What role might patient safety play in the veterinary profession?

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Mark Turner graduated from Liverpool Veterinary School in 1996. His career has included spells as a veterinary surgeon and as a business owner. During this period he has developed an interest in patient safety and a profound belief that risk management properly implemented can improve many aspects of care. Mark is currently undertaking an MRes on veterinary patient safety at the Royal Veterinary College.

He has written for the Veterinary Times and Veterinary Practice, presented at the RCVS Knowledge first international EBVM Conference and at BSAVA Congress 2015 on the subject of Risk Management.

At the beginning of the new millennia, the report into the Bristol heart scandal was published (Department of Health, 2001). It established why the mortality rate after paediatric cardiac surgery (PCS) at Bristol hospital was twice the national average. In many respects it can now be seen as an important turning point in the history of the NHS. The report identified a host of risk factors at work at the time. But as the document went on to say, “professionals working in Bristol… were victims of a combination of circumstances which owed as much to general failings in the NHS at the time,” as to any individual short-comings (Department of Health 2001, p 11).

The report made almost 200 recommendations. Some of these were specific to PCS provision, but many more were generic proposals for a superior health service: one in which care quality was a central aim.

Since then the NHS has embarked on a quiet revolution of clinical services management, which has placed the discipline of ‘patient safety’ centre stage.

Mark Turner

Mark Turner

Patient safety, or risk management, recognises that high quality health provision relies upon an institution-wide commitment to safety. Integral to this is a culture of openness: this allows workers to report accidents, allowing valuable lessons to be learnt for the ‘system.’

A good example of how this ‘systems’ approach can benefit a complex industry is aviation. The airline industry embarked on a well-documented drive to improve its safety record in response to accidents like the Tenerife airport disaster in which 583 people died. (Interestingly, in common with many other accidents of the time, mechanical failure was not the dominant cause.)

It was understood that safety would only improve if the industry learnt lessons from every single incident in which the ‘system’ broke down. The understanding of these accidents and near misses, in all their complexity, could then be incorporated into modifications to work practices. To this end, a culture that exulted pilots made of ‘the right stuff’ was deconstructed, and behaviours, including error reporting, high functioning team work and cross-checking, were encouraged (Gordon, Mendenhall and O’Connor, 2012). Each played an important role in the startling reduction of air accidents.

A similar culture of error reporting and collective learning is taking root in healthcare, not just in the UK but throughout the world. A report published by the Institute of Medicine (IOM) in the US in 2000 had this to say about healthcare: “The focus must shift from blaming individuals for past errors to preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.” (Kohn et al, 2000, p 5.)

This year it was revealed that in a decade the complication rate from paediatric cardiac surgery in the UK has almost halved, from 4.3% in 2000 to 2.6% in 2009. Could patient safety be partly responsible? It seems reasonable to assume as much.

So what role might patient safety play in the veterinary profession? Rates of veterinary error remain opaque, and the safety of our systems is a legitimate subject of debate. Are we anywhere near as unsafe as the US medical system, which may kill 98,000 of its patients a year according to the IOM report quoted earlier? There are many unanswered questions but what is beyond doubt is that we in the veterinary profession have not yet widely adopted the philosophy of care quality that exists in the human health sector. What effect could this social science have on veterinary patient safety? Human medicine has discovered that real improvements start when people understand that mistakes are inevitable in complex industries, and everyone will make them. This shift in perspective allows hospitals to start framing accidents, and near misses, as opportunities to improve the system. Accident auditing, then, rather elegantly, becomes another arm of evidence-based practice. Perhaps all we need to do is learn this single, yet potentially transformative, lesson, in order to start our own safety revolution.

 

References:

Kohn LT, Corrigan JM, and Donaldson MS, (eds) (2000) To Err is Human. Building a Safer Health System. Washington: National Academy Press.

Gordon S, Mendenhall P, O’Connor B (2012) Beyond the Checklist. What Else Health Care Can Learn from Aviation Teamwork and Safety. London: IRL Press.

Department of Health (2001) The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. Learning from Bristol. Available at: http://webarchive.nationalarchives.gov.uk/20090811143745/http:/www.bristol-inquiry.org.uk/final_report/the_report.pdf. (Accessed: 20 October 2015)

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Should vets be as comfortable reading balance sheets as blood results?

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Nazrene Moosa qualified as a veterinary surgeon from the University of Pretoria in South Africa in 1988. She has been in small animal practice ever since – first in South Africa and, for the last 18 years, in the South East of the UK. In the last 27 years she has worked as a sole practitioner/owner as well as for independent and corporate-owned practices, and currently works in a busy small animal practice in West Sussex.

When I first arrived in the UK almost 20 years ago, there were major changes afoot in the profession. My first job was in a corporate practice in Portsmouth, and I have some fond memories of being at the forefront of this new trend.

