OK, good morning, everyone, and welcome to this 2nd webinar of the day, titled Antibiotic Use in Agriculture, Practical tips for Encouraging Change on Farm. And thanks for giving up your Sunday morning to listen to me. Hopefully some of this will be of interest to you.

So as Fiona introduced, I thought I'd just give my, give a little bit of background on myself. My name is Gwen Rees. And I graduated from the University of Liverpool quite a while ago now and spent several years in mixed practise.

In West Wales and then out in New Zealand, where I worked as a purely dairy vet, before returning to the UK and taking up a teaching fellow position in farm animal population medicine at the University of Bristol. And I think during my career up to that point, I'd become increasingly fascinated with the way that farmers use veterinary advice, the decisions that they make when we're not on the farm, and the way that they use the medicines we prescribe, particularly the differences and similarities between farms of different sizes and management types and even between the countries that I've worked. I knew early on I was guilty of leaving a farm thinking, yeah, I've told them what needs to be done, so that's now what they're gonna do.

And I think this naive thinking was really proved wrong quite quickly, and I remember becoming quite frustrated often, not really understanding why my advice wasn't being listened to. I wish I'd had Alison's talks really, back then. So I've heard that right farmers off is hard to reach or impossible to teach, but the more I thought about it and the more I realised that perhaps it was, I just wasn't ready to understand the reasons why my, you know, so-called expert advice might not be getting through.

So after a and for a while, I wrote a PhD proposal, applied for funding, and was lucky enough to be awarded a scholarship to study this very subject, trying to understand the way in which UK dairy farmers use prescription veterinary medicines. Here in the UK. I have actually submitted my thesis a few weeks ago, so I'm no longer a PhD student.

I'm working as a researcher here. And I found this journey from a quantitatively trained veterinary scientist to more of a qualitative researcher trying to understand the social science and behaviours, both difficult and really quite rewarding. So I'm hoping to share with you all a few insights I've gained because it really has changed the way I think about the interactions we are having daily with our farming clients.

So if you're learning objectives at the end of this webinar, hopefully you'll be able to describe what's currently understood about the way antibiotics and other prescription medicines are being used and stored on farms. Explain how the use of non-antimicrobial prescription medicines and effective herd health planning can influence the use of antimicrobials. Discuss the merits and limitations of the latest research on antibiotic use behaviours, relate the latest research to real life situations, and apply this understanding to facilitate practical changes on farm.

So here's an outline of this webinar. We'll start by looking at a few of the things we already know about medicine use on farms in the UK. Then we'll look at the results of some recent work looking at the way they're being kept on farm.

We'll talk a little bit about alternatives to antimicrobials and the use of herd health planning to reduce overall antimicrobial use before looking at the behaviours and motivations of both the farmers and the vets when we're making these prescribing decisions. Finally, then we'll go through some tips for implementing real impactful change on your client's forms. So we all know.

That antimicrobial resistance is bad. It's not like we can escape it in the news and farmers and vets do still receive more than their fair share of blame from various pressure groups and press outlets. But what is the reality?

Well, in recent years, there's been increasing pressure on the veterinary profession to promote responsible use from many sources, and we've already done some sterling work with the BVA producing excellent guidelines for responsible use in order to support the profession in this endeavour. The agricultural industry is also subject to increasing pressures with various stakeholders driving policy change. It's actually really hard to keep up with all the new policy changes that are happening.

And in part this is coming from the government, but most of this change is being driven by consumers, milk buyers, supermarkets, industry bodies and research institutions. The use of antimicrobial use targets and benchmarking are becoming increasingly common. Farm assurance schemes beginning to shift their gears towards responsible use too.

Some private veterinary practises have also been pretty proactive in this area, working with their clients to measure, benchmark, and ultimately to reduce the use of certain antimicrobials, particularly those classified by the World Health organisation, as of the highest critical importance to human health. So here we're really talking about fluoroquinolones, 3rd, 4th generation cephalosporins, and calistins too. And red tractor's new guidelines, which came out last summer on using HPCIS, they requiring a vet report and diagnostic testing are likely to make a big difference in their use.

So we'll have a look at the current picture. This graphic is from the latest VMD VAs report, which is the annual report on antimicrobial resistance and use surveillance, and this data is from 2017, so it's the latest that we have. This shows that progress has been made amongst food producing species since 2013, when back then the figure stood at 62 MBs per PCU, so population corrected unit.

In 2017, this figure for overall use had reduced to 37 Migs per keg or Migs per PCU and bearing in mind that the nearest comparable figures we have for human use from 2014 is 129 Migs per keg. This is less than a third of that use, although I am told that there's a new, figure about to be released in a joint one health report for human use in M for cake as well. So what classes of antimicrobials are we using in farm animals?

Probably unsurprisingly, tetracycline's the top here, and we've got beta lactams and the sort of remethoprim sulfonamides. Macrolides and monoglycosides, they're comprising the majority of the others. And in comparison for HPCIAs, total weight of use is relatively tiny.

