OK. Thank you very much, Antony, for that, very kind introduction. And, hello, everyone, and thank you very much for joining me for what I hope you'll find an interesting and thought provoking session, looking at the value of veterinary nurses, and in particular, the value of their time to veterinary practise, both in terms of the care they provide for our patients and the support that they give their colleagues, as well as the financial value in terms of the income they generate.

So just before I get on to the presentation, I do have a couple of thank yous that I must say. Firstly, I must thank Brian Faulkner and colourful CPD for allowing me to adapt some of the slides from the webinars associated with our certificate and consulting for veterinary nurses and use them in this presentation. And I must also acknowledge material produced by Jane Davidson in blogs or articles which have explored this subject and looked at ways of making veterinary nurses and their work in practise more obvious.

And finally, I must thank the wonderful team that I worked with at my practise who have acted as models on many occasions over the years to provide my bank of photographs, which you're going to see over the next 45 minutes or so. So I'm gonna start with a question for you, and it's not one to be answered by a poll or anything like that, it's just something to make you think. How much do you feel that clients appreciate what veterinary nurses do in a veterinary practise?

And how much do you think they value it? And I'm just gonna let you think about that for a few seconds. So I think the words appreciate and value are similar, but they're subtly different.

Appreciate perhaps has more of an emotional feeling to it. And I suspect that quite a lot of clients do appreciate what veterinary nurses do, because they presume they're the people who shall we say, look after their pet when it's hospitalised. Veterinary nurses make sure their pet is comfortable in its cage before and after surgery, or if it's hospitalised because it's unwell, that it's fed watered, taken out or it's litteratray dealt with and provided with clean bedding.

So it's all about that feeling that veterinary nurses really care for their pets, maybe in a sort of Florence Nightingale type fashion. Value, on the other hand, sounds a little bit more as if it's something to do with finances or money. And I have a feeling that sadly, clients may not necessarily consider that veterinary nurses have value in the financial sense of the word.

But why might that be? Well, perhaps it's because many clients simply have no understanding of the reality of what veterinary nurses do in our practises, the extensive training they undertake and the knowledge that they have. And there may be lots of reasons for this, but I do think that it's partly due to the fact that the vital work that veterinary nurses do is often not visible to our clients.

And that may well be compounded by what seems to be becoming a standard protocol in practises nowadays, being that animals are taken away from their owners out to the back, shall we say, for blood sampling or other procedures, which means that clients simply never see veterinary nurses in action. So that brings me very nicely to one of my favourite subjects, veterinary nurse run consulting services. So why do I think this is such an important area to consider when we're talking about the value of veterinary nurses to practises?

Well, logically to me, it makes sense. If we're looking at how we can increase the visibility of veterinary nurses to the public, putting them in obviously customer facing roles does that. And then if those roles are ones that carry an air of authority, that should result in a greater appreciation of the professional status of veterinary nurses, enhancing their value in the eyes of the public.

And consultations have the potential to do that because people consider consultants to be trusted professionals that they would visit for a service or advice that they believe they're capable of providing. In fact, the definition of the word consultant is someone who provides professional advice to others. And we used ourselves to go to consult with various professionals such as lawyers, doctors, physiotherapists, or a human nurse.

So why not a veterinary nurse? Now I'm not in any way devaluing the work that veterinary nurses do in the back of house areas, and we will look at that a bit later. What I am suggesting is that we can rethink how we run the consulting services in our practises.

And there are lots of places where it makes sense to involve veterinary nurses in terms of helping manage the workload, as well as the potential positive financial impact. And whilst I don't think that the veterinary profession should necessarily always try to follow what our medical colleagues do. It is worth remembering that it's quite normal in human healthcare for patients to see a human nurse for regular checkups, vaccinations, screening checks, and with the advent of the practitioner nurses in doctors' surgeries, even for an assessment for an urgent appointment nowadays.

And we don't question that, because we're having a consultation with a professional qualified person that society has told us we can trust and respect. So before we consider the various consultations that veterinary nurses could be involved with, I ought to just clarify a few points and provide some context applicable to the rest of the presentation. So firstly, I must apologise that as a small animal practitioner, I'm only talking about small animal practise today.

And secondly, it's important that we're aware of the legislation that affects us. Now, I don't have time in this webinar to look in detail at at that, but we must remember that the Veterinary Surgeons Act makes it unlawful for anyone other than a registered veterinary surgeon and member of the Royal College of Veterinary Surgeons to practise veterinary surgery in the UK. And the act defines veterinary surgery as the diagnosis of diseases in and injuries to animals, including tests performed on animals for diagnostic purposes.

The giving of advice based upon such diagnosis, the medical or surgical treatment of animals and the performance of surgical operations on animals. Under the Schedule 3 exemption from the restrictions on the practise of veterinary surgery, veterinary surgeons are allowed to direct registered and student veterinary nurses to perform medical treatment or minor surgery, as long as that doesn't include entry into a body cavity, providing certain requirements are met. And the Royal College's recently produced superb checklist, is really helpful for decisions surrounding delegation to veterinary nurses.

And veterinary surgeons and veterinary nurses make use of the Schedule 3 exemption on a regular basis in practise, and it is relevant to consulting as well as to the work that goes on after patients have been admitted. But it's important that we remember the exemption allows only limited veterinary surgery, and that's sections C and D of what the act defines as veterinary surgery. It does not include making a diagnosis, giving advice based on that diagnosis, or or deciding to perform tests on an animal for diagnostic purposes.

