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Health & NHS

For the NHS there’s no escape from perpetual change - and uncertainty

First year report on the coalition government’s major NHS shake-up – part one:

A year ago root and branch changes in the NHS’ structure – embodied in the coalition government’s Health and Social Act - came into force.  

Having promised in the coalition agreement there would be no more top-down NHS reorganisations, the coalition allowed Andrew Lansley free rein – given a few bumps along the way – to embark on the most radical NHS reorganisation since 1948, re-shaping most of the national service’s institutions.  

At the important level of commissioning of health services for Wiltshire, out went the Primary Care Trust (PCT – known as NHS Wiltshire) and in came Clinical Commissioning Group (CCG – known as Wiltshire CCG) designed to be run by doctors from the county’s 58 general practices.

The respected NHS Managers blogger, Roy Lilley, reported in March on ‘the mood music I hear from Number 10’: “Lansley’s reforms have been a disaster; they have to be fixed by 2015 and competition isn’t going to help.  The only issue is money.”

At their March Board meeting, Wiltshire CCG were very upbeat about their progress and achievements.  Their chairman, Dr Steve Rowlands, declared they had in their first year made significant achievements and were “On the brink of a very exciting time for the CCG.”  

They certainly achieved a good financial result ending their first year spot on budget with a £5 million surplus put away for even rainier days – unless (see below) it is snaffled by the Treasury.

Two of the coalition Act’s aims were to increase transparency and decrease ‘bureaucracy’ and its cost.  The former simply has not yet happened at the local level.  

And in Wiltshire the latter certainly did not happen – the cost of running the CCG is significantly higher than for the PCT which had a considerably larger share of the budget and of commissioning to administer.

The Wiltshire CCG chose to organise itself into three ‘locality’ groups – the one covering the Marlborough area is “NEW” (for North and West Wiltshire.)  And a continuing problem is that these localities meet in private and give only fairly broad reports to the CCG’s (public) board meetings.

One year on the Lansley NHS at our local level looks much like the mirror image of the proverbial swan – beneath the surface the CCG is quietly paddling away at their task of re-shaping primary care services to GPs’ design plans.  

To absurdly tight timetables from the top, they have produced strategic plans for two years, five years and for the Better Care Fund [see Part Two]. And they are working closely with Wiltshire Council on joint commissioning plans.

Above the water there is some chaos and turbulence which will have distracted some CCGs.

First there was the NHS 111 debacle.  This was a government wheeze to save money by scrapping the NHS Direct telephone service and substituting it with a cheaper model for non-emergency inquiries.

Problems with the system were so great that in most parts of the country the introduction of the service was delayed until it was safe for people to use.  NHS Direct which had successfully bid for some of the contracts said the model was economically unsustainable and walked away from their contracts.

For Wiltshire, the contract holder was the private company Harmoni and the service was supposed to go live in April.  It took until October 28 for the CCG to accept the NHS 111 was safe.

In the process Wiltshire CCG had to pay out an extra £590,000 to support the service – all but £200,000 of this should be reclaimed from other CCGs using this Harmoni contract.

After NHS 111, the Department of Health now has another crisis on its hands.  The introduction by the newly formed Health and Social Care Information Centre of the care.data scheme was so badly bungled that its introduction has been delayed by six months.

This scheme will upload all medical records held by GPs into a central data bank - giving researchers access to all the pieces of the health care jigsaw.

The information will be anonymised at various levels so it can be used for researchers trying to design new drugs and treatments.

It has still not been made clear exactly who can access or buy information from these records.

The phrase that has been put forward is that release of information will only happen where there is a “clear health benefit”.  But, opponents of the scheme say, that could surely provide a criterion for any private insurer or health provider to gain access to the data.

In addition doubts over the ability of the NHS to prevent leakage of personal information remain a problem for care.data.

Hovering over the post-Lansley landscape has been the spectre of further and further privatisation of the NHS.  The debate about which services must be subject to open tender (costing the CCG a great deal of staff time and money) is still going on and will run well into 2015 as existing contracts run out.

One argument was over the Wiltshire-wide community health care contract held by Great Western Hospital: the Council believe that re-tendering this will disrupt the introduction of the Better Care Fund (see separate MNO report.)  The CCG fear a legal challenge if they do not put it out to tender and has decided it will go out to tender.