However, this is partly attributed to the lower dose requirements of these drugs. So that's really why we consider these antimicrobials separately to the others. As you can see, in 2017, there was a decrease in use across across all classes of antimicrobials from the previous year, which is excellent news.

OK, and then this graphic again taken from the VAs report just gives us a breakdown of use by species. It's not all species, and it's important to note here that sheep are not present. That's simply because they don't really have any idea what their current use is.

So this is a key area for focus from the Roma Tarts taskforce. We need to improve measurement of antimicrobial use, particularly for beef and sheep, but also for dairy. So where there is no change dated from 2016 to 2017 here, that's simply because 2017 were the first figures published for these species.

So these figures are really a best guess at the moment, and they do need refining and validating. We do need to get better at measuring yeast. But as you can see, pigs are still using a far greater quantity of antimicrobial than the other species listed.

But yeah, take, take these figures with a bit of a pinch of salt until we, until we improve our measuring. OK, so we've looked at how many antimicrobials are being prescribed to UK farms in general, but what is happening to those medicines once they've been prescribed, once they've left the vet practise or car and arrived on the farm. Well, in a paper that was published online back in November and should be out in next week's vet records, which is good timing, we undertook a study as part of my PhD which looked at on-farm storage of prescription veterinary medicines, on some UK dairy farms to try and understand exactly how these medicines are being stored.

So I'll just take you very briefly through a bit of that study because I think some of the results were really quite interesting and give us a bit of an insight as to what's happening when we're not around. So briefly, it was a cross-sectional study. We had 27 dairy farms in the southwest of England and South Wales.

And an initial visit to each research farm was carried out where a full medicine cupboard inventory took place. And I say a medicine cupboard inventory, but this was actually just a full medicine inventory across the farm. So the farmer gave me permission to basically hunt through the entire farm going down into the pit.

Looking in the office, looking in the box on the quad bike, in the car, in the fridge, in the house. I tried to really record every single prescription veterinary medicine that was present on that farm. And the farmers were fantastic about letting me do that, to be fair.

So every, everything that was present was recorded and we took data on medicine type, quantity, labelling, expiry dates, where and how these medicines were being stored. And we also recorded some demographic and form management data at the same time. So as I said, a total of 27 forms were recruited to the study in the summer of 2016.

This is by a combination of nomination by local veterinary practises, word of mouth, and advertising through leaflet distribution. And this recruitment was done by what we call purposive sampling, which is more of a social science, way of sampling for studies. And it's in order to reflect as broad a range of herd sizes, cattle breeds, production goals, and management characteristics as we could.

So as you can see from this table, the median total herd size was 320 animals with 175 cows. In milk, they were producing a median of 1.1 million litres of milk, averaging about 7500 litres per cow per year.

So broadly quite representative of the UK dairy production. Population. As I said, they were all visited for this medicine inventory during a six-week period in September and October 2016.

So this data is from 2016, which does make a difference, when we think about what the milk prices were like at that time, and also that, some of these new regulations haven't come in at that period in time. So how were our farmers storing their medicines? Well, I thought quite positively, really, that 63% of them kept all their medicines in a lockable medicine cupboards, .

We did have some forms storing their medicines in sort of ways that aren't the recommended, so in the non-lockable cupboard or just in the milking parlour, the car shed. The house refrigerator is fairly common. Most farms had a farm refrigerator.

But if it was unlocked, that's counted as separate. And if we look at antimicrobial storage in this graph, which is important if we're to understand the way that farmers are using these antibiotics at their own discretion, it's clear that there's a variation in the total quantities stored, even when corrected for the total number and weight of animals as measured by PCU, so population corrected units. So here, we tried to correct for the total number of animals.

And you'd hope that people would have broadly the same amount of antibiotic per animal or per population corrected unit. But as you can see, there is, you know, the top maybe 25% or 50% of those farms are storing a heck of a lot more than the bottom, and it's trying to understand why some farmers are feeling the need to store so many more antimicrobials than others that we find really interesting. Again, if you correct it by production, because, you might say that a high producing cow is going to require more antimicrobial than a low producing cow.

It doesn't matter what they what they weigh. Well, that maybe did help a little bit, but we've still got these farms, these sort of outlier farms in the top end who are really storing masses of antimicrobials compared to the amount of milk that they're producing. And as you can also see from the darker Two colours on these graphs.

Most of the farms were storing fluoroquinolones and 3rd and 4th generation cephalosporins as well. So in summary, almost 2/3 of farms stored their medicines correctly. 89% were storing critically important antimicrobials on farm in 2016.

And even though at the time the red tractor guidelines hadn't been, changed, there had been a lot of effort to reduce prescribing and use of these medicines before 2016. So this was still considered quite a high figure. I think most interestingly, perhaps almost 3/4 of dairy farms in the study stood prescription veterinary medicines that had passed their expiry date.

And certainly as a vet myself, and I'm sure everyone else would agree, it's probably not that surprising. We know that these medicines go out of date and they stay in the cupboard, and we know that farmers are probably still using them, but that's never actually been measured before. We also found a lot of unlicensed, medicines present on farm.

