Background Veterinary animal welfare advocacy can be undertaken at individual, community, national and international levels. The People’s Dispensary for Sick Animals (PDSA), a veterinary charity with 48 Pet Hospitals UK-wide, created a consultative staff network to put an explicit organisational focus on animal welfare–focused veterinary practice.
Methods PDSA created a national internal committee—a Pet Wellbeing Task Force—composed of veterinary staff representatives. Together with recruited hospital-based Champions who serve as a focus for animal welfare and ethics within their clinical teams, the resulting staff network has described a vision of animal welfare and ethics within companion animal veterinary practice, with accompanying practice-level actions. These actions have formed the basis for national clinical audit, repeated three times since 2013.
Results The audit, alongside targeted interventions, has driven organisational change (eg, new policies), led to measurable improvements in pet wellbeing (eg, improved pain assessment and management) and stimulated collaborative practice-based research with universities.
Conclusion A dedicated staff network has facilitated organisation-wide communication on animal welfare and ethics; offered a safe space to raise and discuss animal welfare and ethical issues; and fostered leadership, by working towards model veterinary practice with respect to animal welfare and ethics, with benefits for pet patients, staff and the wider veterinary and veterinary nursing professions.
- clinical practice
- companion animals
- preventive medicine
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Enhancing, protecting and securing the health and welfare of animals is the fundamental purpose of the veterinary and veterinary nursing professions.1 The veterinary professions have a responsibility to advocate for animals’ best interests at the individual level (eg, veterinary professionals having direct contact with animal keepers and owners), community level (eg, veterinary practices providing animal welfare expertise and advocacy through local media, to local politicians and other outreach activities), national level (eg, veterinary associations formulating and advocating animal welfare policies) and international level (through policy formulation and advocacy, and effective partnerships between national and international veterinary associations, and other international bodies and institutions).2
Overall, the veterinary professions have a dual duty—to advocate for the best interests of animals under the care of individual veterinary surgeons and veterinary nurses (at individual level), as well as to advocate for changes and solutions to address the root causes of animal welfare problems (especially at community, national and international levels).1 2
The national UK veterinary charity, the People’s Dispensary for Sick Animals (PDSA), has provided free and low cost veterinary treatments to the sick and injured animals of people in need since 1917, funded by public support. The charity operates through a nationwide network of 48 Pet Hospitals with a 1000-strong veterinary team, providing treatment to 470,000 pets each year and supporting 300,000 eligible pet owners in receipt of means-tested state benefits. In 2008, the charity began to increase its external, national-level advocacy on common, preventable pet health and welfare problems, informed by its large clinical caseload. Ongoing public awareness–raising activities include campaigns on obesity in companion animals,3 collaborative campaigning to improve the health and welfare of pet rabbits4 and undertaking the UK’s largest annual nationwide assessment of pet dog, cat and rabbit wellbeing—the PDSA Animal Wellbeing (PAW) Report5—centred on the Five Welfare Needs—based legal duty of care.6–8
In 2012, as PDSA grew its national, public visibility on pet wellbeing and animal ethics, beyond (but including) the narrower remit of treating and preventing injuries and disease, the charity reviewed its internal practices, aiming to ensure a complementary approach was being taken at the individual (PDSA clinical staff) and community (PDSA Pet Hospital) levels. In part, this was to increase effective staff input and communication—ensuring hospital staff were aware of external activity and able to influence key messages. It also aimed to ensure the external animal welfare–focused principles and aspirations were being conveyed through the charity’s everyday clinical practices, in accordance with recommended good practice.9 10
PDSA formed a national internal committee, the ‘Pet Wellbeing Task Force’ (PWTF), composed of national, regional and hospital-based veterinary staff representatives, including those working on policy and campaigns, clinical operations, community and education programmes, and including veterinary nurses, veterinary surgeons, animal care assistants, reception staff and area veterinary managers. In addition, clinical-team Pet Wellbeing Champions were appointed in each of PDSA’s 48 Pet Hospitals, according to a role description (online supplementary appendix 1) and an application to hospital managers. Nine of these were appointed as Area Lead Champions, to coordinate activity in their geographical area, providing overall UK-wide coverage. The nine Area Lead Champions are also members of the PWTF.
