Under care: practice scenarios - Professionals
Our Standards Committee and Advice team have produced a range of practice-based scenarios to help explain how the new guidance should be followed in various circumstances, and in relation to different species.
Please select from the following list, or read each in turn.
Please note: this list of scenarios is not exhaustive, and we may add to it in due course.
Practice scenarios
Scenario
This morning, Sandra called Park Veterinary Practice as three of her heifers were aborting.
Zach, a veterinary surgeon, attends and examines the heifers and whilst he is doing so, Sandra asks if it could be anything to do with the injections the ‘other vet’ gave them three days ago.
Zach asks some further questions and Sandra explains that Bridge Vets are carrying out a synchronised breeding programme for the farm.
Both Bridge Vets and Park Veterinary Practice are within 20 miles of the farm.
On checking the farm’s notes, Zach sees that there is no information about recent fertility services or mention of another vet or practice carrying out fertility work.
Zach therefore contacts Bridge Vets to find out more.
Things to think about...
In this case, both practices have taken responsibility for the animals and so have them under their care. Under the new guidance, both must therefore be able to physically examine the animals or visit the premises on a 24/7 basis.
Other than this, the new guidance will have very little impact on this scenario.
However, there is existing RCVS guidance on mutual clients that states:
5.9 Where different veterinary surgeons are treating the same animal, or group of animals, each should keep the other informed of any relevant clinical information, so as to avoid any danger that might arise from conflicting advice, or adverse reactions arising from unsuitable combinations of medicines.
5.10 Even where two veterinary surgeons are treating different groups of animals owned by the same client, each should keep the other informed of any problem that might affect their work.
In light of this, when a veterinary surgeon becomes aware that another veterinary surgeon is involved with an animal they are treating, lines of communication between those two individuals/practices should be opened and each kept informed of the any relevant clinical information as per the above guidance.
If Zach contacts Bridge Vets and they refuse to comply with the above guidance, Zach should contact the RCVS about the conduct of the vets involved.
Scenario
In June, Vanessa (a veterinary surgeon) visited the large-scale commercial broiler unit managed by Jorge as part of the annual quality assurance audit and veterinary health plan consultation.
The following February, Jorge contacts Vanessa and reports that mortality rates in the unit are rising.
Vanessa does not attend the unit, but requests that post-mortems are carried out on the affected birds.
She carries out a clinical assessment based on those results, together with other production and laboratory data.
Based on her clinical assessment, Vanessa prescribes oxytetracycline to be delivered via the drinking system.
Things to think about...
Under the new guidance, before antibiotics can be prescribed for production animals - in this case poultry - veterinary surgeon should have an in-depth knowledge of the premises, including its production systems, the environment, disease challenges and general health status of the flock.
In the vast majority of cases involving production animals, veterinary surgeons are required to attend and inspect the premises and physically examine one representative animal prior to prescribing or have done so recently enough to ensure they have current information and knowledge to prescribe safely and effectively, taking into account relevant data.
However, there is an exception which allows veterinary surgeons to prescribe antibiotics without attending the premises or examining a representative animal in exceptional circumstances.
The way that the large-scale commercial poultry sector works means that prescribing decisions are seldom (if ever) based on physical examination or attendance at the premises. Instead, the focus is on laboratory data, and post-mortems in particular.
Other than in fish enterprises, this is not the case in other sectors and as such, is an exceptional way of working that may amount to exceptional circumstances.
Where veterinary surgeons find themselves in exceptional circumstances and prescribe antibiotics without attending the premises or examining a representative animal, they are obliged to record their justification in the clinical notes.
In this case, Vanessa should note that she had access to reliable data from post-mortem examinations and other laboratory data meaning that physically attending the premises was unlikely to provide any further clinically relevant information.
Scenario
Tomas and his cat, Tilly, have been clients of the local veterinary practice for several years.
Every year, he takes Tilly for her annual heath check and vaccinations and, as part of this appointment, is prescribed a year's worth of preventative flea and worming products which is then supplied to Tomas on a quarterly basis.
For the subsequent supplies, he arranges to pick these up from the practice every three months.
Things to think about...
Under the new guidance, a physical examination should be carried out prior to prescribing antiparasitics unless there are exceptional circumstances.
