Referral practices seeing patients without referring

Re: Referral practices seeing patients without referring

Malcolm Ness — Thu, 13 Feb 2014 10:39:07 GMT

[quote user="Robert Lowe"]Please check with the referral centre. I had a very cheesed off referring practitioner phone me up wanting to know how and why we had seen a client of his without at least requesting a history. Further investigation revealed that the client had been referred from another practice who also had a long history of treating the dog.[/quote]

We see this very frequently. Clients using several primary care practices is becoming much more common.

Re: Referral practices seeing patients without referring

Bob Russell — Wed, 12 Feb 2014 09:55:03 GMT

I am running a business so are the referral practices. I advise clients on the options including price. Some will prefer eye cases seen by a local practice, some will prefer to see Rob!

As long as I am treated in a professional way by referral practices I have no issues. Fortunately we have a choice of centres in this area, all offering good to brilliant services. The other side of this is on occasions I can negotiate on occasions over fees to the benefit of my patients!

I have had owners come to me requesting referral to a particular place. As long as I am happy the necessary skills are available why would I try to change an owners mind?

I will discuss "lower end" referral quite happily especially if budget is limited.

The real problems start when owners are not given the range of options!

Re: Referral practices seeing patients without referring

Arlo Guthrie — Wed, 12 Feb 2014 08:25:30 GMT

[quote user="J G Wray"]Well, bless them., but do you really think the advice given on this basis is altogether altruistic and isn't marketing?[/quote]

JGW, it's quite irrelevant what a referral practitioner's motive is for giving advice here. The point is they do, and Gillian is absolutely right, it would be a great shame to lose that input for whatever reason, including cheap remarks about lining them all up against a wall.

Since you mention it, I tell referral practitioners that participating in these forums is a good way to raise their profile. I'm also going to be doing email profiles of those that do.

Nevertheless, in my experience, the decision to take part in these forums is just not as black and white as 'marketing' or 'altruistic'. Most I have spoken to are a little uncomfortable with the idea of 'marketing' themselves. Most seem to do it for a combination of reasons: because they enjoy it, because it raises their profile / helps market their services, because it is CPD-qualifying, and yes, a dash of altruism.

Re: Referral practices seeing patients without referring

J G Wray — Wed, 12 Feb 2014 07:23:24 GMT

[quote user="Gillian Mostyn"]there are a lot of lovely referral practitioners, in many different types of practices, who give their advice on here FOC - including Mr Lowe. Please don't deliberately antagonize them as it would be a shame to lose their much valued input.[/quote]

Well, bless them., but do you really think the advice given on this basis is altogether altruistic and isn't marketing?

[quote user="Gillian Mostyn"]We all need each other - no?[/quote]

YUp, but there is nothing wrong with being realistic about the relationship. Looking at it as a cosy mutuality between lovely people is crazy. Mr Lowe has been drawn on how referral practices can and will be operating. Now you know.

The long term future of referral practice isn't dependent on direct marketing to the animal owners in general. They need to reach the well heeled and insured customer segments. To suggest that referral practices contribute to the welfare of the majority of patients is an arguable point. Some centres take on the concept of Corporate Social Responsibility by running blood banks, sponsored cases and rabies vaccination programmes. Others look for new diseases to get a profile, but it's all marketing and it's not for a busniess model with access for all.

Being realsitic about this and GPs place in it is no bad thing.

JGW

Re: Referral practices seeing patients without referring

Evelyn Barbour-Hill — Tue, 11 Feb 2014 23:04:47 GMT

[quote user="Robert Lowe"]lot of bigger referral centres are spending a lot of money on soft advertising and networking directly with clients to achieve referral through pull through marketing[/quote]

[quote user="Robert Lowe"]corporate practices directing clinicians to refer in house to less specialist clinicians[/quote]

Which might be quite a reasonable thing to do?

[quote user="Robert Lowe"]or holding referral centres to ransom over practice purchasing[/quote]

while that........ should invite a brief two word response.

Re: Referral practices seeing patients without referring

Gillian Mostyn — Tue, 11 Feb 2014 22:51:54 GMT

JGW - there are a lot of lovely referral practitioners, in many different types of practices, who give their advice on here FOC - including Mr Lowe. Please don't deliberately antagonize them as it would be a shame to lose their much valued input.

