Oct. 15, 2025

148: Is the Veterinary Business Model Failing Our Patients? A Frontline Perspective From a Top UK Charity. With Dr Paul Manktelow

148: Is the Veterinary Business Model Failing Our Patients? A Frontline Perspective From a Top UK Charity. With Dr Paul Manktelow
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Season 1

 “If you can’t afford a pet, you shouldn’t own one.” 

Ever said this line?

Once you’ve  been on the receiving of someone’s anger about the cost of their vet bill, it’s an easy thought to have. 

But it’s not the whole story, is it?

In this episode, I sit down with Dr. Paul Manktelow - a veterinary surgeon with 20+ years in UK animal charities and current Director of Veterinary Services at Blue Cross. Dr Paul shares lessons learned in not-for-profit vet care to help us untangle that tension between care, compassion, and commercial reality.

We cover:

  • Trends from the front lines in the charity sector
  • How “affordability” is shifting under rising cost of living
  • Decision-making tools that balance optimal vs achievable care
  • Business models that either enable or block access to care
  • How vets can approach financial conversations with clarity, dignity, and trust

You’ll learn about:

💡 “Pragmatic care” as the antidote to chasing the mythical ‘gold standard’

💡 Cost-based vs value-based pricing models 

💡How to think in tiers of care—and where the limits lie

Because behind every clinical decision is a human one.

 

Find out how we can help you build you in your vet career at thevetvault.com.

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Topics and Time Stamps

03:11 Balancing Costs and Care in Veterinary Practice

06:45 Challenges and Changes in the Veterinary Profession

11:41 Client Expectations vs Financial Realities

16:32 The Impact of Economic Hardships on Pet Care

32:16 Blue Cross's Model

39:10 Individual Responsibility in Veterinary Practice

42:54 Getting Clear on Quality of Life and Prognosis

47:23 Cost-Based vs Value-Based Pricing Models

01:10:05 Pragmatic Care and Clinical Guidelines

01:16:54 The One Question

 

Addressing the Affordability Crisis and Lessons for Private Practice

The charity sector is witnessing firsthand a significant national affordability crisis, marked by clients often delaying routine treatments, resulting in pets presenting much sicker.
The Blue Cross established a Veterinary Care Fund to help pets owned by people facing financial hardship who fall outside traditional charity eligibility criteria.
  • Scale of Need: This fund, which provides emergency funding for pets in need of urgent care - primarily for pragmatic, curative surgery or quality-of-life improvements, was quickly adopted by over 1,700 practices in about 18 months, covering 93.5% of UK postcodes.
  • Target Demographic: The crisis is impacting the lower third of UK households whose disposable income is falling, including people who are working but struggling. The Blue Cross trusts private practitioners to act as gatekeepers, determining genuine inability to pay.
For private practitioners and business owners, the lessons from the charity sector focus heavily on efficiency, pricing structure, and communication:
  1. Defining Value and Expectation: The veterinary profession is not good at defining its value proposition, leading to client expectations that often clash with the service offered or the cost incurred. Drawing on a supermarket analogy, Dr. Manktelow argues that practices must position themselves clearly as a 'high-end' service, or a budget-friendly service.
  2. Cost-Based Pricing: Instead of the current industry trend of value-based pricing (charging relative to the market), practices should adopt a cost-based pricing model. This involves calculating the true cost of running the business, including staff time, consumables, overheads, and then adding a sustainable profit margin.
  3. Volume over Margin: If a practice chooses to offer a budget service, it must be volume-based—charging less per patient but seeing more patients to generate profit, recognizing that less work per patient allows for a higher throughput.
  4. Avoiding Loss Leaders: Practices should stop using loss leaders, such as heavily discounted neutering. Using neutering as a loss leader forces staff to "disproportionately charge higher prices to make up for the loss" elsewhere, confusing team members about the true cost of service delivery.
  5. Transparent Financial Communication: Vets need to be upfront about costs, as poor communication or a lack of honesty about pricing generates the majority of practice complaints. Vets should strive to be clear about the owner's budget and expectations, recognising that simply asking if a pet is insured is insufficient, as insurance policies have limits and excesses.
  6. Contextualised Care: Ultimately, the wider profession needs to embrace contextualised care, meaning they must adapt their service delivery to meet the specific needs of their customers, factoring in owner finances and circumstances, rather than maintaining a paternalistic relationship.
Dr. Magdalo emphasizes that affordable and accessible veterinary services are needed in the market, asserting that not every practice should drift into offering only the highest-end, gold-standard care. He believes a profit can be generated successfully using a budget practice model based on the lessons learned from the efficiency of the charity sector.

The Charity Model: Efficiency

Charity veterinary services, like those offered by the Blue Cross, are highly efficient, operating on a "primary care plus" model.

1. Operational Efficiency and Funding

To remain sustainable, charities must be "incredibly business-minded" and run their services efficiently, as they cannot invent money.
  • Funding Sources: Major sources of income for UK animal charities include major donors, regular smaller donations, and legacies (money left in wills), which still account for about half of the Blue Cross's income. Many clients who access charity services later leave a gift in their will after a good experience.
  • Client Contributions: Historically, treatment for the poorest eligible clients was free. However, due to escalating costs (forecasted to rise by £2 million between 2023 and 2028 for the Blue Cross's 11 hospitals), the model is adapting. The Blue Cross now charges all clients a highly subsidized consultation fee and expects all clients to contribute towards their pet's treatment, even if they receive some services for free.
  • Budgeting: Charity operations involve an "incredibly efficient budgeting process" based on anticipated pet numbers to ensure sustainability.