These must be left to a veterinary surgeon, and veterinary nurses need to be mindful of this. Nurses can, of course, report clinical findings. So during a consultation, they can inform a client if they see calculus on the animal's teeth and the gums are red, as long as they then refer that animal to a vet for a dental assessment and diagnosis of the problem.

And we must also be aware of the veterinary medicines regulations and remember that only veterinary surgeons are able to prescribe medications to our patients, although they can direct veterinary nurses to administer them. And in order for veterinary surgeons to prescribe medications to treat an animal or to delegate procedures to be performed on an animal under Schedule 3, that animal must be considered to be under the care of the veterinary surgeon. Now there's obviously lots of information about all of this in the codes of professional conduct for veterinary surgeons and veterinary nurses and the supporting guidance that relates to them.

Just bear it all in mind as you're thinking about, consulting and, and how we use these. So, coming to the potential areas for consulting, I do think it helps if we divide them up into broad categories. The first set of consultations includes the perioperative ones.

So those are consultations where we could admit patients and discharge them. And also where nurses provide follow-up, so post-op checks. And I would say that all routine surgeries like neuterings should have post-op checks with nurses.

And many other cases can also be managed. So for example, a pyometra or a stitch up, although some complex cases may need to see a vet. Then we come to growth, maintenance and prevention, which has two different areas.

Firstly, there's preventative healthcare, and that includes vaccinations. So second vaccinations and kennel cough vaccinations, both of which can legally be administered by a veterinary nurse, having been prescribed by a vet. Then there are growth and development related consultations for patients from their 2nd vaccination onwards.

And those will include advice about things like diet and nutrition, as well as guidance about nuing and breeding. And also here, there are socialisation consultations, which could be for animals, both individually with guidance about basic training and socialisation, or more group-related activities like puppy parties. The second area is maintenance, and we can consider these consultations to be aimed at keeping our clients' pets in tip-top condition.

And these are procedures like nail clips, air cleaning, dematting, anal glands, and also in this section are things like screening checks, so routine checkups perhaps for elderly pets or dental clinics. Then we come to therapeutics or treatments, and those include consultations where veterinary nurses are simply administering prescribed medication or other treatments or therapy. So things like repeat Cartrophin or vitamin B12 injections, immunotherapy, second dose hernias, etc.

And in terms of other therapy, we could be looking at things like laser therapy or hydro or physiotherapy, although, of course, veterinary nurses would require additional training and possibly specific qualifications for those. Therapeutic appointments do also cover patients with chronic conditions, such as those on long-term medication. So, for example, diabetics, cats with kidney disease or hyperthyroidism, dogs with Addison's or Cushing's disease, to name but a few.

And of course, agreed protocols are necessary for these to ensure that veterinary surgeons observe their under their care requirements when veterinary nurse consultations are included in the management of patients like this. Weight management is also in this category because once an animal becomes significantly overweight to the point of being considered obese, this is a lifelong condition that requires long-term management and treatment. And finally, there are a few extras that don't really fit into any obvious bracket.

And these include things like registration checks for healthy patients that are new to the practise, where the aim is, shall we say, to capture and convert a new client after an initial inquiry by phone. And there are also consultations to help manage patients with behavioural issues for which veterinary nurses would require additional training, as well as consultations to help owners at the end of their pet's life. So here's a summary of all that, and the differences in colour of the various consultations on this slide is to give an indication of the complexity of the consultation types.

Those in blue will almost certainly be what we could consider functional or task-based consultations, where the animal is presented for something specific to be done. And both the nurse and owner, and maybe even the pet, considering how apparently telepathic some of them are, know in advance what's going to be done and the way the consultation is likely to progress. And these can perhaps be thought of as reasonably straightforward to do and possibly the best ones to start with if you were looking at setting up a new nurse consulting service, or were you to consulting yourself.

The pinkish coloured ones are a little bit more complicated to perform because you may be faced with discussing options for things like blood tests, for example. And bereavement type consultations are likely to involve a lot of emotion. Even weight management consults aren't necessarily simple.

You may have to deal with an owner who's frustrated that their efforts with the diet don't seem to have worked, or who's refusing to weigh out the food. So all of these consultations require a little bit more confidence, additional skills or experience on the part of the veterinary nurse to handle them. And maybe areas that you personally may progress to doing or your practise begins to offer once other more straightforward consultations are established.

So now we've considered all the possible consultations that veterinary nurses could do, let's turn to that difficult subject, charging. Should nurse consultations be charged for? Well, the simple answer is that because clients are receiving a service provided by a professional who is giving their time and making use of their skills, then absolutely, there should be a charge associated with them.

Now I know that this is something that veterinary nurses often find hard to do, and surprisingly, many practises seem to find hard to justify. So to help with this, I think we should consider some of the facts about the economics of veterinary practise. And I'm gonna start with what happens to the money that gets paid at the reception desk.

So firstly, the majority of veterinary businesses will be generating income at a level that requires them to charge VAT. And that means that a 20% tax has to be charged on anything on top of the practise of what the practise chooses to charge and then paid to the government. In effect, as many business owners complain, VAT makes one of their roles that of a tax collector.