And in one case, an illegal medicine which shouldn't have been being used in dairy cattle at all was found. This is a little bit more worrying. Obviously, unlicensed medicines can be cascaded too, but what we need to make sure is that farmers understand that they are off licence, understand that the withdrawal periods are different for these medicines.

So, as a result of this paper, during Antimicrobial Awareness Week in November, the University of Bristol joined together with the BVA, BCVA and ROMA to call on farms to work with their farming clients to remove expired and inappropriate medicines from farm cupboards. So, essentially, a farmer can't use what he doesn't, he or she doesn't have, and it's quite likely that they will use things that they do have in their cupboard. It's ultimately our responsibility, what's in that medicine cupboard, and I think we probably need to be doing a little bit more work to take responsibility for the medicines that are present on the farm and to ensure that the farm only has access to medicines that are appropriate for use.

So we've looked at how farmers are storing the medicines that we prescribe to them, which is important because the vast majority of the time, the farmers making the treatment decision in our absence, using the medicine resources that they have available to them. That is the medicines that they have on farm. But how did these medicines get there?

Well, we prescribe them most of the time. Obviously there are occasionally issues with farmers obtaining medicines that haven't been prescribed the way they're veterinary surgeons, but for the vast majority of cases, they're there because we've prescribed them. So the next step is to have a look at vet prescribing and why we prescribe what we prescribe.

Let's have a look then at the clinical factors that might influence our decision to prescribe an antimicrobial or any prescription veterinary medicine. So when we're out on farm deciding to prescribe, there are just so many questions we have to ask ourselves. It can feel a bit overwhelming when you look at them all written down.

But really, we, we're asking these questions every time we think of prescribing antimicrobials, and often it's briefly and subconsciously that we're answering these questions. So if we think of an example, perhaps a coughing cough with a fever, ask yourself all of these questions, and we should only really be using antimicrobials if most or all of the answers support that decision. Of course, in reality, many of the answers to these questions are unknown, and we have to make the best educated guess that we can.

This isn't necessarily easy, but it is responsible. So we should really be reflecting perhaps on these questions every time that we are thinking of prescribing an antimicrobial. But of course, these are only the clinical factors.

There are a lot of other factors at play here. So alongside all of the clinical factors that need to be considered, there are a myriad of practical factors and socioeconomic factors as well. So is the drug even available in your car?

How much does it cost? Does the farmer have a particular preference? Do you have a particular preference?

Does the milk buyer have regulations minimising the use of CIAs? Does it need to be long acting because it's a crazy limousine steer that's only going to get caught once, etc. Etc.

So there's all these other things that are at play, and it's, it's really not an easy job deciding which which drug to use a lot of the time. And these factors are often just as important to vets in clinical practise. But I think they're often forgotten by the policymakers and the academics.

You know, these real practical factors of what you should use. They need to be taken on board by the policymakers. There's plenty of evidence in human medicine that defensive prescribing is common by general practitioners, and this is understandable really, because it's a product of human nature.

So where there's uncertainty, which is most of the time when you're in primary sort of healthcare, so general practitioners, both of the veterinary and the human variety. And where the stakes are high, so it's human nature to kind of hedge your bets and think, well, I'll give antimicrobials, I'm not really sure, but I'll give them just in case because, I'm not confident in my decision not to. And this, you know, this is the reason why many vets will still give a bottle of calcium under the skin as well as one in the vein or do a boa suture after a prolapse.

Even though there's not really any evidence for doing it. We do it just in case. We don't want to be the vet that doesn't do it, and then the farmer, you know, it's one of those cases where it goes wrong and the farmer thinks that's why.

It's the same with, with antimicrobials and prescribing, really. We think that the potential benefits, even though these are often sort of psychological, outweigh the potential risks. And this is, this is the really difficult part to tackle.

And, well, I'm afraid I don't really have any answer to the dilemma of defensive prescribing. The human medics have also been struggling a lot with this issue. One of the most effective ways to tackle this feeling of uncertainty is to develop practise protocols or on-farm protocols for the treatment of certain conditions.

And this really pro it provides us with a form of psychological safety net, which has proven to be really beneficial within the NHS. Of course, the best way to deal with the issue of uncertainty really is to eliminate that uncertainty, and this is where, you know, the development of fast, cheap and accurate pen side diagnostics really is important, and that would help us a great deal with this. Using an evidence-based approach to antimicrobial use is considered best practise prescribing, but is this really realistic in practise?

There are so many barriers to using an EBVM approach. Compared to human medicine, there's just such a lack of peer-reviewed evidence to answer clinical questions in veterinary medicine, and where the evidence does exist, it can be difficult for the general practitioner to access, as it often sits behind a paywall unless you are enrolled in an academic course. It's well known that there's a bias towards publishing papers where a positive outcome was found, and many randomised control trials in veterinary medicine are funded by the pharmaceutical companies who, you know, obviously they have a vested interest in showing that their drug works.