Nazrene Moosa

Nazrene Moosa

Since then the inexorable march of the corporate practice has forever changed the landscape of the veterinary profession in this country. The sheer number of corporate-owned practices means that, for many vets, and especially for newly graduated vets, a corporate employer will be all they know. Independent practices are becoming less the norm, especially in the small animal sector, and there is an almost inevitability that many of these will succumb to the lure of the corporate pound at some stage.

So the corporates have ensured the survival of many practices that may otherwise have disappeared into the annals of history. They provide employment for many young vets and formulate development programmes that support new graduates. They aim for gold standard care and try to achieve this within a financially sustainable environment. The usual mantra from the corporates is that they allow vets to be vets rather than managers, they enable them to concentrate on the stuff that matters, rather than the humdrum financial and management issues that many vets have little or no interest in. They have experts in human resources and management to do all of the non-veterinary stuff. But is there a way of incorporating (pun intended) vets in a more positive way so we’re more than ‘just vets’?

Fast forward to 2030 and I believe the profession is likely to be predominantly corporate based. Personally I would feel more comfortable if, over the years, something of a paradigm shift had occurred in the way vets viewed their roles. I am hoping, at some stage, the penny will have dropped and the powers that be at teaching institutions will have recognised the need for an increased amount of business training being an integral part of the undergraduate degree. It’s not the sexy end of the job, but needs must and it is an everyday skill that is sadly lacking in many vets today. I remain optimistic that the many development programmes that the corporates of today have in place will have translated into a new breed of vet who is comfortable with the multiple roles of vet/manager/financial expert. Ideally vets would be as comfortable reading balance sheets as blood results and be able to make decisions affecting ‘their’ practices with the knowledge and authority that will ultimately impact on their own lives, and those of their patients, in a positive way.

Read more about Nazrene Moosa →

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Where are all the veterinary nurses? Is there a need for another training option?

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Laura Kidd is a qualified veterinary surgeon, VN lecturer and educational consultant who tutors on a post-graduate VN qualification, as well as teaching clinical skills to veterinary students.

Each year the actual number of veterinary nurses (VNs) in the UK increases (RCVS, 2014) yet, anecdotally, there seem to be insufficient veterinary nurses to meet demand.

The 2014 RCVS Survey of the Veterinary Nurse Profession (Williams and Robinson, 2014) indicates that over the next 10 years the demand for VNs will increase: with members believing that there are not too many VNs being trained (Williams and Robinson, 2014, p88).

Veterinary nursing is a young profession: the average age of VNs in full-time employment is only 30.8 years (Williams and Robinson, 2014, p15). Identifying the reasons for VNs leaving the profession at a young age, and addressing these, is one potential way of increasing VN numbers in the future.

Laura Kidd

Laura Kidd

With the main reasons cited for VNs leaving the profession continuing to be poor pay, stress and not feeling rewarded or valued (Williams and Robinson, 2014, p 43), it is to be hoped that the combined efforts of RCVS, VN Council, BVNA and BVA, in introducing a new Royal Charter (RCVS, 2015, a) and  campaigning  to have Parliament change the law to protect the title ‘veterinary nurse’ (RCVS, 2015, b), will  increase the status of the VN profession. As stated by John Blackwell, President of British Veterinary Association (RCVS, 2015, b), this could lead to increased recognition of ‘the skills of qualified veterinary nurses and the unique contribution they make to the veterinary team’.

The VN profession has changed and evolved significantly over the last 20 plus years, with many more postgraduate qualifications and options for career development. However, whilst the number of VNs who think there are opportunities for career progression has increased, many still do not believe this to be the case (Williams and Robinson, 2014, p82). Additionally, for many, the profession is not considered to provide part-time working opportunities or to be ‘family-friendly’ (Williams and Robinson, 2014, p82).

Most VNs surveyed (Williams and Robinson, 2014, p75) felt that their work gives them satisfaction and variety, but is stressful and the majority of VNs also feel that newly qualified nurses need more support in practice (Williams and Robinson, 2014, p 81). When considering these factors, maybe it is not a surprise that VNs leave the profession at a young age. Perhaps we may, reluctantly, have to accept that, for the time-being, veterinary nursing is a young profession with a high turnover.

However, the current focus on wellbeing within the profession, with attempts to identify and address the causes of the stress which makes some VNs leave the profession, and the stage in their career at which this develops, is to be welcomed.

Furthermore, it is promising that 83% of VNs surveyed (Williams and Robinson, 2014, p43) indicate their intention to remain in the profession for the foreseeable future. Is it therefore possible to improve the salary, work-life balance, career progression (Williams and Robinson, 2014, p93) and professional recognition so that even fewer VNs will leave?

The other main way to increase VN numbers is, of course, to train more students; and increase the numbers qualifying annually.

The VN professional qualification has a very strong emphasis on vocational training, encouraging the development of practical skills and Day One Competences. The broad syllabus and rigorous training are of a very high standard: ensuring that VNs acquire the required knowledge, understanding and research skills for veterinary practice. It is essential that these high standards of training are maintained and developed in order to produce veterinary nurses with the skills required for working within the profession, now and in the future.

