Dechra Veterinary Products has announced the launch of a smaller size vial of Anesketin, its rapid acting dissociative anaesthetic licensed for cats, dogs and horses.

Anesketin solution for injection, containing Ketamine 100 mg/ml, is indicated for induction of anaesthesia. It can also be used as a sole agent for restraint and minor surgical procedures where muscle relaxation is not required in cats. 

Anesketin was previously available in 10ml or 50ml bottles. Dechra says it has added the new 5ml vial in response to feedback from veterinary practices.

Dechra Brand Manager Craig Sankey said: "Anesketin is one of our most popular products in our range due to its versatility. It can be used in combination with appropriate sedatives and analgesics in cats, dogs and horses for induction of anaesthesia.

"5ml Anesketin will help practices comply with controlled drug legislation, saving time and effort in denaturing out of date stock and reducing wastage."

He added: "The introduction of the smaller bottle demonstrates our commitment to responding to the requirements of veterinary professionals and providing a range of high quality products that provide the most effective solution within day-to-day practice."

Support tools are available for customers to order online at www.dechra.co.uk, including an Anesketin controlled drug register.  


Virbac has announced the launch of Eradia, the first and only metronidazole for dogs in a flavoured oral suspension.

Suitable for both puppies and adult dogs, Eradia is presented in a bottle with an award-winning¹ 'All-In-One Smart Cap' which stops the person administering the product from coming into contact with the solution, is child proof and offers flexible dosing options.

Available in 30ml and 100ml bottles to cater for all dogs, Eradia can be administered either directly into the mouth or on to food.

Virbac says that Eradia has been shown to be accepted by 100% of dogs², thereby alleviating any possible problems administering metronidazole.



For more information, contact your Virbac Territory Manager.

References

1. Pharma Pack Award 2018. 
2. Nicolas CS, Martins F, Pujol C. Evaluation of palatability of a metronidazole-based oral suspension in dogs when poured on the food and at different stages of shelf-life. In: Proceeding of the 5^th World Congress on Advanced Clinical Trials and Clinical Research. J Clin Trials. 2018;8:45.

AmerisourceBergen has announced that Centaur Services will open a new 180,100 square foot warehouse in the Midlands next spring.

Centaur will continue to operate its warehouse in Castle Cary, Somerset; the new facility will allow the company to bolster its services to customers throughout Northern England, North Wales and Scotland.

AmerisourceBergen says the new Midlands facility will hold more than 13,000 products and be licensed for the wholesale distribution of veterinary and human medicines. The facility will use a state-of-the-art warehouse management software to provide efficient and accurate order fulfillment and improve the visibility of products in the supply chain.

Brian Topper, Managing Director of AmerisourceBergen Animal Health U.K. said: "Our expanded presence and capabilities in the U.K. is a reflection of the demand for high-quality solutions, and we’re growing to best meet our customers’ needs.

"Practices of all sizes rely on us to provide them with timely access to the products they need on a daily basis. With broader scope and capacity, we’ll be able to go beyond our best-in-class services and provide an unmatched customer experience by delivering critical products to practices in a more efficient and consistent manner than ever before."

The company says that the new warehouse will create more capacity at its Somerset warehouse and put the company in a positive inventory position to buffer against any business continuity challenges that may occur – ensuring that practices and their patients continue to have access to vital products.

Lisa Derbyshire, Director of Operations & Supply Chain at Centaur Services said: "As the industry moves forward, we want to ensure our customers have access to high-quality infrastructure that maximizes product safety and improves operational efficiency. Adding critical resources and upgraded service offerings, like our new distribution center in the Midlands, enables us to be at the forefront of distribution while continuing to provide the excellent service that our customers have come to know and expect from Centaur."

Zoetis has announced that it will continue to supply an alternative equine rotavirus vaccine under a Wholesale Dealer Import Certificate (WDIC) until normal supply of its licensed product, Equip Rotavirus, can be restored.

The RCVS Veterinary Nurse Disciplinary Committee has directed that London-based veterinary nurse Paul Chaney is removed from the Register after he was found guilty of a stealing, possessing and unlawfully administering various veterinary drugs, and that he dishonestly made and deleted clinical records about his own dog. 

Mr Chaney was charged with stealing Trazadone and Metacam from the Hampstead practice he worked at, and of unlawfully possessing Trazadone and Metacam. He was also charged with unlawfully administering Butorphanol to a dog and failing to record the administration of the drug in the dogs records. He was also charged with making and deleting false entries into the clinical records of his own dog to the effect that it had been seen by a vet at the practice and that Metacam had been prescribed. The final charge was that his conduct over the false records was dishonest and misleading. 

The Committee heard that Mr Chaney’s conduct in relation to the first two charges was discovered when, in July 2018, the Department for Environment Food & Rural Affairs (Defra), accompanied by police officers, executed a warrant (for unrelated matters) on the property where he lived. During the course of the search, police officers found Metacam and Trazadone in Mr Chaney’s bedroom which did not seem to have a prescription and so Defra officers launched an investigation.

During the course of this investigation, a Defra investigator was also provided with a video and messages that indicated Mr Chaney had unlawfully administered Butorphanol to a Husky dog in frustration with the animal as it was being too noisy.

The Committee heard that, in November 2018, Mr Chaney accepted a police caution in relation to his possession of Trazadone and Metacam, and the unlawful administration of Butorphanol. The Committee also heard that following the police attending his property and finding the medicines, Mr Chaney went on to create false records at the practice in relation to the examination of his dog in order to justify his unlawful possession of the drugs.

The Committee found all the charges against Mr Chaney proven.

The Committee then went on to consider if the charges, taken both individually and in totality, amounted to disgraceful conduct in a professional capacity. 

