Hope

What will you be doing ten years from now? I’m not sure I know, unless I win the lottery – but then I’d have to start buying tickets wouldn’t I? If we think about what the next ten years might have in store for us here in the health board we might start with what we already know to help us understand what the future might look like. Let’s begin with the size of the population we will be looking after ten years from now.

Cardiff, the capital city of Wales, is booming and it has become one of the fastest growing parts of the UK with unemployment falling and output growing. In the education sector Cardiff University is strengthening its position as the only Russell Group University in Wales and the other higher education sectors are flying high too.

The contrast with other parts of Wales is quite marked as the population growth forecasts demonstrate.New Picture (20)

As you can see the population in our part of the world is going to grow at least twice as fast as the rest of Wales and much more than that in many cases. This is before we factor in the growth the city council have pencilled into the housing stock in Cardiff, with 47,000 new homes to be built according to the Local Development Plan.

10883720543_b4fd2aac29_zWhat will this mean for health care services? The obvious conclusion is that there is going to be significantly more demand for healthcare, and here we will be experiencing a trend line that moves twice as fast as anywhere else. We need to ensure that the external economic growth taking place in the capital is matched by a commensurate adjustment in the way that resources in the NHS are shaped overall. This is a complex area and there are many nuances and difficulties to overcome, but we are making the case that equity of access to healthcare must have some linkage to equity of resources to provide that access. I will keep you posted on this situation.

It looks like in future we are going to have to become really expert at helping our population stay well and we will also need to ensure that we get even better at selecting the right treatments for the specific problems patients have. To help us with this latter challenge, there is a new era approaching when we will be able to match an individual’s genetic signature to a treatment that is tailored to their individual characteristics, including the responsiveness to the proposed treatment.

Although all LHB’s are now designated University Health Boards, I like to think that there remains something distinctive about our organisation. As I have mentioned before, we contribute more than half of the entire Wales research output, and we have many internationally renowned staff who are leaders in their field. Our close working relationship with Cardiff University is one of our great strengths and provides us with one of the most important ways in which we will be able to meet the challenges ahead.

As an illustration, we know that today, lung cancer is a devastating disease and the UK’s biggest cancer killer. It accounts for more than one in five cancer deaths and is the second most common cancer in men and women in the UK. Working with Cancer Research UK, Rachel Butler and the Medical Genetics Team want to change these odds for people with lung cancer.

Genetic testing is already used to detect DNA changes in lung cancer that point to whether a patient will (or will not) benefit from a particular drug, this is known as Personalised or Stratified medicine. Stratified medicine identifies key molecular changes common to different people’s cancers. Patients can then be grouped based on these shared genetic faults, allowing some people to receive a targeted treatment matched to their group. The challenge has been developing targeted treatments that show a long-term benefit for patients while accommodating the cost of widespread molecular testing in the NHS.

Cancer Research UK are preparing to launch an ambitious UK clinical trial for non-small cell lung cancer (NSCLC) called the Matrix trial which tests multiple drugs in multiple groups of patients. Each treatment has been developed to target precise genetic faults, which we’ll be testing for using our specialised ‘next generation sequencing’ system developed specifically for the programme. Our All Wales Genetic Laboratory here at Cardiff and the Vale is one of just three UK laboratories that will be providing the specialist genetic testing that will determine which drugs the lung cancer patients will receive.

Recruitment starts during Autumn 2014 from across the whole of the UK – we expect to recruit 15-20 patients to each of the 16 treatment arms. Additional treatment arms may be added as new therapies linked to genetic markers become available. If a treatment shows promise, then there’s the potential for that arm to break off from the main trial and grow into a larger independent trial with more patients who share that genetic profile.

Early evidence suggests that this genetic approach to the treatment of lung cancer will have a significant impact on patient outcomes.

There’s hope for you.

Keep well.

Picture credit: Diego Torres Silvestre

Picture perfect

Thank you to the people who provide feedback to me via my blog page. I’m learning that you can’t please all of the people all of the time. In fact, that could be the subtitle of my job.

This week I’m going to cut to the chase and talk about someone excellent. Here’s how to spot him – spend a day or two lurking in the corridors of UHW and look out for a man carrying a gold cane and a diamond encrusted key. Easy.