Yet, in spite of the huge demand and competition for places on further and higher education VN courses, there appears to be insufficient VNs to meet the requirements of the profession. This is not a new problem but, anecdotally, the situation is worse than it has ever been.

The number of students able to commence VN training annually is limited by the availability of Training Practices: this is considered to be one of the main challenges to the VN profession (Williams and Robinson, 2014, p94). While it is admirable that so many approved practices support VN training, many cannot, for various reasons. Can we support more practices to become Training Practices in the future?

Furthermore, while the entry requirements for the VN Diploma are relatively low, the qualification is academically demanding. The volume and depth of knowledge is considerable for the level of qualification and the requirement to demonstrate critical reflection through academic writing can be challenging. It is regrettable that some student veterinary nurses, who appear to have the qualities to be very good VNs, are lost to the profession at this stage; unable to pass awarding body exams. Should we be developing an additional VN training pathway which allows more students to demonstrate they have the required skills to provide high quality nursing to their patients?  Without lowering the standards in any way, can we identify a way of increasing the numbers of students who can start and complete VN training?

The future of the VN profession is exciting: it is hoped that the title ‘veterinary nurse’ will become protected and that there will be more stress-free, valued, competent VNs, providing optimum nursing care.

BUT the issues that are facing the profession need to be addressed now: we need to train more VNs and keep the ones we’ve got!

References:

RCVS (2014) RCVS Facts 2014 (accessed 22.8.15)

RCVS (2015, a) New Royal Charter Comes into effect (accessed 22.8.15)

RCVS (2015, b) Protect the title ‘veterinary nurse’! (accessed 22.8.15)

Williams, M. and Robinson, D. (2014) Vet Futures: The 2014 RCVS Survey of the Veterinary Nurse Profession (accessed 22.8.15)

Read more about Laura Kidd→

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Are we animal welfare advocates or profit-seekers?

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David Main is Professor of Animal Welfare at Bristol Veterinary School. His research interests are welfare assessment, intervention strategies to improve welfare and animal welfare education. He is a former member of the Farm Animal Welfare Council, and current member of Soil Association Council. He is project co-ordinator of the AssureWel project; a collaboration with RSPCA and Soil Association, that aims to embed welfare outcomes into the assurance process of certification schemes.

He was principle investigator for the Healthy Feet project that has been widely adopted by the dairy industry and he is also part of the EU WelNet project that is a network of welfare scientists providing welfare advice to the European Commission. 

The recent survey from the Vet Futures project shows that the public place a high degree of trust in the veterinary profession. Despite this encouraging assessment I will argue in this article that the profession should work harder to deliver on a societal expectation for us to be animal welfare advocates and that it ought to introduce safeguards against profit-seeking influences on our clinical decisions.

David Main

Professor David Main

Profession urgently needs to deliver on society’s expectation as animal welfare advocates
Individual clinicians would be well justified to say that their daily ambition in veterinary practice is to promote the interests of animals in their care. However, a minimal scratch below the surface reveals obvious tensions in this well-intentioned mantra within the profession.

At an organisational level, the BVA can be applauded for campaigning for stunning at slaughter. However, this campaign is relatively uncontroversial as it does not conflict with the interests of clients of many BVA members. Could you imagine the BVA launching a public campaign encouraging the pig industry to change its husbandry system in order to reduce the need for tail docking in pigs or improving the prevention and treatment of lameness of dairy cows? It requires strong leadership for the profession to discuss issues that raise difficulties for clients that pay the practice bills. Hopefully discussion around the BVA Animal Welfare Strategy will focus our attention on such issues.

Veterinarians could perhaps also do more at an individual level to act as animal welfare advocates. It is easy to inform clients on the technical rationale for a specific husbandry change but then walk away knowing full well the client will not action the advice. In the medical profession, advanced communication techniques are becoming more widely adopted to promote positive change within their patients. Perhaps we should be more explicit in teaching our veterinary students influencing skills.

Advocacy requires us to promote our patient’s rather than our client’s interests at both an organisation and individual clinician level.

Profession ought to introduce safeguards preventing inappropriate profit-seeking behaviour
Whilst the profession is clearly focused on our client’s interests, widespread profit seeking behaviour amongst clinicians is unlikely. Clients are likely to avoid veterinary surgeons that they perceive to be focused on performing unnecessary expensive treatments. Furthermore, you do not talk need to talk to many veterinary clinicians to realise that money is rarely a primary driver.

I have also argued previously that offering the best veterinary treatments from the animal’s point of view is very often the most profitable for the practice. In practice I suggest that many veterinarians fail to offer the best treatment as they are overly worried about the financial impact on the owner. Since it is not our role to make judgments on how our clients should spend their money, our default position should be to offer the best treatment option. However, we should be careful to avoid causing guilt amongst owners that are not able to afford the treatment. Concentrating on the animal’s interest need not conflict with a legitimate need to operate a profitable veterinary business.