Judith Way, chairing the Committee and speaking on its behalf, said: "The Committee had no doubt that administering a sedative to an animal that required prescription by a veterinary surgeon and then failing to record it in the clinical record with the resultant risk to the animal’s welfare due to lack of knowledge of the administration fell far below the expected standard.

"The Committee also considered that possession of prescription only medicines by a registered veterinary nurse, without the sanction of law, having stolen the same from a practice also fell far below the expected standard.

“The Committee also considered that tampering with the clinical record for a dog, in order to create a misleading impression and in doing so dishonestly, was conduct which fell far below the expected standard.

“Taken as a whole, the Committee considered that Mr Chaney’s conduct had fallen far below the expected standard.”

The Committee therefore found him guilty of disgraceful conduct in a professional capacity in relation to all seven charges.

It next went on to consider what sanction, if any, to impose taking into account the aggravating and mitigating factors.

In considering the aggravating factors, the Committee took into account that Mr Chaney’s conduct had presented a risk of injury to the animal and that much of his conduct was pre-meditated. It also considered that Mr Chaney’s conduct involved a breach of trust to both the practice where he was employed and the owner of the Husky, and it was also an abuse of position in gaining access to and stealing medication. Lastly, because the charges related to two separate incidents, there was a common thread in Mr Chaney disregarding rules on veterinary medicines.

In mitigation, the Committee considered that Mr Chaney had reflected on and gained some insight into  his behaviour, and acknowledged he had made admissions at the outset of the hearing, including apologising for and showing regret about aspects of his conduct.

However, the Committee did not believe he had addressed his understanding of the effect that this conduct had on the risk to animals, the standards of the profession or the maintenance of public confidence in the profession. In mitigation the Committee also considered a number of positive character references and his previous good character.

Judith Way said: “The Committee determined that it would not be sufficient in the circumstances of the case, to satisfy the public interest to suspend the Respondent’s registration. In its view this case involved a serious departure from identified professional standards. The disregard had been deliberate, in relation to ignoring legislation in respect of prescription-only medication and dishonesty in stealing medication.

"There was evidence of attitudinal issues in relation to that behaviour and insufficient evidence of the development of insight. The dishonesty in relation to the clinical record relating to dog O [his own dog] had been an attempt to conceal earlier dishonesty relating to the theft of the medication. In administering the Butorphanol to dog L [the Husky], Mr Chaney had been putting his own interests in quieting the dog ahead of the dog’s interests, which would have required checking with a veterinary surgeon as to appropriate steps.

"The Committee acknowledged that, by directing removal, there would likely be professional reputational damage to Mr Chaney and possible financial loss. However, in the view of the Committee the requirements of the public interest outweighed these factors.”

Accordingly, the Registrar of the RCVS was directed to remove Mr Chaney’s name from the Register of Veterinary Nurses.

Full details can be found here: https://www.rcvs.org.uk/concerns/disciplinary-hearings/

Royal Canin has launched Feline Anallergenic, a new diet formulated to help in the nutritional management of adult cats with nutrient intolerance.

The company says that Anallergenic can be used as the elimination diet of choice when working up dermatosis cases. Nutrient intolerance can be determined by feeding the extensively hydrolysed elimination diet for six to eight weeks followed by reintroduction of the pet’s original diet.

For cases where a nutrient intolerance is proven, Royal Canin says Hypoallergenic should be used for long-term nutritional management, although some refractory cases may need to remain on Anallergenic. 

Anallergenic has been formulated with feather protein hydrolysate, starch instead of whole cereals and a combination of ingredients to help reduce water loss through the skin and strengthen the barrier effect of the skin. 

John O’Connor, Veterinary Marketing Manager at Royal Canin, said: "When a nutrient intolerance is suspected, the cat’s diet should be changed to Anallergenic without any food transition. Dermatosis is complex to understand and identifying the underlying cause can be challenging. Managing cats with dermatosis requires a long-term commitment and it is essential for vets to use nutrition as part of their work up.

"The lower the allergenic potential of the diet, the more reliable the results¹ and nutritional management with Anallergenic can be continued for the cat’s lifetime. With the new, highly palatable² Feline Anallergenic diet, Royal Canin offers the complete nutritional approach to dermatosis."

Alongside the new diet, Royal Canin has produced a range of owner education materials, including a leaflet with top tips and a video about nutrient intolerances to raise awareness of the condition and the importance of owners seeking veterinary advice. The new materials are available via your Royal Canin Veterinary Business Manager.

For more information, visit royalcanin.co.uk/skin

References

1. Jackson HA. Food allergy in dogs – clinical signs and diagnosis. EJCAP. 2009;19(3):230-33
2. Studies on Anallergenic Canine (2011) and Anallergenic Feline (2016), Europe (Royal Canin, data on file).

A motion to conduct a trial of remote prescribing without performing a physical examination (ie. via telemedicine), thereby redefining what it means for an animal to be "under the care" of a veterinary surgeon, was put before RCVS Council last week. I was there to hear the arguments …

The motion was introduced by Kate Richards MRCVS, Chair of the RCVS Standards committee, who explained that it'd been driven by three things, namely: the Vet Futures Initiative, the RCVS Strategic Plan signed off by Council in 2017 and the RCVS telemedicine consultation that took place earlier this year. 

The latter of these showed that 69% of vets opposed the idea of prescribing without a physical exam, which rather beggars the question why it's being discussed at all. However, as Kate explained, when asked whether certain types of products could be remotely prescribed, the answer was more equivocal: 52% of vets said "yes".

Kate also explained that over the last two years, there had been a number of good quality discussions at Standards Committee and Council, but that decision-making had been "hampered by a paucity of evidence on the opportunities, risks and benefits of telemedicine to animals and the public".

