Professional dilemma

RE: Professional dilemma

grumpyoldman — Wed, 11 Apr 2018 21:58:39 GMT

[quote user="Clive Ansell"] anal glands, as well as sometimes triaging sick animals, without a veterinary surgeon being present.[/quote]

Yes ,and they miss things ,Anal sac carcinomas and FBs ,intussceptions particularly if it's the last appointment before the store closes. For us door opens a door closes etc.

RE: Professional dilemma

Clive Ansell — Tue, 10 Apr 2018 11:40:28 GMT

[quote user="An On MRCVS"]

I would appreciate opinions please.

My dilemma is that on some of the days I am not working, and they are unable to get a locum, nurses are carrying out appointments for second vaccinations and minor issues like nails and anal glands, as well as sometimes triaging sick animals, without a veterinary surgeon being present. I always thought this was against RCVS code, so should I ignore it, say something, leave or contact the RCVS for advice.

[/quote]

Guidance from the college is somewhat ambiguous, it just states that it would be helpful to have a veterinary surgeon on premises for nurses doing 2nd vaccines, not that it is, or is not, an absolute requirement.

Maybe voice your concerns, but beyond that it really isn't your problem when you are not at work.

I was in a similar position last summer, albeit as a locum and not a part time employee. It was a group of 8 clinics, where on some days up to 5 were closed as there were no vets to man them. I was uneasy carrying out surgical procedures not knowing from one day to the next whether there would be a VS to carry out requested post op checks. On some occasions animals were sent over from OOH providers, only to have to be sent elsewhere in a game across the west midlands of find a vet. An unsatisfactory situation all round.

In the end I declined all but the simplest of procedure if I was not happy there would be adequate follow up. I don't know where the line of responsibility for ongoing care begins and ends, and once again the guidance is vague. OOH care was straightforward, as an external provider was used, but it was care within the working day that was the issue.

From RCVS code. Vaccination of companion animals

18.10 To give a first vaccination with a POM-V medicine, the animal must be under care of the prescribing veterinary surgeon (see the supporting guidance on the meaning of ‘under his care’) and the veterinary surgeon must carry out a clinical assessment (see the supporting guidance on the meaning of ‘clinical assessment’) and then the veterinary surgeon may administer, or under his or her direction, a veterinary nurse or student veterinary nurse may administer (see paragraph 18.5). If the veterinary surgeon is to certify the vaccination, the certification rules apply (see the supporting guidance on certification) and generally he or she must do it him or herself or witness it done.

18.11 The subsequent vaccination some two weeks or so later (close in time to the first vaccination) is usually authorised by the veterinary surgeon at the time of the first vaccination (directed by the veterinary surgeon when the animal is under his or her care and when the clinical assessment is carried out), and therefore the administration of this second vaccination and all dealings may be through a veterinary nurse or student veterinary nurse at the practice, provided the veterinary surgeon is not intending to certify this vaccination. Nevertheless, it is helpful for a veterinary surgeon to be on the premises at the time the vaccine is administered to the animal, to be able to assist in the event of the animal suffering an adverse reaction.

18.12 For booster or subsequent vaccinations not close in time to the first vaccination, the advice is the same as for the first vaccination (see paragraph 18.10).

RE: Professional dilemma

Bob Russell — Tue, 10 Apr 2018 11:13:40 GMT

Our nursing staff do happily deal with flea related conditions. Advise on acute GI issues and a lot more besides. They always have!

They advise on management, training and many behaviour issues. Good dietary advice, worming, blood pressure checks etc etc. Highly skilled anaesthetists, dental technicians, the list goes on.

What they are not are cut-priced mini-vets although the allowable skills can be extended.

I don't think a nurse should be doing vaccinations without a vet on site. What happens if there is an acute reaction and where would the responsibilities lie in this unlikely event?

A pharmacist is a very highly qualified person with a thorough knowledge of medicines and what to do in such an acute emergency. They also have 999 to ring!

I would love to move the clock back and put a named veterinary surgeon in the hot seat for any events in a practice. I would happily (and selfishly) like to see a ban on non-vet owners plus a reintroduction of naming practices as there was in the old Guide to Professional Conduct. No more 'Only Vet in the Village'!

Obviously just dreaming!

RE: Professional dilemma

Mark Hedberg — Tue, 10 Apr 2018 10:40:52 GMT

[quote user="Chris Barker"]

Training for our RVNs will have to be revolutionised, given that our current cohort are not even automatically qualified as SQPs as no-one seems to have thought to argue their case at the time the system was put in place…

[/quote]

Excellent comment, but a lot of nurses at the time argued that RVNs should be allowed to be SQPs :)

Not an official statement, of course, but noise was made!

