CMA investigation: Is £45 too much for a booster?

RE: CMA investigation: Is £45 too much for a booster?

Beats — Fri, 24 May 2024 09:51:41 GMT

Thank you, Arlo, for your efforts!

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Fri, 24 May 2024 07:59:10 GMT

Me neither! But I am pleased that behind the scenes, there's a tentative agreement for VetSurgeon to join forces with another organisation to try and address some of the driving factors behind spiralling costs which are not covered by the CMA. I expect to have more news on this in the next few weeks.

RE: CMA investigation: Is £45 too much for a booster?

Cinzia Gandini — Thu, 23 May 2024 21:54:35 GMT

Me neither

RE: CMA investigation: Is £45 too much for a booster?

Clive Ansell — Thu, 23 May 2024 08:37:11 GMT

me neither

RE: CMA investigation: Is £45 too much for a booster?

David Mills — Thu, 23 May 2024 06:48:36 GMT

https://www.gov.uk/government/news/cma-presses-ahead-with-full-investigation-into-vets-market

Can't say I'm surprised...

RE: CMA investigation: Is £45 too much for a booster?

Cinzia Gandini — Mon, 25 Mar 2024 19:44:53 GMT

[quote userid="2457" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244133#244133"] vet taking unacceptable risks by choosing a lower level of diagnostics/treatment[/quote]

There's a very good webinar about this, which is the CMA discussion panel at the Vet Show, free to join thanks to the RCVS. It seems that contextualised care is supported to maximise the welfare of the patient.

RE: CMA investigation: Is £45 too much for a booster?

cairncross — Mon, 25 Mar 2024 19:19:09 GMT

if you want to treat the welfare of the general populations dogs in a manner they can access then yes. vets actually will get plenty of satisfaction cases dont go elsewhere and you get to tackle more pragmatic approaches rather than cases being whipped away to referral centre much more satisfaction in sorting things on your wits and tiny budget .

RE: CMA investigation: Is £45 too much for a booster?

Gillian Mostyn — Mon, 25 Mar 2024 16:53:24 GMT

[quote userid="8991" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244120#244120"]I am unconvinced that the fear of litigation leads to defensive medicine. It is more subtle than that. It is the pursuit of the ideal that the younger vets have been taught, and an inability or unwillingness to contemplate more than very mild levels of risk. Example - last week I chatted to a 2y qualified vet who thought steroids for colitis were just masking the problem by treating the signs; I asked so that maropitant we give out by the gallon, what exactly does that do? Stunned silence. [/quote]

I see this all the time. The idea that its the vet taking unacceptable risks by choosing a lower level of diagnostics/treatment, rather than them taking a pragmatic approach after discussion with the client.

I don't like the current issue of vets deciding what risks are and aren't acceptable - and exaggerating them to get the clients to agree. A typical one is routine bloods for animals on NSAIDS. Having a blood test every 6 months will not prevent an AKI, and analgesia shouldn't be withheld if an owner declines them - but i do see occasions where this happens.

RE: CMA investigation: Is £45 too much for a booster?

Cinzia Gandini — Mon, 25 Mar 2024 16:08:05 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244129#244129"]Supervet[/quote]

I think it should be called Humanised Vet meaning a professional that is getting closer and closer to the human medicine and far away from the veterinary filed, even if in the human profession they are discussing about contextualising care and the NHS is offering low cost procedures like in dentistry a few colours for the fillings, and less choice of materials. Ending with a joke, if you asked a cat whether to to go the vet or die under a bush the cat would reply...catch me if you can

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Mon, 25 Mar 2024 11:57:06 GMT

[quote userid="3169" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244122#244122"]In genuine awe of some of the things Supervet et al are pulling off[/quote]

I'm as divided about this as I am about the existence of multi-disciplinary vet hospitals that put great ormond st to shame.