However, it is acceptable to supply against an existing prescription at intervals without a further physical examination providing instructions for dispensing have been included. In so doing, Tomas’ practice is compliant with the rules.
Note that for supply in the absence of a veterinary surgeon, the supply should be pre-authorised by the prescribing veterinary surgeon and only dispensed by a competent and trained person in practice, in line with the practice's standard operating procedure.
Scenario
Jonathan owns a beef and dairy farm in Cheshire.
Ade, a veterinary surgeon based in Somerset, attends the farm on an annual basis to provide consultancy advice and prescribes medicines for the farm as needed between their visits.
Things to think about...
Under the new guidance, any veterinary surgeon who has production animals (in this case cattle) under their care must be able to visit the premises on a 24/7 basis.
They should also be prepared to carry out any necessary investigations and should provide this service within an appropriate timeframe depending on the potential needs of the species which have been brought under their care, which could be immediately.
In light of this, Ade should not continue to prescribe medicines for Jonathan’s animals unless he can engage another veterinary service provider within Jonathan’s proximity to provide the required 24/7 care on his behalf.
If Ade decides to do this, he will need to actively make these arrangements – it is not enough for Jonathan’s cattle to be registered with another practice.
He will also need to ensure that the agreement is made in advance before further veterinary services are offered to Jonathan and confirmed in writing as part of the conditions of service Jonathan agrees.
Veterinary surgeons are obliged to respond to reasonable requests from their regulator, and in the event of a complaint, Ade may be asked to produce evidence of the arrangement with another veterinary practice.
Scenario
Alex keeps a pack of hounds.
At feeding time, one of the dogs, Iceberg, had a fight with another of their dogs and has sustained a wound to the shoulder area.
Although Alex is registered with a veterinary practice, they have not yet attended the practice with the dogs.
Alex calls the practice and speaks to Pippa, a veterinary surgeon.
Alex explains that Iceberg is quite an aggressive dog and will not tolerate being examined by Pippa. Pippa explains that the dog will likely need antibiotics and possibly pain relief and so they should still attend with Iceberg and she will do what she can.
When Alex arrives, Iceberg is muzzled and clearly very distressed. Pippa assesses the situation and decides it is not safe to physically examine Iceberg for her or the team, however, she is able to look at the wounds from a safe distance and carry out a clinical assessment.
She is satisfied that, if left untreated, Iceberg’s welfare would likely suffer.
Pippa prescribes antibiotics and pain relief for Iceberg, and makes a note of the fact it would not have been safe to physically examine him.
Things to think about...
Pippa has taken responsibility for Iceberg and has taken him under her care.
She has carried out a clinical assessment, and when deciding whether to carry out a physical examination, has taken account of the fact that it would not be practical, or indeed safe, to do so.
Notwithstanding this, she is satisfied that she has enough information to diagnose and prescribe safely and effectively. The pain relief in question is not a controlled drug and, as such, she is able to prescribe it based on this assessment.
However, in respect of antibiotics, there are extra considerations to be taken into account before prescribing, namely, that they should not be prescribed unless a physical examination has been carried out unless there are exceptional circumstances.
In this case, risk to personal safety could amount to exceptional circumstances where antibiotics could be prescribed without a physical examination.
As such, it would be a matter for Pippa’s judgement as to whether it was appropriate to do so and her justification should be recorded clearly in the clinical notes.
Scenario
Derek is a contract pig farmer rearing pigs for a group owned by Happy Pigs Ltd. Derek’s farm is taken under the care of Green Livestock Vets.
Green Livestock Vets has never made an in-person visit to Derek’s premises but are within reasonable geographic proximity for this species to do so.
Green Livestock Vets have also discussed the production systems, seen photographs and videos of the farm infrastructure, and are familiar with the disease status and history of the supplied pigs.
Derek is concerned about his pigs and describes symptoms which could be consistent with Streptococcal meningitis and requests treatment with amoxycillin.
Things to think about...
Green Livestock Vets should not remotely prescribe this antibiotic under these circumstances as they have not met the criteria of considerations under the guidance to ensure safe and effective prescribing and responsible use of medicines.
In addition, there is no exceptional circumstance present that would justify the prescription of antimicrobials without ever having attending the premises or examined one representative animal.
