Chief Executive's
Annual Report


Transforming Care

Paul Gray, Chief Executive of NHSScotland and Director-General Health and Social Care, presents his Chief Executive’s Annual Report. He outlines the achievements made during 2015/16, and describes the challenging context in which NHSScotland continues to operate.

In his foreword, Paul pays tribute to the outstanding commitment of all NHSScotland staff, and to the dedication of colleagues in our partner organisations – including those in the voluntary and third sector.

The report charts progress towards our 2020 Vision for Health and Social Care and presents achievements in the three areas often referred to as the ‘Triple Aim’: improving the quality of the care we provide; improving the health of the population; and securing the value and financial sustainability of the health and care services we provide. Our Quality Ambitions for person-centred, safe and effective care have continued to guide our work in improving quality, transforming care and delivering improved performance.

The video stories you see here are people’s personal accounts of NHSScotland and its partners working to achieve the best health outcomes for the people of Scotland.

If you would like to read more, you can access the full report below.

View the animation to see some of NHSScotland’s key achievements in 2015/16.

Realistic Medicine in Person-centred Care

Alastair’s Story

Across the world, a conversation has developed about healthcare that has begun to question the direction of modern medicine as we currently understand it. Chief Medical Officer Dr Catherine Calderwood used the publication of her first annual report, ‘Realistic Medicine’ in January 2016 to engage with doctors in Scotland around this theme.

Realistic medicine proposes a need to move from a culture of ‘doctor knows best’ to one where health and wellbeing is co-produced with people who are supported to better understand their health, their care and to share preferences and decisions that relate to it. This will help to tackle unwarranted variation in practice and outcomes for people that contribute to potential harmful or wasteful care.

Alastair’s story is an example of clinicians working together with people to make informed decisions about their care and medication options. Alastair has decided, with the support of his doctors, not to prolong his life at the expense of his comfort and independence. In his words, he’s happy to choose quality of life rather than “just dragging on”. Happily he’s currently doing well and says after making “a very good team decision” with his doctors, he’s “delighted with the current situation”.

What Matters to You?

Personalising Care

A person-centred approach in healthcare is about focusing on what matters to the person receiving care and their family, friends and unpaid carers. We know that when a person’s individual priorities and values are taken into account, it not only helps them to lead a life that has meaning and purpose to them, but also leads to better clinical outcomes.

One simple but transformative example is the ‘What Matters to Me’ initiative, pioneered at the Royal Hospital for Children in Glasgow by Chief Nurse Jennifer Rodgers and her team. Instead of asking ‘what’s the matter?’ staff ask children ‘what matters to you?’ Children draw posters to display on the ward, with words and pictures showing what they care about – having mummy with me, smiley nurses, friends and family, good food, and games and toys are all popular themes.

The approach has drawn interest from hospitals all over the world and, from initial activity in paediatrics, it’s been taken up and applied to geriatric services, palliative care and many other fields. Asked ‘what matters to you?’, older people often talk about the people and events that have been important in their lives, and mention personal preferences around bed times, privacy, food and other priorities. The ‘What Matters to Me?’ posters displayed by their beds support staff to make a caring connection with the person, and to take their individual preferences into account, contributing greatly to their comfort and wellbeing.

Our film brings together views and comments from Jennifer Rodgers and other nurses and doctors who’ve helped to develop and implement the ‘What Matters to Me’ approach.

Integrating Health and Social Care

Allan’s Story

At the age of 90 and with a number of chronic health problems including cellulitis and chronic obstructive pulmonary disease, widower Allan is determined to continue living independently at his home in Biggar for as long as he can safely do so.

His determined self-reliance may be due in part to his past career. Allan and his wife ran a rapid-response emergency service for dairy farmers throughout Scotland and the North of England. When a dairy farmer was unable to work due to illness or injury, Allan would come to the rescue.

Now it’s Allan who needs a little help - which he gets from the Integrated Community Support (ICS) Team of South Lanarkshire Health and Social Care Partnership. The ICS team includes nurses, physiotherapists, hospital discharge staff, social workers, home care workers and occupational therapists. Medical care is provided by Allan’s GP, linking with hospital consultants where needed. People who have complex care needs benefit from this approach to care, as well as men and women like Allan who have less serious conditions but who need some support to continue living independently.

