Panorama progamme about vets?

Re: Panorama progamme about vets?

Hannah Wynne Richards — Thu, 29 Jul 2010 12:03:12 GMT

Sorry for disappearing everybody-my computer crashed last week-end. Jane has invited me to debate some points directly with her, and since I don't think it ethical to carry out private and public conversations on the same topic, I'll drop out of this thread now

Wynne

Re: Panorama progamme about vets?

bob lehner — Sun, 25 Jul 2010 19:57:50 GMT

One of the most serious issues raised by the program, and the one which might most concern owners, was the fundamental question as to whether the so-called 'trainee-nurses' should have been performing the clinical activities that were shown. Sandy Trees stated that they should not - and this is backed up by the pretty clear guidelines on the RCVS website, under a section entitiled 'Advice on Schedule 3'. The term 'trainee nurse' is not recognised. Nurses are either 'students', who are enrolled on a recognised nursing course, or Listed/RVNs. Anyone else is no more than a lay-assistant and has no legal right to perform Schedule 3 duties.

Re: Panorama progamme about vets?

Evelyn Barbour-Hill — Sun, 25 Jul 2010 18:45:50 GMT

"The camera does not lie" is one of the greatest misconceptions ever.

Re: Panorama progamme about vets?

Niall Taylor — Sun, 25 Jul 2010 11:42:09 GMT

[quote user="Julian Earl"]Once a dog starts struggling like that while it has a major wound, I would not consider it essential to remove the catheter now. [/quote]

And they took perhaps 10 seconds to come to just that conclusion. I'm sure with hindsight they would probably have done things differently, but these situations can blow up very quickly.

Agreed though, best leave it for now - getting bogged down in minutae again!

Niall

Re: Panorama progamme about vets?

Adi Nell — Sun, 25 Jul 2010 10:36:30 GMT

Many thanks for the (mostly) measured responses. Those who've already looked at our website know that we were shocked and horrified by what was protrayed, and investigations are ongoing. We have, indeed, asked for all the footage. We've also been in touch with the RCVS to offer any and all assistance they might require and to ask for their help in selecting an eminent, independent person to sit on our panel of enquiry into what, if anything, a large organisation can do to prevent these things happening again. Ever.

We'll be updating our statements regularly, so do look at our website, but I expect that most of the damage is already done. I'm truly sorry that the whole profession might now tarred because of the actions of a very small group of our employees. Interestingly, we've had a lot of clients calling in to our branches with flowers and chocolates, saying that they have faith in the vets and nurses they see on a regular basis and know well. I hope that the same is happening at your practices.

I was very interested in what Martin Jones wrote yesterday (page 26 of this thread, 24 July, 10.29am). Martin, you seem to have a good intuition / understanding of how these things might work... That's not an excuse - these things should never happen in the first place, but it is difficult to take action when you hear only one side of any story. All allegations, against ALL members of Medivet, will be investigated again, this time with the benefit of, at least, the programme, but ideally with all the footage the BBC has, if they will release it to us.

Anyone who wants to contact me privately can do so via the "conversation" link on my profile. I'll try to come back to the site whenever I can and answer any queries or concerns to the best of my ability.

Kind regards,

Adi

Re: Panorama progamme about vets?

Julian Earl — Sun, 25 Jul 2010 09:52:47 GMT

Sorry Niall but that is not how it appeared to me. Once a dog starts struggling like that while it has a major wound, I would not consider it essential to remove the catheter now. Anyway, I'm going to leave this now - I just do not think that was the right way to handle that dog in that situation.

Re: Panorama progamme about vets?

Niall Taylor — Sun, 25 Jul 2010 08:39:28 GMT

[quote user="Julian Earl"]Can you give me an innocent reason for wrestling the amputee?[/quote]

Sure - they went to get the catheter out, obviously it's essential that this is removed. The dog was normally friendly and had been amenable to handling pre-operatively and was fine on initial approach this time and was led out of the kennels ok. Then the nurse went to pick up the paw and reach for the catheter site and the dog freaked out. The team that was with her went to help; in these circumstances many people would quite reasonably have thought that if the dog could be manually restrained just for the few seconds it takes to remove a catheter then it would be 'job-done' with no need for potentially risky sedation so soon after major surgery. After those few seconds, then perhaps a few seconds more it became obvious that it wasn't going to be possible to remove the catheter this way and that things were getting out of hand. The vet nurse in question then strikes the dog, this is unacceptible to the other nurses involved and brings the whole scenario to a halt. One of the other nurses reports the hitting to a senior vet who then takes disciplinary action against the nurse who hit the dog. He then apologises to everyone in the staff room having realised his error; other members of staff express their disgust at his action.

