In the first of a series of feature articles in Veterinary Record discussing the state of different sectors of the veterinary profession in the UK and what the future might hold, Jonathan Statham and Martin Green give their perspective on developments affecting the provision of cattle veterinary services.
- British Veterinary Association
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THERE has been much debate about how the cattle veterinary profession must reconsider current business models and prepare for new and increasing challenges in practice. Global economic uncertainty is currently combined with dramatic price falls in much of the UK dairy and wider cattle industry. The UK is confronting high costs of production within a fierce global food production market, with the added problem of poorly informed consumer groups. There is also increasing concern regarding the environmental impact of the livestock sector. So, how should cattle veterinary practice change to meet these demands?
Traditional UK farm animal practice remains dependent on the sale of medicines (often at a significant margin) together with government-derived income streams (Table 1). Leading vets have promoted prevention over cure since the late 19th century, and a more preventive approach to practice has been advocated repeatedly since 1938 by government-commissioned inquiries into the veterinary profession (Woods 2007). Why has change, therefore, not occurred previously and what, if anything, may be different now?
The catastrophic outbreak of foot-and-mouth disease in 2001 prompted a strategic government review. From 2006 to 2008, Defra pump-primed an approach to preventive herd health. Farm health planning involved practising vets working with their farming clients to measure, manage and monitor livestock health. It formed a central part of delivering the Animal Health and Welfare Strategy and was driven by fears for the future of farm animal veterinary practice at a time of poor livestock health, declining farming profits, and heightened public health fears about agricultural antibiotic use. It also offered an opportunity to devolve the financial burden of stewarding food production from government to the industry (Statham 2008).
Spiralling costs of government-funded disease control initiatives, such as those for TB, brucellosis and meat inspection, had seen tendering and Treasury-based pressures for cost cuts bear down on vets in practice. This followed the findings of the Competition Commission that complex monopolies existed in the provision of veterinary medicines into the farming sector, resulting in the implementation of a three-year period of enforced free prescriptions together with a drive for greater transparency and competition, along with a burgeoning internet market opportunity. Concerns expressed by bodies such as the BVA about the future viability of farm animal practice prompted a review of veterinary expertise in food animal production by Professor Philip Lowe, which was published in 2009 (Lowe 2009).
Central to the Lowe report were messages promoting the assertion that the large animal veterinary profession should deliver the needs of the farming sector as its primary customer, recognising its position in the chain of food production. The vet-farmer partnership was confirmed as central to the future development of our livestock industry, food safety, public health, and the Government's Animal Health and Welfare Strategy. A number of specific areas were addressed, including future supply of farm vets, the differing roles required of livestock veterinary surgeons in practice, and potential business models for the future.
Supply of veterinary surgeons in the farming and food sectors
With a larger output of graduate cattle vets and threats to workload, concerns have been expressed regarding future job security. Despite this, many veterinary practices continue to report problems, perhaps more significantly, with retention of farm veterinary surgeons. There appears to be continued enthusiasm for the large animal sector at undergraduate level, but many recent graduates do not remain engaged within the sector and, after an initial period of general practice, gravitate towards companion animal practice. Avoiding the ‘spiral of disillusionment’, as described by Lowe (2009) (Fig 1), is the key: where is the defined career structure and job satisfaction that a generation of highly talented goal-driven professionals has been expecting?
Improved retention through provision of genuine opportunities in the farming and food sector, together with a defined career path, should be a priority for the profession. Recent initiatives such as the BVA's ‘Young Vet Network’ and structured CPD have begun to address this need. The British Cattle Veterinary Association (BCVA) surveyed its members to establish the different needs for future training and education and it now signposts training and education for cattle vets from university, through postgraduate development to further qualification and specialisation throughout their careers, dubbed ‘lifelong learning’ (Fig 2). This is now being delivered and aligns with the RCVS's Professional Development Phase, advanced practitioner (Fig 3) and specialist levels.
Roles required of livestock veterinary surgeons
Livestock vets in practice have many roles to execute in terms of food production and security, public health and animal health and welfare. These need to be fulfilled within a profitable and sustainable business, and conflict can exist between these differing roles.