2. Clinical Pragmatism

Charity vets must deliver a decent level of care on a tight budget by focusing on pragmatic clinical approaches.
  • Prognosis over Diagnosis: The focus is on prognosis primarily, often relying on pattern recognition and clinical evidence for common conditions rather than aggressively chasing a definitive diagnosis.
  • Treatment over Extensive Diagnostics: There is not an "aversion to attempting treatment rather than... pursuing multiple sort of diagnostics".
  • Clinical Guidelines: The Blue Cross utilises a veterinary standards team to create clinical guidelines for common conditions, focusing on cost-effective, evidence-based treatment options with positive welfare outcomes. For example, recognising the poor prognosis of abdominal tumours in cats helps dictate moving early to palliative therapy and managing expectations, avoiding costly diagnostics or surgery.
  • Comparable Outcomes: Despite pragmatic approaches, outcomes can be good. Studies on remote management of heart disease during the pandemic showed no change in morbidity or mortality, suggesting that in some situations, the wider profession may be intervening too much. Surgical outcomes for procedures like cruciate repair have also shown comparable results to wider sector data.
If you can't afford a pet, you shouldn't own one.How do you feel about that statement?As a vet, I have mixed feelings about it.On the one hand, I have owned a practice.I've had to pay wages, the drug bills, and all the other things that keep the doors open.
I've had to write off large amounts of unpaid bills because I'd been manipulated and sometimes outright lied to with promises of payments that never came.I've been cursed for being a greedy, money hungry monster.I know you have to, probably.So I have felt that impotent rage of if you can't afford it, don't have it, or at least don't make it my problem.
But I've also seen over and over and over the joy that a pet can bring to those who can least afford veterinary care, or at least not the format of care that I had to offer.I've had to be that monster who has to sever that sacred human animal bond because someone couldn't afford the solutions that I could offer.
How do we balance this as a profession, this responsibility of care, the promise we solemnly made when we were given our vet degrees?How do we square that with the realities of business?Doctor Paul Maktalow has some thoughts.I'm Uber Eimstra, and you're listening to The Vet Vault, where we poke at the tender spots of veterinary practice, and sometimes we find something surprisingly human underneath.
And in this episode, I speak to Doctor Paul Mantello, a veterinary surgeon who's worked for more than 20 years in the UK's charity sector, first at the PDSA and now as a director of veterinary services at the Blue Cross.These are the front lines where effective pet care collides with hard financial limits.
And in this conversation Paul tells us firstly what they are seeing out there on those front lines.What's different in 2025 compared to 10 years, even five years ago?And spoiler alert, this conversation about affordability of care has never been more relevant.
But then we took solutions.How does a charity like the Blue Cross make it work?And what can we As for profit businesses learn from them about pragmatic care?This was one of those episodes that made me sit back and rethink how we define value in veterinary care, not just for our clients, but also for ourselves.
Let's get into it with Doctor Paul Mctello.I'm going to ask you a question that I didn't prep you for.It's a statement that I hear often in the vet world, and I'd love to hear what you think about it when you hear this.
When people say owning a pet is a privilege, it's not a right.Don't own a pet if you can't afford it.Vets love saying that.Yeah, absolutely.I've heard that.I mean, I've worked in the charity sector for over 2 decades now.
Alongside that, I've also worked in private practice.So I can see things from both sides of sort of society's spectrum if you like.And I would say that yes, there is an element of responsibility that people have to have when they do acquire pets and you know, the responsibility to put them to meet their needs.
And one of those needs is veterinary care.And we know veterinary care is expensive.But what we're increasingly seeing in today's world is people that find themselves in unfortunate circumstances who know fault of their own, all of a sudden find themselves in situations where they they really can't afford the basics of their own existence, never mind prepare.
So I think it's an easy statement to make, but I think there are specific societal challenges all across the world at the moment which we have to acknowledge.And then also, I do believe that pets do bring so much to people's lives.And for some people, especially people who are suffering from social isolation, who are unable to work and are in really difficult situations, pets actually have a great way of building up their confidence, maintaining connection with the outside world and giving them a sense of responsibility.
So I think over the years I've seen situations where I actually absolutely have seen the benefits that a pet can bring to a person who could not afford them.See, the reason I ask that question and and what's always bugged me about that statement?I bristle a bit when I hear it.For exactly the reasons that you say.
Some of the people you and I have met in our careers who've loved their pets the most will pay what they can pay, but they can't necessarily afford it.But it's really important for, I think, for them to have that creature in their life, that companion.And also, where do you draw the line with what?
What does afford mean?Don't have a pet if you can't afford it?What afford food and water, or afford vaccinations or afford TBLO surgery?What defines affording it?You're absolutely right.And you know, I've got a dog and when I look at some of the some of the more advanced medical and surgical procedures that we can offer now, I would struggle to afford some of those referrals.
It's because you're a veterinarian, but.Well, exactly.That's a career choice.But I mean, when you look at what is affordable, I can absolutely, my dog's called Rodney and I can absolutely meet his day-to-day needs.I've got him insured and up to a limit and, and I feel that I am in a really privileged position that I can afford to have a dog and meet his needs.
But if, if something were to happen and he did need some sort of advanced medical or surgical procedure that runs into 10s of thousands of pounds, I I would really struggle and would probably have to make a decision about whether or not I would be willing to get into debt, for example, to pay for that.
So I think it is all relative and when the unexpected happens, we we can't, nobody can budget for that unless you are in an incredibly privileged and wealthy position.The Rodney's not necessarily getting a new mitral valve where his mitral valve goes.Well, he's, I did a DNA test on him and he's 12 terriers and a Chihuahua, we call him.
So he's 12 different terriers and 3% Chihuahua.So if there is ever a sort of a Heinz 57 dog, it is him.But he is terrier through and through and, and touch what he's four years old now and he's never had any health problems whatsoever.But I think it's also, it's another challenging 1, isn't it about the sort of breed of, of dog you get and the likelihood of them to, to have health problems and how you can mitigate that at the point of, of acquiring a pet to make sure you do protect yourselves against some of those unexpected costs.
And you you never can completely, but the choice of your pet is is important.Yeah, if somebody makes the statement, don't get a French bulldog unless you can afford it.I'm 100% behind that statement, no?Criticism.Absolutely.Paul, I would love to find out about your world.
You come at the vet profession because of your role at Blue Cross from a different perspective, possibly different world view and as you say, you have both world views.First a little bit of background.You gave it to know what Blue Cross is.The rest of us might not know.Could you give us a bit of a rundown?
What is the Blue Cross?How does it operate?And I know you also at the PDSA previously, if you can talk to that.Is it a similar thing?How do they defer?What does charity of exercise look like in the United Kingdom?I sort of cut my teeth as it were as of that in in the charity sector at PDSA, I was there for in 19 years and that's where I'd really cut my teeth.
If you like in veteran rig and the charity hospitals in the UK generally work on this sort of primary care plus model.So the clients that come can't generally afford referral.So particularly your surgery is leaning towards that referral model.
So most of the vets that work in charity are pretty good at doing fracture repairs and various advanced surgeries, but you are working in a a sort of a pragmatic environment.So you are really looking at clinical legal evidence.It's a lot of pattern recognition, it's a lot of common things, a common sort of approach.
You don't, you're not chasing diagnosis, you're looking at prognosis, but primarily, and you know, there's not an aversion to attempting treatment rather than pursuing all sort of diagnostics.And I worked my way up into a leadership role.PSAI was regional director looking after all the hospital operations in the South Side.
About 15 hospitals was overseeing the veterinary service across the whole South of England, Wales and Northern Ireland.And then this role came up, a Blue Cross as the director of veterinary services.And Blue Cross is a really interesting charity.It's very similar in that it's, it's got a very long history, over 125 years.
And I really like that.I like the fact that these organisations are rooted in, in strong history.And there was lots of links to helping out animals in the war as well, which was, it's a really nice feel good element to the work.But it was interesting to see how the charity had evolved.
And the reason I went to Blue Cross was because it wasn't just focused on veterinary services, the six core services at the charity which include rehoming and foster a behaviour that and veterinary, they're the three, the pet services if you like.But then there was also some people services like pet loss support, pet food banks and education.
And it just felt a little bit more holistic because I think when you're working in veterinary sometimes, especially in the charity sector, you do feel that you're helping to fix one part of the problem.And particularly at the moment we're seeing really complex behavioural needs in dogs, for example.Now as a veterinary surgeon, in practice you have limited impact on the ability to address that.
So now working for a charity that looks at the whole life cycle of the pet was really, really appealing to me.And the fact that the charity was also in a position that it could respond to sort of crisis that that come up, which is how the pet food bank service was set up in the cost of living crisis.
But also we had a really active part in Ukraine as well.When the war was announced in Ukraine, we did a huge amount of fundraising for that and was able to really target funds to supporting the abandoned pets through charities that were working in that region.So you feel like you're doing a lot more, if you like, over the whole life cycle of the pet and addressing the multiple different problems that we're seeing in with pets in the UK at the moment.
I love that approach the more, as you say, the moralistic approach.Is that the parable or the metaphor where people say most problem solving is rescuing the drowning people as they come past you in the river.But the sensible approach is to go upriver and see, well why is everybody falling in the river in the 1st place and stopping them from from starting to drown.
So really great.I do like I did a bit of research about the Blue Cross before this interview.I like the rebranding.Could you tell us the original name of Blue Cross back in the old days?Yeah, that was well before my time.It was Dumb Friends League, wasn't it?
Or something along those lines.How dumb friends league was?I think that that changes.It could get confusing who exactly they were referring to.Well, but do you know what?It's really interesting that actually because it really does indicate as well how society has changed and it's view of pets.
