E34 News

* Please note, this transcript was partly AI generated and may contain errors!

[00:00:00] Munir Adam: Hi guys, good morning, good afternoon, or good evening, whatever it might be for you. It's Munir Adam here, whatever the time of the day, I hope you're well. This episode of Primary Care UK looks at a couple of topics that have been in the news lately and thinks about what the implications of those might be for us frontline clinicians working in primary care.

[00:00:25] The first item in this episode is patient access to appointments. And this also includes the important role of the multi professional team. And the other item, very different from that, is about the Lucy Letby case. Now, many of you listening might be thinking that access, is that even news? I mean, access to appointments as a major problem isn't really news.

[00:00:46] It's nothing new, right? But that doesn't stop it finding its way into the headlines from time to time. And it's something which frustrates us, largely because we want our patients to be able to access the care when they need it. After all, we're dealing with people's health, their lives. But also, of course, because of the pressure that it puts on us in our day to day work.

[00:01:06] Uh, the discussion, I promise you, won't just be a moan about the problem that we all know about, but actually some solutions that have been tried and are being used in some places, and in fact with some good effect too. So always worth a listen. Now, if the issue of access is frustrating, then the issue of the Lucy Letby case, I would imagine, for most of us, is upsetting.

[00:01:27] Upsetting largely because of what this has done to the families, the victims, that have been affected by this. But also upsetting because of how it damages the reputation of our professions. I mean, I believe that despite the busy lives that we, most of us lead, one of the things that keeps us going is the appreciation of our clientele, our patients.

[00:01:52] In fact, some might argue one of the things that keeps a lot of people in the world, in any industry going, is the appreciation they receive. And so, when things happen that damages that, it obviously affects our well being, and of course, it can have practical implications as well, if you're dealing with clients who perhaps don't trust you as much as they did before, right?

[00:02:12] And as Dawn points out later, these sort of topics, they don't normally get discussed in the healthcare community, do they? Certainly not in terms of how it affects us as day to day hard working clinicians. So we thought it would be timely to do that here. But the idea was, and this is from feedback that some of you have given, about trying to include a discussion about items that have been in the mainstream news.

[00:02:36] Well, it's February 2024 and as we come towards the end of Season 2 of Primary Care UK, brought in collaboration with Integrated Care Support Services, we thought these are two topics worth discussing. And to discuss these topics, we have Dawn, who you'll remember from previous episodes like the one to do with Nursing Opportunities, and really pleased to announce a new member joining our Primary Care UK team, Simon Robinson, who is a paramedic by background, but will be introducing himself in a moment.

[00:03:06] So, I'll now hand you over to Dawn and Simon, and as you have a listen to the discussion, ask yourself, how closely does this resonate with my feelings about the subject? 

[00:03:17] Dawn: Hi everybody, welcome to today's podcast. My name is Dawn Hunt. I'm a practice nurse working in Wiltshire. I'm also a clinical lead for Integrated Care Support Services and it's great to be back for another episode. 

[00:03:43] Simon: Hi everyone, my name's Simon Robinson. I'm a paramedic by trade but I work as a Advanced Clinical practitioner and I'm a partner at a a large GP practice in Devon.

[00:03:56] Dawn: So this is our first time doing a podcast together. And today we're just going to be talking about some different stories that have been in the news over the last year or so. And some of them more recently things that we think are pertinent to healthcare workers across primary care and beyond. Stories that you may have picked up on along the way, things that you might be interested in. 

[00:04:19] So we thought we would kick off with talking about access to health. Over to you, Simon. 

News: Primary Care Access

[00:04:26] Simon: ..So this is a big issue. And as we all know, working in healthcare, particularly primary care there is a massive interest in access to health. It gets a lot of bad press. And unfortunately, googling and looking around at different newspaper headings and doing a bit of research a lot of negative press out there. And I think it's quite important for us to discuss this today to actually try and make sense of some of this literature. Unfortunately, a lot of it has got a very political tone to it, which doesn't really help us as practitioners and working and providing a service in quite tough times for the NHS. 

Budgets down, workload up, morale down

[00:05:03] Simon: So, what really are the, issues and why is there, a problem with access to primary care? Couple of things jumped out at me on while looking at research. So, actually, the budget's been falling for quite a few years, really, and the budget's falling by 8. 4%. Bearing in mind primary care deals with 90 percent of the contacts carried out across primary care but only gets less than 10 percent of the budget. So that's disproportionately amount of work for amounts of funding, which primary care gets. 