They will usually have worked with someone who has, You know, a bit of research ethics background, but it's, it is still something to consider. So for vets, I'm afraid it's, it really is true that anecdotal evidence really does still rule supreme. This is more out of necessity because of a lack of evidence, but it's also because it's just very psychologically powerful.

Same as in human medicine, if we use a drug and then the patient gets better, we naturally attribute that to the drug. Even though often self cure or getting better despite the drug has been proven, we'll then form this confirmation bias for that treatment, for that particular desired outcome. And every time we give it and the patient gets better, we think it's because of the drug.

Every time we give it and the patient doesn't get better, we think it's because of another reason, so compliance or misdiagnosis. Equally important to the way we make our prescribing decisions is the way in which those medicines are eventually being used. So as I mentioned previously, farm vets are in a bit of a unique situation whereby we are generally not present when the medicines we prescribe are actually being used.

We prescribe the medicine for the farm to these animals under our care, and we tend to review this once a year with the herd or flock health plan. But in the meantime, the farmer is happily buying antimicrobials and storing them in his or her medicine cupboard for use at a later date. I think finding out what's happening after this point, well, it was really the main aim of my PhD and it was a bit of an unknown at the time.

As we've already discussed, legally the vets are responsible for the medicines that get used on a farm. However, practically, the vets are rarely there when these medicines are being used and they're only really involved in these prescribing decisions from a distance, or a physical distance and a temporal distance. Compliance is very complex and multifactorial.

So the farmer will have, we talked about those clinical factors and practical factors to prescribing earlier, and a farmer will have just as many of these factors influencing their choice of medicine as the vets do. But they're different questions, and we need to really bear that in mind. So, again, it's a little bit of what do I have in the parlour to hand or what do I have in the medicine cupboard.

Have I got a bottle that needs using up? Does that make a difference to which one I will use? Do I care if it's out of date?

Is this my favourite cow? Do I have to give the injection 3 times? Can I even afford to treat this cow in the first place?

Again, looking to human medicine, there's been a lot of work studying patient compliance with prescribed medicines, and it shows that patients will use medicines in many weird and wonderful ways not originally intended by the prescribing practitioner. So while our farmers tend to be much better educated in animal health than the lay public, so we can place this trust in them, misunderstandings and misconceptions are still really quite common, and we should never assume that just because a farmer has always used, say, pen and strap, that he or she actually knows when and how best to use it. Sometimes it's good to just check in and make sure that, The farmers do understand what what the best way to use the antimicrobials we prescribing are.

There is a huge knowledge gap at the moment in this area. A DA funded report produced by Exeter and Bristol universities a while ago found that the values, perceptions and behaviours of farmers when it came to veterinary medicine use are little understood. And in order to better understand these decisions, we needed to use a combination of both quantitative research to work out what's being used and qualitative research to try and understand.

Why these things are being used. So to answer these questions, we need to understand the context on farm and to ask what it is that's influencing these decisions and the social and cultural factors involved. By using some of the research methods that I used in my PhD it was possible to begin to explain why certain treatment decisions were being made and to identify areas for possible intervention and behaviour change.

So a bit like Alison, I do like a good quote. These quotes are from that DA report, but, so these are from a pig farmer and a couple of poultry vets. So the pig farmer says, I think it's a greater danger when they're dished out like Smarties and GP practises for someone with a common cold.

Yeah, there is still a lot of the blame game being played where people use this sort of psychological phenomenon of othering and think that the problem is all other people and not themselves. There's nothing that they can do. Whereas this poultry vet, thought that the fewer you use, the better they work when you do actually use the things, which is quite a positive way of thinking about things.

And a poultry farmer who said that he knew quite a few farmers who were already drug free, I think he needs antimicrobial free, mostly there, and so does believe that it can be done. So as with that risk averse behaviour is really common amongst farmers as well, and they have an equal dislike of uncertainty as illustrated by. These courts, so one of my farmers, we were discussing blanket dry co therapy and he said, well, it's cheaper than a dead cow.

And that was his reason for doing it, and he did not want to change to selective, and it was going to take quite a big effort to, to sort of do that for him because he thought that it was too big a risk to take. And then with a dislike of uncertainty. This other farmer, she thinks she thinks that with medicine, the problem is there's no knowledge.

She's seen her dad in the medicine cupboard literally picking up different bottles of antibiotic and thinking which one today. And I think that probably is more common than we think. So other themes that emerged from my data, were the tensions that are present on a lot of these farms.

So these tensions, they, they're between different members of the team. So be that staff or different family members. There's often a lot going on in the background on farms, and there can be a bit of a power struggle when it comes to the decisions that are being made about medicine use.

And that can be quite difficult for the vet to tune into or to understand because they're not part of that family or that, team as such. But the only farms where this wasn't really an issue on my study was where there was only one farmer and no family or staff, and some farmers actually expressed that that's the reason that they didn't employ staff was that they didn't want to have to deal with the tensions between staff. .