It's all very well and good being able to perform these more complex procedures, but I think there is a danger of losing sight of the fact that it's a dog! And I think that whilst Supervet is a great ambassador for the profession, it also damages the profession by setting expectations very high and causing what I shall call surgical inflation (ie people seeing what can be done, and either finding a way to pay or demanding it on insurance).

[quote userid="5012" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244126#244126"]Traditionally, I think this has been catered very well for by our profession; we have/have had cheaper practices offering basic levels of care right through to all bells and whistles referral centres.[/quote]

But I am not convinced it has ever been easy for a pet owner to differentiate between the different levels of offering, except at the more extreme ends.

Plus the biggest impact on most people's bills perhaps isnt so much the type of practice they use (except at the extremes), but the advice they are given.

RE: CMA investigation: Is £45 too much for a booster?

Clive Ansell — Sun, 24 Mar 2024 11:38:44 GMT

[quote userid="3169" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244122#244122"]There is clearly a market that should be catered for those willing to spend big money.[/quote]

There should (Still) be a market for all pet owners across all spectrums of expectations and affordability. Traditionally, I think this has been catered very well for by our profession; we have/have had cheaper practices offering basic levels of care right through to all bells and whistles referral centres.

[quote userid="3169" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244122#244122"]The reality of the situation is most pet owners are not in that luxurious situation, and we need to do the best we can for all of the animals under our care.[/quote]

Another reality I see is a huge mismatch between expectations and what can or cannot be afforded, a reality gap, or as collegaue would say they want Supervet at Yorkshire vet prices.

RE: CMA investigation: Is £45 too much for a booster?

Michael Woodhouse — Fri, 22 Mar 2024 22:52:31 GMT

[quote userid="8663" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244118#244118"]I'm sorry, but that phrase is blaming vets for exploiting teh wealthy by the words you use![/quote]

I don't blame vets for creating a tier of veterinary medicine only affordable to the wealthy. There is clearly a market that should be catered for those willing to spend big money. In genuine awe of some of the things Supervet et al are pulling off. The reality of the situation is most pet owners are not in that luxurious situation, and we need to do the best we can for all of the animals under our care. Since graduating I read articles with advice like "double your prices, lose some clients but make more money overall". That's fine if a few of us are doing it. The problem is the majority of the profession have gone that way and the majority of clients are not in such a financial position - back to the profession has changed into something the clients don't want.

Our local referral centre has a fixed price of £4000 for a 30kg TPLO. For context, that is every single penny taken home for someone earning the UK average salary of £35,000 for over 7 weeks.

RE: CMA investigation: Is £45 too much for a booster?

David Mills — Fri, 22 Mar 2024 22:28:57 GMT

[quote userid="8663" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244118#244118"]I think many of us do end up generating larger bills than are necessary in some cases. It's not exploiting owners however, because to me your description sounds like a deliberate effort to make money. Few of us are actually incentivised to make big bills. More often I think we add unnecessary elements to fees out of a misplaced wish to 'offer gold standard' or for 'defensive medicine'[/quote]

I think it's almost always the former misconception of 'gold standard'. This is, broadly, what a lot of vets are taught at uni (those with final year rotations in the attached referral centre), CPD, internships etc. This is then translated into how they practice.

With the average age (and years experience) of the vet surgeon decreasing (and I suspect precipitously so in the last 5-10y), a lot of clinics are staffed with mainly 2-6y qualified vets with little clinical guidance or oversight. So rather than being guided by experience - let's not forget 1st opinion is mainly symptom resolution - they apply first principles and approach cases like, no offence, new grads. Lists of problems, differentials, where the symptom, the problem, gets swamped by possibilities. The latter leads to more, excessive, inappropriate, and poorly selected testing. On repeat. Hooves = zebras and what happens, fundamentally, is the art of vet med is lost - a case referred to us this week for possible "serotonin syndrome" (en vogue currently) had a palpable 5cm diameter abdo mass just behind the liver. Overall, it is the application of "referralesque" medicine to first opinion cases - as Stephen May pointed out the two are at pretty polar opposites and the majority of 1st opinion cases do not require a precise diagnosis to treat them successfully.