Allan says, “After leading such an active life, it’s wonderful to be able to retain my independence.” Watch his film here.

Saving Lives at Risk from Cardiac Arrest

Rob’s Story

When your heart stops pumping, your chances of survival reduce by the minute, even the second. Intervention in the form of Cardio Pulmonary Resuscitation (CPR) and defibrillation is highly effective, at least doubling the likelihood of recovery, but it has to be applied quickly.

The Scottish Government’s Out-of-Hospital Cardiac Arrest (OHCA) strategy aims to get emergency services, community groups and the general public working together to save lives. The strategy aims to save 1,000 lives by 2020, to train half a million Scots in CPR, and to make Scotland one of the best countries in the world in terms of OHCA survival.

The Scottish Fire and Rescue Service is a key partner in saving lives when cardiac arrest strikes. A co-responding trial between the Scottish Ambulance Service and Scottish Fire and Rescue Service began in November 2015 covering 10 areas in Scotland, with the intention of getting appropriately trained people to patients in communities as fast as possible, thus increasing their chances of survival.

In the film we meet Rob from Hawick. When Rob suffered an entirely unexpected cardiac arrest at home, family members called 999 and, taking instructions over the phone, immediately started CPR themselves. The fire service arrived in minutes and took over until the ambulance service arrived. “I’ve never been so happy to see a fire engine in all my life,” says Rob’s wife Margaret. Watch Rob’s story here.

Ensuring Children Get the Best Start

The Langlee Early Years Centre, Galashiels

Throughout a child’s journey, from pre-birth to becoming a young adult, we want to ensure they get the best start in life through good pre and post natal care of mothers, quality early learning and child care, family support if needed and excellence and equity throughout their education.

The Early Years Collaborative was launched to strengthen services for children and families and to support the delivery of Getting It Right For Every Child (GIRFEC). The Early Years Collaborative uses improvement methodology to make services as effective and responsive as possible. It aligns closely with the Maternity and Children Quality Improvement Collaborative, an integral part of the Scottish Patient Programme.

The Langlee Early Years Centre in Galashiels in the Scottish Borders has been involved with the Early Years Collaborative from its inception. It provides an open door, all year round service within a safe and relaxing environment where families feel comfortable dropping in for advice and support. A weekly drop-in session helps parents and mums-to-be with health visiting, midwifery, benefits advice and many other issues. Activities include cookery classes, a breast-feeding peer support group and ante-natal sessions. The Centre has amassed a huge amount of data and evidence demonstrating its impact and informing future practice. Langlee is effectively GIRFEC in action. Watch the Langlee story here.

Supporting People to Have Greater Choice and Control in Social Care

Susan’s Story

Self Directed Support (SDS) is Scotland’s approach to social care. It gives people who need support control over how it is delivered. Once social care outcomes are agreed, the individual or family has the freedom to purchase or arrange support in three ways. The budget can be taken as a direct (or cash) payment, allocated to a chosen provider, or arranged by the local authority. Individuals can opt for just one route, or mix and match two or three routes, of funding.

SDS is available to a wide range of people, including disabled people, people with mental health issues, older people and children. Sometimes parents or guardians are involved in the decision-making process.

Susan, who worked as an auxiliary nurse at Glasgow Royal Infirmary for 21 years, was diagnosed with secondary progressive multiple sclerosis in 1993. Still living an independent life at home in Kirkintilloch, she has chosen to receive her social care budget as direct payment, using the funds to employ a personal assistant. Susan advertised in the local paper and conducted interviews herself, choosing Helen, a former care worker who was getting bored in retirement and who wanted to help. The two have become firm friends. According to Susan, “People are frightened of the paperwork, but in reality it’s so easy to do.” Watch Susan’s story here.

Support People to Live Well in their Community – the Link Worker Programme

Marie’s Story

The Link Worker pilot programme in Dundee and Glasgow is right on the front line of the battle against health inequalities. Funded by the Scottish Government, the programme sees a dedicated individual working in GP surgeries, helping patients on a one-to-one basis with non-medical problems that are making them feel unwell including poverty, violence and social isolation.

The Scottish Government has committed to increasing the number of community Link Workers in disadvantaged areas by 250 in the next few years to ensure that anyone who needs psychosocial support receives it. An additional 40 Link Workers will be in place by 2018.

