Insight

We used to assess and document insight a lot, routinely for every patient. It's become more of a trivial afterthought now (and rightly so) with more appropriate and sophisticated consideration of decision/situation specific capacity replacing the concept of insight being present/absent.

I was musing this over with an AMHP as we discussed what insight means, how it's been mis-used in the past in tribunals as a proxy to not being capacitated, how it's seldom relevant now. She raised this because in all her time in the multidisciplinary team it dawned on her that she's never heard us discuss insight. She saw this as a good thing and I'd agree. Insight as a concept has been of enormous import and done rightly is fine, equally it has historically oft times been a shorthand that's too superficial/medical to have the utility it needs. Patients' formulation of their experiences, understanding of needs, engagement with informal family/friends/support and formal health/social servcies can be framed in terms of insight but invariably is better considered in terms of understanding and capacity.

Having chewed the cud with an AMHP and stirred thoughts on the concept of insight at length, I moved on half an hour later and to my shame, I lacked insight.

I met with our Trust's Chief Executive. I do so fairly often. Our Chief Executive is an agreeable, competent, grounded and incredibly sensible soul. I'll frequently meet the Chief Executive and talk through stuff over coffee. Or email stuff that merits Board level consideration. Or the Chief Executive will come see me, which happened yesterday.

Because our Chief Executive is so approachable and engaged with Consultants, I rather fear I've done them a disservice.

I'd always thought the Chief Executive to be influential. I was naive. The Chief Executive has great influence over a great many things, but it's finite and in some ways is actually quite narrow. I'd not really appreciated the constraints that Monitor and CQC and SHA and DoH and others shackle the Chief Executive with. The Chief Executive has responsibility but Executive Directors have their own portfolios and they, not the Chief Executive, sort those. After deciding how things shall be, the Chief Executive then has tiers of managers whose Chinese whispers distort the detail and implementation of the intentions, horribly. Can the Chief Executive direct me to prescribe Mrs Smith olanzapine 5mg velotab at night? No. That's a clinical not a managerial decision, the Chief Executive has no direct influence on what clinicians do in their work.

National drivers constraining the Chief Executive's options. Local commissioners directing the Chief Executive's choices. Tiers of managers running with the Chief Executive's wishes yet effecting implementation (or not) their own way. Managerial decisions' boundary with clinical decision making (and no direct managerial influence in this). Good grief. I'd not really thought through what a grim position it is to hold, having all the responsibility yet with much less opportunity to effect detailed sophisticated systemic change than I'd considered. Worse, I erroneously presumed that the Chief Executive is boss and can sort everything. Most folk do.

I lacked insight into the situation.

Time to remedy this.

Transition

I work with a lot of people.

Or more accurately, as I'm oft times reminded, I meet with a lot of people and they do a lot of work.

One area of work is prescribing. I'm a doctor, doctors have expertise in this area. Psychiatric drugs are contentious, I'm a psychiatrist so can inform on reasoned, evidence based rational prescribing practice. This means I'm often asked to attend Local Authority or PCT or APC meetings to talk through how medication should/shouldn't be used.

This has contributed to significant improvements.

Patients can access any class of drug without constraints placed upon prescribers, rather than being totally protocol driven our patients can access drugs at any stage of illness (so we can freely prescribe outwith NICE guidance), our use of contentious drugs (such as antipsychotics in dementia) is audited and is seen to be good, use of medication in care homes has dropped markedly with rich mental health staff input instead, Local Authority has funded use of support workers/day care to reduce carer stress (and reduce medication through staff input as a viable alternative), GPs 'phone me up for advice or drop a short letter with all the details as well as making formal referrals for input.

Over the last few years things have got a lot better in my corner, with much better medicines management.

A recent PCT meeting I was invited to caused concern. The folk advancing all the work to progress sensible care were no longer in post, within either the Local Authority or the PCT. With the writing on the wall for PCTs, everyone's leaving, sharpish. With Local Authority not able to cut front line Assessment Officers/Social Workers unless they're not needed (and they are!) it's managers/decision makers who're being lost.

But in this state of flux, work that's been gently but purposefully progressing for the last few years now comes to a hiatus.

In this brave new world of austerity and GP consortia, will it all get better, once again?

Being Left Alone

I work with a number of senior, experienced specialist practitioners who, in addition to the perk of getting to pay the NMC a little more each year, also are non-medical prescribers.

