out of hours provision

RE: out of hours provision

Anthony Todd — Fri, 30 Apr 2021 19:20:00 GMT

[quote userid="7269" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230158#230158"] with half days and personally hate them[/quote]

Back in the day shops, certainly in Ruislip, had half days, I think Tuesday, and so did the vets. Most annoyingly unattractive as inevitably there was "something to do" just before you go, or on your way...!"

Got to be "Don't go the work until the day after tomorrow," SIGH!"

RE: out of hours provision

Joyce Whitehead — Fri, 30 Apr 2021 17:51:18 GMT

Ian if I can make a suggestion (which might be hard to achieve until you are fully staffed), I’d be inclined to see if you can go to 4 day weeks if ooh is included. I’ve worked in practices with half days and personally hate them, so many times you don’t get away on time, and it barely gives you time to do anything meaningful. We offer a full day off a week, and 2 for a weekend worked, and have had 6 or 7 applicants for our current vacancy (advertised on here and fb only).

RE: out of hours provision

ian bates — Fri, 30 Apr 2021 10:30:57 GMT

I have to wonder whether the new grad schemes are actually making it worse too. Those on the IVC scheme are not allowed to start on the OOH rota until they have been in Practice for 6 months. This just re-enforces the mindset that 'OOH is just so hideous you cannot possibly cope with it'. Many do not even try and actively seek no OOH jobs.

Historically, we would avoid a NG being on the OOH rota for the first month, then they would be on call with a director for the next 6 months - Director attended if the new grad needed us eg cow c section / GDV etc - and we were always on the phone for advice.

I would argue that is still a better approach that just being completely shielded.

RE: out of hours provision

Neil Wheadon — Fri, 30 Apr 2021 09:17:31 GMT

There are 2 threads to this at the moment, they intermingle

The question I have is 'What will be the signs that the system is under stress?'

Vets have an ability to cope with everything that are thrown at them in the very short term, squeezing in that pyometra at 1600 is a good example, but longer term it's an unwillingness to keep on doing that.

There's reference in this thread to an OOH closing due to staffing issues and the original poster saying that a new one had opened up, so the situation is still fluid. Setting one up is easy, you can delay until you haver the staff, keeping them is another matter as the churn rate in OOH centers shows.

My impression is the OOH center I worked in has got significantly busier but the staffing may not have reflected that. So what are the early warning signs?

Closure, Churn rate....

Neil

RE: out of hours provision

Richard Carter — Fri, 30 Apr 2021 09:06:20 GMT

[quote userid="2131" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230114#230114"]Maybe their professional education should have been better[/quote]

The British schools actively teach students to avoid jobs with ooh and then there is is reinforcing from peers where things didn’t go well and the constant geeing up what the vds, RCVS, client, boss, corporate leaders (take your pick) and you in a constant state of anxiety and depression before anything has actually happened

RE: out of hours provision

Anthony Todd — Thu, 29 Apr 2021 11:21:27 GMT

[quote userid="6765" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230146#230146"]Some smaller clinics have grouped to ease their OOH duties.[/quote]

I hope they will comment on their experiences and opinions.

RE: out of hours provision

Alistair Graham-Evans — Wed, 28 Apr 2021 23:15:25 GMT

We’ve come a long way since when I started doing 1 in 2 on call and then 1 in 1 for a month when the boss was sick!

Your partner was expected to answer the phone as well!

Our OOH centre closed last year due to staffing problems and all our vets (8) agreed they would rather have a 4 day a week roster and operate normally 7 days a week. This seems to reduce call outs after hours but it irks that there are an increasing proportion of OOH requests from clients of other clinics! Unfortunately our regulator seems uninterested in reminding people of their professional obligations. I confess that I am out of the OOH roster these days but always available on my mobile to give advice as needed.
Some smaller clinics have grouped to ease their OOH duties.

RE: out of hours provision

Julian Earl — Wed, 28 Apr 2021 19:17:59 GMT

[quote userid="2122" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230131#230131"]I do NOT miss the embryotomy[/quote]

Am I the only one to suffer instant nightmares at the mention of this word? The tight calf, all dry and foetid smelling and a toxic cow. Usually before breakfast as well IME!! The very worst cases were these embryotomies. Futile cases often. Lucky if the cow survives well afterwards? The Embryotome was never much help, just too tight inside the cow to manouevre it well! A length of dehorning wire attached to twoi wooden handles eg from a surplus broomsticjk worked very well in most cases! I have taken many, many hours trying to salvage these poor animals for salvage is the main purpose here is it not??

