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Review of 'under care' and 24/7 emergency cover (stage 3)

Please note: this consultation has now closed (26/09/22)

Under Care Review banner

Following a decision made by RCVS Council on 6 July 2022, we have launched the final stage of our wide-ranging, three-stage review of the definition of 'under care' and the provision of 24/7 emergency cover, and are now seeking feedback on our proposed new guidance.

Before viewing the online questionnaire, please use the following drop-downs to read more about the background to this review and the current consultation, the full proposed guidance, and the independent research and legal advice we have received.

All this information is also available to download as PDF documents in the 'Related documents' box below.

Once you have read all the supporting information, please click on 'How to respond' for details of how to access our online questionnaire and to send us your feedback.

An introduction from Melissa Donald, RCVS President

 

A. Foreword

A long journey

The journey of reviewing 'under care’ and provision of 24-hour emergency first-aid and pain relief has been a long one, its origins dating back to the Vet Futures initiative in 2016.

“The proposed guidance seeks to protect animal health and welfare and maintain public trust by ensuring that decision-making remains firmly in the hands of individual veterinary surgeons”

Relating as it does to a fundamental aspect of veterinary practice, this review has generated considerable discussion and debate in recent years, with strongly held views presented on all sides during all stages, including evidence-gathering, analysis and feedback.

As ever, it is the College’s responsibility, through the work of our Standards Committee and Council, to consider in detail the views and experience of all our stakeholders along with, in this case, formal legal advice and commissioned independent research, and to propose a way forward.

The pandemic effect

A significant contributor to the length of this journey, of course, has been the Covid-19 pandemic, which has delayed the review’s progress by around two years. Nevertheless, numerous lockdowns have afforded us the chance to explore our long-held understanding of what ‘under care’ means in principle, and to learn how new guidance could best work in practice, across all species types.

Along with many things, the past two years have demonstrated that the veterinary professions are highly capable of adapting to changing societal needs. As veterinary professionals, we cannot, and should not, expect established ways of practice to go unchallenged and remain unchanged, particularly in the face of shifting public expectations and advancements in technology. However, it is our collective responsibility to ensure that any changes continue to allow us to provide safe and effective care for our patients, and meet the appropriate expectations of our clients.

The need for change

Whilst therefore recognising and reflecting this need for change, the proposed guidance seeks to protect animal health and welfare and maintain public trust by ensuring that decision-making remains firmly in the hands of individual veterinary surgeons, as to what they, in their professional judgement, consider appropriate in a specific situation.

This consultation, then, whilst not a referendum on whether RCVS guidance on ‘under care’ and 24-hour emergency first-aid and pain relief should change – that decision having been made by Standards Committee and approved by Council based on the evidence gathered, including the views of the profession and objective evidence, and legal advice – is a crucial opportunity for you to tell us whether we have got the draft guidance right, or if there is anything we might have missed.

Animal health and welfare

In the online survey you can provide feedback on each individual element of the proposed guidance. We are particularly keen to know if there are any factors we may have overlooked that could impact on animal health and welfare, and/or public trust.

Before answering the questions, however, I would urge you to read the background and detail of the proposal set out on the following pages. This will help to explain the journey to this point and the challenges we have met along the way.

Full details on how to respond are set out below, together with a timeline of what will happen next, but please make sure to send us your feedback by 5pm on Monday, 26 September 2022.

Thank you in advance for your time and consideration.

Dr Melissa Donald BVMS MRCVS
Former Chair, RCVS Standards Committee

B. Background

"As this review hinges on the legal interpretation of the terms ‘clinical assessment’ and ‘under care’, we sought legal advice to ensure that the basis of the guidance that governs the profession is correct and reliable."

  1. The Royal College of Veterinary Surgeons (RCVS) is both the Royal College and regulatory body for veterinary surgeons and veterinary nurses in the UK. As a regulator, we set, uphold and advance veterinary standards and, as a Royal College, we promote, encourage and advance the study and practice of the art and science of veterinary surgery and medicine. We do all these things in the interests of animal health and welfare, and in the wider public interest.
  1. Our review of telemedicine, ‘under care’ and 24/7 first-aid and pain relief began in 2016 with the Vet Futures initiative. This then led to the ambition in the RCVS Strategic Plan 2017-2019 to ‘review the regulatory framework for veterinary businesses to ensure a level playing field, enable a range of business models to coexist, ensure professionalism in commercial settings, and explore the implications for regulation of new technologies (eg telemedicine)’. This led to consideration of ‘telemedicine’ in its narrowest sense, ie in relation to remote prescribing, including the possibility of ‘trialling’ remote prescribing.
  2. A key theme that emerged through these discussions was that remote prescribing and out-of-hours care were closely linked. The reason being that if a medicine is prescribed without a physical examination, consideration needs to be given to where owners go to seek help for their animals in the event of an adverse reaction or deterioration.
  3. All the of the above ultimately resulted in the current, broad-ranging review of under care and out-of-hours guidance that began in 2019, conducted by the RCVS Standards Committee. As this review hinges on the legal interpretation of the terms ‘clinical assessment’ and ‘under care’, we sought legal advice to ensure that the basis of the guidance that governs the profession is correct and reliable. That legal advice is discussed further below and underpins the recommendations made.
  4. The Standards Committee presented its findings to Council in spring 2022, and we now wish to consult on the changes proposed as a result.