We talk about trust, so trust really is key. This kind out of Alison's PhD work and so much other work as well that this relationship. Between the farmer and the vet is really important when we're in when we're sort of giving advice.

If we want that advice to be enacted, there has to be a trust relationship. But this trust also extends to the relationship between the farmer and the other people working on that farm, be they the family or employed staff. And one farmer said, to be honest, I think if anything, he and he being the stock persons got worse as time goes on.

I know now that if I turn my back, he won't be doing things to the same standard. And with this farm, that had actually led to the farmer stopping giving this stock person any responsibility for medicine use, because they didn't trust that they would carry out the instructions as required. So there's mounting evidence to show that farmers don't do what the vet expects with their medicines.

As I said, I was often guilty of assuming that when I left a medicine on the farm, it would be used as I'd intended. It's just not the case for so many reasons, and it's been shown that farmers regularly exceed data sheet guidelines when treating mastitis. Certainly that was the case on my PhD as well.

So just giving 3 tubes. As it says on the data sheet, doesn't happen that often. It's usually extended to more tubes than that.

As you can see from this quote, you know, the protocol says standard mastitis treatment is 3 days, but we actually find we need to do 5 or we get them coming back round again the week afterwards with the same thing. So this is, you know, it's anecdotal evidence, but it's really important to this farmer, and they strongly believe that they need to give it more regularly. And we need to really respect that that is their opinion, and we need to be aware that that's what they're doing and how they're using, how they're using their.

Antimicrobials. So what is it the farmers actually do? Well.

They regularly exceed data sheet recommendations. They do use expired medicines. If they're available in the cupboard, they will use them.

We don't really know if that's actually a bad thing or not. We assume that the further an antimicrobial has expired, the less efficacious it is, and if it's less efficacious, it might have a higher driver for resistance, but there isn't actually any evidence to show that expired medicines have reduced efficacy, and in fact, there are some Human studies that show that they, they retain their efficacy for long past their expiry date. I think possibly what's more important is the broached by date, because as soon as the dirty needle has gone into that bottle and contaminated it, most of the bottles that farmers have are multi-use.

And they're supposed to be throwing those antimicrobials away, usually in 28 days with vaccines, it's supposed to be that day. I don't think that's happening, well, I know that's not happening on some of the forms, that we were on, and that's far more likely to be having an effect on the efficacy of that drug. Farmers are also double tubing mastitis cases quite a bit.

So the first time they'll identify a case of mastitis, they will stick two tubes in there. And for some farmers, this was because they had big Holton cows with big others, they just didn't think that one tube was going to be in a volume for others. They had heard that a friend had done it and that it worked, and so they did it too.

Farmers will use medicines off licence. I didn't, as part of my study, look at whether the prescription for off-license use had been sort of compliant or anything, but there are, there are off-license medicines on farms and they are being used, as are antibiotic powders and foot baths. And we know from work by Paul Williams and Gustavo, from MSD that vaccines are being stored at incorrect temperatures on farms, so often the vaccines that farmers have might not be working in the first place.

So, what is it that farmers really want? Farmers have explicitly stated their preference for simple set protocols for treatment. This is particularly true of farms with a large number of staff actually, so the bigger the farm, the more likely they are to really want to have some set protocols that have been developed with their vet.

Laminated posters in the dairy were really popular, but farmers, the most important thing to them is that these protocols aren't a one size fits all protocol that the practise has for every single herd. They want a protocol that has been specifically developed with their farm in mind because they really believe that their farm is unique and has unique disease problems and requires a unique treatment protocol. So farmers, they do enjoy health planning when it's seen as being practical, but health planning simply for farm assurance is sick, is seen as a box ticking exercise.

I think we're all quite aware of that. Farmers value the time to talk with their vet, and they'll often utilise time when the vet's doing other things on farmers. You know, you're often expected to multitask.

So if you're doing routine fertility work or TB testing, this is when the farmer's gonna pick your brains about herd health planning. So occasionally there's a lack of consistency between vets from the same practise, and this came up from farmers as being a bit of a problem. They that did degrade somewhat the trust that they had in their vets if they were getting different advice from different vets within the same practise.

And I think this is quite an important point that we can look at when it comes to developing practice-wide protocols. Obviously, everyone wants their own clinical freedom. But really appearing to be consistent in our approach, it does help to develop trust in that approach, and I think it's quite an important thing for farmers that came out of the interviews that I did with them.

And essentially, farmers want healthy, happy cows and smaller bills. We, we're all quite aware of this, but they're intrinsically motivated towards health planning and responsible use because of this. Responsible use means using less, that usually means smaller bills, but.

It also, you know, health planning means healthier cows. So they do have this motivation and as Alison said, it's just sort of tapping into how to use that. So can we change farmer behaviour?

I mean, should we change farmer behaviour? Is that really our role? I think probably it is in this context, but we do have to consider the context.

So what will work for some farms might be impossible for others. And there are many different pressures on farmers, such as time, resources, money, social and cultural pressures. So we need to be empathetic.