In our film, Marie explains how she was introduced to a Link Worker (which she refers to as Community Link Practitioners or CLPs) by her doctor when she was uncomfortable attending a hospital appointment on her own. Following that initial contact, Marie has accessed counselling and joined a walking group. She now feels much more positive and has less need to see her doctor.

Empowering People and Improving Care Through Digital Health – ‘My Diabetes My Way’

Ross’s Story

Involving people in the management of their own health can have highly positive outcomes. It’s particularly important in conditions like diabetes, where self-monitoring is an essential part of daily life.

‘My Diabetes My Way’ is a highly interactive digital portal delivering support and information to patients. Once registered on the website, anyone with diabetes in Scotland can access their own electronic Personal Health Record. Patients can manually upload the information they record at home, including body weight and blood pressure, while glucose results are uploaded automatically. A secure messaging facility lets patients and healthcare professionals swap information between routine appointments. There’s also a wealth of multimedia resources to help patients understand and manage their condition. Over eight thousand people are now fully active on the site - more than 44 per cent of those who’ve registered.

Ross in our film is the former chair of the National Diabetes Patient Group and has been using the digital service to help manage his own condition since its launch in 2010. He says he’s much more in control of his diabetes, and enjoys constructive discussions with his consultant now that he has access to the numbers that matter. “This is one of the most effective ways of helping people with diabetes I know of”, says Ross. “I would say it’s the envy of the rest of the UK and many other parts of the world.”

Achievements in Numbers

Satisfaction with NHSScotland remains high, with 90 per cent of hospital inpatients who participated in the Scottish Inpatient Patient Experience Survey 2016 reporting overall care and treatment to be good or excellent, and 87 per cent who responded to the Health and Care Experience Survey 2015/16 rating the overall care provided by their GP Practice as good or excellent.

In autumn 2015, the first national Cancer Patient Experience Survey was launched to provide high-quality national and local data on patients’ experiences of cancer care. The results published in June 2016 found that 94 per cent of patients rated their care positively (giving an overall rating of seven out of 10 or above).

The Maternity Care Experience Survey, which was conducted in 2015, showed a very positive picture of women’s experiences of maternity care overall. In most instances women said that they received excellent care from staff, with 92 per cent of women rating their care during labour and birth as either excellent or good.

90% of hospital in patients reported care and treatmen to be good or excellent
         87% rated care provided by their GP Practice as good or excellent
          94% of cancer patients rated their care positively
           92% of women rated their care during labour and birth as either excellent or good

Sources: Scottish Inpatient Patient Experience Survey. 
Health and Care Experience Survey.
Cancer Patient Experience Survey. 
Maternity Care Experience Survey.

The Scottish Patient Safety Programme (SPSP) is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm whenever care is delivered.

Within acute care there has been an overall reduction in Hospital Standardised Mortality Ratios (HSMR) of 16.5 per cent, with a 21 per cent reduction in mortality from sepsis and 11 hospitals showing a 19 per cent reduction in cardiac arrest rates.

16.5% reduction in Hospital Standardised Mortality Ratios (HSMR) of 16.5%
      21% reduction in mortality from sepsis 
      11 hospitals showing a 19% reduction in cardiac arrest rates

Sources: Quarterly Hospital Standardised Mortality Ratios (HSMR), ISD Scotland.
Scottish Patient Safety Programme Acute Adult: End of phase report August 2016,
Healthcare Improvement Scotland.
Scottish Patient Safety Programme Acute Adult: End of phase report August 2016,
Healthcare Improvement Scotland.

Scotland’s unscheduled care performance was the best we have seen since 2011/12. Some 94.1 per cent of patients were seen and subsequently admitted, transferred or discharged within four hours. Scotland’s core A&E Departments have been the best performing in the UK since March 2015.

94.1% of patients were seen and subsequently admitted, transferred or discharged within four hours.

Sources: A&E Activity and Waiting Times, Information Services Division (ISD), July 2016.

The impact on delayed discharge performance of new integrated ways of working is starting to be seen already. Bed days associated with delayed discharges have been on an overall downward trend throughout the year, running at 9 per cent below the level in 2014/15.

There was a 9% reduction in the total number of bed days occupied by delayed discharge in 2015/16 compared to the previous year.

Sources: ISD Scotland: Delayed Discharges.