I would rather have any uterine prolapse than a dystocia on any day!!With a prolapse the preparation is the key! Firstly get your epidural in ASAP to allow time for it to work fully. Nobody vcan ouyt-push a straining cow!! Plenty of warm water kindly suppliedby the farmer. Add some Pevidine solution if you think it might help but the waterdoes 99% of the cleaning of course. Remove the cleansing wgile it iseasy andthere in front of you!

Then you can start easing the uterus back where irt belobngs!Use your fists as blunt pushing implements, not your outspread hands and fingers. Fingertips can easily push through a compromised uterine wall. Please do not ask me how I know this!! TY... Eventually the last bit of the uterus almost falls back into the abdomen due to its weight, positioning andgravity. Then you can give the aftercare treatment: Calcum iv preferably, Br-spectrumantibiosis of your choice. If you do need to suture a uterine tear, for whatever reason here, thick catgut is fine!

Then stand back and all being well accept the plaudits of the watching farmer before heading home to have our breakfast! HOPE THIS HELPS someone?

RE: out of hours provision

George Cooper — Wed, 28 Apr 2021 17:08:55 GMT

Responding to both Jill and Neil!! Thanks for being stimulated, you colleagues, by my words - though I'm not quite understanding the "sorry...pull you up a bit" or the "but with all due respect" from Jill, both of which imply that, broadly there's agreement ... ... ... ... ...with an invisible "BUT"!!

I'm not ever going to "BUT" your points, both of which are undeniably correct, and within your timeframes. My comments refer purely to "after graduation in 1972" which is my time-stamp, indelibly placed on my life experience and subsequent opinionation (to coin a word) to this day!

Family - yes, I had one, and took my share of feeding, changing, school running, weekending that most committed parents undertake - and it did have to dovetail with the requirements of the practice and with the acquiescence of all the family, who actually often attended calls with me or assisted in the surgery. I was perhaps fortunate that Wife Number One had a mother who thought she was a horse, and "got" the animal dedication thing.

So far as Neil's "outburst" of indignation that finishing times have crept ever later.....mmmmm! I only finished working (in September) after an age-related altercation with a corporate, coloured by the the remnants of bruising from a semi-replacement hip occasioned by a trip on a loose dressing gown cord whilst sleep-walking 12 months ago. I'm so sorry your ladder failed you, and share your admiration for your son finishing at 1700 (17:00?). Incidentally, to pull you up a bit, when I read your response I read the first relevant sentence as referring to eighteen-hundred in years!!!

And my son, just to elaborate, runs a children's bookshop and he and his wife together never stop. Right now working 18 hour days refurbishing and shop-fitting a unit donated by The Council recognising what they will bring to the City Centre Regeneration Scheme - and I could NOT be any prouder of him, of them, and of what they have achieved inside 6 years. 30,000 followers on Facebook??

RE: out of hours provision

Lucy Fleming — Wed, 28 Apr 2021 17:05:43 GMT

[quote userid="8958" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230135#230135"]When I first qualified a 1730 finish was the norm, the one I did in Westmoor was 1800. (that was 1991)[/quote]

I used to finish at 5pm in my first job as a new grad, and that was 2008! That was rural Bay of Plenty, NZ though. A more relaxed way of life...

We closed at 5 for a while in the first covid lockdown, it was so nice! I'm not a night owl and even finishing at 6pm means just the energy to cook a proper meal rather than sling something pre-made in the oven is not there. You wouldn't think an hour would make such a difference but it really did.

RE: out of hours provision

Neil Wheadon — Wed, 28 Apr 2021 15:14:10 GMT

[quote userid="2122" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230131#230131"] I recall one BVA president when still a student came to do management "seeing practice" with me, and her comment, which actually changed my thinking, was "We want to work, and work hard, all day, but we also want to know that we can arrange to meet friends at, the gym at 6.30 or 7pm."[/quote]

Sorry George, a bit like Jill, I'm going to pull you up a bit.

I referred to the above earlier in the thread.

When I first qualified a 1730 finish was the norm, the one I did in Westmoor was 1800. (that was 1991)

These days you're lucky to get out before 1900 (in practices that don't do OOH) and that practically destroys any chance of meeting friends. I tried a squash ladder, it was hopeless, the earliest I could ever play was 2000, very few wanted to play at that time, they'd finished work at 1700, had dinner and that was that. One of the lifestyle choices our eldest son has made is to finish at 1700, he's seen it in us, much like I didn't go farming as my father was 365 day 24/7.