As a rule, most of the fees we quote and charge to our clients are what are termed gross figures. And so they include the VAT. So that to find the actual fee that the practise receives, that figure must be divided by 1.2.

In other words, for the practise to receive 100 pounds, a client must pay 120. So, let's consider for a 120 pounds payment, 20 pounds goes to the government as tax. So what happens to the 100 pounds that's left?

So, as a guide in the average veterinary practise in the UK, 25 pounds will go to cover what are termed cost of sales. And these include things that are associated with the work that we do, and they will vary as the amount of work changes. So they'll go up when the practise is busy and down when it's quiet.

And typically they're things like drug and food purchases, so the wholesaler bill and external laboratory charges. Then 40 pounds goes to pay the costs of staff. About half of this will be the costs of vets' salaries, and the other half the cost of salaries for the nursing, reception and practise management teams.

And these will include payments on top of what employees see in their pay packet, so national insurance and pension contributions that employers make on behalf of the business. Of the remaining 35 pounds, some is used to cover what are called overheads. And overheads are costs that are termed fixed, which means that they don't change regardless of the volume of work being done.

And they include things like expenses associated with the building, office necessities, professional fees, or accountancy, marketing and other random things like training or vehicle costs. And as a rule, overheads will take say 20 to 25 pounds. The remaining 10 to 15 pounds is the surplus, and that's available to be reinvested in the business.

It might be used to make large one-off purchases like new equipment, or maybe to extend the building, or consider what you could consider investing in additional staff as the practise grows. Additionally, it does provide a return on investment for business owners. So how do the fees that we charge to our clients cover these costs?

Well, those items that are cost of sales, so the wholesaler bill and external lab fees are charged directly. And as long as we remember to list these items correctly on our clients' bills, the cost fees to the businesses are covered by the sale of them when we supply them. But what about the remaining 75%?

Well, that has to come from income generated by charging for professional time. And that's generally considered to be the service fees for what veterinary surgeons do. But we mustn't forget that registered veterinary nurses are also professionals and therefore entitled to charge a fee for their services.

And when veterinary nurses are taking consultations, it's very clear that they are the professionals providing the service. So appropriate time-related professional fees can and should be transparently charged. Doing so enhances the client's perception of the professional status of veterinary nurses, as well as potentially increasing practise income.

But what do you charge? Well, as a general rule, in those practises that do charge specific fees for the professional time input of veterinary nurses, the rate is usually about half of that of veterinary surgeons, although the exact fees will depend on how the practise chooses to charge for its services, and it will vary between businesses. So practically, what does all this mean in terms of how we might charge for nurse consultations?

Some veterinary nurse run consultations are not necessarily charged at the time the consultation actually takes place, because they have been what we could term pre-charged with something else. And these are going to be typically things like second vaccinations, follow-on treatments, or post-op checks. I do think it's important, however, that whilst no money may be paid at the time of consultations like this, some sort of invoice should be generated.

For example, we might do something like post-op check with a veterinary nurse, cost included in procedure, so that the client appreciates that they're receiving a service and understand which staff member is providing it. There will also be some consultations that because of their aims, so for example, signing up a new patient or providing support at the end of a pet's life, a practise may elect to offer without charging. However, please, can I request that these are not called free?

Saying something is free devalues it and thus the professional delivering it. It somehow sounds almost tacky and designed to attract our attention, though not necessarily in a good way. Free samples are often seen as things that we can take and throw away if we don't like them.

So please, can I encourage you to use the word complimentary instead? Complimentary sounds much nicer. There's a perception that something of value is being given as a mark of good service, a courtesy, and people generally appreciate things that are complementary.

So think how nice complimentary bottles of water in a hotel fridge are, or as one hotel I stayed in provided complimentary chocolates. Complimentary is good, free is cheap and worthless, and we must change what we say. And I'm sorry for the rant, but that alone will have an impact on how our clients, in other words, the public perceive the value of veterinary nurses.

Other consultations should be charged, they are worthy of a professional time charge fee. You might choose perhaps to offer some as a, as a pack or a bundle. Maybe for example, for weight clinics as a bundle, or possibly include them in the practise healthcare plan, but again, complimentary, not free.

Or they might even be included perhaps in a deal with food purchase. But it is really important that procedures like nail clipping, ear cleaning, or emptying anal glands are offered at the same price regardless of whether a vet or a nurse does them. At the end of the day, a nail clip is a nail clip, whoever does it.

And I'd suggest that ideally these service type appointments should be done by nurses wherever possible. If a client insists on seeing a vet, they should pay a vet consult fee, because often such clients may be hoping to sneak in some ailment or other query from the vet. So a full consultation is likely to be fair.

Charging less for a nurse than a vet for performing exactly the same procedure again devalues the nurses in the eyes of clients and has the potential for them to be seen as cheap alternatives to seeing a vet. Unfortunately, however, senior management in practises sometimes believe the myth that nurse consultations don't make any money. But I can tell you this is wrong.

I know that from experience. Some years ago, the nursing team at my practise encouraged us to undergo the training to become a royal canon approved weight management centre. And the approach that we agreed in terms of referring overweight pets to the nurse team meant that somehow we had to find consulting times for nurses that weren't at the very restricted slots we offered.

We had 2 consulting rooms, and they were both generally used by vets, and we didn't have another room to make available. There was no free space in the practise. So short of extending or moving premises, which weren't options, it meant we had to share the consulting space between the teams.