DSC_2699The man is Paul Crompton and he heads up the Media Resource Centre here. What’s he done? Well, Paul was nominated by Professor Michael Peres of the Rochester Institute of Technology and Professor Norman Barker of John Hopkins Medicine for the prestigious Schmidt Award and was made a fellow of the Bio- communications Association for his “outstanding contribution to the progress of bio-communications.”

The award dates back to 1948 and Paul is only the sixth British person to become an award winner. Some of you might remember Professor Ralph Marshall who founded the Media Resource Centre and who was honoured in 1998. The winner’s get, you’ve guessed it, a diamond encrusted key and a gold headed cane – a traditional symbol of high achievement and honour, the latter of which they get to keep for a year.

This is an international award and Paul travelled to Minnesota this year for the annual meeting of the BCA. Paul says, “When it came to the actual Schmidt presentation, I was quite taken aback. Unbeknown to me, Professor Peres had gathered some video interviews with colleagues from Cardiff and the US, which he played whilst recounting some of the work I have done in the past 20 years.

“Being counted amongst the Schmidt Laureates, as they are known, is a real honour; many of the names being icons of our profession.

“One major thank you has to be the team I work with in Media Resources. I am nothing without them. They constantly rise to the challenges we face and support me with their skill, hard work and commitment in delivering the services we provide our patients and clinical colleagues.”

Congratulations and well done to Paul – another example of the excellence that, when we pause and a take a breath to look around us, we can find throughout the UHB.

On a final note I’d just like to pass my on-going gratitude to everyone who is working in our busy unscheduled care system, whether in CRTs, the wards, EU, doctors, therapists and every other member of this chain of committed people who work each day directly or indirectly to support the sick and the vulnerable. Your hard work and dedication is something I’m really proud of – and I want to let you know that I understand the current pressures you are working under and am working hard to find ways of getting some more resource to support the teams who are most hard pressed.

Keep well.

Stigma

It’s interesting how society places a value judgement on some illnesses. If you are unlucky enough to break your leg in a fall you are likely to find people sympathising with you and there is no question that you’ll seek out treatment and benefit from everything our health service can offer.

The same is true of cancer, heart disease and almost all other physical complaints. Sometimes there is a suggestion that people are contributing to their own ill health, by smoking for instance, and there is a debate to be had about the extent to which any health service should always be there for us come what may if we are not prepared to take some responsibility for own health.

This is a difficult area, but many people argue it is not unreasonable to expect that as patients we should make some contribution to getting better or preventing recurrence. Our own Optimising Outcomes Framework takes us a little in this direction by requiring patients who choose to have non-urgent elective procedures to participate in smoking cessation and/or weight reduction programmes before we agree to list them for a procedure. This is because there is evidence that some avoidable harm can be prevented if people take these steps and that the chances of a successful outcome can be improved.

In the world of mental health there is still a fairly widespread reluctance to acknowledge that mental ill health is just as much a part of the human condition as cancer or heart disease.

People do not choose to be mentally unwell, just as people do not choose to have cancer. Yet those who suffer may go unsupported or be unable to be open about the problem – which can compound a sense of isolation that can be a part of the disease process.

It’s not their fault and very few people actually want to be unwell – but still there is judgement and with it an implied projection of moral weakness or a failure of character in the person with the problem. Ridiculous!

In the physical world there are examples of this kind of judgement being applied, although it is much less common. Here are some facts for you about a disease that suffers from this sort of prejudice. It is:

  • The 8th leading cause of death
  • More prevalent than any one cancer, or HIV
  • Potentially lethal – two variants of this disease kill three people every minute – that’s 1.4 million in 2010 compared to 1.2 million who died from malaria.
  • Often silent and people may not realise they are infected – one in three people on the planet have been exposed to the virus.

Full team with Minister and AdamThe disease is hepatitis, which is a cluster of similar viruses that attack the liver. Hepatitis C is a real menace because the body is generally unable to clear the virus itself. Four out of five people develop a chronic infection, which may then lead to cirrhosis and liver cancer after 15-30 years. If you are infected you will face many challenges as the treatment is prolonged (24, 48 or even 72 months are required) and some variants of the virus are much harder to eradicate.

There is no vaccine and so it is vital that the risk of exposure is reduced. For those who are infected this is a major responsibility they have once diagnosed as this will help to contain the spread of the disease. It is possible to spread the virus through contact with the blood or other body fluids (i.e. saliva, semen, vaginal fluid) of an infected person, although it is unlikely to be contracted through kissing or the use of cutlery.