Perhaps the picture of the CCG quietly paddling away beneath all this turmoil is a little too benign.  

Throughout the year, most CCGs have suddenly found holes in their budgets as NHS England scooped up millions of pounds to pay for the specialist services (treatments for rare cancers and other rare diseases) they commission. This was a major deficiency in the coalition government’s reorganisation.

No one thought to define which treatments are specialist services.  Wiltshire CCG lost £2 million in September and now stands to lose another £3.9 million.  Keeping to the agreed annual surplus (as required by the Department of Health) becomes even trickier with this kind of uncertainty.

There have been other problems following the reorganisation.  One neighbouring CCG suddenly found itself being charged by PropCo (the company the Health and Social Care Act set-up to look after all NHS land and property) for the CCG’s headquarters which happened to be owned by Swindon Council.  

In another blow to CCGs’ finances, NHS England has proposed that all England’s CCGs should contribute to a £250 million fund in 2014-2015 to cover any ‘legacy debts’ left over from the PCT regimes – mainly unclaimed, retrospective costs of continuing health care.  

The Wiltshire CCG is putting aside £2 million as its share of this fund.  This will be especially galling for them as they inherited a handsome reserve from the Wiltshire PCT and have been working hard to pay off continuing health care claims.

This proposal goes directly against the promise made by Andrew Lansley that CCGs would not inherit liabilities from previous organisations.  NHS Clinical Commissioners, which represents the CCGs, says the proposal is a “significant concern” for its members.

Wiltshire CCG has been making steady headway in its commissioning plans – particularly in its plan to transform services so more people can be treated at home or nearer to their homes.  One example is the introduction of 23 Care Coordinators across the county to strengthen the Neighbourhood Nursing service and support the Council’s somewhat under-funded Help to Live at Home scheme.

Some of the Care Coordinators are trained in social work, some are trained nurses.  In some ways they foreshadow (or pre-empt?) the BCF – acting as links between GPs and at risk patients.

Apart from some ‘teething problems’, the only reported issue for Care Coordinators in our area is that one of them was given a workload she considered beyond her capacity.

In another innovation, the CCG has made a distinct difference in introducing much faster diagnosis of dementia – now less than four weeks rather than many months under the PCT.  This scheme is costing £600,000 and involves training for GPs.  

The only question to ask is why it took so long for GPs to push for faster diagnosis of dementia in this way.

And in the background is another coalition agreement promise: that the NHS’ annual budget would rise in real terms during the five year Parliament.  Whichever way you cut the figures the NHS is struggling within its tightly constrained budget.

Whether, for instance the budget went up by 0.09 per cent in 2011-2012 or up by 0.02 per cent depends on how and when you view the figures.  What is certain is that the budget has had to cope with the £2-3 billion costs of the Lansley restructuring – with its huge redundancies bill to be followed by many of those paid off returning to NHS employment.

And there have been annual repayments at year end to the Treasury of £1.9 billion (2010-2011), £1.4 billion (2011-2012) and £1.5 billion (2012-2013.)  

This last repayment included provisions made by the outgoing PCTs to pay for those claims for historic continuing health care money.  The Department of Health’s accounts say it was returned to the Treasury to “help in wider fiscal deficit reduction.”

Losing these provisions and having to fund the ‘legacy debts fund’ (mentioned above), local commissioning is being made to pay twice for such costs.

From April 1 another method of funnelling NHS money back to the Treasury comes into force. Changed guidance on old regulations for the VAT payable on outsourced services could lose the NHS £500 million a year.

You can go on adding sums of money that need to be spent and give NHS finance officers more sleepless nights:   the government’s instant reaction to the Francis Report on Mid-Staffs was that student nurses must spend time as healthcare assistants: this may well cost £225 million.

Just as the government has eased private providers’ access to the NHS pension fund, employer contributions will be going up by £125 million.

And then the Care Quality Commission, the health service regulator, asks for an extra £40 million to employ 700 more staff (yes, that is about £57,000 in employment costs each.)  Remember the promise to cut back room staff and push funds to frontline staff?