We completely rethought the way we use the consulting rooms, and instead of the traditional 3-hour blocks for the vets at either end of the day with a gap in between, we changed to offering consultations pretty much all day, with, in effect, one consulting room used by a veterinary nurse for about 75 to 80% of the time. I have to admit to being a little bit nervous because we ended up with fewer vet consults each week. But I needn't have worried because practise income continued to increase.

So why might that have happened? Well, first of all, if veterinary nurses take on the pre-charged consults like second vaccinations, post-op checks or follow-on treatments, fees for these have already been charged and hopefully paid. So the income is exactly the same as if a vet were doing the consultation.

Similarly, if nurses start seeing any patient for maintenance type procedures like nail clips instead of the vets, and as I've just said, we charge the fee exactly the same as for a vet doing it, once again, the income will be the same. So there is no difference in income if consultations of this type are simply swapped from vets to nurses. But of course, if the nursing team take these consultations off the vets, new vet consulting slots will open up in the diary, and they can be used for sick patients, which a vet must see in order to diagnose and provide treatment.

Now, depending on how the practise is set up and how much space there is, the number that would become available varies. But these new cases are likely to generate higher income levels compared with post-doc checks, nail clips, or vaccinations. So in other words, if veterinary nurses take on the consultations, it's appropriate for them to perform.

The average turnover per hour for veterinary surgeon consults will increase because the cases are likely to be more lucrative. Additionally, Even if only a relatively small number of consulting slots open up for them, vets will end up with spare time, which might allow them to have lunch and be a little bit less grumpy. Or of course, it could be used for generating income in other ways, perhaps additional surgical procedures, or simply managing cases more efficiently by reporting lab results and getting medication prescribed without delay, or as we decided to offer in our practise, providing a routine visit service for a nominal cost, sort of creating another consulting session out in the community, as it were.

On top of that, nurses will be doing new consultations that weren't previously offered to clients, such as health screening for older patients, dental checks, weight clinics, and all of these can be charged for and will generate new income. And in addition, specific diets sold as part of weight clinics or through recommendation for older pets will also generate income. Live stage food sales may also increase since plants regularly visiting the practise with young animals for growth clinics may be more likely to buy it.

And sales of parasite control might go up, partly due to the increase in client visits to the practise, and partly because veterinary nurses may have more time to advise clients about the practice's parasite control policy, seeing this as a key role during their consultations. In my practise in the year after changing our consulting pattern, we actually saw a 48% increase in food sales and a 35% increase in sales of parasite control, which is pretty astounding. And additionally, there may be other incidental sales, merchandise, etc.

Simply because of increased plant footfall. So having, I hope, been persuaded that we should be charging clients for consultations with veterinary nurses, will the clients happily pay to see them? Now, there's a perception that they won't, but I don't believe that that's true.

And that comes down to whether they consider the nurses as professionals, and if they see there is value in the service they receive. And that goes back to our language and how we promote nurse consultations. Advertising them as free or using terms such as seeing a nurse is only 20 pounds, or it's cheaper to see the nurse, devalues veterinary nurses.

And as I said when talking about the word free, may well mean clients would resist a charge at another time. Promoting consultations with veterinary nurses as valuable services aimed at keeping the animal healthy or helping with its recovery from illness, provided by qualified, trained professionals who are highly skilled at what they do, sends a very different signal. As I said at the beginning, we're quite used to paying for professional services ourselves.

Changing the conversation so that the whole practise team promotes veterinary nurses in this way and encourages them to be visible to clients should mean that clients will see and respect them as qualified professionals that are therefore worthy of a professional fee. And remember, to make any nurse consulting service work effectively, it's important that the rest of the team are on board and you'll need to get the buying of vets, reception and management teams and provide some staff training to make sure that not only are nurse consults described appropriately, but appropriate cases are booked in for the nurses, with policies and protocols in place so that veterinary nurses can provide this important service whilst remaining within the law and their professional conduct obligations. So, I hope we've all agreed that veterinary nurses' time is worthy of a professional fee, but does that only apply in the consulting room where they're charging their time as a consultant?

Well, of course not. And as we've discussed when we talked about the economics of veterinary practise, professional time charges are the service fees. It's considered fair for individuals to pay for the skills and advice of a professional.

And in veterinary practises, our veterinary nurses use their skills in a huge variety of ways in lots of different areas of our building. Though with the way many practises have traditionally invoiced clients for treatment provided to their pets, there has generally been a description of the service rather than the detail of the professional time charge. These days, with the RCVS guidance to the code of professional conduct advising that invoices are itemised, most veterinary bills do give a breakdown of costs incurred.

But the detail of which professional team provides that service is rarely given. And I do think that the contribution of veterinary nurses to the service fees is still not generally made clear, with their time and skill input frequently being hidden in the overall description of the service. A couple of years ago, one of the tasks I offered to do as part of the BM Futures working group was to look through the price list of my practise and consider which of the fees that we charged included veterinary nurse time and skills input.

When I printed it out, the price list covered 9 pages, and I went through and highlighted the procedures where a veterinary nurse was essential to the service being safely or effectively provided in orange, and those where a veterinary nurse would frequently be the professional providing the whole service in green. The result was eye opening. And this is a selection of extracts from a few of those pages, and you'll see how the orange highlighter was used so much that it began to run out.