[00:05:34] But we've also got to look at increased life expectancies and, people living longer, all these new advanced medications and treatments, which weren't around five, 10, 15 years ago. And a lot of this work is it's coming from secondary care who traditionally would be doing this work, but it's becoming to primary care. 

[00:05:51] Dawn: Yeah. Thank you, Simon. Yeah. And I think it's interesting how this then affects the day to day morale of those working in primary care and the impact that it has.

[00:06:03] I think my experience and talking with colleagues in my practice, in other practices is that time is very stretched. Nobody has enough time. There's not enough funding and everything is squeezed into less time than it requires, which means that people are really stretched and stressed.

[00:06:25] And I think that is adding to the burden as, as well as the kind of the lack of finances as well. So I think it's it's a real mixed bag of challenges. 

[00:06:39] Simon: There was an interesting article in the Guardian earlier this month written by a GP strong political stance there. However, it was just documenting and talking through his typical day. Works in Tower Hamlet in London, and it's about all the challenges and the amount of patients that he was meant to get through in a day, plus the emergencies in the walk ins, plus the home visits, plus the admin; and it it was quite a well written article. Articles like that actually explaining to the general public, how busy, and the constraints that primary care is up is, you know, is vital. The Times, there's another report in the Times mentioned that last year, there were 426 million appointments in primary care in the whole year, which is, you know, a vast number.

[00:07:26] Dawn: It's extraordinary. 426 million appointments in 2023 in primary care. Wow. 

[00:07:34] Simon: That's a staggering amount. It is. So, what can we do to improve access? Well, we all know that there's an issue with recruitment and retention, not just of GPs, but of healthcare professions across the boards, whether it's practice nurses, allied health professionals, advanced clinical practitioners, we know the staff are stretched.

Is technology a solution?

[00:07:51] Simon: So other ways, and certainly where I'm working, we're looking at use of technology. And I know this is not new and it's been out for some time, but using different types of technology, such as e consult or Accurix or Anima. And these technologies can be used to streamline what patient requirements, what they need, what they're after and, and, and signpost them or, streamline them into the best effective health professional, to be dealt with in a, in an efficient manner. 

[00:08:18] Dawn: And I think actually that's one good thing that's come out of the pandemic is we had to, I think during the pandemic, we were pushed forward to use things like remote consultations and to get to grips with different ways of doing things.

[00:08:33] And actually, I think in many practices those new ways of doing things have stuck. I think people have embraced yes, new technology and new systems. 

[00:08:43] Simon: And as we've seen, certainly where I work, it has increased patients access to primary care. For instance, people can e consult from any time at home.

[00:08:53] They don't have to wait around for or wait for cues or callbacks from a phone system. And we can use it and we can expect or request replies via text or e consult as well. So for instance, if they're at work they can get replies and it allows us to do things such as electronic prescribing to increase efficiency.

[00:09:11] Dawn: Yeah, absolutely. And I think also just even things like sending text messages to patients and receiving replies, they can send in photos. It just makes it much easier to do remote consultations and to to triage as well. 

[00:09:24] Simon: Absolutely. And also, as we find, certainly, it allows us to use safety netting and patient education.

[00:09:31] We can attach contemporary evidence based links to either texts or e consults to a, you know, give the patient the information and the best evidence out there to, to give that informed joint decision. So that's, I think, imperative. 

[00:09:48] Dawn: I guess one of the challenges of that is with older patients who aren't using mobile phones, who aren't on the internet, and then the challenge of that.

[00:09:58] How have you found that in your day to day practice, Simon? 

[00:10:01] Simon: Adding or using technology has has enhanced patient's ability to for communication, but also increasing the use of new phone systems and cloud based phone systems to allow patients to choose which way they want to contact us.

[00:10:16] When we first started using the e-consult method in 2019, we went to another practice in London and I said about the elderly population and perhaps not being so computer literate. And I was, I was told off that age is not a discriminating factor. And I stand corrected.

[00:10:32] And we find that a lot of our senior population like the technology, just as much as, as, as the younger tech population, and as I said, they don't have to wait around or try to queue on phone systems. They can send their question, their query and they will get a response back usually within 48 hours.