However, perceptions as well as reality matters amongst our clients and society. The obvious difference between the business structure of veterinary and medical practitioners in the UK means the profession will always be at risk of challenge for excessive profiteering. Since we still live in the age of the media scare story it would seem prudent for the profession to embed some anti-profit seeking safeguards in our regulatory controls before, rather than after, a problem is highlighted.

A potential safeguard could be a prohibition within the RCVS Practice Standards Scheme of crude turnover-based incentives. Salary based on performance, of course, is a legitimate management tool, but incentives could be based on health outcomes rather than simply selling more stuff. A debate at a practice or national level on the nature of these safeguards could be a healthy demonstration of the profession’s desire to act as animal advocates.

Read more about Prof David Main→

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Could we work collaboratively with those we think of as competitors?

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Erwin Hohn and Adi Nell are both Senior Partners at Medivet. Erwin has a postgraduate degree in sociology and an MBA. Adi has advanced clinical qualifications and has recently completed MBA studies.

What’s coming?
None of us knows what the future will bring. There’s been much written in the vet press and many meetings have been held to look at the challenges we face. Major issues included work-life balance and

Erwin Hohn

Erwin Hohn

financial viability, the rise of corporates and feminisation in the profession, as well as standards of care. There are others: business skills, student debt, lack of leadership, excessive regulation and legislation, lack of evidence-based veterinary medicine, competition from non-vets, online pharmacies, mobile veterinary clinics, the Internet and its legions of unqualified experts, the rapidly-rising cost of offering a comprehensive service, and rising client expectations, to name just some.

We propose a new model of working together that could change the face of veterinary care. This model offers new ways of working and solutions to many of these challenges.

In 1817, the renowned economist Daniel Ricardo came up with a novel idea: stick to what you do best. This has been proved successful over and over again – but, oddly, is often overlooked. If you do what you do best and I don’t compete with that, but offer another service that I can do really well, we’ll maximise our profits and can support each other rather than competing.

Can we apply this to our profession?

Theory into practice
In our practices, we play to our vets’ strengths by allowing each one to do what they do best. We’ll refer to each other internally or between branches in a group. That’s just what Ricardo suggested.

Adi Nell

Adi Nell

By expanding this principle, we could work collaboratively with those we think of as competitors, both veterinary and non-veterinary. This would serve to advance the health and wellbeing of our patients, not just cure or prevent disease.

We already do this to a degree: practices share out of hours work, for example, or refer to specialist centres. The problem with the referral example is it’s currently one way only – if a complex fracture repair turns into an amputation, could it not be referred back to you?

We can apply this more widely. Breeders could refer puppies to a small vaccination clinic. That branch does the vaccination, but sends the puppies to a larger practice for x-rays when they’re lame. In turn, the larger practice sends its inoculations to the vaccination clinic or small satellite, and they refer clients who want to buy puppies back to the breeder. I could, for example, support your investment in an MRI unit and you could support my laparoscopic surgery.

This is how many human community health programmes work all round the world, right now.

Pie in the sky?
This collaborative approach deals with many of the challenges the profession has identified. By specialising in what each party does best, costs are reduced and financial viability is enhanced. Those who do what they love doing have fewer problems with work-life balance. Corporates become part of the solution. And client expectations are much easier to meet if we play only to our strengths.

It’s easier to develop business skills for a narrower range of services than for a much broader one – and it’s easier to choose your own hours. That same focus makes regulators and legal compliance easier. Non-veterinary competitors become collaborators. Rising costs are controlled by the same narrower focus, and evidence-based medicine is enhanced by sharing outcomes.

This utopia may seem difficult to achieve. But there are simple, practical steps that we can take right now to make our lives more professionally fulfilling, less stressful and more financially rewarding.

Reference:
Hohn, Erwin W (Sep 2014) The Development of Veterinary Community Health. Proceedings of the 39th World Small Animal Veterinary Association Congress, 249-252.

Read more about Erwin Hohn→
Read more about Adi Nell→

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Does a business approach to veterinary practice management damage the profession’s reputation for care and compassion?

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John Sheridan was President of the British Small Animal Veterinary Association (1974-1975) and first President of the Veterinary Practice Management Association (1993-1996).

The list of goals identified by the first Vet Futures Group meeting included an objective that ‘practice should be less focused on margins from medicine sales’.

To my knowledge this is a message that has been promoted by the profession for at least the last 40 years. Conventional wisdom suggests that, for too long, vets have relied on generating profit from the sale of medicines to sustain the viability of veterinary practice, because they have been fearful of charging properly for their professional services.

After all those years, what has changed?

Not a lot!