Neil

RE: out of hours provision

Jill Butterworth — Wed, 28 Apr 2021 14:19:24 GMT

[quote userid="2122" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230131#230131"]Personal take on this. After graduation in '72 most practices then were actually mixed, but with increasing numbers of mainly City based small animal units. City - as opposed to towns, because town practices generally had a decent weight of farm and equine work outside the town. And in them good ol' days the expectation (and RCVS ruling) was that every veterinary surgeon did their full share of OOH, unless The Boss was a golfer (!) who had somehow "opted out" of that obligation. Rotas were usually very fairly apportioned with a modicum of TOIL built into the week.[/quote]

Those times were good, but with all due respect, nearly all of those vets you refer to had a wife at home to see to the kids/house etc. Knowing this about practice made me chose not to have children, but young vets nowadays, quite rightly, do want a family, and the most of the responsibility still falls on the woman.

RE: out of hours provision

George Cooper — Wed, 28 Apr 2021 13:41:00 GMT

Personal take on this. After graduation in '72 most practices then were actually mixed, but with increasing numbers of mainly City based small animal units. City - as opposed to towns, because town practices generally had a decent weight of farm and equine work outside the town. And in them good ol' days the expectation (and RCVS ruling) was that every veterinary surgeon did their full share of OOH, unless The Boss was a golfer (!) who had somehow "opted out" of that obligation. Rotas were usually very fairly apportioned with a modicum of TOIL built into the week.

I thoroughly enjoyed everything that rang the phone, from torsions to fractures, and all intermediate points. Even now, despite having ceased work only 6 months ago, I still miss that call to a lambing in March where you get to see the dawn break as you drive home afterwards. Most particularly I miss the calving cow, the smell in the byre, the rattle of chains, the snickering of dam talking to the calf. I do NOT miss the embryotomy - and in my first position which lasted a minimal 9 months I seemed to catch most of these - doing six in that time. Nor do I miss uterine prolapse, the worst of which on the top of the Blackdown Hills near Ilminster was in sub zero temperatures under the lee of a dry stone wall, the wind blowing the falling snow all round us. At least my job was warm, but even with a Bagshaw hoist and an old Fergie to do the lifting, it still took ages. My bete noir (or something)

Having said that, and retreated out from day to day vetting, I moved into part - time work, with the OOH work contracted out. Travelling to work, doing a good day's SA prior to returning home, for only 2 or 3 days a week was undoubtedly brilliant. I did find that when the weekends came around I had huge pangs of guilt, feeling that I oughta be doing summat, and gardening or golfing just didn't cut it for me! It seemed to be in them thar days that a night of two a week, plus a full weekend or a half weekend was totally accepted, along with intermittent days off or half days. It seemed to be from 2000 that the biggest changes in attitude and staffing came about. I recall one BVA president when still a student came to do management "seeing practice" with me, and her comment, which actually changed my thinking, was "We want to work, and work hard, all day, but we also want to know that we can arrange to meet friends at, the gym at 6.30 or 7pm."

One undoubted benefit with P/T work without OOH was that we were free to choose where we lived, - and also, with personal circumstances, get on with the other things that life threw at us. TOIL, or a reduced salary to "buy out" of OOH are options. We tried, in a 5 man practice, to have 1 week of only OOH for one VS, the other 4 covering the daily work, but in the end it proved to be so complicated (before smart fones) that we abandoned it. I did find in a practice where we had a fair number of part time vets, we were able to staff a forgiving OOH rota as well as decent time off, and I belief is that we got more and "better" work from those on part time rotas.

SUCH a complex subject, and so divisive, and potentially costly to manage. Good luck Ian. Let us know what happens.

RE: out of hours provision

Bob Russell — Wed, 28 Apr 2021 13:22:37 GMT

Before the local referral centre became corporate owned I would phone them to ask if they would deal with a case if I feared it might go pear shaped. They had the history and everyone was happy. Sadly now that referral centre now requires the patient to be seen prior to referral.

RE: out of hours provision

Lucy Fleming — Wed, 28 Apr 2021 12:54:06 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230121#230121"]

The size of the "catchment" ie likely call-out numbers, is really immaterial, you will still have to be alert, sober and by a telephone.....

Might be better to be busy rather than just "available"??