The virus is able to live outside of the body for a relatively long time, which means that the risk of exposure from shared razors, toothbrushes or other household articles is much greater. If you are a drug user then you can be infected by using the equipment for injecting drugs (not just the needle) or by sharing a straw or note if you snort cocaine. Unsterilised tattoo or body piercing equipment is another route for infection.

Unfortunately there is a degree of stigma associated with the disease which may prevent people who believe they may have been exposed from coming forward. As a society this is very harmful, and places us at increased risk as the virus doesn’t know who we are or what we do for a living and makes no judgement about whether or not anyone deserves to be infected.

This is why Delyth Tomkinson, Brendan Healy and colleagues from across the NHS in Wales have been at a stall in the Hayes in Cardiff centre this week. Delyth and colleagues from the Welsh Hepatitis Nurse Forum have been championing the cause of promoting access to testing and treatment for this disease.

Minister getting tested(web)This is particularly important as there are thought to be 14,000 people with undiagnosed disease in Wales. Getting a test is simple – talk to your GP or pick up a self-referral from the cashiers desk in the concourse at UHW and our team will take care of the rest. I think Delyth and the rest of the team are great ambassadors for the health board – and their powers of persuasion are not to be underestimated – just ask the Health Minister, Mark Drakeford who agreed to be tested to show his personal commitment to the cause.

On World Hepatitis Day our team were out there sending a very clear message that prevention is better than cure; that getting tested is simple and easy to do and will reduce the chance that the disease will spread by ensuring people who are infected know they are and so can ensure they protect those around them and of course get the treatment that may eradicate the virus for them.

If putting a value judgement on a virus isn’t nonsensical enough, the consequence of allowing stigma to persist is that those who like to judge are putting themselves and their families at greater risk by creating a climate where the very thing that would protect us all is less likely to happen.

I’d like to think that those of us who work at the health board believe we should never fail to challenge prejudice of any kind. Making value judgements about the health challenges people face is a world apart from a mature conversation between a health care professional and the patient about what they can do to help themselves.

Keep well

Matter over mind?

Summer is well and truly upon us. The heat of the July sun contrasts strongly with the same sunshine on a winter’s day. As the Earth tilts slightly towards the sun this tiny movement increases the sun’s power and we feel the difference. The margins are so small – if the Earth were only in a slightly different plane of space life might never have got going.

For the ancient civilisations this natural phenomena of the seasonal fluctuations warranted an explanation. Lacking the insights we have today, people found the answers in myths of gods – myths that were layered and developed over millennia, developing and changing shape as the civilisations themselves waxed and waned.

We know that between 1425 and 1200 BC, on the island of Crete there were a people that we now call Mycenaean. Archaeologists have discovered clay tablets with scratchings on them that turn out to be a development of an earlier Minoan language, known as Linear B. From these tablets it is possible to make out the first appearance of a goddess who would later be named Demeter by Homer.

DementerDemeter was the goddess of the harvest, who presided over the grains and the fertility of the Earth and from Homer we have the story of Demeter and her daughter Persephone, who was abducted to the underworld by Hades. Demeter searched for her beloved daughter ceaselessly, preoccupied with her loss and grief. While she searched, the seasons halted and living things stopped growing and then began to die. In time Zeus intervened and Persephone was returned to her mother, but only after she had eaten pomegranate seeds given to her by Hades. Having done so, Persephone was bound to Hades and must return to him for one third of the year – during which time nothing will grow – winter in other words.

Dementia is a Latin word derived from the word root mens or mind and de which means removal or separation – so dementia becomes ‘removal or separation of the mind’. The term was first used in 1861 to describe the symptoms of what we now know as dementia. Language just like mythology is layered and also changes shape and meaning over time as do memories.  Is there an echo of Demeter in the word dementia? I don’t know, but there’s something about poor Demeter frantically searching for her lost daughter and forgetting to undertake her duties that resonates with me.

Launch1(web)It certainly did last week when we launched our Three Year Dementia Care plan. At its heart it has three themes: prevent, delay and cope. There is no cure for dementia and the number of people with dementia is set to rise. Currently there are thought to be 45,000 people with the disease in Wales, and in our population the number of affected people is set to increase by 60% over the next 25 years.

We have worked together with people with dementia, their carers and the professionals who have expertise in this field to develop our plan. Clearly prevention and delay have to be key cards that we play in our battle with this disease.

