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Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]

A little short-sighted perhaps?

The British Medical Association’s response to a proposal by the British government to allow optometrists more leeway to prescribe medication for eye problems.

“In order to safeguard patient care, the BMA’s ophthalmic committee can only envisage extremely limited opportunities for optometrists to make therapeutic interventions.”

I wonder whose interests are really being ‘safeguarded’ here.

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16 comments to A little short-sighted perhaps?

  • Brian

    Quite.

    I’ve just visited the optician, and she suspects I may have an eye problem. So I’ve got to vist my GP (taking the morning off work, therefore no pay) so that he can refer me for an appointment with a specialist (another morning off, no pay, perhaps this year, perhaps next or the year after, depending on how the targets are going).

    Since I don’t currently HAVE a GP, I apparently have to register (in person, another morning off, no pay) before I can make an appointment.

    Can anyone (at the British Medical Association or elsewhere) please explain how any of this is related to treating my eye problem (if I have one), and in what way it is preferable to having the optician who spotted it in the first place deal with it?

  • The sooner the medical closed-shop is broken up, the better. It’ll never happen though: The Doctors are too well organised.

  • The problem is that people still believe that being a GP is something really clever. It’s not.

    Why don’t car mechanics earn what GPs do? Simple. Because anyone can set up as a car mechanic.

  • nick

    GPs study for 10 years to perform their job. This is why they are paid what they are paid. They do their job well. In Australia, opticians can refer to eye specialists, and offer advice on over the counter treatments. GPs don’t have a problem with this. Unfortunately, in the NHS, GPs are forced into the role of rationing the health budget – leading to the sort of discontent expressed in this post. This is no reason to denigrate GPs.

  • Daveon

    Brian, I feel shocked I need to point this out on a Libertarian site, but if the mornings off and the inconvenience are a problem, not to mention a loss of income, you can always pay.

    A first consult with a specialist will not cost much, my sister in law had one in Bath while over from South Africa, cost her £60, was seen immediately and given recommendations for her doctor at home.

    Alternatively you could skip the GP and use a walk in private medical centre. I’ve done that myself in London when I wasn’t prepared to wait the three days for my GP to tell me I needed anti-biotics. Cost about £30, worth every penny.

    If you have a problem, then you can decide your course of treatment.

  • Brian, I feel shocked I need to point this out on a Libertarian site, but if the mornings off and the inconvenience are a problem, not to mention a loss of income, you can always pay.

    That is true but it also rather misses the point that even if you pay, you still get your wages raided to pay for the NHS, making the true cost of going privately rather higher as you have to (in effect) pay twise if you are employed. The state does not reward taking responsibility for your own medical care.

  • J

    Can anyone (at the British Medical Association or elsewhere) please explain how any of this is related to treating my eye problem (if I have one), and in what way it is preferable to having the optician who spotted it in the first place deal with it?

    There is a reason, although not necessarily a justification. There is in medicine a fairly important concept known as continuity of care. This is the notion that having one person aware of all of your health problems is more beneficial than (just) having lots of people only aware of your health problems in their specialist field. There is evidence to support this notion, which I’ll let you find for yourself, although you could start here:

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15548934&dopt=Abstract

    So, if the optometrist simply gave you a prescription and left it at that, your GP would never know about it. Then, a year later when you go to your GP for something you think is entirely unrelated, the GP won’t know that your ailment may be linked to the drugs your optometrist gave you, or that eye problems are a common diagnostic indicator of what you may have now, etc. etc.

    Now, the question is, when do the (widely accepted) benefits of continuity of care give way to the benefits of rapid treatment, patient choice etc. etc. I’ve got no idea.

    Certainly, the BMA exist to make their members better off doesn’t invalidate all that they say, but it does mean they shouldn’t be treated as a panel of independent experts (though I’d dispute that such a thing can exist anyway).

    What you need in these cases is research and evidence, but it’s extremely hard to do.

  • MarkE

    J

    Good and valid points about continuity of care, but with two gaps.

    1/. Last time any member of my family saw doctors frequently was when the children were very young, but they seldom got to see the same locum twice. Perhaps that is unique to Rural Oxfordshire.

    2/. When my clients get advice from other professionals who may overlap with my role, the advisor usually sends me a courtesy letter to keep me informed. This only falls down if the client is running the other in parallel before sacking me. Can Optometrists etc. not write letters, or can GPs not read?