We need to try and understand the context that the farmers working within. We need to try not to get frustrated when it seems like our advice isn't being taken up. We need to take some responsibility for that and perhaps change our approach to delivering that advice.

Obviously, with some farmers, it is harder than others, but there is no such thing as the impossible to reach farmer. And it's the same as in human medicine. Again, I know I keep reflecting back to human medicine that we, there are just so many parallels and we need to create this partnership approach and working out how a farmer can come up with their own solutions that will work in their own context on their own farm.

So yeah, the vet former relationship is really special and we need to be quite proud of it, really. OK, so we've been through quite a lot already. We've considered why we prescribe how farmers store medicines and why they use them the way they do.

Next, let's have a quick look at the use of alternatives to antimicrobials and a bit about proactive health planning as key tools for improving the responsible use of prescription veterinary medicines. Vaccines, vaccines, vaccines, that's all I can say. Reducing antimicrobial use significantly requires reducing the burden of disease on a farm and improving the health of the animals in other ways, so that the antimicrobials are not required in the first place.

Yes, some antimicrobials are being used where they didn't need to be used at all, but often when we're using antimicrobials, it's because there's a disease present. And what we need to do is try and nip that in the bud. So the use of vaccines has been identified as a key way of tackling AMR and, you know, it's not rocket science.

We do all know this, but despite this, uptake is still really variable across farms. In the beef industry, the rumour task force has set a target of a year on year increase in vaccine sales, and a recent HDB report showed an increase in the total doses sold between 2011 and 2017, so that's really positive. But if we really want to grasp at this sort of low hanging fruit.

Identify those forms of yours who are not utilising vaccination strategies effectively and try and spread the gospel. It's, it might require rolling out a programme of diagnostic testing and monitoring first if this isn't in place, because we need to establish the current disease status, but there are plenty of farm economists producing papers showing the cost-benefit analysis for this for various diseases, and it's almost always worthwhile. Many vets expressed concern that reducing their antibiotic sales will drive down income and profit margins.

And, you know, that's a valid concern. We need to be viable businesses, but I think that's thinking quite narrowly sometimes because if we really work to change the conversation away from treatment and towards prevention. Then we can increase revenue by emphasising far more on the disease monitoring and vaccination and prevention, side of things and away from just firefighting disease as it happens.

So, non-steroidals are another key option which can often be used more appropriately instead of antimicrobials to treat certain diseases. So the main diseases where antimicrobials are used on farms would be mastitis, lameness, calf scour, and pneumonia. Yet there's so much evidence to show that across all of these diseases.

In some instances, the use of non-steroidals can improve outcomes or reduce the need to use antimicrobials at all. So again, these are conversations that many of you will already be having with your farmers, but I think we can work to have with more of our farmers and maybe the more difficult farmers to reach about increasing their use of non-steroidals in order to reduce the need for antimicrobials. So medicine audits can be another great way to get a handle on what it is your farmers are actually using, and we can then use the results of these as a prompt.

To start those conversations about medicine use and alternatives to antimicrobials. These are becoming more popular of late, so we're seeing them cropping up in a lot of practises, particularly around this region, because these are the practises we work with, but they, they are really quite an effective way of beginning these conversations with farmers, of getting a grasp on what they're doing and then being able to actually have a chat with them about what they're doing. So, as an example, Andrew Turner, one of our clinicians at Langford Farm practise recently published a paper showing that we can actually reduce or completely cease the use of highest priority critically important antimicrobials without adversely affecting production, health or welfare in dairy cows.

And that's really important because that's been a big concern of everyone when we talk about reducing the use of these antimicrobials, as well, We can't just stop or animals will get sick or stop producing as much milk, but as long as we So ease the use in a really careful way and use approaches that improve herd health planning and utilise medicines auditing. It's been shown that this can be done without any negative effects. So as you can see here, by using medicine audits combined with proactive head health planning, they managed to reduce HPCIA use dramatically.

And I think importantly, this was completely voluntary from the farmer's point of view. They didn't have to do this, but they, because of the approach that was used, they were all really on board with it. From 2010 to 2015, there was a really dramatic decrease and nowadays they they really don't use any HPCIS at all.

So while Langford Farm practise, it is a private business, but it's run as a teaching practise alongside the veterinary school. And so as such, it might not be fully representative of what clinicians in private practise are going through. It has been shown by Jenny Bellini, Janet Friar's more practise that this approach can also work in a purely private practise.

In just one year, they managed to make incredible reductions in HPCIA use. So with the new red tractor guidelines, all veterinary practises should be dramatically reducing their use of antimicrobials, and it's important to know that this is possible, and we can do it without adversely affecting productivity, health or welfare, and while promoting other veterinary services to replace the profit losses that might be, might be entailed. Another proven way of improving responsible antimicrobial use is using participatory farmer action groups.

Some of you may have seen some of the work that Lisa Morgans has been doing, and she's currently completing a PhD looking at using peer to peer facilitated learning between farmers and has found that where farmers are learning from each other's best practises, this is actually a really effective way of providing accountability and benchmarking and reducing overall antimicrobial use through management changes. This approach has now been adopted by one of New Zealand's largest veterinary practises too, which is. Very interesting, it'd be great to see what happens over there.