So something started off as a quick, few seconds long job then deteriorated before those involved realised they were going to have to take another course of action and stopped. Total time during which dog was distressed say 10 or 15 seconds. But of course that's the 10 or 15 seconds that is used on the programme and with the words "the whole thing lasted a total of half an hour" ringing in our ears from another case a minute or two before we are left to assume that this dog was brutalised for a prolonged period by uncaring nurses.

Stitch up.

Now obviously I have no idea whether my story bears any resemblance to what actually happened but it is possible and we need to give the people involved the benefit of the doubt before condemning them. I say again, the programme makers had an agenda, they were setting out to 'dig the dirt' on this practice and the profession in general by implication. The least we can do is reserve judgement until all the facts are in.

Niall

Re: Panorama progamme about vets?

Julian Earl — Sun, 25 Jul 2010 00:08:47 GMT

[quote user="Martin Jones"]

[quote user="Julian Earl"]

If you read what I actually said, you will see that I suggested we should not have the primary reaction of, "Yes it looks terrible, but there may have been a reason for it".

[/quote]

I'm still interpreting this to mean that you have decided on guilt, based on the presentation of events by Panorama. Guilty till innocent? I take issue with this, but would be both pleased and relieved to stand corrected.

[/quote]

For the events that I mentioned in my original post I can think of no justification for what was seen. Can you give me an innocent reason for wrestling the amputee? I can't think of one that is sensible or likely. Likewise, the nurse(s) attempting the catheterisation - I think we have all agreed that was improper. The insurance forms are worthy of more explanation but one could question whether the same argument (that it was three conditions) would have been used if the diabetes limit was not being reached; maybe I am too strict in the way I interpret my clients insurance claims but to me it is more than likely that it was indeed all diabetes-related and that is how I personally would have made such a claim.

Re: Panorama progamme about vets?

Niall Taylor — Sat, 24 Jul 2010 22:36:03 GMT

[quote user="Catherine Williams"]It's a judgement call and I'm not sure how firm rules can be made. I wont bend the law, I wont go against my clinical opinion, I wont change my clinical notes because they are insured or fudge the details but when something could be argued either way I'm going to support my client. Is that wrong?[/quote]

Well said Catherine - of course it's not wrong, I would do exactly the same. It's just a pity that some don't recognise the grey that lies between black and white extremes.

Niall

Re: Panorama progamme about vets?

Evelyn Barbour-Hill — Sat, 24 Jul 2010 20:42:05 GMT

[quote user="Catherine Williams"] I wont bend the law, I wont go against my clinical opinion, I wont change my clinical notes because they are insured or fudge the details but when something could be argued either way I'm going to support my client. Is that wrong?[/quote]

Of course not. Fill in the forms truthfully, and where there's a doubt give your client - your client - the benefit of the doubt.

Re: Panorama progamme about vets?

Catherine Williams — Sat, 24 Jul 2010 17:55:17 GMT

I've had similar situations, a diabetic dog, doing ok but not quite as well as I wanted. Insured with a supermarket policy that covered for 1yr only + no longer covering for the diabetes. He also showed poor hair growth, bit of a belly etc so I worked him up for suspected Cushings, turned out he wasn't cushingoid. When we claimed it was as a new condition, "possible Cushings", now I didn't see a problem with that, it might be related to the Diabetes but I would not consider it as the same condition, the majority of diabetics aren't Cushingoid and vice versa. Would the consensus be that this is inappropriate?

The problem is at what point do you say conditions are not related. My lass is hypothyroid, she also now has KCS, there is sometimes an association but I haven't claimed it as the same condition, should I have done? She has a cover for life policy so I lose another excess, I wouldn't expect either condition to reach my claimable max so there's no gain for me in separating them. Similarly as one of her presenting signs with the hypothyroidism was GI issues maybe I should claim every episode of diarrhoea as a continuation of her thyroid issues...I doubt the insurance company would weather that.

