Under Care consultation

RE: Under Care consultation

cairncross — Wed, 28 Sep 2022 09:29:41 GMT

Some sort of warning that information given/fished could be used to prevent a claim being validated in future. Do these conversations rule out lots of conditions if not on a lifetime policy?

RE: Under Care consultation

Alastair Welch — Tue, 27 Sep 2022 21:04:37 GMT

The legal advice (brief as it seems) is in truth pretty reasonable, and accurately reflects the custom and practice of much of what goes on today. In some circumstances it is perfectly reasonable for an animal to be considered 'under your care' without seeing the animal and to go on to prescribe POM's for that animal: in some circumstances it is not. It comes down to individual circumstances and providing definitive advice which covers every conceivable situation is not possible.

The nettle which the College are studiously striving to avoid grasping is the connection between the provision of 24/7 care and an animal being considered 'under your care'. That is to say they seem determined to stick with the idea that veterinary surgeons are somehow responsible for the provision of care for animals with which hitherto they have no connection and yet content to accept that animal owners can seek veterinary care from whomsoever they choose including providers who are unable to provide 24/7 care.

We must move to a situation where the requirement to provide 24/7 care becomes an option. It is utter madness that an unknown member of the public can demand to rouse you from your bed and been seen on pain of the loss of your right to practice. It might have been appropriate once upon a time but it is not any more.

RE: Under Care consultation

Richard Carter — Tue, 27 Sep 2022 18:01:51 GMT

The RCVS gets to decide what is an act of veterinary surgery and who can be admitted to the register and what is required to remain on the register.

It most definitely is an act of veterinary surgery to prescribe a medication for an animal that is a patient. That can’t be challenged by any other organisation but they do have other ways of moving the goal posts and I don’t know if for instance a call centre of vets registered but not in U.K. can still stay in the rules. The VMD controls the purchase and restrictions on sale of certain drugs, the categories etc, not the RCVS but even there, the internet has largely bypassed any effectiveness

The ‘under care’ is more woolly and made up from tradition and in- house rules but you could argue the RCVS is entitled to set up in-house rules for membership to follow if they want to stay on the register?

RE: Under Care consultation

lisashaul — Tue, 27 Sep 2022 17:36:11 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239309#239309"]We should determine what is under our care![/quote]

That very issue is what has confused me about the Royal College for years...

It just seems so obvious that the RCVS should exist to create and then mandate "best practice" systems, as agreed by the profession overall, surely.

How did we let ourselves get weaseled by words, so that the profession ends up serving the lawyer's purposes.

RE: Under Care consultation

Jo Dyer — Tue, 27 Sep 2022 17:27:26 GMT

[quote userid="6353" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239308#239308"]This is but a summary; the full text will be in the hands of the Registrar and I am sure will contain far more, very carefully argued detail.[/quote]

Sorry Chris but you’re wrong. As I said in my post, the document on the website is the entirety of the advice from Fenella Morris KC.

RE: Under Care consultation

Bob Russell — Tue, 27 Sep 2022 16:41:49 GMT

It is the profession that should be making the rules. If the rules need to change to protect animal welfare etc then that is what should be done.

We should determine what is under our care!

RE: Under Care consultation

Chris Barker — Tue, 27 Sep 2022 16:33:02 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239302#239302"]That is half a page and we are about to turn the profession upside down based on that? Has the world really gone that mad?[/quote]

It is a very brief summary; I would not be surprised if there is an ancillary document which provides far more, very carefully argued detail.

I guess that by reaching for the opinion of a 'higher authority' , a KC/QC, the RCVS is hoping that the opinion is as definitive, as authoritative as possible without a test case being taken to court.

RE: Under Care consultation

Bob Russell — Tue, 27 Sep 2022 09:31:13 GMT

That is half a page and we are about to turn the profession upside down based on that? Has the world really gone that mad?

Edit: Where an insurance company requires or even suggests some form of remote triage prior to an in person consultation, the vet is working for the insurance company and not the client. This should be made clear to clients.

RE: Under Care consultation

Coopers Wamae — Mon, 26 Sep 2022 16:13:56 GMT

The BVA has said it is ‘extremely disappointed’ with the scope of an RCVS consultation on proposed changes to its guidance on ‘under care’. Renegades or something else.

bvajournals.onlinelibrary.wiley.com/.../vetr.2240

RE: Under Care consultation

Jo Dyer — Mon, 26 Sep 2022 06:41:22 GMT

[quote userid="12572" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/238990#238990"]

I have not seen the original opinion from which the summary statement was made;

https://www.rcvs.org.uk/document-library/legal-advice--fennella-morris-qc-mar-2022/

[/quote]

It appears I was mistaken here. I have been informed by our Registrar that the document on the link is the full advice from the KC (was QC) and therefore I have seen all the legal advice. I am happy to set the record straight and I apologise if I have misled anyone.

