Reflection

It’s been 24 Years………………………………….!

The last time prior to this crisis I did anything close to being useful on a ward was 24 years ago. 4 weeks ago I was back with a ward team. I wanted to reflect and share some thoughts as it might help a little with the conversations that are already happening around rehabilitation, silos of practice, the future, patient cohorts and Physiotherapy in general.
 
When I turned up to the ward I was assigned to, I have to say I was nervous, thinking ”I am so out of date!” However, good support, a drag out of the memory bank and some common sense and I made a start. Quite quickly, in the days following, the ward was 90% COVID-19 +ve and although this changes your thinking, it didn’t detract from the job in hand.
 
What I quickly began to see were that patients in these scenarios, the frail, fractured hips, complex multi-morbidity and COVID-19 symptoms, needed to be approached with the model of what some may consider basic function: sit and reach, turn in bed, sit to stand and reverse, standing safely, weight transference, walking with and without support. The clinical reasoning really underpinned building these “basic” life functions into a fatigue resistant, safe and successful model but, most importantly, in a bespoke way towards their own social and medical needs. What I quickly realised; the assumed “basics” are complex.
 
Using ADL (activity of daily living) equipment with grounded clinical reasoning behind such choices, understanding the home situation and the context of the patients’ lives were vital in working towards the “basic” goals. Although these “basic” functional tasks are static in someways, the way they are approached from a therapist perspective is complex, due to the fact that they really are so person/life/home/socially centred. The patients’ perception of themselves and their situation leading the narrative around what might be possible is a communication challenge, and one that had to be undertaken sensitively at all times.
I reflected this reasoning experience against my own practice. Firstly, it really emphasised the over complexity that MSK practice may make on a number of presentations that are seen within the general population. The close scrutiny of identifying muscular imbalances, “weakness”, inhibition, “dysfunction” have been challenged of late as not being a valid, reliable observation or even an entity. Although, I am sure there is a debate to be had here, what is not, in my mind, is the validity of a patient not being able to achieve life functions. So, I once again had a really good rebalance of getting to the root need of what might be a successful outcome for a patient before embarking on anything progressive.  Basic loss of function and the mechanisms around that achievement underpin the complexity of reasoning. Multiple causes, medical, social, emotional, biochemical, pathological in multiple domains and relationships lead to the observations we see. As we try to “analyse” this, much of it is beyond what perhaps is possible, but what we can do is look to resolve a persons clear lack of capacity in a simple but broad way using multiple methods as appropriate.

 

This requires looking outside of our normal MSK pathways of practice as well as utilising the grounded skills we learned as new graduates as part of our early rotations and wider experiences. One problem is that using a linear model of practice fails in the multi-morbidity model of population healthcare. As part of my work in First Contact Practice I cited system knowledge as a key element of requirement needed in primary care, and this was not only biological systems but health systems as well, including the knowledge of how the system offers care in the widest sense to serve our patients as effectively as possible.
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So, to my second point of reflection and the thorny subject of the Bio-Psychosocial approach and all its interpretations. My experience made me really think about the word social” in the context of MSK and also from the ward/community rehabilitation context. Many times early in my career, I tried to understand MSK patients’ social elements as sports, interests, work, hobbies etc. then as my knowledge and experience developed, I sought to understand the person perspective, values, beliefs based on their lives, interactions, culture, expectations and this proved valuable and much has been cited around these constructs. But in the context of ward to community rehab, I realised that the word “social” also links to the care sector, and this was an area I knew very little, if nothing about.
How the care sector operates and works, the pathways, the potential support available were all new processes that I had not taken into account at really any level other than a low level of understanding from working in primary care. This network is VITAL in the future planning for these patients, and although I was OK (just) on the wards it was in this area I was of little benefit.
Therefore, opening up the word Social in the BPS model for me now needs to include a knowledge base around health AND SOCIAL CARE. I wonder how many of my MSK colleagues can truthfully say they know the local social care network well enough to give good advice but also link into really widening the support systems that patients will need to attain the “basics”. So in this context attaining the Basics is Complex. If anything I am now consciously incompetent in this area which is a move forward from where I was previously.
 
We might be great in MSK at giving a range of progressive knee and shoulder exercises, but contextually, is this the rehab that meets the patient needs or are our heads slightly in the sand here in the current climate? Is exercise on its own really enough? If we are working much of our practice in a digital way, then let’s use this opportunity to offer the widest health and social support we can. I believe that the broad skills of our profession are ideally suited here as our community colleagues can provide huge value and support in determining the development of practice. Let’s really drive down the barriers and get integrated where we can, not just an MSK pathway in a linear way, but broadly across the health and social care sectors.
 
I know that there have been challenges where physiotherapists are accused of lacking exercise prescription skills within certain cohorts of patients. I would now start to argue that if this is so we can improve that very easily, but where we can really have a significant impact is around supporting the needs of the population suffering in this crisis. Perhaps, at this moment, we need to judge that the low level MSK aches and pains that we have seen in the past is just not a priority.
 
