Complaints regarding remote prescribing

RE: Complaints regarding remote prescribing

bob lehner — Mon, 07 Sep 2020 09:03:49 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225255#225255"]

Telling people to get product elsewhere was our punishment, even though no other business has to work in such a way. None of the arguments we presented worked and it was a bit of a stitch up.

There is an arguement that the internet has allowed a proliferation of sales outlets such that this burden could legitimately be lifted.

[/quote]

Yes - I remember at the time being totally amazed that the profession took it so lightly - we just seemed to just roll over with legs in the air like a moribund sheep.

To be honest I think it signalled the beginning of the end of the glory days of ownership of independent veterinary practice - and been pretty well going downhill ever since.

RE: Complaints regarding remote prescribing

Iain Richards — Sun, 06 Sep 2020 09:50:27 GMT

From memory Bob, the CC said that if the overall spend went up, it didn't matter because the consumer had freedom of choice. We tried the arguments of medicines not being smarites, and the, "how do you support OOH". THe latter is written in the report as, "not being particulalry onerous". Part of their reasoning was that by using mark-up (less than most holiday bric-a-brac) to subsidise our businesses, we aactually gave a false impression of costs with lower consult fees.

RE: Complaints regarding remote prescribing

Bob Russell — Fri, 04 Sep 2020 13:48:51 GMT

Not to mention that most practices had little clue that this was going on in the background!

A 50% mark up was/is about the right level to cover storage/wastage plus disposal of medicines that go out of date. This was never a reflection of profiteering and the Competition Commission should have been better educated.

OK it did result in higher fees so really the client gained little.

RE: Complaints regarding remote prescribing

Iain Richards — Fri, 04 Sep 2020 09:06:55 GMT

[quote userid="13609" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225252#225252"]Why?[/quote]

The why is because the Competition Commision investigated the selling of POMs in 2003 and found that the profession operated a complex monopoly to keep prices high. (A complex monopoly beng a pattern of behaviour rather than price fixing - so everyone marked up about 50% on list). Telling people to get product elsewhere was our punishment, even though no other business has to work in such a way. None of the arguments we presented worked and it was a bit of a stitch up.

There is an arguement that the internet has allowed a proliferation of sales outlets such that this burden could legitimately be lifted.

RE: Complaints regarding remote prescribing

Andreas Ege — Fri, 04 Sep 2020 00:25:30 GMT

[quote userid="6897" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225208#225208"]5 '.The client being unaware of the ability to purchase medication elsewhere following a diagnosis' All practices should have this information displayed in the waiting room where the client can see it[/quote]

Why?

If I take my motorbike to a garage, they don't tell me if the spare parts are cheaper somewhere else. Neither does the supermarket for my milk. Nor the electricity provider for my electric power. Or the.... you get the drift.

Why should I, as a vet, do the legwork for clients that they can get medications (or services, for that matter) cheaper somewhere else?

Don't get me wrong, I'd rather have practices make their money using their core skills - knowlegde and medical/ surgical expertise, rather than selling drugs or food (ok, I have it easy saying that, I'm a locum ;-) ). But I really don't see why vets, as far as I can see as the only profession or business, has to educate clients that they can get it cheaper somewhere else.

Hell, I don't even get an estimate at any garage I've ever been unless I ask.

RE: Complaints regarding remote prescribing

David Mills — Wed, 02 Sep 2020 20:38:15 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225226#225226"]Crusty old farts like you and I can do phone consults well, the less expericned struggle.[/quote]

Ahem, I'm only 37 next week!

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225226#225226"]Corona will not be here forever, so normality will resume[/quote]

It may not be, but there have been some changes during the pandemic that I suspect are here to stay. As I say, there are huge efficiencies in having people working from home from management to vets and nurses. Whereas there may be a limit in these in our profession, it may well change the make-up of cities and towns, which will affect the profession in some ways.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225226#225226"]"Virtuous notions"?[/quote]

Potato/potato. I've heard vets who've never done ear cytology in their lives now seeing it as the de facto reason to see an ear case. Similarly, organisations who have been quite happy poaching clients now throwing toys out their prams about 'under our care' and 'welfare'. I'm not saying this is you, but it does make me smile wryly how quite moral some people in the profession have become during covid!

RE: Complaints regarding remote prescribing

Beats — Wed, 02 Sep 2020 20:25:37 GMT

Is the blurred line in this not at what point a patient is under the care of a bricks and mortar clinic?

1, Only if vet prescribing is personally familiar

2. Only if vet prescribing is mainly works in the same building as a vet who is personally familiar with the pet, and has a good knowledge of how that vet works and can read into their notes their meaning.

3. Only if vet prescribing mainly works in same building as a vet who is personally familiar with the pet, with reference only to the notes left by that colleague and without necessary having a personal working relationship with that vet.

