Schedule 3 Consultation

RE: Schedule 3 Consultation

easy307 — Wed, 10 May 2017 06:58:37 GMT

I recently received this response from the RCVS regarding delegation of tasks to both VNs and lay staff :

"Delegation to RVNs/SVNs

Due to the varied nature of veterinary work, we do not have a definitive list of procedures that can be delegated to RVNs and SVNs under Schedule 3. This is because whether a procedure is appropriate to delegate is dependent on a number of variables, including but not limited to condition/breed/species of the animal, any aggravating factors, competency and experience levels of the RVN/SVN. This is by no means exhaustive and there could be a number of other factors which could influence whether it is appropriate to delegate an activity under Schedule 3. Our supporting guidance on ‘Delegation to veterinary nurses’ (chapter 18) provides further detail. I have included the relevant paragraphs below.

18.4 Under this Schedule 3 exemption, the privilege of giving any medical treatment or carrying out minor surgery, not involving entry into a body cavity, is given to:

a. Registered veterinary nurses under the direction of their veterinary surgeon employer to animals under their employer's care. The directing veterinary surgeon must be satisfied that the veterinary nurse is qualified to carry out the medical treatment or minor surgery (see paragraph 18.5).

b. Student veterinary nurses under the direction of their veterinary surgeon employer to animals under their employer's care. In addition, medical treatment or minor surgery must be supervised by a veterinary surgeon or registered veterinary nurse and, in the case of minor surgery, the supervision must be direct, continuous and personal. The medical treatment or minor surgery must be carried out in the course of the student veterinary nurse's training (see paragraph 18.5).

18.5 The RCVS has interpreted these as follows:

a. 'direction' means that the veterinary surgeon instructs the veterinary nurse or student veterinary nurse as to the tasks to be performed, but is not necessarily present.

b. 'supervision' means that the veterinary surgeon is present on the premises and able to respond to a request for assistance if needed.

c. 'direct, continuous and personal supervision' means that the veterinary surgeon or veterinary nurse is present and giving the student veterinary nurse his/her undivided personal attention.

18.6 A veterinary nurse or student veterinary nurse is not entitled independently to undertake either medical treatment or minor surgery.

18.7 In considering whether to direct a veterinary nurse or student veterinary nurse to carry out 'Schedule 3 procedures’, a veterinary surgeon must consider how difficult the procedure is in the light of any associated risks, whether the nurse is qualified to treat the species concerned, understands the associated risks and has the necessary experience and good sense to react appropriately if any problem should arise. The veterinary surgeon must also be sure that he/she will be available to answer any call for assistance, and finally, should be satisfied that the nurse feels capable of carrying out the procedure competently and successfully.

If you have queries regarding specific procedures, we may be able to advise upon these and I’m happy to try and help. Some duties within practice will never fall within the Schedule 3 definition and therefore can only be undertaken by vets. If the procedure involves more than minor surgery, it will not fall within Schedule 3; nor will anything that involves entry into a body cavity. Some examples of procedures/duties that we consider do not fall within the Schedule 3 definition, and therefore may not be carried out by an RVN or SVN relying on the exemption include:

· Administration of epidural anaesthesia (involves entry into a body cavity)
· Placement of tracheotomy
· Biopsy/lump removal (we have taken advice from a veterinary surgeon attached to the College who expressed some concerns with an RVN/SVN doing this)

Some examples that we consider do fall within the Schedule 3 definition, and therefore may be carried by an RVN or SVN relying on the exemption, provided that the factors outlined in the first paragraph above and discussed at paragraph 18.7 of the supporting guidance would also render this appropriate, include:

· Taking blood samples / extraction of blood from a vein
· Administering blood transfusions (but a vet should be on hand in case of anaphylactic reactions, and also because conditions requiring this will mean animal is probably already critical)
· Fine needle aspirate (as long as no entry into a body cavity)
· Internal expression of anal glands

However, it is important to remember that just because a procedure can be delegated to an RVN or SVN in theory, does not mean that it should be in practice in every situation, and consideration should always be given to whether delegation is appropriate in the particular case. It should also be borne in mind that views within the profession are not stagnant, and therefore the College’s guidance on specific procedures and tasks may change over time.

Delegation to lay staff and RVNs/SVNs not working under the direction of their veterinary surgeon employer

There is no exemption for other members of practice staff to undertake duties that would fall within Schedule 3, and therefore those staff members are limited to carrying out lay duties. There are certain procedures which we advise cannot be justifiably delegated to lay persons and therefore should never be delegated to them – such as intravenous and intramuscular injections. A lay person could, however, in theory, undertake a simple subcutaneous injection or administer a medication orally, provided that their veterinary surgeon employer considered them to be competent to do so and had directed them to do it, and they did not themselves choose which the drug or dosage.

