29 Aug 2023
Richard Brown takes a look at the sector’s bad decisions made during his 40-year career in the first of a two-part series.
Richard Brown
Job Title
Image © ellisia /Adobe Stock
More than 40 years ago I qualified. Now, with retirement beckoning, I have had an opportunity to look back. What is staring me in the face is that the profession now faces larger challenges than four decades ago.
We were more contented. Not extremely happy, but able to accept our lot. I also recognise that the profession has in many areas improved dramatically. I, myself, have benefited from these changes. However, some fundamental issues exist that, if not corrected, will seriously damage our profession. Thus, this piece, while critical in many aspects, is passed on in the spirit of “faithful are the wounds of a friend” (Proverbs 27: 6).
Four decades ago, suicides within the profession did occur and challenges to mental and physical health existed, but not at the current rate. In my first job, my neighbour was a vet who had left the profession. He had suffered severely from brucellosis. In short, events forced him out. Although the nature of some of the stresses we took on were different from today – for example, we did not have the pressure of social media – the majority are similar, like long hours, feeling inadequate in certain situations, ill health, the occasional unappreciative owner, isolation in the clinical decision-making process, a complaint, occasional difficulties with colleagues morphing into chronic issues, and going the extra mile for the client who expects this to be a norm.
It would be very, very reasonable for you, the reader, to suggest that my personal view stated in this article is akin to the classic Four Yorkshiremen sketch by Monty Python. In that sketch, four old men, who 40 years ago worked in the most awful work conditions, rejoice how great those conditions were. They exaggerate them and say how the current generation are wimps1,2.
We did work very hard, long hours and in some difficult, even risky, situations. Some unacceptable discrimination existed, particularly directed to female vets when they started working on farms. One colleague was asked at calvings to strip to the waist like the other vets. This stopped when, in the next few months, she demonstrated that she was the best vet at performing caesareans.
My starting salary was low at £4,500 and while petrol for private use was free a lot of my income went into the heating bill in north-east Scotland. My annual car mileage was many thousands of miles since we were very busy. But our bosses were, by today’s standards, tough, but caring. They wanted us to succeed, to have a life outside work and to become part of the local community.
I recollect clearly one night being called out to a uterine prolapse at a big dairy. Off I went – I had done a few in the year before. Suddenly, out of the darkness, a silvery blue car swept past me at speed. It looked like my boss’ car. On arrival, sure enough George, my boss, was there.
He said: “I thought we could do this together, Richard, but you lead.” Away we went and successfully replaced the womb. Alone in the quiet of the dairy parlour while cleaning up, I thanked George, but said I was happy to do them myself.
He replied: “Oh, I knew you could cope. You have already done a few. But, Richard, what you do not know is that this farm is very peculiar. We still do not know why, but nearly all his prolapses die. And I was not going to have a young vet blamed for something over which he had no control, bye.” And he shot off. And sure enough, the cow did die and I still do not know why.
But it was what nowadays might be called “tough love”. One day I was called, by radio, to a calving. My calving jack had just broken down and I radioed back saying I would have to come in first.
George said: “No need to come in. I will meet you at Grange crossroads and lend you mine.” We met, he handed it over. On arrival, I realised quickly it was a caesarean and later found out George knew that was highly likely.
No, we were not a tough bunch, and we reacted in many ways similarly to any clinician today. But we operated in a different environment. My view is that the problems currently facing the veterinary profession are a result of choices that have affected the working environment. In the past 40 years, three choices have been made. Each choice was the decision of making one entity a priority and, therefore, to a certain degree, neglecting another important entity. We, as a profession, came to a fork in the road and each time chose the wrong path – and now we are in serious trouble.
The consequences of these decisions has been to exasperate problems present 40 years ago and allow them now to become deep rooted. My main concern is that current solutions tendered are “sticking plasters” or “medicines to relieve symptoms rather than achieve a cure”. Therefore, these will be ineffective to cure fundamental weaknesses in the infrastructure of the UK veterinary profession. The required solution – if I am correct, and I admit I could be wrong – may well be more dramatic. We may need solutions of a more “surgical” or dramatic nature whereby we cut out some things and also where we are willing to take “strong curative medicine” which may well have temporary side effects while we travel to the goal of a healed profession.
