Dr. James Russell

British Veterinary Association photo

Dr. James Russell, a farm veterinarian who is president of the British Veterinary Association, believes that practitioners have adapted to the COVID-19 pandemic sufficiently to allow telemedicine regulations that were relaxed in March to be reinstated.

When regulators around the world started relaxing restrictions on the remote prescribing of medications for veterinary patients this spring, few practitioners complained.

The United States, United Kingdom and countries throughout the European Union had imposed strict lockdowns designed to counter a spike in COVID-19 cases that they feared could overwhelm their health-care systems. Telemedicine, authorities decided, could enable animals to be treated from a distance while their owners hunkered down safely in isolation.

Now, some six months later, pushback is coming from the veterinary community in the U.K., out of concern that virtual consultations may pose risks to animal welfare.

The British Veterinary Association, the profession's largest membership group there, has asked the regulatory body Royal College of Veterinary Surgeons to immediately reinstate rules governing telemedicine that were relaxed on March 24.

Under normal circumstances, most of the world's veterinary regulators mandate a physical exam of an animal as a prerequisite to remote care. The reasoning is grounded in the idea that remote care is risky for animals because they, unlike humans, can't tell doctors how they feel. Many regulators, however, began prioritizing human health when the pandemic got into full swing around March and April.

In the U.S., requisites concerning telemedicine often are codified in state regulations, which vary by jurisdiction. Some states, such as Arizona, California, Oregon and Pennsylvania, have relaxed veterinary-client-patient-relationship requirements to allow remote prescribing during the pandemic. The abatement in those states persists, for now, even as lockdowns have eased.

In Britain, the RCVS has extended a relaxation of its remote prescribing rules several times. It was its latest extension — by at least one more month, until the end of October — that prompted the BVA to speak up.

BVA president Dr. James Russell told the VIN News Service that the association isn't necessarily opposed to tweaking the rules around telemedicine more broadly. Remote prescribing in some instances can make sense, he said, offering the example of a cat with hypertrophic cardiomyopathy, a heart condition, that is so stressed by visiting a veterinarian that its condition worsens. "We've got a very open mind about this," he said in a telephone interview.

Still, Russell said the BVA wants a broader RCVS-led consultation process and rule review that started last year to be completed before any changes are enacted. In the meantime, he's worried that pet owners are becoming too accustomed to what was meant to be a short-term fix.

"The college has opened up a consultation on this, and all the while, the general public is growing more and more expectant that this is just the norm," Russell said. "So it's going to be a very challenging one to put back in the bag if the consultation [results in a decision that] the rules shouldn't change."

For the RCVS's part, the COVID-19 situation in the U.K. remains serious enough to justify allowing remote prescribing without a physical examination. The college's president, Dr. Mandisa Greene, said in an Oct. 2 statement that circumstances might still arise in which it would not be possible for a pet owner to see a veterinarian in person.

"These could include further local lockdowns, ongoing quarantine arrangements and the remaining fact that some members of both the veterinary team and the public continue to shield," Greene said. "It remains our intention that this guidance will continue to be a temporary measure and may be subject to further extensions or updates given the uncertain nature of the COVID-19 pandemic."

The COVID-19 situation in the U.K., as in elsewhere in the world, remains precarious. Britain started in May to ease nationwide lockdown measures, but a recent resurgence of cases has prompted lawmakers to impose new restrictions in some local areas, such as Liverpool, involving the closure of restaurants, bars and gyms, and bans on some indoor social gatherings. The U.K.'s opposition Labor party called last week for a two- to three-week "circuit-breaker" national lockdown, though its calls have been resisted so far by the ruling Conservative party.

Russell says the BVA's desire for a return to the stricter telemedicine rules is based on two factors. First, he said there are currently no regulations to prevent a pet owner from visiting a veterinarian in person. "Even in the most extreme areas of Liverpool and what-have-you, where they're being locked down very hard, going to the vet for animal welfare reasons is considered a valid reason to leave home," Russell said.

Secondly, he said, practitioners, having had six months to adjust to the pandemic, are now better equipped to see patients safely, whether by offering curbside services or applying cleaning protocols. "Vets have learned and adapted," Russell said. "They've done a brilliant job and they're working safely in seeing patients right across the country."