When working independently/ outside of practice (i.e. not under the direction of their veterinary surgeon employer, to animals under their employer’s care), RVNs and SVNs may not undertake Schedule 3 veterinary nursing activities, and are in effect limited to undertaking similar procedures that any lay person could, despite their RVN/SVN status.

Some procedures we are commonly asked about in relation to lay staff, and RVNs/SVNs when they are working independently/not under the direction of their veterinary surgeon employer, include:

Nail clipping / Grooming: This is permitted, as it is not an act of veterinary surgery, however anything unusual should be referred to a veterinary surgeon.

Advice and health checks: They may not carry out a general physical exam, take blood samples, put up IV drips, take and process x-rays or carry out post-operative checks (aside from making a record of weight or temperature for example). While VNs advise on weight, age-related problems and dental concerns in the context of a veterinary practice, the giving of such advice outside of the practice context causes some concern, and care must be taken not to enter into the realm of veterinary surgery within the meaning of the Act – i.e. there should be no element of diagnosis.

Cleaning ears: The external meatus may be cleaned by a lay person as part of general grooming provided it does not include entry into the ear cavity. Where minor hair/debris removal is involved in a non-infected ear, this would not usually be considered an act of veterinary surgery, but where infection is present or there is any possibility of a ruptured ear drum, this should be dealt with by a veterinary surgeon.

Anal glands (EXTERNAL): External expression of the anal glands may be undertaken by competent owners or lay people, including RVNs/SVNs not acting under the direction of their veterinary surgeon employer. By ‘competent owners or lay people’, we mean those who have had the procedure demonstrated and explained to them by a veterinary surgeon. There are also some other provisos. In our view, routine, prophylactic expression of anal glands should only be undertaken on the advice of a veterinary surgeon. If a para-anal sac problem is suspected, the animal should be seen by a veterinary surgeon for confirmation of the diagnosis and advice regarding any necessary treatment. A vet should first identify that prophylactic/regular para-anal sac emptying might be needed; should then ensure the individual knows what they are doing; and should advise in regard to the frequency of emptying. For a lay person to forcefully squeeze anal sacs that don’t actually need emptying could be inappropriate.

Microchipping: We have comprehensive information about microchipping (chapter 29 of our supporting guidance). The important aspects to note are that implantation by methods other than the subcutaneous route, ear tag or bolus will generally amount to veterinary surgery in view of the potential for pain or stress or for spreading disease, and in some cases the likely handling difficulties. More stringent regulations apply to the microchipping of dogs, and I refer you to chapter 29 for more information."

RE: Schedule 3 Consultation

Arlo Guthrie — Tue, 09 May 2017 13:41:38 GMT

[quote user="J G Wray"]We're not doing anything exceptional. All we're doing is taking a professional person and giving them a chargeable, valuable role in practice, which also frees up veterinary surgeons' time, within the existing framework.[/quote]

How do you know you're not doing something exceptional?!

The quote in the press release from the RCVS about the consultation (story here) said:

Evidence gathered during the initial stage of the VN Futures project suggested that there is some uncertainty around the interpretation of Schedule 3 in clinical practice. For example, many veterinary nurses do not undertake Schedule 3 work or are uncertain as to whether they do, while some veterinary surgeons are reluctant to delegate Schedule 3 tasks to veterinary nurses.

No numbers in that, but it certainly mirrors what I hear from elsewhere.

[quote user="J G Wray"]Is there any other purpose for changing Schedule 3 than giving professionals a chargeable, valuable role which frees up vets time?[/quote]

Well, I don't have an opinion about whether it needs changing - I just have always thought it needs greater clarity.

But in answer to your question, perhaps one other purpose, which is to maximise job satisfaction (which is related to but not exactly the same as being 'valuable').

RE: Schedule 3 Consultation

Iain Richards — Tue, 09 May 2017 13:21:42 GMT

I suspect JW does exactly what most practices are doing at present. We, vets, allow nurses a considerable freedom in all manner of tasks, essentially by vets being the ultimately responsible person. My personal beef with the college is its continual refusal to acknowledge RVNs controlling anaesthesia. There is a very tenuous argument that adjusting the dials is prescribing medicines in the absolute sense of the act. I disagree. Aspects to disagreeing, a) Having a vet to control the anaesthetic will be prohibitively expensive for the client, so the task is devolved to the nurse b) the vet operating can only ever have a nominal, not a real, control of the anaesthetic* c) nurses are far better than vets as they, nurses, really care about pain relief d) even if it was strictly against the VSA/Medicines Act - who is going to bring a prosecution and in whose interests?