  • J

    MarkE:

    Changes in the NHS, and life generally, have made it harder to see the same GP consistently. This is partly because most people would rather see a doctor they’ve never met right now, than see one they know in two days time. As people get older, the ailments they get tend to be more complex and systemic, and they would be well advised to see the same doctor each time. It may well matter less for the young and generally health, who normally get simple infections and injuries.

    As for people exchanging information and writing letters etc. – well, yes and no. The current system of communication is very burdensome and inefficient. They do all send letters to each other, but they often take weeks or months to arrive, can get lost and misfiled, can be illegible etc. etc. The NHS are in the middle of a much publicised 12bn technology project to fix this. My insider view on that project is that it will suceed, in broad terms.

    However, even an efficient electronic message saying ‘patient 12345 given 10mg xyz for suspected pqr’ is no substitute for a GP being able to physically see someone, ask them questions that they think relevant and so forth.

    For those not yet bored, I should also say that all GP practices will regularly review their patients, so if you are seeing different doctors at the same practice, every fortnight or so they will run through their patients and discuss who is being treated how, what treatments seem to be working well, and so forth.

    Most lay people (including me, until I worked in it) think medicine is mainly about looking at a problem, diagnosing the underlying disease/problem, giving the correct treatment. In fact, it’s all much much much more complicated.

  • Daveon

    Perry,

    You do still get your “wages raided” for the NHS, however, the NHS is still there should you need treatment above and beyond what you can afford etc…

    There is nothing to stop you getting your consultant to give an opinion and then stiffing the NHS for the bill for treatment, which, frankly, is normally the expensive part. Seeing the consultant is usually a small part of the actual cost if you have something wrong with you.

    I certainly dispute that this makes the overall costs higher. I’ll conceed that we British seem to have a sheep like attitude towards healthcare, but having seen how it can fail in the US, I’d rather have a UK failure.

    OTOH – I’d rather have neither and opt for for something like the models used in most of the rest of the world.

  • Lizzie

    It’s crazy that GPs don’t usually bother to contact opticians and dentists. The whole body works together – if one bit of it’s breaking down, it’s almost certain there’s something going on elsewhere. In 2004 my optician picked up that I had macular degeneration. My GP said that I couldn’t possibly have that as it was an age-related thing, and I was only 21; it took quite a battle to get a referral to the hospital. (They “sewed up” the holes with lasers.) She never bothered to investigate what might have caused it.

    I’ve since found out that I have a chronic disease which does in fact cause age-related symptoms! I’ve also concluded that my GP is an incompetent moron, and I’ve recently changed to a new one, who seems promising. The first time I saw him, he sent me for a full spectrum of blood tests – something I’ve never had done before. (My new GP was quite horrified at that.)

    I think that a lot of GPs have settled into a kind of complacent arrogance. Their jobs are secure for life (as long as they don’t go feeling up patients), because there will always be sick people who can’t afford pivate insurance. They have kind of a vested interest in keeping people ill, really (whether or not they realise it), which may explain why they never really seem interested in helping people to become healthy. It’s far easier – and cheaper – to just write out a prescription for something to suppress symptoms rather than address what’s causing the body to misbehave. And until GPs, dentists, opticians and other healthcare professionals can work together properly, patients are going to continue to suffer.

  • J

    They have kind of a vested interest in keeping people ill, really (whether or not they realise it), which may explain why they never really seem interested in helping people to become healthy.

    I don’t think that’s fair, any more than its fair to say that pharamceutical companies are all trying to poison us. Partly because it’s blindingly obvious that every clinician I’ve ever met has a very strong personal interest in making people better, and partly because the charge can be laid at the feet of everyone who does anything – window cleaners really want to make your windows dirtier etc. etc. What is true to some extent (and is worrying) is that parts of both the medical and pharma industries would like to define ‘healthy’ in rather strict terms, which make the state apparently impossible to achieve, thereby ensuring that doctors will always need to intervene. This attitude is willingly re-inforced by a pathetic public who like to think their problems are an illness and so not their fault. But no practising clinician complains about the lack of sick people to help.


    It’s far easier – and cheaper – to just write out a prescription for something to suppress symptoms rather than address what’s causing the body to misbehave.