Should the government's approach to lockdown change again dramatically, Russell said the BVA would be prepared to accept an ongoing relaxation of telemedicine rules. "Of course, human health and veterinarians' commitment to helping stop the spread of COVID will trump all else," he said. "At that point, we would have to reconsider our position, but it would have been after quite a significant change in tone from the guidance coming out from [the] government."

Practitioners still turning to telemedicine, but in fewer numbers

Results of a recent survey by the RCVS indicate that demand for in-person veterinary services in the U.K. has recovered to more normal levels. The RCVS conducted four surveys this year to gauge how the profession is coping with the pandemic. Its fourth and latest poll, results of which were published on Oct. 5, garnered responses from 241 practices questioned between Sept. 1 and Sept. 7. Of those, 58% said they were operating a "near normal" in-person service, while 27% said it was "business as usual." For 80% of respondents, their practice’s cash-flow position had stayed the same or even improved compared with before the pandemic.

The survey further found that 50% of respondents were using remote consulting, down from 80% in June. Of those 50%, more than half (56%) were using remote consulting for existing patients only, 43% were using it for both new and existing patients, and just 1% were using it for new patients only. Practices were using remote consulting mostly for triage and repeat prescriptions, with a minority using it for prescriptions for new conditions.

Dr. Richard Weston, a veterinarian at Pet Healthcare Centers in the English town of Wigan, welcomes moves by the BVA to have the RCVS's code of conduct reinstated. Weston has long been a vocal critic of moves to relax rules around telemedicine. He challenged the RCVS about its approach to the issue last year, according to the minutes of the RCVS's 2019 annual general meeting. Even so, Weston accepted temporary relaxation of telemedicine rules this year.

"Whilst I reluctantly agreed there was a place for remote prescribing in May to July — albeit our practice managed to get through that period without prescribing to patients that had not been examined — circumstances in practices have improved during August and September," Weston told VIN News via email.

"Why does it take to the end of October, and then a meeting, to reinstate a rule that is already in place?" he asked rhetorically. "This is not rocket science: Check animal in, get past history, see animal in the flesh and then it is under our care. I ask the college to stop looking at ways of diluting the exceptionally high standards our profession has always promoted."

In recent weeks, the RCVS has moved to allay practitioners' concerns. On Oct. 2, when it confirmed the extension of its temporary guidance, the RCVS added a caveat that any prescribing veterinarian "must consider" whether the animal can first be seen in person. On Oct. 15, the RCVS introduced "additional safeguards" starting Nov. 1, should its temporary guidance be extended again. These include a requirement that remote prescribing should be carried out only by veterinarians who can follow up in person if necessary, including outside normal business hours.

Russell at the BVA welcomed the RCVS's updated guidance but questioned keeping rule exemptions in place at all, given that existing lockdown rules do not prevent patients from seeing veterinarians in person. "When you put: 'if at all possible, see the animal' alongside the fact that we're not finding any evidence that it's not possible to see the animal, why leave it there?" he asked.

RCVS spokesperson Luke Bishop, in an emailed statement to VIN News, acknowledged that stricter government restrictions imposed earlier in the year, such as a ban on elective procedures, were eased months ago. But he said a recent announcement from lawmakers and the general trend in coronavirus infection figures "demonstrate that there is a need for this guidance to continue in some form, especially as there is likely to be an increasing number of people (which could include both veterinary staff and clients) who are either temporarily self-isolating or shielding."

Bishop said the RCVS had voted to retain the extension "after much deliberation and discussion," including consideration of available evidence through industry feedback and government guidance. "We have assured the BVA, and would like to reassure the wider profession and the public, that our policy is informed by experiences of the profession at the time, and that it retains considerations of animal health and welfare, and public health, at its heart," Bishop said.

In the meantime, the RCVS is poised to press on with its broader review of telemedicine rules.

Dr. Melissa Donald, chair of the RCVS Standards Committee, said last week that the review would be underway again "shortly," with virtual focus group discussions being arranged by RAND Europe, a not-for-profit research institute. Donald said RAND Europe is in the process of inviting key veterinary stakeholders, such as representative bodies and charities, to contribute to the review.

Findings from focus-group discussions will inform a survey to be sent in early 2021 to all veterinarians and veterinary nurses, along with stakeholder organizations and the animal-owning public.