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Martin Alder
The Editor
Veterinary Record
Sir,
The changes to the Veterinary Surgeons Act (and with that the proposed Practice Standards Scheme) have been presented as the modernisation of the Veterinary profession and a way of bringing greater public understanding to the process by which vets are regulated and made accountable. Would that it were so.
The fact that veterinarians will remain professionally unaccountable for their clinical practice has to cast serious doubt on their right to consider that they actually belong to a ‘profession’. One of the criteria that establishes ‘professional’ status has to be accountability to a regulating body for the way in which the knowledge specific to that profession is used. At present, the only place vets can be held accountability for their clinical actions is through the civil courts; a state of affairs that would be thought inconceivable for any other medical/care-based profession.
This complete lack of professional accountability has deep ramifications; vets who are negligent in their direct actions are entirely free of any professional sanction, but so are practices and organisations that simply fail to follow best practice. There is, for instance, no way of making a vet accountable for ignoring infection control practices outside of a civil suit, and it is entirely unclear that the new practice standards scheme will change this in the least. Such failure falls outside of the disciplinary remit of the RCVS and no change to this principle is made in the new Act.
In establishing a process and principle of professional accountability a profession also makes explicit its duty of care. At present, although vets are trained to treat animals, they are actually under no professional duty to do so (unless such a failure can be considered disgraceful professional misconduct), nor are they under any obligation to consider the impact of their actions on the owners of pets, the public at large or the public standing of their own profession.
Those of us outside of the veterinary profession who have had cause to rue the statutes empowering the RCVS in its regulation of vets can see little in the new proposals to commend themselves. While the practice standards scheme is welcome, it falls far short of that which is needed to bring the veterinary profession fully into the 21st century.
Jill Moss,
Mark Dosher
PETS-MRSA.COM
The following response was made
J. C. Hern, the RCVS Registrar, comments:
Ms Moss and Mr Dosher have raised a number of serious concerns about the ability of the veterinary profession to regulate itself, which are based on misunder-standings. All of the bodies which regulate professions, whether veterinary, medical or otherwise, have a limited and parallel jurisdiction to that of the civil courts. Negligence is a matter for the civil courts and regulatory bodies are not in a position to usurp this.
The business of regulatory bodies is professional misconduct, which in legal terms is not the same thing, although there is an overlap if the negligence is very serious. This can be seen from the reports of the Disciplinary Committee, which are on the RCVS web-site at www.rcvs.org.uk
The current Guide to Professional Conduct, also on the RCVS website, already sets out a veterinary surgeon's responsibilities towards patients, clients, the general public and professional col-leagues, and makes clear that accessibility, accountability and transparency are fun-damental to the regulation of the veterinary profession. Indeed, all veterinary surgeons on admission to the profession make a declaration that their 'constant endeavour will be to ensure the welfare of the animals committed to my care'.
The new RCVS Practice Standards Scheme is designed to build on these existing responsibilities and to address the need to regulate the delivery of veterinary services. Practice standards nre not limited to premises and equipment and will extend to clinical issues. As the standards are developed and adopted by the profession they will provide a proactive means of regulation, by means of advice and inspections, to supplement the limited powers under the current legislation to react when things go wrong.
This is very much in line with the expectations of a modern regulator. It should also be pointed out that no amount of standards and monitoring will eliminate the inevitable risks that arise with many medical treatments and surgical procedures. Sadly, no regulator can ensure a 'zero-risk' environment.
J. C. Hem, Registrar, RCVS, Belgravia House, 62-64 Horseferry Road, London SWIP2AF
Dear Ms Moss,
I have taken over responsibility from Dr Brian Crook for dealing with your enquiry. This is because the matters you have raised are more to do with HSE's operational arm than with our HSL laboratory services. It may well be that you were not aware of the linkage between HSE and HSL. I manage the national team responsible for developing operational policy with respect to health issues in agriculture and related areas, including veterinary practices.
The HSE's Field Operations Directorate carries out enforcement of the Health and Safety at Work etc Act 1974 and related statutory provisions at veterinary practices. This legislation is concerned with the health, safety and welfare of people and not animals. Infections in animals are not normally our concern. The exception is where such infections can give rise to a risk to people as a result of work activities that involve the said animals. For example in agriculture this would include the classical zoonoses such as Orf, Newcastle disease and Lyme disease. HSE's priorities are set out in a strategy that is published on our website, www.hse.gov.uk.