Elective waiting times have been transformed over the last ten years despite growth in demand, however we recognise that sustaining elective waiting times is a challenge. In 2015/16, diagnostic waiting times statistics showed that 94.6 per cent of elective patients had been waiting six weeks or less at the end of March 2016.

Almost 300,000 or 94.4 per cent of elective inpatient and day case patients were treated within 12 weeks in 2015/16, while 88.0 per cent of new outpatients had been waiting 12 weeks or less at end March 2016.

94% of elective patients had been waiting six weeks or less for a diagnostic test, at the end of March 2016
      88.0% of new outpatients had been waiting 12 weeks or less
      94.4% of elective inpatient and day case patients were treated within 12 weeks

Sources: ISD Scotland: Diagnostics Waiting Times.
ISD Scotland: Inpatient, Day Case & Outpatient stage of treatment waiting times.

In the combined calendar years of 2014 and 2015, 25.1 per cent of lung, breast and colorectal cancers were diagnosed at the earliest stage, an increase of 8.0 per cent on the baseline combined calendar years of 2010 and 2011.

25.1% of lung breast and colorectal cancers (in combined calendar years 2014 and 2015) were diagnosed at the earliest stage an increase of 8.0% on the baseline (combined calendar years 2010 and 2011

Sources: ISD Scotland: Detect Cancer Early staging data year 4 July 2016.

Scotland leads the way on In-vitro Fertilisation (IVF) access in the UK. Eligible couples are provided with two full cycles of IVF treatment, with treatment provided within twelve months of referral for 99.9 per cent of patients in 2015/16. Over the last four years we have invested around £18 million to reduce the waiting times and improve the outcomes for patients undergoing IVF treatment.

99.9% of all eligible patients provided with IVF treatment within 12 months of referral

Sources: ISD Scotland: IVF Waiting Times in Scotland.

As a result of improved treatments and a greater focus on prevention, premature mortality (deaths among those aged under 75 years) has reduced substantially, down 17 per cent since 2005 to a death rate of 440.5 deaths per 100,000 population in 2015.

17% premature mortality rates (deaths under 75) reduced by 17% between 2005 and 2015

Sources: National Records of Scotland: Age-standardised Death Rates Calculated using the European Standard Population.

The latest Scottish Health Survey reveals encouraging progress in reducing smoking rates. It shows that 21 per cent of adults now smoke – one in five adults in Scotland. There was also a significant decrease from 2014 to 2015 in the proportion of children who were exposed to second-hand smoke in the home (11 per cent to 6 per cent).

Scotland is also seen as a world-leader in addressing alcohol-related harm. It was recognised several years ago that Scotland’s relationship with alcohol had become unbalanced, and bold action has been taken to tackle alcohol misuse. Alcohol Brief Interventions (ABIs) play an important preventative role in tackling this as part of a wider strategic approach to addressing problem alcohol use. In 2015/16, 97,245 ABIs were carried out, exceeding the target of 61,081 by 59 per cent.

NHS Boards and their delivery of the Childsmile Programme have ensured that continued progress is made in improving the oral health of children. The latest results from the National Dental Inspection Programme (NDIP) showed that 75 per cent of children in Scotland at Primary 7 had ‘no obvious decay experience’, compared with 59 per cent in 2007.

21% of adults now smoke, 1 in 5 adults in Scotland
      the percentage of children exposed to 2nd hand smoke in the home has decreased from 11% to 6% 
      97,245 (ABIs) were carried out exceeding the target of 61,081 by 59% 
      75% of children in Scotland at Primary 7 have no obvious decay experience

Sources: Alcohol Brief Interventions 2014/15, ISD Scotland, June 2015.
Scottish Health Survey 2015, The Scottish Government.
Latest National Dental Inspection Programme (NDIP).

After clean water, vaccines have had the greatest impact on people’s health around the world. Vaccination programmes are one of the most effective ways of protecting the public against serious diseases and of reducing the spread of disease. Scotland has a number of well-established vaccination programmes for people across all ages and at various stages in their lives.

In September 2015, Scotland became one of the first countries in the world to introduce a Meningitis B vaccine. It is given alongside other routine immunisations at two and four months of age, with a booster dose at 12-13 months. Provisional vaccine uptake for the first routine cohort eligible for infant Men B vaccination is 95.7 per cent for one dose and 82.4 per cent for two doses by six months of age.