RE: Professional dilemma

Clive Ansell — Tue, 10 Apr 2018 10:26:31 GMT

[quote user="Julie Innes"]I don't want to put a young bitch to sleep with a pyo. All very well saying its the owners fault, but you can't enforce a rule that only wealthy people have animals. Even insurance is becoming too expensive for some people now (? thanks to vets charging more and more?)[/quote]

So who's fault is it then, Dennis Compton's ? , if an owner chooses not to get their bitch speyed and it later develops a pyometra the responsibility for that is 100% theirs. Getting a bitch speyed is still stupidly cheap in many areas, some places still <£100. There is no excuse.

RE: Professional dilemma

Richard Carter — Tue, 10 Apr 2018 10:05:55 GMT

Lots of problems with some of the comments made - stop trying to close the doors and look towards a veterinary team rather than vets vs nurses

[quote user="Chris Barker"]But as soon as the animal concerned has clinical issues (eg. hypersensitivity, alopecia, self-inflicted dermatitis etc) this strays into the area of diagnosis/treatment which, until the Vet Surgeons Act is changed, remain the preserve of the veterinary surgeon.[/quote]

Time to change the Act then - RVNs can quite successfully deal with flea allergic disease, first presentation gastro-enteritis without needing access to POMs. Clients can diagnose, the breeder can diagnose. We as vets have to be the best option not the 'legal' option

[quote user="Chris Barker"] should be recognised at this first contact/first consultation[/quote]

Think you harking back to a 'golden' James Herriot era when the vet wore a tie and was king (or queen) and in charge - RVNs should be able to detect abnormalities and refer back to a RCVS.

[quote user="Chris Barker"]VS no longer interested in establishing the relationship between new client, new owner, new puppy/kitten and their practice, for in the end it is the quality of this relationship [/quote]

Many practices are now not owned by vets, the hours open are longer than an 8 hour working day which I remind you is a legal obligation so the vets are working shifts and rotas and multiple vets either within the practice or with OOH external input are dealing with patients and clients.

Some of us in more rural practices may still have the one to one client/vet relationship but for most clients these days, the vet has become just the next one available.

You are also missing the point that a good RVN is as good at building confidence in the practice as any vet

RE: Professional dilemma

Bob Russell — Tue, 10 Apr 2018 09:30:27 GMT

I do the first vaccs. I do the second and third ones. I even do the 'FOC' flea checks on a Wednesday.

Our clients pay for the service and expect it.

I do respect the qualifications of RVN's and find it is appalling that they do not even meet the requirements to automatically be able to perform the role of an SQP!

Clients can be fleeced by the apparent budget practices (which are not most of the time). The PDSA do offer true 'affordable' care but this is often abused by clients too tight to pay full fees.

'Affordable veterinary care' is complete bull. What they are meaning is that pets should be cheaper to keep! Not at all what it should be - a luxury.

For those that hit hard times then some sort of back up is helpful (charities) but most needing affordable pet care should not be buying pets especially French Bulldogs or designer mongrels.

RE: Professional dilemma

Wren — Tue, 10 Apr 2018 09:12:47 GMT

[quote user="Iain Richards"]

Excellent comments as ever from Chris and JG.

Where is the drive for, "affordable veterinary care" coming from? It was here before the Labour party stuff on welfare, so what's been the driver? It also seems to be mostly small animal practice, I'm not aware of it in farm work and it seems illogical for the equine lot!

Thoughts?

[/quote]

You'd think it would be illogical, but we're as much under pressure from our clients as anyone else. An awful, awful lot of people can't really afford to keep horses. Maybe they're just keeping the boat afloat when everything is going well, but one or two unusual expenses and the whole thing suddenly becomes beyond their means. I find a lot are simply juggling which bill to pay this month, and which to put off. And for a lot of people the first cut they make is to cancel their insurance... We get a lot of hassle over the cost of re-checks and repeat blood tests for monitoring those on long term medication.

RE: Professional dilemma

Julie Innes — Tue, 10 Apr 2018 09:09:21 GMT

[quote user="Iain Richards"]Where is the drive for, "affordable veterinary care" coming from?[/quote]

I think it is in response to those of us who get upset by the "vets are only interested in making money", and seeing animals that we could help, but can't. I don't want to put a young bitch to sleep with a pyo. All very well saying its the owners fault, but you can't enforce a rule that only wealthy people have animals. Even insurance is becoming too expensive for some people now (? thanks to vets charging more and more?)

