humanity - over-the-counter access to old, broad spectrum antibiotics or over-prescription by doctors of statins and mind-altering drugs?
Then the hypocrisy issue raises itself. Livestock is often regularly dosed with antibiotics, in some countries more than others. The motives for doing this have to be questioned but how can livestock having access to antibiotics be squared with humans never having access to them except through the restrictive practice of prescription?
Restrictive practices abound in the medical industry.
Wherever there are gatekeepers there are restrictive practices, whether in the private sector or the state sector.
Health insurers requiring their clients to use data-sucking websites to access their full discounts is a restrictive practice.
Wherever marketing is heavy, restrictive practices lurk. It may not be easy to justify more nurses as they may count as an overhead but more marketing staff and data collectors are a cost burden on the patient, whether he or she pays by premium or through taxes.
Why some continental European health systems seem to effortlessly get better health outcomes than the British systems for only a little more money - and with, relatively speaking, little queuing - is because the gatekeepers and the data collectors are kept to the minimum. The patient makes most of the decisions and keeps the data. Each insurer pays part of the cost instead of gatekeeping.
If they move to more gatekeeping and data collecting, as they might, they will find themselves moving closer to the American or British systems, with their inherent inefficiencies.
A few good quality opticians show it is possible to get it nearly right in Britain. The battery of tests is extensive but kept pretty low cost. The marketing is kept confined to the physical products. Digital data keeping is kept slim. It is possible to get everything free if you cannot afford. Staff have to show some competence not hide behind procedure. Decision making is kept decentralised. It is possible for the client to go where he wants; means do not restrict it.
When it is said Party X or Party Y will destroy the NHS, the point is largely missed. The only way the NHS will be destroyed is if the restrictive practices are not recognised and removed, not by blanket legislation but piecemeal as and when they are noticed.
Loud voices of outrage from within the system directed at government often signal a wish to perpetuate and hide restrictive practices but these could make up 20% of the costs. If the NHS funding shortfall is £30 billion over 5 years and government will make up £8 billion, the remainder will not come from cutting the volume of services. It must come from tackling restrictive practices.
Over-enthusiastic grumbles about needs expressed by the public sound like an unwillingness to change and a wish to impose needless duties upon it.