And even in my career, I'm sure you'll appreciate this.We were talking about a relationship between pets and owners about sort of 20 years ago, and now we're talking about fur babies and pet parents.So the whole dynamic between ourselves and the pets that are living with us is completely changed.
And I think that has implications on things like, you know, veterinary care and the choices that people are making for the pets.So it is a really interesting sort of observation, isn't it?But we're seeing it, especially since the pandemic as well.We're seeing a whole new generation of pet owners that have come into the the market, if you like, that have very different relationships with their animals.
So funding wise, because again, when we talk, this conversation is inherently going to be a lot about money, take care and money and the conflict that exists between the two.Where does the Blue Cross and Peter say, for that matter, where?Where do you get money from?Who pays for the treatments?Yeah.
So I suppose we're quite lucky in the UK, the charity concept is very sort of well established and people like to donate to charities.There are challenges with that in the current financial environment.But generally most charities, the animal charities will go out for sort of major donors.
So people who want to donate to A cause, the majority of fundraising in the UKI would suggest comes from legacies.That's people who leave money to charities in their wells.Obviously you sort of fundraising initiatives like going to shows and engaging people with the cause and what we do and people that want to regularly donate.
I mean, it's, it's become quite a thing over the last few years where you can just leave a couple of pounds to a charity every month in your sort of direct debit that actually when you get a few 100 people that sign into that can generate substantial amounts of money.But I would say about half of our income comes from legacies still.
And what we find is it's often people who have had an experience with the charity that have, you know, we've treated their pet at a time of crisis in their life.And so they leave a gift in their will or they've rehomed the pet from us and they've had a good experience.
When I'm in a position to, I want to give something back.So it's almost that full circle moment.And then do the clients pay anything?I don't know.When I spent my three years in the UK, it was interesting.I, I we don't have anything like this in Australia, but our little practice out in West Wales was affiliated with the PDSA and we got some money for certain people.
People have to register and then they could get a certain level of vet care funded by the PDSA.But if I recall they still paid something like they had to pay like a monthly subscription fee or something, I can't remember.Do do they pay at all or is it just for free?Yeah.So historically treatment has been free.
Now the you've got to remember these are people that are deemed as the poorest in society.So these are people that have to be eligible to use our services.They have to be on sort of state awarded benefits.But obviously the cost of running a veterinary service are escalating.
I mean in, you know, between 2023 and 2028, our forecasting is a rise in £2,000,000 in cost.That's base cost.That's not doing anything, changing our service, not investing in infrastructure or staffing.For how many hospitals?If I remind me, I don't know if you said how many hospitals have you, that's.
For four hospitals.So that's putting our running costs from 10.2 million up to 12.2 million, which is a substantial increase.And so last year we introduced, so actually it was in 2021 actually, we looked at another section of society.
We always think of society in layers.We have the poorest in society that we gave free treatment for.There was another group of people that were also on benefits but weren't deemed as as poor by the benefits system.So a lot of those people might be receiving in work benefits and we started opening the service up to them.
They paid but at a highly subsidised rate.So we we've almost got this sort of two tier service that we offer.But in last year, you know, we were looking at our financial modelling, so we started charging all clients a consultation fee, again, highly subsidized, but that would be at the point they access the care and then the surgery for this band of clients would would still be free in an emergency situation.
We're constantly having to look at our sort of pricing models.However, what I would say is that all clients would be expected to contribute towards their pets treatment even if they received something for free.And we do get a lot of contributions from our clients.It's really positive that people are demonstrating they do want to pay something.
They're just in the circumstances where they can't pay the whole bill.But we look at this really and you know, charities have had to become very business minded over the past couple of decades.There is not money falling off trees for us.So we have to run our services incredibly efficiently.
We have to budget for even the contributions that are given.So our teams work really hard to generate those and then we have to budget on pet numbers.It's become an incredibly efficient budgeting process in order to to help the pets that we need to in the communities that we serve, but also generate the income that we need to make our services sustainable.
I have to come back to the the efficiency.I want to double click on that at some point.Like how how do you do it?How do you make it viable to provide a decent level of care on such a tight budget?But for now, I'd love to just get an indication of what you are seeing.
Let's let's say the veterinary profession, the animal care profession is Paul's patient and you've got your hands in its Ingram feeling the pulse of the animal care profession.Or maybe you're doing a rectal exam.What are you feeling?
What's your vibe from your vantage point on what's happening in the world of veterinary science and pet care?I think we're in a little bit of trouble and it's, you know, I, I, I love this profession, I'm a vet through and through, but I think we're in a little bit of trouble in terms of how the profession is feeling and, and how it's perceived.
So you you probably heard in the UK, the Competition and Markets Authority are investigating veterinary services in the UK and whether or not pet owners have been given adequate sort of options and whether the emergence of corporates has affected people's choices in terms of access to care and the affordability of it as well.
And that's not been great because that's really shone a light and and the media of course get hold of these sorts of stories and of painted development profession as you know, RIP off merchants.And that's not been great in terms of public trust.However, I would say that when you look at pet owners, pet guardians and their views on the profession, it's still relatively positive.
I would say if you look at social media, it looks like everybody jumps in and says, yeah, I've had to pay this much for a blood test and it's disgusting and bets for a RIP off.And they're all driving around in amazing cars, which we all know in the profession is is not the case.But yeah, there's a risk there of that sort of public trust.
But I think and especially since the pandemic, I think there's been this narrative in the profession that we are in this cycle of sort of burnout and drop out and there's a mental health crisis in the profession.And we keep seeing these emerging statistics of, you know, the increased rate of suicide and all these things.
So it just, I do worry about new grads coming into the profession, seeing all this and thinking of God.Our expectation is that this is going to be really, really tough.It's going to be hard talking about money.It's going to be hard trying to convince somebody that I'm not trying to sort of RIP them off, but don't have their pets interest at heart.
And it does feel like the narrative is playing into this a little bit.I don't think it's as bad as it looks from the outside.I think there's still really, really great work going on.I think there's still some fantastic people engaged in the profession.But I think there's a lot of spotlight on our profession at the moment.
And I'm sure you're seeing similar things in your part of the world.But there's a lot going on at the moment.And I think if you just looked at the headlines, it would seem like a bleak place.It is, it is.And I, I'm with you that I feel like a lot of that is, that's just what the media and social media does.
It loves a bit of outrage and a bit of click bait.So it gets attention.So maybe it isn't a bit of an echo chamber that oh, this is so bad and down on ground level, it's not necessarily that bad.But very often with this, with the smoke, this fire, when you and I have been vets for about the same amount of time and I, I spent my time in the UK many moons ago, I can't even remember.
How has it changed do you think work as a veterinarian in terms of those things that we're talking about has changed for the worse or better or just the same as always?I would say it does it does feel a little bit different.I'm, I used to love sort of consulting.
I mean, I was a surgeon at heart, but I used to sort of, you know, in, in that really sort of efficient.Let's go out and get through the list really quickly.And, and obviously I'm a little bit older now and I don't do as much clinical work, but I really see, I tried consulting quite tricky now.I think that there's so much more fear in terms of missing things and client expectations and feel like when I first graduated, I worked in various different areas.
And one of the first places I worked in Leeds in the north, which is where I'm from.And the people in that area didn't have a lot of money.And I felt like it was a bit easier in a way because people were a bit more pragmatic around keeping their pets.
And like I said, we referred back to us before dogs were dogs and cats were cats.And if they developed a condition, people would often say, well, I don't want to put them through that or I don't have the money for that.And it was a much easier conversation than what I find we're in now because even with charitable clients, their expectations are a lot higher.
Medical surgical treatment has advanced so much.And I'm absolutely all for that.I think it's fantastic what we can now do in the profession.But when you see these sort of TV shows that show animals getting prosthetic legs or having major spinal surgery and they don't talk about costs whatsoever, then your average sort of pattern is coming into you and saying, well, but I want that.
And you're like, OK, but that's a referral level procedure.This estimate between 10 and 15,000 lbs.And there's this level of outrage like, well, that's disgusting.And you're like, but that's what it costs.And, and I've never ever really commented on the cost of veterinary care.
I think veterinary services are, are businesses generally.And I think people should be able to charge what they want in their business, but just if I get against the value proposition is really, really important.And I always use a supermarket analogy for this.You know, we, we've got lots of supermarkets in the UK.
You might have heard of M&S and Marks and Spencer's and Waitrose.And they're sort of the top end.You pay a lot more for your products there.At the lower end, we've got the merchants of a lot of these German sorts, really efficient supermarkets like ALDI and Lidl.And in those, you know, you queue at the checkouts, you know, they throw your shopping at you don't they don't even, you know, you don't get time to pack it and the the cost is a lot lower, but you know what you're getting.
It's like picking a flight, you know, if you go with a high and flight carrier, you pay more, but you expect a level of service similarly at that budget end as well.But what we're not very good at in the world of veterinary is defining that value proposition and clients understanding that this is a budget service you're getting here or this is a very high end service and that differentiation just doesn't seem to be there.