So exactly where in the back of house parts of our practise do veterinary nurses provide professional time and skills which contribute to the service charges levied to our clients? Well, my exercise with the prices confirmed what in reality I already knew, which was the veterinary nurses are important just about everywhere. After all, veterinary nurses are generally the team that take responsibility for maintaining hygiene throughout the clinical areas of practise.

And without good hygiene and sterility in those areas where it's necessary, the surgical and medical efforts of the veterinary surgeon team are at risk of failure. So let's just quickly go through this stylized depiction of the areas in our practise that clients rarely if ever see and think about where nurses have key roles and contribute their time. So of course, the wards and hospitalisation areas, the dental areas, the radiography or imaging suites, the prep room, the operating theatre, the laboratory, and what I suppose we might call general treatment areas.

So yes, absolutely everywhere. But do we ever give the nursing team the credit on the patient invoice for the input of their professional time? And the answer to that, I'm afraid is generally no.

And despite being a huge fan of the veterinary nursing profession, remembering how many times a tolerant, understanding and experienced veterinary nurse supported and guided me during my early years after I graduated, I have to confess that the invoices at my practise, despite often being quite detailed, didn't actually make the care, skill, or assistance provided by the veterinary nurses clear. Having gone through our price list, I had intended to rectify the situation. But I'm afraid my career took a different turn and I left the practise before I could do so.

So let's have a think about how we could make those changes. And let's consider some of the typical fees that our clients might see at the reception desk, and how we might make things clearer. And I think that those, shall we say, routine or shop price fees are particularly bad because they're often quoted as a guaranteed set figure.

And when we book our clients' pets in for these procedures, we frequently describe them very simply. So we might simply say cat castration. But let's actually think about everything that happens to a cat after it's admitted for neutering until it's happened and then goes home.

Now, I know that there may be different approaches and individual practises to this, and, and various people may do things in different ways, but what I've done here is I'm gonna go through a typical route that we would tend to have used at my old practise. So first, it's provided with a cage with bedding and probably a litter tray. It receives a pre-med.

It may have an IV catheter placed. It's given an injection of an intravenous anaesthetic agent and may receive some oxygen via a mask. The scrotum is clipped and cleaned.

The surgeon is provided with the equipment they need. The surgery is completed. After the procedure.

The surgical site is cleaned. The catheter is removed, the leg bandaged, and the cat popped back into the cage to recover, being checked on as required. It made pork fed before it's sent home, and once it's left with its owner, the cage is cleaned and at some stage the bedding will be washed.

And of course the cat will have to have been both admitted and discharged later. So how much of all of that time spent dealing with the patient undergoing something as simple in inverted commas as a cat castrate can we attribute to veterinary nurses? Well, realistically, it's the vast majority of it.

Everything that's now written in red on this slide. The area that's specified as being the sole responsibility of the veterinary surgeon as dictated by the Veterinary Surgeons Act are those shown in bold black type. The vet must decide on the medications to be used and prescribe them, administer the anaesthetic, and then perform the procedure.

But the veterinary nursing team do pretty much everything else. So how might that look if we itemised and detailed the professional responsible for each different part? So, here with a gratuitous picture of my cat Tipsy, just because she's cute, is a made up example of an invoice.

Wow. So I don't imagine that any of our clients realised how much was involved in a cat castrate. And look at the amount of veterinary nurse involvement.

And of course, all drugs used should be itemised separately on top of this. And there's also the cleaning of the cage, washing of the bedding, cleaning of any surgical kit, and potentially packaging it again for sterilisation. We could make the invoice for a cat castrate extend to more than a whole page.

Now I appreciate that I'm perhaps exaggerating a little bit and that we could potentially charge something a bit less detailed but still demonstrates veterinary nurse involvement. How about we do something like cat castration comprising admit consult veterinary nurse, administer pre-med and prepare for surgery, veterinary nurse. Anaesthesia induction and perform surgical castration vet.

Anaesthesia monitoring monitoring and surgical assistance, veterinary nurse. Hospitalisation for surgical procedure, veterinary nurse, discharge consult, veterinary nurse, and all of the drugs listed separately as being prescribed by the vet. However, my exaggeration in the initial breakdown was to demonstrate the point that even for one of what we consider a minor procedure we performed, which is very simply described when booked and often frustratingly billed just under a vet's initials on the practise management system, which implies that they alone generated the income.

There's a huge amount of veterinary nurse contribution towards that flat rate fee, which goes unseen. Let's work through something a little bit more complex. Let's consider an enterotomy to remove a stone in a Labrador, accompanied by a lovely photo of a friend's dog, Nelly, to help us.

Now, OK, I know we shouldn't be throwing sticks for dogs, but I'm honestly not sure that Claire actually threw this stick for Nellie. I think Nellie simply decided she wanted to help out by collecting firewood. Anyway.

A patient of this type would be ill and therefore would have a consultation with a veterinary surgeon, not a nurse. But once admitted, it's likely that the nursing team would be very involved with the dog's care. So let's give credit where it's due.

Consultation and admit sick patient vet. Collect blood sample and perform laboratory tests. Veterinary nurse.

Insert IV catheter and set up IV fluid therapy, veterinary nurse. Pre-medication prescribed by vet, administered by veterinary nurse. Take radiograph of abdomen, veterinary nurse.

