So, after months of speculation, the Panorama documentary: It shouldn't happen at a vets' finally aired last night. Early reaction from most of the profession seems to be one of mild relief that by focussing so heavily on Medivet, the documentary has left everyone else more or less unscathed.
There's also a great deal of sympathy for those hard-working and professional vets and nurses who work at Medivet. They're the biggest losers in all of this, tarred by the indefensible behaviour of a very small number of colleagues, and by the very nature of most of the filming in the documentary (give me a fish-eye lapel camera, and I could make even Mother Theresa look like a crack dealer).
But can everyone else really sit back, think 'not my problem', 'sensationalist rubbish', or 'it'll blow over in a week' and move on?
If you consider only the more headline-grabbing elements of the documentary, any of those would be a reasonable position to take. But look beyond 'Vet Makes Fraudulent Insurance Claim', and it seems the producers might accidentally have hit upon some big challenges facing the profession. Might now be a good moment to reflect on and debate some of these issues?
The first story covered by the documentary was that of an owner who'd found their cat 'weeing blood', taken it to Medivet and been quoted £815.05 for a bank of tests. They'd left in disgust, and visited another practice. This one gave a diagnosis without tests, the bill for which came to 75 quid, including £28 worth of food.
Veterinary costs were a recurring theme throughout the documentary. At the start, Jeremy Vine pointed out the £20,000 lifetime cost of owning a dog, and the £15,000 cost of owning a cat. He said vet bills have trebled in a decade. Mid-way through the programme, the voice-over read: "Veterinary medicine is increasingly high tech, and increasingly expensive. The new generation of vets is taught that working up to an accurate diagnosis may involve extensive tests. More veterinary work means more costs. And later in the documentary, Alex Lee, the reporter, was said to have found evidence of two clients that had spent over £100,000 on their pets over a ten year period.
At the end of it all, the real issue is not about the disparity between one vet's bill and another's, but whether the profession is becoming over-qualified or over-equipped for the job, and consequently at risk of pricing itself out of the market.
Commenting on state-of-the-art care, Professor Innes from the University of Liverpool said in the programme: "We would never push clients into procedures that are unnecessary, but if people want to access the best healthcare for their pet, that's up to them."
Surely every pet owner wants to access the best healthcare for their pet? Of course, Professor Innes is right, there is a market for complex procedures and diagnostic tests. But there's a very fine line between 'pushing' a client into a procedure, and recommending a procedure (to someone who feels emotionally duty-bound to do the best for their cherished pet).
For me, it was ironically one of the Medivet staff who seemed to hit the nail on the head when she said: "The 'Medivet Way' is to work it up to find out why straight away, so... And people can't afford it now really, you know."
Is the word 'Medivet' in her quote interchangeable with a growing list of practices? Does something need to give? Is it time to call a halt to the development of increasingly complex procedures and diagnostic tests developed to save the life of what is, after all, just a cat or a dog?
Or is it a question of veterinary surgeons ceasing to recommend any particular treatment above a certain cost, and instead simply laying out the options available to the client: "Mrs Jones, you've got three options here. Option one is my best guess, and I might be wrong. Option two is my best guess plus these tests, which will help confirm whether I am right and will cost x. Option three is referral to the world's leading expert, who is based in Dallas, but that'll give time for the MRI on board the specially chartered 747". I'm being flippant, but my point is a serious one: as more expensive treatment and diagnostic options become available, so it becomes ever riskier recommending them, rather than simply informing the owner of their choices.
The next story was an important one too. It was the one where a student nurse and the unqualified reporter were tasked with catheterising a dog unsupervised. They struggled. As did the dog. Thanks to the hidden camera, and the reporter interjecting: 'What a nightmare', it made for dramatic TV. But as many have commented in the VetSurgeon forums, a difficult to catheterise dog is not exactly out of the ordinary. And who thinks this was the first time the procedure has been done by lay staff?