    Yes, but bear in mind that we have no idea at all what the root causes for many things are. The choice is to treat the symptom, and carry on the 10-20 year research effort to find the root cause, or do nothing. In many cases there’s no financial incentive to fix the root cause – why find a cure for herpes infection, when its so easy to treat the sympotms?

    And until GPs, dentists, opticians and other healthcare professionals can work together properly, patients are going to continue to suffer.

    That’s true, especially as regards dentistry which is a rather strangely separate discipline. But the situation is in general improving, I think, both here and in the US.

  • J
    continuity of care is no longer an effective principle of health care in the UK.

    If a patient is sent by a generalist to a hospital with, say rectal bleeding, the patient will be checked for one possible cause, then when that is ruled out, sent home.

    The problem in the UK is that the state crowds out medicine. See NHS Doctor Blog for a regular supply of examples.

    Having said that, in the specific instance mentioned by Brian, the proposed reforms would help matters. Now what would be handy is if the sort of experience that Brian encountered was included in the consultation.

  • Lizzie

    Maybe I’m just sour because I’ve had such a bad experience. If my former GP had taken a good long look at the fact that I had so many illnesses (and that maybe that at such a young age I shouldn’t be so ill!), if she’d just sent me for the full spectrum of tests years ago rather than just giving me drugs to alleviate my symptoms (and they did work to alleviate the symptoms, but in the long run they’ve broken my liver and kidneys!) then we could have started treating the root of my problems.

    This new GP, when I enrolled at the surgery, asked me to type up a list of all my illnesses and medical treatments. When I took it along to him, I asked why he needed it, when he could have just looked at my notes. He replied that he preferred to try and see things from the patient’s point of view as well as just read what another doctor had decided to write about them. I was bowled over! That’s such a great attitude, and I’ve never come across it before in the NHS (and I’ve had a lot of experience!). He sent me for all those tests because he was quite horrified that I’d been reassured that all these symptoms were “perfectly normal” all these years and that I’d been on such strong medication without being sent for blood tests. He genuinely wanted to know what was wrong with me, and what he could do to help.

    So I’m certainly not trying to damn all NHS docs, because clearly some of them do truly care about their patients, and it seems I’ve been lucky enough to finally find one. But to a lot of them, we are just an inconvenience.

    I wouldn’t think the window cleaner thing is quite correct because window cleaners aren’t paid out of the public purse. NHS doctors are. They get paid whether they make a patient better or not. A window cleaner who did a shoddy job wouldn’t be asked back a second time – with a GP, you don’t really have much choice unless you can afford it. And most of us can’t.

    Totally agree about the pathetic public, by the way. A lot of modern illness is due in no small part to crappy diet and lifestyle choices, and then when people get ill they wonder why. I’m including myself in that, to a certain extent. I managed to complicate things by drinking on a weekly basis for a couple of years when I wasn’t up to it in the first place (I would do it in order to forget how crappy I felt) and I’m taking full responsibility for that part. I wouldn’t be quite so bad now had I not done that; although I would still be very ill – I’ve just helped things along! I’m now doing everything right, which has included cutting out some foods (it turned out that I’m intolerant to a number of my very favourite things). It’s hard sometimes, but I’m finally taking responsibility for myself.

    (And there is no cure for herpes, by the way. It’s not something that can be cured. Once you’ve got it, you’ve got it for life. But you can stop it flaring up, mostly by keeping your stress levels down and your immune system robust.)

  • Brian

    Thank you, chaps. It has been a rather interesting discussion. I have to admit (curls up and dies of embarrasment) that the thought of going private never entered my head. On the other hand, I WAS going private, at the opticians.

    As for continuity of care, as a contract programmer I lead a rather peripatetic existance, and haven’t seen the same doctor twice since…er…since I can remember. Or the same dentist or optician come to that.

    Since eyes are clearly necessary for my work, perhaps the treatment not provided by the NHS while I sit around in waiting rooms, and therefore paid for out of my own pocket (again, as Perry points out) when I go private is tax-deductable?

  • Paul Marks

    The B.M.A. is a union (as are the similar organizations for lawyers).

    It may, like the old craft guilds, really care about the quality of work done – but, also like the old craft guilds, it also cares that its members do not face competition.