Perform abdominal ultrasound vet. Anaesthesia induction bets. Laparotomy and enterotomy to remove stone from duodenum, be.

Anaesthesia monitoring and surgical assistance, veterinary nurse. Sterile surgical kit, veterinary nurse. Surgical theatre fee to cover the cleaning and preparing of the theatre, veterinary nurse.

Immediate post-op monitoring, veterinary nurse. Hospitalisation and nursing support, veterinary nurse, discharge consultation, veterinary nurse, post-op checks, and I think there'll probably be 2 of these, one likely to be a vet and one with a veterinary nurse. And of course, there would also be the drugs used as well as the various disposables listed and itemised.

And since the drugs must be prescribed by a vet and the decision to use the disposables would lie with the vet, these areas would be shown as being allocated to a vet. But you can see once again how breaking down the cost and considering which professional is responsible for providing which service makes veterinary nurse involvement clear. And of course, with a non-routine procedure like this, it's possible to actually specify fees for all the separate parts of the procedure, which provides even more clarity of the financial value of veterinary nurse professional time.

And what about things like dentistry? Could we demonstrate veterinary nurse involvement in regeneration here? Well, of course, the answer is yes.

Often charges for dental procedures may be shown on an invoice as something like dental scale and polish plus 3 extractions. Now we know that extracting teeth is not considered minor surgery and cannot therefore be delegated under Schedule 3 to veterinary nurses. However, it's very likely that it would be the nurse who would perform the scale and polish.

So how about detailing who does what by charging a dental procedure like assess dental health and extract 3 teeth vet and scale and polish teeth veterinary nurse. And certainly in my practise, it was often the veterinary nurses who performed dental radiography. So if a dental procedure did include a radiograph, why not itemise it as full mouth radiographs, veterinary nurse or 3 dental radiographs, veterinary nurse.

And of course, patients undergoing dentistry always require anaesthesia and hospitalisation. So without wishing to labour the point, credit for the contributions in the areas of pre-med, anaesthesia and hospitalisation can be detailed for dental procedures in the same way that I've suggested in previous examples. Even within veterinary surgeon performed consults, it is possible to make veterinary nurses' time contributions more obvious.

So for example, if it were necessary to collect blood from a cat, then instead of simply pricing blood sample fee, we could charge something like nursing assistance for blood sample collection. And obtain blood sample, vet in this particular instance. And then to show the time and skill provided by the veterinary nurse whilst running those tests, perhaps perform laboratory tests veterinary nurse could be itemised along with consultation vet and laboratory reporting fee vets, so the professional responsibilities are shared and itemised appropriately.

And what about euthanasia? So here's a gratuitous picture of my other cat, Kiki, very naughtily sitting on my table to brighten a sad subject. We all know that veterinary nurses may well play an important role during the final appointment with clients.

So perhaps we should demonstrate that on our invoices. We could perhaps say placing IV catheter, RVN and assistance during an euthanasia RVN and euthanasia vet, instead of simply euthanasia and cremation. And of course veterinary nurses and veterinary surgeons are always prepared to provide valuable support at this time.

And of course that's something that we would never consider charging a fee for. So I've gone through and given a few examples of how we might consider approaching our invoicing differently so that income generation for the practise is more transparent. But I hope you've got the idea.

Don't forget, however, the veterinary nurses are often also responsible for some of the administrative type tasks, such as completing insurance claims. So if a practise chooses to charge a fee for this service, then the fact that it's been provided by a veterinary nurse should be made clear. And remember there are other areas of the practise where veterinary nurses often have responsibility.

And these could include the pharmacy, with nurses frequently being the ones who monitor stock levels and order supplies. And then there's responsibility for maintaining and servicing equipment like the X-ray machine, anaesthetic machine, dental machines. And nurses will also be likely to be responsible for running quality control checks on lab machines and organising the packaging and sending off of any samples going to external laboratories.

And what about things like dealing with waste, including that unpleasant but sometimes necessary task of checking and cleaning out the freezer, as well as ensuring that there are adequate supplies of cremation and waste disposal bags. Now, tasks of this type are probably what we would consider maintenance of the practise or maintenance of customer service. And whilst they're obviously valuable for the smooth running of the business or the provision of a certain level of service to customers, they're not the types of things for which fees would normally be charged to clients.

They're simply accepted as costs of running a business. But we should remember that they do take up some of the nurses valuable time. And finally, of course, experienced veterinary nurses are often involved in help train the next generation of nurses through clinical coach draws.

This type of work is vital to ensure that there are skilled, qualified nurses coming into the workforce each year to continue to support our patients, their owners and veterinary practises. And this takes up a significant amount of senior nurses' time. And whilst it may not generate income for the practise directly, there's no doubt that they are making a valuable and extremely important by doing this.

At the end of the day, veterinary practises are run by teams, and this is an old photo of some of the fabulous people I used to work with at the end of a fun evening of tenpin bowling. We must remember that no one group of people could run the practise alone. We all needed to help and support each other in order that we can continue to provide the level of patient and customer care required to keep the business successful and our patients healthy.

Every team member is important, and I hope no one thinks I've in any way devalued the contribution that veterinary surgeons make by highlighting the involvement of veterinary nurses. And we mustn't forget reception teams and those in management roles. Their contribution is valuable too, although the work they do is difficult to show on our invoices.