More interesting was the polar opposite interpretations of the law on this issue expressed by Medivet on the one hand, and Professor Sandy Trees for the RCVS on the other. In response to the question of whether a trainee should be placing a catheter, Jeremy Vine read from a statement in which Medivet insisted that everything it allows its trainees to do is legal, and that there was no definitive list of procedures that could be carried out by trainees. Two minutes later, and we had Professor Trees appearing to contradict Medivet's statement.
Then we see the reporter and a student nurse taking a blood sample from a cat, before the arrival of a vet. Medivet says: "This procedure was completely legal, normal and was carried out at the direction of a vet. This means that the vet does not have to be present at the time. [The tasks] were not illegal. The trainee veterinary nurses were properly trained and experienced. RCVS inspectors have never raised this as an issue, and it is common practice." But when Jeremy Vine then asked Professor Trees: "Would it be OK for a student veterinary nurse to take a blood sample before a vet arrived into the practice", the answer is no. When pressed: "So supervision means that the vet has to be in the building", Professor Trees hesitates before delivering his more ambiguous reply: 'I would say so, yes'.
How on earth did that happen? How did one of the biggest veterinary groups come to be at loggerheads with the regulator on TV? Remember that Medivet would have had some time to prepare its response, and presumably had it checked by a team of lawyers first. Professor Trees may or may not have had the luxury of as much warning. Still, if el Presidente himself cannot give more than a personal opinion in answer to such an important question, something is amiss. After all, people's careers are at stake here.
The issue here is whether regulation needs to become more prescriptive. For example, is it fair that the responsibility for defining precisely what is 'minor surgery (not involving entry into a body cavity)', and therefore able to be performed by a qualified veterinary nurse, currently rests with the individual veterinary surgeon. And if it comes to it, the only way the veterinary surgeon is going to know whether he or she made the right call is if and when it comes to be tested in court.
Talk about closing the stable door after the horse has bolted.
Surely it is time now, particularly in the (like it or not) increasingly corporate and less personally accountable world we live in, for the profession and everyone in it to have clearer leadership in terms of what is and what is not acceptable.
I won't dwell on any of the other stories covered by the documentary, because I don't think any of them are individually revealing of very much.
A student nurse struck a dog. 'Walloped' according to the reporter; 'smacked' according to an onlooker. There's a difference. Either way, a difficult one to defend.
Then a member of staff (and I couldn't work out whether it was the vet or the nursing assistant) started playing with an anaesthetised kitten as if it were a puppet. That was damning for the lack of humanity it showed.
Next we saw a new grad trying to intubate a cat. For some reason, it didn't go as smoothly as it should. Some speculation in the VetSurgeon forums as to whether she applied the local anaesthetic correctly or not, but the cat was fine. Mistakes happen.
Next we saw a dog that had a condition which made it susceptible to cuts. A 'new girl' says she thinks she must have accidentally cut its pad as she closed the kennel door. Not the end of the world, except we then see the staff plotting to tell the owner that it happened before the dog arrived at the practice, and that they would need £13 worth of Fuciderm. Again, it isn't what you would call the crime of the century. But it was nevertheless a damning piece of film for the lack of honesty shown by the staff.
Then we had the case of the dodgy insurance claims, where the practice allegedly split what should have been one claim into three 'by accident', so that they could effectively increase the total amount the owner would be able to claim. Difficult to get really het up about this one. I mean, I know it's wrong. But it wasn't exactly in the same league as Lord Brocket taking the oxyacetylene torch to his car collection. And as far as I could see, the unwitting beneficiaries of this one were the dog and its owner. No, the real problem was that in the same breath as Medivet proclaimed its innocence, its employee was there in technicolor explaining exactly how and why the deed was done.
Guy Carter, one of the Medivet partners was next on the rack. The Panorama reporter alleged that he instructed staff to bill a client for a monitor that wasn't used. The company says it was. So it's their word against hers. Unfortunately, the company's word wasn't looking that good by this stage in the proceedings.
As I said earlier, these things don't individually tell anyone much. But collectively, I wonder whether they don't highlight another important issue, which is the apparent 'disconnect' (hate using the word like that, just can't think of a better alternative at this time of night) between what the public wants (i.e. a close, trusting relationship with an accountable James Herriot-type-figure, personified in the film by Bob Stevenson), and what the corporates can realistically deliver.