It's a difficult one. I can see we don't want to sell ourselves short, but I do think we need to be overly greedy either

RE: Professional dilemma

Iain Richards — Mon, 09 Apr 2018 19:53:40 GMT

Excellent comments as ever from Chris and JG.

Thoughts?

RE: Professional dilemma

Neil Wheadon — Mon, 09 Apr 2018 17:59:16 GMT

[quote user="J G Wray"]We have steadily being moving toward a pricing structure where there is only one charge for a veterinary surgeon consultation, so that it is clearly something other than a commoditised service event.[/quote]

Interesting comment this one. On a recent locum I was looking for the repeat consult and the owner told me they'd done away with it a few years ago and no-one had noticed

Neil

PS However I have just seen a client who has moved practices with 2 dogs on long term medication and although you're dying to ask why they moved, (I NEVER do) he did let it slip right at the end that it was a rise to £18 in the prescription price, so maybe my comment above needs to be taken in context, as they may simply stop coming.

RE: Professional dilemma

J G Wray — Mon, 09 Apr 2018 12:46:34 GMT

[quote user="Chris Barker"] And here I will stamp my foot and register my opposition. The first consultation is not simply a commodity to be knocked out at the cheapest rate possible.[/quote]

I'm not quite so forthright about this. We offer an introduction to the practice Free of Charge (FOC). We keep track of FOCs because they crucify turnover, and have a clear justification for those that we have. This is a consultation with a veterinary surgeon.

I have just pulled a price list and looked at the margins on our vaccinations, in other words that part of the fee which relates exclusively to professional input. It varies from (ex VAT) £1.76 to £23.60, with most sub £10. Our consultation fee is £39.93.

There are fees which are commoditised and vaccinations along with neutering are the most obvious in GP.

There will only be more competition and downward pressure on these.

We have already discussed what happens when the prices are forced downward and the answer, for us, lies in divorcing what is clearly an interaction with a veterinary surgeon and gaining their professional expertise from the provision of one of these services. We have steadily being moving toward a pricing structure where there is only one charge for a veterinary surgeon consultation, so that it is clearly something other than a commoditised service event.

This way of thinking is an evolution from the long held and largely LA mentality of supplying drugs and charging the client a professional fee whilst they are there, but is the only way forward I can see and largely borrows from the drivers in Corporate practice, for established practices working at capacity.

Our service : drugs income ratio is 70:30 That's a comfortable place to be, for now, but it takes time and determination

[quote user="Chris Barker"]And I would find it sad should the drive to empower RVNs reflect a growing cadre of VS no longer interested in establishing the relationship between new client, new owner, new puppy/kitten and their practice, for in the end it is the quality of this relationship which protects the welfare of the animals under our care.[/quote]

Our RVNs are fee generators. We charge for their professional time and empower them significantly, but the comment that this reflects a growing cadre of VS who do not wish to interact is patently untrue. There is nothing lost.

Two of our RVNs are going for SQP status, because that's what they've decided their CPD should be. I have no idea, until they show me, whether this will improve the practice, make it progress, but they know that it doesn't really matter, that it's OK for it to be a damp squib, because at least it's an evolution of what we do. Sticking to inflexible thinking around pricing, commoditisation, leveraging RVNs, repeating previous behaviours and attitudes and expecting a different outcome or safety from competition, now that's madness.

RE: Professional dilemma

Evelyn Barbour-Hill — Sun, 08 Apr 2018 21:28:48 GMT

[quote user="Chris Barker"] To me, the involvement of a VS at this initial consultation/initial assessment is vital - there is so much to be checked, be it congenital eye disease, tooth mal-alignment, congenital cardiac disease, etc, all of which deserve to be, no, should be recognised at this first contact/first consultation. [/quote]

Quite so. As it is also vital at the second vaccination and at each of the free monthly check-ups until six months old that follow. (You do all do that sort of thing, don't you?)

RE: Professional dilemma

Chris Barker — Sun, 08 Apr 2018 20:03:06 GMT

[quote user="Michael Woodhouse"]The difference is much greater for an experienced vet. If we were using nurses in this way then I'd charge the same as I would for a vet.[/quote]

But this is not how the mooted role of the nurse practitioner/nurse prescriber role is being ‘sold’. The argument runs that if the profession were to properly support RVNs, to give them an expanded role, then they could provide the service at lower cost to the public (and thereby ‘broaden access to veterinary services’ by serving those who are financially compromised) while freeing up vets to focus on more specialised work (all supposing there is ‘more specialised’ work for us all to be getting on with, and that we as proud professionals want to give up on the mundane, like establishing a long-term relationship with our clients and their pets…)

Let me say at the outset that I have no issue with suitably trained RVNs prescribing certain parasiticide drugs, on a preventative basis to an agreed protocol. But as soon as the animal concerned has clinical issues (eg. hypersensitivity, alopecia, self-inflicted dermatitis etc) this strays into the area of diagnosis/treatment which, until the Vet Surgeons Act is changed, remain the preserve of the veterinary surgeon.