In September 2015 Scotland became 1 of the 1st countries in the world to introduce a MenB vaccine. Provisional vaccine uptake for the 1st routine cohort eligible for infant MenB vaccination is 95.7% for 1 dose and 82.4% for 2 doses by 6 months of age

Sources: Health Protection Scotland: Provisional vaccine uptake for the new meningococcal B (MenB) immunisation programme in Scotland, March 2016.

The NHSScotland workforce is vital in responding to the challenges faced by the Service. Our shared 2020 Workforce Vision is that we will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations.

Numbers of NHSScotland staff continued to rise to 138,000+ WTE in 2015/16
over the reporting year 2015/16 NHS Boards have delivered 4187 new employment opportunities for young people (aged 16-24)an increase of 37% over the same period last year.

Over the reporting year 2015/16, NHS Boards have delivered 4,187 new employment opportunities for young people (aged 16 to 24). This figure includes Modern Apprentice opportunities. This is an increase of 37 per cent over the same period last year when 3050 were appointed. Evidence suggests that a total of 10,699 employability opportunities for young people have been offered by NHS Boards over the past three years.

Sources: ISD Scotland Workforce Statistics.
Management data collated on behalf of NHSScotland by Employee Experience Team, Health Workforce and Strategic Change Directorate, Scottish Government.

Financial Overview

In 2015/16, health spending in Scotland exceeded £12 billion for the first time and amounted to 40 per cent of total Scottish Government spending. In line with the Scottish Government commitment to protect the NHSScotland resource budget, the 14 Territorial NHS Boards received an above inflation baseline increase of 3.4 per cent, which was directed towards the provision of frontline healthcare services for patients and their families.

Health spending accounted for 40% of Scottish Government spending
£10.4bn to the 14 territorial NHS Boards
      £1.3bn to the 7 special NHS boards and Healthcare Improvement Scotland
      Health spending in Scotland exceeded £12bn for the 8th year in a row all NHS Boards achieved their financial targets
      £0.5bn used to provide funding for national publi chealth programmes

For the eighth year in a row, all NHS Boards achieved their financial targets. Once again, this demonstrates the commitment of all those involved across NHSScotland in managing resources, often within very challenging circumstances, and delivering high quality services underpinned by financial strength.

The Scottish Government allocated £10.4 billion directly to the 14 Territorial NHS Boards. The seven Special NHS Boards and Healthcare Improvement Scotland received £1.3 billion, and £0.5 billion was used to fund a variety of other support programmes, research, and improving access to services.

NHS Boards were required to deliver at a corporate level efficiency savings of £293 million for NHSScotland for 2015/16. This equates to 3.0 per cent of their baseline funding. Savings requirements ranged from 0.4 per cent (NHS Education for Scotland) to 7.1 per cent (Golden Jubilee Foundation Board). Almost all boards achieved this level of efficiency and a number over-delivered, bringing the final total for 2015/16 to just over £290 million.

If you would like to read more about the financial performance of NHSScotland, including capital investment and efficiency savings, you can download the full report here.

Patient Feedback

NHSScotland is committed to supporting a culture of openness that welcomes feedback, comments, concerns and complaints, and uses them all as a source of intelligence to drive continuous improvement.

There were 21,456 complaints made about NHS services in Scotland in 2015/16 – a four per cent fall in the total number of complaints compared to the previous year. NHS Boards must listen to all complaints received, learn from them and take action where necessary in order to continuously improve services.

NHSScotland continued to engage with the independent website Patient Opinion, which provides an online route for people to share their experiences of care – whether good or bad – and to use this to improve care. There were 1,779 stories shared about NHSScotland in 2015/16, and these were viewed a total of 600,000 times. Fifty-four per cent were positive and 63 changes and improvements to services were made or planned as a direct result of a story shared in this way.

Here are just some of the stories posted and the resulting actions taken.

“I was admitted as an emergency recently in the evening which required surgery and was discharged four days later. My whole experience was excellent and I could not fault the care I received. This was spoiled however by my initial experience in A&E. On arrival ... I approached the reception desk where I was left to stand for over 5 minutes despite being the only person waiting. Two receptionists were at their desks and made no attempt to say that they would help me shortly.”