The full wording of motion was: "Council is invited to consider the recommendation of Standards Committee to conduct a limited and time-bound trial to assess the benefits and risks of allowing the remote prescription of POM-V (excluding opiates, sedatives and potentially also critically important antibiotics) where there has been no physical examination."

However, in order for the trial to take place, it would be necessary to make a temporary change to the Supporting Guidance of the Code of Professional Conduct concerning the definition of "Under his care" (Ed's note. C'mon RCVS, isn’t that a bit anachronistic? Both your CEO and your President are now "her". "Under Care" would do it.), adding the words in italics to para 4.1: "A veterinary surgeon cannot usually have an animal under his or her care if there has been no physical examination; consequently a veterinary surgeon should not treat an animal or prescribe POM-V medicines via the Internet alone, other than in circumstance where a telemedicine service is a part of the RCVS telemedicine trial".

In the best interests of animal welfare

Amanda Boag (MRCVS, Vets Now, RCVS President) then reminded everyone that: "RCVS Council needs to act in the best interest of animal welfare and the public, and whilst sustainability of veterinary services is important, it isn't our role to promote anything novel or to protect traditional models."

Really? Strikes me that the sustainability of veterinary services isn’t just "important", it's an essential part of ensuring good animal welfare. Surely, therefore, it most certainly is the role of Council to protect traditional business models or, for that matter, to promote novel methods if (and I stress "if") doing so protects or enhances animal welfare.

Don’t confuse telemedicine with remote prescribing

Jo Dyer (MRCVS, small animal locum, Devon) opened by pointing out that this is not about telemedicine per se. Telemedicine has been going on since the invention of the telephone in the late 1800s, supplemented over the last 20 years or so by photography and video sent over the internet. Telemedicine does not, in and of itself, require a change in regulation.

What this is about, she explained, is the much narrower act of remote prescribing without physically examining the animal, something which would require the profession to redefine "under his care", which in turn "makes up the foundation of what forms the relationship with the owner and the animal in order that we can safeguard the use of medicines, safeguard the animals under our care and safeguard our clients."

No evidence remote prescribing increases access to veterinary services

Jo argued that the only reason Council should be considering the prescription of medicines without a physical examination would be if it were in the interests of animal welfare. And yet, she said, there is no evidence to support this idea.

Some have suggested that it could increase access to veterinary care. However, Jo said she had been unable to find any evidence to support this idea either. Not just in the veterinary profession, but in the medical profession in the Western and the developing world.

Jo also noted that the trial proposal was to use commercial organisations which have a financial interest in a positive outcome, which would render the results biased and unreliable.

She then raised the issue of antimicrobial resistance, highlighting the use of cytology and culture sensitivity to make sure the right antibiotics are used. Remote prescribing, she said, would be a retrograde step, even if only non-critical antibiotics could be prescribed remotely.

Spawning a new class of limited service provider

Next she highlighted the impact of the trial on 24-7 cover. Under the proposal, "Those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

As Jo pointed out, this would by definition mean that any veterinary surgeon, not just those practising telemedicine, could set themselves up as a limited service provider and refer all cases they didn’t want to see (whether OOH or not) to a local practice. This, she argued, should only happen after a proper debate, and not be just the unintended side-effect of regulation change to allow remote prescribing.

In fact, there is evidence that this is exactly what is happening in human medicine. Only the following evening, the BBC aired Diagnosis on Demand: The Computer Will See You Now, a documentary about telemedicine and artificial intelligence in human medicine. It should be required watching for all RCVS Councillors.

The programme makers visited GP at Hand, a telemedicine business based on the Lillie Road in Fulham, London that has been formed in partnership with Babylon. Coincidentally just up the road from where I used to live, it's a pretty nondescript sort of a place, but now home to the fastest-growing GP surgery in the UK. Since late 2017, it has amassed a staggering 30,000 clients from across London, virtually none of whom will ever visit the place. The problem is that GP at Hand has skimmed away fee-paying clients from across the capital that had in effect been helping to subsidise local care elsewhere.

More information needed for such an important decision

Jo concluded by saying that a decision of this magnitude, particularly when it seems to go against the wishes of the majority of the profession, demands checks to ensure no conflicts of interest, legal advice and wider consultation with organisations such as the VMD, Defra, the BVA and its subdivisions and the VDS. Therefore, she would propose a new motion to delay the decision until more information is made available.

Chris Barker (MRCVS, small animal practice, Cumbria) was up next. He felt that the RCVS consultation was very effective and gave a good picture of what veterinary surgeons see as the risks inherent in remote prescribing. However, he felt that the analysis has been marshalled to suit an agenda and minimises the concerns of general practitioners.

Fragmentation and multiple consultants leading to a loss of responsibility

The trial, he said, will lead to fragmentation of veterinary provision and send the message to the public that it is quite OK to go to more than one vet for advice and treatment, and that will lead to confusion and the loss of individual responsibility for the veterinary care of an animal that exists today.

An inspection with no history: not a proper examination.

Chris argued that the act of prescribing demands a physical examination, but that a video consultation could only ever be an inspection. He also highlighted the importance of patient histories and argued that the immediacy of telemedicine simply doesn’t allow a practitioner to get the patient history from another vet.

Chris also argued that the profession is not structured to allow for clients to consult multiple veterinary service providers simultaneously: once a client leaves his practice, he has a duty under GDPR to expunge much of their records, and he for one didn’t much care for the idea of re-registering a client at 2:00am.

Some of the issues Chris raised may of course be solved by technology in the foreseeable future. GDPR already calls for data portability, presumably it will not be long before owners expect the same data portability for their animals' clinical histories.

Who wants clients who only ever call when telemedicine has failed?

Still, his overall point was an important one: whether or not there will be vets out there who are happy to pick up and see failed telemedicine cases at 3:00am in the morning from people who are not clients of their practice and who don’t otherwise contribute financially to the business.