But as I said much earlier on, the people in practise with the professional qualifications to allow them to charge fees for their services are the veterinary surgeons and veterinary nurses. And with two sets of professionals working together to deliver the care for our patients, I believe that sharing the generation of these fees to demonstrate the Contributions of the individual teams can only be good for raising the profile of veterinary nurses and enhancing their value in terms of the care that they provide to our patients and the financial contribution to practising, as well as highlighting their personal status. So as I come to the end of the presentation, I have a few final thoughts.

Firstly, as well as splitting our fees so they're apportioned to the appropriate professional, it would be great if they could also be recorded on the practise management system as having been generated by that individual, even if built in a compound manner. Although I do appreciate this may not necessarily be easy. The reason for this is that whilst highlighting how the workload has been shared, is great for demonstrating the role that veterinary nurses play to clients, and perhaps even to the nursing team themselves, it's figures that are looked at within the business when analysing income generated.

And if we're really going to fairly gauge the financial value that veterinary nurses bring to our practises, it would be really good to have concrete evidence of that from the practise management system. Once again, I urge you to consider the language that's used in relation to veterinary nurses in your practises and make sure that it's such that it will show them in a professional light and not inadvertently devalue them. And remember that increasing visibility to clients of veterinary nurses, particularly in roles with professional authority as offered by consulting, should enhance the public's perception of their worth and charging appropriately will add to this as well as to practise income.

And consider the ways that we've discussed to ensure that professional services provided by the veterinary nursing team are charged transparently. And it may be worth re-evaluating the roles taken by the team members within practise and seeing where clarity over charging can be achieved. If we do this, then I believe that over time, clients will come to realise the true value of veterinary nurses, as well as appreciating them.

And you never know. Perhaps if we change our fee structures so that our invoices demonstrate in detail exactly what procedures entail with all the steps and professionals involved, this might actually serve to open clients' eyes to the complexity of the work that we all do and the skill required, which could well result in the beginning to think that veterinary fees are actually incredibly reasonable rather than expensive. Thank you very much for listening all of you.

So that's come to the end. I hope you enjoy that and I think we should have time for questions, Antony, if there are any. That's great, thanks for that.

We've got a question here. Anonymous, can veterinary nurses perform anal gland expression internally? Yes, they can.

It's not entering a body cavity. When you perform it in internally, you're putting your finger inside the animal's rectum, and the rectum is not the body cavity. The abdominal cavity within which the, gastrointestinal system is suspended, that's what you can't go into.

So you can't go putting your hands inside the abdominal cavity, but you can pop your fingers up an animal's bottom to empty its anal glands. If you're not allowed to do that, then surely You're not actually allowed to take its temperature. Absolutely, I've clarified this with the RCVS.

You can absolutely veterinary nurses can express anal glands, you know, popping a finger inside the rectum, that's perfectly OK. Having said that, in, you know, it should be the vet who decides that they need emptying, so you shouldn't just randomly be emptying anal glands for no particular reason, but I don't imagine any of us want to do that anyway. No, that's, that's right.

And of course we've got, you know, non-vets who, who do AI in cattle, for example, so I think it's, it's OK to enter those sorts of . Areas, isn't it? So, Justine is asking, how much would you charge for weight management consults?

How do you find compliance in this instance when we provided them free before, I think she's saying, you know, we've that they've done them free in the past. So I, I do think it's difficult, and I think for me to put a figure on it would be wrong because the figure is specific for individual practises, and that depends, you know, when you, when you're pricing fees in a practise, what you actually need to do is look at how much it costs you to run that practise per hour. It shouldn't just be a random figure picked out of your head.

If you're going to do it effectively, really, you need to How much does it cost me to run a practise per hour and look at all your costs involved. Once you've done that, you can decide on what your fees are. Having said that, I think what you could consider doing that may work well is you could consider getting the veterinary surgeon to, shall we say, almost prescribe a set of 4 or 6 weight management consults.

Or, for example, to offer them complimentary to patients that are on your health plan, or perhaps offer them, you know, maybe at a special rate, you know, a bundle, maybe, at a special reduced rate, if the client chooses to buy the food from the practise. And I think it's hard if you've never charged in the past, it's going to be really difficult to change that. But there are ways of doing it, and if you can get the vet to prescribe them, then they become more valuable.

That's great, Steph. Jose, you're saying thank you. It was a really great presentation.

You're welcome. And Jessica said thank you, very informative. So as I say, always the problem with webinars, you can't hear the tumultuous applause.

That's OK. You, you knew that there were some appreciative people here who'd enjoyed the talk, . Hannah's saying, do you have any social media tips on promoting RBN skills and consultation availability?

So I, I think, you know, all that you can do is, you know, use your practise Facebook page as much as you possibly can. I'm not sure how many practises have Instagram accounts now, but many, many veterinary nurses probably have their own Instagram accounts. Consider, you know, putting photos on your Instagram accounts of what you can do.

. Put information on your Facebook pages. Certainly at my practise, we did, promote our nurse consults through Facebook and, and on our websites and and clients love them, and, and clients will interact with them. They'll, they'll send in pictures of their animals, or they'll comment on, on, you know, the veterinary nurses who are posting them.