In 1981 when I graduated, specialists were a rarity and most would be found within veterinary schools. I can only recollect three from outside – the lecturers on fish, on ophthalmology and on race horses. A direct consequence of this was that our own in-house lecturers were a mix of specialists and practitioners.
The latter had been out working in practice for more than 10 years. Thus there was always available what I might call “deep knowledge” of “basic competencies”. In case discussions it was not uncommon for those from the practitioner background to ask of the specialist or the lecturer with only a couple of years’ practice experience a simple, but pivotal, question or give an equally prescient observation, often simplifying matters.
Nowadays – I am willing to be corrected on this – more frequently than not, I see CVs of veterinary school lecturers who have gone into general practice for two years and then returned to study for an internship. Later, now specialist qualified, they go on to lecture about that field with respect to the basic competencies and general practice.
However, even though they are experienced university staff with good post-graduate qualifications and research publications, they only have two years’ experience of the reality. That practical reality often is not completely congruous with pure veterinary theory. This is commonly due to the ever-present issue in practice of difficult-to-assess random related events. The “noise” that occurs. Coping with “noise” takes years of practice and is almost a sixth sense. It takes a long time to become highly proficient and experienced in general practice.
George, my first boss, told me as I was a new graduate I would be a very real liability in my first six months. I would only begin to be, in economic terms, earning for the practice after 12 months – that was when my salary moved up from £4,500 to £5,300. After two years I would be “starting” to become a true practitioner – not the finished article and certainly not capable to lecture students.
The consequences of not prioritising general practice can be seen, for example, by letters published in Vet Times. A practitioner has to defend the sine qua non importance of EMS3.
It is underlined by the fact that when the RCVS published its Workforce Action Plan that set out how the sector could work together to mitigate crisis4, it listed seven ambitions. I ask you, reader, where among the seven, would you find general practice? It came fifth, behind veterinary nurses at number three. I suggest to you that practitioners are not apparently the main priority.
And the “ambition” was marked by a theoretical modelling rather than specific approach: “General practice – a chosen pathway: this includes encouraging confidence in pursuing a career in general practice and the opportunities it offers; encouraging shared training where appropriate between vets and vet nurses at undergraduate level; and learn and model against other professions, such as the medical profession.”
Vet practitioners were correctly criticised for being poor businessmen 40 years ago. It was acknowledged that we were good clinicians, but when it came to handling money, we were mediocre and business planning was very ad hoc. Many practices had a box for cash that did not go through the till; farm accounts were based on a vast paper ledger. Bills were just about sent out monthly. Small animal accounts were run on a cash basis.
Money was taken at the hour of treatment and, occasionally, one just asked a client: “Well, what money do you have on you right now?” Bad payers were only chased up when there was nothing better to do. Some farm clients used the vets’ account – in debit – as a minor bank. It was an account that was very useful to them when bank interest rates were high. So, the profession was ripe for change.
As the drive towards financial excellent practice went forward, it was not recognised by vets that in many small and diverse ways practices received favours from clients. Local communities had long recognised it was worthwhile keeping the vets functioning: in economic terms, vets had a value. Baked items were dropped by; on finishing a call there might be half a dozen eggs, a neep or a small sack of potatoes on the car seat. The garages would get vets’ cars back on the road quickly and everyone would help you if you came off the road or got stuck for no charge. Dentists and doctors would make sure you were seen to – and I am pretty sure I am not the only vet to have been stopped and then let off by the traffic police, after a warning. These minor paybacks or privileges were a hint to us that focusing on finance alone might have consequences.
Computers came in to iron out many of the financial inconsistencies. It was not all plain sailing. The first one resulted in my partner and I putting all the pricing in by hand. It took us every evening for two months. Then a decade later, I canvassed all the local practices to find out which was the best computer system – least time-wasting and most economic – and a much-improved system came. I was promised I would not have to go through the same experience: “It will be already tailor made for you,” said the salesman. I recollect clearly that I still often had to be the tailor. But it did produce results; more money came in. This was mostly because staff entered all that was used. Accounts were always issued promptly and booster reminders were automated.