I am unconvinced that the fear of litigation leads to defensive medicine. It is more subtle than that. It is the pursuit of the ideal that the younger vets have been taught, and an inability or unwillingness to contemplate more than very mild levels of risk. Example - last week I chatted to a 2y qualified vet who thought steroids for colitis were just masking the problem by treating the signs; I asked so that maropitant we give out by the gallon, what exactly does that do? Stunned silence.

What this pursuit of 'gold' leads to is what we have currently - because "gold" makes more money than symptomology. So employers pump up the validity of "excellence" and "high standard" and "gold standard" as the expected level. That feeds into the collective ego. But it also blinds the collective to the squeezed owner. It leads to a weird resentment, like in the BBC article, that "pets should be insured", and a backgorund grumble from the inexperienced vets about people not being able to afford what they (wothout experience) think as "minimum" care (bloods before unblocking a bladder).

This is not necessarily to blame the vets, but as per Michael Woodhouse above many have made the choice and they cannot in good conscience hide behind "pets should be insured". Ironically, insured pets sometimes get far more inappropriate care than non-insured.

If the levels of pet ownership are to be maintained, then there will be a gradual or sudden reset. I anticipate that the CMA will go full throttle and there will be some enforcement of practice sell-off - they have already done this last year. The question is whether another large group fills that gap (I hilariously saw an advert this week for an "independent practice group" with over 100 clinics) or start-ups do.

What is clear is that the RCVS and BVA should hang their collective heads in shame that it has taken the CMA to shine a light on this, and the BVA in particular have seemed to baulk at the findings and the investigation itself, instead croaking about "conversations about the cost of pet care" - no. Pet care does not need to be as expensive as it currently is, or in some areas, made to be. How bloody embarrassing for both institutions.

RE: CMA investigation: Is £45 too much for a booster?

Alasdair Hotston Moore — Fri, 22 Mar 2024 14:49:38 GMT

[quote userid="3169" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244113#244113"]I don't blame vets for expoliting the wealthy[/quote]

I'm sorry, but that phrase is blaming vets for exploiting teh wealthy by the words you use!

I think many of us do end up generating larger bills than are necessary in some cases. It's not exploiting owners however, because to me your description sounds like a deliberate effort to make money. Few of us are actually incentivised to make big bills. More often I think we add unnecessary elements to fees out of a misplaced wish to 'offer gold standard' or for 'defensive medicine'

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Fri, 22 Mar 2024 09:43:52 GMT

[quote userid="3169" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244113#244113"]Because enough people are clearly willing to pay that. [/quote]

But there's 'willing' .... and there's 'willing'.

I would imagine that in almost every case where people spend frankly silly amounts of money on treatment for a dog, there are lots of emotional levers being pulled that just aren't in play when you buy a new tv, or a piece of furniture, or whatever.

For example:

People for whom the dog is their 'friend', 'one of the family' there's the emotional pull to treat them as such.
The dog is their child's companion
The vet said the best course of action is x, and anything less than that is something to feel guilty about
The dog making dog eyes at you as you make the decision
People who really believe that no expense should be spared in extending the life of their animal

Nobody is ever going to blame anyone else for a situation where they overspent on, I dunno, a plasma TV. By contrast, people who feel they have been pressured into parting with huge amounts of cash on the treatment of a dog will often blame everyone else, and I would imagine you lot are first in the firing line.

Also, when we think of problems with job satisfaction in the profession, there is a simple equation:

Save dog, reasonable bill, less than expected = eternal gratitude to vet who is now saviour of the world = great job satisfaction for vet.

Save dog, eye watering bill, more than expected = resentment, blame, running around grumbling about vet to friends and on social media = soul-destroying for vet.

Again, the biggest factor affecting money spent by client is not your consultation fee, but the cost of implementing your advice. Make your advice cheaper, and you'll have a more rewarding life.