C. The current position

Under care

"The terms 'under care' and 'clinical assessment' are not defined by legislation, so it is left to the RCVS to interpret what they mean."

  1. Before a veterinary surgeon can prescribe prescription-only veterinary medicines (POM-Vs), according to Schedule 3, paragraph 4 of the Veterinary Medicines Regulations 2013 (VMRs) they must first carry out a ‘clinical assessment’ and have the animal ‘under their care’. These terms are not defined by the VMRs and so it is left to the RCVS to interpret what they mean.
  1. It is important to note that, under the VMRs, the requirements to carry out a clinical assessment and have the animal under one’s care only apply to the prescription of POM-Vs. This means that when prescribing other classes of medicines or treatment not involving the prescription of POM-Vs, veterinary surgeons do not need to satisfy these requirements (although there are more general obligations relating to the provision of veterinary care, 24-hour emergency first-aid and pain relief, and responsible prescribing that must be met).
  2. Our current guidance on prescribing POM-Vs effectively requires a physical examination to be carried out before a veterinary surgeon can establish that an animal is under their care. The guidance states that animals should be ‘seen’ immediately prior to prescribing or ‘recently or often enough for the veterinary surgeon to have personal knowledge’ of the animal or herd. It goes on to say that a veterinary surgeon cannot usually have an animal under their care if there has been no physical examination and that they should not prescribe POM-Vs via the internet alone. Remote prescribing is therefore allowed under our current guidance, but only where the animal is already under the veterinary surgeon’s care. 
  3. We recognise, however, that there are some situations where the precise requirements of the VMRs are not practical, for example, when prescribing for herds, shoals and flocks, or issuing repeat prescriptions as a locum. In addition, the current guidance was written at a time before good quality video calls were widely accessible and physiological data could, in some cases, be gathered at a distance.

    24-hour emergency first aid and pain relief

  1. The RCVS Code of Professional Conduct requires all veterinary surgeons in practice to ‘take steps to provide 24-hour emergency first aid and pain relief to all animals according to their skills and the specific situation’. Veterinary surgeons are not obliged to provide the service personally or expected to remain constantly on duty. They are, however, required to ensure clients are directed to another appropriate service when they are off duty or otherwise unable to provide the service. The current guidance is set out in full in Chapter 3: 24-hour emergency first aid and pain relief.
  2. The out-of-hours obligations for veterinary surgeons working for limited service providers (LSPs), or based in referral practices, are slightly different to the general position described above and this is discussed more below.

D. The review

"The issue of whether a physical examination is necessary [in order to make a clinical assessment] should be a matter of judgement for the veterinary surgeon in each, individual case."

  1. The current review began in 2019 to find out whether the current rules are fit for purpose, or whether change is required. As with all RCVS guidance, the aim is to protect animal health and welfare, maintain and uphold veterinary standards and ensure public confidence in the profession.
  1. To assist with data gathering, the Standards Committee engaged the services of RAND Europe (an independent consultancy). The review comprised focus group discussions with members of the professions, the outcomes of which informed a survey which went out in May 2021 and had 5,544 responses. RAND analysed the survey responses and produced a report.
  2. As a result of the difficulties arising from the Covid-19 pandemic, it was necessary to suspend the normal guidance and introduce temporary guidance allowing veterinary surgeons to establish ‘under care’ remotely in certain situations. The purpose of this was to ensure that veterinary surgeons could continue to care for animals without breaching government guidelines and restrictions, and in a way that was safe for them, their teams and their clients.
  3. The operation of this temporary guidance presented us with a unique opportunity to carry out research and gather evidence based on real experiences. We therefore commissioned two independent pieces of research from SAVSnet and VetCompass to find out how veterinary surgeons applied the temporary guidance, and to compare treatment before and after the pandemic to see whether there were any negative implications for animal health and welfare. The findings showed that veterinary surgeons behaved responsibly and, where issues were identified, these have been factored into the proposals (see section B of the online survey). In the words of VetCompass: ‘Throughout the pandemic, veterinary professionals have acted in a manner that not only protected human health but ensured animal health or welfare were not compromised’. The research report from SAVSnet and executive summary with presentation from VetCompass are available to view online. 
  4. As explained above, this review hinges on the interpretation of legislation and, in particular, the terms ‘clinical assessment’ and ‘under care’. Therefore, we sought legal advice to ensure the basis of the guidance that governs the profession is correct and reliable. Interpreting legislation requires an assessment of intention at the time it was enacted, as well as applying the context of today’s world.
  5. In the case of ‘clinical assessment’, we have been advised that this should be interpreted as including both in-person and remote clinical assessments. The issue of whether a physical examination is necessary should be a matter of judgement for the veterinary surgeon in each, individual case. We were further advised that ‘under care’ does not change the interpretation of ‘clinical assessment’ and involves consideration of whether the veterinary surgeon has taken professional responsibility for the animal. This legal advice can be viewed online.
  6. The proposals in this consultation therefore reflect the findings of the review, the results of the independent research projects, and legal advice we have received.