Patient attending A&E; at Victoria Hospital, NHS Fife

[The manager has] asked me to pass on her sincere apologies to you and confirms having sent the link to your story to all of our reception staff. Along with the link she has sent a covering e-mail asking them to ensure that patients are acknowledged and reminding them of the need for good customer care at all times. The Manager wanted to assure you of the action taken to try to ensure this does not happen again.

“My gran who is a healthy woman took a stroke two weeks ago and …. was taken to hospital within the hour. Monklands hospital staff have to be thanked as they have done a brilliant job looking after my gran and she is slowly getting better.”

Relative of patient at Monklands Hospital, NHS Lanarkshire

I’m sorry to hear about your gran’s stroke. I was so pleased to hear that she is slowly getting better and am sure this will be a relief to you and your family. Your feedback is very much appreciated and it will be my pleasure to share it with [the team].

“I couldn't hear through the glass panel at the reception point. It was incredibly stressful …. The woman on the other side was struggling to hear too. I use hearing aids and there was no loop provision - it was a dreadful experience. Very upsetting to me.”

Mother of patient attending Stirling Community Hospital Minor Injuries Unit, NHS Forth Valley

Since your posting staff have visited the Minor Injuries Unit to look at the hearing loop and discovered that there was a fault with the system, there was a problem with one of the switches, it has now been fixed and the loop system is now working properly. I really appreciate you taking the time to tell us about your experience.

“Signs are very confusing and make an already difficult experience even more stressful. Leaving ward there is no sign directing to way out and as all corridors look the same you can end up with much longer walk than needed. Signs are even more difficult for people with dementia and not dementia friendly AT ALL.”

Carer of patient attending geriatric assessment at Wishaw General Hospital, NHS Lanarkshire

Thank you for taking the time to get in touch. NHS Lanarkshire has developed colourful, pictorial signage for use throughout hospital which you may have seen on doors to bedrooms, toilets and bathrooms in the wards. Wishaw General has installed new exterior signage at the rear of the main building directing patients/visitors into the hospital. Internally we continue to trial new signage directing patients/visitors to all wards and departments.

“I had to walk to theatre and on entering theatre surgeon, anesthetist, theatre nurse all standing chatting in corner. Very impersonal, and not very reassuring. Felt as if I was just a number and no one was really bothered as to how I was feeling.”

Patient attending for General Surgery at Crosshouse Hospital, NHS Ayrshire & Arran.

I have read your story and I am sorry that in this case you did not have a good experience. I will pass this to all the team for their reflection and I am sure the staff will learn from this. Thank you for letting us know about your feelings, it can be easy for us to forget how stressful these events can be.

“This room appears to contain 'equipment' required by all members of staff. While I was lying with my top off having the ECG done various members of staff were in and out making me feel very vulnerable.”

Patient attending for ECG at Cardiology Unit, Hairmyres Hospital, NHS Lanarkshire

We are in the process of having privacy screens fitted in the department but this work will take another four weeks or so. In the meantime we will be using portable privacy screens, using additional signage to indicate to staff that clinical examinations/investigations are underway and we are also going to revise arrangements for storing equipment in these areas.

“I attended a manometry appointment today at Victoria Hospital Kirkcaldy and although the test I underwent was not one of the best experiences I have had I would like to thank [staff] for the kindness and patience shown towards me. I would also like to suggest that if there was the opportunity for patients to listen to music during this procedure then it may help them to relax easier and for the procedure to go more smoothly and quicker.”

Patient attending Gastroenterology, Victoria Hospital, NHS Fife

Thank you for taking the time to tell us about your appointment at the Victoria Hospital. I was delighted to hear that you were treated with kindness and patience, which is what we want for all patients. Having to undergo a procedure like this is not pleasant and we want to do all we can to make it as comfortable as possible for people. Your suggestion makes a lot of sense and I will pass this on to the team to see if this would be a possibility. I am hopeful that we will be able to do something positive here.

“Excellent care from all involved. Always have a smile on their faces, thanks especially to [staff] who saw my husband in the clinic and put all of my and his worries at ease.”

Patient attending wheelchair service at Woodend Hospital, NHS Grampian

Thank you for the kind comments about our wheelchair service. Staff will be much gladdened to hear what a difference they have made to your lives. You describe beautifully how we would like all our services to be.