Providing 24-hour cover in a genuinely inclusive fashion presents challenges well beyond the EU Working Time Directive and may potentially constrain the delivery of more proactive advisory services. Demanding night rotas may present both a financial burden to veterinary practices and contribute to the loss of highly talented young vets from the sector. There is a significant cost to providing these services, especially in remote areas, and this issue needs to be resolved.
The role of veterinary surgeons as independent arbiters of animal health and welfare has come under fire, such as in the book ‘Farmageddon: The True Cost of Cheap Meat’, by Philip Lymbery, of Compassion in World Farming. However, there is much evidence for a more positive role for the veterinary profession in sustainable food production, including the aspiration to move livestock from a ‘life worth living’ to a ‘good life’, as promoted by the Farm Animal Welfare Committee.
In relation to welfare, the issue of farm size or scale has received much attention and remains an easy target, even though evidence for a relationship between welfare and size of enterprise is lacking. Indeed, larger scale farming businesses can offer an opportunity for the production of food with excellent welfare and a smaller impact on the environment per unit of food produced; we should therefore evaluate how effective systems are and what they deliver, rather than focus on size. Resilience in our capacity to produce food globally is likely to be critical in a future with a growing world population (Beddington 2011, Green and others 2011, Statham and others 2012b). Unfortunately, the relationships between size of enterprise, degree of intensification, production level, welfare and environmental impact are complex and not fully understood; a great deal more work is needed to help us make informed, scientific decisions.
Business models for the future
Following the recommendations of the Lowe report, a Veterinary Development Council sought to identify and classify different business models for veterinary practices and the provision of veterinary services.
The place for paraprofessional input as part of the veterinary practice team was also discussed and indeed this role increasingly exists. A wide range of potential activities could be undertaken by appropriately trained people and charged accordingly. A veterinary-led team could include technicians, ‘generalists’ and specialist veterinarians. It is important to have close integration with the veterinary practice structure to prevent fragmentation or duplication of services and to deliver the maximum cost-benefit. There is also a need to provide these services inside a regulatory framework to ensure efficient, safe, consistent and, above all, welfare-friendly delivery. A Defra-led review of the exemption orders under the Veterinary Surgeons Act is underway, with a broad-based industry steering group. The potential oversupply of veterinary surgeons in the jobs market may challenge the differential role for paraprofessionals in the team.
Medicines supply and veterinary dispensing
Perhaps the greatest challenge currently facing the traditional business model of cattle practice is that centred around the supply of medicines to the livestock industry. The ‘One Health’ agenda has driven consumer concerns regarding antimicrobial resistance (AMR), with impetus from some human health professionals. EU perspectives demand increasing notice and Scandinavian lobbying is challenging the accepted norms of medicines usage and prescribing in the UK. The European Medicines Agency and the Committee for Veterinary Medicinal Products wield growing influence on how this debate will evolve. The EU is considering sheltering some key antibiotics from veterinary use to protect their efficacy in human medicine.
The use of antibiotics in agriculture is often cited as a major source of antibiotic resistance in pathogenic bacteria of people. García-Álvarez and others (2011) identified a new strain of meticillin-resistant Staphylococcus aureus (MRSA), which occurs both in human and dairy cow populations. Yet, Reid (2012) indicates that the link between on-farm use and the primary development of resistance in human pathogens is unlikely. The reality is that this issue is now at least partially driven by politics. Global travel and transfer of AMR is highly significant for human medicine; a Swedish study found that 36 per cent (50/138) of people who travelled outside Europe and presented with diarrhoea on their return to Sweden had extended-spectrum beta-lactamase-producing Escherichia coli in their stools, compared with 3 per cent (2/63) of those who had travelled within Europe (van der Bij and Pitout 2012).
However, the precautionary principle applies and we need to use antibiotics responsibly. Much remains unclear, but the correct balance needs to be struck between controlling the risk of AMR and providing the necessary medicines to enable high levels of animal health and welfare to be maintained.