What is beyond dispute is that the NHS spend as a percentage of GDP is falling – the Office for Budget Responsibility’s chart shows this clearly.  And at least one expert expects there to be an NHS funding crisis before the 2015 General Election.


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Podiatrist offers free foot clinic for Marlborough residents

Podiatrist Emma AnsellPodiatrist Emma AnsellMarlborough residents with troublesome toes are being offered a free health check by podiatrist Emma Ansell this weekend.

Emma, who has been practising chiropody and podiatry for 14 years, will be holding the free sessions at the Marlborough practice of physiotherapist James Hatt & Associates on Saturday (March 15).

Last year, Emma brought her Hollywood-style med-ped treatment. Combining foot care with foot beauty, the treatment has been attracting customers from as far afield as Bath and Gloucestershire.

This weekend, Emma will be sticking to chiropody and podiatry - looking at problems including corns, calluses, verucas, ingrown toenails, fungal toenails, and dry and cracked heels, and advising patients on the best course of treatment.

Emma said: “As the demand for such services increases, accessibility through the NHS can be difficult. I’m seeing patients on a daily basis that have been struggling with their foot conditions for months, and in some cases years, and have been unable to get the appropriate treatment they need or want.”

She added: “I'm passionate about offering a complete foot care service, making sure that it's not just about cutting and filing toenails.

“It's important for each of my patients to understand their current foot health condition and if they have a specific foot related problem, that they are offered support and advice to help them manage their condition.”

Appointments are being offered on a first-come, first-served basis and can be made by telephone on 01380 730473.

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Care.data scheme in chaos as government signals new legislation

NHS England's jigsaw logo for care.dataNHS England's jigsaw logo for care.dataWhether or not you have asked your GP to opt you out of the government’s scheme to provide your confidential medical records now held at local surgeries to researchers and others, or whether you intend to do so soon, the care.data scheme has been pronounced as being in chaos by one of its firm supporters.

Just over a week ago, physician, academic and science writer Dr Ben Goldacre wrote in praise of care.data (generally spoken as care-dot-data.)  At the weekend he was embarrassed, he said, to have to write that the scheme was a mess in need of new primary legislation to ensure it is secure and will not sell information to commercial buyers.

At briefings on Friday evening it was revealed that Health Secretary Jeremy Hunt would announce this week that he will legislate on care.data, but as an add-on to the Care Bill that is currently before Parliament. He will have to hurry as the Bill starts its report stage in the Commons next Monday (March 10.)

However the briefings seemed to come up very short on what critics want.  Hunt said he would prevent data – even when made anonymous – being sold to insurance companies.

But the words used were that data will only be released when there is a “clear health benefit” rather than for “purely commercial” use by insurers and other companies.

This seems to be an empty promise as health insurance companies – like BUPA and the American health insurance companies the government is keen to get involved in the NHS – could easily argue that they needed the data to provide ‘clear health benefits’ for their subscribers.

The Health Service Journal’s version of the Friday briefing was that NHS England was even considering a total u-turn and making the scheme one that patients could opt in to rather than opt out of. As one comment on the HSJ site said: “If the default is ‘opt out’ then care.data is dead.”

The care.data shambles is fast becoming a major test of whether the NHS is safe in the hands of the coalition government. Part of the problem is that having talked up the benefits and absolute safety of the scheme, the government has been caught out by the revelation of a recent sale of confidential data to the insurance industry.

No sooner had care.data been put on hold for six months to give the government time to explain the benefits and safeguards to the public, than it was revealed that data for 47 million hospital patients had been sold to a group of insurers.

Some hours later, the head of care.data refused to tell MPs about this sale because his organisation was too new. However, it has been pointed out that the insurance industry’s report using the purchased data carried the logo of his new organisation.  He has further explaining to do.

And as though ministers had not enough problems, the chairman of the British Medical Association’s GPs committee has said doctors – who have the task of uploading the records from their surgeries to the central data bank – will have to be indemnified against potential legal action from patients who believe their records have been wrongly used.

That surely shows how little faith there is that our records will not be misused or will not be leaked or hacked.

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Hospital seeks nominations for its annual People’s Choice Award for community staff

Last year Sue Tucker (right) won the People’s Choice Award in Great Western Hospital Foundation Trust’s annual staff excellence awards. She works as an antenatal and newborn screening coordinator with the hospital’s community health services.