4. Only if vet prescribing works within the same building, or a branch practice thereof (within 40minutes drive), as the vet who is familiar with the patient and has access to any previous notes.

5. Only if vet prescribing works within the same building, or a branch thereof (irrespective of distance), as the vet who is familiar with the patient and has access to any previous notes.

6. Only if vet prescribing has, on at least one occasion, set foot in any of a very large group of practices covering a large geographic area, at least one of which has a vet within it that has personal knowledge of the pet.

7. Only if vet prescribing has a vague association with a group of bricks and mortar clinics at one of which the pet is registered and could attend if needed, and could, theoretically at least, personally see that pet within the next week in person.

8. Only if vet prescribing has a vague association with a group of bricks and mortar clinics at one of which the pet is registered and could attend if needed, and pays taxes in the UK and is registered with the RCVS irrepsective of where in the globe they are working from.

9. Only if vet prescribing has a vague association with a group of bricks and mortar clinics, and the pet could, at least in theory, be seen at one of those bricks and mortar practices within 24 hours.

for each scenario, could split into:

a) prescribing a medicine that has previously been prescribed, or for a condition that has previously been diagnosed.

b) prescribing a medicine that has not previously been prescribed, or for a condition that has not previously been diagnosed.

I'm not quite sure how one distinguishes between OK to prescribe without physical exam of patient and tie this to being registered at a bricks and mortar clinic without some clear limitation to what this means. Remote prescribing from a bricks and mortar clinic could easily mean (9b) to some, while I suspect others would consider this to be "pure" remote prescribing to which they are against (even if in favour of themselves being able to prescribe to patients registered at the single building they work from). The issue would maybe be that there are reports of veterinary clinics not run by vets? And at what point does one propose making the cut-off between a rural practice with a 2 day a week branch in neighbouring village and a large corporate entitiy with clinics within one hour of 90% of pets (hypotehtically speaking) and owning an online veterinary pharmacy? Or is that OK because the only ones to be excluded are those without ties to a large chain of veterinary clinics (or smaller chain in a more localised environment)?

RE: Complaints regarding remote prescribing

Iain Richards — Wed, 02 Sep 2020 19:25:41 GMT

I thikn we are slighlty at cross purposes David, "the issue" is the ill-defined telemedicine that has been discussed for the last three years. I'm absolutely with you that more folk could be using video consults certainly for all follow-ups that are nice and stable. Crusty old farts like you and I can do phone consults well, the less expericned struggle.

Corona will not be here forever, so normality will resume. "Virtuous notions"? I prefer to call them professional responsibilty!

RE: Complaints regarding remote prescribing

David Mills — Wed, 02 Sep 2020 17:21:17 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225217#225217"]Fair comment, but the issue predated Covid.[/quote]

?! The 'issue' of what?

Current restrictions mean that people have to maintain physical distancing where possible at work, with colleagues, members of the public, everyone. This limits, if people observe govt guidance, the capacity on-site - we are currently running at about 20% of pre-covid levels of F2F client interactions. For instance, we have a capacity in our hospital of about 40% of workforce pre-covid, we can only use 1/6 consulting rooms.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225217#225217"]but you also have a client base and a business structure that is very differnent to most practices.[/quote]

I hear this a lot, but it isn't that different in a charity compared to a busy similarly-staffed private hospital.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225217#225217"]So I come back to the Why? Why work on a limited platform?[/quote]

As I've tried to explain, because of necessity, otherwise you would leave large swathes of animals untreated. I'm sure some places aren't using it, but they are walking a HSE tightrope.

There is a resistance to remote consulting, and many of those that I hear it from haven't done it, or put obstacles in the way of it. Why not ask how it can help, and how people can get better at it, than retreat to a shifting bunker built on virtuous notions of 'under my care' etc?

RE: Complaints regarding remote prescribing

Iain Richards — Wed, 02 Sep 2020 17:01:24 GMT

Because, currently, it is impossible for practices in most cases to both practise physical distancing and running a service 'as normal'.

Fair comment, but the issue predated Covid. You've had a positive experience, possible becaue you are expereinced, but you also have a client base and a business structure that is very differnent to most practices. IN answer to your other points, I'd say "telemedicine" is poor medicine, or perhaps it's better to say it is a poor subsitite for good medicine (NOT "gold" standard, I hasten to add). The poor expereince is a combination of both the humna aspect and the undeniable limitations of remote interaction. So I come back to the Why? Why work on a limited platform?

RE: Complaints regarding remote prescribing

David Mills — Wed, 02 Sep 2020 16:48:09 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225213#225213"]and the results are very variable. [/quote]

Are they? If so, do you think it's a problem with those conducting them or the concept itself?