Like every Trust, we have a large number of policies, strategies, frameworks, pathways and protocols that are seen as telling staff what to do. Who likes this? I know of no clinical colleague who embraces such policy documentation with joy and enthusiasm. Some colleagues vociferously oppose it as curtailing clinical freedom and, in maveric piques, go against it all.

People don't generally like being told what to do, how to do it, when to do it and what format they have to use.

There's no policy documentation on how non-medical prescribers have to document their prescribing activity. As part of medicines management within our corner, I reviewed it. All of it. There was rather a lot of it. They'd extensive documentation of their Continuing Professional Development, tidily presented in a folder, with the activity and supervision and time taken. They'd evidenced letters to the GP and referrer for all prescriptions, with copies of all of these. They'd detailed the discussions before prescribing, with every case I picked up specifically detailing what had been discussed between them, the patient/carer and a Consultant Psychiatrist. Letters had details of all prescribing, including the specific prescription number of the script. They'd a photocopy of all prescriptions.

I thought it'd be a lot of work for them. It looked fantastic. It wasn't a lot of work, or time, they'd been incredibly efficiant. They simply detailed a one line record of CPD in their folder as it happened. They succinctly summarised prescribing in a couple paragraphs to the GP for each script. They used the copier in the office to keep a copy of all prescriptions, so it was just a few moments to do that. There was little time invested in to it, yet their audit trail of non-medical prescribing activity wasn't just okay, it was flawless.

It's good to see.

It supports what I believe, so is something that stuck in my mind. If folk are told what to do, it's oft times seen as a nuisance and hassle. Leave a nurse (all the non-medical prescribers were nurses) to just crack on and do it herself, without any direction, without any manager, without any Modern Matron, and they're utterly brilliant at sorting stuff themselves.

Now, if I can just persuade folk to leave clinicians alone more of the time . . .

Heresy

What is "clinical governance" about? I mean, really? What does it tangibly change in my patients' world?

There's a pervasive assumption that it's always right, always good, always clear, always happening and always helpful to patients.

Wrong, wrong, wrong, wrong, wrong.

But this is heresy and I shall be burnt. So it goes.

Policies

I do not like them in a box.
I do not like them with a fox.
I do not like them in a house.
I do mot like them with a mouse.
I do not like them here or there.
I do not like them anywhere.
- Dr Seuss

It's always good to get a second opinion on contentious and contested issues. As well as frequent consults with Dr Google, it's sometimes good to reflect 'pon the wise counsel of Dr Seuss, too.

My current raison d'etre seems to be to manage policy. It's impossible for front line clinicians to manage policy day to day, so we have team meetings where we agree what policies we're not able to do, reason why we can't, which I then minute and send to managers. Maybe we'll be the next Mid Staffs with managers being informed by clinicians and Consultants what the problems are, but doing modest amounts to effect change. Who knows. We shall see. The important bit of it is that clinical teams are 'fessing up to what we can and can't deliver on, documenting that our practice is at variance with Trust guidance, reasoning why we're not doing it and informing the managament structure of this different clinical care.

It's not ideal, to meet up once a month to have to reflect on how we work, especially since 2 hours is a fair bit of time for a whole team to take out, but it's saved us a lot of time, in the long run. Not doing form filling, when the information's already captured and documented in 3 places already, has saved masses of time. And moved to a more paperless practice. And made everything more legible. And made it easier to print/email information. Clinical and secretarial staff have a lot of clever ways of working smartly.

But the main reason for this is the massive industry of policy generation that's become unhelpful. Excluding corporate/finance policies, our Trust has over 200 policies that apply to clinical staff, seeing patients. In a moment of ennui, I popped onto the web site and looked.

My oh my.

How can that work? A new junior doc or seconded nurse or bank nurse or trainee AMHP social worker or psychologist is in our service. They go to a clinic or DV or ward to see a patient. They have all their clinical process and knowledge and skills in their heads, structuring what they do and how they do it. They have the GMC/NMC/regulatory body directives in their heads, structuring what they do and how they do it. They have national guidance influencing their thinking. Maybe. They have legislative direction (particularly that MCA 2005 and MHA 1983) structuring how they work. There's usually us Consultants with our foibles, meaning certain types of assessment or interventions are "how we like things to be" which influences clinical care. On top of all this professional material, can anyone credibly believe these staff will also read, understand, implement and use over 200 policies in their practice, as well?