Interestingly the prevention component of our plan draws on evidence that is locally derived. The Caerphilly Cohort Study led by Professor Peter Elwood OBE from the School of Medicine at Cardiff University, monitored the health habits of 2,235 men over a 35-year period. It found that five behaviours are integral to having the best chance of a disease free life: taking regular exercise, a healthy body weight, a healthy diet and a low alcohol intake.

Plan Cover EnglishThe people who consistently followed four or five of these behaviours experienced a 60% decline in dementia and cognitive decline – with exercise being the strongest mitigating factor – as well as 70% fewer instances of diabetes, heart disease and stroke, compared with people who followed none.

So let’s all enjoy the sunshine then and also make an effort to take some exercise. It might be easier to do so now while the days are long and warm, rather than when they shorten and the cold sets in. The evidence is clear that we can lay down the foundation of a healthier and more fulfilling older age for ourselves and those around us by taking a few steps now to modify our behaviour.

Keep well

Making it all add up

Bench2(sweb)

Families from across Wales attended the ceremony.

Last Friday saw the opening of a very special memorial in the grounds of UHW. It is part of a number of activities that marked Transplant Week as we thank those who have selflessly donated organs to help others. Families of donors from our health board area and across Wales were joined by staff from the hospital at the unveiling which commemorates the generosity that over the last six years has enabled us to contribute to 341 life saving transplants across the UK.

Bench4(web)

Some of those UHW staff who save lives with their organ donation work.

We have three specialist nurses for organ donation (Susie Cambray, Emma Bennett and Angharad Griffiths) working in the health board. Theirs is a challenging and very sensitive task, working as they do in our critical and intensive care areas, and our emergency department. Their role is to provide support and advice to staff and families to help ensure that every patient at the end of their life is given the opportunity to fulfil their wish to become an organ donor.  The emphasis is to provide families with the current and accurate information they will need to make an informed choice – and the right choice for them. Our team works with the broader clinical team to support families at this difficult time with whichever decision is made.

In Wales, the government has published a Transplant Bill which aims to change our system from opt in to opt out. This is something that has been done in other countries and is driven by a shortage of donor organs across the NHS. Working within this framework we would hope that in the years ahead it might possible to make organ donation a much more normal part of end of life care for the patient’s families.

Standing in the shoes of another can help us to understand things from someone else’s perspective. What would it be like perhaps to be a wife, watching her husband struggle with daily renal dialysis, or a parent of a child with a congenital and potentially fatal heart defect, or a grandmother who is no longer able to see her grandchildren playing in the garden? If we look at things from their perspective it is easy to see what a truly remarkable gift a donor makes.

A reminder about the centrality of family to a sense of who we are and our place in the world, at least for me, was provided a couple of weeks ago when we celebrated together as a family (with one or two important absentees) a 151st birthday. In all around a hundred friends and family came to our home to join in on our special day. My mother-in-law and her husband brought some of their oldest friends, our daughter invited a gang of her friends and my wife asked her best friends to be with her that day. Most of the wider family were there too, as you’d expect.

What was great to see was how well the generations got on together, sharing stories, playing ridiculous games, eating food and the odd (and maybe more) glass of wine or beer. Everyone seemed full of life and it was a really happy day, as judged by the pile of thank you letters, cards and emails we have received subsequently.

Reflecting on that day, I wonder what price I’d pay to ensure that those to whom I’m closest could enjoy another day like that? What would I do if I knew in advance I could help one of them enjoy more such days should some unforeseen circumstance befall me and I could help them? Well I know what I’d want – but I’m not sure everyone around me is as clear about this as I’d like. So in the days ahead I’m just going to gently talk this through so I make my wishes clear. Maybe that’s something we could all do?

Keep well.

PS 151 is a ripe old age but in case you’re wondering no I don’t belong to a family that has someone sitting in the corner with a face like a walnut who can remember Queen Victoria and the advent of electricity. No, the truth is that we were actually celebrating three milestones at once, 80, 50 and 21, which when you add it all up comes to 151.

 

Punk Health Care

After a short break I’m pleased to say I’m now back to these letters. It’s been nice of some of you to say that you’ve noticed I’ve not been writing them over the last few weeks – and that’s helped encourage me to keep finding the time to share my thoughts – thank you.