[00:10:48] It's also got an element of triage in there as well. And for making sure that patients are suitable, come through to us and shouldn't be going to have a place like accident and emergency. 

[00:10:59] Dawn: And in our practice, we've kept a triage system in place so that anybody who needs to speak with a doctor on the day is able to, to call in and will speak with a doctor and then as required, they'll, they'll then be seen face to face or on the day again, if needed, or booking appointment, you know down the line. 

The multi-discliplinary team in action

[00:11:20] Simon: So, as, you mentioned, Dawn, one of the ways we found to increase access to health is having a multi disciplinary team. Now, this is something we, we did our practice in 2015, and it started off with a paramedic, nurse and a pharmacist. Since then it's grown in our practice to a team of 11.

[00:11:40] It's a team of very experienced within their areas ranging from nursing backgrounds, paramedic backgrounds and physios and a pediatric nurse. Now these staff have all come from different areas, most of them working outside the traditional boundaries of their professions, such as our physios who actually worked in acute care at home teams, and they have developed their extensive skills, their advanced practice skills through that experience.

[00:12:09] Having a team, a multidisciplinary team, everyone has a strength in different areas, and it's trying to unify that team in order to provide a service. Now, as you briefly mentioned, we do have the phone in the consults and we have a on the day service. So we have an urgent care team where patients with a acute presentation can be seen on the day.

[00:12:34] And we generally try and see them within two hours, that's the aim. And that could be either by phone in. e consult email and anyway, we would pick that up and manage it as a team. 

[00:12:46] Dawn: And what sort of area are you covering as a team? As in, are you covering a PCN or is that within your GP practice?

[00:12:55] Simon: So the area I work at Beaker Medical Group, we are a complete Single PCN, single practice PCN, which has its has its advantages. So the team will cover a population of around 43, 000 patients. We have a strong focus on pediatrics, because we have a large pediatric population, we cover and manage most acute presentations, but we also have a GP as well, and we have ability to prescribe refer and to develop ongoing care pathways. 

[00:13:28] Dawn: And how long has this been going on, your MDT? 

[00:13:32] Simon: So this was developed in 2015. And since we've grown in strength. And it's very popular with patients for that. Purely to be seen on the day.

[00:13:41] And it has at first taken a lot of a strain off, off the GPs. However, since COVID we are seeing a lot more presentations across the board. And we are having to, we've had to increase that team and the hours available to manage our on the day demand. 

[00:13:58] One of the main things for the team is retention. I'm not sure if you've seen it in your team post COVID with a high turnover of staff being burnt out. And one of the main focuses for me as a team lead is retention and supporting as well as growth and investment in that staff to support them with their care. 

[00:14:20] Dawn: Absolutely. I think that's so important. Isn't it? And what kind of things do you have in place to support your staff and to maintain retention? 

[00:14:29] Simon: One of the things doing, doing urgent care day in day out is, is, is quite a challenging role. And One of the things I've put in place is a secondary role. So each team member has a secondary role, so it's an area they take responsibility for.

[00:14:43] So thinking of advanced practice pillars, one of the areas is a leadership and management side. So we, for instance, one of my team members is, is lead for research and she will take the lead on any new research coming into the practice. This gives us enables me to, um, and support for her to go off and do the research because ultimately it's going to benefit our patients and our group as a whole.

[00:15:07] So having these extra roles, it just takes the time off, as I put it, the front line, just allow them to develop and, and to develop in a in ways which will actually benefit everyone within the group. 

[00:15:19] Dawn: Absolutely. We've got something in Southwest London that's for all allied Healthcare Professionals and ARRS Roles and Practice Nurses. It's a coaching free coaching for AHPs. And yeah, and for the ARRS and GPNs. You get six sessions and it's for you to use as whatever is best for you. So you could use it for thinking about professional development. Or just being able to, if you're thinking about changes in your day to day career, but also just to help to process things where you might be feeling burnt out, or self care and I think that's been really positive. 

[00:15:56] And for people in other areas, I'm sure that coaching is. available for you in various ways. So do contact your ICB lead to ask if there is any coaching available for you but in Southwest London, you'd go into the integrated care support services website but that, that kind of thing should be available and is really positive for retention.