The suggestion has been floated that the nurse practitioner should be allowed not only to perform 2nd primary vaccinations but also 1st primaries. And here I will stamp my foot and register my opposition. The first consultation is not simply a commodity to be knocked out at the cheapest rate possible. To me, the involvement of a VS at this initial consultation/initial assessment is vital - there is so much to be checked, be it congenital eye disease, tooth mal-alignment, congenital cardiac disease, etc, all of which deserve to be, no, should be recognised at this first contact/first consultation.

A lot will have to change before nurses can be given the nod to dispense/to vaccinate ‘off their own bat’. The majority of our drugs/vaccines are POM-Vs and are licensed as such on the strict understanding that it will be vets that will be administering them. Training for our RVNs will have to be revolutionised, given that our current cohort are not even automatically qualified as SQPs as no-one seems to have thought to argue their case at the time the system was put in place…

I find myself siding with the gentleman of the parish who reminds us that profit for a practice is essential so that it can properly provide veterinary care to its clients. And therefore I would agree with Michael who would charge exactly the same whether it be a vet or a nurse that provides the service. For however the dispensing of POM-Vs is organised, the same professional decisions will need to be made, the same indemnity cover held by the practice in case of adverse effect, and the same profit made in order to support the business model which serves to provide the practice staff and premises that provide service to the client

I would challenge the contention that if practices were to lower costs for the dispensing of parasiticides etc that it would increase access to professional service. The public can already obtain serviceable parasiticides through the POM-VPS stream without ever needing to visit a veterinary clinic. The cost of primary vaccinations is already subject to significant financial competition between neighbouring practices. If access to this service can only be increased by dropping the price further, then we are doing a disservice to animals of those owners who can/will only partake of this service at ‘rock-bottom’ prices. For if such owners cannot currently meet the costs of vaccination then they risk being wholly unable to meet the potential costs of treatment for future accident/illness of their pet. Perhaps we should be dissuading them from taking on the responsibility of pet ownership rather than encouraging them with loss-leading primary vaccination prices?

And I would find it sad should the drive to empower RVNs reflect a growing cadre of VS no longer interested in establishing the relationship between new client, new owner, new puppy/kitten and their practice, for in the end it is the quality of this relationship which protects the welfare of the animals under our care.

RE: Professional dilemma

grumpyoldman — Sun, 08 Apr 2018 00:03:14 GMT

It does seem to be becoming more common as nurses take on the role of JVP too. I have answered our Ooh emergency line a few times on bank holidays and had a JVP nurse request histories for patients with ears and skin problems. When I asked to speak to the vet ,they were not present that day, they became quite defensive and evasive about who was in charge and supervising them. This was always going to happen when they were given JVPs, with financial pressure on them the temptation to overstep the mark probably irresistible.

As the MRCVS insitu you are probably going to be accountable for what is going on around you so make sure you have covered yourself , and get work elsewhere ASAP.

RE: Professional dilemma

Michael Woodhouse — Sat, 07 Apr 2018 21:56:02 GMT

[quote user="Anthony Todd"]Should vaccinations etc be cheaper if done by "only" a nurse?[/quote]

A nurse earning £20,000 per year costs the practice £1.81 per 10 min appointment

A new grad vet earning £30,000 per year costs the practice £2.71 per 10 min appointment

(based on 46 weeks of chargeable work with a 5 day week and a 8 hour day)

The difference is much greater for an experienced vet. If we were using nurses in this way then I'd charge the same as I would for a vet.

RE: Professional dilemma

Rob Loxley — Sat, 07 Apr 2018 17:54:52 GMT

[quote user="Anthony Todd"]Should vaccinations etc be cheaper if done by "only" a nurse?[/quote]

Depends what you are pricing on; generally we charge for professional time taken & drugs used (and overheads and profit etc need factoring in)

RE: Professional dilemma

Anthony Todd — Sat, 07 Apr 2018 15:43:01 GMT

Should vaccinations etc be cheaper if done by "only" a nurse?

RE: Professional dilemma

Nicola Cole — Sat, 07 Apr 2018 14:33:20 GMT

[quote user="Michael Woodhouse"]

Anon wasn’t giving an opinion on whether they should be doing it or not, just asking whether it was against the rules.