So people's expectations can often be very different to the service that they're being offered.And I think also that we're struggling as a profession to have really sensible conversations about costs, about quality of life.And there is this real aversion to talking about euthanasia, which I think is a real challenge.
And it's sort of causing us problems, I think in, in, in offering treatment options to clients.You find that even in your work in the charity sector?Because I've, I've would imagine that when I rock up at Blue Cross Hospital, my expectation is that I'm, I'm not an M&S, I'm definitely an LD or not.
Do you still find that people want the luxury experience or are they more pragmatic?No, absolutely.I mean you get, I would say the choice of our clients who are absolutely incredibly grateful for the service that we offer.And I think that we, because we really do have a very strong sort of vet me standards team who have looked at the level of scope of service we offer it.
It doesn't feel like an LD I would say.I would say when I walk into a Blue Cross hospital, it does feel a little and I've said primary care plus before, however, sometimes it gets very busy.There's a long wait in the waiting room.You know, I, I would expect that if I was going to a charity hospital and I had to wait for it sort of 40 minutes to be seen, that that would be part of the expectation.
But you still get people that are, well, I've been waiting 40 minutes, you know, when am I going to be seen?But I think that expectation level that that happens across all levels of practice.I mean, I've worked, I used to finish work on a Friday at the charity hospital in East London and then I'd go to work on a Saturday in in Belgravia, which is a very well heeled part of London and have exactly the same conversations with the clients there about expectations about cost of treatment.
So I think it's all, it's all relative to be honest.Talk to me about the other side of the because when we, you and I talk about the animal care vetting profession and all of our listeners, it's from the vet perspective.But there's another side to it.There's the client perspective.Are you seeing patterns in your work, how things are changing for our clients, not our patients.
We, as you say, we're getting much better at treating our patients, but what's it like from the other side?It's an interesting 1, isn't it?And I think what we're seeing is we're getting clients who are bringing pets into us that are much sicker.People are delaying routine sort of treatments and a lot of pets have been referred to as from neighboring practices where the clients have sort of run out of money.
But I think there is a bit more fear for pet owners to take their pets to a vet.But for obvious reasons that we've talked about, there's a lot in the media about how expensive veterinary care is.And I recently had to go on the BBC and talk about a journalist that got hold of a story that more pets were being put to sleep because of rising vet care costs.
It was really challenging interview from the journalist who was really sort of going for the profession really and saying, well, this is really unethical, isn't it?You would put a dog to sleep with a broken leg if he only couldn't afford it.It's really challenging going interviews like this when the profession has been portrayed as this sort of unethical, money grabbing people when actually what the journalist was failing to understand was this animal with a broken leg has got a serious welfare concern.
This is not a healthy animal and we have to do something.But I think when the general public are hearing things like this or seeing headlines like that, they are, they're worried.They're scared that they're going to be hit with big bills, so they're delaying treatment.And that's having consequences ultimately on the welfare of the pet, but on the ultimate cost of what they will end up paying because the condition obviously progresses.
So I think there is something around access to vet care.There's also something around the sort of, I reference the new generation of pet owners that we've seen since the pandemic and where they access information.And there's some research showing that trends are going towards Internet and influencers as the main source.
That does concern me that vets are not being the trusted source of information anymore.And there are some vets out there that are really jumping on that and doing some great work in the social media space, which is fantastic to see.But most vets who work in practice, they haven't got the time or the inclination to do that.
So I do worry that certain influencers are stepping into the space that vets should be occupying in terms of information and advice.And you're definitely seeing in the pet nutrition space, you're seeing all sorts of self-proclaimed professionals giving lots of advice on things which will ultimately impact our profession and the reputation of it and the trust within it.
But it's, it's interesting, isn't it?So where people are going for information and how they feel about taking their, the pets into the vets and how that, that that relationship of just pre pandemic, we saw people that were, you know, generational pet owners.We'd seen their their parents and their grandparents with their dogs.
We'd seen them with multiple pets through their lifetime.They were bonded to practices.That's not the case anymore.I think the dynamics of veterinary services are changing.You've also seen people that might go to one practice for their preventive care because it's cheaper there.And if the pet gets sick, they might take them to another one.
So we don't have that, that that kind of bonded sort of concept that we had before.And I think we need to adapt to that as a profession.I think we need to accept that we offer a service and we should set ourselves up to do that to the best of our ability.That's a huge one.
You're right.There's some scary things happening out there in that regard.I, I had a conversation at a conference once with a guy who does owner education, pet education.That's his business.They put on big webinars and then they get advertising and they obviously want as many people to attend as possible.
And he said they started with getting veterinarians as speakers, the experts to host these webinars.The numbers were OK.And then they tried alternative health people.And then suddenly they like 10X people attending.You go like, why are we so bad at it?
Why did people that are we boring or is it is it are people just generally anti science?There's definitely that sort of trend.And I feel like COVID had a big hand in that.We're like, well, we're part of we're in the pocket of the big food manufacturers and big pharma and we just taking kickbacks and you can't trust science.
So let's talk to the guy on.Instagram Well, it's, it's really interesting to say that I went to a sort of a convention a couple of weeks ago run by RCVS knowledge, which is looking at this concept of contextualised care, which is an emerging sort of, it's a, it's a buzzword in the UK at the moment.
And it's how do we offer care to patients based on, you know, the owner's circumstances, finances, the needs of the patient, the welfare, all that sort of stuff.Now for, for me, it feels a little bit common sense.It's what we should be doing any way, but it feels like the profession's almost lost its way a little bit and we need to instill some more of these skills, how to offer things in a much more sort of contextualised way.
And there was this whole conversation about educating clients and pet owners, and it was just really interesting because it just felt like a load of vets talking about what kinds need to be educated on.And I made the point and I just say, why don't we ask the people sat around the table because they did have pet owners there.
And I said we should be leading him with what do you need?You know, rather than right, we're the experts.We're going to now create this whole set of resources on what pet owners need in order to provide better care for their pets.And so it is a little bit of the problem with the profession that we are.
There's almost this paternalistic relationship with with our clients.And if you draw back a little bit into the concept of of business and any sort of service delivery, any business will tell you that you offer your service according to the needs of your customers.
That is exactly what you do.And the insight comes from your service users.It doesn't come from your professionals delivering the service.We have to adapt to what our consumers need.And I think because the world of pet ownership is changing so much, I, I think we need to adapt as a service to meet the needs of the people that that are coming, are coming to us and years to come.
And then just, it's a really simple one is communication, for example.I mean, the world of communication has changed absolutely massively.And a lot of practices are getting on board with that.You know, clients don't want to phone and speak to somebody, they want to send a WhatsApp message.But it's, if we, if we are meeting our, our customers, our clients, our pet owners, where they are, then we're going to be much more effective at delivering better healthcare to the patients that we're serving.
And you know, even in the world of human healthcare, they do it's, it's a lot easier because the patient is also the the customer.We've got that additional challenge that, you know, we need to try and get access to our patients through a person who ultimately is the person that's paying for our services and who we have the relationship with.
Yep.So back to the clients and their experience because you talk about they are worried they don't want to come to us because they worry they going to get stung with a big bill.But are you guys seeing, well, I know you are looked at your at the Blue Cross website and you've got a massive increased demand for people who can't afford vet bills.
So it's, it's also not just a perceived fear.There's a genuine cost of living crisis as well.So we've got increasing vet fees on the one side and then less disposable income on the other side.Is that a real thing that you guys are experiencing?Yeah.So in 2023, I set up a veterinary care fund, which was really, I saw the cost of living crisis that was coming out of not just pandemic, but the war in Ukraine, which was having a massive impact in terms of economics in the UK with sort of shock waves across the world.
And I looked at, OK, we, we need to steady ourselves for this.We need to acknowledge the fact that across the UK, they're going to be people that don't have access to charity services, that are going to be really, really struggling to pay for veterinary care in their pets.And at Blue Cross, we've got a vested interest in this because remember, we've got a national rehoming network as well.
So if people have to relinquish pets, we see the impact of that as well.So it was almost a preventive measure of how do we keep people and pets together.So we had some funding to look at.Can we look at a national fund that would help people who are going into private practices around the country, all over the country, and you couldn't afford to pay their full bill.
And we would contribute towards that.Now there were some boundaries around that.It had to be pragmatic treatment.We weren't going to be funding you, you know, these huge diagnostic work UPS that didn't end up in a result and if it was helping to fund surgery would be curative and there would be some quality of life measures and improved welfare expectations.
But it was all vet driven and before we looked at this we had about 23 practices across the UK that regular and they requested help.Is there any funding that we can help this client through?And in the space of about 18 months, we've got over 1700 practices now signed up for this fund across to the UK.
Now what this tells me is that this problem is national.We now cover 93 1/2% of UK post codes with this fund.So what that's telling us is that there are people going into pretty much every practice across the UK that are falling into financial hardship.
And it was a really interesting, it's giving us lots of data as well.What is really good is that we did no marketing for this one.This was just word of mouth from vets speaking to vets and saying, hey, look, I think the Blue Cross is, is helping people that, that are struggling to afford their bills.