That's my theory anyway, and I'm sticking to it for now!

RE: CMA investigation: Is £45 too much for a booster?

Michael Woodhouse — Thu, 21 Mar 2024 23:50:35 GMT

[quote userid="24356" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244099#244099"]Can’t remember the outcome but it certainly wasn’t as good as my dog who was walking soundly 2weeks after his TPLO, and as a client I know which service I would want. [/quote]

I won't labour the point but not my experience with lateral sutures. If my dog ruptured her cruciate I wouldn't even consider referral.

[quote userid="8991" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244090#244090"]eferral centre said definitely needs surgery (cat walking, urinating, happy). It's obscene. There's no evidence surgery makes any difference. But a specialist OPINION (probably grad, then intern then specialist) based on never managing these conservatively triumphs. How awful. How arrogant. How illogical. In the arena of a lack of published evidence experience is ignored, and the one eyed vet is king. [/quote]

Yes absolutely. Take cruciate disease and the actual, published evidence of the superiority of one technique over another. Although I do refer where appropriate, the last dog I sent anywhere else was a complicated humeral condylar fracture maybe a year ago (hasn't done well, glad I didn't give it a go). I've had a search of the emails and can only see one eye case referred this year by the entire 4.5 vet team..

[quote userid="8991" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244090#244090"]Those opposing on here - vets - I don't understand. Transparency is the route to trust. I'm amazed people are resisting.[/quote]

The concept over on VV is that this is absolutely nothing to do with the actual vets, working in practice is madness. They chose not to work OOH. Chose not to push themselves. Chose not to learn new techniques from the internet and books. Chose not to buy into practice. Chose to work for the corporate machine. Virtually 100% their fault, one way or another.

[quote userid="5012" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244100#244100"]nsure why they carry such a high price tag[/quote]

Because enough people are clearly willing to pay that. All well and good the people creaming off the profitable work, but we can't and shouldn't forget about the working people. We use lots of Librela, Cytopoint and Bravecto, but I have literally forgotten the last dog I put on a food trial as I found them an expensive folly. I don't blame vets for expoliting the wealthy, but the simple fact is that everyone needs vet care and there is a huge population sitting between blue cross and referral.

I still think we sit in the old-fashioned sweet spot. Mixed practice. Bit of everything. Some pets, go out in car and do some calls. A house call affordable and not a huge burden. Do own OOH. Fix almost everything ourselves. None of us are rich and I'm sure I could probably get a paid job on more money than I earn as a director, but there is more to life than money. Most of my friends are clients and I want to be able to look them in the eye.

There is no solution I can see to any of this that the majority of the profession, who want their cake and to eat it, would agree to. A reversion to the olden days (when people were poorer but happier, but maybe worked a bit less hard for more hours) would work, but be unpalatable. Who in their right mind would go back to doing OOH when that responsibility was taken away (I know I wouldn't). We are all stuffed.

My worry is anything likely to be instigated as a result of this review impact my practice disproportionately. I really don't want to be writing prescriptions and we do need drug income to keep fees affordable.

RE: CMA investigation: Is £45 too much for a booster?

Clive Ansell — Thu, 21 Mar 2024 22:00:32 GMT

[quote userid="9239" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244108#244108"]1. Give the pet care the owners want and can afford without judgement. Don't feel frustrated that the owner refuses the treatment that you know would be better (even if only theoretically) for their pet. Give a cheaper option if there is one available and make it clear that we don't pressure them in to one decision or another. I use this phrase: "please chose what you think is best for you, I understand that money don't grow in trees and we are here to support you and not judge you". [/quote]

Many of us already do this.

Most of my work is in some of the poorest and most deprived parts of the country. I will offer and discuss what is available, and will happily tailor a treatment plan suited to a clients wants, needs and budget. Costs are often a limiting factor though.