90% of vets say remote prescription is high risk or inappropriate

Lastly, Chris drew attention to a question in the RCVS consultation which asked respondents what risk they thought there would be in a remote consultation when the consulting vet did not know the owner, did not know the animal and does not know the situation in which the animal is kept: "90% of responding veterinary professionals either chose it as high risk or simply not appropriate at all. I know of no better body of people than practitioners in Britain to understand the welfare and the risk to the welfare of animals."

The risk of misdiagnosis

Martin Peaty (MRCVS, equine practitioner, Wiltshire) spoke next, highlighting the risk he saw to animal welfare from misdiagnosis. He drew attention to concerns raised by the Quality Care Commission in human medicine, in particular that there is no access to the long term medical records of the patient, and the risk of misdiagnosis: "And that’s in human patients who can fluently articulate their symptoms", he said, "I think we should be much more cautious in exercising care before allowing remote diagnosis and prescription."

Martin's point seemed especially apposite in the light of an article which appeared in The Times two days later: 'NHS app 'no match for trip to the GP', in which Professor Helen Stokes-Lampard, chairwoman of the Royal College of GPs expressed concerns about online consultation systems, particularly for vulnerable groups, such as children.  

Remote prescribing demands that vets sacrifice principles

Martin also outlined the three principles which underpin current practice: physically examining the animal, considering its history and providing 24 hour care, the latter in part in case of a reaction to a prescribed medicine.

"These proposals ask us to sacrifice these principles for telemedicine businesses whilst for good reason they remain in place for other veterinary practices. I think that is hypocritical. I think it is wrong."

Not enough follow-up

Sue Paterson (MRCVS, a referral specialist who offers a dermatology telemedicine service to the profession and the public, Merseyside) jumped in next. She was unashamedly enthusiastic about the benefits of telemedicine, in particular how it allows practitioners to engage with the public and make veterinary advice more accessible, not to mention because: "I am sick to death of people coming into consults when they have been on Facebook or they’ve been on to talk to Dr Google."

However, despite her enthusiasm and despite finding that users of her service do not want antibiotics, just advice, help and reassurance from people they trust, Sue was still against the idea of remote prescription: "I don’t want to prescribe because I can't follow those cases up, because I can’t maintain the level of client care that I think is really important, so for me, I would not want to see this change to the code."

We won’t know what we missed, or the consequences of what we missed

Caroline Allen (MRCVS, charity veterinary director, London) said the biggest issue for her is that without a physical examination, she won’t ever know what she missed (the heart murmur, the goitre, the subtle muscle wastage), or for that matter, the animal welfare consequences of what she missed.

As others had done, Caroline highlighted the importance of getting a weight every time and how difficult it is for clients to measure accurately.

Lastly, she made the thought-provoking point that allowing the remote prescription of drugs without a physical examination would risk legitimising Dr Google in the eyes of the public. After all, if no veterinary physical exam is needed, surely owners can just look it up on the internet for themselves?

In defence of the RCVS

At this point in the discussion, RCVS CEO Lizzie Lockett addressed the suggestion that the whole process of investigating and voting on telemedicine was being driven by hidden agendas, something she absolutely and eloquently rejected. She explained that sure, some parties had been more engaged in the whole process than others, but emphatically denied there had been any influence. Council, she said, had asked Standards to investigate and develop a proposal, which it had done diligently. Now it is down to Council to decide whether the proposal stands or falls; the College exists to implement the decision.

RCVS Vice President, Professor Stephen May went further, saying that many present would be aware that he'd been a vocal critic of the way that a number of other regulators in modern society push things out to court for decisions, rather than taking decisions collectively and then sticking by them. "I’m really proud that we are discussing this and I’m really pleased that this is up to us how we move things forward in the interest of animal health and welfare and supporting the public in that."

The need for a more nuanced, less polarised debate

However, he said he was worried about the way the debate was being polarised into a yes or no when he felt the profession should thinking about how it should adapt to the changing circumstances, thinking about cases which are amenable to a distant relationship and in what context that is appropriate, taking into account the risks. 

Remote prescription is already happening, illegally

Melissa Donald (MRCVS, small animal practice, Scotland) questioned whether telemedicine and remote prescription is what the public wants. She said that remote prescription is already happening, illegally from abroad, and that the College needs to have a more robust response than "it’s not our problem". She therefore recommended a further period of consultation, particularly with public focus groups, and internet research to see how much remote prescription is already happening. 

Vets are professionals

Tim Walker (Lay) said he was struck by the need to assemble better evidence. He felt there needs to be more thought given to the transference of responsibility for cases between a telemedicine provider and a traditional practitioner. Tim also felt that the definition of "under his care" will almost certainly need to be rethought in the not-too-distant future, because the idea of a patient being under the care of just one practitioner is starting to look dated; in the human sphere, patients are looked after by teams of people.

Tim highlighted the approach he said is taken by the GMC, which obliges doctors to be able to demonstrate that they have done sufficient due diligence to prescribe, not that they can simply do so automatically under certain circumstances. That, he said, is what professionalism should be about.

Taking the lead

Mark Castle (Lay) said he thought that the public was looking for a choice, that technology is constantly throwing up new opportunities, and he expected that in the future more and more will be able to be done remotely, so he wanted the RCVS to take the lead in this area.

Lucy Goodwin (MRCVS, BSAVA Head of Education) was positive about the idea of conducting a time-limited, controlled trial: "We say we want evidence, so let’s go and collect it", but had a number of reservations. Not least of these was the fact that the participants in any trial would be on best behaviour, so it may not be able to extrapolate the numbers to the profession at large. Beyond that, she was also concerned that the scope of the trial should be better defined, in particular which categories of drug could be included within it. 