Why are we consulting?

  1. With all the above in mind, we would like your views on our proposed guidance on ‘under care’, in particular, on whether there are adequate safeguards built in to protect animal health and welfare and to maintain public confidence in the veterinary profession. As regards out-of-hours care, we would like to know whether you agree with the approach taken, together with some specific questions about what level of 24-hour emergency cover is appropriate for limited service providers and referral practices.
  2. We believe that the proposed guidance set out in Section E will continue to protect animal health and welfare and ensure veterinary surgeons prescribe POM-Vs safely. The proposed guidance is intended to uphold public trust in the profession and give clarity, as well as providing a degree of future proofing so that the profession is prepared for the inevitable development of technology.
  3. We also intend to consult with members of the public to better understand their views and how the proposals might affect access to veterinary care.

E. Proposed 'under care' guidance

  1. We propose that the current guidance on ‘under care’ be removed and replaced with the following.

Prescribing POM-Vs

  1. According to the Veterinary Medicines Regulations 2013 (VMRs), to prescribe prescription-only veterinary medicines (POM-Vs), a veterinary surgeon must carry out a clinical assessment of the animal and the animal must be under their care. The terms ‘clinical assessment’ and ‘under…care’ are not defined by the VMRs, however the RCVS has interpreted them in the following way.
  2. An animal is under a veterinary surgeon’s care when the veterinary surgeon is given, and accepts, responsibility for the health of an animal (or a herd, flock or group of animals) whether generally, or by undertaking a specific procedure or test, or prescribing a course of treatment. Responsibility for an animal may be given by the owner/client, statute or other authority.
  3. A clinical assessment is any assessment which provides the veterinary surgeon with enough information to diagnose and prescribe safely and effectively. A clinical assessment may include a physical examination, however, this may not be necessary in every case.
  4. Whether or not a physical examination is necessary is a matter for the veterinary surgeon’s judgement. The following factors are relevant in this respect, however veterinary surgeons should note this list is not exhaustive:
    1. The health condition, or potential health conditions, being treated and any associated risks (see further guidance below at paragraph 5 and 6)
    2. The nature of the medication being prescribed, including any possible side effects (see further guidance below at paragraphs 7 and 8)
    3. When the animal (or premises in the case of agricultural animals) was last physically examined by a veterinary surgeon
    4. Whether there is access to the animal’s previous clinical history
    5. The experience and reliability of the animal owner
    6. Whether the animal is known to the veterinary surgeon and/or whether there is an existing relationship with the client or animal owner
    7. The practicality of a physical examination for individual animals, particularly when dealing with herds, flocks or groups of animals
    8. The health status of the herd, flock or group of animals
    9. The overall state of the animal’s health
    10. The impact of any prescription made without physical examination on the ability to gather subsequent diagnostic information
  5. The more complex or unusual the health needs of the animal, or where a differential diagnosis includes serious conditions not yet ruled out, the more likely a physical examination will be necessary.
  6. In respect of paragraph 4(a) above, a physical examination is required where a notifiable disease is suspected or part of a differential diagnosis.
  7. In respect of paragraph 4(b) above, and given the importance of minimising the development of antimicrobial resistance:
    1. A physical examination is required in all but exceptional circumstances where a veterinary surgeon prescribes antimicrobials for an individual animal or group of animals that are not agricultural animals. Veterinary surgeons should be prepared to justify their decision in cases where antimicrobials are prescribed without a physical examination and record this justification in the clinical notes.
    2. When prescribing antimicrobials for agricultural animals, veterinary surgeons should ensure they have an in-depth knowledge of the premises, including its production systems, the environment, disease challenges and the general health status of the herd or flock. Veterinary surgeons should have attended the premises and physically examined at least one animal immediately prior to prescribing or, where this is not possible, recently enough to ensure they have adequate information and knowledge to prescribe responsibly. Veterinary surgeons should be prepared to justify their decision in cases where antimicrobials are prescribed without conducting a physical examination and record this justification in the clinical notes.