However practice owners measure the success of their own business (animal welfare, client satisfaction, client/patient database growth, stable motivated employees, market share, professional standards, personal income etc), each one of those ambitions depends on the ability of the business to generate a healthy return on investment for the owner/investor and sufficient profit to finance growth and continuing investment in practice resources.

john_sheridan

John Sheridan

The limited income and expenditure benchmark data relating to the independent veterinary practice sector in the UK suggests, however, that the median real profit (after owners’ remuneration) generated by independent veterinary practices is poor and declining (circa 7% or less), when many ‘corporate’ groups are seeking and achieving 18% or more.

My experience over the years as a management consultant to the profession indicates that the margin generated by the sale of medicines and other products after allowing for an appropriate share of establishment, overhead and staff costs is modest but certainly not excessive – whilst the margin generated by the sale of professional time and expertise hovers around nil and, in many practices, is negative.

The problem is not confined to the UK and recent studies such as the VetPartners/National Commission on Veterinary Economic Issues /Bayer Animal Health North America study in the United States found that:

  • There was a clear link between the use of a range of business practices with practice profitability
  • 61% of study practices generated poor or negative levels of profit
  • Veterinary practice profits were lower than six other professional groups
  • Veterinary earnings were lower than seven other professional groups
  • A steady decline in client/patient database per veterinarian
  • A steady decline in median number of transactions per veterinarian
  • Six key factors that limit client visits to veterinary practice – four of which are under vet control

I suspect that a comparable study in the UK would result in similar findings. All this at a time of major challenges for veterinary practice owners grappling with the impact of:

  • More vet schools
  • More graduates
  • More practices
  • More competition in a demanding marketplace
  • Declining footfall
  • Shrinking client database
  • Downward pressure on veterinary salaries
  • More regulation
  • Growth in the ‘corporate’ sector and decline in the proportion of independent practices
  • Declining profits, practice values and pension investment
  • Growing stress

The literature review conducted by the Vet Futures team (January 2015) highlights a number of these and other issues and points towards some of the ways in which better business skills can address them.

What is the risk to the reputation of veterinary practice?
One of the cultural shifts that is expected to shape consumer behaviour, and identified by the Vet Futures literature review, concerns the growth of ‘mindfulness and the importance of ethical responsibilities’.

The good news is that vets are amongst the most respected professions and that 86% of Britons surveyed had a ‘great deal’ or ‘fair amount’ of respect for vets (Angus Reid Public Opinion 2014). More recent data from an omnibus survey carried out by the Vet Futures team amongst the GB public showed that 94% of the population trust veterinary surgeons generally or completely.

That reputation is our brand. It has been slowly built over many generations by veterinary surgeons and their practice teams up and down the country, every day of the week, dealing first hand with practical animal welfare challenges and delivering professional, caring and compassionate services for their owners.

Will it continue? Of course it will – but only if veterinary practices continue to be viable businesses generating the revenue necessary to enable them to thrive, cover all their costs and, when judged appropriate by their owners, to offer professional services on a pro-bono basis for wild animals, stray animals and those belonging to individual owners in need.

Will it continue? Of course it will – but only if the vet schools, our regulatory and professional bodies and the leaders and members of the practising arm of our profession, acknowledge that business expertise is as important as professional skills in the provision of veterinary services in a demanding marketplace.

Inadequate information leads to poor decision making and our professional bodies are currently ill-equipped to support the commercial needs of their members in practice or respond to adverse reports in the media about practice profits, veterinary fees and so on.

A major problem for the associations that represent the interests of the practising arm of the veterinary profession is that they simply don’t have any/sufficient generic information about the economic health of the practices that are owned by their members or where their members are employed.

Only when that information is readily available will the profession be in a strong position, backed by the evidence to prove it, to promote the message that:

  • Better business is essential for the delivery of better medicine
  • Veterinary fees are costly – so they should be. It’s simply not possible to offer comprehensive professional veterinary services on the cheap
  • In well-managed practices, however, vet fees represent excellent value for money and the payback in healthy pet animals and livestock kept commercially is substantial
  • A business-like approach to practice management is not a question of feathering the veterinary nest but of providing the facilities, the equipment, the skills and the commitment necessary to deliver the standard of professional expertise demanded by animal owners and by the profession’s regulatory bodies.

John Sheridan was President of the British Small Animal Veterinary Association (1974-1975) and first President of the Veterinary Practice Management Association (1993-1996). He was joint founder of Veterinary Practice Initiatives, the first veterinary corporate consolidator in the UK, and was Chief Veterinary Officer from its launch in July 1998 until he retired from the company executive team in 2003. John Sheridan now offers part-time management consultancy to the veterinary profession. He has spoken widely on veterinary practice management issues in the UK and overseas for many years, publishes the VeterinaryBusiness.org practice management resource and presents a new episode of the Veterinary Business Video Show every two weeks.

Read more about John Sheridan →

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Will hospice care become a standard part of practice?

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Kath Dyson qualified from Glasgow in 1989. She then spent several years in small animal practice, going part time in 1996 due to ME. Eventually retiring from veterinary practice in 2009 she moved into human health and social care as a part time home care worker/home help.