[quote user="J G Wray"] the relationship is not one of mutuality, rather, as I've mentioned before, it is one of utter dependence as referral vets don't put food on their table without the primary practitioner[/quote]

True. But as I wouldn't have a clue how to do a hemilaminectomy or cataract removal, it would be very difficult to provide a complete service for my clients without the support of my local friendly specialists!! We all need each other - no?

Re: Referral practices seeing patients without referring

Robert Lowe — Tue, 11 Feb 2014 22:51:25 GMT

[quote user="J G Wray"]Do you ever receive gifts from referring practices? [/quote]

Sometimes - if we have helped with a difficult situation, seen the vet/nurses own animal, driven to the practice to help with a dog already anaesthetised and in theatre.

Utter dependence is too absolute. A reasonable set of our patients come to us on recommendation from friends, internet enquiries, disappointment with the current situation, heard me speak at the WI etc.. In these scenarios they drive the referral and ask to be referred to a centre of their choice. I think if you take the opinion that the primary practitioner is the only person that a client listens to when being referred to then you are being somewhat naive.

We aren't and don't need to yet but a lot of bigger referral centres are spending a lot of money on soft advertising and networking directly with clients to achieve referral through pull through marketing. They are doing this as they see corporate practices directing clinicians to refer in house to less specialist clinicians or holding referral centres to ransom over practice purchasing. However, this marketing is indiscriminate in its approach to the typical veterinary consumer and won't differentiate which type of practice the client is registered with. As much as I don't want to do this, I suspect that in the future we, the referral clinician population, will bypass you in terms of marketing in the same way that BUPA hospitals do. I am not sure I like this or am comfortable with it but its how I see it progressing.

Re: Referral practices seeing patients without referring

J G Wray — Tue, 11 Feb 2014 22:30:08 GMT

[quote user="Robert Lowe"]And JGW sometimes the feeling is mutual ;)[/quote]

Tell me something. Do you ever receive gifts from referring practices? This may seem counter intuitive, since the relationship is not one of mutuality, rather, as I've mentioned before, it is one of utter dependence as referral vets don't put food on their table without the primary practitioner, but some people do, send presents that is.

JGW

Re: Referral practices seeing patients without referring

Robert Lowe — Tue, 11 Feb 2014 21:09:15 GMT

Please check with the referral centre. I had a very cheesed off referring practitioner phone me up wanting to know how and why we had seen a client of his without at least requesting a history. Further investigation revealed that the client had been referred from another practice who also had a long history of treating the dog. We had seen the case in completely good faith and despite taking a extensive history from the client we had no inkling that they used 2 practices.

And JGW sometimes the feeling is mutual ;)

Re: Referral practices seeing patients without referring

Martin Atkinson — Tue, 11 Feb 2014 19:09:55 GMT

[quote user="ChrisBVSc"]

Check they didn't walk in via the University 1st opinion practice doors, presumably this would make it completely legitimate.

[/quote]Again this happened with me. A client who was referred to Cambridge for a bone tumour, rocked up there without warning with another dog with a pyo that I'd booked in for surgery the next day. I'm not sure what the client told them but they were not happy with me until I explained the situation then their anger turned on him. This a bit different though as at least they did contact me the next day and hadn't actively encouraged the client.

Re: Referral practices seeing patients without referring

An On MRCVS — Tue, 11 Feb 2014 18:59:52 GMT

[quote user="ChrisBVSc"]

Check they didn't walk in via the University 1st opinion practice doors, presumably this would make it completely legitimate.

[/quote]

Sorry I meant a private multi-disciplinary referral centre not related to University at all.

It can be hard to understand JGW's lingo at times ;-)

I totally agree that I shouldn't be making assumptions without speaking to the vet, and my letter/email to the clinical director will be toned that way.

Thanks again

Re: Referral practices seeing patients without referring

Laurence Webb — Tue, 11 Feb 2014 18:37:33 GMT

[quote user="An On MRCVS"] what does the GtoPC say on this?[/quote]

As you didn't refer them then it should fall under succession

5.2 Veterinary surgeons and veterinary nurses should liaise with colleagues where more than one veterinary surgeon has responsibility for the care of a group of animals. Relevant clinical information should be provided promptly to colleagues taking over responsibility for a case and proper documentation should be provided for all referral or re-directed cases. Cases should be referred responsibly.