Last appointment tonight, was a very itchy young 60Kg + XL Bully. Little money. suspect skin allergy/atopy, but cannot exclude mange either. Advised Bravecto, but declined on costs, offered Advocate as cheaper, declined on costs, went away with a pot full of preds - suck it and see. Apoquel or Cytopoint out of the question. skin work up out of the question. Referral, more chance of flying unaided to the moon.

Many of us daily just do what we can with what we've got.

RE: CMA investigation: Is £45 too much for a booster?

Clive Ansell — Thu, 21 Mar 2024 21:46:20 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244104#244104"]

And for me it raises the question of whether the profession has a duty of care to save clients from themselves.

[/quote]

Absolutely not.

I will discuss and offer a range of treatments or options for a given condition. I will even say what I would (or wouldn't) do if it were my dog or cat. If I think things are going too far and an animal should be PTS, I will say . I have a reputation for straight talking, say it as it is, even brash and uncaring sometimes

RE: CMA investigation: Is £45 too much for a booster?

Elizabeth — Thu, 21 Mar 2024 20:39:37 GMT

I think what is so frustrating about this is that we have been told to do CPD, which we have done, and told the right way to do stuff. We have been told that we may be negligent in missing out certain steps, so we have changed our practices and improved our abilities. We have got satisfaction from our better medical practices. Yet now it seems that everyone preferred us before we improved and we get criticised for our improvements.

RE: CMA investigation: Is £45 too much for a booster?

Dinu Catilina — Thu, 21 Mar 2024 13:36:04 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244104#244104"]And for me it raises the question of whether the profession has a duty of care to save clients from themselves.[/quote]

No, it does not.

[quote userid="24356" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244105#244105"]Do we go open up budget surgeries with short consult times, minimal testing and few qualified nurses?[/quote]

I don't think this is the solution. We also have to be careful not to turn the conversation in to referral centres bashing, if people want and can spend thousands then why not? Some people buy bags or cars or jewellery and this is totally their right to do so.

In my opinion, which can be very wrong, we are missing two things:

1. Give the pet care the owners want and can afford without judgement. Don't feel frustrated that the owner refuses the treatment that you know would be better (even if only theoretically) for their pet. Give a cheaper option if there is one available and make it clear that we don't pressure them in to one decision or another. I use this phrase: "please chose what you think is best for you, I understand that money don't grow in trees and we are here to support you and not judge you".

2. Get more general practitioners to do more things. Referral is great but there are some things that with just a little bit more of training and guts can be fixed in general practice like some of the long bone fractures, cruciates, some oncology cases, etc. Even if you get a mobile surgeon in it still is more expensive than doing it yourself, it adds 1000-1500 to the bill straight away.

Getting read of the cascade will change nothing for the owner. Yes drugs will be cheaper but practices will have to put their fees up to compensate otherwise they'll lose money.

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Thu, 21 Mar 2024 11:20:12 GMT

[quote userid="24356" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244105#244105"]I agrée with what you just said Arlo, but I really don’t know what the answer is.[/quote]

Elizabeth Well, I am certainly not claiming to have the answer either. Just trying to get people talking and thinking about it all.

That said, a few thoughts:

I don't think the issue is consults or consult fees, except to the extent that they might even be too cheap.
The cases that are most damaging the profession are those where the problem is the degree of treatment. Like Clive's case above. They may not be the most common problem, but they make for particularly resentful (and noisy) clients and worse still, dreadful media coverage. These need to be addressed somehow. Not sure how. Perhaps have a profession-wide agreement on the maximum that should be spent on fixing an animal, which might be perhaps calculated on the likely lifespan of the animal and the owner's ability to pay. Could that work? How else could one discourage clients from spending silly amounts of money which put them in penury. A starting point would be a profession-wide agreement to discourage it!
[quote userid="24356" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244105#244105"]
Do we use more steroids and less cytopoint/apoquel, risk not giving fluids for raisin ingestion etc? Less monitoring in surgery?