I was chatting about this with a locum vet this afternoon. His experience is that in small practices where the owner is present, there is always a better atmosphere. Staff take more pride in their work, and deliver a higher standard of care than in the corporates.
Isn't that really what the documentary showed? Yes, they were especially excruciating examples of how people behave when they don't have a real sense of ownership in a business. But isn't a lower, less personal standard of care an inevitable consequence of corporatisation?
Incidentally, my apologies for labelling Medivet a corporate rather than a partnership, but like it or not, that's the public perception of a chain.
Finally, the star of the show made his grand entrance. Kfir Segev, charged with recommending £2200 worth of MRI scan for a dog that was obviously dying. Now that is despicable. He's found guilty of unprofessional conduct, and struck off. I suppose 'vet commits fraud, is found out and punished' is not the stuff of which great documentaries are made, so Panorama tried to make something of the fact that he continued to work for 28 days whilst deciding whether to exercise his right to appeal. And? Perhaps sensing they still had a bit of a non-story on their hands, they tried to make an issue out of the fact that he'd continued to work as a practice manager after being struck off. It was all a bit lame, really.
Still, not as lame as the finale, which was the 'revelation' that Medivet collected blood from rescue dogs, in return for donations of food and supplies. Panorama claimed the blood was sold at a profit. Medivet claimed it is subsidised. Does anyone actually care either way?
Since the documentary was broadcast last night, Medivet has issued a further statement in which it does the honourable thing, and takes responsibility for everything it needed to. Medivet will recover from this. If the professionalism of the response is anything to go by, it will emerge stronger. Still, the big questions remain. How to address the spiralling costs that accompany the latest advances. Can the profession afford, any longer, to leave so much to the discretion of the individual, or is it time to demand a more prescriptive regulatory environment? And finally, how can the corporates deliver the kind of service that the public seems to want? Doubtless there will be some who'd like them to fail in this regard. But as we've just seen, it does nobody any favours if they are allowed to do so in a way that threatens to bring the whole profession into disrepute.
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I'm not presuming anything of the kind! :)
All I AM saying is that unlike many other purchases, veterinary care invariably comes with a strong emotional pressure to buy. Either out of a sense of duty to the pet, or as a result of a recommendation from an authoritative figure (i.e. the vet), or a bit of both.
As veterinary costs escalate, so I think it is increasingly important for vets not to increase the pressure on the owner. i.e. to inform, rather than recommend.
Having said that, I disagree with you when you say that 'we have to offer the best' (I read you to mean always).
And the pet owner on benefits, with no insurance? Is it sensible even to advise them of the existence of 'Bionic vet', for example?
Surely not without probing a little first to check that they have some unknown benefactor who would cover costs they blatantly can't afford.
Otherwise all you do is lumber them with the guilt of not being able to help their animal.
Incidentally, my 'just a cat or dog' remark was devil's advocate.
I agree absolutely that for many, their most important companion in life is their animal.
Arlo I think you are falling into the old trap of presuming owners can't/won't pay for advanced treatment/tests, we have to offer the best and let the owners decide what they can afford and what they feel is best for their animal , they are not our pets and only the owner can decide the importance of a pet in their life. Like it or not although they are "just a cat or a dog" pets can be the most important companion some clients have in their lives and you shouldn't make decisions on their behalf as to what is justifiable when treating them.
When presented with a young male cat with haematuria surely the practitioner who dispenses antibiotics and "a bag of food"is the poorer clinician as he/she has obviously recognised that it is most likely urolithiasis by providing the food, but choosing to give antibiotics which are not actually indicated, no mention made of any followup or warning that the condition could ultimately be life threatening either.