If you refer to the strategy you will probably gather that inspection of veterinary practices is not one of our priorities. I think this is only reasonable as they have a good health and safety record and it is right that we direct our finite resources to areas where there is a greater risk of harm. You will recall the exchanges you had with Andy Fisher of the HSE Press Office in January of this year when he advised you that we knew of no cases of animal to human transmission of MRSA.
This is not, of course, the same as saying such transmission could not happen, but it does serve to indicate that we do not appear to be facing a serious risk to human health. The Health Protection Agency (HPA) and Defra support that view, as evidenced in the Defra question and answer brief that you have made accessible on your own web site. Similarly, Dr Scott-Park, the President Elect of the British Veterinary Association (BVA) is quoted on 30 March 2005 on their web site as stating 'Current scientific evidence supports the opinion that the risk of pet-transmitted MRSA is small and that pet owners who undertake hygienic precautions are at minimal risk'
The same would apply to workers in veterinary practice. Dr Scott-Park goes on to state 'Furthermore, there are no proven recorded cases of MRSA jumping from animals to human.' And she goes on to say 'the BVA's major concern at present relates to MRSA passing from humans to animals, the more likely path'.
This echoes the views expressed in the Defra Q&A brief on your web site. Therefore, unless you have some evidence of harm to humans at the Medivet practice caused by MRSA transmission from animals treated there, then I can see no locus for action by HSE. I regret that simply stating you believe some animals have acquired MRSA infection at the practice does not amount to sufficient evidence to justify our intervention.
In terms of the risk of transmission from pet to pet, then you will be aware the situation is being monitored and investigated by Defra, HPA, BVA and the British Small Animal Veterinary Association, the latter has also produced relevant guidance for vets. f you have a complaint about the professional conduct of the practice then it should be addressed to the RCVS as the body having relevant regulatory powers under the Veterinary Surgeons Act 1966.
But, I am sure you already know this. I regret that my reply is likely to disappoint you, but if you feel I have misunderstood your position then please do not hesitate to contact me.
Yours sincerely, Frank J Perkins HM Principal Inspector of Health and Safety Agricultural and Food Sector - Health, Education & Chemicals Section
VPN Tel. 513 2890 VPN Fax. 523 2869 (0115 971 2890) (0115 971 2802) frank.perkins@hse.gsi.gov.uk
Dear Mr Perkins,
Thank you for your email and I appreciate the time you have taken to reply to me.
Whilst I fully appreciate that Health and Safety legislation is concerned with human, rather than animal, health I believe that there are a number of key points of which you may be unaware. The exception you note (those cases where infections in veterinary practices may give rise to risk to people) is precisely the point I have been making. I firmly believe that as a result of being confined to a room barefoot and with small open wounds for two days, my own infection of MRSA occurred at the Hendon Medivet clinic, and analysis of the strain showed that it was completely unrelated to the strain found in my dog, thus demonstrating that I could not have contracted my infection from her. It was, perhaps, fortunate for me that my infection was relatively insignificant, but had I been in less robust health, the consequences to myself would have been much more significant.
It is not true that there have been no recorded cases of MRSA being passed from pet to owner: Asymptomatic Nasal Carriage of Mupirocin-Resistant, Methicillin-Resistant Staphylococcus aureus (MRSA) in a Pet Dog Associated with MRSA Infection in Household Contacts Farrin A. Manian Division of Infectious Diseases, St. John's Mercy Medical Centre St. Louis Missouri Received 29 May 2002; accepted 5 August 2002,; electronically published 6 January 2003. clearly documents a repeated process of infection from pet to owner, and it has to be assumed that this was not he only occurrence to have ever taken place.
It should also be noted that in this paper, the authors noted only one other case of MRSA in dogs, whereas the Idexx laboratory in Wetherby has isolated over 250 case of MRSA in animals (I have attached a copy of the letter in which they describe this). It also a fact that other animals have been infected at the same Medivet premises as Bella was, and these animals have returned home to owners concerned with their own vulnerability to MRSA.
