“It is difficult to get a man to understand something when his job depends on not understanding it.”
Upton Sinclair US novelist & socialist politician (1878 – 1968)
This could perhaps be paraphrased
“It is difficult to get a man to promote something if his income depends on not promoting it”
If your NHS doctor refers you to a specialist, she does not lose out on income as a result. If your veterinary surgeon offers referral for your pet, he (or his employer) inevitably loses the income from the further investigation and treatment of your pet’s illness which goes to the referral practice and not to the practice of the referring veterinary surgeon. Your vet is therefore inevitably conflicted. Fortunately, in our experience the vast majority of veterinary surgeons are ethical individuals who have a strong sense of integrity and the welfare interests of their patients at heart. However, there are great financial pressures on everyone these days and no barrel contains only good apples. Furthermore, there has been a growth in corporate practices over the last few years and the conflict for veterinary surgeons employed in corporate practices is perhaps greater since a veterinary surgeon working for a corporate practice may be under some pressure from his paymasters to retain business within the corporation rather than to refer elsewhere even if the latter action is ultimately in the best interests of the animal.
In recent years, we have become more aware of cases receiving inadequate treatment with an unsuitably qualified individual when the offer of an earlier referral to a suitably qualified specialist would have been more appropriate for the animal and almost certainly more cost effective for the animal’s owner. In some practices a trend has developed to have “visiting specialists” or “in house specialists” but these individuals are not financially independent of the referring practice and are often not as well qualified as they might be, nor are they supported by all the other specialist services that might be present at a specialist referral centre. Click here to read more about appropriate specialist veterinary qualifications and here to read Justin’s seven questions.
The Royal College of Veterinary Surgeons (RCVS – http://www.rcvs.org.uk/ ) publishes a Guide to Professional Conduct (the “Guide”) which is the “rule book” by which all veterinary surgeons operate and against which any vet can be brought to account by the disciplinary procedures of the RCVS. In the sections that follow, excerpts from the Guide are highlighted in blue and italics.
The Guide contains the following advice on the relationship between veterinary surgeons and their clients:
The professional/client relationship is one of mutual trust and respect, under which a veterinary surgeon must:
a. maintain client confidentiality
b. treat the client with respect, and observe professional courtesies
c. avoid conflicts of interest
d. give due consideration to the client’s concerns and wishes where these do not conflict with the patient’s welfare
e. provide fully itemised accounts if requested.
So, “a veterinary surgeon must avoid conflicts of interest” with their clients, but immediately any animal is considered for referral, that veterinary surgeon is placed in a position of conflict, since income may be lost to him or his employer if a patient is sent to another practice. The poor vet cannot help but contravene the letter of this regulation.
The problem is epitomised by the quotation from Upton Sinclair at the head of this blog. Why would a veterinary surgeon promote referral when in doing so he will lose income? Given this inevitable risk of a conflict one might expect that the RCVS has solid governance in place to ensure that the conflict is resolved only in the interests of the client and the animal. The emphasis in the “Guide” is perhaps not quite as much in favour of the animal owner and the animal as one might expect.
Whether or not a case is referred is agreed by discussion between the client and his usual veterinary surgeon
Note that that there is no requirement for the veterinary surgeon to “initiate a discussion about appropriate referral when this is in the interests of the animal’s welfare”. If the client does not initiate the discussion, then the vet may be absolved of responsibility just by keeping quiet. A veterinary surgeon looking after his own or his employer’s income might well keep his head below the parapet and not initiate such a discussion unless pressed by the owner.
Veterinary surgeons must not:
a. speak or write disparagingly about another veterinary surgeon
b. obstruct a client from changing to another veterinary practice
c. discourage a client from seeking a second opinion
Note again that this list is couched in terms of “must not obstruct” and “must not discourage” rather than perhaps a more appropriate, “must offer the client an appropriate option of”
Your own veterinary surgeon has a responsibility to provide you with all the information needed to make a proper and fully informed decision about referral.
Yet again, this statement embodies no onus on the veterinary surgeon to initiate the process even if this is in the interests of the animal, only a requirement to participate in providing information.
So, how do you ensure that your pet receives referral when it is appropriate to do so? For a start, you should always ask your vet about referral if you think it might be appropriate. You should also ask about the standard of qualification of any “specialist” that you might be referred to and in doing this you will need to understand the different types of specialist qualifications by following the link earlier in this blog
Finally, the “Guide” does contain a list of responsibilities that veterinary surgeons have to their clients written in terms of what they should do. These are listed below and can be helpful to you.
The provision of veterinary services creates a contractual relationship under which the veterinary surgeon should:
a. ensure that clear written information is provided about practice arrangements, including the provision, initial cost and location of the out-of-hours emergency service, and information on the care of in-patients
b. take all reasonable care in using their professional skills to treat patients
c. keep their skills and knowledge up to date
d. keep within their own areas of competence save for the requirement to provide emergency first aid
e. maintain clear, accurate and comprehensive case records and account
f. ensure that a range of reasonable treatment options are offered and explained, including prognoses and possible side effects
g. give realistic fee estimates based on treatment option
h. keep the client informed of progress, and of any escalation in costs once treatment has started
i. obtain the client’s consent to treatment unless delay would adversely affect the animal’s welfare (to give informed consent, clients must be aware of risks)
j. ensure that all staff are properly trained and supervised where appropriate
k. ensure that the client is made aware of any procedures to be performed by support staff who are not veterinary surgeons
l. recognise that the client has freedom of choice
In the context of referral, the most relevant items in this list are items d, f and l.
Item d: Your veterinary surgeon is required by the RCVS to be sure that he keeps within his area of competence. You should have no qualms about asking your veterinary surgeon if work he is proposing to do is within his area of competence or whether it would be more appropriate to refer to a centre or individual with higher levels of qualification and competence as recognised by the RCVS.
Item f: Your veterinary surgeon is required by the RCVS to discuss a range of reasonable treatment options with you. It is always reasonable for you to ask if these options should include consideration of referral to a suitably qualified specialist. Your veterinary surgeon also has a responsibility to discuss fully with you the different levels of qualification that a given specialist has, but will only be obliged to do so if asked directly about this so you should be sure to familiarise yourself with these through the link earlier in this blog.
Item l: Your veterinary surgeon is required by the RCVS to recognise your freedom to choose who treats your animal.
Specialist veterinary services can be expensive, but your vet should be able to contact the chosen referral centre to obtain an estimate of costs for you before referral. Remember, that your own veterinary surgeon may not have much incentive to start a discussion about all of your choices for referral and may also not have an incentive to discuss the standards of qualification of an individual or centre that he refers to unless asked directly. Remember also, the Upton Sinclair quotation from the start of this blog. Don’t be afraid to ask your veterinary surgeon about referral to a suitably qualified specialist if you think this might benefit your pet and don’t be afraid to ask if the referral centre or individual under discussion is independent or whether there is some form of financial benefit for your own veterinary surgeon or the company that he works for.
Ultimately, you have the freedom to choose who treats your pet and if you want this to be a properly qualified specialist (Diploma holder or RCVS Recognised Specialist) then your veterinary surgeon is obliged by the RCVS to assist you in locating such an individual, but only if you ask him or her to do so and only if you are specific about your requirements.
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