*Making allowances for when the faeces hits the ventilator. It can be done, but only in extreme circumstances. Anyone suggesting, "It's fine, I can do both tasks perfectly well," doesn't understand the complexities of anaesthesia.

RE: Schedule 3 Consultation

J G Wray — Tue, 09 May 2017 13:09:21 GMT

[quote user="Arlo Guthrie"]Can I suggest you are probably the exception, rather than the rule .. [/quote]

We're not doing anything exceptional. All we're doing is taking a professional person and giving them a chargeable, valuable role in practice, which also frees up veterinary surgeons' time, within the existing framework.

Is there any other purpose for changing Schedule 3 than giving professionals a chargeable, valuable role which frees up vets time?

RE: Schedule 3 Consultation

Arlo Guthrie — Tue, 09 May 2017 11:55:26 GMT

[quote user="J G Wray"]My RVNs are leveraging their professional consultations so effectively at the moment, they are turning over 40-50% of a FTE VS, all without a new VSA or change in Schedule 3 and there's much more to come from them[/quote]

Can I suggest you are probably the exception, rather than the rule

RE: Schedule 3 Consultation

J G Wray — Tue, 09 May 2017 11:49:24 GMT

[quote user="Arlo Guthrie"]

[quote user="Iain Richards"]The college seem to want to have a nice list of exact tasks that nurses can do and exact offences that vets can transgress and so the machinery of the regulator is seen to be first-rate.[/quote]

I really don't believe it's about that. I think it's about making better use of employees' time and skills.

[/quote]

Mild conspiracy theory

The RCVS is highlighting areas where the VSA is "deficient", areas which they find hard to police i.e. problems for them. The RCVS accumulates "evidence" of the need for change. RCVS touts a consultation on the need for a new VSA.... oh they've done that as well.

All good news for RCVS. Marginal gains for the professions. It's just Schedule 3 stuff. My RVNs are leveraging their professional consultations so effectively at the moment, they are turning over 40-50% of a FTE VS, all without a new VSA or change in Schedule 3 and there's much more to come from them

RE: Schedule 3 Consultation

Arlo Guthrie — Tue, 09 May 2017 11:21:31 GMT

[quote user="Iain Richards"]There's a false sporting analogy that football is a rubbish game because it has rules, whereas rugby is a splendid game as it has laws. Both have laws, it's just that in rugby (union) the way the referee manages the game can make a massive difference to the quality of the game (at all levels).[/quote]

Take your point, and ordinarily I lean more in that direction myself. But in this case, I think there is evidence that many veterinary surgeons are interpreting (or interpretating, as someone said to me in a slightly Trumpesque way the other day!) the 'laws' in an overly restrictive way. A list of examples would be as much about educating everyone what is and isn't OK. I suspect they could never be prescriptive anyway, just examples.

I really don't believe it's about that. I think it's about making better use of employees' time and skills.

RE: Schedule 3 Consultation

J G Wray — Tue, 09 May 2017 09:04:38 GMT

[quote user="Iain Richards"]Whereas what we really need is a Nigel ("We haven't been introduced yet, I'm the referee") Owens. Someone who understands the game and can let it flow as a spectacle, as well as being capable of ruling over a serious misdemeanour. [/quote]

Favourite Nigel Owens quote

".. I'm straighter than that throw in.." pause whilst big hairy rugby players stop laughing.

RE: Schedule 3 Consultation

Iain Richards — Tue, 09 May 2017 08:54:00 GMT

There's a false sporting analogy that football is a rubbish game because it has rules, whereas rugby is a splendid game as it has laws. Both have laws, it's just that in rugby (union) the way the referee manages the game can make a massive difference to the quality of the game (at all levels). The college seem to want to have a nice list of exact tasks that nurses can do and exact offences that vets can transgress and so the machinery of the regulator is seen to be first-rate.

Whereas what we really need is a Nigel ("We haven't been introduced yet, I'm the referee") Owens. Someone who understands the game and can let it flow as a spectacle, as well as being capable of ruling over a serious misdemeanour. The VSA starts by stating that it is a bill,"for the management of the profession" So before we start being proscriptive, let's be a bit more imaginative. I suspect there is more leeway in the current, perhaps vague, VSA than we think.