Given the factors to be taken into consideration when deciding whether a physical examination is necessary, in this scenario it may be difficult to justify prescribing any POM-V without carrying out any indicated further investigations and understanding the level of knowledge/training of the keeper.
Scenario
Sunny’s Cocker Spaniel, Fido, had a cluster of seizures two years ago and, since then, has been prescribed phenobarbital twice daily.
Fido was given a six-month long prescription, and Sunny picks these up at monthly intervals.
Fido is usually seen at the practice every six months for a blood test and physical examination, but Sunny has been unable to get Fido to an appointment within this timeframe and cannot attend the practice for a further two weeks.
As such, Fido now risks being without phenobarbital until he can be seen.
The vet issues one further prescription phenobarbital to cover these two weeks before the dog can be examined again.
Things to think about...
For all controlled drugs, in most situations veterinary surgeons should only prescribe 30 days’ worth of treatment. The exception being where there are long term ongoing medical conditions, for example, when treating epilepsy in dogs.
If more than 30 days’ worth of treatment is prescribed, the prescribing veterinary surgeon must be sure the owner is competent to use the medicine safely.
Under the new guidance, it is acceptable for a vet to issue a further prescription for a controlled drug previously prescribed, however, the vet should carry out a clinical assessment to ensure they have enough information to do so safely and effectively.
In line with general guidance on prescribing controlled drugs, they should only prescribe the minimum required.
Scenario
Nina’s cat, Snowflake, has been in a fight with another cat and has sustained an injury.
Snowflake is bad tempered, and Nina knows from experience that she will not be able to catch her, let alone get her in the carrier to take her to the vet.
Nina calls her usual veterinary practice and speaks to Anton, a veterinary surgeon.
She describes the situation and Anton explains that he will need to see Snowflake as she may need antibiotics and makes some suggestions to calm and catch her.
Nina tries everything she can think of, but cannot catch Snowflake. She calls the practice back and suggests that Anton see Snowflake at her house.
Anton cannot see how attending Nina’s home would help as he is no more likely to be able to catch Snowflake than Nina.
Anton knows that Snowflake’s wound needs to be assessed as a matter of animal welfare and says he will prescribe a single dose of gabapentin to calm Snowflake enough to so Nina can get her to the practice.
Things to think about
Anton has taken Snowflake under his care by taking responsibility for her.
He knows Snowflake will more than likely requirement treatment, but cannot get all the information he needs without a physical examination (he is also mindful that antibiotics might be indicated and that a physical examination is required for this).
Anton has exhausted other avenues of getting Snowflake to the practice and therefore prescribing a very small dose of a controlled drug may be justifiable as exceptional circumstances in the interests of animal welfare.
Scenario
Taylor is a veterinary surgeon who works remotely and advertises their services on social media.
After seeing one of Taylor’s ads, Sylvia contacts Taylor about her cat, Whiskey, who has an upset stomach. Whiskey is not currently registered with any veterinary practice.
Taylor listens to Sylvia’s concerns, asks a number of questions and, with Sylvia’s help, visually assesses Whiskey over a video call.
Taylor prescribes anti-sickness medication and tells Sylvia that although they have an arrangement with a veterinary practice, it would 'probably be better' to take Whiskey to a local vet if he does not improve over the course of the next week.
Three days later, Whiskey has visibly deteriorated and is very lethargic.
Sylvia contacts Taylor and asks for the details of the vet they have an arrangement with. Taylor says they will ring straight back with the details.
Sylvia waits for 30 minutes and, in that time, tries calling Taylor back on several occasions with no answer. Sylvia then spends over an hour telephoning local practices and eventually finds one that is able to see Whiskey straight away.
On arriving at the practice, Whiskey crashes and although the veterinary team rush to help, they cannot save him.
Sylvia is devastated and believes that, had she been able to access veterinary care immediately through Taylor, Whiskey might have been saved. She therefore raises a concern with the RCVS.
Taylor tells the RCVS that the practice they have an arrangement with were not picking up the telephone when they tried to get in touch about Whiskey and that they did all they could to arrange for him to be seen in person.
They also say that the reason Sylvia couldn’t get through to them was because they were on the phone trying to sort things out.
As part of the investigation, the RCVS requests that Taylor provides a copy of the written agreement with the other practice in respect of 24/7 follow-up care.