It is also true that, speaking informally, Occupational Health department of hospitals will tend to consider pets when presented with repeated colonisation and infection of staff with MRSA. It is true that the prevalent route of transmission appears to be from human to animal, but as there has been virtually no research on the prevalence of MRSA colonisation in healthy pets of infected owners, it cannot be said with any certainty that there is no significant risk.
Veterinary practices, whilst quite possibly having very good health and safety records, have traditionally and systematically failed to establish levels of MRSA contamination in their premises. The fact that it is only in the very recent past that vets have even acknowledged the possibility that pets could carry MRSA serves to show that there has been no interest in investigating the issue.
Thus, the lack of data only illustrates a failure to collect, rather than definitely establishing the level of risk. Finally, I am pleased that the organisations you mention are monitoring and investigating the risk of pet-to-pet transmission of MRSA, but I am unaware of any mechanism by which this is to be achieved. DEFRA, the HPA, the BVA and the BSAVA have not indicated in any accessible arena the mechanism by which this monitoring is to be carried out nor the expected response; and whilst the BSAVA and the RCVS have produced relevant guidelines, these are voluntary and no vet is under any obligation to adhere to them.
I really do appreciate that MRSA in pets is probably considered to be of little importance in the range of issues dealt with by the HSE, but it is worth considering that the BVA, in six months, as a result of my campaign, has gone from essentially denying that MRSA presents a problem in pets to making public statements urging vets to practice proper infection control.
Whilst some will argue that my own infection cannot be proved conclusively to have arisen from the Medivet premises, there really is no other reasonable explanation. As I was infected, so will others be, but for someone it will be too late to do anything about it. The history of infectious processes is characterised by the failure to anticipate trends in epidemiology or, conversely, the creating of a state of alarm disproportionate to the actual risk. My aim is to achieve that middle ground; the proper acceptance by regulatory bodies concerned with societal wellbeing of the potential for serious harm. Thank you for taking the time to read this.
Yours sincerely
Jill Moss.
Dear Ms Moss,
Thank you for your e mail of 6 April 2005.
I was not sure if you were seeking a response, but have decided it might be helpful to comment on some of the points you have raised. The American paper you cite concerns a case where transmission from pet to owner was considered to be a possibility rather than proven, as shown by the repeated use of the word 'likely'.To quote from it directly: "It is likely that the dog (which had not been ill or hospitalized or received antibiotics previously) initially became colonized by MRSA through contact (often intimate) with the patient, who had previously been hospitalized. In turn, the dog likely served as a source of reinfection or recolonization for both the patient and his wife. Direct person-to-person transmission of MRSA between the patient and his wife might have also occurred".
It may be an academic point but the animal appeared in this case to have been a reservoir rather than infected, hence the use of the word 'Asymptomatic' in the title of the case report.. However, this case does not really make any significant difference to HSE's position. I made it clear in my earlier note that, although no proven recorded case of pet to human transmission had occurred, this was not the same as saying such transmission could not happen, i.e. I accept it is a possibility.
But, HSE and all of the organisations mentioned in my previous note are satisfied that, currently, there is no hard scientific evidence of a serious risk to humans. In terms of other evidence coming to HSE, we have had no reports under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 of workers being harmed by MRSA transmission from animals. Similarly, we have had no complaints or other approaches, from any members of the public (apart from yourself) alleging that such harm has occurred to them.
The issues of prudent behaviour and the state of an individual's health/vulnerability have to be considered. In the American case above the couple involved were a male with diabetes, renal problems and a non-healing leg amputation; his wife had diabetes and a kidney transplant, yet "On further questioning, the couple reported that the dog routinely slept in their bed and frequently licked their faces".
In your own case it appears from what you said that you were in the Medivet Practice premises barefoot and with small open wounds, i.e. in a state where you would be more susceptible to infection. Keeping a pet gives real enjoyment to people, but it is important to recognise that, because of certain habits animals have, there are potential risks to human health.
While simple hygiene precautions such as hand washing before handling food are needed to prevent, for example, stomach upsets in a generally healthy person, further precautions would be needed for someone in a condition where they were more susceptible to infection. One of the authors of the letter to the editor of the 'Veterinary Microbiology' journal, Angela Kearns, is from the HPA Staphylococcus Reference Laboratory.