And what it was very clear is that vets were really doing their best.So we did some audits of these cases and we continually audit them and were coming through.These are vets that are really trying to push costs down for roaders already and are really taking pragmatic approaches.But these are people that are just faced in, in this situation.
And even in post codes where you would expect, you know, clients to be relatively wealthy, there are still people within them.So we did some poverty mapping and it's very clear in the UK if you split household income into thirds, so you've got the, the wealthy third, the middle third or the lowest third, the wealthiest third are sort of fine that their, their disposable income is kind of staying the same, if not going slightly up.
But it's this lower 3rd that are really concerning.That's a third of all UK households.Their disposable income is going down and it is continuing to go down year on, year on year.Now these are not necessarily people that are in the benefit system in the UK.These are people that are working, these are people that have families and you know, a lot of these people have pets.
So the Vet Me care fund that we set up was really to address that, that the people that fall outside the catchment of our hospitals, outside of eligibility criteria for charity help and they're struggling.They're really, really struggling.And it, it does point to a little bit of a, a welfare crisis, I think because it's it, it doesn't look like it's improving.
People are getting poorer and that's just a fact.Why do you vet those people, excuse the pun?How do you decide who gets access to that fund?Because again, they're not officially because.I remember the PDSA, you had to be on on benefits already, government benefits.
So there was that.What determines this?So we have a similar sort of eligibility criteria to access our hospitals, but with the veterinary care fund, we sort of have empowered the vets in practice to assess that for us, that we don't ask them to check benefits at all.
I think the whole process of asking people to produce documents to prove that you're poor is is is isn't great.I've never really liked it.But we do have a responsibility to manage our funds appropriately.But we simply ask the vets and say, is this client unable to afford the treatment that you're providing?
And what we're finding is that vets are actually very good gatekeepers of that.Then there is a real sense of responsibility that, you know, I'm accessing the charities help.There are some steps you have to go through.Obviously it's not simple, but we have made it relatively simple.It's the vets that are the ones that we trust to determine that for us.
And when we get the testimonials from the clients that have accessed their funds, it's very, very clear that those people are very deserving of these funds.And we're getting some stories through which they're just heartbreaking.You know, we've got people that husband has had a stroke and he's just lost his job and the family.
We're going to have to keep this pet up.But we, we gave them some money and it's not a huge amount of money.The maximum amount that we'll award is £300 and it's usually towards a treatment cost.We're not, we're not paying for usually the whole lot, but we are definitely keeping pets and, and families together.
So it's hugely rewarding for that respect.But it's, it's a limited pot of money.You could, you could give me £5,000,000 right now and I would run out of that at the end of the year for this fund because the problem is global at the moment.And yeah, I'm hoping that the situation will improve in the UK, but it's a concern.
Is there a sensible response to that beyond just more fundraising, finding more money to help people?Like what, what do you guys do?How are you responding to it?And what do we as a wider profession do about this?Because the big thing from my perspective in this conversation, this is your job, right?
Charity work, that is literally your job.But in privacy practice, we still, and especially in Australia, we don't have the and I don't know about the states, but here it's definitely not as well established.It's very often there is no tap out that this I am the last line of defense.I'm like well if you can't afford my care you can go try another practice but they're probably going to tell you the same stuff.
You shit out of luck, sorry.So my question is what?What do we do on the floor as GP practitioners or business owners to address this problem?Yeah.And, and the challenge in the it's, it's really not as simple as going out and doing some more fundraising.
I wish it were.We've got fundraising teams that are working incredibly hard.The fundraising environment is getting more and more challenging.There are less people able obviously to to to donate to charities and that's the problem.And we're having to look very closely at the services we can offer because ultimately we can't invent money.
We have some reserves, we're dipping into them on an annual basis at the moment.But to be financially sustainable for the long term, we have to look at what is possible.So there is that challenge.But I think on a sort of an individual level, we've all got a responsibility in terms of what we do with the patient that's in front of us.
And if we've got to think of that patient's welfare and we've got to think and advocate for that pet.And I think that what I would urge veterinary practitioners across the world to think about is that there isn't anybody that's able to come and rescue this for you when that problem's in front of you, you're going to have to help that owner make the decisions that are appropriate for their pet.
And if that means going for sort of more pragmatic options, if that means being very realistic about the prognosis of that pet, if that means thinking about euthanasia.Because the other thing as well is that people go, you know, let's let's get the pet signed over and let's get them to a rehoming centre.
And you're seeing requests for rehoming centres to take on animals that have got complex medical and such problems that need fixing at a cost to the charity, with little chance of these animals getting rehomed.So I think that we have to, as a profession, acknowledge that at some point something's got to give and supporting an owner through that difficult decision is sometimes in the best interest of the animal at that time.
Tough ask because because you're right and that is again for our generation that is just part and parcel of the job is yes, sometimes I have to be cruel to be kind, not cruel to the animal, but not do what I'd love to do and have a difficult conversation with an owner.Increasingly I do hear a call.
Who did I speak to you?I spoke to somebody at a conference the other day, somebody from WA with an association with the local government actually straining social workers to work in vet hospitals to have these conversations because they are saying it's not really fair for the veterinarians to have this level of conversation.
Get into your money problems and your psychological problems and your home life and you mess that with the healthcare of the pet.It's it's a heavy burden to carry for individual veterinarians.Do you guys have like, is it tough for, for your vets, for you working in in a charity service?
Is it is it harder?Is it more draining or is it actually fulfilling?And how do you get better at those sort of conversations?Yeah, it's a really great question, isn't it?And a lot of the clients, by definition, when you are dealing with a poor demographic in society will be coming with sort of complex needs themselves and very complex and sometimes heartbreaking home situations.
But I think we are there to advocate for the pets.That is our role in any whatever practice you're working at, whatever area that is our main priority is that is the welfare of that pets.But you, like you say, you do have to contextualise that sometimes in the owner's circumstances as well.And I've seen situations where in a different circumstance, the decision for that pet might have been different.
And I and I get that and that can be tough for vets, but we are also working within the constraints of the world that's presented in front of us as well.I think sometimes it's really interesting because historically charity vets might not have had to have those financial conversations and can just crack on and do the treatment.
So they struggle a little bit sometimes with the financial element of it as much as, but in private practice when we introduced charging for a consult.So that sort of tier of service that we offered, the vets do struggle with it a little bit, but it's the reality of the world that we live in.We offer a service and it comes at a cost.
So we've got to get better at it.I think as a profession.I think for for me, and I did have a really interesting conversation with a a pet owner at this conference that I just talked about and they did some research as well and show the sort of things that people really are really, really interested in.
For pet owners.It's the main thing that they care about is the quality of life of their pet during treatment and the quality of life after as well.Is that going to suffer or are they going to cope with the treatments being proposed and what is it going to be like afterwards?
And that's something that didn't come up very highly on the veterinary surgeon survey, which was interesting.And I think that when we go into these conversations, quality of life for me is probably one of the most important things.And prognosis over diagnosis is something that I've always been a really passionate about.
Before we start embarking on these invasive and costly treatment options, can we just pause a minute and think about, OK, what is that pets welfare and quality be like going to be like during and afterwards?And if it's not meeting the client's expectations and it can't meet their circumstances, then is it really the right thing to do?
Because we're seeing a lot at the moment of pets that have gone down some quite aggressive treatment therapies that the owners have run out of money and they've been referred to us.And in hindsight, it wasn't the right decision.And that's not great because it really does put that only in not only a difficult emotional position, but then there's a lot of trust as well with vets.
So yeah, it's an interesting conundrum to have.Yeah.How do you get better at that?Let's say we've got a younger vet or less experienced vet listening to this.And it's great to hear that institutions like the Royal College are addressing this.And I know it's a big thing.The states have, well the spectrum of care.
But how do you get better at the front end of that conversation to go, all right, well, before we do all these things, let's talk about where this is heading.Yeah.And there's another thing that's starting to mix now, isn't it, as we've talked about is the relationship that that that person has with that animal as well.
And I've made some sort of false assumptions in my time that when I'm working at one of these very wealthy areas with very well heeled owners that they want to do everything that that they can.And I've been caught short sometimes when people say, oh, no, no, no, I'm not going to.
I'm not going to put a dog through that.I'm not going to pay for that.That's ridiculous.So I think it's that there's another complex thing there in what is, well, what are people prepared to pay, but over the years and what when you work at a senior level, you get visibility of all the complaints that come in.
And the majority of complaints that we get in vermic practice are either down to communication or down to not being upfront about the costs of treatment.Very rarely is there much substance in the actual treatment itself.It's generally about the communication of it.
I mean, obviously there are exceptions to that and things happen, but my advice would always be just be very upfront about A, what are people prepared to pay and B what are they prepared to do as well.People don't necessarily always want to put their pets through prolonged treatment courses with not great outcomes.