There’s a lot going on at the moment which is one of the reasons why my letter writing has slipped – but sharing what’s good about what we do still feels just as important as ever.

3654698329_b4e3e862b4_zEvery now and again I catch a song that I haven’t heard for a long time – and just recently I heard Siouxsie and the Banshees’ version of Dear Prudence that took me back to a concert in the eighties in Scarborough of all places. I remember the punk rock revolution arriving and sweeping away all my old listening habits – Deep Purple, Black Sabbath – Uriah Heep anyone? There was something invigorating and fresh about the new wave that assaulted the public, starting for me in the summer of 1977, the Silver Jubilee and all that.

I responded in a teenage way to the Something Better Change atmosphere and it seemed to chime in with an adolescent desire to make the world a different and hopefully better place. There was in retrospect something else too, which over the years since then, I keep returning to. Some people describe me as a very rational person. I certainly believe that to deal with a situation, it is essential to engage with the facts – the world as it really is not the world as we’d like or wish it to be.

So, as I reflect on what it was that resonated so strongly with me when that wave of new, non-pretentious, seemingly spontaneous and explosive music appeared, it was that it somehow swept away all contrivance and pretence – it cut through the thirty minute guitar solos and heaven forbid, drum solos too, and just said it like it was.

Of course as the years pass, this sense of rebelliousness diminishes – but it doesn’t altogether leave, and I must say, to my mind there is something of a parallel to be drawn with another kind of prudence, one that we have all recently heard rather a lot about – prudent health care.

As you probably know, Prudent Healthcare is a new policy idea that has been developed in Wales that might shape how we approach the NHS (and health care across the world) in years to come. At its heart is a simple set of propositions. These are:

 

  • Do no avoidable harm – that is we should aim to make what we do error free, so that it does what it says on the tin. Naturally, we do harm patients, when we operate on them for instance – but if we are to remove the tumour that kind of harm is unavoidable. But if we operate in the wrong area, cause the patient to bleed excessively, over or under medicate, fail to offer thrombo-prophylaxis as we should, or cause the patient to have an infection, then we are creating avoidable harm. A study published in the BMA in 2001 estimated that up to 10% of all health care interventions are associated with avoidable harm.
  • Carry out the minimum appropriate intervention – this is capable of being misunderstood as being to do with depriving the patient of the treatment they need and offering something less as an alternative and I think we need to find a better way to describe what it really means. In fact it is much more to do with working out the most effective treatment that will secure the right outcome, and then making sure it is done properly. There is plenty of evidence that patients are sometimes over treated with no prospect of a good outcome. An example we can all relate to is prescribing antibiotics to a patient who has a heavy cold, where there is no evidence of a bacterial infection.
  • Promote equity between patients and professionals – there is plenty of evidence to suggest that equalising the power relationship between the patient and the professional leads to better outcomes that matter to the patient. It is interesting to observe that some studies suggest that up to 20% of all health care interventions have no impact on outcomes that matter to the patient. For instance, an operation can be judged a success by a professional if it is completed as planned, with no infection, good healing and no complications, but it may not achieve what the patient wanted it to do, perhaps because they misunderstood what was being offered or what the likely functional outcome would be.

Recently health care professionals and scientists (AHPs) in our organisation came together to explore what these propositions meant to them. Seventyfour examples in poster form of best practice were submitted for two awards, Driving Prudent Health Care and Excellence in Practice. That’s an amazing fact – which means that in our health board we have experts in their field who are innovating and leading the development of health care across a very broad spread of patients and conditions.

The Driving Prudent Health Care winners were Samantha Price and Natalie Aitken who are Clinical Lead Specialist Speech and Language Therapists. They demonstrated how they have worked together with local education authorities to develop a joint, integrated pathway for children with speech, language and communication difficulties which effectively organises and filters service users into the right service, which can then provide what they need, but not more than what the need. The outcome they have achieved ensured that accessing the appropriate level of service is easier to achieve, and is delivered with greater consistency and reliability.

Physiotherapists George Oliver and Hilary Hyett  were winners in the Excellence in Practice category, for their work in an evaluation of the musculoskeletal physiotherapy service, which was able to evidence very meaningfully how well this service performs. As their poster says, the feedback was “Very Good. Well Impressed. Well done NHS”.

Congratulations to the winners, but also to all the other staff who contributed to the conference and who are part of our brilliant AHP team who serve so many patients across our community every day. As the man said:

 

Dear Prudence, won’t you come out to play?