So this is just a graph showing the reduction for most participating farms, although for some farms use did increase, and Lisa's currently looking into possible reasons why that might have happened. It's thought to be due to specific farm contexts, and the increase in total weight when moving away from HPCIAs. OK, so we've covered a lot of ground, but I thought we'd finish up with the key practical steps that can really make a difference to on-arm medicine prescribing and use.

Number one is benchmark your farms. So I'm sure many of you will have started to do this, but some of you might not because it is quite daunting. It it can feel like it might be a lot of work and you don't know where to start.

But it's really so important because How can we change what we can't measure? Basically, if we don't know what's going on, we don't know where we need to head in the future. Another simple step to take is to incorporate a medicine review in the annual herd health plan.

So we're doing her health planning anyway. Let's make the medicine part of that actually count. Let's make it more than the tick box exercise and review the medicines that are being used.

And when we're looking at medicine use, think wider than just antimicrobials. Think about the use of teat sealants, the use of vaccines, and the use of non-steroidals too, because we need to be increasing the use of those three things while decreasing the use of antimicrobials really. There are so many different ways of measuring use.

I mean, there's been papers published on this, and it's an ongoing discussion between anyone who measures antibiotic use. But each way has its own pros and cons, and really, you need to just think about what the best metric for your practise and your farmer is. The AHDB does have an antibiotic benchmarking tool.

So for those, those of you that haven't started or don't really know where to, you can go online. There's a pretty simple Excel spreadsheet available, That and it's a great way to get started because it'll allow you or the farmer to input animal, antimicrobial, total antimicrobial use, and it will then give you some benchmarking data that you can use across your farms. And be aware that soon farmers will be recording their antimicrobial use and required to submit this data.

And this is probably going to be done by an electronic cattle medicine book, which is currently being trialled by AHDB and it's probably going to be launched sometime later this year. This is going to be another really good way to begin the conversation about use with your clients. So keep an eye out for that.

So during your head health plan, look back at everything the farmers bought and used in the past year. That's what we mean by a medicine review really. So what, what is it that the farmers buying?

What is it that they're using or keeping in stock? I'd say it's best to do this with the farmer and to sit down and go through it rather than review it yourself and then go and have a chat. But ask the really simple questions while you're there and you might be surprised by the answers, trying to find out what they're using, why their use of a certain medicine has increased or decreased if you weren't involved in those decisions, which often were not.

Farmers in my study indicated a really strong desire for further training to be available either for themselves or for the staff on their farm to increase the sort of knowledge base about the use of veterinary medicines. And, last year, NOAA launched this AMBP Animal Medicine's Best practise Training course, which you can signpost to farmers too. It's 59.95 for farmers to access an online training course and receive a certificate, .

And I'm told that there are free training materials on there for vets as well, so have a look at that. So as a practise, maybe look to develop clinical guidelines to ensure consistency between vets, because that has come up as being quite important to farmers. They also want farm level protocols.

They don't want just these practise wide protocols. Even if you just relabel the protocols with their farm name and tell them it's specific to their farm, that's going to be enough for them to trust that. They just want to know that it's been Made with their farm in mind because in their mind, their farm is completely different from the next door farm and requires a completely different approach to everything.

So basically, don't just stick these in the herd health plan to languish on the shelf for the next 12 months, maybe provide laminated sheets for the dairy or the office, just make them a little bit more usable and practical. So Lisa Morgan's here at Bristol and HDB produced this handy sheet for vets to compete with their farmers. Just explaining the different types of antibiotics that they might be using on their farms.

So it's all very well telling a farmer, you know, we need to use less fluoroquinolones, but they might not know what the brand name for that is, they might not know what it is. So this can be printed off, laminated, and you can fill in for that particular farm, what are the brand names that they use that they should be avoiding or that they should be using. And I think this is a quite a simple but really effective way of just increasing the awareness about which antimicrobials are more responsible.

So the last main one that I want to talk about is the medicine cupboard health check. I'm quite a big advocate for this. This is something that I called for in my paper, but I think we should be doing a medicine cupboard health check with our farmers every year.

And it doesn't need to be done at the same time as health planning. It can be done while we're on the farm for another reason if we want, but go and stand in front of that medicine cupboard with the farmer and go through what the farmer has in stock. It's simple, but it's effective.

Ask the farmer if they want to know any more about any of the medicines. Check that things are in date, and if they're off licence, ensure the farmers aware of when to use them and of the changes in the statutory withdrawal periods because of this off licence, cascade use. And offer to dispose of inappropriate medicines as well because often these medicines are on farm because the farmer doesn't really know what else to do with them.

They hide them away every time they have a red tractor visit and then they put them back in the cupboard again. And I think we just need to, in a very non-judgmental way, help our farmers to just keep their medicine cupboards healthy. OK, well, thank you very much.