Vets don't want a trial of telemedicine

Mandisa Greene said that whilst she is positive about telemedicine as it had been described, and not averse to a trial, she didn’t see the point in a trial when the people who actually do the prescribing don’t want it. 

A voice in favour

Chris Tufnell (Past President) began by declaring that he consults to the Affordable Pet Care Company which is shortly to launch a telemedicine service, although he said the service would be unaffected by the decision being taken by Council. He was also at pains to stress that he hadn’t had any other fingers in this particular pie, in particular that he hadn’t been to any of the Standards Committee meetings or presented to them, or been involved in formulating the proposed trial.

Whether you agree or disagree with Chris, it was at least good to hear someone speaking in favour of the motion. Chris opened by arguing that veterinary surgeons are good at making decisions based on imperfect information: "Client histories, as we know, are of variable quality. We make decisions daily on whether we are happy with the information we get from the practice lab or whether we need to send the sample to a reference lab. When I started in practice, practice lab machines were routinely described as random number generators."

"We make decisions on a daily basis on what the limitations of our abilities are. It’s called professional judgement and what we are proposing here is actually a test of our definition of 'in our care'. We’re talking about testing the possibility of making remote prescriptions. The responsibilities around prescribing won’t change, and those responsibilities include the responsible use of antibiotics."

Chris then argued that all the motion was calling for is a trial of something that unlike, for example, deregulating advertising and practice ownership, is not going to give a slice of the consultation fee to non-vets. He also pointed out that people will always be able to highlight cases that would be completely unsuitable for remote prescribing, but that this is not about replacing the consulting room.

Filling the void

What it is about, he said, is removing barriers to care; filling the vacuum between a concerned owner, and the £60 - £100+ they’ll be charged for a consultation. It’s a vacuum that is currently filled by the 'free' (except it's not) phone advice given out by practices, by Facebook and by Dr. Google. 

He then pointed to an example from the US, where 83% of people who visited https://www.whiskerdocs.com for pet advice and thought their problem was suitable for home treatment, were in fact wrong and ended up being instructed to visit their veterinary practice. This, he said, could lead to better productivity in practice.

Could telemedicine help retention?

Telemedicine, he said, could also provide a role for people thinking of leaving practice, which is potentially an important factor at a time when retention is proving such an issue. 

Evidence-gathering, clinical freedom and professional judgement

Like others, Chris argued that the trial is about putting the RCVS at the forefront of progression in our increasingly digitised society, at a time when remote information from wearables is going to become more and more common. In summary, he said: "This trial is about an evidence-based profession looking for evidence, it’s about clinical freedom and it’s about putting professional judgement in the hands of the professionals."

A two-tier service

Lynne Hill (Past President) said her main concern is about having to redefine "under his care" and how remote prescribing via telemedicine would lead to a two-tier level of care, which she thought would be wrong.

She also highlighted that the College had debated the definition of "under his care" in relation to farm animal practice, where some farmers have multiple vets, some of which offer herd health care and nothing else. Deregulating to account for this has, she said, been responsible for the demise of farm animal practice. Quite simply there are less vets around to see animals. 

Show me the money

Lynn also noted the altruistic nature of the debate thus far, and reminded everyone that this is really about business and making money. The companies that are set up to provide telemedicine and possibly take part in the trial will not be in it for the welfare of animals, but to make money.

She also scoffed at the idea that telemedicine and remote prescribing will mean the 10% of people who do not currently have a vet are "now going to get madly involved in telemedicine." The reason they don’t have a vet at the moment, she said, is because they don’t want to pay. Telemedicine doesn’t change that. 

Lastly, as others had done, she highlighted the difference between human medicine, where patients can describe their symptoms, and veterinary medicine, where they can’t.

Leadership is about taking the right decision, not jumping on the bandwagon

"Leadership is not always about jumping on the bandwagon and going forward because something is out there. Leadership is actually about looking and deciding and making the right decision."

The disingenuous antimicrobial argument

Dave Leicester (MRCVS) was up next, arguing that it would be wrong to say that a body of professionals can be trusted to make decisions about animal welfare, but not about prescribing. He also felt it was a little disingenuous to do a lot of hand-wringing over antimicrobials when, as a profession: "We’ve managed to make a 3rd generation cephalosporin the most prescribed antibiotic in cats."

Finally, Dave made the point that in his 15-year experience working for OOH emergency service providers, they’d managed to work very successfully without access to patient medical histories.

Setting veterinary standards

Claire McLaughlin (Lay) reiterated that the role of the RCVS is to set veterinary standards, something it can’t very well do without knowing what is going on in practice, and finding out how these things work in practice. “We need to be in a process which takes us to able to set those standards. Whether the trial that is proposed is the right trial or not, we can’t just say no, it’s fine as it is because people will work within their professional competence. As Eleanor [RCVS Registrar] will tell you, they don’t work within their professional competence because they come before disciplinary committee all the time. I think we would be remiss if we didn’t start a process now or continue this process in a way that allows us to set appropriate standards.”

Colonel Neil Smith (MRCVS, Chief Veterinary Office for the Army) began by declaring that he provides telemedicine services for animals in disparate parts of the world as part of his day job, but these animals are very much under care and there is an existing relationship with patients. He is also involved with the provision of limited veterinary services for homeless people via StreetVet, a charity which has had to form relationships with practices that can cover the 125 hours per week when it is not present. 

Lowering veterinary standards

Neil explained that his "massive" concern with the proposal lies in particular with the part that says: "Given the limited nature of the service that can be provided by telemedicine alone, however, it is proposed that those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

This, he said, would lower veterinary standards, if all somebody providing telemedicine has to do is point people in the direction of a practice. 

For that reason, Neil said, he could not support the proposal as is, and would instead recommend that it goes back to Standards and is then brought back at the next council meeting with a clearer idea of what the trial is all about.