RE: Under Care consultation

Clive Ansell — Sat, 24 Sep 2022 18:46:04 GMT

Please forgive my ignorance, but what exactly is the benefit to the profession of telemedicine, or more specifically video and telephone consultations?

I did many during the covid pandemic lockdowns, and was allocated the same time per consultation as I would have been for a physical hands on consultation.

In some cases, a telemed consultation would become a physical one, so taking two appointments slots where one physical one would have done the job.

Therefore a better and more efficient use of my professional time is conducting traditional hands on consultations.

I do not oppose telemedicine per se, but it needs careful cases selection and an awareness of the limitations.

RE: Under Care consultation

Neil Wheadon — Sat, 24 Sep 2022 08:45:43 GMT

[quote userid="17113" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239271#239271"]So, a question that could be asked is, why are the insurance companies feeling that it works better to subscribe to a veterinary advice service for their clients?[/quote]

To avoid paying OOH costs or daytime consults. As Clive has pointed out over 80% of calls aren't emergencies.

In effect telemedicine in this case is an absolute no brainer for an insurance company

I liken this to calling 111, it's a triage service to ascertain if an animal needs seeing and there is value in this

Taking it further (as is inevitable) is the isuue

Neil

RE: Under Care consultation

lisashaul — Sat, 24 Sep 2022 08:17:33 GMT

Regarding telemedicine fees and money's left for "real" consults...

For most of the companies/situations I know of, the consults are free (as many as wanted) contracted for by the owners' insurance company.

The "organic" customers are usually charged a very modest fee, refundable if a recommendation to see a vet is made (which brings it's own challenges).

So, a question that could be asked is, why are the insurance companies feeling that it works better to subscribe to a veterinary advice service for their clients?

RE: Under Care consultation

Richard Carter — Sat, 24 Sep 2022 07:06:03 GMT

Yes, and the power of big companies with good advertising- our parasite control has plummeted since the online delivered at a price we can’t match. The client doesn’t know and mostly doesn’t care. We might earn a prescription fee but obviously this is about to go as well to tinternet..

Perhaps time we followed the dentists with the treatment / health care plan where not only for the monthly fee are you getting vaccs, parasite control but also your time- £50/ month free consults, £100/ month free consults and basic surgery?

Or take the internet printout, hand them back and show the door? You not obliged to take over someone else’s case.

Another case of shiny and modern and we have to because others do it wins over old fashioned client patient relationship

RE: Under Care consultation

cairncross — Sat, 24 Sep 2022 06:39:38 GMT

I fear this has the potential to drive many more from the profession than it has to provide a situation where they can maintain within.

Mainly for the reasons that Neil has described and I agree on , now that we are experiencing the beginning of this phenomenon. I have found the process of creeping round the online vets suggestions difficult and stressful as well as consuming much more time than available

There is significant evidence in the human field of the benefits of a good stable local GP system being a much better way to deliver improved outcomes than tech or putting funding into expensive proceedures or pharma.

On the financial side a telemedicine call extracting 35 to 65 pounds of budget will be removing a significant if not all of the available budget from many of my clients if they then need further treatment. Both my kids schools have sent letters complaining almost no one has paid the school fees of 80 pounds, the energy firms knew that unless the government stepped in almost no one could pay their heating bills,

We trialed different ooh fees last year to try and find a balance where staff wernt getting over run and as many in need cases as possible got seen. At 60 pounds everyone wanted seen at 128 it slowed significantly and at 200 almost no one. I imaging these boundaries are currently shrinking

Telemedicine fees will impact and rule out many animals actually getting physical treatment in the real world.

RE: Under Care consultation

Neil Wheadon — Fri, 23 Sep 2022 12:16:14 GMT

Hi Lisa

As an experienced vet and an understanding of the limitations you will be providing a great service and yes ‘let the market decide’

However this is not where this is going long term, it’s opening a box that cannot be closed similar to non vets can own practices

I don’t know how much you charge but looking at a telemedicine site, one vet is asking £63/consult. If I were a client, I’d be expecting a little more than ‘check Bonzo’s colour please’

Yes practices are overstretched but in many cases they will know the case or client as they have the practice records, something a telemedicine doesn’t so can make an informed judgement. (I do understand this, 9 years doing OOH with no clinical records takes skill and experience, the similarities are there) In my experience every practice I have worked in want clients to call. In reality remote consults will INCREASE the workload to a practice as a practice will have to access the records, record them, read them, understand them and tip toe around the notes trying not to drop both the telemedicine vet and vets in it with the client as most using this service will hang on to any nuance of language. Compare this to a 5 minute call to the practice where full records and case knowledge are available.