The organisation-wide staff network of Pet Wellbeing Champions, Area Lead Champions and Pet Wellbeing Task Force facilitates two-way communication between the hospital-based Champions and the national policy-guiding Task Force on matters of animal welfare and ethics. The Pet Wellbeing Champions are allocated time off-rota to undertake activities related to their role and to consult with their wider hospital team when necessary. They can propose areas where new policies or guidelines may be relevant for consideration by the PWTF, with the network functioning as a safe space where any concerns or dilemmas relating to animal welfare and ethics in a hospital can be raised, discussed and where necessary, acted on. The PWTF can consult hospital staff on matters relating to animal welfare and ethics, and disseminate new policies or external campaign updates to all hospital staff, via the Pet Wellbeing Champions.
The Pet Wellbeing Champions are encouraged and supported to undertake Continuing Professional Development (CPD) on animal welfare and ethics, including attendance at a national PDSA Pet Wellbeing Champions’ Day where invited external experts speak on identified priority areas.
An early PWTF activity was to describe a hospital-wide ‘vision for animal welfare and ethics at PDSA’. Thinking about the individual-level and community-level animal welfare responsibilities of veterinary professionals, the PWTF considered the staff behaviours and activities that would be demonstrated in PDSA hospitals if opportunities to improve and promote animal welfare were being identified and taken. This created a list of 28 individual actions (expanded to 31 in 2018) that formed the basis for a hospital clinical audit questionnaire survey (online supplementary appendix 2), conducted in 2013, 2014 and 2018. The survey questions corresponded to the specified hospital actions. In 2018, the total 31 questions were divided between 27 factual questions (eg, “Does your hospital separate species in the waiting room?”) and four attitudinal questions (eg, “Are you satisfied with the pain relief provided to surgical patients?”). The 2013 and 2014 questionnaires contained 28 questions; 25 factual and three attitudinal. The original 28 questions were unchanged across the three surveys. The three extra questions in 2018 corresponded to three additional actions identified by the PWTF.
The confidential survey was distributed by the PWTF to the Pet Wellbeing Champion in 42 of 43 PDSA hospitals in 2013 and 2014 and and 43 of 48 hospitals in 2018. The number of distributed surveys was slightly fewer than the total number of hospitals due to active recruitment of Pet Wellbeing Champions at some hospitals at the time of surveying. The Pet Wellbeing Champions completed the survey in consultation with colleagues in their hospital teams, to gain hospital-wide information and perspectives. The PWTF has subsequently developed interventions to progress improvement areas identified by the audit, to drive a process of continuous improvement. It has also, separately, developed new policies in response to issues raised by individual Pet Wellbeing Champions.
‘Animal welfare and ethics at PDSA’ all-hospital clinical audit survey
Response rates of 86 per cent, 83 per cent and 95 per cent were achieved in 2013, 2014 and 2018, respectively. Example results are presented where some of the greatest between-year changes were recorded.
PetWise MOTs (named after the UK’s familiar, multi-point vehicle maintenance checks) are a novel, PDSA-developed quality-of-life assessment tool, based on the Five Welfare Needs laid out in the UK Animal Welfare Acts.6–8 A veterinary consultation is used to discuss each of the Five Needs as they relate to a client’s pet, with a Red, Amber and Green scheme used to commend good practice and to sensitively communicate recommended improvement areas to owners when indicated.
In 2018, 100 per cent (n=43) of surveyed hospitals reported they are offering PetWise MOTs, from 36 per cent (n=15) in 2013 (figure 1), with some in 2018 conducting over 60 every week. They are offered equally for dogs, cats and rabbits, though many hospitals reported that it is harder to attract rabbit owners. Some hospitals reported they have adapted the consultation for use with guinea pig owners.
Pain-scoring tools for hospitalised patients
In 2018, 78 per cent (n=34) of surveyed hospitals reported using pain-scoring tools at least sometimes, compared to 48 per cent (n=20) in 2014 (figure 2). A validated pain-scoring tool uses a standardised method to assess and monitor pain in pet patients. Most hospitals reported using either the Glasgow Composite Measure Pain Scale or the Colorado State University Acute Pain Scale, with one hospital also using a published rabbit grimace scale.
Neutering kittens at four months old
Seventy-eight per cent (n=34) of surveyed hospitals in 2018 were routinely recommending neutering kittens at four months of age, from 24 per cent (n=10) in 2013 (figure 3). In 2014, as part of its work with the Cat Population Control Group—a coalition of veterinary organisations and animal welfare charities—the PWTF worked with PDSA’s internal clinical standards committee to introduce four-month kitten neutering as standard practice.
Good working relationship with other local animal charities
Seventy-six per cent (n=33) of surveyed hospitals in 2018 reported having a good working relationship with other local animal charities (eg, inspectors, rehoming centres), from 56 per cent (n=24) in 2013 (figure 4).