[/quote]

I would say, generally no - I much prefer an undisturbed on call night to one where I am in the practice/ out on farms for most of the time I would normally be asleep or relaxing! Given that in many/ most practices that do their own on call (certainly in ours) you still usually have to do a full day's work the next day, being up all night is difficult. I take your point about the fact that being on call/ alert is in itself a burden (I find I don't sleep as well when I'm on call, which apparently is fairly common).

That's also the issue with increasing practice size (or banding together in a group) - servicing more clients/ pets means more likely to be called out/ doing work, even as the frequency with which you are on call decreases. There's no one right answer as to which is "better" - more frequent but less busy, but possibly having to work on little sleep (in my experience rearranging things and getting to go home and sleep is often touted but rarely occurs), or less frequent but more likely to be busy - maybe with a scheduled day off or half day the next day to take this into account? I kind of prefer the former. We also took on OOH work for another practice for a short while, which I hated - the benefit of seeing our own patients OOH means access to histories etc, which you don't have if seeing patients for another practice. Not the end of the world, in the majority of cases, but still annoying. For that reason, I personally wouldn't be keen to join a sharing arrangement, but if I worked in a smaller practice and had a 1 in 2 or one in three rota I might very well think differently.

Generally I agree with the comments that practices doing their own on call will tend to be open shorter hours, and I think that is true, but I also think the difference is reducing, especially in the small animal "market" where convenient appointments for owners are potentially a competing factor.

For example, we're open 8 am to 7pm on weekdays (mixed practice doing on call), and 9-1 Saturdays, 10-1 Sundays. The SA practice in the next town over (they're practically the same town nowadays, so it's probably no more than 10 minutes drive) doesn't do their own on call. They are open 9am to 7pm weekdays, and 9 am to 6pm Saturday, 10 am to 4pm Sunday. A lot more weekend consulting, and I don't know their specific vet hours, but very little difference on weekdays.

(FWIW, I'm perfectly happy doing on call. Sure, it would be great not to have to do it, but the hassle of transferring patients, the loss of case continuity etc for me is a downside that doesn't outweigh it currently. I think you do get good experience with managing emergencies, but also agree with those comments that most OOH cases aren't true emergencies, they are more to reassure worried owners (sometimes worried vets) and to improve animal welfare by getting painful conditions treated more quickly. Still potentially skills you can acquire without doing on call.)

RE: out of hours provision

ian bates — Wed, 28 Apr 2021 11:49:18 GMT

Thank you every one for the huge response! I have been following quietly with great interest and really appreciate the time (and effort!) you have given this. I do feel better for having shared the problem and it’s really helpful to get a feel for opinion within the profession.

Amazingly, since my original post, another OOH centre has been proposed, closer to our Practice. (nothing for 20 years and then 2 pop up within a month!) However, the other CD’s are still reluctant………

Anyway I will keep quietly nudging and see what happens……….

(in response to some of the questions – we offer a 4 ½ day week, a telephonist screens the out of hours calls, always a half day after a weekend on call, and prior to Covid on the 1-6 rota we also offered 2 long week ends in 6).

Thanks again,

Ian

RE: out of hours provision

Anthony Todd — Tue, 27 Apr 2021 13:37:06 GMT

Surely the point is that if you are "on call"!

The size of the "catchment" ie likely call-out numbers, is really immaterial, you will still have to be alert, sober and by a telephone.....

Might be better to be busy rather than just "available"??

PS No thought, anyone, on widening the rota, ie joining with other practices?? Is one night in 4 plus X neighbours better than one night in 4?

RE: out of hours provision

George Cooper — Tue, 27 Apr 2021 12:59:59 GMT

Confess that I haven't trawled the four (thus far) pages contributed - but one thought strikes me that if you end up at 4.5 VS from 6.5, would you not be likely to also see a diminution of actual OOH cases? If so, the fear of being overwhelmed could be mitigated. One further thought to assist the preservation of sanity would be to "close the books" and not take on any further clients for the time being. At least by so doing you are proactively setting about minimising your anticipated overload, and that alone should buy you some time. Apologies for repetition if these thoughts have surfaced previously.

