I AM writing this during the
extremely cold spell in early January
2010. Schools have been closed for
days and I have resorted to walking
the dog wearing crampons I last
used as a student in the Scottish
Highlands.
Christmas is over and I have
dismantled our fake tree and put it and
the rest of Christmas into two body
bags in the loft. The practice is quiet as
people cancel due to ice-bound roads
and pavements. I visited an elderly client
who was housebound due to icy
pavements. On the table in her living
room was a pile of asthma inhalers
propping up a pile of tobacco pouches
and cigarette papers. I was glad to be
her vet and not her
GP!
I spent an hour
clearing our drive last
night so I could get in
and out as I was on-
call. I wonder what the
RCVS would make of
non-attendance to out-
of-hours calls due to
weather conditions?
It might be an
excuse to get that mid-
life-crisis 4×4 through
the practice books.
(Maybe those of you
more inclined to the
mid-life-crisis sports car
or motorbike could try it on as an
emergency response vehicle?)
Due to school closures we have also
been doing some home schooling and I
have run some rudimentary physics
experiments for the children in the
kitchen. My star pupil did comment at
one point when things were bubbling,
fizzing and spilling everywhere, “What’s
happening now Daddy? I’m a bit
scared.” It was certainly more Hogwarts
than Eton.
As a super special Christmas treat
we were the lucky winners in the
HMRC random PAYE inspection
lottery. Their computer picks out
random businesses to inspect and ours
was selected.
The inspection started just before
Christmas, which was nice. They had
requested a room to themselves for the
morning and we had allocated a consult
room which in the event they did not
use. This was lucky as the temptation to
book a few anal gland empties in there
first thing was very strong.
They sat themselves in the office
space only recently occupied by the
Practice Standards inspector who now
seemed a much less daunting character
by comparison.
My partner was consulting initially
so I naively volunteered to start off with
them. I made them coffee and offered them biscuits and began my best
attempt at a charm offensive. After
some time my partner, who is normally
very straight and can turn on the charm
when needed, breezed in. I was running
out of steam and was ready for a tag-
team style swap over.
“This shouldn’t take too long,”
commented the inspector to my partner.
“Good, we’ve got a business to
run,” was my partner’s response.
The atmosphere chilled noticeably.
“Another coffee anyone?” I
volunteered, and left him to it.
Afterwards we were joking about
pepping up their beverages with a bit of
diazepam or something, just to help
them along. Or frusemide to distract them…
Of course this was just foolish jesting and
using the practice
drugs is a line I would
never cross, ever. Many
vets do, unfortunately,
although usually on
themselves and not to
drug the tax inspector.
I have had the
occasion to take
Valium once: it was
prescribed by my GP
as a pre-med before a
minor op to be carried
out under local anaesthetic by him at the
GP surgery. It was scheduled to happen
just after both our evening surgeries had finished.
He suggested a range of doses of Valium to take and after a brief
consideration of the pharmacokinetics
of the situation (i.e. I hadn’t enough
time between taking it and going under
the knife for it to work properly) I
opted for the higher end of the dose
range to be swallowed immediately after
the phones had been put through and
the front door of the practice was
locked.
Unfortunately, I was then cornered
by a member of staff about an
employment issue and I am not sure
what kind of response she got from me.
At the clinic, the doctor and I were the
only ones there.
After last month’s slightly critical
look at the NHS, this is a good example
of them providing a much more
customer-focused service: late evening
surgical appointments. Whether this has
anything to do with the fact that GP
practices (like vet practices) have their
own budgets, enjoy quite a lot of
autonomy and are paid by results we
can only wonder.
The other thing that was different
up there was how sinister a surgical kit
can look when you are its intended
subject, not its user! The doctor stood, scalpel in hand, and remarked, “You
seem a little tense.”
If we had swapped places he might
have realised why. I have much more
empathy with our patients after having
this experience and can definitely state
that, for patients, “White Coat
Syndrome” is very real.