My angst is that oft times too much policy is generated by folk who aren't clinicians. Worse, it's done without any consultation with practising coal face clinicians. Even worse, the decision to make something happen is usually to make a policy, then consult on the policy. It's as if any alternative to a policy is never ever even entertained as a possibility. Yet how many clinical teams working in creative, iterative models of care, have working their practice defined clearly within a policy? Even the operational policies of the teams seem to be works of fiction that bear little resemblance to the function and activities of the teams.

How many times has a clinical team said, "Oooh yes, our clinical care in this area is so much better than it was last year, because we've embedded this Trust policy into our working practice and now everything's brilliant!"
Never happened, in my corner. Curious, then, that policy documentation is generated at such a staggering rate when the outcome/utility from it is evidenced as so poor. Hmmm.

People working far away from a specific clinical team will generate a policy that applies to that clinical team. They're working in the dark and generate material that's usually pretty sensible on reading through it, but is oft times unnecessary, overly tortuous and very very rarely impacts on direct clinical care.

I'll leave the final words, once again, to my colleague Dr Seuss :

Say! In the dark?
Here in the dark!
Would you, could you, in the dark?
I would not, could not, in the dark.

Nursing levels

There has been a lot of discussion about inadequate staffing levels. It's abundantly clear that having too few qualified nursing staff on wards compromises patient care and results in more deaths. The evidence consistently shows this. Accounts within clinical practice consistently illustrates this. Patients admitted (and their course, with some unnecessary deaths) consistently experience this.

It's therefore not surprising to me that when the Healthcare Commission investigated shabby care in hospitals, they found ward staff to be good, but management systems not supporting them (through cutting costs and not staffing wards with adequate numbers/adequate qualified staff). Subsequently the Care Quality Commission (CQC) have done the same. The CQC regulates hospitals, challenging them on quality and services. How deeply have their investigations and reports rocked managers worlds?

Has it changed anything in practice?

We learnt of the woeful outcomes at Mid Staffordshire NHS Foundation Trust with the report stating :
"It appears that some staff from whom we heard were often demotivated, undervalued and working in an understaffed and stressful environment"
"The staff who worked on these wards all agreed that there was a shortage of nursing staff."
"We heard these wards were significantly short of nurses, especially at nights and weekends."
"Some staff expressed the view that there were insufficient nurses before the reorganisation and that there were fewer after."
"Many witnesses noted that there were too few nurses and that those that were there were doing their best in difficult circumstances."

The Mid Staffs report described good nurses doing the best they could. To my knowledge, nobody was reported to the NMC for poor professional practice. Nor should they be. They worked as well as they could within the environment that managers generated for them. Indeed, the independent and detailed investigation found and documented that the nurses worked inordinately hard and beyond their duties, putting in huge effort to care for their patients.

The issue wasn't poor nursing, the hospital was fortunate and had great nurses. The issue was the the hospital, to save cash, didn't staff the wards with enough nurses (i.e. qualified staff) to keep patients safe. How huge is that. Not that there weren't enough nurses for gold standard care. Not that there weren't enough nurses for reasonable quality care. There weren't enough staff for safe care. Patients needlessly died.

But time's moved on.

Things surely have improved. Lessons learned. Erm, sadly it seems not. Scarborough looks to be operating in a scarily similar manner to Mid Staffs.

So it goes.

This week I read a new report by the CQC. This is dear to me, since it's about older adult mental health services, within a Trust providing mental health services. Not mine, I may add. The CQC are positive about the Trust. "The Trust has cooperated fully with us during the course of our enquiry . . . the Trust has not waited for the publication of our report. It has proactively started a process to improve its mental health service for older people."

One unit was terrible (and closed), the other units were fine.

So it's a decent Trust, with decent units, providing decent care. The management structure quickly made management changes and 'fessed up to shoddy care, investigating things themselves and reporting themselves to the CQC and making changes themselves. All genuinely poisitve stuff, the way the Trust behaved really does seem sound.

Most of the problem seems to have been one unit which was doing quirky things which nobody knew about. Things like using strong opiate analgesics inappropriately and hooking folk with dementia up to syringe drivers to control agitation. This was a huge error in governance which the Trust raised it's hand up and sorted out. Grand.