In human healthcare, modern hospice and palliative care, pioneered here in the UK, is now mainstream, although it has taken several decades for this to happen. Care of the terminally ill and dying is a core subject in the medical curriculum, as well as being a recognised and evolving speciality. The work of charities like Marie Curie and Macmillan is well known. Tesco supported the ‘Help the Hospices’ campaign, and ‘Children’s Hospice’ has been on the TV. A 2008 poll of British Medical Journal readers asking ‘which project would make the greatest difference to healthcare’ (of all projects worldwide) found that ‘palliative care for all at the end of life’ received the most votes*. There is also high profile political support for better access to palliative care, for all who might benefit (probably most of us at some point).

In veterinary medicine, an increasing number of vets now offer this type of service, mainly in America but also more recently in the UK. Most do so by offering palliative and hospice care and euthanasia as a mobile service to people’s homes.

Kath_Dyson

Kath Dyson

Over the last 25 years there has been a lot going on in the USA in the development of animal hospice care. The American Veterinary Medical Association Guidelines on Veterinary Hospice Care were first published in 2001 and renewed in 2007. The International Association for Animal Hospice and Palliative Care formed in 2009 and the ‘Veterinary Clinics of North America’ published a ‘Palliative Medicine and Hospice Care’ issue in 2011. There have been a number of symposia and conferences including, or, in the past decade, devoted to these subjects in the US, with more coming up all the time, and there are various resources and courses available including online webinars and chapters in various textbooks.

Here in the UK, the ‘BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care’ was published in 2010, and BSAVA Congress included a session on palliative care.

Despite the overlap between human and animal hospice there are some obvious differences. In animal hospice it is the pet’s owner who takes on all the financial, practical and emotional costs involved, whereas human patients have a lot more support available. Euthanasia is always an option in veterinary medicine, and indeed euthanasia of an animal can legally be carried out by anyone, so long as it is done humanely.

The aim of animal hospice is for the terminally ill patient to remain free of pain and distress and, when the time is right, for the animal to die peacefully whether by euthanasia or naturally, and it takes into account the needs of the whole family.

Regarding natural death and euthanasia, there is some debate within the animal hospice movement about these topics and various shades of opinion. Some regard euthanasia as more of a last resort, with hospice assisted natural death being seen as preferable and only a minority of patients requiring euthanasia. Others feel that euthanasia is more often likely to be the preferable outcome of a period of hospice care in the animal patient, even though they do not rule out a natural death. All these options would be fully discussed with the client in either case, and remain flexible depending on the changing situation of the patient.

The human surgeon and writer Atul Gawande describes the helplessness human doctors often feel when faced with incurable patients, and how palliative care can help. ‘These are patients with untreatable disease,’ he says ‘and yet palliative specialists have been remarkably successful at helping them. The key is simply that they take suffering seriously, as a problem in itself’**

Vets have always taken suffering seriously, and additional expertise in end of life care could help the profession to be even better able to provide truly lifelong care to all their animal patients.

*www.bmj.com/campaign/making-difference
**Atul Gawande ‘Complications- a surgeon’s notes on an imperfect science’ Profile books 2003 p143

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

We can’t change attitudes towards ethnicity and culture overnight but we must be united and forward thinking

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Due to the sensitive nature of the topic the author wishes to remain anonymous. 

Ethnocultural empathy is an interesting term which I am sure many of you have not come across. By the end of this blog, one will hopefully understand why this term is important for the future of the veterinary profession. It all started with a personal situation I unfortunately had to deal with. I ended up feeling isolated and my professional integrity was damaged due to inaction, a lack of knowledge and support.

Being from an ethnic minority background, I am aware of differing attitudes to diversity in this country. I have experienced occasions where people have acted inappropriately towards me but thankfully this has been very uncommon. I chose to be a vet due to my love of animals and even though the profession is mainly made up of white middle class British graduates, I have rarely had a problem. The vets I have met and studied and worked with have been nothing less than amazing. The clients I have also encountered have occasionally had suspicions at the beginning but have been very welcoming and friendly. I always feared I would encounter a client who would dislike me purely for my ethnicity and unfortunately this fear was to become reality.

It was a Sunday on call when I got a phone call for a calving from one of our clients. As I was on my way, one of my bosses phoned me to say he had been rung directly and they wanted him instead. The client had refused to have me on his farm for no good reason and would rather have any other vet from my practice, even a new graduate who had just started. The farmer tried to prove his innocence to my boss but unfortunately this did not make sense. I had previously attended the farm for two successful calvings. The farmer had previously ignored me in front of my colleagues and acted rudely on other occasions towards me. It was suggested by one practice partner that the farmer may have some issues with my ethnicity.

When requesting help from my practice partners, I was not appropriately supported. It seemed that the requests of the client were more important than the issues I faced. I tried the Royal College of Veterinary Surgeons, British Veterinary Association and Veterinary Defence Society for advice but was again unsuccessful. Vetlife was very sympathetic but unfortunately none of the vets had any experience in this area.