And whereas on the flip side of it, people will do everything they can to give their pet another couple of weeks of life.So you've got to be really, really clear what the owner's expectations of that treatment is and whether or not the treatment is going to match it.But as I say, being very honest and open about the owners budget is super important I find.
And it's something I learned very quickly in permanent practice that you have to understand how much they're prepared to pay.There was a bit of an uptake in insurance I I understand last year in the UK and I think about 4 million pets are insured now, which is relatively high, but there's 36 million pets in the UK.
So.You know, there's about well about 10-11 million dogs and cats, but then there's a lot of other sort of exotic pets and smaller pets.But the majority of pets therefore are not insured.I heard colleagues when I was working in this broad practice, the first question that asked her is your pet insured?And that's, that was almost the finance conversation done.
And they used to hear that.And I'm like, yeah, but what's their insurance limit?Like what's the, what's the, you know, excess they've got to pay on that.That's not a financial conversation.Is it insured?Because all that's doing is giving that owner the sense that, oh, right, right.They're just going to charge what they want now because it's insured.
That's not a proper financial conversation in my view, Yeah.I'm curious for those of us who do not work in a charity hospital, and this is probably more for the level of the practice owner or the management, how do we get better at it at catering?
Can we?Is there is the current business model of veterinary business model capable of catering for everybody?Because if you go to a veterinary business coach, I have a lot of conversations with people and generally the advice for private practice owners is charge more, raise your prices.You want to be at the 80th percentile of veterinary pricing, but what about the the other end and especially in places like in Australia or the rest of the world where there's not a Blue Cross or APDSA for people who can't reach for that?
Are we leaving people behind and how do we prevent that?They'd say Paul gets fired from Blue Cross.I was going to say quit, but I don't think you're going to quit and you start your own vet business.How would you institute this in your vet business?And this is a really interesting question, isn't it?
And I'm going to start off by saying, as a business, I believe you can charge whatever you want for your services.I really, really do believe that whether or not your customers can afford it is another question.And I think that's the key point.And this is the bit where business models will fail, I think.
And what we're seeing at the moment, yeah, across the world, is that people don't have as much disposable income.So in that model where you raise your profit just by increasing your prices, you're going to out price some of your clients out of the market.And that's fine.If you don't want to see those clients anymore, you can just say to them, look, this is how much the cost of it are.
I, I suggest you go somewhere else.Now, if everybody's doing that, that's not great because there's going to be a whole chunk of people in the population that have got pets that have got no access to veterinary care.So I think for me, and it's really interesting that I'm now being asked to talk at veterinary conferences on how to develop pricing models, how to run efficient practices and things like that.
And I think it's, it's a really interesting sort of gap in skills that we've now got in the profession where we're now calling on the charities who do run efficient hospitals.And the recent talk that I gave was how to develop a cost based pricing model rather than what we currently do in veterinary, which is a value based or we look at what everybody else is charging in the market and and set our prices relative to that.
But you know, to answer your question, if I left Blue Cross now and set up my own practice, I'm pretty confident I could turn a profit on a budget practice model with what I've learned in the charity sector.And, and basically, and we, we have to do our own pricing modelling as well.
And we have to look at how we run efficiently.But, but if you're going to offer sort of a cheaper option service model, it, it has to be volume based.So what you talk about there is, is put your prices up.What that's doing is that's increasing your average transaction value.
So for every pet that walks in the door, you're charging them more money and that's fine.That's one way of increasing your profit.The other way of looking at it is saying, OK, if I want to offer a more sort of budget service, for example, going back to your supermarket options, well, it has to be on pet volumes.
I have to see more people and I have to look at my scope of service and I have to charge them less.But you make your your value or your income and your profit on.And there are actually some models in the states that are emerging that are doing that, that are turning profit on budget models and also funding models where, you know, it's really interesting is because we the model that we've got in that we practice is that it's very transactional, isn't it?
It's OK.So client walks in, they pay at the point of service and we expect people to have 1000 lbs laying around to to pay for that.I think if you look at it from the other side and you say, OK, I mean, I don't have 1000 lbs in my back pocket on many days of the week.It's just not something that that you have.
So if you assume that people come into your practice don't have money but could pay you overtime or could you access some funding from somewhere or or just taking a slightly different approach to how income is achieved.I've seen these practices that in the states are generating profits that are very healthy in terms of what private practices are generating.
But I talked to a recent conference on a cost based pricing model, which is what we've developed, which is again the common business practice.You look at all the costs of running your business, you look at all your available sort of vet and nurse hours and then you divide 1 by the other and you say, well if I'm going to charge this per vet hour, I'm going to break even.
But it's absolutely grounded on evidence on this is what things cost.And I think when we've done the bottling of Blue Cross for this year's budgets, if I charge my VET time out £150 an hour, I break even.And I think that's pretty good budget model.
Obviously we don't charge that because we get some funding in, but I think understanding your cost base is really, really important.And then you can add on whatever margin you want.But that's not kind of what we do in VET.We practice and we do this really strange thing where, for example, neutering is always done at a discount, it's always done at a discount, it's always a loss leader.
But what that's doing is it's telling the people that work in our practices, they don't understand how much these things cost for a star.And then what you're doing then is you're just putting the margin somewhere else.So you're disproportionately charging higher prices to make up for the loss that you've made there.
It's a really hard cycle to break because nobody wants to be the first practice that charges double for neutering what everybody else is charging, because we use that to get our clients and get them bonded.But if you think of a model where clients that might not be bonded to practices so much in the future, why not let people go to the practice down the road and do all the neutering down there at a loss?
And then you just charge a cost based price model pushing margin for everything else and make a healthy profit and not having to do the loss making work.So it's a really interesting conundrum we've got ourselves into, but somebody's going to have to be brave and, and and break the mould, I think, and actually just say, actually, no, this is how much things cost.
I'm just going to add in a bit of a margin and medicines, we've completely messed ourselves up here as well because traditionally we didn't charge for time appropriately.We put mark up on treatments.So some of these medicines have got 1000% mark up on them.And of course the Internet pharmacies have emerged and they're doing things way cheaper than we can.
So again, it doesn't look great and it's not a model, but I think a lot of businesses have adopted it's, it's, it's an interesting problem we've got.Figuring out that your cost of delivering a service.Is it as complicated as it sounds?Because I mean, I've run an emergency service and there's a lot of moving parts to keep in mind.
You know, it's literally from how much electricity am I paying per hour cleaning things or like how much work is it for the Blue Cross to figure this out?Or is there a simple recipe or a resource that people can go to?Assumption the cost is easy, that's the easy bit.You just roll in what you've spent.
OK, that that's the easy bit.I think the the difficult bit is to then look at how much individual procedures are going to cost.And let's be honest, the majority of cost in inventory practice are staff time.That is the majority of things that any business owner is paying for or charity.
That is the fact.So that's the biggest focus really.The tricky bit then comes in about how you then charge out for things, how long does what, what is the cost of doing this procedure?For example, how much time is it going to take?What are the consumables in there, all that sort of stuff.
I mean, we, we do something simple.We just roll all our costs of consumables, overheads, rates, electricity, rents, all that sort of stuff into one big thing and we've got our full sort of cost base.How you then apportion it out per hour of time is a little bit more tricky.That takes a bit of modelling, but we've got some amazing modellers and financial spreadsheets that would break the Internet, the size and scale of them.
But we've managed to do it.You only have to do it once and you get a relative idea of how much things cost you to do and then you could decide what margin you put on them.So it's a big piece of work initially, but it sets yourself and every year all you have to do is tweak it and it's a lot easier after that point.
We're we're getting into cost models now, which is.Yeah, you're right.I find interesting.I have so many conversations with with people at all different levels of the vet profession, including owners of large corporate groups who's struggling with these issues.So it was really interesting.I did that talk at the very conference in January last year on a cost based model, how to build sustainable pricing models.
And I just, you know, you, you get that fear sometimes when you're, you know, am I overstepping the market?Why is a charity that walking into a room full of practice owners telling them how to price their services?And you know what, it was so well received.I had loads of people coming up to me afterwards and asking me, could you give me a hand?
Because what people were saying, which was again, really interesting.The problem, this what woman was saying to me, do you know the biggest problem I have is my staff do not understand the cost of delivery services.So what they're doing, and she gave a really good example, is an animal's coming in and came in with a pyometra.Now as a practice they were charging about 1200 lbs for that, that procedure.
But what the team were doing was giving antibiotics to that pet for a few days and then booking it in for a routine neutering which was £350.And she said just cannot get them to understand that that muta is 1200 lbs.
It's the same price as what I'm doing the pyometra for.And I just said to her, well, you know what the problem is, don't you like the, the problem is that you're charging the wrong amount for that neutering procedure.And yes, I get it.The B uproar and the practice if all of a sudden you, you tried to charge.
And neutering is the really interesting thing because when we looked at our pricing at Blue Cross, the thing we used to do free neutering our Blue Cross and we introduced neutering charges for all our clients because my feeling was, well, actually there's loads of options for neutering out there.