If telemedicine sticks to yours and mine expectations then it can work but it won’t, it will balloon to an absolute mess

Neil

RE: Under Care consultation

lisashaul — Fri, 23 Sep 2022 11:37:04 GMT

I will essay one further small response, then stop before the inevitable pile-on

Within strict boundaries, telemedicine very much does work.

Vet in practice, especially the overstretched OOH service provider with only one vet on, are short of time...Many daytime practices seem to have no vets ..

What works well ...

Triage and advice and guidance (and many owners can help you check RR, HR, mm colour and CRT and pain and a video consult can tell you a lot about demeanor and responses to handling)

Pain conditions in need of examination and treatment (as in please ring back the vet practice that said they can't see you for two weeks and say we have assessed this animal as needing seeing sooner)

Simple, early stages vomiting and diarrhea (with built in rechecks and escalation points)

Ditto for early, likely KC

Simple or early skin lesions

Early stage Intoxications

QOL and EOL discussion where the owner has been given information by their vet, but hasn't absorbed and processed.

Parasites, lifestage factors, behavioural flags, and diet.

So, within well set out limits, what would you rather?

Clients getting all their info from Google?...

Or then ringing their vet up at 2am as they are worried by what they read?

Or having a careful conversation with a RCVS compliant vet, who can signpost on the speed at which they need to be seen by a vet (and often it is... "you shouldn't wait, you need to see an OOH vet").

And, let me point out again, these are vets that usually can't give any more time and/commitment in practice at that stage in their life. Many already work in-clinic part-time, and use the Telemedicine shifts to earn extra hours.

So this is additional, skilled labour that the profession could be looking at integrating to get the best use of, to free up and support in-clinic vet time, not just issuing blanket condemnations of.

RE: Under Care consultation

Neil Wheadon — Fri, 23 Sep 2022 11:04:50 GMT

You can’t effectively telemedicine in animals, period

why?

1) Animals can’t talk/communicate. I am increasingly convinced that even examining animals much is guesswork On a first consultation. Using people studies has validity but it’s like saying an apple is a pineapple

2) Experience

Like doing OOH work you need a foundation to differentiate what’s likely and what isn’t. To do this even to a degree of effectiveness you need a solid wide spread grounding and I’d go so far as to say that vets these days see a far less diverse range of cases than the older generation simply because of referrals

3) Stress

I’ve done telemedicine, 10 years ago. I had a job that provides phone advise to clients, for which I was paid £10/case. However with experience and language you were able to be tactful but ever mindful that you weren’t dropping the original vet in it. Vets seek perfection, we see enough stress in the profession without having ‘Dr Mike, the feline specialist’ available remotely to shoot us down if the client wants this because this is where this is going.

I’ve seen a website for this. Vets are effectively bidding against each other to get owners attention. Fees from £35 to £65 for a tele consult. Where’s the value. At these fees they should be FULLY ACCOUNTABLE

It’s hideous, it’s a step into the dark ages of a modern medium taken too far. Yes it can work for simple things, but what defence does the profession have and yes that’s the RCVS when the tidal wave of misdiagnosis and vet on vet litigation starts to happen. I’m glad that my days are numbered in this profession as I don’t want ‘Dr Mike’ hanging over me every time I open my mouth in a consult or to clear up the mess that ‘Dr Mike’ has created

Neil

RE: Under Care consultation

Bob Russell — Thu, 22 Sep 2022 14:17:19 GMT

Quiite an interesting article with some history of telemedicine in humans.

https://aeon.co/essays/virtual-medicine-and-the-ethics-of-presence-and-absence?utm_source=pocket-newtab-global-en-GB

Some interesting points!

No smellyvision. Colours difficult to identify without standardised charts. Cannot look in ears, rarely mouth. Might just be able to get a flea hunt done if the owner has a suitable comb! No auscultation, no palpation therefore no diagnosis possible. A list of differentials may be possible.

If I could be sure this would be used only in selected situations and/or for triage purposes, I would be less worried. I have seen attempts at a fairly full examination and the results have been pretty awful.

For charities with limited budgets it may be a way of treating more patients for less. Most of the time the patient will get away with it but I assume pet owners using charity facilities are willing to accept this compromise. I certainly would not!