And I think the thing to do is to really highlight that clients like them and the animals are are benefiting from them and, you know, push all the real positives about them definitely. No, that's great. Just making sure everybody's hearing us OK cause it was I don't know if it's slightly not not as clear, but sorry if that's the case.

Alison also said thank you very much, and Jessica said, I've completed the colourful consultation and would definitely recommend it. Well thank you that's from Jessica. Thank you very much.

Helen said it's sort of a question. I personally think nail clips should be a different charge to the vets. The reason is that often the price is undercharged by the vets in the first place.

So a vet nail clip should at least should be at least a consult fee. The same time in the VN1 charged appropriately for and time, this helps clients see the difference between a diagnostic professional and a non-diagnostic professional. What are your thoughts and apps from Helen?

So I think Helen, in many ways, that's kind of what I was suggesting. If a veterinary surgeon, if, if a client wants to see a veterinary surgeon to have their nails their animals nails clipped, and that's all they want, then they should be paying a consultation fee. If on the other hand, they simply require their animals nails clipped and they accept that it is a functional, task that is required to be done, a sort of maintenance procedure, then they should be seeing a veterinary nurse.

And yes, that will be a different price from a full vet consultation fee. But what I was saying, I suppose, was if practise is offered a nail clip alone with a vet for the sake of argument, 20 quid. And offered nail clip alone with a nurse for 10 pounds, that's wrong, OK?

It should very much be nail clip alone, should be 20 pounds, 15 pounds, whatever it is, and you know, really it should be ideally seen by a veterinary nurse. And if a vet, if they want to see a vet, they should pay the full consultation fee. Does that help?

Yeah, no, I, I get that. Hopefully that's helpful for you, Helen. Hannah said we're about to do a full relaunch of our consults, clinics, and this has been a great confidence boost.

Thank you, Steph. All the nurses are doing colourful consult CPT too. So there we go.

Excellent, thank you. Leanne saying thank you so much for the information, . Somebody anonymously says we used to also make RVM business cards to hand out in discharge packs.

And another anonymous person said, do you think we should do weight clinics? I think you've answered it, but I'll ask it anyway, similar to something like Weight Watchers or Slimming World, where you charge per visit to encourage them to achieve their goal, do 5 sessions, get 6 complimentary with a bag of food. So yeah, I think we've already answered that.

That's that's certainly a very sensible option, definitely. That's a good way of doing it. I think unless people have got any more questions, always.

Good to see a flurry of questions coming through there. Thank you so much, except for an excellent webinar. I think it's Certainly at the webinar that, you know, we hold nurses in very high regard, that's why we do so much CPD, which is just for nurses, but also, you know, much of the CPD we do, we feel is, you know, is good for nurses as well on, you know, anaesthesia, radiography, etc.

These are areas that when you are 3 or 4 years qualified, you can have a real huge depth of, Of information and knowledge in those areas, and often, you know, a very good VN can help a young vet, you know, as they're starting in practise, can't they? Yeah, absolutely, absolutely. I remember many times when you know, a veterinary nurse was able to help me out and .

You know, the classic one was the first ever caesarean I was faced with in a, in a Labrador, and I remember kind of wandering around the operating theatre and sort of saying to the veterinary nurse at the time, so I'm, I'm gonna do this, I'm gonna do this, and this is how I'm going to do it, and this is what I'm, and does that sound OK in terms of, you know, how other vets you've seen do it? And she looked at me and went, I've never done a caesarean either, and that resulted complete panic attack. However, we were pleased to hear that the bitch survived and we delivered 6, Labrador copies, and they all survived as well.

So between the two of us, we muddled along and we managed. But yeah, I mean, I, I used to rely on my veterinary nurses to, you know, really kind of help me in the first few years in particular, they, they have a wealth variance, so absolutely we should celebrate that. And they usually get better at getting a vein than us as well, aren't they?

Oh, absolutely, absolutely, yeah, my practise, all the nurses used to put all the IV catheters in and some of the places that I do locums at now, the nurses don't do that. And I'm like, oh heavens, I can't remember even how to put an IV catheter in. So yeah, I, I, you know, I think, I think we should, I think we need all to respect the capabilities and the, the skills.

And the, and the, contributions of each other. At no point should veterinary nurses devalue what vets do, and vets shouldn't devalue what nurses do, as I, as I said, we are a full team and we can't, one of us can't do it on our own, but it's accepting and appreciating that and allowing the various individuals to do what are appropriate for their skill set and their professional qualifications. It's collaboration rather than competition, and you know, I think the profession is so much richer having both sets of people in it than if there was only, you know, one of those.

So, you know, I'd just like to thank everybody on for all the fantastic work you do, I'm glad, you know, that we've been able to get Stef on and obviously from the comments, it's been really useful for people, so, thank you so much, Steph, and hopefully we will hear from you again. Before too long. Thank you.

You're very welcome. And thank you everybody for, for listening and engaging with it. Thanks Steph, thanks everyone for listening.

We are actually doing another webinar at 2 o'clock, which is on coronavirus and how practise should should be approaching that. So if you would like to come to that, I think there will be a link or or Dawn can put a link on. What I'll do is I'll just not immediately end the meeting and we'll let Dawn.

Add that into the chat box so those of you who are interested or perhaps want to pass it on to your practise manager or whoever, can, can go and listen to that. So hopefully some interesting information following on at 2 o'clock. Thanks very much again, Steph and take care, bye bye everyone.

Bye.