Tuesday, 8 October 2019
VetScript editor's pick - October 2019
The decoupling of veterinary authorisations from the prescribing of restricted veterinary medicines has been under the microscope, due in part to concerns about ‘fly-in, fly-out’ veterinarians and poor drug stewardship. Keen to know exactly why some veterinarians are so unhappy with this brave new unbundled world, the NZVA recently surveyed some of its members. Matt Philp reports on the results.
When the authorising of restricted veterinary medicines (RVMs) was decoupled from dispensing a few years ago, more than one veterinarian took a financial hit. As the NZVA’s Ash Keown says, the awkward truth is that “in large animal practice we have relied heavily on drug sales as a revenue source”. But loss of income hasn’t been the only unintended consequence. Increasingly, veterinarians are suggesting that drug stewardship, herd health and animal welfare are also at risk.
“Decoupling in itself is not the issue,” says NZVA Chief Veterinary Officer Helen Beattie. “It’s how that process is being used to supply drugs. The stories I hear are concerning enough to do something about it.”
That ‘something’ has included the commissioning earlier this year of a survey of NZVA members, mostly large animal veterinarians. The association had been aware of disquiet about the phenomenon of distance authorisations and the advent of ‘fly-in, fly-out vets’, but it recognised that that was just one piece of the puzzle.
“The idea was that if we could drill down deeper into what veterinarians struggle with in regards to authorisation as it stands, maybe we can start to find some solutions,” says Ash, the NZVA’s Veterinary Manager (Large Animal).
On the question of veterinarians authorising medications at a distance, the survey drew a strong response. Some 70% of the 290-odd respondents said that RVMs should only be authorised for use in an area local to the authorising veterinarian. But as Ash points out, distance is not necessarily a good indicator of stewardship, and often such arrangements can’t be avoided – for example, when the farm in question is very remote, or in the case of industries where there are only a few specialist veterinarians servicing the entire country. “If we slapped a blanket ban on distance we’d be failing to acknowledge that we have colleagues who need to function in [that way],” he says.
More revealing – and, ultimately, more productive – was the response to a section of the survey looking at consultation. Almost 40% of respondents had at some point been asked to provide emergency or follow-up care for animals for whom they hadn’t authorised drugs. More to the point, typically the authorising veterinarian hadn’t engaged with the local clinic to ensure it could provide that care – in fact, only seven percent had good post-authorisation arrangements in place, evidence of a significant deficiency in collegial communication.
“We have a proportion of the profession who don’t seem to be making proactive arrangements for after-hours or emergency care, which is something we need to keep reminding them they have an obligation to do. This is not just about RVMs; in the Code of Professional Conduct there’s a bit about providing the necessary follow-up for anything you’ve consulted on. You need to make arrangements in advance.”
As it happens, most respondents didn’t mind providing follow-up care if they had a pre-existing relationship with the client. Absent that relationship, however, 78% weren’t particularly keen. “As long as it’s not an emergency they’re entitled not to go,” says Ash. “But they’re not comfortable about that, and that came through strongly in the survey. In practice, they’re probably still providing that service.”
It’s an area that the NZVA believes needs to be addressed. “Veterinarians need to get more confident about referring clients back to the primary care providers, and that will be easier if we can somehow make that relationship more official,” says Ash, who thinks the profession could borrow from the human medicine field’s concept of a registered primary provider. “If a farmer based in Southland decides to seek the services of someone based in Northland to get an authorisation, they would have to list that Northland veterinarian as their primary provider, and that primary provider would then be obliged to make arrangements for the after-hours – and if they can’t do that, then they probably shouldn’t accept that relationship.”
He says the NZVA wants to better define the relationship in collaboration with VCNZ and the Agricultural Compounds and Veterinary Medicines (ACVM) Group, the body within the Ministry for Primary Industries (MPI) that oversees this area.
The survey also highlighted practices that are more immediately concerning. While most respondents had never dispensed RVMs under an authorisation from another veterinarian, of the 35% who had ‘filled a script’ only 11% were certain they had an MPI-approved operating plan, which is a legal requirement.
Even more disquieting, the survey revealed real risks arising from situations where individual clients are using multiple veterinarians for authorisations. Some 42% of respondents indicated that their clients had more than one source – which, in itself, is not necessarily a concern. “Clients have the right to use more than one veterinarian,” notes Ash. But only nine percent suggested that there was good communication between the various authorising veterinarians, creating potential for drug overlap and overuse.
Helen Beattie says that such poor management cuts against the 2030 antimicrobial resistance strategy and the goal of good product stewardship. “If three different veterinarians are authorising drugs, the farmer potentially has access to three times the supply. It flies completely in the face of what we’re trying to do.”
“There needs to be some level of visibility about drug quantities, indications, and so on,” says Ash, who points out that the Code stipulates that veterinarians must share relevant information with those who need to know. “It needs to form part of the information gathering required under ACVM rules. Veterinarians need to ask, ‘Do you get drugs from elsewhere? If yes, can I see the authorisation so I know what you’re getting?’ If the client is reluctant to provide that information, I’d suggest that you don’t authorise the drugs.”
He says the NZVA may need to consider whether it’s appropriate to allow multiple authorisations to a single farm entity. “We need to engage VCNZ and the ACVM Group on that question. If a farmer wants to use the services of more than one veterinarian we have to work with that, but it can’t be at the expense of product stewardship.”
Given that concern, it’s noteworthy that more than half of the respondents said they had been unable to determine where an RVM they saw on-farm had come from, and 41% thought it was due to illegal or unethical behaviour. Ash remarks that in those situations, veterinarians really should take their concerns to the appropriate regulatory authority.
“If, for example, you think a veterinarian has failed to do their due diligence in authorising drugs, then that would be relevant both to the requirements of the ACVM Group and – because the veterinarian has potentially failed to uphold their obligations under the Code – to VCNZ. The same thing would apply for failing to provide for after-hours. If the conduct of someone else (for example an RVM supplier) is questionable, notification should be directed to the ACVM Group.”
What next? The NZVA isn’t proposing a ‘recoupling’ of authorising and dispensing of drugs – that ship has sailed. “The survey identified specific concerns among members and indicated that there is room for improvement,” says Ash.
“We are underway on drafting potential solutions. Once that draft is completed, we will invite member feedback. Then, in the longer term, we will advocate for the implementation of the solutions chosen by members by engaging with VCNZ and the ACVM Group. There is a lot of work to do and we have begun the process. ”