Taking over a colleague’s case

5.4 Although both veterinary surgeon and client have freedom of choice, in the interests of the welfare of the animals involved, a veterinary surgeon should not knowingly take over a colleague's case without informing the colleague in question and obtaining a clinical history.

5.5 When an animal is initially presented, a veterinary surgeon should ask whether the animal is already receiving veterinary attention or treatment and, if so, when it was last seen; then, contact the original veterinary surgeon for a case history. It should be made clear to the client that this is necessary in the interests of the patient. If the client refuses to provide information, the case should be declined.

Mutual clients

5.7 Where different veterinary surgeons are treating the same animal, or group of animals, each should keep the other informed of any relevant clinical information, so as to avoid any danger that might arise from conflicting advice, or adverse reactions arising from unsuitable combinations of medicines.

Re: Referral practices seeing patients without referring

ChrisBVSc — Tue, 11 Feb 2014 18:29:12 GMT

Check they didn't walk in via the University 1st opinion practice doors, presumably this would make it completely legitimate.

Re: Referral practices seeing patients without referring

Tom Ward — Tue, 11 Feb 2014 18:25:09 GMT

Def need to err on the side of caution here. My mantra (maybe naively) is: assume the vet has acted properly and professionally until proven otherwise. We have to hope that of our profession don't we?

Re: Referral practices seeing patients without referring

Hannah Wynne Richards — Tue, 11 Feb 2014 18:08:18 GMT

That might have been a valid point if it was a practice which also saw 1st opinion cases, but not with a Type 3 ( University ) centre.

Wynne

Re: Referral practices seeing patients without referring

Rob Loxley — Tue, 11 Feb 2014 17:56:48 GMT

Not saying it's happened in this case, but how many times has an animal been presented to you claiming it's never been to no vet before (often with a major problem and insurance taken out only a few weeks ago...)?
What I'm saying is make sure you've heard both sides before coming to a conclusion (or RCVS complaint).

Re: Referral practices seeing patients without referring

Martin Atkinson — Tue, 11 Feb 2014 17:31:36 GMT

I've had a situation where the referral centre investigated a patient's cardiac problem when it was referred for an ophthalmic problem not just as a risk assessment but as a separate entity and changed the medication without asking me first. This was a large private multi-centre practice spanning much of greater London with one or two referral specialist within the group. I was not best pleased.

Re: Referral practices seeing patients without referring

Hannah Wynne Richards — Tue, 11 Feb 2014 16:54:02 GMT

Rads mean the animal must have been seen formally, so the unethical behaviour is institutionalised.

In the 1st case, I wonder if the veterinary surgeon was the friend, and did a favour FOC (why else wouldn't the tests have been done at the referralcentre?) so it may be news to the clinical director.

Whether the centre, or an individual VS was guilty, it's still grossly unethical conduct

Wynne

Re: Referral practices seeing patients without referring

An On MRCVS — Tue, 11 Feb 2014 16:07:00 GMT

[quote user="Marie Kubiak"]

Did the referral centres request history from you first or make you aware of the situation before seeing the dogs? Was the 'friend' a vet there? If not the vet may have been pressured into seeing 'a friend's pet' informally but should have at least contacted you to check you were happy for them to see it or wanted to refer it onwards.

Marie

[/quote]

No, in first case I only found out when owner called me t o check how much is it going to be to perform ACTH stim test, xrays and ultrasound as specialist has recommended it. In second case I found out at time of admitting the dog for castration when they mentioned that he was xrayed at referral centre for carpus valgus and they said it didn't need surgery to correct it. Both the dogs are only registered with me and don't have any other primary vet.

[quote user="J G Wray"]

If the OP was referring to a type 3 practice then you might as well bang your head against a brick wall. They are neither completely professional people, because they think of themselves as clinicians presented with units of work operating in a hierarchy of required sunshine and don't like to get involved with all the dirty stuff, nor are they dependent in any sense on primary vets. Send the Clinical director a detailed complaint and have a drink.