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225213#225213"] GP friend feels they are, "poor medicine" with a for instance of overprescribing antibiotics for sore throuats, just in case it is a septic tonsilitis[/quote]

This is a misuse of remote consultations, not a fundamental problem with them. GPs and antibiotic overuse isn't a new thing.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225213#225213"]"Why?" What purpose does it serve?[/quote]

Because, currently, it is impossible for practices in most cases to both practise physical distancing and running a service 'as normal'.

RE: Complaints regarding remote prescribing

Iain Richards — Wed, 02 Sep 2020 15:38:12 GMT

The Covid pandemic has provided an unintended beta-test for remote consultations and the results are very variable. Most of what I have heard is that they are very limited in their scope, even when all aspects are ideal (compliant patient, good connection, sensible owner etc. A GP friend feels they are, "poor medicine" with a for instance of overprescribing antibiotics for sore throuats, just in case it is a septic tonsilitis (Looking into mouths is a "banned" prodcedure at present).

The comments here have made me re-ask the question - "Why?" What purpose does it serve?

RE: Complaints regarding remote prescribing

patrick murphy — Wed, 02 Sep 2020 15:11:50 GMT

I completely agree with everything said by Malcolm, and especially registrar actions. what now about re-certification to maintain our status along with the medical profession. who certifies the certifiers? and will they not just recruit specialists to assess us who in turn are somewhat removed from the day to day matters that we all have to deal with?

RE: Complaints regarding remote prescribing

bob lehner — Wed, 02 Sep 2020 13:29:41 GMT

Looking at the 'concerns' listed:

1. 'Client concern that the medication was incorrect or unnecessary (misdiagnosis concern)'. May or may not be true - but does anyone seriously think that remote consultations will not lead to increased misdiagnosis?

2..'The vet concluding they cannot prescribe a treatment based on a telephone, video or photographic consultation and the need for a in person consultation;'. Totally reasonable for the vet to refuse to precribe if not happy that he/she cannot arrive at a proper dianosis without seeing the animal.

3.'The cost of providing a prescription'. This is just a commercial decision made by the practice - no different from any of its other charges.

4. 'The cost of the prescription itself'. Again just a commercial decision by the practice. Clients are free to shop around if they want to.

5 '.The client being unaware of the ability to purchase medication elsewhere following a diagnosis' All practices should have this information displayed in the waiting room where the client can see it and can then make thoir own decision as to where they obtain medicines.. Of course it wont be obvious via a remote consultation unless the VS specifically mentions it - which on the whole he/she is unlikely to do unless asked..

In my opinion every remote cosultation should carry a warning as to its limitations.....

RE: Complaints regarding remote prescribing

Clive Ansell — Wed, 02 Sep 2020 13:09:12 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing"]

No word on the absolute number of 'concerns', but they included:

Client concern that the medication was incorrect or unnecessary (misdiagnosis concern);
The vet concluding they cannot prescribe a treatment based on a telephone, video or photographic consultation and the need for a in person consultation;
The cost of providing a prescription;
The cost of the prescription itself;
The client being unaware of the ability to purchase medication elsewhere following a diagnosis.'

[/quote]

Surely non of these would amount to professional misconduct, so not RCVS territory ?

3, 4 and 5 are purely customer service issues, avoidable with communication.

2 is common sense, related to the limitation of a remote consultation.

1 may be the basis of a complaint, but again if the limitations of a remote consultation are pointed out at the onset (i.e no examination is taking place) it is avoidable. In any event, not an RCVS issue. It is also important at the onset to differentiate between misdiagnosis, missed diagnosis, and diagnosis not yet reached (because client will not invest in diagnostic work to do so)

RE: Complaints regarding remote prescribing

David Mills — Wed, 02 Sep 2020 12:59:19 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing"]Any case in which there is an alleged misdiagnosis, and consequently the possible inappropriate dispensing of pharmaceuticals, might reflect on either the clinical competence or judgement of the veterinary surgeon involved. Misdiagnosis and inappropriate treatment could easily compromise the welfare of the animal under care, even if only by delaying the initiation of more suitable therapy. Anything that compromises the welfare of an animal under treatment should be considered a potential disciplinary matter.[/quote]

Overstated. Misdiagnosis in itself, as the VDS will tell you, is not an act of negligence if the diagnosis (whether wrong or otherwise) is made in a reasonable manner. Missing a foreign body, for instance (if it's in the stomach rather than the intestines) would be a neat example. Telemedicine should be considered on its own merits, with its own restrictions, in exactly the same way as a clinical examination's limits are considered in any negligence claim.

These kind of muddying statements are unhelpful.

