De-skilling of the general practitioner - Veterinary Practice
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De-skilling of the general practitioner

“IT’S amazing what you can do nowadays,” is something we sometimes hear said by clients after we have referred a patient for hip replacement, laser retinal reattachment surgery, MRI scan, etc.

The profession is stretching its range and expanding its horizons. New multi-disciplinary referral centres are opening up year on year and often with a difficult case it’s not a question of “What can we do?” but “Where do we stop?” for the vet and client to ask.

It’s an exciting time to be a vet and great to be able to offer treatments that were previously unavailable to patients.

Most of the cases we refer are insured and for referral practices about
80% of their clients are insured. At the moment only about 15-17% of pets are
insured in the UK. Various industry surveys currently put future market saturation (i.e. everyone who uses a vet now and might possibly want pet
insurance in the future) at 40-50%. So at most, about half of general practice
clients will ever be insured.

If you consider your current client base, of the uninsured clients, how many can afford a four figure referral bill for their pet? No one knows, and it will vary where you practice, but at a guess anywhere between 5% and about 30%. So add that to the current insured ones and that means that currently between 20% and at most 50% of a first opinion practice’s clients will be able to make use of referral services.

Two-tier system

It is, unfortunately but inevitably,a two tier system. For the majority of the UK pet-owning population, veterinary referral clinics and their clinicians sadly
are just never going to be part of their pet’s healthcare.

Now before I receive another two page diatribe from a specialist accusing me of being a luddite and not wanting to make use of or appreciating the skills of specialists, let me make it clear that I do appreciate them and refer cases regularly and have good working relationships with our referral vets in various disciplines, from the surgeon down the road to the specialist cardiologist 150 miles away, and many others.

It’s a great system with very well qualified and experienced vets available to see patients and for telephone support. But the fact remains that for at least half the patients at a first opinion practice, the first opinion vets are on their own when it comes to treating them.

Which brings me to the topic of de-skilling of the veterinary general practitioner. Here is an example, it is anecdotal and was passed on to me during lunch at a CPD course – as all the best veterinary anecdotes are.

A young dog had a fairly simple fracture. Because of cost referral wasn’t an option. A new graduate was in charge of the case and no one at the practice had much orthopaedic experience. The practice’s usual referral vet was contacted and advised the young vet to fix it in-house as it was straightforward and the general surgery competence in the practice was good.

The referral vet even went as far as to offer to be pretty much on the phone all the way through. The new graduate had always been told during lectures to refer most fractures, partly from fear of being sued if things went wrong.

(Remember, the vet giving the lecture will have been used to a client base of 80% insured clients and 20% uninsured but able to pay).

Hardly progress…

In the end the dog had its leg amputated. So the orthopaedic service to clients in that practice to approximately half its clients is to offer solely amputation or casting, hardly progress.

To varying degrees that picture will be repeated in different disciplines in
many practices around the country: techniques that were routinely practised in first opinion practice 10-20 years ago have moved into the realm of the
referral practice and thus lost to half of the pet population of the UK.

The causes are multiple: fear of litigation and defensive medicine, lecturers repeatedly advising referral, the profession being overseen and run by mainly academics and specialists (e.g. automatic appointment to RCVS Council of university staff).

It is something the practice needs to think about. We must continue to progress, but we must remember the 50% or more of patients who will not
benefit from the highest level of medicine and surgery, and first opinion vets must not be put off attempting surgical and other treatment methods that they feel they have a reasonable chance of success in.

This especially applies to techniques that used to be routinely practised in the
first opinion practice. For example, I wouldn’t try to do a hip replacement, but as a practice we do some orthopaedic work and I did recently do a very successful femoral fracture pinning – and I’ve only ever done about three of those in my life. OK, the femoral pinning was in a chicken and was based on the BSAVA parrot book, but that’s another story…

There are, therefore, two related issues here: firstly, deskilling of today’s GP vets and, secondly, lack of accessibility to referral centres because of costs. The lack of accessibility to referral centres is mainly an issue for new and advanced treatments, but also includes a few procedures that used to be carried out by GPs, e.g. fracture repair, cruciate surgery.

So what should the profession be doing to improve the care of the nonreferral candidates? You tell me. Here are some ideas (some of which I think are good ideas, some are just ideas, some are bad ideas. I hope readers all rate them differently):

•A fund (either national or per-practice) contributed to by referral practices to which GP vets could apply for their clients who can’t afford their services. A bit like private schools offering scholarships to clever but poor kids.

• An in-house fund contributed to by each first opinion practice to help refer their cases whose owners can’t afford it. This could be part of a loyalty or healthcare scheme.

• Less scaring of vets into defensive medicine.

• Local networks of GP vets “with an interest in…” a certain subject seeing
each other’s cases at normal prices in those subject areas where they have a
particular interest/extra experience/extra training. This would just be an extension of what happens within practices every day and wouldn’t be seen as “A referral to a specialist” by vet, client or the RCVS.

• More active promotion of insurance to all clients.

• Mandatory insurance: we could all just decide one day to insist that all clients must have some sort of pet health insurance. This would allow us as a profession to move forward to being a fully vertically integrated profession like human health, with GPs, specialists, specialist institutions, etc.

• Stop referring anything ever and take back ownership of all our cases.

• Just do our best and hope it works and we don’t get sued.

So as the festive season approaches and we all get in the spirit of giving, let us
think how we can offer the highest standard of care the whole profession can provide to more or all pets, and not just to the insured or the wealthy

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