Anyway, after the event the GP
drove me home and I post-op-
medicated with half a bottle of wine. I
recounted my experience several times
over to my wife as the Valium had
reduced my short-term memory to that
of a goldfish. She gave up on me
eventually and left me alone in a drug-
induced coma on the settee. The next
morning I told her everything again.
Comparisons with the NHS,
doctors, vets and our patients are
sometimes useful, sometimes
exasperating and often misleading. I
have received a number of e-mails (on
garethcross@hotmail.com) after my last
article which discussed an experience we
had at our local hospital.
Some e-mails were sympathetic,
some shocked at the service level we
received, and one or two sympathetic to
our experience but with a caveat about
comparing NHS and vets.
Here is an extract from one such e-
mail: “[I] have some issues with the
comparison to the NHS. When you see
an NHS medico, you do not have to be
concerned that a whole range of
unnecessary and expensive tests are
being performed in order to maximise
hospital income, and that
recommendations for treatment have a
better chance of meeting the needs of
the diagnosis first and foremost, rather
than the aforementioned income
considerations…”
Opposite problem
The problem the NHS has is directly
the opposite one we have: namely, that
treatment options are limited due to
their cost rather than made more
attractive to the clinician. The NHS as a
whole has a fixed budget to deal with its
patients (and GP practices have a
budget individually) and treatment may
well be limited, slow in supply, not
available locally, etc., due to costs.
This is the opposite to our private
system that provides instant healthcare
as supply meets demand and the more
treatment we provide the better for us
financially. Offering more treatment may
well benefit the patient if not the client.
So costs are a factor in treatment in
any system, but in the NHS they have a
retarding effect on treatment and
conversely in our, or any other private
system (e.g. USA insurance-based
human healthcare system) they may
have a positive or exaggerating effect on
treatment offered.
I am not defending over-treatment
here. That is a separate issue.
This brings us round to our
professional quandary of our income
being tied to how we treat our patients
– that old chestnut and one which has
been much aired in the veterinary and
national press by a certain member of
our profession recently.
When it comes to costs, the
Competition Commission would not
allow us to fix costs across the nation (if
it did and we all charged the same, how
would Panorama, the Daily Mail, etc., be
able to run all those “vets are shockers”
stories).
The RCVS has no remit to set cost
guidelines so we are on our own there. I
cannot imagine the RCVS or BVA
divisions laying down clinical protocols
to follow like they have nationally in the
NHS (and if they did, tell me honestly,
would you follow them?).
So deciding how we treat and how
much to charge for it is inevitably down
to individual practices and individual
vets. In the fact that we make more
money on more complex cases and get
more income the more we do, we are
not so different from many other
professions and trades – for example,
private medical practitioners (e.g.
osteopaths, chiropodists, etc.), garage
mechanics, builders, plumbers, etc., all
work with the temptation to “over-
treat” in their own field.
We are all individually responsible
for this, there is no mechanism for the
veterinary profession as a whole,
nationally, to define costs and treatment
protocols.
What is one vet’s “unnecessary and
expensive tests” is another’s “minimum
database”. If you want conformity in
treatment methods, that means
someone has to set them and someone
has to enforce them, but who…?
Does anyone want more regulation?
The vet who has caused much of the fuss recently referred to an
upcoming exposé in Panorama of how
awful/expensive, etc., etc., vets are. He
challenged vets to strive to have “…
nothing to fear from programmes like
Panaroma…”. Well, I’m there already: I
have nothing to fear from them. I, and
most of you reading this, will practise
with a clear conscience in what we do
and how much we charge.
There is no national conspiracy so
if a few vets are exposed as charlatans,
the majority of us are not obliged to
share their shame. If I watched an
episode of Rogue Traders, it wouldn’t
make me think all plumbers and
builders were crooks, I’d keep using the
ones I trust.
As always, it boils down to us all
giving the clients the best service and
doing the best clinical job we can.
What some rogue vet does somewhere
else is nothing to do with me or you,
or our clients and patients.