It was agreed with my boss that I would not go back to the farm, after weeks of trying to get some support from my practice. This left me in a position of isolation and made me question my ability in farm animal practice. Mentally I was very affected and this adversely affected my personal life. It was after a few months, I decided to try again and raise this issue with the professional veterinary bodies to try to increase awareness and support thus preventing this situation adversely affecting other vets in the future.

Of those responding to the RCVS Survey of the Veterinary Profession 2014, only 3% identified themselves as from an ethnic minority. Also as of July 2014, out of 26,439 registered veterinary surgeons, 7,835 (approximately 30%) qualified from outside the UK, which leads to a large cultural mix. This will only increase in the coming years with the change in the population demographic and appeal of the profession in the UK. I know we can’t change clients’ attitudes towards ethnicity and culture overnight but we must be united and an example of a forward thinking profession to the public. For example, the NHS, dentists and lawyers all have committees, advice and guidance for colleagues in my position and I feel the veterinary profession should also go forward in this way. In my opinion there should be more education at undergraduate level which is supported with further guidance, training and support for qualified veterinary surgeons.

It is becoming clear that in order to build a profession that is successful at improving conditions and resolving problems, we need to understand and support the many cultures working in the veterinary profession. As educated members of any community, veterinary surgeons should be expected to exercise tolerance and understanding and to help avoid harmful bigotry and discrimination. This is where ethnocultural empathy, the understanding of feelings of individuals that are ethnically and/or culturally different from one’s self, is key to future progression.

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Beyond the farm gate – Do vets have a role across the food chain?

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Javier Dominguez Orive is the Food Standard Agency’s Veterinary Director and Head of Foodborne Diseases Control Unit.

We are used to seeing veterinary surgeons in their clinical role taking care of pets as well as large animals on the farm and in zoos, but can vets add value to society outside of a clinical setting?  Should they get involved, beyond the farm gate, for example, working in the food processing industry, for retailers, or for the Government leading on food safety policies? And if they do, despite these roles being important, will they feel as valued as other veterinary surgeons working in clinical practice?

It’s important to remember that the farming industry exists because production animals will become food at some point. The health and welfare of livestock is not only key to good productivity but also for the production of safe and good quality animal products. Yet there are constant threats to this. Zoonotic diseases, for instance, are common and can be caused by viruses, bacteria, parasites or fungi. Scientists estimate that more than six out of every 10 infectious diseases in humans are spread from animals. Live animals, either directly or through vectors, and their products could be a route of transmission for many diseases.

And it is veterinary surgeons who are best placed, with our understanding of animal physiology, health and production, to help prevent and control these diseases by maintaining high standards of food and animals safety.

javier_dominguez_orive

Javier Dominguez Orive

My impression is that the role of a vet working outside clinical practice is widely accepted, valued and recognised in other parts of the world, including continental Europe. In Spain, where I trained and worked for many years, all veterinary schools’ Latin motto is “Higia Pecoris Salus Populi” – “Healthy Livestock – Healthy People” – the traditional one health concept. This concept is strongly embedded in the veterinary surgeon’s education in continental Europe, USA, South America, Australia, and gives vets an advantage over their UK counterparts to extend their knowledge in, for instance, the controls maintaining food quality and safety. It is widely accepted and encouraged in these regions that many veterinary graduates will pursue a career outside clinical practice. And because our skills are perfectly transferable, in other parts of the world vets are also involved in foodstuffs of non-animal origin, such as fresh produce, fruits, etc.  The principles to managing food safety risks for food of animal origin are identical to those for the production of salads or bottled water.

But is this widely accepted here in the United Kingdom?

Are we preparing the new generation of vets for these potential roles? Or are we creating yet another generation of veterinary surgeons who won’t consider these careers because they will be viewed as ‘second class vets’?

And what about vets involved in delivering official food controls, or working in developing food safety policies in government? Vets not only have the ability and skills to develop and negotiate legislation affecting farmers and the food industry, but their deep understanding of animal husbandry and production, as well as animal health and welfare, can play an essential role in crafting effective regulation. But again vets may not see these roles as suitable career choices because they’ll probably be viewed as ‘third class vets’?

With the speed that new veterinary schools keep opening in the UK, there is a risk that in the near future clinical practice won’t be able to sustain so many new graduates and as a consequence they will have to look elsewhere for work. If there’s already concern that too many vets today see non-clinical jobs negatively, are we doing enough to ensure the next generation of vets feel otherwise?

We need to do more to inform and expose undergraduates to other job opportunities and give them the confidence to explore alternative careers options outside of clinical practice.

Do you agree? Should we do more to inform and expose undergraduates to other job opportunities? Should we be encouraging them to think more constructively about careers outside of clinical practice? Or is the status quo where we want to remain?