Sue was nominated by a couple who said she had given them support well beyond what they expected when they lost their baby.

Now GWH is asking again for nominations from patients and service users across Wiltshire who have experienced great care from the Trust’s community staff.  These services include community hospitals, community and neighbourhood nurses, care coordinators, therapists and staff in the services for children and young people.

Oonagh Fitzgerald, the director of staffing at GWH, believes the awards are a great way to celebrate successes to which staff contribute so much: “In a busy NHS Trust we don’t always get the chance to step back and reflect on the difference our staff make to people’s lives.”

“This is why I think the People’s Choice Award is particularly special; it’s a chance for patients and service users, their relatives or their friends to acknowledge those teams or individual members of staff who have gone the extra mile for them, and a chance for our Trust to formally recognise them.”

Judges, including a patient representative, will select a shortlist from the nominations received from the public and all those shortlisted will be invited to the awards ceremony in June at the STEAM museum in Swindon where the winners will be announced.

The deadline for nominations is 5.00pm on Friday, March 7.  You can download a nomination form at the GWH website or contact This email address is being protected from spambots. You need JavaScript enabled to view it. or call 01793 604431 to request a nomination form.

You only have to listen to Sue Tucker to know it is worth taking the time to make a nomination: “I was so pleased to win: it was a real honour to be nominated.  It validates what you do on a daily basis when someone going through a difficult time makes the decision to nominate you.”

 

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Update: medical records & care.data - admission that patients ‘may lose trust’ in NHS

Our original report on 'care.data' can still be read below this new report.

NHS England, who are running the care.data scheme to share medical records with third parties, have issued a worrying risk assessment of their scheme.

It says that using medical records without patients’ consent may lead to them losing trust in the confidentiality of the NHS.  

The assessment says the scheme runs the risk of degrading patient trust in the NHS, putting information at risk of hackers and identifies ‘a small residual risk’ that patients will be identified.

A frame from the NHS England video: is privacy just like a jigsaw?A frame from the NHS England video: is privacy just like a jigsaw?But it states baldly that the projected benefits of the scheme (see our earlier story below) outweigh the risks to patient privacy.  One of the identified benefits is providing a boost to economic growth.

A GP who lives in the north of England where the leaflets have already been delivered, wrote to the GP’s magazine PULSE that she had not been told how patients should opt out.  She added that some GPs were telling their patients to opt out of the ‘summary record scheme’ which is not at all the same as care.data.

Pulse had previously reported a poll of GPs indicating that 40 per cent of England’s GPs would be opting out of care.data as regards their own medical records.

This GP pointed out that as information already given by patients was provided in strict confidence and good faith that it would never be shared, the default position ought to be that patients opt in to the scheme rather than having the responsibility to opt out.

She also says that the NHS’ own mandatory training on Information Governance states that consent must be sought each time information from medical records is proposed to be shared.  “How”, she asks, “can automatic sharing of these past records without actively seeking current verbal or written consent be legal under the data protection act?”

The basic problem is that at law medical records remain the property of the Secretary of State for Health – the man whose overall responsibility for the NHS was removed by the coalition government’s Health and Social Care Act.

The opt out form can be found here.

Go to this site to see the care.data leaflet.

And to this site to read the full risk assessment text from NHS England.

There is a short animated video promoting care.data on this page.

MNO's FIRST REPORT ON CARE.DATA STARTS HERE:

Before the end of the month we will all be getting a leaflet through the door about the government’s plans for our medical records.

The leaflet is titled “Better information means better care” and will explain how, from March, our medical records will be extracted from GP surgeries and passed to a new body called the Health and Social Care Information centre (HSCIC) so they can be placed on the ‘care.data’ database.

The idea is to allow medical records to be shared with other parts of the NHS, researchers and private pharmaceutical companies.  And the aim is to improve and hasten research that will lead to advances in medicines and treatments.

The information will be ‘anonymised’ – it will not include your name but will still carry your NHS number, date of birth, post code, gender and ethnicity.  And as people in rural post codes know it is very easy to identify who’s who among a small number of homes.

It has also been admitted that there is a small risk that some patients could be identified by insurers and commercial health providers who could match their own data against the anonymised records.

