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The PRN: demoralising and tragic

by
01 July 2017, at 1:00am

GARETH CROSS returns to the subject of the RSA’s Preferred Referral Network and talks to a vet about his experiences on ‘the wrong side’ of the RSA

VETS TYPICALLY ARE A FAIRLY INDEPENDENT-minded and driven bunch of people and many of us have chosen to advance our skills in clinical work, maybe as far as to take referrals. The RCVS’s attempt at applying a standard to vets’ efforts in this regard saw the launch of the “Advanced Practitioner” (or AP) status for vets in the middle ground between GP and Specialist. Many vets in this middle tier (AP or not) provide vital second opinion services to local GP vets and often have had long relationships with them. Some of these vets will also spend part or most of their time working in first opinion practice. To achieve the academic qualification, get the practical experience and in many cases, own and run a practice, requires a huge investment in time and effort. This diversity of achievement typifies what being a vet is all about: dedication, vocation, mastery of skills and an independent spirit of work. For vets to make a living, we also need a steady stream of cases, whether first or second opinion. How would such vets feel then when, in a distant office, a decision was made that effectively said: “Hey, you there working all those long hours and with all those years of experience and training. We are going to send people away from you to somewhere else”? This is what the Royal Sun Alliance did in December 2015 when it launched its “Preferred Referral Network” (PRN). They underwrite many insurance companies, but the main ones that affect us as vets are Tesco, More Than and Argos. If you work in first opinion practice and want to refer a case that is insured by one of these companies, the people in that distant office now decide which referral vets see your cases. Referral vets you may have used for years, who may be very convenient for your clients, you may now be prohibited from using – or if you do, the client will be fined £200. This is frustrating for first opinion vets, inconvenient for the client and as for the patient? No one in that office was thinking of them. The referral vet may now find themselves frozen out of cases. How would it affect their livelihood? Tesco, More Than and Argos are all big players and RSA has about a 30% share in the pet insurance market. So, no matter how good you are, at least a quarter of incoming referrals will be sent away from you. I have spoken to several large referral centres that are not on the network and several said, off the record, that they will just refund the client the £200 and not worry about it. For smaller referral vet practices, it is not so easy to splash the cash like that. Stephan has been providing referral services for practices in the Cambridge area and beyond for 17 years. He is an “old style RCVS Certificate” holder and has AP status. I asked him about how it feels to be on the wrong side of the RSA preferred referral network, what the RSA have told him and what his plans are. 

What was your reaction when you read the letter in 2015 informing you of the RSA decision? 

Initially, it was not that much of a surprise given the significant difference in charges (without wanting to start debate about the right of who should charge what), but I disagreed with being dictated to, becoming contracted to and dependent on insurance. I have the impression owners also see it as if we are on the payroll of the insurer removing further obligation from them. I initially underestimated the effect of this decision, especially because to begin with claims continued to be accepted, despite ticking one of the new “are you part of the PRN?” boxes [on the insurance form].

What was their reply when you asked to be considered for the network?

There was only an e-mail facility and when I enquired, there was no reply. I was later told that “the list was adequately filled” and “admission was now by invitation only”. They would contact me
with further developments, but never did. When I recently managed to discuss this oneto- one over the phone with the RSA, I was told that this area was already wellrepresented. Pressing
for a written explanation, they advised me as before using a stock
reply that “they continuously assess and review network coverage and capability requirements and at this stage would not be inviting me”. They then outlined their policy that “at this stage their focus is on dedicated referral premises, rather than individual clinicians”. This to me is discrimination. 

How have local vets responded to the situation? Are any still sending you RSA cases?

It is hard not to suspect that a significant reduction in income is not in some way related to the fact that I was not included on the network, and more recently to clients that I had to turn away because of the £200 penalty. Over a longer period, this would
explain some loss (and I would truly estimate that could be around 25%). 

Have you had any clients arrive at your practice as the referring vet was unaware of the situation? 

Initially this did not seem to be an issue because these claims were not rejected. Then slowly the effects kicked in, but at this point clients were likely to stay and question or challenge the situation.
In one case I was deducted the £200 penalty from a direct claim for
a consultation and treatment because a local client (four miles down the road) refused to drive two hours (no idea why the vet school was not considered). I have just seen my first case where
the clients themselves decided to pay the £200 because they wanted to stick with me. I guess though that most of the filtering happens at the referring vets.

How has it affected your motivation for further study, investment in the practice, etc.?

Financial insecurity is not something you expect in the late stages of your “career”. With regards to investment, you have no choice but to continue this, if only to replace equipment. It would be nice
to challenge the PRN situation and find a middle ground between
them and the independent large referral centres, perhaps not so much for me now but for others to come, levelling the impact of insurance. Insurance is a mixed blessing. I hear people constantly talking about how welcome it is to see the same person and offer continuity of care, but it is hardly sustainable. With the market players now and the PRN referral work on top, you are effectively
rowing against the tide in a single-man practice.

Will a potential 25% loss in business affect your ability to maintain the 150 hours’ CPD over three years that is required to maintain the AP status?

I don’t think so, ultimately. On the issue of the AP status, I am
considering dropping this. It’s a label  and certainly has not made any impression on the RSA network.

I would guess that smaller outfits such as yourself are cheaper than the large Specialist-led centres, which makes a mockery of the whole reason RSA did this in the first place, i.e. to save themselves
money. Do you have any comment on this?

The RSA never enquired about my charges, which are competitive, in the first place. That is one of the things I fail to understand since the whole reason for the PRN, I thought, was to level the costs or at best be a costcutting exercise.

Demoralising impact

That gives us some insight into the demoralising impact on mental
health and business viability of this policy of the RSA. The question is: what can we do about it? There is a group made up of vets from large centres – “Vets for Choice” – who were challenging the RSA on this. Continued from page 6 However, they are not representing
the smaller practices affected. Will the BVA and RCVS do anything?
There has been no successful intervention in the 18 months since
the PRN came into being. If other insurers decide to use the same network, it will put those outside it out of business. Also for those in the PRN, they have made certain concessions and pricing
agreements with the RSA which they may find restrictive in the future. Will the RCVS and BVA allow this cartel to continue? Will the smaller practices be squeezed out by those in the PRN and those big enough to soak up £200 per case? How many vets will be put off the huge commitment of further study and achieving the AP status with the risk of then not being allowed to see referrals as they are not in the PRN? It is too demoralising to consider. We are a highly-educated, dedicated and regulated profession. It is a tragedy that a financial decision by an insurance company has been allowed to interfere with patient care and vets’ livelihoods.