When you can't be conclusive as to whether 2 issues are related who do you give the benefit of the doubt to? I don't look at saving my client's insurance pot as more money I can access, I see it as less money the client has to find for future treatment and a better chance they will continue to treat that dog. If the dog develops diabetic catarracts and needs appropriate treatment for this there is a lot better chance that it will happen if the insurance company are still helping out. I wont automatically lump or separate conditions at an owner's request, I need to feel there is reasonable clinical grounds for it. An episode of diarrhoea 3 months previously is not going to be claimed as the same condition as a current episode if there have been no issues in between but if an animal has had several episodes of neck pain a month or 2 apart and a number of niggles in between then I am likely to consider it the same condition. It's a judgement call and I'm not sure how firm rules can be made. I wont bend the law, I wont go against my clinical opinion, I wont change my clinical notes because they are insured or fudge the details but when something could be argued either way I'm going to support my client. Is that wrong?

Re: Panorama progamme about vets?

Louise Buckley — Sat, 24 Jul 2010 16:18:07 GMT

[quote user="robloxley"]

I'm slightly lost to see how the vet gains by separating out the items into 3 claims; I can only see that the client loses in paying 3 excesses, unless reaching per-condition limits or excluded prior conditions muddies things, but again what benefit to the vet? Are they charging the client per claim form filled out?

[/quote]

Fair point but only really from a short term point of view (in both cases). Wiping out a client's coverage for a chronic condition runs the risk that the client will no-longer be able to afford the cost of treating the diabetes. Resulting, presumeably, in premature euthanasia for the cat and reduced profit on that cat for Medivet in the longer term. You could make a case for arguing that the vet made the decision on the basis of what was going to best facilitate that cat's ongoing survival! Given the grey area this is, is not the vet's role to abide by their sworn in oath to protect the welfare of animals?

Re: Panorama progamme about vets?

Rob Loxley — Sat, 24 Jul 2010 16:09:05 GMT

[quote user="alex gough"]We are being asked to certify these things as facts.[/quote]

[quote user="Louise Buckley"]

Maybe I missed something in the programme but there was no definite way of knowing all three conditions were related. The problem as I saw it was the vet described them as all related to the diabetes and then submitted them separately.

I suppose one other way to look at it (rather than medivet just wanting to make more money which seems to be the assumed implication/motive)

[/quote]

We often get pressure from clients wanting us to lump things together to reduce excesses, or split things out to get round exclusions, but our comment is always that we will fill in the form with the clinical information (be it firm diagnosis or often presenting signs) and provide the insurance company with access to the relevant clinical notes to allow them to determine the claim. We often point out that what clients are suggesting amounts to fraud.
That way it is clear that any grief over how the insurance company assess and determine the claim(s) is between the insurance company and the client.

Re: Panorama progamme about vets?

Alex Gough — Sat, 24 Jul 2010 16:07:30 GMT

I agree that that is a grey area. I dont think it is totally unreasonable to investigate liver disease in a diabetic patient, especially if there were appropriate clinical signs (and we don't know if there were in this case). And yes, if it turns out that it was likely a diabetic hepatopathy, should it (to change the scenario slightly) be excluded if the diabetes was a pre-existing condition. Of course the vet was naive and/or fraudulent because of the way the intent was expressed on camera.

Pre-authorisations can help of course, but I just had a case of GME that waited to come to me until a pre-auth was done. By the time I saw the case, the GME had rotted two large holes in its cerebellum and the dog had to be euthanased - time doesn't always allow pre-authorisation.

Isn't crazy that there aren't clearer rules on this? Maybe something good will come out of the Panorama programme if it means that clearer guidelines on things like insurance, or whether a trainee performing venipuncture should be under direct and continuous supervision of a RVN/vet, or just have someone in the building (something more definite than "I should say so.")

And regarding an earlier post - yes, the vet who gave the cat antibiotics without any further testing that would suggest an infection is potentially guilty of overtreating that animal, as the antibiotics were unlikely to be necessary, and will add to the burden of resistant microbes in the population, when the veterinary profession is already under pressure regarding its use of unnecessary antibiotics. Panorama obviously was holding him/her up as how we should be behaving. I look forward to a future Panorama programme which talks about MRSA and how the vet profession contributes to it, and watch it contradict itself entirely.

Alex

Re: Panorama progamme about vets?

