Supplementary memorandum submitted by
the Ashlea Veterinary Centre Ltd (Vet 04a)
Many thanks for your invitation to address the
Committee; I hope I was able to offer some useful insight into
what might be loosely termed the practical wing of our profession.
And I apologise if while on my soapbox my replies strayed too
far from the questions actually being posed!
Discussion was necessarily cut short by the
division bell and you did suggest that if I had any other relevant
comments I should pass them to you. So forgive me . . . I have!
Together with some points of clarification on matters raised during
the RCVS session and on documents made available to me by the
Committee.
A. SUBJECTS RAISED
DURING QUESTIONING
OF THE
RCVS
1. David Taylor MP raised what he perceives
to be the undue influence of the Pet food industry on the veterinary
profession
— My veterinary training has given
me sufficient understanding of the complexities of animal nutrition
for me to recognise that even with my knowledge I would struggle
to create a satisfactory home-cooked diet which would adequately
supply the nutritional needs of my pets.
— Natural diets, in effect, supply
an excess of nutrients from which the body selects the necessary
and excretes the surplus. Scientific formulation of diets seeks
to minimise such waste while avoiding the inclusion of unnecessary
or even harmful ingredients.
— Since I qualified in 1980 the average
life expectancy of the domestic cat has risen from 11-12 years
to somewhere in their late teens. While I would like to claim
that the improvement stems from the particular achievements of
veterinary surgeons, in reality the reason is far more prosaic—the
standard of lifelong nutrition which has improved markedly allowing
pets to live to their true potential.
— In answering further questions Sheila
Crispin revealed a limited grasp of how veterinary practices have
to function—both as a healthcare provider and as a viable
business. Within practice we sell our knowledge, we sell our veterinary
skills and we sell product. Unavoidably, even the provision of
the "best" wormer, the "best" flea product,
or the most suitable antibiotic involves not only a professional
choice but also a business choice. It is no different when we
come to assess commercial diets or when we consider whether a
"natural" diet would be more suitable for a particular
animal. We apply our professional training and make a professional
decision.
2. During her evidence Sheila Crispin suggested
that concerns had been raised within the RCVS because a proportion
of "corporate" practices had "connections with
the pet food industry or other commercial organisations"
— I struggled at the time to understand
this assertion and, after due reflection, I still do!
— I can only think that Sheila is referring
to "Companion Care", a corporate that developed originally
as a franchise system based in retail-park based pet food stores.
Companion Care is now a wholly owned subsidiary of Pets at Home,
a pet food retailer with 200 stores across the UK. The Company
runs 39 clinics countrywide, 35 within Pets at Home stores, with
veterinary surgeons installed in each branch on a "joint
venture partner" basis.
— Of the 39 Companion Care clinics
no less than 28 are already registered as members of the RCVS's
Practice Standards Scheme . . . Given that membership of the PSS
has been held out by the RCVS as evidence of all that is great
and good about the practising veterinary profession, I find it
very strange that Sheila should choose this corporate as an illustration
of the concerns which have driven the RCVS to seek powers to regulate
all veterinary practices.
— I also feel that Sheila overstated
the case when she claimed that one "awful" practice
could bring down the reputation of the whole profession.
3. Discipline
— The subject of professional discipline
is central to the RCVS case, and also features strongly in DEFRA's
submission to the Committee.
— There is little doubt that whatever
the stated nature of most complaints made to the RCVS, the majority
of complaints centre on poor clinical outcome and the costs associated
with clinical work.
— I believe there is a valid case to
be made for widening the remit of the RCVS to cover areas of clinical
competence. At present the RCVS can only investigate `professional
misconduct' and unless alleged incompetence is sufficient to warrant
a charge of professional misconduct owners must seek recompense
through the Courts.
— However for the RCVS to become involved
in assessing clinical competence would represent a complete sea-change
in professional regulation. I have little doubt that the costs
of professional indemnity insurance for veterinary surgeons would
rise significantly, with knock-on effects for the cost of veterinary
services.
— The Chair asked for some statistical
detail on the incidence level of complaints.
Our practice is purely small animal, three full
time veterinary equivalence with some 2800 "active"
clients. In the last year we performed 2,194 first consultations,
2,650 vaccinations, 232 routine neutering procedures and 397 other
surgical procedures. Allowing a 5% error for other initial investigations
not recorded under these headings I estimate some 5,750 client-vet
interactions, any of which could have resulted in either a satisfied
client or a complaint!