If they have got permission to use the records and you are a client, they could match the anonymised information with their own data.   They will have your date of birth and post code and could make a match with the same categories of information on medical records.

Then they could see whether you had a drink problem or a long-term illness or even if you had told your doctor a certain condition was prevalent in your family.

The scheme is backed by many medical charities who say they need it to speed up their research.  And it is opposed by some who see it as a breach of principle about keeping private our most private data.

Any organisation or researchers can apply to the HSCIC for data and each application will be considered individually. 

The HSCIC will charge a fee to cover its costs, but there is no control at all over the potential profits that can be made from the data.

The government’s original idea was to make the scheme compulsory.  But you will be able to opt out of it.  

However the leaflet will not contain an opt-out form.  To opt out you have to go to your GP. And there has been criticism that information about this route for opting out is pretty well hidden away.

When asked in the House of Commons whether the Department of Health had an estimate of the number of hours GPs will spend talking to patients about care.data, the minister, Dr Dan Poulter, Parliamentary Under Secretary of State in the Department of Health, had no clear answer.  But there is, he said, “a patient information line which patients can call if they have questions, which will ease the burden on GP practices.”

There is a possibility that the scheme will prove to be breach of new EU privacy rules.

The costs of this scheme have not been finalised.  But the leaflet distribution will cost NHS England £1.2 million.

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Care.data: take a look at what the Health & Social Care Act says

The NHS' Care.data leafletThe NHS' Care.data leafletThis morning you could hear John Humphrys on Radio 4’s Today programme trying to get his head round the confidentiality issues on the collection by a new NHS organisation of all medical records from GPs’ surgeries – and their dissemination to others.

The man behind this scheme is Tim Kelsey (NHS National Director for Patients and Information.)  He told Today there was no chance that confidential information revealing  the identity of the person the records were about, would ever leak out.

Humphrys should have asked him what section 256 of the coalition government’s Health and Social Care Act really means. 

This quotation from the Act probably needs to be read in a very quiet place:

“Requests for collection under section 255: confidential information
(1)A request under section 255 is a confidential collection request if it is a request for the Information Centre to establish and operate a system for the collection of information which is in a form which— (a)identifies any individual to whom the information relates who is not an individual who provides health care or adult social care, or (b)enables the identity of such an individual to be ascertained.

(2)A person may make a confidential collection request under section 255 only if the request— (a)is a mandatory request, (b)relates to information which the person making the request (“R”) may require to be disclosed to R or to the Information Centre by the person holding it, or (c)relates to information which may otherwise be lawfully disclosed to the Information Centre or to R by the person holding it.”

Section 255 does say “the Secretary of State may direct the Information Centre not to comply with a request specified in the direction which is not a mandatory request.” But it also says he “may direct the Information Centre to comply with a request specified in the direction which was made by a person outside England.”

This last sentence is probably there to ease the way for American companies to enter the health service in England under the forthcoming trade deal between the EU and the USA.

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Take a ride around Maggie Bell’s patch to see how healthcare is changing in Wiltshire

Maggie Bell at Ramsbury SurgeryMaggie Bell at Ramsbury SurgeryFor evidence that healthcare in Wiltshire is changing all you need is an introduction to Maggie Bell.  She’s one of the Wiltshire Clinical Commissioning Group’s (CCG) new Care Coordinators – there are 29 working across the county at a cost of £1.3 million a year.

She was the first to start work.  Since September she’s been based at Ramsbury Surgery and has responsibility for patients registered with the GPs’ surgeries at Ramsbury, Marlborough and Great Bedwyn.

She reports to a manager at Ramsbury surgery and to the leader of the community nursing team based at Savernake Hospital. She is employed by GWH and paid by them with funding from the CCG.

She has a list of 22 people she visits: “But it’s growing all the time.”  If there’s an obvious medical problem she will visit with the community matron from Savernake Hospital: “If someone has a social need but they also have a medical need, it’s better we both go on a single visit – people don’t like lots of people coming into their home.”

The CCG’s flagship policy is its Community Transformation plan which aims to bring health care closer to people’s homes, keep them out of hospital for longer and make sure they are safe when they leave hospital.  It is aimed particularly at the elderly, most vulnerable patients.