So the Trust, a decent Trust, find an area of rubbish care, sort it out and 'fess up to the CQC they've been rubbish, they're investigated and all's seen to now be okay.

Apart from one area.

Page 30 : "We looked at the relative costs of nursing staff against the trust’s spend on senior managers and managers for the years 2005/06 to 2008/09. Our analysis showed that while the spending costs for qualified nurses had dropped over that period from £26.1 million to £25.4 million and for unqualified nurses from £14 million to £12.5 million, the costs for senior managers and managers had risen from £4.5 million to £6.8 million"

"Our impression as we visited the older people’s mental health inpatient units was of highly dedicated ward managers, nurses and nursing assistants working under constant pressure. On more than one occasion, we came across ward managers who were trying to do their best for their patients with too little resource and fearful that they had not covered every aspect of patient care and the management of their ward."

Page 52 : "We found that members of staff working in these clinical effectiveness and risk roles in the trust appeared to have a good grasp of what needed to be done but were frustrated by the lack of effective systems to enable them to feel as confident as they should around overall clinical governance and compliance."

The CQC evidence that the wards were understaffed and staff knew what needed doing. And the Trust board spent a lot on management and moved from generating loss to generating surpluss. What have the Trust done to support nursing colleagues on the ward?

They closed the ward. They appointed a lot of Modern Matrons. They appointed a Director of Nursing.

Okay, I'm sold that they need the Director of Nursing but the Board minutes reporting ". . . outstanding concerns against overspending on in-patient wards and [the Director of Finance] pointed out the need to ensure optimum ward rotas," leaves me cold. More nurse management, less ward nurses.

The pages on community staff levels, case loads of 27.2 cases/staff is a whole post in itself, with community resources and practice meritting discussion. But to stay vaguely on topic, suffice to say that governance of ward process and staffing on the in-patient ward lead to grim patient care.

How many Trusts are staffing in-patient units well? How many Trusts are staffing in-patient units, if not well, at least adequately? Gah. So it goes.

Read the report from the CQC and see what you make of it.

Acute Wards

I do work on medical and surgical wards, covering liaison psychiatry for older adults in the acute hospital.

Things ain't great.

Medication is accidentally omitted (oddly, never reported to the NPSA despite their alert on this issue).

People are left lying in urine.

People are left unfed.

This happens every day.

Rather than plan person centred care, Wellness Recovery Action Plans, sophisticated dementia care and the like, basics need to improve. They're not poor because the wards are poor. The nurses and HCAs aren't turning up to work full of wickedness, intending to do a bad day's work. The crunch is that they're understaffed.

As an outsider seeing this, and not someone they can sack, it's been easy for me to raise this with their management structure. Which I did. They took note of the serious concerns raised, the unacceptable standards of care, care at variance with national guidance and the risk generated for their Trust through suboptimal care. Excellent. So what's happened?

They now have Modern Matrons charged to make it better, but they've no resources (at all, no extra time, no teaching time, no money, no staff, nothing). But because it's such an important issue, the Modern Matrons must ensure that Dementia Champions are trained. They don't have a view on what these Champions will do, but the Trust needs to have some, so staff have to be removed from the ward for training (but there's neither cover nor a training budget for this training). Failure will therefore be a ward level failure, with the managers having given strategic direction and solutions. Hmmm.

How will the Trust be sure that things are in place? Nurses will check. Except the senior nurses, who 2 years ago were seeing patients, now don't. They now "support the governance framework" through checking things on clipboards are ticked off and done. This drives them to distraction, they're band 8 nurses, not band 3 clerical support, but that's what the Trust requires of them. Tick, tick, tick.

So when there's a clinical problem, the solution was remove nursing time from the ward and remove senior nurses to do surveys/tick boxes, compounding the problem of a lack of hands on ward time.

My, how my colleagues in the acute Trust live in interesting times.

Services

There's a lot of pressure for mental health Trusts to modernise.

It's understood that there's a lot of activity that isn't seen to be useful. Quite reasonably, it's seen that this needs changing.

Is it helpful to see a practice nurse for blood tests for lithium monitoring every 3 months, in Primary Care. And then see a Consultant Psychiatrist every 3 months in out-patient clinic. And then see a mental health nurse every 3 months in lithium clinic.