Accessible care

Caroline Allen then jumped in again, saying that whilst she agreed with the idea that more data is needed, she also thought that telemedicine and remote prescription is being driven by the issue of accessible care, and it is that, in fact, which needs to be investigated and understood and debated first.

The digital age

Past President Professor Stuart Reid highlighted that the veterinary students of today live their lives in the digital environment and their world will be very different from ours. The same goes for pet owners. He reiterated that as the regulator, the RCVS needs to be ahead of the game, and that if this is what the public wants, then it has to find a way of regulating it. 

Stuart finished by saying that he felt conflicted about the vote; that he had significant problems with the proposal and is not entirely sure that a trial is the right thing, but: "In the referendum we're about to have, I want to say yes but I want to see what the deal is as well." He added: "I didn't vote out by the way, in case this gets back to my employers, but I do think we have to think very carefully about throwing the baby out with the bathwater here."

Pressure to prescribe

Martin Peaty then recounted how at a Vivet Conference last year, a provider of telemedicine (which he thought was Babylon) explained that doctors on its system were retained on the basis of a post-consultation customer satisfaction survey. That, he thought, would make it difficult for practitioners not to prescribe things when they know it will affect their job. 

David Bray (Lay), said he believed the telemedicine and remote prescribing will come and it will become more common to have pets treated by multiple vets, so he was fully supportive of a trial. 

When it came to the vote ...

Guessing at which way the people who spoke might have voted, it seemed as though there were probably enough councillors with sufficient reservations about the motion, which would have given the go ahead for the trial, for it to be voted down.

That said, the overall sentiment in the room seemed to be that the discussion about the regulation of telemedicine and remote prescription needs to continue, and not get kicked into the long grass simply because of a disagreement over the proposed trial. 

At this point, Jo Dyer and others stepped in to argue that the decision to proceed with the trial should not be made until the issues raised in the debate had been addressed. There was then a lot of going backwards and forwards, discussing whether this would need a new motion, which is not allowed under Council rules, or whether the existing motion could be amended, which is allowed.

In the end, the decision was taken to hold two votes, the first being to refer the issue back to the Standards Committee which was carried by 18 to 12, with one abstention. 

The second vote was:

"Council is invited to consider the recommendation of Standards Committee to prepare and develop a proposal for a time-bound and limited trial to assess the benefits and risks of allowing the remote prescription of POM-V with appropriate stakeholder engagement and with consideration of the issues that we've discussed today and the detail on them, including 24/7 care and classes of drugs, especially antimicrobials. So we are asking for the detail on that to be worked up on the basis that it will at some time come back to Council."

The second vote was carried by 21 to 8 with 3 abstentions. 

In other words, the trial will not now go ahead unless Standards can develop a new proposal which addresses the concerns raised by Council.

VetSurgeon Conclusion

Looked at solely in terms of its impact on animal welfare, this debate seems to come down to one question, which is whether more animals will benefit from easier, cheaper access to veterinary services available via telemedicine and remote prescription than will suffer as a result of misdiagnoses and missed diagnoses that will surely be the inevitable consequence of veterinary surgeons working only from the more limited, and potentially inaccurate or even false information they will get from a video consultation.

For sure, more wearables are coming, and they will overcome some of the problems caused by the fact that animal patients cannot describe their symptoms. Doubtless someone will also invent a set of weighing scales that makes it possible for owners to do the job reliably accurately. Patient histories will surely become more portable. But these things are not with us just yet. 

In any event, it is not just about the immediate impact on the quality of care delivered to patients. The way the trial has been framed thus far takes us in the direction of a two-tier profession. What happens if more veterinary surgeons prefer, or make a better living from working from the comfort of their own home without the added responsibility that comes with providing the physical care. Who’ll do the ‘real' vetting?

If you look at the popularity of human telemedicine, the 30,000 patients who have signed up for telemedicine at the small practice in the Lillie Road in London, it seems obvious that patients want the convenience of consulting online, without having to schlep to the practice and find a parking space. It also seems self evident that if online consultations are offered at a lower price point, it will inevitably lead to more pet owners availing themselves of veterinary advice, though as Lynn Hill said, it’s unlikely to cause a mad rush whilst Dr Google is still free. 

Perhaps, though, there is another valid way to solve this conundrum. Rather than rushing headlong into a trial that could irrevocably change the very nature of the profession, how about establishing some pragmatic ground rules from the outset. For example, that unless by unanimous agreement of Council in the future, telemedicine should only be allowed as an extension of the service offered by existing bricks and mortar practices to their existing clients. 

When it comes to remote prescribing, surely the safest way to regulate it (if you’re going to allow it at all) is to do so on a drug-by-drug basis. Perhaps trial it with the endo- and ecto-parasticides for existing clients of existing practices. Find out whether the convenience of the online consultation leads to higher standards of parasite control for greater numbers of pets. If it doesn’t, then ditch it. Either way, it doesn't preclude trying another category of drug.

That’s my tuppence worth, for what it’s worth, which probably isn’t quite tuppence!

The new equine Veterinary Journal UK Vet: Equine has published new evidence-based guidelines on the management of equine glandular gastric disease (EGGD) which publishers say could help improve management of the condition in practice.

Equine glandular gastric disease is a complex syndrome that is distinct from gastric ulceration. A number of studies now indicate that it is an inflammatory gastritis, predominantly at the gastric outflow, which has different causes and risk factors from gastric ulcers. As such, medication effective in treating gastric ulceration may be less effective for this specific condition.

The clinical signs of EGGD are diverse and non-specific and may be mild or recurrent. They may include changes in temperament, changes in rideability, unexplained weight loss, reduced appetite or cutaneous sensitivity manifesting as biting of the flanks or resentment of girthing, grooming, leg aids or rugging. Recommendations for reducing the prevalence of disease, based on putative risk factors, include providing rest days from work, maximising turn-out, minimising management changes and other potential stress factors and minimising changes in equine companions and human carers.