Level of staff discussion about ethically challenging cases
The survey asks if hospital staff are satisfied with the level of staff discussion about ethically challenging cases, for example, how long to hospitalise patients for, or when to offer treatment versus euthanasia. The percentage of surveyed hospitals reporting complete satisfaction rose from 40 per cent (n=17) in 2014 to 49 per cent (n=21) in 2018, but is less than half of all hospitals (figure 5).
New policies and guidance in response to Pet Wellbeing Champion feedback
Animal behaviour and training accreditations
Pet Wellbeing Champions requested that PDSA clarify its internal guidance to hospital staff on accreditations and assurances to look for when recommending animal behaviourists and trainers to pet-owning clients. The PWTF reviewed guidance to ensure that staff were signposting to behavioural practitioners who used humane, effective techniques such as positive reinforcement, and not outmoded concepts such as dominance-based training or approaches relying on physical punishment.11 This resulted in a new national internal policy, jointly issued with PDSA’s internal clinical standards committee, which directs to animal behaviourists registered with the Animal Behaviour and Training Council (ABTC) and/or who are a full member of the Association of Pet Behaviour Counsellors and/or are a Certified Clinical Animal Behaviourist. It directs to dog trainers who are a member of the Association of Pet Dog Trainers and/or are registered as an Animal Training Instructor by the ABTC. The new guidance aligned PDSA’s internal policy with its external activities as an Advisory Organisation to the ABTC who are working towards professionalising animal behaviour and training services in the UK.
The Pet Wellbeing clinical audit revealed varying satisfaction levels with the provision of analgesia for surgical patients, so a national protocol was developed and introduced in 2018 to standardise provision of perioperative analgesia. This stated that all surgical procedures classified by the World Small Animal Veterinary Association (WSAVA) as resulting in moderate to severe pain12 will be provided with full opioid agonist analgesia unless there were defined clinical circumstances that would make this inappropriate.
Retrospective analysis of clinical records showed that the use of a full opioid agonist for ovariohysterectomy in bitches (classified as causing moderate pain12) was approximately static between May 2017 (used in 49 per cent of procedures undertaken) and May 2018 (used in 53 per cent of procedures undertaken). Between autumn 2018, when the new protocol was introduced, and October 2019, the percentage rose to 90 per cent.
Other policies and guidance developed through the PWTF include humane techniques for euthanasia of small pets and how to identify and submit case studies to the media to raise awareness of preventable conditions (eg, chocolate and other toxicities) and of the charity’s work.
Being animal welfare-focused is distinct from being client-focused or vet-focused,2 9 and relates to the primary motivation of veterinary professionals. Client-focused practice prioritises a client’s interests; for example, withholding advice on a patient’s obesity for fear of causing client offence. Vet-focused practice prioritises a veterinary professional’s interests; for example, recommending a surgical procedure because it would be more professionally interesting to perform than a reasonable, alternative non-surgical option. The veterinary profession is animal welfare-focused,2 prioritising the interests of animals. Working with clients and ensuring financial sustainability are enablers for veterinary surgeons and veterinary nurses to improve animal welfare. This is conveyed in the PWTF vision as an organisational principle that PDSA upholds as a veterinary charity.
The high response rate to the PWTF survey in 2018 is indicative of the explicit animal welfare–focused approach becoming culturally embedded across the charity and was achieved through increased management support for survey promotion and completion. Animal welfare, and veterinary and animal ethics, was established as an integral part of veterinary clinical practice and policy.
Activities promoting positive animal welfare outcomes and ethical reflection by hospital staff, before, during and after a patient’s time within a veterinary practice, were audited as an aspect of veterinary clinical audit, using the clinical audit step-wise cycle.13 14 The audit was based on a broad set of indicators (practices and behaviours reflecting animal welfare–focused practice) rather than a more restricted set such as the type used to audit a single clinical treatment or procedure. The overall set was agreed through consultation with clinical staff and compared with published recommended approaches.9 The process fulfilled the consensus criteria for veterinary clinical audit, that is, that an audit should be a continuous cycle, should use the best available evidence and should lead to improvements in patient care.14 The staff-generated indicators are re-evaluated on a regular basis by consulting the literature for any new evidence that arises,14 as demonstrated by the addition of three new audited actions in 2018, and the audit process has achieved desired outcomes including stimulating both organisational change and further practice-based research in collaboration with universities.13
The audit functions as an effective staff engagement tool, with some respondents, for example, making free-hand comments that they ‘would like more information’ or ‘are now aware’ about areas raised. The Pet Wellbeing Champion role and the survey also ensure that all hospital staff roles are consulted on animal welfare and ethics, and are able to serve as animal welfare ambassadors.15 16 The Pet Wellbeing Champions’ job roles and geographical location are known but these, and other demographic factors, have not to date been analysed for potential bias in audit responses. Job role, for example, could influence knowledge and attitudes, perhaps through frequency of management briefings or differing perceptions of what is achievable in a PDSA hospital. Such potential bias should be minimised through the Pet Wellbeing Champions being requested to complete the questionnaires in consultation with their wider hospital team.