In recent years our evidence base in livestock disease areas has advanced, for example in mastitis control (Bradley and others 2007, Green and others 2007). Expert systems have evolved to support improved herd performance. At the same time, there is increasing recognition of the social science barriers that exist to implementing change, and strategies for successfully overcoming them are now available (Garforth and others 2004, Ellis-Iversen 2010, Jansen and others 2010). A surge in energetic knowledge exchange programmes from industry through levy bodies such as DairyCo regarding mastitis and lameness control and the EBLEX's Better Returns programme, alongside XLVets' FarmSkills training and national programmes for bovine viral diarrhoea (BVD) control in Scotland and Ireland, have provided new structures for improved support. England in particular needs to develop a genuine consensus platform for further livestock industry initiatives, although an English BVD initiative is emerging.
So, what might the future hold? Although long-established mixed practices continue to deliver a high level of customer service and clinical standards, the trend towards more and more larger practices seems likely. This might drive further specialisation before graduation, as the need for omnicompetence is eroded. Similarly, internal practice specialisation may increase as the technical breadth of cattle veterinary work becomes too wide and greater individual focus is required; practices already promote individual expertise in mastitis, reproduction and nutrition, etc. The challenge may be to adequately assure the quality of such approaches and the extent to which the RCVS's advanced practitioner and specialist tiers adequately define this expertise. Internal specialisation may support the growth of more practice-based research, with close-to-market based studies offering new insights into applied production animal science.
From a business perspective, the traditional mix of medicines sales, reactive ambulatory work, pre-booked fertility visits and government-sponsored disease control programmes is already changing. State veterinary work may decline for some vets, but a closer link to legislative public good functions may also evolve as state veterinary resources continue to decline. Despite the likely ongoing impact of internet pharmacies, lower medicines margins may still offer significant income and opportunities for knowledge exchange, and support for responsible use of veterinary medicines is likely to grow. The veterinary-led team is likely to develop, but the challenge of maintaining a functioning veterinary practice umbrella for paraprofessionals to achieve balanced welfare and skill delivery is less certain. Corporate farm animal practice is emerging, but how much of the sector will become corporate or remain independent is uncertain. Parallels exist in other industries where initial growth is often followed by a plateau as venture capital leaves the sector.
The cultural barriers preventing the veterinary profession from effectively marketing its services are becoming increasingly historic. Collaborative groups have emerged from the profession in recent years, such as XLVets, which represents the interests of more than 50 livestock-focused veterinary practices from the north of Scotland to Cornwall.
Who will be the customer of the future for cattle practice? It seems likely that larger farmer groups may continue to emerge with their own veterinary provision and resources. However, lessons from other sectors suggest again that the role of the genuinely independent cattle vet will retain added value, if quality standards remain high. Fully vertically integrated organisations are likely to achieve some market share, with veterinary provision included in the process from genetics through purchased feed inputs to product marketing. Will retailers evolve their relationship further?
Cattle Health UK
There is a pivotal role for independent practitioners in the delivery of government veterinary services, including surveillance and bovine TB control. A holistic model for endemic disease control similar to successful models in Ireland and Australia has significant support and Cattle Health UK, a model proposed and lobbied for by BCVA (Statham 2013), offers a positive opportunity for improving UK cattle health, with cattle vets centrally at the hub. The recent change in the delivery model for state veterinary services could highlight the opportunity for public and private partnership represented by this concept. However, the risk remains that this change is motivated by government budget constraints rather than strategic outcome.
Undoubtedly, substantial challenges remain for successful delivery of proactive herd health and production management (HHPM) programmes, but certain significant changes have emerged. First, the concepts and tools of HHPM have evolved (Green and others 2012). Secondly, the farming client base served by cattle practice has also developed under market pressures. However, perhaps above all, the need for change is emerging once again. Food security for a rapidly growing world population is climbing up the policy priority ladder. Genuine expertise is required to deliver food supplies for the future in an environmentally sustainable way (Green and others 2011, Statham and others 2012a, b). Increasing livestock production to feed the growing world population, while simultaneously limiting the damaging impact on our environment and minimising the challenge to animal health and welfare, provides an enormous opportunity for the veterinary profession (Fig 4). Who is better placed than the vet to coordinate these conflicting demands at the hub of the farm enterprise team?