The new guidelines have been published by a group of equine medicine specialists, based on a review of published and unpublished evidence. The intention is to provide veterinary practitioners with up-to-date guidance on risk factors, diagnosis, treatment, dietary management and prevention of EGGD.

David Rendle, an internal medicine specialist at Rainbow Equine Hospital in North Yorkshire who chaired the group and is a consultant editor of UK Vet: Equine said: "Our findings challenge long-standing dogma on EGGD, a condition about which there is currently very little advice available to vets and horse owners. It is becoming increasingly clear that the distinction between disease of the squamous and glandular mucosa is important clinically and the group felt that updated guidance may help to improve management of EGGD in practice."

Provision of evidence based clinical guidelines should enable practitioners to adopt more standardised and logical approaches and base EGGD management decisions on the most current data.

Professor Josh Slater, Professor of Equine Clinical Studies at the Royal Veterinary College said: "Clinical guidelines are commonly used in human health care and have been shown to improve clinical outcomes by condensing data from large numbers of research publications and promoting rapid adoption into clinical practice. These new guidelines represent a step forward in the management of this complex condition by combining a consensus of expert opinion with the best available current clinical research and evidence."

Mark Bowen, Professor of veterinary internal medicine at the University of Nottingham who is based at Oakham Veterinary Hospital said: "Whilst the panel hasn’t come up with miracle cures there was universal agreement that new treatment options have to be integrated in a logical and responsible manner."

"Our understanding of this condition is in its infancy but we hope that the summary document, which also highlights the gaps in our knowledge, will provide a useful framework for vets to follow and will be a stimulus for future research."

The guidelines can be found here: https://www.magonlinelibrary.com/doi/full/10.12968/ukve.2018.2.S1.3

Photo: Marked multi-focal depressed haemorrhagic and fibrinosuppurative lesions

Boehringer Ingelheim has launched Bovalto Respi Intranasal, an intranasal pneumonia vaccine for calves.

Bovalto Respi Intranasal protects against the two main respiratory viruses – RSV and PI3, using modified live viral strains that have been shown to protect against experimental challenge from recent field isolates¹. 

The vaccine is delivered as a single shot, from 10 days of age and provides immunity for 12 weeks, from 10 days after vaccination².

In order to overcome the challenges of effective delivery, Boehringer is offering dedicated administration packs, available directly from its ruminant specialist team.

The packs include a vaccinator, a set of nozzles that deliver the vaccine at the optimum droplet size and a soft Bovalto Respisafe applicator which fits against the calf’s nostril. The aim is to make sure that vaccination is a comfortable process for both farmer and calf, as well as addressing the challenge of the delivery of vaccine to the desired area in the nasal passages.

Correct administration of the vaccine ensures that the spray is delivered effectively to the mucosal surface and local lymphoid tissue, achieving the optimal immune response. If the droplet size is too big, the vaccine may be deposited lower in the airway and run out of the nose. If droplet size is too small then the vaccine may be carried to the back of the throat and swallowed. Time and money is spent vaccinating calves so the process needs to be as efficient as possible to give optimal protection. 

Matt Yarnall, brand manager at Boehringer Ingelheim said: "The UK BRD vaccine market is growing each year but, as a management tool, vaccination remains quite low down the list of actions, according to the 2017 Calfmatters survey.

"If adding to the Bovalto range encourages more farmers to vaccinate against pneumonia so improving calf heath and lowering antibiotic use, that can only be a step in the right direction."

References

1. Philippe-Reversat et al. (2017) Acta vet. BRNO 86: 325-332
2. Bovalto Respi Intranasal datasheet

Retired Plymouth-based vet Edmund Shillabeer has had his application to be removed from the Register approved by the RCVS, and will therefore not have to face multiple charges that he failed to provide adequate care for his patients in 2021. 

Mr Shillabeer faced five charges which largely related to his alleged prescription of contra-indicated NSAIDs and corticosteroids.

He was also charged with prescribing frusemide to a pregnant dog when there was no evidence of a benefit of so doing. 

He was also charged with performing inadequate spay surgery.

Mr Shillabeer did not admit to any of the charges, engaged with the College and responded to all requests for information, as well as being present in-person at the hearing.

He made an application to the Committee to dispose of the matter by way of adjournment, subject to the Committee accepting his written undertaking to remove his name from the Register and never to apply to be restored to the Register.

In support of his application, Mr Shillabeer’s legal counsel referred to his client’s witness statement, which set out that he had previously attempted to sell his practice but had been unsuccessful and that he had since closed it.

His legal counsel also asked the Committee to consider the fact that Mr Shillabeer is almost 85 years old and has had an unblemished 60-year career, has had no previous disciplinary findings against him, had put his practice up for sale and made efforts to guide his previous clients to ensure continuity of care elsewhere, and that he deeply regrets anything he has done, which has failed to protect the welfare of animals, or has caused concern or upset to his clients and fellow members of the profession.

Mr Shillabeer's counsel also asked the Committee to take into consideration that his undertakings would have the effect of protecting the welfare of animals and uphold the reputation of the profession as Mr Shillabeer is no longer in practice.

He stated it would be not proportionate, or in the public interest, for there to be a lengthy contested hearing resulting in substantial costs for both the RCVS and Mr Shillabeer.

The College’s legal representative stated that the RCVS did not oppose the application, and that it took a neutral stance.

She highlighted that Mr Shillabeer’s removal from the Register, together with his undertaking never to apply for restoration, would go far beyond anything the Committee could direct by way of sanction after a full enquiry, that Mr Shillabeer retired from practice on 23 July 2024 and does not intend to return, that a full enquiry would take a significant amount of time and expense, that the complainant supports the case being dealt with in the manner proposed by Mr Shillabeer, and that there are no previous findings against Mr Shillabeer.