Unnecessary clinical contacts are in part historical, from a time when counselling and IAPT and Primary Care's mental health work was thin, so mental health services delivered almost all support, for mental wellbeing. Ongoing support, vists for "tea and cake" were seen as useful, because they were valued.

Now lower level support's delivered (notionally) through Primary Care and specialist mental health services, in this "tiered model" of care, only see the "properly ill patients" with "complex needs."

Except by and large we don't. Mostly we get the same referrals as we did years ago. Changing practice of Consultant Psychiatrists is not a quick or simple task. Having large out-patient clinics one day then saying let's not have large out-patient clinics the next is a tricky proposition to sell, let alone manage. So practice overall has shifted a touch, some clinicians have shifted dramatically, but by and large there's not the "modernisation" that the great and the good wish to see.

The consequence of this is that change is foisted upon us, rather than change being locally and clinically driven.

Managerial change, rather than change from folk on the shop floor seeing what's going on, has the advantage that it happens. It has the potential disadvantage of being divorced from patient need, clinical practice and professional requirements.

I'm uneasy about this.

In my corner we're being left alone. We changed our services and they work pretty well, older adult services nationally aren't targetted for being dismantled at present. It's general adult psychiatry that's being shaken up. Previously a team with a Consultant Psychiatrist was responsible for care of a patient. If additional input was needed, they referred to that source (GP, psychologist, local authority social services, acute Trust's dietician/physio/SALT, neurologist) and that bit of unmet need was met. The team and Consultant Psychiatrist continued delivery of core mental health care. All could work nicely.

Nationally this is changing. In major cities it already has. My colleagues relate how this has resulted from indifferent to horrific service delivery. The change involves a shift from a core team and Consultant Psychiatrist looking after a geographical patch/a number of GPs surgeries (a sector model) to having a number of specialist teams (a functional model).

You're referred by your GP to mental health services. You're seen by Team 1, the gatekeeping and access team. They work out, after one visit, what's wrong with you and what care you'll need. Geeenius. After baring your soul and explaining it all to Team 1, you never see them again (and they never see you again, they never see the consequences of their actions, the clinicians never see anyone recover or improve or get better, ever again). They pass you on to, say, Team 2, the Early Intervention team. They help you for a while but, if you're not cured, they pass you on to Team 3. Team 2 never see you again, either. Having bared your soul and gone over everything, again, to team 2, you now do that with Team 3. Team 3 feel you're making progress but when it gets fraught they think you need more help. They pass you over to Team 4, the home treatment team. They've never seen you before either, so in your acute state of distress you go through it all, again. They try but then reckon you need admission. There's a dedicated in-patient team who only see in-patients now, so you're passed over to Team 5, in-patients. They've never seen you well or in the community but will deliver all your mental health care whlist you're an in-patient, after (of course) you've gone through your tale with yet another team.

Say one team sees your low mood and poor coping as an understandable reaction to social stresses you're having, through relationship problems and money worries and being physically unwell. Say another team sees your low mood and poor coping (with changes in how you're managing relationships and money and stress) as a result of major mood disorder, arising through chemical brain imbalance and psychiatric disorder. One team has a care plan involving support and psychological work. The other team has a care plan involving antidepressant drugs, probably lithium, maybe ECT. Your care changes radically as you pass through from psychosocial to biomedical Consultants.

Not only is there no continuity, but patients at vulnerable times have to develop therapeutic relationships over and over again.

In what way is this better?

Cause and Effect

There's been a scheme of late, in an adjacent county, to promote breast feeding. It's been praised as a success. This is because the PCT and midwives and health visitors all have seen that more people have attended or had contact with breast feeding promotion, so more women have had the right information and support. More, patient feedback forms were used. They’re not ill, they’re not even under health services, but they’re still patients and not service users. Hmmm, odd, that. Ho hum.

Anyway, the patient feedback was embarrassingly good. Gushing praise ‘bout dedicated, passionate, informed breast feeding counsellors and peer support counselling and breast feeding cafes and baby bistros where mums could meet for advice and support from other mums and from informed/expert resources too. Mums love it, see it all as a great success and really value it.

Everyone wins.

The PCT wins, they commission a great community programme for young mums and babies, ticking the box for a national agenda (promoting breast feeding) in a locality where breastfeeding rates are low, at under 1/3 of the national average.

The acute Trust wins, saying they’re generating a great patient centred valuable service, through investing in staff and developing projects to invest in mums and babies, getting young babies off to the best start in life.