RE: Complaints regarding remote prescribing

Evelyn Barbour-Hill — Wed, 02 Sep 2020 12:55:39 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing"]The vet concluding they cannot prescribe a treatment based on a telephone, video or photographic consultation and the need for a in person consultation;[/quote]

That's surely quite the opposite of a cause for complaint!

RE: Complaints regarding remote prescribing

Bob Russell — Wed, 02 Sep 2020 10:37:23 GMT

Thankfully Nockolds don't use the term concerns but actually the correct term, complaint.

There may be concerns regarding the health and welfare of veterinary staff or client but a complaint that the service offered has been poor/expensive/inadequate.

I have a complaint running with Amazon relating to bad handling of a problem. I have no concerns at all for Amazon!! It will continue to offer lousy service whatever the outcome of my complaint.

'Call me Nick' was so damaging to our profession because he just did not get that this is a profession to be regulated. He was more concerned about customer 'service'.

RE: Complaints regarding remote prescribing

Chris Barker — Wed, 02 Sep 2020 10:06:01 GMT

[quote userid="2100" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225177#225177"] I wondered whether there are circumstances where complaints (God I hate them being called 'concerns'. People don't make a concern, they make a complaint!) did not go through a triage system, but that you could take a problem direct to them?[/quote]

Clients ('Consumers') can take their complaint direct to Nockolds - indeed their website encourages this approach. However Nockolds are expected to make an initial assessment as to whether the 'concern' contains any allegations which could amount to professional misconduct, at which point they are meant to immediately refer the 'case' to the RCVS Prof Con dept. From the other side the RCVS is meant to perform a regular audit of concerns submitted to Nockolds to ensure that no matters of professional conduct are being missed by being misdirected down the mediation route.

Now all of this may be happening, but the press release offers no detail to confirm this

RE: Complaints regarding remote prescribing

Chris Barker — Wed, 02 Sep 2020 09:58:48 GMT

[quote userid="9239" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225186#225186"]I thought the DC was not interested in cases of misdiagnosis and inappropriate treatment except when it's repeated and serious[/quote]

Absolutely But this requires assessment, assessment by a panel which includes a vet so that the appropriateness of any treatment is checked

Nockolds have limited veterinary input and expressly should not be making the judgement as to whether a complaint regarding professional behaviour is, or is not, a disciplinary matter

RE: Complaints regarding remote prescribing

Malcolm Ness — Wed, 02 Sep 2020 09:20:31 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225185#225185"]Concern was so wrong![/quote]

It was, and it still is. The term is misleading and dishonest. Its adoption confirmed that control of the College had fallen into the wrong hands. RCVS has lost its way and any evidence of it being a functioning self-governing liberal profession is increasingly hard to discern. With hindsight, the re-organisation and consequent appointment of 'Call me Nick' the first CEO was a grave error. While the concept had some merit, there was a poor understanding of which parts of former failure were systemic and which were simply the consequence of an under-performing Registrar. The changes wrought by 'Call me Nick' (effectively neutering Council to facilitate the dismantling of a professional body and its replacement with a woke consumer-rights organisation) were disastrous.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing/225185#225185"]I hope in the LWP suggested reforms it is restored to complaint[/quote]

Me too. It would be a welcome sign that the tide had started to turn, though I fear that the rot is well and truly set and that any change in terminology might turn out to be nothing more than a sop.

RE: Complaints regarding remote prescribing

Dinu Catilina — Wed, 02 Sep 2020 08:25:33 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing"]Misdiagnosis and inappropriate treatment could easily compromise the welfare of the animal under care, even if only by delaying the initiation of more suitable therapy. Anything that compromises the welfare of an animal under treatment should be considered a potential disciplinary matter.[/quote]

Hi Chris, I thought the DC was not interested in cases of misdiagnosis and inappropriate treatment except when it's repeated and serious. So unless there will be multiple complaints against the same veterinary surgeon I can't see why the DC should be involved.

If the complaints are of financial nature (I speculate they might be) from clients wanting for example refunds then the mediation service may be appropriate?

RCVS however can draw conclusions from this and I hope they do.

RE: Complaints regarding remote prescribing

Iain Richards — Wed, 02 Sep 2020 08:16:47 GMT

Concern was so wrong! I hope in the LWP suggested reforms it is restored to complaint

RE: Complaints regarding remote prescribing

Arlo Guthrie — Wed, 02 Sep 2020 07:09:45 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/29328/complaints-regarding-remote-prescribing"]I'm not sure from where this news release has come[/quote]

Morning Chris, the press release came from Nockolds.

When I read the release, I wondered whether there are circumstances where complaints (God I hate them being called 'concerns'. People don't make a concern, they make a complaint!) did not go through a triage system, but that you could take a problem direct to them?

But I'd be happy to go and check with them/the RCVS on this.