RE: out of hours provision

Joyce Whitehead — Tue, 27 Apr 2021 12:43:13 GMT

This is an interesting discussion. As we are equine/small animal, we have always done our own OOH, and so far haven’t struggled with recruitment. We are going up a vet at the moment (ironically this is partly to take me and husband off the ooh rota, we cover the same nights, but we are both over 60 now and want to wind back a bit). I’ve done ooh all my career despite always being purely small animal myself. Sometimes for long periods we did 2 in 3 which was awful but only covering a small practice it was quite quiet. My first job (early 80s) I worked 2 weeknights and a 1 in 2 weekends, and on those weekends we worked all day Saturday and Sunday. It almost killed us and I wouldn’t recommend it to anyone, but after 2 years I was a fairly competent vet.

Our vets now all work a 4 day week, and have 2 days off in the week of their weekend on. Everyone gets a long weekend a month too as part of this. The non on call vets usually finish 5.30 ish, on call about 6.30. We don’t get too many ooh calls, and although we all have had the odd terrible one, that’s unusual, and if someone has a bad night we can usually get them home to rest as soon as possible. A nurse is always on to help too. We don’t have staff in the surgery overnight, but have cctv, and we live 50 metres from the surgery, but we make owners aware of this, and obviously someone will stay on the odd occasion that is required.

I’m glad to say we already have some promising applicants for our post, so hopefully can get a candidate. There is no easy answer as I know that city practices have very different clients to our rural ones in many cases.

RE: out of hours provision

Gillian Mostyn — Tue, 27 Apr 2021 06:16:48 GMT

I also think some cases are best sent home to convalesce. However, I think we'd all accept in some cases it wouldn't be ethical to move the pet or withdraw adequate parenteral analgesia.

[quote userid="8858" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230111#230111"]I primed the OOH clinic who would take the call, or see the animal, if the owner wanted advice or the animal deteriorated unexpectedly. [/quote]

Exactly. the situation is different when there is the fallback of separate all night OOH provision.

RE: out of hours provision

Evelyn Barbour-Hill — Mon, 26 Apr 2021 23:37:18 GMT

[quote userid="5012" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230091#230091"]I've been recently working with newish grad vets - they are horrified at the suggestion of any OOH commitments whatsoever. [/quote]

Then they aren't proper veterinary surgeons.

Maybe their professional education should have been better.

Sorry, but it has to be said.

RE: out of hours provision

janine redman — Mon, 26 Apr 2021 21:35:47 GMT

As far as possible most patients would prefer to be at home and most clients would prefer them at home within reason . They are more likely to get a better level of observation at home too . It is a matter of selecting which patients need to stay in and how best to manage those within the team. I used to take patients home with me , now it is more a shared task aided by remote cameras but it is tiring .
My current practice is 5 metres from my house and I have a camera that allows me to view the patient but still requires me to wake up and check in through the night.

I think a lot of patients that currently stay in could be discharged overnight and seen the next morning with better levels of overall care.

RE: out of hours provision

Jill Butterworth — Mon, 26 Apr 2021 20:38:03 GMT

I occasionally used to send animals which were stable to their own basket overnight and they would return to us in the morning when I heard this was how the local hospital often managed non critical cases. It was a compromise approach for clients with limited funds: the pet and owner were happy, and their money was being used wisely rather than on loaded fees or transport costs. I primed the OOH clinic who would take the call, or see the animal, if the owner wanted advice or the animal deteriorated unexpectedly.

RE: out of hours provision

Julie Turner — Mon, 26 Apr 2021 20:34:40 GMT

I used to have to do these inhuman long weekends in various forms.
I wasn’t biologically built for repeated sleep interruptions, and could hardly sleep anyway thinking I might have a call out.
we need dedicated out of hours cover, and I don’t blame the new grads for avoiding this on top of very long and potentially intensive working days. Why does anyone think we have so many mental health issues within the profession?
I am not saying this is easy nor inexpensive. We need to alert clients to the cost

l would say they should incorporate this into their decision to be privileged to own a pet, but realise it ain’t gonna happen.
solution - no idea, but good to chew this over

RE: out of hours provision

Anthony Todd — Mon, 26 Apr 2021 14:42:45 GMT

[quote userid="2457" url="~/001/nonclinical/f/life-in-practice-discussions/29789/out-of-hours-provision/230105#230105"]sorry - I don't understand? Are you meaning that everything was cared for at home?[/quote]

Yes, and it was amazing how many clients had a nursing or medical connection

I was once patiently [?] explaining anaesthesia and recovery until I foundI was talking to a Consultant Anaesthetist at Guys.....

I wonder how staff supply and retention would fare if nothing was kept on the premises overnight and how much it would affect outcomes??

Que: exceptions.......