Hopefully you are now better able to sort of go through these learning objectives again, so better able to describe what's currently understood about the way antibiotics and other prescription veterinary medicines are being used and stored on farm. They are able to explain how the use of non-antimicrobial prescription medicines and effective head health planning can influence the use of antimicrobials. To discuss the merits and limitations of the latest research on antibiotic use behaviours, relate the latest research to real life situations and apply this understanding to facilitate practical changes on farm.

My sort of overall conclusions then. Farmers use and store antibiotics in a huge variety of ways and often in ways that we couldn't even guess. But vets are best placed to encourage real change.

It's, it's our job really, and this is, we're the best people for it. Change is possible without negative health production or economic effects. So it's really nice to know that that that's the case.

Health planning and medicine audits can be a really powerful tool when we try and encourage change, but we really do need to invest time to empower farmers to become as responsible as possible. OK, thank you very much. I thought I'd put this picture in just to show I do get out on farms and come in and shit quite regularly, don't just sit behind a desk, but thanks for listening.

Brilliant, thank you so much, Gwen, that was a very detailed insightful, presentation. Thank you. Couple of questions if that's OK that I.

Read out from the chat boxes. So the first one coming from Brian is to the best of your knowledge, are there enough economical and effective animal side diagnostics being developed to help us identify the bugs and better prescribe? Oh, that's such a good question.

There are a lot of different research projects and diagnostics. That are being looked at and studied at the moment, some by private companies and some by sort of academic institutions. I'm actually part of, quite a large research project with Alison who spoke first, and with the universities of Exeter, Edinburgh and Bristol, looking at the need.

For penide diagnostics and what it is that farmers and vets want from them. It is certainly an area of massively increasing focus. We don't have any spectacular news yet.

It's just starting and it's very difficult to keep track of everything that's happening. But I think certainly this is the way things are moving, and hopefully in the near future, there'll be some some better tools in our toolkitt. Brilliant, fantastic.

. There are two other sort of questions slash comments which are similar in their approach, so I shall try my best to sort of combine those. 11 comment is looking at how would you respond to vets that are finding it difficult, where they have farmers that they know are sourcing their antibiotics from outside their own area, or even their own country. So this is specifically.

A practitioner working in Scotland where they know drugs are coming across from Northern Ireland and obviously you were saying that, you know, vets really need to be sort of the the gatekeepers here. I guess that's a bit of a frustration for some vets. What would you sort of comment on that?

Yeah, so that's a really interesting one and it's one that came out. So my work's been looking at South Wales and the Southwest, and that hasn't really been something that we've seen. Much of it used to be a problem in South Wales where things were coming over on the ferry from Ireland, but that seems to have settled down.

I then went out and did a talk for the Northern Irish Veterinary Association last year, and they said that it was a huge problem over there and that drugs are being bought from different vet practises and from over the border, and I am aware that it's a problem in Scotland as well. So it's not something I've had come out of my research, but I've certainly heard that that's an issue for certain regions, and that is a really difficult one to tackle, I think. Probably my approach to it would be to really sit down with these farmers and discuss, the need for a coherent and responsible medicine use plan on the farm, and that if, if a farmer is getting medicines from other places, that makes it very difficult to have.

An accurate medicine audit to do any accurate benchmarking, to work on responsible use, and, just trying to emphasise the negatives of doing it while also emphasising the positives of working with one farmer who knows exactly what's going on, who can write really effective health plans for you. But I, I understand that, yeah, that's a really tricky one, and I'm not sure that there's a simple answer without sort of, maybe help from the BMD and things to really tighten up on, on the legislative side. Yeah.

Yeah, I just see there's a a follow-up comment. It's very frustrating when it's vets doing the selling in Northern Ireland, so yes, as you say, obviously that's. Yeah, yeah, I've heard that and again that is frustrating and I guess us trying to talk to all the vets and try and get everyone on board with this.

Is, is the best way. We're one profession, so we need to work together. And I think the BVA and BCVA have been trying really hard and I know the Northern Ireland Veterinary Association is also working on it, but, you know, you'll always get people a bit slower on the uptick, you know.

Yeah, like you say, a coordinated approach sounds like the best way forward. Fantastic. OK, I can't see any more comments or questions coming through.

Oh, no. FYI Farming Connect grants in Wales available to promote best use of drugs done by the vet. Contact your local Farming Connect person.

Oh, excellent. There we go, it's good to know. Yeah.

Fantastic. Thank you for that, Philip. With that comment, brilliant.

OK. So I think that draws us to an end with Q&A and comments. If anyone wants to click on the link that's shared in the chat box to go through their goodie bag, I would at this stage just encourage you to bear that in mind.

There's some definitely some very good goody bags options there. Thank you so much, Gwen, thank you for putting your contact details as well on this last slide. Again, if anyone's looking for more, information or they're interested in your work and want to, you know, catch up with, I'm sure you'd be happy to accept, yeah.

That's brilliant. Thank you, Gwen, thank you. And thank you to Norbert for sponsoring the session.