A process of hospital-wide continual improvement can be sustained until all hospitals are undertaking all activities most or all of the time. Three activities are ongoing at PDSA:
Creating an audit-linked tool kit
Each of the survey questions relates to an action that should have an associated evidence base or rationale and may be the subject of linked training resources. Relevant peer-reviewed papers and available training resources can be collated in an online repository as a tool kit to assist hospital-based veterinary professionals and managers.
Creating hospital-specific action plans
Actions should be assessed for their desirability and feasibility at individual hospitals. A hospital, for example, that is not using pheromone products to help reduce stress in hospitalised patients17 may not be designed in a way that would achieve sufficient atmospheric concentrations. Similarly, design limitations may not currently enable separation of species in waiting rooms or wards.17 A hospital action plan may have two survey-linked goals in the first instance, incorporating (1) a national priority (eg, an issue judged by the PWTF to require national focus until a defined, minimum national prevalence is attained) and (2) an additional local priority, based on local team consultation and consensus.
Pet Wellbeing Champions’ Day
A national PDSA Pet Wellbeing Champions’ Day, open to all Pet Wellbeing Champions, has offered CPD based on priorities identified by the survey, serving as a focus for attention and action. Topics have included ethical decision-making, puppy socialisation, first aid for behaviour cases, quality-of-life assessment and PetWise MOTs, four-month kitten neutering, pain assessment, feline-friendly hospitalisation, pet obesity, and rabbit companionship and bonding.
The Pet Wellbeing Champions’ Day and other interventions are likely to have contributed to improvements recorded and reported across the successive surveys:
PDSA began developing MOTs as a quality-of-life tool to assess dog, cat and rabbit wellness in 2012 and introduced them in to hospitals in 2013, coupled with training sessions for Pet Wellbeing Champions at the 2014 and 2015 Pet Wellbeing Champions’ Day. In 2014, the charity received funding from the Marchig Animal Welfare Trust to offer free microchipping, neutering and PetWise MOTs for cats, conducting 104,312 MOTs between 2014 and 2017. This has served to embed MOTs as part of core practice across the charity. In a partnership with the University of Bristol, Roberts18 found that overall, a higher frequency of green scores and a lower frequency of red and amber scores was reported at a follow-up MOT compared with a first MOT. PDSA’s formalised approach to using the Five Welfare Needs to provide information to pet owners on improving the welfare of their pets, through PetWise MOTs, has been selected as a good practice example within the WSAVA Animal Welfare Guidelines for Companion Animal Practitioners and Veterinary Teams.19 PetWise MOTs have been adopted by other animal charities and some private veterinary practices. Through this wider adoption by practices, they are a veterinary-driven route to addressing some of the prevalent companion animal welfare problems reported in the PAW Reports (eg,5 20).
Pain assessment and management
The Pet Wellbeing Champion network and audit stimulated a discussion about analgesia for hospitalised patients, with inter-surgeon and inter-hospital differences in practices noted. Similar variability has been recorded in previous surveys of UK analgesic prescribing; for example, female veterinary surgeons were more likely than male veterinary surgeons to prescribe postoperative non-steroidal anti-inflammatory drugs (NSAIDs) to dogs for routine surgeries (defined as neutering and lump removal) and veterinary surgeons with a shorter time since graduation were more likely to prescribe perioperative NSAIDs and opioids to cats for routine surgeries.21 An initial resulting action was to aim to promote and standardise pain assessment using validated tools across all hospitals, followed by the introduction of a revised all-hospital analgesia protocol to provide more effective analgesia where required. The 2015 and 2016 Pet Wellbeing Champions’ Days included lectures on pain assessment from European Specialists in Veterinary Anaesthesia and Analgesia, which are likely to have contributed to the increase in pain assessment recorded in the 2018 survey.