[00:16:18] Simon: I think so. That sounds, sounds a really, really positive step forward. It's having, you know, having that support of others in the, in the greater team and to keep the, the good quality staff in the workplace. 

[00:16:31] Dawn: And I think that's, and I will pick this up again later with our next topic, but I think teamwork and supporting each other is, it's a game changer and it, it changes the whole work environment. And I think it can really change how you feel as a healthcare professional. 

[00:16:46] One thing I also wanted to mention is that we've got and I'm sure this is going on around the country as well but in Southwest London at the moment, we've got a webinar next month, which is talking about multidisciplinary teams and best practice. Multiple disciplinary teams across care homes and within primary care.

[00:17:05] And that's a bit of what you were talking about as well, Simon, of how can we share best practice? I think it's quite easy just to, especially as we were talking about earlier with a lack of time, it can be easy just to keep your head down and keep cracking on rather than sharing with each other at different meetings and in peer support groups and forums.

News: The Lucy Letby case - implications for healthcare staff

[00:17:25] Dawn: So a new story that I wanted to talk about today that I have found has really struck me over the last year has been the Lucy Letby case. And I just thought I'd give a brief recap to start with of of what the, the case was and then we can talk around it. 

[00:17:43] So Lucy Letby was a nurse. Perhaps I just want to also say that this is, and I'm sure most people know the story, but it's quite an upsetting case as well. So it's just worth giving a heads up about that. So Lucy Letby used a variety of methods to secretly attack a total of 13 babies in the neonatal ward at the Countess of Chester Hospital between 2015 and 2016.

[00:18:11] She's since been found guilty of seven counts of, of murder of seven babies. And it was first noted by the doctors at the hospital when they began to see a significant rise in the number of babies who were dying or unexpectedly collapsing. They were unable to find a medical explanation, and so the police were alerted and an investigation followed.

[00:18:33] And so this came into the news last year around the summer of 2023 and the final verdicts were were returned in August 2023. So it's worth just saying to start with that this is, this is an utterly horrifying, tragic case. And I think in a way that's, that's partly why I wanted to talk about it because it can be so easy for these kinds of things not to be talked about amongst healthcare professionals.

[00:19:02] And I just thought it's really good to have to have a a space and a time just to just to speak about the impact that this had on us as a nation but also what the impact that it has on us as healthcare professionals. And we also just want to say that our thoughts are with the families of the victims and all that they've gone through.

[00:19:20] Simon: Yeah, absolutely. Horrifying case. And I think one of the main parts, as you've mentioned, is, is the, the trust in healthcare professionals. You know, you, you're taking your, your sick children which is a very difficult time anyway, to a place where you consider them to, to get better, to see the most trusted people and unfortunately, a massive abuse of trust which not only for those, For victims and the families, but also for the other healthcare professionals who are there doing a fantastic job.

[00:19:53] Dawn: It's an erosion of trust, exactly as you say, between between healthcare professionals and for the patients, for the babies themselves, and then for the families. It's just, it's unthinkable. As you say, for, for those who should be the most trustworthy. And time and again in groups that I'm in, when we talk about why we came into the profession that we're doing, it's because people want to help one another, because they want to support other people, because they want to walk alongside and empower others.

[00:20:25] And you know, at the very centre of the code of conduct for a nurse is a responsibility to do no harm. Lucy Letby has just gone against everything that it stands for to be a nurse, to be a healthcare professional. 

[00:20:42] Simon: I think this has massive ramifications for all healthcare workers and not just in this case, but we've seen other cases where patients have been assaulted. 

Enabling Whistleblowing

[00:20:53] Dawn: Another issue that this brings up also is whistleblowing. In just thinking around whistleblowing, that patient safety is everybody's responsibility. And I, I think it's really important that we create a culture of openness and transparency and not a blame culture. It's important that we can speak up when something's wrong and identify and address risks to patient safety.

[00:21:20] And I think it's important that we can do that as an individual. It's also really important that an organization creates and maintains that, that culture as well. 

[00:21:30] Simon: I think this gets back to your point from earlier about about the teamwork and supporting one another and, and certainly for instance, as I'm sure you're aware or work as well, it's sometimes be very isolating working in in your room all day and only seeing people at breaks, if you get breaks. 

[00:21:46] So it's knowing what how people are in themselves. Are they acting normally? Are they well? Are they unwell? 

Supervision & Support- lacking?