Things to think about...
Under the new guidance, when taking cats and other small animals under their care, veterinary surgeons must be able, on a 24/7 basis, to physically examine the animal.
Vets should also be prepared to carry out any necessary investigation in the event the animal does not improve, suffers an adverse reaction or deteriorates.
If a veterinary surgeon is unable to provide this service themselves, they are required to make arrangements for another veterinary service provider to do so on their behalf.
The guidance is clear that it is the veterinary surgeon’s responsibility to make these arrangements and it is not sufficient for the client to be registered at another practice.
When arrangements of this nature are made, this should be done in advance before veterinary services are offered and confirmed in writing as part of the conditions of service agreed by the client.
The guidance also states that 'veterinary surgeons should provide clients with full details of this arrangement, including relevant telephone numbers, location details, when the service is available and the nature of service provided'.
It is clear from this scenario that Taylor has breached the guidance.
Although the question of whether there was actually an agreement is in place has yet to be answered (this will be determined by whether Taylor can provide evidence of such an arrangement having been made in advance), Taylor did not provide details of this provider to Sylvia before offering treatment for Whiskey and indeed never disclosed to Sylvia who the 24/7 follow up care would be provided by.
It should be noted that, had Taylor complied with the guidance on 24/7 follow-up care, the remote prescribing itself in this case may have been appropriate.
Scenario
Remote Vets 4U is an online-only company based in the United Kingdom. It provides a platform for animal owners to access veterinary care remotely 24/7 and employs veterinarians based outside the UK.
Stuart is employed by Remote Vets 4U and lives in Greece. Until recently, Stuart was registered both as an MRCVS and with the Greek veterinary regulator but has since let his RCVS registration lapse.
This morning, Stuart had a remote consultation with Parminder and her dog, Rex. Before beginning the consultation, Stuart confirmed with Parminder that Rex is registered at a veterinary practice locally and obtains the details so that he can pass on any relevant clinical information following this consultation.
Parminder explains that Rex is lame and that this has come on suddenly over the past couple of days. Stuart has seen a video of Rex in advance and asks a number of questions during the consultation.
Following this assessment, Stuart decides he has enough information to prescribe anti-inflammatories effectively and safely and says he will send Parminder a prescription via email.
He also tells Parminder that if Rex doesn’t improve over the next couple of days, she should attend her usual practice for further investigation.
Things to think about...
Veterinary surgeons who provide veterinary services to animals in the UK are considered to be practising in the UK regardless of where there are physically based. This means that they must be an MRCVS on the 'UK-practising' category of the RCVS register, keep up to date with continuing professional development (CPD) and have professional indemnity insurance (PII). Stuart does not satisfy these criteria and, as such, should not be providing any such service.
Even if Stuart was properly registered, had completed CPD and had PII in place, there are still a number of barriers before POM-Vs could be prescribed from outside the UK, as set out below.
According to the VMRs, veterinary surgeons must take the animal under their care and carry out a clinical assessment. The College's new guidance states having an animal 'under care' means that the veterinary surgeon has been given, and accepted, responsibility for the animal.
Stuart has clearly taken responsibility for Rex and, as such, according to the new guidance, must be able, on a 24/7 basis, to physically examine him and carry out any necessary investigations. This service should be provided within a reasonable timeframe, which could be immediately.
Stuart would not be able to fulfil this obligation himself from Greece and so he (or Remote Vets 4U on his behalf) would have to find a veterinary provider, based in the UK to provide this service.
It is Stuart’s responsibility to make any such arrangement (it is not enough that Rex is registered at another practice) and it must be made in advance before veterinary services are offered with the terms confirmed in writing.
Remote Vets 4U is an online-only business and, as such, clients would be able to contact them from anywhere in the UK. This means that if they, or Stuart, were going to go down the route of putting these arrangements in place, they would have to ensure that there was cover local to all clients who use their service which would be logistically challenging.
Finally, even if Stuart and Remote Vets 4U were able to fulfil their obligations in terms of 24/7 follow up care, they would not be able to supply any medicines prescribed as medicines may only be supplied from ‘Registered Veterinary Practice Premises’ (RVPPs) which, due to inspection requirements, can only be registered in the UK.