A few months ago our practice received a very professional looking brochure from an orthopaedic referral practice.
I flicked through it and thought, because the presentation was so good, it must be in the home counties or London and passed it on round the office. Later on a colleague (an actual Devonian, not just one of us who have moved down here for the lifestyle) told me she had seen practice there and it was near Totnes, in South Devon. This was the first thing that interested me about the practice.
The practice was Seymour Vets, which is a recent incarnation of a long-established practice previously known as Munnings, Mitchell and Peplow. It is in some ways a traditional mixed practice, based in rural South Devon, and it is RCVS accredited as a tier 2 training practice. It provides a full service across all sectors – farm, equine and small. The area is beautiful, being near both Dartmoor and the sea.
There are three partners: Huw Peplow and Richard Mitchell who have been there approximately 20 years each and Matt Gopal who joined the practice in 2004. Matt is also an organic smallholder and is thus well placed to offer informed and empathetic advice to organic farm clients.
The partners are assisted by three other vets who have joined the practice within the last five years, along with five nurses and nine other members of staff. The main surgery is in Totnes and there is one branch.
The Totnes area has a variety of farmland, from wild moorland on Dartmoor to the more mellow South Hams. Totnes and its surroundings are, like much of Devon, not a particularly wealthy area in which to practise small animal work compared to the Midlands or the south-east for example, but there is a significant minority of well-heeled retirees in the area who I imagine are valuable clients with their dogs and cats.
The practice also offers an orthopaedic referral service led by Huw Peplow and this is what interested me about the practice.
This is a quote from the literature that gives an idea of the level of work the practice does: “Over the past 20 years Mr Peplow has been advancing his orthopaedic skills, this allows Seymour Vets to offer its services as an orthopaedic referral practice.
Currently we offer to our clients and to those referred from other practices, the following procedures: hip replacement (cemented or biological fixation); fracture repairs (ASIF internal and IMEX external); treatment of development problems – osteochondritis, growth plate abnormalities, bone cysts, elbow dysplasia; spinal disease – laminectomy, fenestration, myelogram; diagnosis and fixation treatment of cruciate disease – triple pelvic levelling osteotomy (TPLO), triple tibial osteotomy (TT0), tibial tuberosity advancement (TTA); over the top cruciate repair.”
The RCVS has recently rolled out its new modular certificate system and abolished the old subject-specific one. This has left an education gap for vets wanting to do referral work and looking for a way to start on the ladder from practice.
The new certificates are widely perceived to be of a lower academic standard than the old ones, and some subjects no longer have a specific certificate available, for example ophthalmology and surgery. There are many advantages to the new system and many people felt that the old system had become too difficult; it had a high drop-out rate and a very high exam fail rate by those who made it to the end.
So the new system has good points, but for those vets specifically intending to see second opinion and referral work later in their careers, and who can’t do internships or residencies, the way forward is now not so clear as it was. This is, of course, exactly what some members of the RCVS want: there is a minority of senior RCVS members who want only RCVS diploma holders to see any referral work. [This information was passed to me by a diploma holder and previous university lecturer.]
So how would a very competent and experienced vet go about starting to see referrals now? Is the new certificate system applicable to those people or should they gain sufficient experience and CPD and then advertise when they feel ready? Could it be done? Could someone run a referral service and be widely respected by clients and their professional peers without going through a certificate or diploma programme?
The RCVS has informed me, and it is discussed in the Guide to Professional Conduct, that as long as you make clients and referring vets aware of your level of expertise and qualification, and don’t call yourself a specialist unless you are one, then any vet can do second opinion work.
So I was ruminating on this around the time when the brochure for Seymour Vets came through the post and, on close inspection, found that none of the vets there has any post graduation qualification. So I ’phoned Huw Peplow and interviewed him for Veterinary Practice to discuss his practice and referral work. There follows a rough distillation of our telephone conversation that was conducted whilst I supervised a typically noisy bath-time for our four and two year olds.
Cases found their way…
I began by asking Huw about how he started taking second opinion cases. As he did more complex cases within his own practice over the years and the VNs of South Devon came and went between practices, his ex nurses would say at their new practices, “You could send that [broken leg, spine, etc.] to Huw,” and so over the years cases found their way to him from local practices.
After five years of taking referral work in this way, the practice decided to build on this and advertise further afield.
What about doing a certificate himself? He was one of many who enrolled and then didn’t find time to complete it mainly due to “what I can hear in the background” – meaning children and general life leaving little time at home for further work on top of being a vet and running a business. He has attended a lot of CPD over the years including a training course for the hip replacements.
What about other certificate and diploma holders? He commented that he would view a surgery certificate holder as being at a similar level of expertise to himself but that a diploma was certainly “a higher level”.
Should only diploma holders be allowed to see referral cases? “Completely incorrect!” was his response to that one.
What about his compliance with the Guide to Professional Conduct? He does advise clients that he does not have any further qualification. The wording on the practice literature is interesting as well. The brochure for vets contains the sentence, “We keep accurate record of our success rates, which is how we like to judge our work”, and it offers references from current practices which use Seymour Vets.
I think the phrase “… how we like to judge our work” is interesting and is a coded way of dealing with the question of qualifications. I asked Huw if he had a formal clinical audit system. He does not, but can provide case histories from the practice records.
Clinical audit seems to be quite trendy at the moment and it may be useful in this setting to formalise some of the figures.
What about other local referral practices? His practice is viewed and operates as an equal service and although in competition with them there is some slack in the market to take up locally. Huw commented that he has a good relationship with other orthopaedic vets both locally and further afield. He views his and their success rates to be similar.
That’s a version of our conversation written up from notes I made at the time, between refereeing bath-time squabbles and trying to explain why if they keep splashing so much we’ll need a new kitchen ceiling downstairs.
I put in that contextual note because it coloured our conversation: we were two busy practitioners who had been trying to speak on the ’phone for weeks and when we finally could when neither of us was operating/consulting/out on farms, etc., it ended up being bath-time for the children.
This hectic life that many of us vets lead does mean that study and achievement of paper qualifications, be they personal, e.g. a certificate, or for the practice, e.g. practice standards scheme, can lag behind our actual skill level or standard of business.
We can work well and improve ourselves and raise our game, but getting the time to formalise that for assessment by a third party and do the paperwork sometimes slips down the priority list and never gets completed. I am not implying that this is a good thing, or certificates and practice standards are bad, but many vets and vet practices (and Huw Peplow and his practice are just one good example) work at a level way above what you might expect from the level of paper achievement.
I think that with the changeover of certificate structure and changing working patterns of vets, we may see more vets offering local referrals in this way. After all, those who do this will not in the end be judged by the clients, but by their peers who refer them the cases. Anyone not up to the job will soon find that his or her case supply dries up, whatever level of qualification is held.
GP vets refer to other vets they trust with their cases clinically and trust with the handling of the client and who have good communication with their referring vets. That trust will often come from some extra letters after their name, but also from reputation and personal contact. The choice of who to refer to is also often dictated by geography and client wishes as well as the difficulty of case.
Veterinary practices are diversifying and evolving. They now fulfil different and extra roles than previously, with many specialities including surgery, emergency work, etc., and some established practices extending to offer referral work.
Huw’s orthopaedic work may have started 20 years ago, but in some ways he’s showing some of us the future.