Javier Dominguez Orive is the Food Standard Agency’s Veterinary Director and Head of Foodborne Diseases Control Unit. He trained in Spain and has worked in Veterinary Public Health in Peru, as a microbiologist at the University of Gent, Belgium, and in 1999 moved to the UK to work as an Official Veterinarian.

Read more about Javier Dominguez Orive →

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.

Should VAT on vet fees be scrapped?

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Stuart Winter writes the pets, wildlife and bird watching column for the Sunday Express and is the author of the books Birdman Abroad and Tales of a Tabloid Twitcher. He campaigns for the end to VAT on vet fees for pets.

Watching the shocked reactions of the elderly pensioner as she examined her veterinary bill accentuated the unfairness of our tax system in an instant.

Astonishment turned to apoplexy and then distress. Emergency abdominal surgery had saved her beloved terrier’s life and there was no question, in her mind, that the four-figure fee was more than worth the life of one small dog. It was the added VAT that took her breath away.

“Four hundred pounds VAT? That’s more than my electricity bill for the entire year,” she exclaimed in tears infused with anger and pain. “Why should the Government benefit from my little dog’s distress? It is daylight robbery.”

In a few, sob-filled sentences she had dissected a tax travesty as inequitable as those that had Bostonians pouring tea into the sea 200 years ago and, more recently, Community Charge protestors rioting across the land.

Stuart Winter and Molly

Stuart Winter and Molly

I watched from across the surgery waiting room with as much sympathy for the distraught woman as for her terrier recovering from life-or-death trauma. Pet owners, it seems, are a more tolerant breed than those early American settlers or Poll Tax demonstrators, accepting passively what any right-minded society would regard as nothing more than extortion. What other form of tax benefits from disease, disaster and distress?

Admittedly, the value added taxation system is as labyrinthine as the intestines of the poor terrier that had come successfully through surgery only to be reunited with an owner in tears. In truth, VAT is more convoluted. We pay it on chocolate biscuits but not small, round chocolate-covered sponges; it is levied on women’s sanitary wear but not designer labels for babes-in-arms. And who can forget “Pastiegate” when the Chancellor deemed hot, take-away sausage rolls should not be exempt from VAT? The outrage caused a u-turn overnight.

Pet-owners have yet to feel any such generosity from the Treasury keen to fill the coffers with a 20 per cent levy on any goods and services deemed luxuries. That said, gas and electricity bills are also subject to VAT, albeit at the reduced rate of five per cent. Other reduced rate items include smoking cessation materials such as patches and gum, children’s car seats and mobility aids for the elderly.

All worthy exemptions but why have companion pets not been included in this list or, indeed, among those zero-rated items such as books, newspapers, water supplies, children’s footwear, food and, significantly, our own medical treatments and health care?

Cherished pets will never be regarded as luxuries by their owners whose lives they bless with joy as well as fulfilling that most vital of human needs: companionship. For Chancellors, however, pets are nothing more than cash-cows. And we are talking about milking huge sums.

The pet food industry delivers a £520 million windfall from its £2.6 billion annual sales. Vets’ bills from a population of 10.5 million dogs, 10.3 million cats, 900,000 equines and an estimated 40 million other rabbits, guinea pigs, hamsters, birds, exotics and fish, produces another huge pay day for the Treasury.

My back of an envelope calculations, reckoned from our outlays on a fortunately healthy spaniel and our daughter’s mischievous Bengal cat, could produce a £200 million annual VAT bonus for the Exchequer from their occasional visits to the vet and pet insurance payments, working on the assumption that domestic animals account for around a third of the £3billion spent on veterinary services across the industry (this figure includes livestock).

Wiping the VAT off vets’ fees for domestic animals, or at least reducing it to five pence in the pound, would undoubtedly improve the nation’s animal welfare obligations overnight. It would allow hard-pressed families waiting for their monthly pay cheques to seek earlier attention as well as allowing more owners to afford and take out pet insurance. It could encourage more pet owners to register with a vet.

Shifting Government thinking on the subject, however, is a labour of Herculean proportions. No Chancellor delights in losing revenue. Treating, curing and caring for sick and injured animals is nothing more than a service and services are ripe to be harvested. It is time for a counter argument. Pet ownership is not a luxury. It is more than a privilege. Is it not a human right? Welcoming animals into our lives makes our lives more fulfilled and more civilised. In short, animal ownership exemplifies the very principle of Article 8 of the European Convention on Human Rights that provides a right to respect an individual’s “private and family life, his home and correspondence”.

For millions, giving a home to an animal is one of the essentials of family life. It satisfies our most imperative instincts to care and nurture. Pets are the cement in a contented household. Effectively taxing this relationship by putting VAT on veterinary care is nothing short of monstrous.

Stuart Winter writes the pets, wildlife and bird watching column for the Sunday Express and is the author of the books Birdman Abroad and Tales of a Tabloid Twitcher. He campaigns for the end to VAT on vet fees for pets.

Read more about Stuart Winter→

The views expressed here are those of the author and do not necessarily reflect those of either the RCVS or the BVA.