Maggie Bell is not a nurse.  Her training and experience has been in social care.  And her role is preventative – to keep people healthy and help them avoid issues like isolation and stress that can lead to illness especially in the elderly.

One of her many jobs is to monitor people once they have left hospital.  She has access to the GWH data base that tells her who has been discharged and she will then contact or visit those who are likely to be at risk to make sure they are doing well.

This is a sure way to prevent the all too frequent occurrence of quick re-admissions to hospital – especially of the elderly.
“The GPs love it – to be honest they think it’s an absolutely brilliant scheme.”

The now defunct Wiltshire Primary Care Trust established the county’s ground-breaking neighbourhood teams of nurses and physios. When the PCT was no longer allowed to provide services, the teams were transferred under contract to Great Western Hospital and will be run by them until April 2016.

In their Community Transformation Plan the CCG are taking the neighbourhood team idea to a whole new level – and are working closely with Wiltshire Council to develop this new way of working at community level. Across the county, they’re designing local care for 23 clusters each of about 20,000 people.

In this they are ahead of the field:  the government has ordered that from April 2015 a slice off the CCGs’ funding will go towards a £3.8 billion pooled budget for CCGs and councils to join up health and social care services in England – the much-talked about ‘integration’ of care.

This fund was called the Integration Transformation Fund – a descriptive title.  But the politicians have got at it and it is now called the Better Care Fund – an aspirational title.

Maggie Bell and her fellow care coordinators are the first part of the CCG’s Community Transformation Plan.  Among other initiatives still to come is a ‘rapid response’ service that will bring health and social care within one hour to support people in time of crisis and prevent ‘unnecessary’ hospital admissions.

Maggie worked for two years as team leader for the Marlborough area’s Leonard Cheshire Disability’s Help to Live at Home team – a Wiltshire Council scheme. Now she really feels she’s making a difference: “I have the added advantage of knowing the area, the social services and community health team.”

“I’m stopping people being unhappy – to be frank. It helps people keep healthy when they know someone cares – especially people who come out of hospital. It’s good for them to know someone’s there.”

Margaret RendleMargaret RendleMaggie took me with her to visit Margaret Rendle who’s over 80 and lives in Marlborough. He husband died very recently and suddenly. Her GP asked Maggie to see her because she was afraid Margaret was very isolated, had all the problems of coping with the bereavement and needed to get out of her house more.

And frankly, Margaret’s not at all happy.  She’s still in shock and not feeling too good in herself.

Maggie filling in that formMaggie filling in that formShe’s got bad arthritis in her hands, so Maggie fills in the huge Council form – “It’s as big as a book” – to get her council tax changed.  And Maggie takes a look at the carers’ log to make sure they’re coming as they should.

Margaret is desperate to keep out of hospital – worried what would happen to her partially disabled son.

Maggie Bell is going to phone her bank to ask about her husband’s will. She’s going to talk to her GP as Margaret wants to know why her husband died in hospital so suddenly.

And there’s a large bill for the carers her husband needed that’s making Margaret anxious and must be sorted out. Margaret is very relieved and grateful that Maggie is on her case.

Maggie & her essential carMaggie & her essential carAlthough they are such a new addition to the NHS’ armoury, the Care Coordinators are settling in well and getting on with their important job.  As Maggie puts it: “Things are going very well with all the coordinators – the commissioners are very pleased – like the GPs.”

Every month all the 29 Care Coordinators meet together for a forum – exchanging information about support charities and care agencies and go through a case study to see how they can do things even better.  And they probably moan a little about the mileage allowance!

They do a great deal of driving – especially in the most rural areas like Maggie’s.  Quite who picks up the carbon footprint for all that driving must remain another mystery of the complex restructuring of the NHS.

As other parts of the Community Transformation scheme come on line, the Care Coordinators jobs will change as they have more local elements to fit in with.   The aim is that by the end of 2015 the CCG’s new community system will be looking after many more of the vulnerable – who are most often the elderly – in their homes and keeping them out of hospital.

Care Coordinators are a first step in the plan. And Maggie's enthusiastic about what they can do: "I love my job."

[With thanks to Margaret Rendle and Maggie Bell.]

 

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