Dear Prudence, greet the brand new day

The sun is up, the sky is blue

It’s beautiful and so are you,

Dear Prudence, won’t you come out to play.


Keep Well

Trusted to care

This week saw the publication of a report into care at the Princess of Wales and Neath Port Talbot Hospitals. For all of us who care about the NHS it is terribly sad to hear about situations that have gone wrong, for whatever reason. The Andrews Report, as it is being referred to, is well written, balanced and far-reaching. There are many thought provoking ideas and comments in this report and we all need to have a think about what we can do as a result. Two aspects of the report particularly struck me, although there is much more that is important too. First of all, the report describes situations that staff were witnessing, and understood to be wrong, but were accepting. The report says:

This toleration of lack of care acted for the review team as a diagnostic measure of the culture of care at ABMU.”

I understand that it might seem like a big step to take to speak up or take action. However I want to encourage you to speak up if you are concerned. I promise you that your concerns New Picture (1)will be listened to and where necessary action will be taken in response. I already have a steady stream of people making contact with me and I really find this very helpful and reassuring. The Chair of the Health Board, Maria, also welcomes approaches from staff using our Safety Valve mechanism. The Safety Valve is an idea we had to encourage staff to speak up if they were concerned – as whistle blowing for many people feels like a big step to take. The Safety Valve is a much less formal mechanism and we can agree with you how you’d like your concern to be addressed. Someone said to me once that the standard you are prepared to walk past is the standard you are prepared to accept. I think that’s true, and there is a boundary that we understand is the dividing line between what is acceptable and what isn’t. From my perspective, I can’t put right what I don’t know about – or if you prefer ignorance isn’t bliss. We face many challenges in our Health Board, but we are full of talented, well trained and committed people. I believe we can and are making progress and while there’s a long way to go, with everyone’s help we can continue to build a better service for our patients. For me, the second striking feature of this report is that it opens out another conversation or dialogue that we must also do more to develop – and that is with the public and the people who use our services. The report says:

“The current culture of care of any hospital is defined by what staff and management seem to regard as acceptable along that spectrum. Clearly some of the public, relatives and patients don’t agree with what ABMU hospitals have decided they are able to provide. It would be helpful if the hospitals made their definition more clear and specific and shared that with the public in order to get mutual agreement on what is feasible and can be expected within existing resources.”

This enlightened view is developed in the report and is worth reading for this theme alone. It is a fact that resources are not unlimited and maybe we should now be more explicit about what we think we can deliver at all times, what we aspire to do at all times but may not always achieve and what we cannot promise to do at all. This would then be the starting point for a discussion with the public, and might lead to an agreement being reached about what we should all expect that would help staff and patients alike. I’d be interested to hear what you think about this. As a Board we had already begun to consider what we should do to improve on the conversations we have with the public. We have many ideas in development now and would welcome any suggestions about how we can do more. As I’ve said more than once, I’m worried about the impact that this publicity is having on the confidence of the public. We are thinking through what we are going to do to reassure the public that we have ways and means of identifying problems and responding to them – which I think lies at the heart of developing greater trust. We can’t promise that nothing will ever go wrong – that’s unrealistic. We can promise though to work hard to make things as safe as possible and that when it does go wrong to find out what happened and then work to put it right.

To finish, I’m going to share a letter sent to me this week by a patient called Mr Gareth Jones – who has given me permission to share what he had to say. He writes that he was taken ill in his GP’s surgery and when his GP said ‘Hospital’  “…with all the negative media coverage in Wales I was petrified but too ill to argue.” He continues (the capital letters are his):

 “I SHOULDN’T HAVE HAD A CARE IN THE WORLD, from stepping onto the ambulance to arrival at Llandough, transfer to the wards [I] also spent time in intensive care unit at Llandough and later intensive care and high dependency unit at B7 of the University Hospital of Wales, the care and consideration coupled with the total dedication of the medical and nursing staff was as good, if not better than anywhere in the world. My family and I are totally in your debt forever, From the bottom of my heart THANK YOU”

Thank you Mr Jones for writing to me to let me know about your experience and for allowing me to share it in this letter – I’m really grateful to you and I’m very happy to hear that we were able to help you on this occasion, and I’d like to pass along my thanks and congratulations to everyone involved in you care. Keep well.