RE: Under Care consultation

lisashaul — Wed, 21 Sep 2022 11:13:12 GMT

Clive, the remote consult scenario you recount was just poor practice by the initiating vet, regardless of whether it was remote or not.

I feel that I would like to put up a small defence for Telemedicine. It is currently the only way I am able to continue working (health reasons) and the company I work at (as well as kindly keeping my job open for 6 months to improve, whilst I had to leave my clinic job completely), has really good "clinical guard-rails" - good policies and procedures so that we aren't exceeding what is sensible (practical/ethical or legal) to be assayed over a video-consult.

RE: Under Care consultation

Richard Carter — Wed, 21 Sep 2022 10:12:57 GMT

[quote userid="12572" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239239#239239"]the only way a public body such as the RCVS could be realistically legally challenged was via a Judicial Review (JR) [which considers] the process by which the decisions were made [and decides if the process was correct or if the decision is unsafe and needs to be made again][/quote]

This is what I was trying to get over about the RCVS being equivalent to a court and ‘owning’ the legislation of the veterinary surgeons act. Any decisions or restrictions that are introduced are legal as long as it deals with issues within the act and people haven’t wandered off piste

RE: Under Care consultation

Bob Russell — Wed, 21 Sep 2022 08:15:09 GMT

Sadly I (and perhaps many others in the profession) have limited respect or trust when it comes to their views.

I don't see acting in the interests of the profession nor our patients.

RE: Under Care consultation

Jo Dyer — Wed, 21 Sep 2022 07:53:23 GMT

[quote userid="2100" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239221#239221"]I was told that the change is a done deal [/quote]

Really? As I said, that was my concern and was a reason that I voted against the consultation. The minutes of the July meeting (p34 of the pdf) can be found in the September 22 Council meeting papers on the RCVS website here;

https://www.rcvs.org.uk/who-we-are/rcvs-council/council-meetings/

On p42 of the pdf at paragraph 2 is my comment regarding concern about it being a done deal, and below it the reply from one of the senior team;

‘the guidance would remain as it currently was until such a time that Council agreed to change the wording, it would not be changed as soon as the consultation launched – the consultation included a draft and was asking the profession for its views on the draft’

[quote userid="2100" url="~/001/nonclinical/f/life-in-practice-discussions/30406/under-care-consultation/239221#239221"]

the College has had legal advice that the law as it stands allows for remote consulting / under care to be defined differently, and if the College does NOT accept that, then it will be open to legal challenge.

[/quote]

I also said this at the meeting (p40 of the pdf referred to above);

“the only way a public body such as the RCVS could be realistically legally challenged was via a Judicial Review (JR) [which considers] the process by which the decisions were made [and decides if the process was correct or if the decision is unsafe and needs to be made again]; it was difficult to believe that it would lose a JR regarding the under care relationship, which had been in place for a long time;”

The decision made regarding the inclusion of the current Under Care clause was made decades ago. I don’t know how a judge would be able to review it, to be honest.

I don't really understand it all, frankly. My simplistic belief is that if someone wants to challenge us legally, we (RCVS) have the defence that we are doing what is best for animal welfare, and in line with our aims and objectives, so bring it on! However I accept that the majority of my Council colleagues see things differently and I respect their views.

RE: Under Care consultation

Clive Ansell — Wed, 21 Sep 2022 07:36:26 GMT

I had a recent example of remote consulting not really working.

Owner contacts insurance company and is directed to a remote service (unsure if an MRCVS or not), who says that lesion on dogs nose looks like an insect bite, sting or similar. Take the email transcript of this consultation, show you vet and get a tube of Isaderm.

Me, being a stick in the mud one for the rules, said no, I want a copy of the clinical history before accepting the case, and I can only prescibe Isaderm if I see the patient, or I can prescribe a POM-V on presentation of a correctly written and signed prescription. Neither were forthcoming.

Unhappy client reluctantly makes an appointment whilst whining about fees. Dog had an obvious skin mass on its muzzle, which was removed and turned out to be a mast cell tumour. It was immediately obvious on a face to face clinical examination

RE: Under Care consultation

Richard Carter — Tue, 20 Sep 2022 16:52:11 GMT

Completely fictional story

Company A sells a popular POM heart medicine- very safe, very effective..

Chief executive comes to product manager and says want your sales up. The product manager say, would be easy if we didn’t have those vets putting a markup and insisting on checks…

Chief says- well we had COVID and we don’t really need to have massive marketing or cpd anymore because there only a few corporate people of influence left and we can deal with those so take your saved budget of a few million and get some rules changed and if you meet resistance, we can get more lawyers than the opposition..