Then the financial drive progressed with the ability to analyse the financial data in much more depth. The financial performance of individual vets could be produced. I was fortunate in that the one time it was used in relation to my work, a colleague suggested that I and the other colleagues were not turning over as much as she was. There was a pause and then the data checked. In fact, I and other colleagues were turning over more than her. However, in other practices this can be a new and, in my view, unnecessary dynamic. It is obvious to anyone experienced in practice who is not pulling their weight – one does not need a computer.
Before computers, I was correctly taken to task by my partner, Gordon, (he was the more reticent Scot) for blathering too much with kitten first vaccinations (I was the more verbose conversational Englishman). Gordon then tried the same criticism with a younger Scottish colleague. She correctly saw him off. She pointed out that she was not blathering (like Richard Brown), but was spending time to ensure it was highly likely the client would come back to buy cat food, cat wormers, ectoparasite control and boosters with the practice. She had taken an economist’s approach. And she was correct. Soon after, foot-and-mouth struck the UK, the practice almost came to a halt. One reason we survived was because at least 30% of the practice cash receipts were the food sales.
All the time the profession was receiving more material by, for example, CPD, by which they could produce more financial efficiencies. For example, on the suspicion of certain clinical entities a set of very detailed protocols of testing and treatment would be engaged, though not all were required in every case.
Lastly, the coup de grace – groups of practices were purchased by business entities who had investors supporting them. This confirmed that the main motive and objective was the return of the investment. Of course, this pursuit for the “bottom line” is not obvious to anyone reviewing the very professionally produced advertising and public information supplied by these entities.
As veterinarians, we may well be ambivalent to this scenario. Perhaps because we are not asking the question: “Given a reasonable risk assessment and avoiding a “precautionary approach”, do the suggested tests and therapy make economic sense for the client?” There is evidence coming from the US and UK in the human field that the quality of health care is not necessarily related to profitability of the health care provider5,6. And in the popular press, plenty of data suggests that vets are “milking it”.
That accusation has always been present, even 40 years ago, but now in my personal view the mud is beginning to stick in too many cases.
Distinguishing between financial issues and economic issues is not straightforward. I studied land economics at university and clearly remember a lecturer describing how the Forestry Commission solved an accounting issue it was wrestling with. It discovered in its return to Treasury that the books could not be balanced; it had not made enough money from logging. So it added a figure (millions) for “amenity value”. This was the value of all the benefits the commission gave to UK citizens who enjoyed walking through its forests, picnicking in them and other activities.
At first sight this looks like cooking the books, but it was accepted by Treasury. Now, decades later, we know for certain that walks, runs, hill climbing and relaxing in the woods does improve health, mentation and fitness and so must have a value that can, with some thought, be given a monetary value.
We know ourselves that it is not purely financial matters that motivate us at work. A very long list of parameters affects the “valuation” of our job – hours per week, number of weekends on duty, night duty yes or no, CPD paid or not paid, RCVS membership paid yes or no, length of holidays, degree of support.
The surprise is we seem to take a financial approach to our clients, yet at the same time we want a long-term economically viable relationship with them, and paradoxically many of us still prioritise a financial approach to veterinary employment. Even if it is part-time, the money aspect may over-influence our decision making.
Once, when deciding on locum work, my wife and I finally realised that a nearby local locum job at much less pay had many “economically valuable and accountable” advantages compared to a better paid job far away. And employers may be valuing certain non-financial items differently from the employee – the provision of free CPD comes to mind.
When I first started in practice, a well-defined concept was that you had work and you had play. Work was expected to be unpleasant at times – thus you were paid for it. Perhaps it was a biblical concept “through the sweat of your face, you shall eat bread” (Genesis 3: 19).
A lucky few who enjoyed work had a satisfying life both at work and play. But for the majority, the main satisfaction was a job done to the best of one’s ability, given the time and space allowed. Thus, George, my first boss, was absolutely insistent we all took at least a one hour break at lunch time. He roasted support staff if they cut into our lunch break. And he wanted everyone off and away at the end of the day and on time.