We can, cautiously, scale these number using
RCVS figures from its 2007 Annual report:
There are 15,671 registered "home practicing
vets"
General practice 13,380 in (85.4%), Universities
791 in (5%), Government 856 (5.5%) etc
There are 3,932 practices currently known to
the RCVS
Small animal 2103 (53.4%) Mixed 1635 (41.6) Equine
134 (3.4%) Large animal 64 (1.5%)
Average practice size = 3.4 FTVE
As we are slightly smaller than the average practice
size, our figures need to be inflated by a factor of 3.4/3 = 1.13.
So if our work rate is typical of small animal
practice SA then the total number of client-vet interactions in
small animal work in the UK per annum = 1.13 x 5750 x 2103 = 13,301,475
We might assume that mixed practice interactions
are at a lower level (allowing for non-consulting time (travelling)
during the working day)—for calculation I will assume 30%
lower.
Client- vet interactions in mixed practice in
the UK per annum = 1.13 x 5750 x 0.7 x 1635
= 7,436,389
Without including equine and LA practices Total
interactions per annum = c. 20 million.
Complaints to RCVS per year = 700
— In summary I don't think we do badly
as a profession!
These figures represent no more than 1 complaint
per year for every 5.5 practices.
Or to put it another way a complaint incidence
of 0.0035% per consultation/operation.
4. The Corporate "threat"
— The distrust that the RCVS shows
towards corporate business structures is long-standing. When I
first entered the profession I witnessed the RCVS's dogged resistance
to the entirely legal conversion of veterinary partnerships into
limited companies. Eventually the RCVS recognised that it could
not legally obstruct the converting veterinary partnerships, veterinary
practices owned by limited companies emerged, and the sky did
not fall in . . . But the distrust continues.
— There is little doubt that current
developments within the profession will continue to favour the
gradual amalgamation of practices. Fewer assistants are prepared
to make the commitment (both financial and personal) required
to become principals. Feminisation of the profession may accelerate
this process.
— Whether these merged practices form
part of a growing corporate business structure, or simply function
as multi-centre practices run on traditional lines remains to
be seen.
— There is nothing empirically stronger
about the corporate practice business model. Corporate "chains"
have not grown at anything like the speed predicted in their original
prospectuses and the first corporate failure occurred in 2007
when the VPI (Veterinary Practices Initiatives) ceased trading.
— The largest corporate, CVS, now runs
49 group practices—a total of 134 individual sites. CVS
tends to buy small animal practices, preferring to buy practices
situated in rented buildings and ones close to dedicated out-of-hours
clinics, so that it can offer proper work-life balance to its
employees. It tends to ask the previous owners to stay in post
as employees for 6-24 months after purchase. And it doesn't rock
the boat—if the practice offers an idiosyncratic service
which benefits the profitability of the practice in the particular
locality (eg. healthcare schemes etc) it leaves them undisturbed.
— None is this is typical of the type
of predatory corporate that the RCVS seems to fear. CVS has now
bought its own specialist laboratory, its own specialist histopathology
service, and is, I given to understand, negotiating to purchase
its own veterinary referral centre. All sensible business moves,
none of which compromise animal welfare, in fact probably quite
the opposite.
— And as mentioned previously in relation
to Companion Care, CVS supports the PSS—of its clinics 19
are already registered under the voluntary scheme with five of
them being Tier3/Hospital status.
— I genuinely see little threat to
animal welfare from the growth of corporate ownership. The point
I made in my original submission remains—at the point of
delivery there is a professional relationship between a client
and an attending veterinary surgeon over which the RCVS has full
jurisdiction without any recourse to the extra powers it seeks
with which to regulate the management of veterinary practices,
be it by veterinary surgeons or by non-veterinary owners.
5. Compulsory Practice Standards
— As I said as the Division bell sounded,
I fear that the profession is already on its way to becoming a
niche provider to those members of the public that can afford
our fees, fees which necessarily rise as the result of inflation,
new hazardous waste disposal regulations, extensions to employment
law, etc, etc. Increasing our costs further through additional
regulation, such as compulsory practice standards, can only increase
the number of people who find us non-affordable and thereby directly
compromise animal welfare.
— Compulsory practice standards would
undoubtedly see the end of small charity-supported clinics, such
as the one run in Carlisle by the local branch of the RSPCA. Such
clinics employ veterinary surgeons on an occasional basis in order
to offer a basic level of veterinary attention to owners of limited
financial means; to upgrade such facilities would be unaffordable
to local branches (which have to raise all their income locally),
with inevitable knock-on consequences for animal welfare.
6. Veterinary Nurse registration
— However laudable it may be to recognise
Veterinary Nursing as a separate profession, with attendant registration,
defined areas of responsibility and formal disciplinary machinery,
this is not without cost and consequence and I do not believe
that this has been adequately thought through by the RCVS.
— At present the law recognises the
ultimate responsibility of the veterinary surgeon for all that
happens to an animal during the course of any veterinary treatment.