Robin Grimmer — Sat, 24 Jul 2010 16:06:32 GMT

I've just got one point on restraint of animals in the Panorama programme - take Yogi being restrained for the iv catheter. It was clear that Yogi didn't like being restrained. Whether this was because of his upper airway obstruction or possibly just his nature. I don't think the catheter actually went anwyhere near his skin (as said in the film) because he was struggling so much, so I don't think EMLA cream would have made any difference in this case.

Also , re the sharpei. No, he wasn't handled very sympathetically, and it's obviously very emotive because he had just an amputation. But the fact remains, how would you have taken out the catheter? He clearly (like many sharpeis) did not like being restrained, so it would have been a struggle for anyone. And you are not going to want to sedate him again just after he is recovering from a general anaesthetic.

Re: Panorama progamme about vets?

Louise Buckley — Sat, 24 Jul 2010 15:35:58 GMT

[quote user="alex gough"]

I think there is an issue here with conditions being related to previous claims or pre-existing conditions. In many cases there is just no way of knowing, and all you can do is give an opinion. Is a head trauma on a dog aged 1 related to an epilepsy it gets aged 3. Who knows? Is the fact that a cat develops a squamous cell carcinoma related to its FIV status? Who knows? Should the dog with bacterial endocarditis be excluded because it might be related to its dental disease? We are being asked to certify these things as facts.

Alex

[/quote]

I suppose one other way to look at it (rather than medivet just wanting to make more money which seems to be the assumed implication/motive) is that if there is a grey area should this greyness seek to benefit the insurance company (by reducing its payout) or the animal/pet owner (by increasing the coverage allowed by the policy)?

If it is not known, or it is open to reasonable doubt, that the diabetes caused the other complaints who should benefit from this doubt? To add in a further complication, but one that is pertinant to vets practising everywhere, if we accept that there is reasonable doubt that A caused B, C, & D is it necessary that the doubt should remain at the end of the investigations or is it necessary only that the doubt should be present at the start of investigations?

Re: Panorama progamme about vets?

Alex Gough — Sat, 24 Jul 2010 15:25:46 GMT

I think there is an issue here with conditions being related to previous claims or pre-existing conditions. In many cases there is just no way of knowing, and all you can do is give an opinion. Is a head trauma on a dog aged 1 related to an epilepsy it gets aged 3. Who knows? Is the fact that a cat develops a squamous cell carcinoma related to its FIV status? Who knows? Should the dog with bacterial endocarditis be excluded because it might be related to its dental disease? We are being asked to certify these things as facts.

Alex

Re: Panorama progamme about vets?

Louise Buckley — Sat, 24 Jul 2010 15:19:39 GMT

[quote user="james hunt"]

Ok, i'm about to betray my complete failure to understand pathology and it's relationship to pet insurance now, but I would have thought that the three claims submitted WERE for three different conditions.

My reasoning being that although DM patients may have an increased risk of UTI, not all DM patients develop a UTI, and not all patients with UTI's have DM...therefore although the patient may have been more likely to develop UTI due to its DM this was not inevitable, and there is no possible way to determine whether the UTI would have occurred had the animal not been diabetic.

Similar reasoning for liver - just because the final result of the investigation suggested elevation of liver parameters was due to DM, how was the attending supposed to be able to exclude other causes of liver disease without performing an investigation?

Am i being even more dense than usual?

[/quote]

Not at all. To be honest that is how I interpreted it and how I have seen claims put in on many occasions through 12 years in practice. I think it was more the intention behind the 3 claims. However, that strikes me as odd and I cannot help but feel that the vet was set up in some way (although I am not sure how). I am not convinced a trainee only a few months into the job would know enough to even query the submitting of the three claim forms for three different conditions.

Re: Panorama progamme about vets?

james hunt — Sat, 24 Jul 2010 14:41:45 GMT

Am i being even more dense than usual?

Re: Panorama progamme about vets?

Martin Jones — Sat, 24 Jul 2010 12:04:02 GMT

Silly me, should have got out while the going was good.......

Julian,

[quote user="Julian Earl"]

If you read what I actually said, you will see that I suggested we should not have the primary reaction of, "Yes it looks terrible, but there may have been a reason for it".

[/quote]

[quote user="Julian Earl"]

It is not pompous to declare that wrestling an amputee would not happen on my watch. Neither is it falling into an obvious trap to say so.