RE: Professional dilemma

J G Wray — Sat, 07 Apr 2018 13:56:15 GMT

[quote user="Michael Woodhouse"]I think we get ridiculously protectionist when it comes to some of these things and it makes us look silly as a profession.[/quote]

Who makes the rules? Is it the profession?

Who could change the rules? Is it the profession?

Why should we put up with being made to look foolish?

RE: Professional dilemma

Michael Woodhouse — Sat, 07 Apr 2018 13:24:39 GMT

I think we get ridiculously protectionist when it comes to some of these things and it makes us look silly as a profession. There is no reason a qualified nurse shouldn't be doing 2nd vaccinations even as the only person in a building. We are quite happy farmers vaccinating their own livestock. Personally I'd be quite happy a VN doing all vaccinations and health checks and referring to a vet if they found abnormalities.

Triage is clearly in their scope of competence. No reason they can't even speak to the vet on the phone with their findings and some initial medical treatment be prescribed (I'd be happy our student nurse starting fluids and giving analgesia after speaking to me). We are a mixed practice so there can be long periods in the day when there is not a vet in the building but that doesn't stop people coming to the door with sick animals. They likely wait less time that you would in A&E with the same condition.....

Lets embrace nurses as a profession and give them some more responsibility. Vaccination and flea and worm prophylaxis are obvious gains. Castrating cats is so easy they clearly should be doing that (when a untrained farmer can legally cut a calf, lamb or piglet). We didn't get super-powers the day we graduated.....

RE: Professional dilemma

Linda Filshie — Sat, 07 Apr 2018 11:05:04 GMT

[quote user="Nicola M"]

Human example so may be different but at my local GP practice the nurse isnt allowed to administer a vaccine unless a doctor is in the building.

[/quote]

Yet isn't it odd that you can go to the Tesco (other supermarket chains are available) pharmacy and get the 'flu vacc with only the pharmacist and some shelf stackers to help if you have a reaction

RE: Professional dilemma

Anthony Todd — Sat, 07 Apr 2018 10:52:36 GMT

[quote user="Nicola M"]

Human example so may be different but at my local GP practice the nurse isnt allowed to administer a vaccine unless a doctor is in the building.

[/quote]

At our local GP practice there is a notice saying something like "only see the doctor if you are really ill, otherwise you will see the nurse".....

If doctors are paid on a per capita basis, and not what they actually do, no wonder most of the time there are no appointments with your preferred doctors.....

RE: Professional dilemma

Richard Carter — Sat, 07 Apr 2018 10:02:41 GMT

so we have had the official line from the great and the good and it follows the usual 'vet responsible etc...'

I do think we need a revision of responsibilities

Under care should literally mean the animal that is in your surgery under your direct care - i.e you and your staff are taking care of it. It should not mean the nebulous telephone call from someone unable or unwilling to get their animal in with a list of problems that really is not the responsibility of anyone else.

Your nurse or receptionist is triaging every time there is a request for an appointment over telephone so lets not get too precious about a nurse who is a professional and trained person having a look at a patient and deciding whether it needs to be seen by a vet or it is something minor and can be stabilised under a first aid category. This needs to be revised and the 'only a vet' rubbish really needs updating. Nurses, trained auxillaries used to be able to do stitch ups, they used to do superficial first aid, even cat castrates. Certainly in other countries nurses perform GAs independently of vets while the vets are operating on other patients.

Think we can be too precious about out perceived position on this planet. As Antony mentioned on another post - we used to be historically one step up from the farrier and knackerman.

RE: Professional dilemma

J G Wray — Sat, 07 Apr 2018 07:18:24 GMT

[quote user="Chris Barker"]

So should you telephone the RCVS for advice? Yes, you should, and if you do not receive sufficient guidance to help you understand your responsibilities under the Code of Conduct then please do get in contact with me.

[/quote]

If you contact RCVS, then the department is no longer called Professional Conduct, it’s something like Professional Standards and something.

Don’t forget to follow VDS guidelines for speaking to RCVS. Make sure you take notes, date and time of contact and get the full name and status of the person you speak to. They have a habit of expecting you to give your full name and contact details yet only offer their forename.

There has been a previous discussion about this so called “whistle blower” obligation. At least one person expressed concern for the “whistle blower” and what happens to them afterwards. There is no clear understanding how RCVS will handle the information they receive. If an investigation were undertaken, for instance, natural justice rules would dictate that a vet accused of misconduct would be allowed to know their accuser.

If What seems a cut and dried case of misconduct to a “whistle blower” were actually more nuanced or difficult for RCVS to proceed on, then the “whistle blower” may be in a very difficult position in respect of their employment contract and certainly with their work colleagues. RCVS can offer no protection.