To return to the illustration I used during the evidence session,
if an animal dies while under anaesthetic responsibility is clear—as
the controlling veterinary surgeon I would bear ultimately responsibility.
Any monitoring of the anaesthetised animal by an assisting veterinary
nurse is just that, assistance. I carry the necessary indemnity
insurance to protect me and the practice in case of any error
of judgement, and should any allegations of negligence be made
the chain of responsibility is clear for the owner to be able
to draft any legal proceedings.
— In the "new world" the
veterinary nurse will carry his/her own responsibility plus the
additional cost of his/her own indemnity insurance. Now if an
animal dies under an anaesthetic responsibility is unclear, or
is shared. At a stroke the RCVS has changed the team ethos.
— It is no longer—"What
went wrong . . . and what can we do about it?" It becomes
"Who did what . . . and who did what incorrectly?".
Out goes team spirit; in comes a blame culture.
— I do not argue that this is insurmountable,
but simply that it illustrates that once again the RCVS is functioning
at a simplistic "good idea" level with inadequate regard
for the consequences and costs of their proposals.
B. COMMENTS ON
THE DEFRA SUBMISSION
VET 18
— I greatly appreciated the opportunity
to read the submission from DEFRA before travelling to London
to appear before the Committee. It did, of course, mean that I
had to sit and squirm in embarrassment for the profession as our
governing Council revealed just how poorly informed it has been
with regard to DEFRA's true intentions towards a new VSA.
— As I mentioned in my oral evidence
I think there is an unspoken agenda at work which has led DEFRA
to lend its support to the re-opening of the VSA. While the DEFRA
document seeks to argue its case from first principles a clear
undercurrent flows throughout.
— DEFRA sees the re-opening of the
Act as "an opportunity to clarify roles". It believes
that "the definition of veterinary surgery contained in the
Act needs to be looked at again". And it is quite ready to
emasculate the RCVS—"the current restrictions on what
procedures are exclusively the preserve of RCVS registered veterinarians
and the current policy and legal mechanisms for enabling some
of these activities to be done by others is, in our view, are
inadequate and not sustainable".
— It foresees a regulatory framework
similar to that recently established in New South Wales (the Oz
version, not the Cardiff one . . .) where acts of veterinary science
are either "restricted" (vet only) or "non-restricted"
( . . . open to defined "others"). Regulation would
be "risk-based and proportionate". A veterinary procedure
would only be "restricted/reserved" if in being performed
it threatened the wellbeing or welfare of the animal; lesser interventions
would require less regulation. And DEFRA envisages that the assessment
of which procedures should be restricted or reserved "could
be done by an Advisory Committee appointed by the Minister".
— At a stroke this would remove the
log-jam created by the RCVS's current refusal to countenance the
downgrading of the performance and interpretation of the Bovine
TB skin test from its current status as "an act of veterinary
surgery".
— To DEFRA this could represent a significant
financial saving as it would allow properly trained technicians
to take over responsibility for both major cattle health monitoring
schemes (Brucellosis—blood testing; Tuberculosis—skin
testing). And the change could be hidden behind claims that a
renewed Act introduced a lighter touch to regulation, allowing
additional competition into the provision of veterinary surgeons,
etc. All pet Government policies.
— However, as in all situations, the
law of unforeseen consequences will intrude . . .
— I spoke over the weekend with a former
colleague who is now principal of a 21-vet practice south of Glasgow,
in an area that has seen two mixed practices withdraw from the
provision of large animal services within the last 18 months.
He tells me that his practice has already "dropped"
one vet following DEFRA's decision to increase the interval between
herd Brucellosis blood tests. If TB testing were to be taken away
from veterinary surgeons this would cause his practice to shed
another veterinary post. But for another practice he knows in
Gloucestershire the change would be far more significant, removing
c.£200K of turnover. This turnover is not replaceable—with
it would go 2-3 vet and 1-2 vet nurse posts.
— And so the policy change would see
a shrinkage in the pool of available experienced LA practitioners
at a time when the need for veterinary surveillance on farms is
growing—be it for dealing with self-inflicted injuries such
as the release of Foot and Mouth virus from Pirbright or climate-associated
diseases such as Bluetongue which threaten to become endemic in
the UK.
— And that is before one considers
similar consequences to the Profession's ability to maintain the
sacred cow of 24/7 emergency provision which I highlighted to
the Committee on 18 February.
At this point I must stop for fear of overwhelming
you with detail. I hope these insights will be of use to you and
your Committee. And again, thank you for the opportunity to contribute
to the debate.
C T Barker BVSc Mlitt CertVR MRCVS
Ashlea Veterinary Centre Ltd
February 2008
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