This fact suggests to me that HPA have their finger on the pulse of this potential reservoir of infection and are well placed to act should this prove to be a significant risk to the generally healthy population within the context of the continuing fight against MRSA. While there may well have been benefits from your own campaign, in terms of raising the general level of awareness of the issue, I do consider it is important that we keep the risks in proportion.
And, in saying this, I do hope that you will accept that I am in no way seeking to undermine or minimise your own sad loss. I have had several dogs and fully understand what an important part they play in our lives and how much we miss them when they are gone.
Yours sincerely,
Frank J Perkins HM Principal Inspector of Health and Safety Agriculture and Food Sector - Health, Education & Chemicals Section VPN Tel. 513 2890 VPN Fax. 523 2869 (0115 971 2890) (0115 971 2802) frank.perkins@hse.gsi.gov.uk
Dear Mr Dismore (Local MP)
Medivet - Hendon Clinic
I refer to your letter dated 10th January 2005 on behalf of your constituent, Jill Moss. Officers have spoken to Ms Moss and are surprised to learn that she has been informed that the RCVS do not have power to act on such matters. I can confirm that this is not a matter that is covered by any trading standards legislation.
However, veterinary practices are covered by workplace health and safety law, enforced by the Health and Safety Executive. The Control of Substances Hazardous to Health Regulation: includes requirements to control pathogenic organisms, such as MRSA, where there is a risk to staff or public arising from a work activity.
Whilst it may be difficult in practice for the HSE to take formal enforcement action in such circumstances as Ms Moss has raised, it would appear to us that they do have powers to investigate, and take action if considered appropriate.
Yours sincerely
Steve Presland
Head of Environmental Services
Andrew Dismore Labour Member of Parliament for Hendon
17th March 2005
HOUSE OF COMMONS
LONDON SW1A OAA
Our Ref. 11/04/9085
Please quote reference on all correspondence
Dear Ms Moss, Thank you for your letter of the 28th of February.
The HSE will always set its own priorities, based on risk assessments for particular industries and activities. In fact, the Work and Pensions Committee of which I am a member recently published a report on the work of the Health and Safety Executive and I am enclosing a copy of this.
You will see the recommendations we made, to increase HSE resources. As things presently stand, I suspect the HSE will not prioritise the particular problem to which you refer, bearing in mind the much greater risks they have to monitor in other areas of the work place. The HSE is answerable to the Health and Safety Commission, an agency which is at arms length from the Government in the way that it operates, and quite rightly so, to ensure no Government interference in such an important issue.
Yours sincerely, Andrew Dismore
Andrew Dismore
MP
House of Commons
Westminster
London
SW1A 0AA
February 28th 2005
Dear Mr Dismore Thank you for forwarding the copy of the letter you received from Steve Presland at Barnet Environmental Services. The trail of responsibility (for addressing outbreaks or infection on veterinary premises) seems to lead to the HSE, but they appear to have complete discretion in deciding whether to proceed or not, regardless of the fact that an outbreak has occurred and at least one human has become infected.
From emails I have received from Terry Vaughan, (Group manager, Health And Safety And Licensing) the HSE appears to consider that the risks presented to humans from MRSA infected companion animals is low, but I suspect that this judgement has only been reached because of the lack of any serious research into the matter rather than an appropriately calculated probability of risk.
Coupled with that is the fact that the HSE had to be convinced (and were shocked to discover) that the RCVS has no jurisdiction over infected veterinary premises, so clearly there is a lack of clarity and understanding on the part of the HSE, of the role of the RCVS.
My website is in the process of becoming a registered charity, and this is one of the issues it will be seeking to publicise through its activities at conferences and through the press. The fact that the HSE can decide, apparently arbitrarily, to act or not must be of great public interest given the general and growing concern over MRSA in all its forms.
The website is receiving regular questions about this area of responsibility and we have no satisfactory answer to give. Perhaps you are aware of the person either in local or central Government who would be able to give a definitive answer. I look forward to hearing from you.
Yours sincerely
Jill Moss