      Note: For more information about responsible prescribing to minimise antimicrobial resistance, please see Chapter 4: Medicines, paragraphs 4.23 and 4.24.
  8. In respect of 4(b) above, when prescribing controlled drugs to an animal in the first instance, veterinary surgeons should carry out a physical examination in all but exceptional circumstances and be prepared to justify their decision where no physical examination has taken place. This justification should be recorded in the clinical notes. It is acceptable to issue a repeat prescription for controlled drugs without a physical examination, however, veterinary surgeons should carry out a further clinical assessment to ensure they have enough information to do so safely and effectively.
  9. Where a physical examination is not carried out immediately prior to prescribing POM-Vs, veterinary surgeons should ensure that a 24/7 follow-up service involving physical examination and any other necessary investigation if required is immediately available in the event that the animal does not improve, suffers an adverse reaction or deteriorates. Where a veterinary surgeon is not able to provide this service themselves, they should arrange for another veterinary service provider to do so. This arrangement should be made before veterinary services are offered and confirmed in writing as part of the conditions of service agreed by the client.
  10. Veterinary surgeons must maintain clinical records of animals, herds, flocks or other groups of animals under their care.

F. Recommendations regarding 24-hour emergency cover

"Animal welfare is best served by the current requirement that veterinary surgeons in practice take steps to provide 24-hour emergency first-aid and pain relief."

  1. We do not propose any substantive change to our current guidance on 24-hour emergency first aid and pain relief, except for the proposed guidance for limited service providers (LSPs) set out below. We believe that, in the absence of an animal equivalent to a local accident and emergency department, animal welfare is best served by the current requirement that veterinary surgeons in practice take steps to provide 24-hour emergency first-aid and pain relief.
  1. Our current supporting guidance only recognises two kinds of LSP, namely, vaccination clinics and neutering clinics. Veterinary surgeons who work in vaccinations clinics are required to make provision for 24-hour emergency cover for the period in which adverse reactions may arise. Those working in neutering clinics must make provision for the entire post-operative period during which complications arising from the surgery may develop.
  2. We recognise that there are many other types of LSP not currently provided for, and that fairness requires that providers should be treated the same unless there is good reason not to. We therefore propose that the current guidance on LSPs (see paragraphs 3.49-3.41 of Chapter 3: 24-hour emergency first aid and pain relief) be removed and replaced with that set out below, which provides a broader definition of the type of practice that can be considered an LSP and imposes a general obligation to provide out-of-hours emergency care that is proportionate to the service offered.
  3. We believe that the proposed guidance will protect animal health and welfare whilst providing clarity and ensuring fairness.

Limited service providers

1. A limited service provider is a practice that offers no more than one service to its clients and includes, but is not limited to, vaccination clinics, equine reproductive clinics and neutering clinics. For these purposes, a ‘practice’ is a Registered Veterinary Practice Premises (RVPP) as entered into the register held by the RCVS.

2. Limited service providers should provide 24-hour emergency cover that is proportionate to the service they offer. This means that veterinary surgeons working for limited service providers should ensure that the 24-hour emergency cover provision covers any adverse reaction or complication that could be related to procedures or examinations carried out, or medicines prescribed or used.

G. How to respond [NB consultation now closed 26/09/22]

  1. This consultation is for veterinary professionals and those working alongside them, vet and vet nurse students, and representatives of stakeholder organisations.
  1. Details of a separate consultation exercise for the animal-owning/-keeping public will be published in due course.
  2. Before you respond to this consultation, we would urge you to view the additional reports, research papers and legal advice information attached to this page. 
  3. This is your opportunity to tell us whether our proposed new guidance on ‘under care’ and 24-hour emergency first-aid and pain relief contains adequate safeguards to protect animal health and welfare, and to maintain public confidence in the veterinary professions.
  4. We would like to know how much you either agree or disagree with each element of the guidance, and whether you have any specific comments or suggestions to make in each case.
  5. To submit your views, please visit our online survey. You will first be prompted to answer a few demographic questions, for example, whether you are responding as an individual or on behalf of an organisation, before answering questions on the guidance itself.

    Go to survey
  6. Please note: if you have enable cookies on your browser, your responses may be saved as you progress through the question. However, we recommend that you view the questions first and prepare your responses offline, before adding and submitting your responses in one sitting.
  7. The deadline for responses is 5pm on Monday, 26 September 2022.
  8. Thank you for taking the time to send us your views. We do not ask for any personal identification details in the questionnaire, so all individuals' responses are anonymous. We may quote some responses in any report produced following this consultation, providing you have consented to us doing so. Where comments from organisations are used as part of any report, the organisation will be identified.
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