The aim was to make sure the veterinary life did not suck you in and absorb your life, though we did still go to farmer meetings and CPD. So, once work was over, the expectation was that you would go and find something relaxing to do, completely unrelated to work. Well almost. George did wonder if I would join the local rugby team. He suggested not only would it be relaxation, but I would meet farm clients in a non-clinical setting and, therefore, get to know them better. As a 5ft 8in, 69kg English-accented player among some large Scots, I demurred and went off to other pastimes – squash, hill running and small-bore shooting.
Another principal I worked with, Gordon, was one of the fastest, most hardworking and diligent workers I ever met. His nicknames were Flash Gordon and Blink, and he is Gone. Farmers loved his direct, hardworking and no-nonsense proactive approach. But to suggest he was gung ho would be an error. He could handle the smallest, most delicate, materials with skill and was a very good surgeon.
However, at 6pm on the dot, assuming he was not on duty, he was gone. One second he was there and the next split second gone. Gone off, to either play golf, play bridge, play bowls, play rugby and cricket (when young), go to a concert or enjoy fine wine at a restaurant.
Of course, if there was a dire emergency he could be found. And one evening he did actually call me apologising profusely. A horse we had castrated that afternoon was reportedly bleeding badly. ”Better with two vets, hope you don’t mind.” I agreed, after all I had been involved. We ended up with our heads left and right in the groin of the standing horse with very little blood to see. At that point, Gordon had silent hysterics which, of course, was infectious. Biting my lips and with tears streaming down my face we beat a gracious retreat. That occasion of extra out-of-hours work was exceptional and therefore remembered.
In discussion with students today, I am concerned that the approach is too centred on the veterinary career. It appears that applicants have to demonstrate that they have been engaged in animal-related activities for large parts of their school holidays – lambing, local animal charities, farms, vet practices.
And true enough, they are expected to show they have other interests, but often the aim is to show not just that they take part but that they are very talented in other fields: as one colleague much younger than me mentioned, there are too many “overachievers” in the veterinary profession. Even in relaxation they do not play, for example, for the local 2nd XV rugby team, but are bordering on the international team level or winning national prizes.
Two issues exist here. Firstly, very high achievers are not easy to manage. They may, for example, be active in pursuit of “gold standard” treatment, which is a fallacy. Secondly, individuals with all those talents performed at such a high level should be able to earn a much higher salary in other professions. They may find that a less-disciplined, but more goal-orientated, business environment is better for them to express their talents and receive credit.
They will, in this high-flying business career, have plenty of opportunities as a supporter to improve animal welfare. I suggest we should in fact be trying to dissuade extremely talented students from becoming vets. They need to prove they understand and are willing to take on a career that will not remunerate them according to their talents.
A local school student arrived at our practice with the aim of being a vet. He was a very talented, charming student who would later go on to be dux of the school – best academic student of his year.
I explained that I saw my role was to dissuade him from becoming a vet. He said “fair enough” and suggested therefore he come back more often. Round one to him. This I agreed to.
He was given good and very varied clinical experiences. We also gave him many unpleasant, but necessary, jobs. But he still kept on coming back. Round two to him. Finally, I made him go through every x-ray the practice had ever taken. His objective to look for fractures and detail them. He changed this into his Scottish higher project and completed it. Round three to him, and the match.
At that point I surrendered. I said he was welcome to join. He then asked me for a reference, which I supplied detailing how I had attempted to thwart his ambition, but he appeared so determined that it only seemed reasonable to let him into veterinary school. He would surely complete. The university told him they had never seen a reference like that before and also let him in. He continues to have a good career. By contrast, both our children have declined attempting a veterinary career. One, now an accountant, wrote a tongue-in-cheek Vet Times article detailing his reasons why7. The other decided to become a GP.
Much about the veterinary profession is excellent. The public understands this and has come to expect very high standards from us. The past 40 years working as a vet have been difficult at times but over all it has been fun, fascinating and fulfilling.
My experience is not exceptional: the profession is full of careers more diverse and effective than mine8,9. What is less well understood are the occasions of extreme pressures within this apparently highly successful profession and our current inability to solve these.
The aim of this first article has been to assist in identifying the root causes of the problems that we face. Next time, in part two, I will discuss one or two possible solutions.
The author asked to acknowledge his wife, Heather.