[/quote]This is way above my pay grade, and I don't know enough to be able to comment on your specific examples, but yes, bottom line is that I think the value of all these things have to be looked at and questioned by the profession, on behalf of the public (which cannot itself know the value of, for example, more monitoring during surgery).

Seems to me that the biggest influence on veterinary bills is NOT your time, which if anything deserves to be better rewarded, but the degree and complexity of treatment.

So I can't help feeling that whilst it might go against the grain, the solution is to provide simpler, less expensive treatment, but charge the same (or more) for your time.

RE: CMA investigation: Is £45 too much for a booster?

Elizabeth — Thu, 21 Mar 2024 10:58:18 GMT

I agrée with what you just said Arlo, but I really don’t know what the answer is. Do we go open up budget surgeries with short consult times, minimal testing and few qualified nurses? Do we use more steroids and less cytopoint/apoquel, risk not giving fluids for raisin ingestion etc? Less monitoring in surgery?

Maybe we should, but would we be able to staff it? Would the RVNs be happy working their role being reduced, would the vets be happy to work with 5 minute appontements to keep the money coming in, and without the satisfaction of working up properly?

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Thu, 21 Mar 2024 10:19:33 GMT

[quote userid="5012" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244102#244102"]

Many can't, and get in to ludicrous amounts of debt to be able too.

I've got an ongoing case at the moment, inoperable cancer in lung, liver, and spine in a 10 year old dog. £14000 and still counting so far, and it is not going to end well whenever that is. Insurance burned out at £4000, and the other £10000 or so has been put on to credit cards. There is a massive disconnect between reality and expectations.

[/quote]

Crazy. It really is. And for me it raises the question of whether the profession has a duty of care to save clients from themselves.

[quote userid="5012" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244102#244102"]I struggle with it from a moral perspective, when as a nation we often cannot provide adequate healthcare for people, as well as being unable to provide adequate veterinary care in many cases for pets, certainly OOH. [/quote]

Me too.

RE: CMA investigation: Is £45 too much for a booster?

Clive Ansell — Thu, 21 Mar 2024 09:51:27 GMT

[quote userid="2100" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244101#244101"]When I walk round a state of the art veterinary referral centre, I find myself by turns amazed at what the profession can offer, but on the other hand wondering who on earth can afford it, and, if I am honest, whether we (society) are losing sight of the fact that it is, after all, just a dog.[/quote]

I agree. I recently attended a CPD evening and tour of a local new referral facility, akin to a 22nd century space age hospital Amazing.

I struggle with it from a moral perspective, when as a nation we often cannot provide adequate healthcare for people, as well as being unable to provide adequate veterinary care in many cases for pets, certainly OOH.

[quote userid="2100" url="~/f/non-clinical-questions/30762/cma-investigation-is-45-too-much-for-a-booster/244101#244101"]The question is whether they can afford it, and the evidence suggests that they cannot. [/quote]

Many can't, and get in to ludicrous amounts of debt to be able too.

Back in the day the dog with have been PTS, or given preds (corticosteroids) and painkillers, then PTS when quailty of life declined. Bring back Mr Todd all is forgiven (Anthony, not the barber)

RE: CMA investigation: Is £45 too much for a booster?

Arlo Guthrie — Thu, 21 Mar 2024 09:27:29 GMT

Hi Elizabeth I think there are two important points here.

The first is that of course you would want that service and of course clients want it. That's not my point. The question is whether they can afford it, and the evidence suggests that they cannot.

The second is that I am not arguing there should have been no progress; that things should be the same as they were 20 years ago. Of course not.

It's all a question of degree.

When I walk round a state of the art veterinary referral centre, I find myself by turns amazed at what the profession can offer, but on the other hand wondering who on earth can afford it, and, if I am honest, whether we (society) are losing sight of the fact that it is, after all, just a dog.

(and I had better clarify that I do think dogs play a hugely important role in society - it just seems to me that the amount of resource and money being spent extending their lives for quite a limited time has got a bit out of proportion).