The synergy of financial resources and individual expertise
To understand how monitoring services are set up and work is organized, we need to study the business model of veterinary practices. For general medicine, although there are some differences between practices, visits are generally billed on a fee-for-service basis that includes the price of the visit (with or without travel expenses) and products if prescribed. The introduction of monitoring services modifies the billing system for visits by applying a yearly fee determined by the different types and range of services selected.
As noted in the preceding post, product sales represent today between 65 and 85% of the turnover of the rural activity of the fifteen practices surveyed, the remainder corresponding to medical procedures. Monitoring fees do not seem to contribute significantly to turnover, but the service allows practices to maintain close contacts with farms, cultivate good relationships with farmers and ensure the sale of other, more profitable services.
A second means to achieve economic equilibrium is maintaining mixing activities. Six of the practices surveyed (out of 14) were able to sustain their rural activity, which is shrinking, by developing their canine activity, which is expanding. Combining the two types of activities is therefore essential from a financial perspective.
All of the veterinary practices surveyed are organised in a similar way, particularly with regard to the frequency of appointments with farmers. The veterinarians usually meet up at the practice in the morning and wait for farmers to call in. There are more visits in the morning as this is when farmers are with their animals. In fact, in all the practices surveyed, there are more veterinarians available for rural activities in the morning than in the afternoon. Visits requiring a prior appointment are often scheduled in the morning (monitoring reproduction, surgery, vaccination...) to coincide with the rhythm of the animals. Veterinary practices also have comparable on-call systems. Ten have an in-house on-call system and eight have mixed systems. Three practices share their on-call time with neighbouring practices, thus increasing the number of veterinarians in the rotation.
When monitoring services are added to these general medicine activities, the way work is organised in the practices changes. Indeed, two opposing visions of medicine may be observed: on the one hand, the idea of highly specialized care with a guarantee of quality services, and on the other, the idea of general medicine able to handle all emergencies. Practices in the first group, capable of offering up to five different kinds of monitoring care, arrange the schedules of the veterinarians so that some of them can only do monitoring, while the other practices focus on their role as "firefighting veterinarians" and make the most of the versatility of their technical and health knowledge and skills. In both cases, in order for some veterinarians to be able to only provide monitoring services, other veterinarians (whether they are from the same practice or not) must manage the farm health emergencies. The veterinary profession is therefore above all a collective one where the services offered depend on how the practices are organized, and where activities are becoming increasingly compartmentalised, which means that veterinarians have to specialize and even prioritize their tasks within a practice.
Overall, the wish to move towards preventive medicine is reasoned through at the collective level of the practice. This synergy and interdependence are visible at the financial and organizational level of the practices. Moreover, to secure their place on farms, veterinarians have to integrate themselves into an existing market, so they need to mark themselves out both within the profession and within the farming world.
Inter and intra-professional competition
The internal organisation of a veterinary practice tends to structure the services it offers. However, this survey also has shown that the provision of monitoring services depends on "capturing customers" in a highly competitive agricultural world.
Although veterinarians are responsible for the overall health of a herd, they are not the only ones to intervene on a farm. Different actors can offer the same service on farms, for example around reproduction (inseminator, veterinarians) or milk quality (milk control, veterinarians). Veterinarians claim that four factors set them apart from other professionals: their professional expertise; regular physical presence on farms (proximity, responsiveness, availability); in-depth knowledge of the farm; and a relationship of trust with farmers. Competition with the outside world remains the prevailing model and few partnership relationships are established between veterinarians and the other various actors.
Beyond competition with actors outside the profession, competition also exists within the profession between colleagues. Independent veterinarians fear losing procedures that once were their exclusive domain and a steady source of income, such as disease prevention, which largely has been taken over by GDS (French health protection groups), or the sale of drug products, an activity now offered by supply cooperatives (excluding antimicrobials) and "profiteer" veterinarians (veterinarians who prescribe medicines, including antimicrobials, outside their customer sector).
In order to ensure a foothold on farms and maintain their rural activity, some practices have formed alliances. There are different degrees of alliance depending on the strategies of a practice, ranging from buying up sites in order to ensure a monopoly on a territory to joining "competence networks". The latter are groupings of veterinary practices under a franchise. Various networks exist in France, one of the best known in the beef sector being the "Réseau Cristal" (according to one of the network's managers, the entity groups together 27 structures, or approximately 300 veterinarians). This network has a strong presence in the departments of Bretagne and Pays de la Loire. Of the fifteen practices surveyed, five belong to a competence network (Réseau Cristal for four of these) and two are negotiating to join one.
The objective of this type of network is above all growth, expanding over France, and to obtain a monopoly over sales activities by favouring companies created by and for the network (product manufacturing, laboratories, etc.). In order to join Réseau Cristal, there are several conditions, the first of which is to have an activity in the livestock production sector, and the second to have a business project. Finally, depending on various parameters, such as the number of full-time equivalents in the structure and type of activity, practices must pay an annual fee to join the network. Other veterinarians who do not wish to join a network cite the loss of proximity to farmers and even the loss of independence at the practice level.
This level of analysis of veterinary practices on a given territory makes it possible to show that, although the provision of services is above all an organisational question at the practice level, it also is directly influenced by inter and intra-professional competition and the presence of practice networks on the territory.
The survey made it possible to define three types of veterinary practices. At one end of the spectrum are "family practices" which have no plans to expand and wish to maintain friendly relationships both with farmers and within the practice. At the other end are large practices with plans to expand and pool skills and veterinarians, these practices generally belong to competence networks, and may be identified as "corporate practices". Lastly, a group of practices is emerging in the middle of the spectrum, ones which wish to pool resources while remaining at the local level, and are identified as "semi-integrated practices”.
This multiscale analysis allows us to understand the place and role of veterinarians both on farms and within practices. By studying how veterinarians work, the results of the survey show that despite the desire to move towards preventive health practices, the boundary between curative and preventive services remains blurred and these are not separate on farms. The sale of products, both drugs and other products, remains very important, if only to maintain a practice’s rural activities, and medical procedures are also combined with monitoring services. Thus, monitoring services are not exclusively based on the provision of advice, and undoubtedly represent a new way of working that render it possible to maintain older ways. Although veterinarians speak of "collective medicine", in reality this type of service does not completely replace individual medicine.
Indeed, this study highlights that the commercialization of monitoring services is above all part of an effort to synergize services. Beyond revenue, monitoring services allow veterinary practices to maintain "a foot on the farm" and thus to be in a position that enables them to sell other types of services which maintain their operations. As a result, the implementation of these activities is an organizational issue that ensures synergy between income sources and human resources. Some veterinarians thus may only provide monitoring services because other veterinarians are running the rest of the practice and managing client emergencies.
Finally, the territory scale brings to light an issue facing the profession, that of a rising shortage of veterinarians, which is leading to the expansion of practices. Faced with these networks of veterinary practices, small practices advocating proximity and a family style of work organization are offering some resistance. Two different visions of medicine have emerged: the first based on increasingly advanced specialisations, and the second devoted to 'generalist medicine'. Further investigations will have to examine this recent trend: are we witnessing the formation of "two-tiered medicine" (but where there is a market for each of the models), or is this the beginning of a more profound transformation that will eventually lead to the disappearance of a certain type of service?