Four-month kitten neutering
Ninety-one per cent of pet cats in the UK are neutered.5 Thirteen per cent of owners of female cats say that their cat has had at least one litter and 70 per cent of those say that the litter was unplanned.20 Although puberty is typically between five and eight months of age, pregnancy can be seen in queens as young as four months of age. The timing of neutering is therefore essential to prevent unwanted litters, with the historic UK cat neutering age of six months based on tradition rather than evidence. The British Small Animal Veterinary Association, British Veterinary Association and the Cat Group (a coalition of veterinary associations and animal welfare charities focused on improving feline welfare) recommend that pet cats are normally neutered from four months old for population control.22–24 The introduction of four-month neutering as PDSA policy followed staff consultation using the Pet Wellbeing Champion network to assess awareness, barriers and disseminate latest evidence. The PWTF will continue to work with the Pet Wellbeing Champions to support hospitals still transitioning to four-month neutering.
Collaborative working relationships with other local animal charities
Collaborative relationships between charities in communities can ensure each makes complementary and effective contributions to animal welfare improvements. The audit revealed that PDSA hospitals are working with other animal welfare charities (eg, Dogs Trust, Blue Cross, Cats Protection), dog wardens and local animal rehoming centres. Several said that a close working relationship with local charity inspectors (eg, Royal Society for the Prevention of Cruelty to Animals inspectors) helps with addressing cases of suspected animal abuse. The introduction of a hospital Client Services Manager (CSM) role in 2014 may have assisted with improved community relations, with some hospitals reporting that their CSM has been actively visiting local veterinary practices and charities to build relationships and initiate joint working for mutual benefit.
Staff discussion about ethically challenging cases
Veterinary surgeons regularly face ethical dilemmas which they find stressful and can negatively impact on their wellbeing.25 26 Different members of a clinical team can draw different legitimate conclusions on what is an ethical way to proceed with a given clinical case; such differences can be a source of conflict and moral stress if they are not understood and respected. Open discussion on ethical reasoning and ethical dilemmas can help ensure decisions are arrived at and supported by as many team members who will be involved with a patient’s care (or affected by a patient’s euthanasia) as possible, while open reflection on recent cases and decisions can inform team approaches to future similar cases.27–29
There is an apparently high level of interest in this area among PDSA hospital staff, indicated by free-hand responses to the survey and strongly positive delegate feedback on the topic following a session by a veterinary ethicist at the 2014 Pet Wellbeing Champions’ Day. The PWTF is exploring piloting novel hospital-based approaches as part of a university research project.
A national internal committee, the PWTF, populated by representatives from a range of veterinary job roles from across the UK is providing a focus for thoughts, action and audit-driven continual improvement on animal welfare and ethics across a large, multi-site veterinary organisation. A network of hospital-based Pet Wellbeing Champions ensures effective two-way communication between the hospitals and the national PWTF, both to deliver national pet wellbeing initiatives and to gather thoughts and ideas for the PWTF to explore and progress. PDSA offers this as an approach that other veterinary practices, whether private or charitable, could adopt or adapt; even the nominating of a dedicated animal welfare and ethics champion in a small veterinary practice can provide a focus for animal welfare and ethics-related activities, coupled with related clinical audit when resources permit.
Developing and auditing animal welfare policies and activities in veterinary practices, at the individual and community levels, has benefits for patient welfare, client satisfaction, staff morale, staff development, staff health and safety, and the professional reputation of veterinary surgeons and veterinary nurses.17 30
Outcomes such as frequent quality-of-life assessments with tailored pet-specific recommendations for owners, routinely performing kitten neutering at four months, regularly pain-scoring hospitalised patients and standardising the provision of effective analgesia all contribute to improved animal wellbeing.
When patient stress is reduced during hospital visits, through practices such as separated waiting areas and minimal animal restraint, clients are appreciative and there is a reduced risk to staff from animal bites and scratches.17
Veterinary charities, like private veterinary businesses, must be financially viable, but veterinary professionals are highly motivated to improve animal wellbeing and appreciate an explicit focus on this, alongside other key management indicators, enhancing staff morale. Due to the different funding models between veterinary and medical healthcare in the UK, there will always be public interest and debate in veterinary fees and value.31 Focusing on, auditing and improving animal welfare and ethical decision-making in veterinary practices complements and reinforces external veterinary animal welfare campaigns. This visible advocacy for animals’ best interests across the individual, community, national and international levels meets society’s expectation of the veterinary and veterinary nursing professions as animal welfare–focused professions.
The authors would like to thank David Main, Rebecca Ashman, Steve Howard and Stuart Insley for their reflections and comments on initial drafts of this paper and their inputs to developing the PDSA Pet Wellbeing Task Force. Many thanks are also extended to the Pet Wellbeing Champions and PDSA hospital teams who support and implement the PWTF work on a daily basis.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data related to the work reported in this paper are available on reasonable request, with all requests subject to PDSA assessment and right to refuse.
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