There's lots of private practices that are doing it at a loss.I'm happy for our clients to go and do it there if it's cheaper.But the bit that that me teens feel really passionate about, it's really interesting because they see it as a really important sort of preventive welfare focus thing.But the way I see it is, I said, but if you're going to double the price of your sick and injured pets treatment to give this at a loss, is that OK?
And it doesn't sit comfortably with me and you know, the fact that her and team were making really questionable clinical decisions to try and and work the prices.I love them.That is just so difficult.Veterinarian.We are such Robin Hoods really.Steal from some, steal from somebody.
Steal from ourselves.Steal from ourselves to help people.We just so badly want to help people that will be with all these clever little tricks.Yeah, but it's interesting, isn't it?Because if we're uncomfortable talking about something that comes across as, it doesn't give confidence, does it?And I learned that pretty quickly that if I went in to a conversation with a client about money and I was like, oh, I'm really sorry, this is going to cost this much.
It does not instill any confidence that that you're charging the right amount to that client.And they don't trust that those prices are valid.So I learned pretty quickly that even if I thought some of the prices and the practices I worked in were quite expensive, I said, well, this is a fact.This is how much this costs.
Are you comfortable with that?It's not whether or not I'm comfortable with it.I'm irrelevant in that conversation.I'm not the one paying the bill.But what I would see vets doing was a lot would be like, gosh, that's really expensive, isn't it?I'm not going to charge.I'm not going to charge everything on this bill.And all that's doing is pushing the cost somewhere else.
You, you, you, you're forcing the practice at that point to put costs up to, you know, to balance the books.So yeah, it's a really interesting one.Random question, how much is a sustainable profit margin?What is Paul's new business?What?What are you aiming for for a profit margin that you think can renovate practice sustainably?
Well, that's a really interesting question and I know that I think a lot of practices are struggling to break even at the moment, but I think you need to make a decent amount of profit that you can then invest into the team, the practice, maintaining the building, the infrastructure and investing in new technologies as well.
I've got a number in my head because also I'm a bit of an entrepreneur and I have a couple of my own businesses, and I'd like to think that 20% is a reasonable amount.I think most of the time the way that practices and technology and medicine is evolving, you're probably going to invest in something if you're delivering that level of profit.
But I don't think that's a level of profit that at the moment.I think a lot of the private sector is aspiring to and we've seen massive increases in costs of delivering our services over the last few years, especially around staffing costs.I mean we've been through a workforce crisis in the UK which is we were paying locums crazy amounts of money to keep services open at one point and it's untenable.
And if I played to locum bets, if the markets there for high paid locum shifts go, go and do it.I know if I was in that position I probably would.But the bubble burst at some point and people realise that actually, no, this isn't tenable anymore.I can't run a service while paying this amount of money out every day.
So yeah, it's an interesting one.What's your version on the percentage profit one just out of interest?No, it's, it's not mine so much.It's just conversations that I've had recently with people who are much more suited to have this conversation run big businesses or have run big businesses. 15% I've heard increasingly as a reasonable margin that can sustain a business that allow growth.
While or so it's something that you can happily tell a client, right?You could say to a client, yeah, we aim for 15%.When they give you that all you care about is the money conversation, then you go, no, that's not lucky about it.We do aim for 15% profit so that we can pay our staff.
So yeah, that's, but it's I, I don't have my own personal insight because I know 20% is has traditionally been put out there and I know some of the corporates aim for 30, but does that push it too hard?Is that sustainable for your clients as well?So there we go.It's really interesting the concept of a business as well, isn't it?
We're treating sick pets.And I used to get asked this question a lot by charity clients and they used to say to me, do you think you'd ever want to be a proper vet?And you'd be like, you know, I mean, working in a practice where I was doing sort of quite advanced orthopaedics and ophthalmology procedures and things like that.
And I was a little bit like, what do you mean a proper vet?I feel like I'm a proper vet and they're like, no, no, no, but get paid, go to practice and get paid.And there's there was assumption that because you work for charity, you volunteered your time and you didn't get paid.And we do, we do pay obviously I've had.
So there's not many people that can work for free.We don't often compete with private sector salaries, but we compete on other things like with life balance and holidays and all that sort of stuff.And we do have to be relatively competitive.But it's just this concept of there are people comfortable with a business that's set up to treat sick and injured pets that is making a profit and profiting of sick pets.
It's just a concept that I think that we struggle with as a profession a little bit.I'm really comfortable with it because I know sort of how the world works.And but, but it's just, I think just as a profession, we struggle with that a little bit as well.It's such a, well, we could talk about this.It's something I've given a lot of thought to recently because again, in the podcast I talk to and think a lot about the problems in the profession and moving upstream.
Where do these problems come from?And I recently read a book by Seth Godin and the whole book is about systems and changing systems.If you want to change the outcome of a system and how do you do it and where do you which levers you pull?And he talks about the concept that most businesses, countries, organizations are very large, complex systems that have been created over years to decades, to hundreds of years sometimes.
And once it's set, the system wants what the system wants, has an output that it needs to deliver, and it will do its damnedest to give that output.And it will be very resistant to change because you've got all these little cogs.Every human is a node in the system that has to do its job.
And it all works towards this output.And reading that book made me think about the system of the veterinary health care.And it made me wonder, what is that desired output?What is that outcome that the veterinary system works for?And I thought about it for quite a long time and I was like, well, it's probably a profit, right?
Because we have businesses, a lot of people will say, no, the outcome is pet health, healthy animals, animal care.But I don't know, I feel like that's a byproduct or one of the ingredients that goes into it.But for the standard private practice, private business that started 100 and something years ago, the outcome that the system wants is still profit.
And if that's true, and I'd love your thoughts, is that true?But if that is true, that is a direct opposition to what veterinarians go in for because we don't want to go into it for the profit.We want the healthy animals.We want the pet care and so we set up, our system is set up for friction from the beginning.
And I don't know the solution.Is the solution more Blue Cross, more PDSA, but it's not a profit based outcome thing.Or is it just getting better at that friction, finding ways to reduce that friction and living with it?Because that is the reality of the system?Yeah, I think the sweet spot isn't it?
Is that your end?The point is to achieve a profit, but it's the way that you do that and you do that by delivering a highly patient focused, customer centric, welfare centred service.
And interestingly in the UK when I was first entering my sort of career, veterinary businesses had to be owned by veterinary surgeons.Now that was that was something.So I think there the the sort of the meeting of the moons, if you like, of OK, yes, I want to generate a profit because I own a business, but I'm actually also a vet and I'm going to do it in this way.
Now, I'm not saying that all vets are great business owners.I think there's lots of conflicts there.But now there's been that sort of disconnect.Now you don't have to be a vet to own a veterinary business.So it has that created a divergent of what the business is trying to achieve and what veterinary surgeons are trying to achieve.I think there's a connect that you can make there that actually the way that we to deliver a profit is through a high quality service that is meeting the needs of the pets and the people that we serve.
But it is an interesting 1, isn't it?And about, I think my experience and from talking to lots of people in the profession is that they don't understand enough about the business and the pricing and how the decisions that are being made that they see reflected in some of the impacts on pets and and clients.
And that's creating a bit of a disconnect at the moment in the profession.And I'll give you an example, a nurse that as he works with me in in another business worked in a night service and they had to do an overhaul of their prices and inpatient care doubled per night.
And there was no explanation to the team.From her perspective, she was delivering the same service to those inpatients.And she actually disconnected at that point from that business because she was like, this is ridiculous.And and the having to bear the brunt of that by trying to explain to owners, yeah, I know your pet was in last week and we charged you £500 a night.
It's now £1000 a night for inpatient care.And obviously the owners aren't going to handle it.They're going to just go elsewhere or try and look elsewhere.But with no explanation as to the rise in those costs, there's immediately now a disconnect between the business and the people that are working in that business and having to have those conversations with clients.
So, yeah, but I do think there is a place in the market for a affordable and accessible veterinary service.I don't think we should all just drift into this.Let's all offer the highest end gold standard care that we can because that is not what society needs right now and and never has it in my opinion.
So, and I think there is potentially, if anybody's interested, that they would be a healthy profit to be generated in, in a model such as that, just as every other industry has proven it can do, supermarkets, airlines, that there is always all the scale of affordability in product offerings and different value propositions.
And I think that that it could be done.And if I wasn't working in charity practice, I probably wouldn't.We're doing it, but yeah.You think that that do you have a tiered level of care within one business or are those going to be separate businesses?Can the practice that offers the high end also have a lower cost service or is it too much?
Is it too different?I, I in theory, yes, it's a different, it's a very tricky skill set for clinicians, I would say.So when I was working at PSA, we used to outsource our out of hours.So they used to go to, you know, private practices.
And those vets would really struggle quite understandably between two different service models whereby for one, you're, you expected to do XY and Z as a minimum for every patient.And for another group of patients, again, it was evidence based.
And arguably you could say, well, actually, if you don't really need to do all that, should you be?But there was very, a lot of limitations on, on what PDS were prepared to pay for.I, I guess the clinicians really struggled with it.It, it was quite difficult to get yourself into two different models in the space of half an hour with two different patients that are coming in.