[00:21:53] Simon: But also one of the big things around here is about supervision. It's starting to be really emphasised with new supervision courses. And I think it's very important to have in that team to have that structure of, of supervision. And we're not talking about looking over people's shoulders, what they're doing or not doing, but also their, their holistic care of that practitioner and supporting them. 

[00:22:13] Dawn: Absolutely. I think clinical supervision is key.

[00:22:17] And I think also being able to have a colleague that you can go to and say, can I just run this past you? And a culture where you can ask for second opinions and also where you can in a, you know, not, not in a confrontational way, but where you can ask each other, are you sure that that's, the way that it should be done or you sure that's, you know, let's come back to best practice. Let's come back to the guidance. And so I think regular training is really important as well. Updates, working alongside each other sharing best practice and um,

[00:22:51] Simon: one of the ways we, we, we kind of manage this, we, we started to have coffee break discussions where usually twice a week someone will bring up a case, clinical case and we will discuss it and, and it's a a very open, this is what we had, this is what I did and what's your opinions, and we kind of learn off each other. So it's that chance learning, and it's about having that, that discussion and, and, and being quite open but also, as you mentioned, having that ability to have that, a bit of advice and being, being open, but not everybody knows everything. 

[00:23:22] It's such a gray area, isn't it? Primary care and it's we don't have all the diagnostic equipment to hand. We, we have hopefully a good set of communication skills, the ability to take a decent history and and a very basic observation and examination tools.

CPD, appraisals and always learning new things 

[00:23:39] Dawn: Also, just to build on what you were saying there, we're, there's always scope for all of us to continue learning and to continue to improve our practice. And it's really important that we don't get stuck in a rut and that we are open to new and better ways of doing things.

[00:23:56] I think for nurses. To revalidate every three years is actually really valuable for that because every three years you're looking at you know, how many hours of CPD have you done in the last three years and how you can reflect on that. As a paramedic, do you have something similar to revalidation?

[00:24:13] Simon: No, we don't. 

[00:24:14] Every year the HCPC sends out and we have to, we have to verify that we are still Competent and we are achieving. However my, my wife who's a midwife by background, going through her revalidation and having nurses on my team, which I've gone through as well, I think it's a, it's a good system. Although at times I think it can be very labor intensive when you're doing a full-time job. I've brought in using the 14 fish which is a appraisal and portfolio tool to support all within the team. There are revalidation tools on there for the nurses as well, which they can use to support with that and to hopefully make things easier and save some time because as you know, firsthand, it can take a lot of time at home to complete.

[00:24:59] Dawn: Absolutely. And I think another kind of feedback mechanism also can be with annual appraisals. And that's a brilliant way to, to feed back to colleagues and with using things like 14 fish or survey monkey. What, what are our colleagues doing well? How can we encourage them? And also what could they be doing differently or better or where is there room for improvement?

[00:25:22] Simon: Yes, absolutely. The you know, the 360 appraisals are a bit of an eye opener. So you look at thinking about academic models, like the Johari's window of not knowing your blind side and not knowing what you don't know, et cetera, and having a 360 appraisal can identify and open up these areas and, you know, your strengths and weaknesses and perhaps things to, to, to work on, I think are invaluable.

Whistleblowing: moral duty

[00:25:46] Dawn: I think something also that's worth talking about here is just is, is whistleblowing and thinking about how we respond if we are concerned about somebody else's practice. and the importance of responding. I think sometimes whistleblowers can be perceived as troublemakers, or they're not towing the line, or they're not doing what they should be doing, or they're, you know, destabilizing targets.

[00:26:17] But I think, and I think sometimes you can think, a person might say, you know, I don't want to cause any trouble. I don't want to make this situation difficult. But actually, it's coming back to the importance of raising a concern and doing that. Don't wait for a problem to develop. But this is following RCN, Royal College of Nursing guidance.

[00:26:40] If you see poor care or feel you're being prevented from providing safe. or compassionate care, you should raise your concern as soon as you can. And I think also when we do raise a concern, often, you know, nobody's got the full picture. All we've got is what we've seen, but it could be that I raise a concern and actually 14 concerns have already been raised about this particular person, and what you're doing is adding to the fuller picture, and then you think about how many people have not raised concerns to do with that case that actually would have been really valuable.

