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For the most part the Veterinary Medicines Directorate does a really good job; it's an effective independent agency of government and manages to do what it does by recovering its costs from the marketplace without public subsidy. It also manages to be very approachable by its various business stakeholders. It's chief executive, Peter Borriello, was congratulated on this at the end of the meeting and had the humility to acknowledge that he could take no credit for VMD's accessibility; it was a legacy of his predecessors in the post of head of VMD that he'd had the good sense to maintain. Despite the celebrations it seemed to me that the day was 90% focused on antimicrobial resistance or AMR.
Peter Borriello opened the day with a talk which he introduced as AMR = "Assumptions Mostly Reasonable"....by which he was saying that the broad thrust of recent developments in European medicines legislation is based not on evidence that there is for example any evidence of inappropriate use of veterinary antimicrobials in the United Kingdom, but on reasonable assumptions about what will stop antimicrobial resistance becoming even more of a problem world-wide than it is at present. This was followed by a slide in which the very first bullet point was labelled "inappropriate prescribing". It would be easy to infer from this that "inappropriate prescribing of antimicrobials by vets" leads to an increase in the risk to humans of treatment failure due to acquired antimicrobial resistance. Rather than for example humans being infected by microorganisms that were resistant to antimicrobials in the first place...or by organisms acquiring resistance due to inappropriate prescribing by GPs. In fact, some of today's papers are carrying stories to do with increased use of antibiotics being driven by hospitals and out-of-hours GPs. It seems to me that even this story does not necessarily indicate 'inappropriate prescribing' The fact is that if patients attempt to access healthcare out of hours, and if their symptoms indicate an infection may be involved in the cause of the condition, or even just in making the presenting condition worse, then doctors, like vets may have little choice other than to prescribe some kind of antimicrobial therapy whilst they await the outcome of further tests. Patients are quick enough to complain if things go badly and treatment isn't forthcoming; faced with signs indicative of some kind of infection you have to be pretty brave to withhold treatment, and very certain that your regulatory body, healthcare trust or other governing body will stand behind you in a crisis where with the benefit of hindsight patients are able to make a case that antimicrobial treatment could have helped had it not been withheld. Vets are in a very similar position whether they are in companion animal medicine or production medicine; often antibiotics have to be prescribed on presenting clinical signs in the first instance, even if treatment is reviewed in the light of further examination or diagnostic tests. This story might just indicate either that there is a growing demand for out-of-hours healthcare and that diagnostic facilities are not organised to support that demand.
Antimicrobial resistance is a growing problem worldwide however, and even if there is no evidence of any problem with the UK distribution system I cannot blame Peter Borriello or the VMD for European legislation designed either to ensure that European prescribers demonstrate that they do have their houses in order, or even legislation designed to improve the situation; the question is, will the result of any measures be an improvement? Both Peter Borriello and a subsequent presenter talked of a need to focus on the facilitation of electronic data recording, collection and capture and to encourage industry to 'innovate and invest so we can capture the data' from all species but with a 'focus on pigs, poultry and cattle'. This may or may not be a reasonable position....it depends upon what you are importing. Because if you are importing fresh or chilled animal produce from countries that do not have robust distribution channels, or care particularly about antimicrobial resistance, it could be that your resistant veterinary organisms are being imported from abroad rather than incubated locally.
Nevertheless, if greater monitoring is the price of continued availability of antimicrobials to veterinary surgeons in order to safeguard animal welfare perhaps we have no choice but to support it. During the presentation one of the presenters cited the 'antibiotic guardian' website as something they felt should be supported and it seems to me to be a useful initiative even if only as an education tool. But if you are going to start collecting more data on antibiotic usage there is a massive question over how you are going to do it. Starting with what data will you collect? What are you going to do with the data when you've collected them? And will you be able to interpret the data given that animal production systems differ around Europe and the relative risk of bacteria entering the food chain may be unrelated to absolute tonnages of antibiotic used, numbers of animals, or weight of processed product but more to do with how the animals are processed.
There were some interesting discussions around production systems in Europe. The Danish system was suggested as a system that was perceived to be reasonably robust but where antimicrobial usage for disease prevention in animals is still acceptable with the caveat that sometimes the terminology varies across the countries and disciplines; what many vets refer to as metaphylaxis some human healthcare professionals refer to as prophylaxis. Out of these discussions, whilst you could see very early on that the devil would be in the detail, you could start to see that if expectations were managed there could be some value in benchmarking systems.
However, reading between the lines of what was said on the day there is still a problem in terms of considering how data could be collected and how databases on antibiotic usage could be collated, even before you consider how the results might be interpreted. One of Peter Borriello's comments which was refreshingly candid was that "...government systems don't work" ie. that big government database projects don't deliver on time, cost or scope. We all know this but it's nice to see a civil servant candidly acknowledge this. However, he also said that "...databases are not owned". And later he said that he wanted private industry to step up to the plate, that there was a small amount of money available, but only until March 2015 and nothing thereafter.
The truth is that databases are owned for a variety of reasons. Legally there is copyright in a database and it is as well to sort out early on who owns it, because invariably somebody does. There is a cost to building and maintaining a database and you can do a great deal of damage with a database or with the data it contains if you fail to take reasonable precautions to secure it, or are not careful about how it is used. So databases are owned...of course they are. And there is a cost to building them which has to be recovered from somewhere.
So somebody somewhere has to have a revenue stream to build this database. Logically, given that you cannot interpret data on antibiotic usage in the absence of benchmarking systems that allow you to interpret prescribing behaviour, in the UK the people who you would have thought would be the primary candidates for looking at prescribing behaviour would be the people inspecting the channel. In the UK, the Veterinary Medicines Directorate, through it's Investigations and Inspections Team (IIT) inspect those veterinary practices that are not part of the RCVS Practice Standards Scheme (PSS) and charge a fee for that. And the Royal College of Veterinary Surgeons inspect those veterinary practices that are part of the PSS and charge a fee for participation. RCVS has reserves approaching £12million, but these are not owned by government; PSS was never designed to be about monitoring antibiotic usage and the RCVS was recently criticised for failing to adequately manage the construction of its own database. The truth is, it is about as good as government is at managing IT projects. And VMD has a revenue stream but is apparently not prepared at the present time to commit any money to building a database.
One of the reasons why VMD survived the Hampton review and was allowed to remain a stand-alone independent agency was because it does manage to recover its cost from the marketplace. That's because it has the power under legislation to be able to do so. I suspect that it may have to rethink its position on ownership of databases and funding because there is no appetite in the present climate for new legislation and the only people with the power to levy fees to build databases and require participation in them are the regulators.
Recovering your costs from the marketplace is fine and we all love a free ride but you can only hitch a lift if there's a vehicle going your way
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