[/quote]

We clearly disagree on these two points. Perhaps best left there as an agreement to disagree, other than to say that I wouldn't condone such behaviour either and to remember that your watch is not restricted to those moments when you're actually in the room, but also includes the time you spend out of the practice sleeping, eating, watching TV and so on.

[quote user="Julian Earl"]

All the best; have a good weekend.

[/quote]

Ah, common ground. And to you.

Wynne,

You're now alleging that criminal behaviour may have taken place and are asking questions, rather than stating it as a bald fact, and refraining from making inappropriate comments on a case that we all know about. This is a little watered-down from your previous approach (Julian, this is the kind of thing I was referring to).

I am so switching the computer off for the weekend. Quite happy to take up the discussion again on Monday, but till then I'm off.

Martin

Re: Panorama progamme about vets?

Hannah Wynne Richards — Sat, 24 Jul 2010 11:40:55 GMT

Petra Thanks

Martin The reason I'm alleging criminal behaviour, is that 2 "trainee nurses " who did not appear to be even enrolled as VN trainees with RCVS were attempting venupuncture

Jane

1) were Alex Lee and the other "trainee " enrolled with RCVS ?

2) were you aware that they were attempting venupuncture, if so, was this with your consent, ?

and 3) if not enrolled, was this common practicewithin the group ?

Wynne

Re: Panorama progamme about vets?

Julian Earl — Sat, 24 Jul 2010 11:26:31 GMT

[quote user="Martin Jones"]

Defending the indefensible. This weaselly little phrase is likely to join the pantheon of the greats, alongside 'not fit for purpose' or 'I'm not a racist, but'. We all agree that thumping animals and fiddling insurance are abhorrent behaviours. We should perhaps be more circumspect in calling for blood in specific examples shown on a now-shabby TV periodical, and rather more trusting that professional colleagues will deal with it. I understand, for example, that the company is trying to source all the footage taken in order to consider the entire case, both for and against its employees. Anybody pompously proclaiming that it wouldn't happen on their watch lives in a rather rarefied atmosphere, which may have damaged their outgoing filter somewhat. I trust all the people that I work with, but am aware that they're all human, that patients can be a little testing at times and that workload can sometimes become unbearable. Therefore, I'd never defend striking a patient, but I'm bl**dy glad I wasn't on panorama when it happened - in other words, 'there but for the grace....'. Nobody is defending the indefensible and we all abhor the behaviour; most are simply not falling into the obvious trap set by the programme.

[/quote]

It is not pompous to declare that wrestling an amputee would not happen on my watch. Neither is it falling into an obvious trap to say so.

[quote user="Martin Jones"]

We all have a few issues to take away as a result of the programme.

Shouting from the rooftops that we should string 'em up and that anybody who doesn't agree is just 'defending the indefensible' is, I'm afraid, hugely insulting.

I have a weekend off. I think I may go and enjoy it. It's been a stimulating discussion, probably the best that I've experienced on here (well done, Arlo), but next week is another country right now. Thanks to all

Martin

[/quote]

Has anybody "shouted from the rooftops" about stringing them up? Most criticisms have been stating that these events should not have happened because there are better ways of doing things. No-one has suggested stringing up or striking off or anything else as far as I can recall which then rather negates your "anybody who doesn't agree is just 'defending the indefensible' is, I'm afraid, hugely insulting" comment. There is no suggestion of that argument in anything that I or anyone else has posted.

If you read what I actually said, you will see that I suggested we should not have the primary reaction of, "Yes it looks terrible, but there may have been a reason for it". The specific events that I mentioned are ones for which there are no mitigating circumstances and we should be, and generally have been, critical. If you feel insulted by my suggestion that we should, as a profession, be self-critical then apologies for offending your sensibilities.

As to what should happen - I would not presume to judge; that is best left to others.

All the best; have a good weekend.

Re: Panorama progamme about vets?

Martin Jones — Sat, 24 Jul 2010 10:29:32 GMT

[quote user="Julian Earl"]

Sorry but your reply does not compute. Is there a possible realistic explanation for the insurance issue that is acceptable? It may well have been an individual who took the action regarding the claim(s) but it was Medivet who tried to explain it away as an error an not an attempt to fiddle the system.