Paul Morris, chairing the Committee and speaking on its behalf, said: “Taking into account the undertaking never to practice again, in conjunction with all of the circumstances and context set out, the Committee considered that by allowing the application, such an outcome would be sufficient to uphold the public interest, confidence in the profession and the RCVS as regulator, and protect the welfare of animals.

“As a result of all the factors set out, the Committee decided that this is not a case in which the public interest or the welfare of animals demands that there be a full hearing.

“Taking into account proportionality and weighing in the balance all the circumstances of the case, the interests of justice, the public interest, the need to uphold proper standards of conduct and performance, and the need to protect the welfare of animals, the Committee decided to grant the respondent’s application.”

Mr Shillabeer was removed from the Register with immediate effect.

https://www.rcvs.org.uk/concerns/disciplinary-hearings/ 

Online veterinary pharmacy Vet-Medic has announced the results of a survey which showed that veterinary practices are charging pet owners 100% more than online pharmacies for well-known drugs.

The survey compared the prices charged by veterinary practices, online pharmacies, pet superstores, supermarkets and veterinary medicine suppliers. Amongst other things, it found a six-pack of Frontline for cats available online for £16.33, vs £38.95 in practice. Optimmune was available for £23.86, compared to a practice in North London selling it for £59.81.

Andrew Evans, Managing Director of Vet-Medic said: "This research offers huge insight into the pricing structures of pet medication. When we commissioned the research to help us keep our own pricing competitive, we made an assumption that online shopping should come out cheaper but were staggered by how much."

He added: "Not many pet owners are aware that vets are obliged, in most circumstances, to provide them with a prescription when asked. How and where the prescription medicine is purchased is actually the owners' choice."

The BVA responded to the survey yesterday. President-Elect Harvey Locke said: "The Vet-Medic claim that veterinary practices are over-inflating the price of veterinary medicines is an unfair accusation.

"Veterinary practices will mark up the cost of the medicines they supply in order to cover the costs of keeping and dispensing them. This includes having trained staff available, buying the necessary equipment, and storage facilities that are governed by strict rules, and covering the cost of wasted medicines that have a short shelf life.

"Online pharmacies have similar overheads but are able to buy in much larger quantities than the average veterinary practice due to the much higher volumes sold. Many of the internet prices revealed in the survey are around the same cost as veterinary practices can buy the medicines from wholesalers suggesting that some of the internet companies are sourcing cheaper drugs abroad.

"As with many products buying online can be cheaper and consumers have a choice. Many pet owners choose to use the veterinary practice pharmacy because a lot of advice and assistance is available, including demonstrations on how to administer the treatments.

"Vet-Medic's assertion that pet owners don't know that they can obtain a prescription from their veterinary surgeon is also false. Over 50% of UK practices are registered under the RCVS Practice Standards Scheme. One of the conditions of the scheme is that a notice must be displayed in the waiting room informing clients that prescriptions are available on request, the price of a prescription, and the price list of the top ten medicines that the practice has dispensed in the last three month period.

"It's important to remember that under the law veterinary practices are not allowed to fix the price of medicines. As they are independent businesses this means that it is up to each practice to charge according to their own circumstances to cover their individual overheads."

The Royal Veterinary College’s VetCompass programme has published the results of new research which shows that ownership of Chihuahuas is growing despite the breed being particularly prone to expensive dental problems and obesity.

According to the study¹, which looked at Chihuahuas treated in first opinion practice, ownership in the UK has increased over five-fold in the past decade from 1.0% of all puppies born in 2005 to 5.4% in 2016.

However, the study also found the breed was particularly susceptible to a number of health issues, including: dental disease (13.5%), obesity (5.9%) and retained baby teeth (5.7%).

Compared with other dogs, Chihuahuas were also more prone to aggression (4.2%), slipping kneecap (4.0%) and retained testicles (3.9%).

Other findings included:

• Males are more likely than females to show aggression, heart murmur, ear infection, conjunctivitis and upper respiratory tract infection. There were no disorders that were more common in females.
• The average adult Chihuahua bodyweight was 3.4kg.
• The average Chihuahua lifespan was 8.2 years. Females (10.2 years) generally outlived males (6.9 years).
• The most common causes of Chihuahua deaths were heart disease (18.8%), lower respiratory tract disorder 16.3% and traumatic injury (13.8%).

Dan O’Neill, senior lecturer at the RVC and author of the paper, said: "Chihuahuas are an old breed but the recent craze for them can cause some real welfare issues for this tiny dog. There is increasing evidence that unscrupulous breeders and dealers both inside and outside the UK are cashing in on this trend by making a lot of money but with little regard for the welfare of these puppies and breeding bitches."

Camilla Pegram, VetCompass epidemiologist at the RVC and co-author of the paper said: "Dental disease and retained baby teeth should be recognised as important health concerns for Chihuahuas, with preventative care for dental disease a key topic for discussion between vets and owners. In addition, many of the common or predisposed disorders, such as dental disease, retained baby teeth, sliding kneecap and retained testicle(s), often require surgical intervention. The Chihuahua’s small size increases its anaesthetic risk. Obesity has many detrimental effects, including increased anaesthetic risk, and aggression makes them challenging patients and pets, therefore nutrition, lifestyle and behaviour are also key areas for veterinary-owner discussions."

The full paper is open access: https://doi.org/10.1186/s12917-020-2258-1.

Reference:

1. O'Neill, D.G., Packer, R.M.A., Lobb, M., Church, D.B., Brodbelt, D.C. and Pegram, C. (2020) 'Demography and commonly recorded clinical conditions of Chihuahuas under primary veterinary care in the UK in 2016', BMC Veterinary Research.