The local community/patient population wins, with mums saying it’s all great and generating oodles of feedback forms saying so.

A year on, a keen midwife and health visitor evaluated the impact of this combination of successful projects. Everyone was still optimistic, dedicated, enthused and happy. All was as popular as ever. Everyone saying what a fantastic development it is. The midwife and health visitor looked at breast feeding rates now, compared to the years gone by.

They’re no different.

A good idea is had. Good, passionate, competent staff develop the idea. Managers in the PCT fund the idea. The idea’s delivered and the patient love the service. Ticks lots of boxes ‘bout addressing a local failing in low breastfeeding rates, improving patient choice and community services and peer support and Local Extension of Services and whatnots.

But the service isn’t effective.

It costs a lot of money. The staff time (daytime and evenings), the ongoing staff training, the cost of the use of the properties it’s delivered in, all adds up. Adds up to quite a lot, actually. Massive investment (in time and money) to improve breast feeding, for no improvement in breast feeding uptake or mums maintaining breast feeding.

Should the health service continue to fund this?

We’ve an identical scenario in mental health services locally, that’s popular and well received and highly valued by patients, but doesn’t deliver any beneficial outcomes that patients or staff can see. But it’s just as hard to say that we’ll stop that and use the money in a different and better way, to be more useful. Both commissioners in both situations and flapping about “patient choice” and saying they like the “service” even though it isn’t an effective service.

Is seeing something and liking it and believing it’s doing something else a valid use of taxpayers’ money? Or a valid use of NHS staff and patients’ time? It’s a bit like reckoning that, statistically speaking, those people who have more birthdays live longer, thus I must eat more cake with candles on top. It’s all gone a bit peculiar.

What matters?

I've been to a number of meetings and conferences committees that have left me thoughtfully confused. As I've said before, I invest time in this malarky because if someone doesn't we'll get sold down the river, so it's best to at least chip in to have a voice in the process.

I think the GMC expect us to, aren't they about protecting patients? Ah no, their tag line now summaries that they too now are focussed on, "Regulating doctors, ensuring good medical practce." Well, they used to care about protecting patients. I'm sure as a doctor we're still obliged to protect patients from malign care. Thus, if managers are having a brainstorming session and generate what I would charitably call "idiosyncratic ideas" that will affect clinical practice unhelpfully, I like to be able to interject a bit of common sense and pragmatism in to the deliberations.

Mostly this works, which is why I keep doing it. I'm over stating it a bit, since in my corner the managers are actually pretty sensible and clever and helpful folk. The problems mostly involve evidencing something or doing something that we all know is nonsense but, for mind numbingly frustratingly incomprehensible and labyrinthine reasons just, "has to be done." So we get around a table and mull over how we do something we mostly agree doesn't truly need doing, and think of how it can have the least hassle for staff and least nuisance for patients.

Meetings with the SHA and PCT and partner organisations have been more . . . curious.

There's an enthusiasm to measure things. Evidence things. Prove things. Monitor things. Manage things.

This has lead to me knowing far too much about "things" which no sane man should know. Things like "quality metrics" which I won't sully your pure and beautiful minds with; enjoy the innocence, unfettered with such nonsense.

The notion proposed in my corner is that "quality" and "outcomes" are measured. Along with the work done (the content of a service line, i.e. the staff and resources). And the activity undertaken. And, for this work, the cost to our Trust for this. Anyone flirting with management will recognise this unholity trinity of Service Line Reporting (SLR) there, which is then fused with quality and outcomes and Payment By Results (PbR) and Quality Outcomes into some hideously ghastly abomination.

Zarathustra will love this. H P Lovecraft couldn't craft a finer tale of complexity, understated malevolence, despair and of something slumbering, quiescent, about to errupt causing "much badness." Reality is indeed more curious than fiction.

For now, within our corner, we're having to report to the SHA on quality. And report on Service Line Reporting to entertain Monitor.

So, over to you. What do you think will be looked at, when considering quality? For a patient, going through our service, what things matter? What is quality, what things should be recorded and reported and publically shared, to reflect whether we're doing well or not? I've my views, which I'll whitter on about another time, but for now, have a blank bit of paper. Add what so ever you will. If you're interested in a quality mental health care from our Trust, what would you be wanting to know about? What's on your list? What matters?