From time to time I think all referral vets should be put against a wall and shot

JGW

[/quote]

I am referring to practice type 3

I don't want to go to the extreme of writing a complaint to RCVS, but will definitely let their clinical director know about this.

Thank you for your suggestions

Re: Referral practices seeing patients without referring

J G Wray — Tue, 11 Feb 2014 13:58:08 GMT

I have a theory based on very little and nothing worthwhile that the origins of a referral practice are telling.

They can be divided into several types

1. Those that have grown from a primary practice carrying the vets with them. They know how to behave.

2. Practices that have grown from academics setting up as a referral practice. These carry the University mentality.

3. The University referral practices who operate in a bubble with few reference points to the outside world.

Types 1& 2 don't put food on their childrens' table without keeping primary vets sweet. Type 1 know this and deal with it and type 2 sort of know this and don't always deal with it. Type 3 don't know and don't care.

Type1 handle clients well as a rule

Type 2 are variable with their greatest fault being indecisive, surgeons apart.

Type 3 rely on the "awe factor" of the MAJOR INSTITUTION to keep clients quiet and undemanding

Type 1 are interested in diagnosis and treatment and can/will discuss prognosis

Type 2&3 have never managed post op or post referral in detail and therefore prognosis carries no interest for them. This is a problem.

If you have problem with Type1 they are usually on it in a flash

If you have problem with type 2 they are defensive, hurt, cagey and possessed of sloping shoulders and slippery fingers.

If you have problem with type 3 practices e.g. why a patient was returned after 5 days of their care with a tick on its head from a Borrelia area, or why the report is so slow in coming , or why the report changes the name of the patient half way through, or why they didn't do an abdominal ultrasound... long stories....then it's difficult to find who is in charge, because they work in teams in shifts and have no single point of contact or charge.

If the OP was referring to a type 1 practice then give 'em a ring and the benefit of the doubt until positively proven otherwise.

If the OP was referring to a type 2 practice then give' em a ring and hold out for a Director and if they're not available, put them on the back foot by telling them you have a complaint. As mollifiers they make good vets. Don't let them off the hook.

From time to time I think all referral vets should be put against a wall and shot

JGW

Re: Referral practices seeing patients without referring

Thomas Johnson — Tue, 11 Feb 2014 12:07:22 GMT

[quote user="An On MRCVS"]

In past 2 weeks I have 2 instances where dogs under my care have been seen by 2 well known reputable referral centres without me referring to them directly. They were taken there as in both cases owner's friend worked there.

Both referral centres are very proud to announce on their website that they don't see first opinion cases without referral and they have done this.

What am I supposed to do, what does the GtoPC say on this?

Anon only because I don't want to say out their name out loud as I still consider them best of the best specialist centres in UK.

[/quote]

In your situation I'd give them a call, probably speak to the vet who saw the animal. If I wasn't happy with what they said I'd put a complaint in writing to the practice. If that didn't get me anywhere then I's peak to the RCVS.

Re: Referral practices seeing patients without referring

Bob Russell — Tue, 11 Feb 2014 11:43:04 GMT

Talk to the referral practice to get their side of the story. There may have been a misunderstanding. Quietly off the record initially (but record notes and names for future reference).

If this is satisfactory it stops there. If not then write formally for an explanation.

If this is not satisfactory report the bu**ers to the RCVS.

Referral practice is based on trust between colleagues. We are trusting our patients to them, trusting them to give us reasonable support and trusting them to hand them back to us at an acceptable stage and not hold on to them to milk insurance.

The decision to refer is the primary vets responsibility. We take the flack if we get it wrong!

Re: Referral practices seeing patients without referring

Marie Kubiak — Tue, 11 Feb 2014 11:10:53 GMT

I had this recently - a case was referred to us by a local practitioner and we spoke to the owner and booked it in. We made calls to a previous referral clinic it had been to, to get notes from a previous work up, they repeatedly refused to send history then called the owner and rearranged the referral to them despite the client and referring vet stating they preferred to come to us! RCVS were pressing us to formally complain but I have left it as I don't want to stir up a hornets nest. I think it is incredibly bad mannered and professional ethics should stop vets behaving in this way but sadly there are a few who don't play by the rules.

Marie