[00:27:17] Simon: Yeah, I think it's, I think it's your duty, isn't it? As you just mentioned, it's, it's, it's getting all those, all those pictures together. And when we look back at going slightly off beast here, but you look back at some of the, the, the child abuse cases and stuff where healthcare professionals have not joined up all those pieces. And if they had, they would have perhaps the results would have been a lot different. So I think it's a duty to, to a whistleblow and you can do this in many different ways. But it's ultimately having the, having the sense of duty to step up and actually say, no, this must stop or something's not right here. And having that conversation with, with, with your line manager or team lead and trying to identify things early before they, before they get really bad and, and, and trying to support with a solution. 

[00:27:57] Dawn: And all employers should have a formal policy for raising concerns, which you can consult for guidance on how to raise a concern in the first instance.

[00:28:08] And the policy should also detail with who you should raise your concern. You can usually do that verbally or in writing. and really important to keep records and notes throughout the process of the issues that you're concerned about for future reference. 

[00:28:27] I think that word duty is a really important one that all NHS employees have a contractual right and a duty to raise concerns with their employer that they consider to be in the public interest.

Martha's Law

[00:28:39] Simon: The Martha's Law is interesting. Asking for a second opinion. There was something in the news today. I read, I read the news online about some alleged protests from healthcare workers in a hospital saying how time consuming this was and et cetera. I think that's probably a minority there. And I, I think having. The ability to kind of get in that second opinion, and there are teams out there who specialize in that second opinion within healthcare, trust, secondary care units.

[00:29:18] Dawn: And now there's been so much press about this that I think people are much, much more aware that they can ask for a second opinion.

[00:29:26] But I think it's, it's very difficult, or it can be very difficult if somebody is under confident and and as we talked about before, putting your trust in healthcare professionals. But it's exactly that, that we are within our rights and that all patients are within their rights to ask for a second opinion. Yeah. 

[00:29:47] Okay, Well, I've really appreciated chatting through some of these issues and stories, Simon. It's been really valuable just to sort of air them and, and talk around them and, and think through the effect that this has on us as healthcare professionals. 

Final comment

[00:30:03] Simon: Yes, it's, it's great. It's speaking to, speaking to yourself who works obviously in a different part of the country and, and just having a You know, getting some insights and but these are all very valid areas and points and and effects, everyday practice in primary care.

[00:30:17] And I think it's important to, to have that ability to discuss with colleagues and to bring some of these quite sensitive subjects. And looking at the, the media and how it portrays primary care about having the ability to discuss the positives behind it and and look at some of the potential solutions to fix it.

[00:30:33] But it's, it's all about having that discussion. 

[00:30:36] Dawn: Yeah, and I think a big thing that's come up from today is the thinking about the teams working together, supporting one another, looking after ourselves, but also having a culture where we can ask questions, where we can learn from each other and share best practice.

[00:30:57] Simon: Absolutely. You know, we, we've all got different backgrounds. We've all got different ways of learning. And we've all got different histories. So bringing it all together and sharing the, sharing the learning. 

[00:31:08] Dawn: Brilliant. Thanks so much, Simon. Thanks so much for listening, everybody. And we hope to be back with more of these podcasts very soon.

[00:31:18] Munir Adam: So the idea there was that we chose a couple of, uh, items that have been in the news, and we discussed it and expressed our views about it. That's all. It may well be that you have a different perspective on some of the discussion, or that there are other important perspectives. And that's okay. Really, the intention wasn't to try to provide a comprehensive analysis of anything, but really just to share how at least some people in the frontline feel about some of these issues.

[00:31:46] And we hope that at least some of it resonates with most of you. And better still, we hope that you've heard something that you can apply to your day to day work, either as an individual or as a group. You can, of course, let us know by emailing us, and you can also leave us feedback on Apple Podcasts and Spotify and other places, and share with us other news items that you would like us to cover in future, or just other topics, for episodes, as we plan for Season 3 that starts in April.

[00:32:13] And the next episode, which is the final episode in this season, will be a recap over the last year. How much of it do you remember? See you then. Keep well, and keep safe.

[00:32:24] Primary Care UK was developed by Therapeutic Reflections Limited to inform, educate, support, and unite the primary care workforce. Specifically, it is not for the general public or patients. All information and advice contained therein is time, location, and context dependent and is general advice only.

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[00:33:20] Thank you for listening.