[/quote]

Julian, thank you for replying. I think, though, that you're still riding roughshod over the point I'm making. From the programme, there appears to be a strong case for insurance fraud. I trust - and this word is apposite - that the matter will be properly investigated and appropriate action taken. Trial by peers is rather more robust and objective than trial by television. The programme makers wanted to make medivet look bad - and in this, were handed several opportunities by medivet employees - and one way of doing that is to make them look dishonest in dealing with concerns. So somebody might have sent a letter to head office to ask about a supposed case of insurance fraud. Head office would then have questioned an employee, who may have denied the fraud. Panorama, tellingly, wouldn't have allowed anybody to actually see the evidence. Faced with this, human resources would sniff a big conflict arising out of any perceived martyring of an employee and the company may have been forced to side with its employees, perhaps in the mistaken belief that it was telling the truth. End result? In a biased report, Medivet as a corporation are made to look like they condone and cover up insurance fraud.

This is the result for which the programme makers were hoping in the wider audience. We, as people who understand how it works, should be looking a little deeper. If it's shown that a fraud has taken place, and that the company was instrumental in creating a climate of fraud and then attempting to cover it up, then I'll hold Niall's coat whilst he takes his (hopefully) metaphorical stick to them all.

There is no knee-jerk indignity to the programme. I would suspect that the vast majority of us are relieved that we weren't in it, that superficially at least, non-medivet vets came out of it ok, and are aware that the issues presented will filter out to challenge the entire profession, but will likely do so more slowly, giving us time to think about where we are and where we're likely to be. I've been scanning quite a few pet-owner forums, and it's quite clear that not all is well; interestingly, quite a few (human) medics and nurses are calling for owner access to theatre when their pet is being operated upon. If someone starts quoting Orem at us, then we may well be in a difficult position on this one. An owner in the room when the ovarian stump starts to bleed? It frightens the life out of me, but it's clear that now-reduced trust and changing owner expectations could point us that way. We all have a few issues to take away as a result of the programme.

Shouting from the rooftops that we should string 'em up and that anybody who doesn't agree is just 'defending the indefensible' is, I'm afraid, hugely insulting.

Martin

Re: Panorama progamme about vets?

Laurence Webb — Sat, 24 Jul 2010 09:57:39 GMT

When I was a student at Langford in the mid 90s the cat/dog neutering was done on 3 operating tables in the same room. Animals were anaesthetised, clipped, prepped and operated on all in the same place. Not ideal and not how I'd choose to do it, but if that was the example set by a teaching facility 15 years ago I don't see that it is so shocking to see it happening today.

Obviously if the practice routinely has someone performing dentals or treating abscesses at the same time as or before a sterile surgery is done then that's bad practice.

One minor part of the program that amused me was when a nurse was discussing Medivet's approach of diagnosis before treatment was the subtitler's interpretation what she said. Must book myself in for 'joint psychology' course soon.

Re: Panorama progamme about vets?

Mark Holmes — Sat, 24 Jul 2010 09:26:31 GMT

Wynne, "Why were two animals operated on in the same room together?"

Simply Wynne, as in lots of general practice, to make efficient use of the resources available and hence keep costs and therefore fees reduced. We have to appreciate as a profession that beyond a certain level, every increased percentage in success rates or decreased risk of post operative infection comes as a greater and greater cost. These costs need to reflected in fees and we need to remember about the animals at the bottom of the chain who don't get treatment due to the costs involved. I would vouch that beyond a level, for every animal which is saved a post operative infection or peri anaesthetic complication including death there are a number of animals who die or have less effective treatment as a consequence of the additional costs involved.

As illustration I can give the following 2 examples, I have worked in many diiffernt practices as a locum. Some were "advanced" followed every detail, persued every line of improvement, had isolated operating facilities, full scrub facilities etc etc. They would charge 1200-1500 for a fracture repair. The other was more practical, had fewer facilities and charged £500-£600 for a similar proceedure. There were fewer three legged dogs at the second practice. (and I would imagine fewer dogs in bags as amputations were not cheap in the first practice either)

The second example occured at the second practice, cat spays were offered at £25 a pop. In order to do it at that rate I used to walk i to a conveyorbelt of cat spays most mornings and at the busiest point I speyed a dozen cats in just over an hour. We had very few post op infections or perianaesthetic problems (i've seen greater numbers elsewhere), working in inner city Birmingham these cats would not have been neutered at a greater price.

I am not advocating cat conveyer belts or being flippant about standards but we need to remember that resources are valuable and we may well do more good for a population by living with a small amount of risk to the individual. Or at least clients need to have that choice if money is tight.

Regards