So I, I recognise that it's challenging for clinicians if you're trying to do a full, so scope of service at different value levels.But I think it's a skill that that all vets should also have because not everybody that walks into the practice is going to be able to afford everything that you can offer.
The challenge with that is always, and again, I you talk about the emergency and that's often the commander for emergency because in many instances you are the only option available and it's urgent.It has to get done now.So it does make it much harder.Where do you put yourself at the specialist level?
Full service bells and whistles, gold standard versus pragmatic care.I like the word pragmatic care that you used earlier.And the problem with that is usually, again, it's big, nice and conflict avoid.And we tend to then if the option is there for the more pragmatic kid to sort of default to that to go, well, we could do all the stuff or we could, I wouldn't say cut corners, but aim a little bit lower and then people will obviously go, well, I'll go cheaper option.
If they're both going to give you a good outcome, let's go for the for the cheaper option.Yeah, and that's all.I would argue if you're getting the same sort of welfare outcome then then why not do that?But but what you, what you then got to do is you've got to recognise that that is taking less time, that it's using less resources.
So actually you could see more patients.And actually if you're charging half to that client, you should be able to see another patient that you can also charge half to.And that's the whole concept of the budget model is the fact that you're recognising that you are doing less work per patient, which allows you to see more patients.
So I think that that's the only way that that sort of model can make the money or have the impact in our case, which is see the pets that we want to see.So for you guys to institute that pragmatic care, which is the norm for you, so a high level of care that's going to give good outcomes, but spending as little as possible, Are there things off the top of your head, the biggest needle movers that reduce this, your cost of care?
Yeah.So we have a veterinary standards team now.These are vets that meet once a week and they look at our scope of service and some of the common conditions that we treat.And they've created a whole suite of sort of clinical guidelines.Now, again, what these are doing is they're looking at common sort of conditions.
We we, we go for the costly things first, obviously, because that's where you can have the biggest impact.And they look for all the evidence that's out there.So it's really important.That's love evidence.We don't like just being told that, you know, you don't need to do that.So they'll do a lot of sort of literature reviews, a lot of research and look for different sort of treatment options, the welfare outcomes and what we are comfortable with as a level of service.
And I guess, you know, I could give you an example of this.So abdominal tumours in cats, for example, is a good example.So our team looked at the outcomes of abdominal tumours in cats and you know, as most people listen to this will probably be aware, they're not good.
There isn't really any situation in which when you feel an abdominal tumour in a cat, it's going to end well.So on that basis, that helps us because that would then dictate that we actually are moving into a palliative situation with that cat.
We wouldn't necessarily consider even doing extensive imaging, diagnostics, biopsies, surgery, because we know that in the vast majority of those cases, that's not going to be a good outcome for that cat.
So that's a really, really good example there because that's the difference between having that conversation very early on with the owner, managing their expectations and potentially considering something like steroid therapy as a palliative care.That's sort of a really clean cut and simple example, but they have to go and get the evidence.
So it's, it's just looking at outcomes, welfare implications.And some things that we do choose to do are quite expensive, I would say.And you look at the cost of treating specific cases and you're like, but it means that you can really take a pragmatic view and get get a good welfare outcome and things like diabetes treatment.
How often do you really need to have those pets in for blood monitoring?Or can you set up a system where the owner can self monitor at home or they can work on the clinical signs to adjust dose rates and things like that and get you get really confident and experienced at dealing with some of these cases with minimal intervention.
So I think you need the framework in the background of that really to be able to do that.And you need the confidence.Like I sort of got my confidence when I went into charity practice and I was working with, I think there's five or six of the vets in the practice.And collectively they had between them probably about 150 years experience.
And they would often be chatting about cases in the lunch break or the tea room because you get breaks in charity practice as well, which is another great thing.I mean, you're busy in between those breaks.It's you work as powerhouses, but you also get a cup of tea.So you got a chance to discuss some of these cases.And I learned most of my clinical insight from these really experienced vets.
And a lot of it was pattern recognition.It was like common things are common, you know, just sensible, common sense approach to things.Yeah.The do you guys, I'm sure you're getting interesting data from all of this because what I'm, I immediately think, wow, it'd be so interesting to compare outcomes with your hospitals for let's say completely fixable things.
I immediately think of the caesarean section or you mentioned by Metro earlier or more life threatening like a GDV or something like that, the Blue Cross version of that.What are your outcomes versus the bells and whistles emergency center with the central outline and all that sort of stuff.
Are you getting way with outcomes or is it parity?Do you guys have the data?Do you?Because this would be amazing studies to look at.Yeah.I mean, our outcomes are are pretty good, I would say.And what's really interesting is when you look at some sort of pandemic studies, and I was at a PDSA from the start of the pandemic and then moved to Blue Cross.
But we looked at the management of conditions that had been moved to remote management and looked at whether there was any change in mobility or mortality of certain conditions.And we looked at heart disease.And it was really interesting.
There was absolutely no change in the management of those conditions when our service went fully remote, which is just brilliant for me as I've had.But it also indicates that we're just doing too much.We are in some situations intervening and trying to do too much stuff when the outcomes actually are very similar when when we can step away a little bit.
And we did some cruciate outcome surgical outcomes, which were really good compared to wider sector data.So it just it's good and we, you know, don't necessarily do some of the high tech surgical interventions, but then when you've got an experienced surgeon doing something day in day out, the outcomes are pretty good.
I would say are.Your guidelines publicly available.Would they be certainly drinking to sea for a private factor?And as I say, well, these are acceptable standards for Blue Cross.I wonder what we can institute.Yeah.So we do have plans to share them on a wider scale.
At the moment, we don't have a mechanism for that.So we don't have, we're trying to develop an app and all sorts of things like that.But I think what I'd like to do with them and especially with the practices that are partnering with us on the Veterinary Care fund is to really offer them up to clients that are clearly struggling with affordability because they, we know that because their practices are asking for grants from us, from the charity.
But a great scenario for me is, you know, we've got a client that's come in, they've got a diabetic dog, they're struggling to afford the treatment costs.And we can say, yeah, OK, we can help with that.But hey, here's our clinical guideline on managing diabetic patients.Have a look at it.
No pressure.Have a look at it and see if there's anything that you could do to drive down the cost of treating diabetic patients and clients that might not be able to afford it.And I think anything that we can do to sort of influence the ability for vets to, to empower them really to offer more affordable or accessible vet carries my job.
My job will be done.I can retire then, please.Let me know how I can help.I love this.I love this conversation, but I'm going to have to let you go at some point.Standard questions.Are you a podcast listener other than making your own podcast?I am a podcast listener.
Yeah.I was going to like ask if it was appropriate to completely look at my own podcast.But you can absolutely plug it.Plug it I'll.I'll I'll do that, but then I'll give you another podcast.Again, enjoy listening to.Yeah, and so obviously my own podcast, the console Room, which was a lockdown project really.
But I I've just loved doing it and I really sort of explore the the modern world of pet care, if you like.So I go into some interesting subjects I think are interesting not just for vet me professionals, but for pet owners and people that work alongside in other questions as well.Some of my favourites at the moment are I love there's a journalist called Elizabeth Day that does a podcast called How to Fail and it's great, really great.
It's just celebrity interviews and stuff, but her style of interviewing is great.And then I don't really watch the news anymore.I've sort of switched off from the news for obvious reasons.But there is a podcast which is done by the Guardian, the UK is called In Focus, and that's the only sort of news or podcast to listen to because it's really short. 30 Minutes gives you a really nice balanced overview of some of the biggest subjects that are going on and topics around the world at the moment.
So yeah, they're my 2.A bit of entertainment and a bit of fact.Nice.I like it.All right, Paul, you have an opportunity to speak, which you do all the time, but you have an opportunity to speak to all the veteran new grads of 2025 and you have a couple of minutes to give them one little bit of one message or one bit of advice.
What does Paul tell them?So mine is really practical advice, go get yourself a job in a bar or a restaurant while you're doing your veterinary training.I think learning skills of hospitality, customer service, teamwork, how to work under pressure and dealing with complaints will set you up for your career and give you those life skills that you absolutely need.
It's a great job, don't let it get you down.Love that, Paul, thank you so, so much for your generous time and for the incredible work you do and for sharing the stuff that you're learning with the rest of the profession.That's very thought provoking.It's going to make me think I'm going to have have to get back to you and say, well, hang on, I had other questions.
Yeah.To follow up.Maybe we can talk about it on your podcast then.Yeah, yeah, we can talk about other stuff.I I really appreciate it.Thanks for making the time before you disappear.I wanted to tell you about my weekly newsletter.
I speak to so many interesting people and learn so many new things while making the clinical podcast.So I thought I'd grant a little summary each week of the stuff that stood out for me.We call it the Vet Vault 321 and it consists of three clinical pearls.These are three things that I've taken away from making the clinical podcast episodes, my light bulb moments, two other things.
These could be quotes, links, movies, books, a podcast highlight, maybe even from our own podcast.Anything that I've come across outside of clinical vetting that I think that you might find interesting.And then one thing to think about, which is usually something that I'm pondering this week and that I'd like you to ponder with me.
If you'd like to get these in your inbox each week, then follow the newsletter link in the show description wherever you're listening.It's free and I'd like to think it's useful.OK, we'll see you next time.

Dr Paul Manktelow