As regards the case against Kfir Segev I am not sure what the other complaints against him were, but from what I can see their main complaint on the programme was the cost of the tests ie MRI and the fact the owner had had himself had an MRI scan which cost £600 instead of the £2200 quoted and the fact that the dog had secondaries in the chest( which Kfir missed on the xray). Specialist oncology is now more readily available in veterinary medicine and it is not wrong to refer animals for this, if owners are aware that of the costs and that remission is not always possible and may be months rather than years. The costs of veterinary MRI will be higher as GA is required, often more than one area of the body will need to be scanned and if numerous different sequences are used GA times are longer. A nurse, a vet and a specialist radiographer need to be present and a specialist needs to read the films this automatically raises costs. If the MRI is on site at the practice there are very high costs involved in purchasing the equipment, maintaining it and staffing it, if it is provided by an external provider the practice has to pay their fees, so we are not comparing like with like. To be honest in this case Kfir should really have ordered CT to assess the chest before ordering MRI for the other area (shoulder ?).
A comment on your part about the insurance claim. If it is shown that fraud took place, then the RCVS would probably come down on it harder than almost anything else on the program.
As an MRCVS, signing something you shouldn't is generally an express route to being struck off.
Not that I necessarily think fraud has taken place in this instance. The owner would have had to pay three the excess fees, so would have been less well off in the short term.
Thank you so much Jane, Martin, Julian and sailboat. It's nerve-wracking waiting to see what people think of one's efforts, and I'm relieved!
Ailsa, I didn't mean to say that vets don't give owners the options. I guess many do (I also guess that the change from dictating to the owner, to advising them is one of the big changes of the last 20 years).
But it is a very, very grey area, largely down to semantics. While one owner will leave the practice considering themselves 'informed', another might (under the very same circumstances) think they have been 'advised', and yet another will feel they have been 'instructed'.
Perhaps two words would sort out the interesting issue of spiralling costs which you have quite rightly raised Arlo, Informed consent.
We can no longer assume that what we decide to do for an animal is the best thing, without offering the options to the owner.
On the question of whether the'trainee' nurses should have be performing these duties I think that Sandy Trees was absolutely correct.
The RCVS website has a section 'Advice on Schedule 3' which spells it out pretty clearly.
The term 'trainee' nurse is not a recognised description - nurses are either 'students', who are enrolled on a recognised nursing course, or Qualified/RVNs. Anyone else is no more than a lay-assistant and has no legal right to perform Schedule 3 duties.
Surely on the point of giving options to the clients with the pros and cons is always part of our duty. People come to us for advice, but they also come to us with constraints, be that financial, or "not wanting anything invasive" or simply wanting a "quick fix" I think as long as you explain the benefits of doing the tests/procedures you recommend and the risks of not doing them (ie if your working diagnosis from history and clinical exam alone is incorrect) then it is up to the client to decide. The client who walked out after being presented with an estimate he did not like was in the wrong to walk out without paying his consultation fee and that should be followed up. One of my favourite phrases is "I advise .... because ......., but there's always a plan A, B & C"; this gives clients the opportunity to decide, whilst not feeling bulldozered into doing something they don't want to or feeling guilty. Surely this is what most other people do too? That way nobody can accuse you of "over-diagnosing" or just "guessing" Since they have had the informed decision.
I'm very grateful for the support we've received from across the profession. It was very heartening to see the lack of schadenfreude from our colleagues. What was broadcast was appalling and we're going to get it sorted as quickly as we can. Many thanks to all for your understanding, and rest assured that we will be taking any steps needed to set things right.
Not having had to deal with SA insurance (LA insurance seems much more straightforward) I wonder what pressure is put upon the consulting vet to throw a battery of tests at the pet at the initial consultation 'just in case'. If an 'oldie'like me and (clearly) some other posters on this forum relies initially on his/her clinical examination, experience and acumen, and the case goes pear-shaped,will the insurance still pay? I have heard (purely anecdotal)stories of insurance claims being refused because "the vet didn't......" Does this remote pressure from the insurance companies (and their advisers)really exist, and should it be allowed to do so?
Nice one Arlo a very level, thoughtful and accurate response.
Publishing Editor: Arlo Guthrie
Clinical Editor: Alasdair Hotston Moore MA VetMB CertSAC CertVR CertSAS FRCVS
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