My third point therefore is around silos of practice. Not in MSK as such, but in truly integrated care for patients in these situations and in this crisis. Is it time to reconsider how MSK practice in the NHS is really utilised and what skills in the future are going to be important for the populations we serve? My MSK team have been amazing in redeploying (as many others have) across frailty, community services and ward support. The learning after this will be so rich, we must take this opportunity forwards into the future.
There is much learning to be had, but to start that, questions need to be posed. These will inevitably be tough questions around using resources wisely. So, is MSK an independent area of practice when it comes to rehab or should we be better at using our broad skills to approach MSK, frailty, pulmonary rehab, community enablement, social care referrals in one hit? Time to stop moving patients about and perhaps reconsider rehabilitation in its broadest sense possible? Where can really impact the NHS Long Term Plan? We have directors of Nursing and AHPs leading the professional line, we have Medical Directors as well. There is no better time to consider the need for Directors of Rehabilitation that have a focus in community, public health and rehabilitation across all domains?
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So, lastly what is expertise going to look like in MSK in the future as a result of what is happening right now? I don’t know, but my experience so far would suggest that we need to serve the population right now and in the immediate future. I am less confident that we need an in-depth knowledge of the rotator cuff, transversus abdominus, or best surgical approaches for traumatic knee injuries. In my opinion, we need expertise in multi-morbidity rehabilitation, with a focus on MSK, but integrated as part of “life function rehabilitation” that sits alongside an improved knowledge of the “social” element of care at its broadest and supportive context.
Defining MSK expertise differently from knowing all about the possible surgical options and high performance level/elite principles as opposed to knowing more about social care options may not look quite so jazzy and expert, but right now it’s a whole lot more useful to the folk that really need our help.
 
Can we ready ourselves for this? It can only make MSK practice more valuable to the population we serve if we do embrace this knowledge and perspective.
 
How we will understand this will be an iterative process, and it will require commissioners to think differently, STPs to work far more rapidly and the profession to see MSK Physiotherapy as integrated and not separate from our ward and community colleagues.
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It has been humbling to see the work, contributions and support our profession has so far offered, but perhaps there is even more to come.
 
Thanks to all!
Neil Langridge
Consultant MSK Physiotherapist

Reflections on Knowledge and engagement with the Other

I feel very lucky and privileged to be a Physiotherapist. Physiotherapy, a profession that encompasses many dimensions such as clinical, educational, leadership, consultancy and research but most importantly, as a group of responsible people who engage and supports Others.  It is with this in mind, at this most challenging time, that I reflect on my journey with my profession and how I value others.

I was very fortunate to meet Dr Filip Maric amongst a number of inspiring people including Joost van Wijchen, Laura Rathbone, Els Lamers, Ann Gates and Vincent Bastiaans at HAN University as part of an International week.  It was a wonderful visit that both stimulated and challenged me.  During many conversations, I was struck in particular with Filip’s area of interest of fundamental ethics, particularly from the viewpoint of Emmanuel Levinas and I would like to thank Filip for introducing me to this.

The ever-growing fountains of knowledge:

Physiotherapy, as a profession, has grown in its wealth of knowledge with an ever-expanding research base.  An area of interest of mine is how to consider this wealth of knowledge and apply it, in the best way, for the individual person or group of people.  Most of my focus is usually on individuals due to the nature of my job but I recognise that population health is of the utmost importance.  For the purposes of this post, I would like to focus on the care of individuals.

The field of philosophy examines the assumptions, foundations, and implications of science, as well as the manner in which it progressively explains phenomena and predicts occurrences.  I believe now, perhaps more than ever, that science and the humanities are both of equal importance within the context of growing knowledge and technological advancement.  Kerry, Maddocks and Mumford (2008) made a very clear point on this over a decade ago.

How might we understand knowledge and unpack it?

I often refer to Aristotle who describes knowledge as episteme (knowledge as fact), techne (knowledge as craftsmanship) and phronesis (knowledge as wisdom; to do the right thing at the right time, in the right context).  This can be unpacked further but it is clear that knowledge that is viewed in this way is complex and dynamic phenomenon.

If we look at knowledge as facts, it could be seen from the viewpoint of science.  Science attempts to discern objective, concrete and universal knowledge, often through repeatable and measurable ways through the use of our senses.  For science to be taken seriously, it has to rigorously test hypotheses, often through failure, in order to make advancement.  However, the scientific lens may not unearth all of the areas that Aristotle refers to and it may assume that these universal laws are applicable in every context.  This philosophical bias (Andersen, Anjum and Rocca, 2019) may, for good reason, emphasise carefully controlled studies over other methods to minimise contextual or confounding factors in order to establish a truth without bias but in doing this, possibly risk missing the very elements that may be of importance (Kerry, 2017).

Knowledge that is seen as craftsmanship or wisdom, by its very nature, is inherently value laden and embedded within a social context.  As such, knowledge does not exist in its own vacuum and therefore, is not complete without a way in which it is applied in the real social world.  In Physiotherapy practice, it makes sense to me that the ethical position on how we apply this knowledge is of prime importance.  The judicious use of knowledge requires the application of its multiple sources to be grounded within an ethical framework in which it is delivered.  Tonelli (2010) makes the compelling case that clinical research, pathophysiologic rationale and clinical experience are all required to make sound judgement in a casuistic way for the individual case.  This multi-dimensional perspective of understanding knowledge, amongst many reasons, may be why knowledge translation is challenging.  Added to this, the consequences of certain philosophical biases that are incorporated into practice underscore the ethical nature of Physiotherapy practice, thus calling forth the need for a deeper understanding of human beings embedded within their socio-cultural contexts within the complexities of health care.

To summarise, I believe that knowledge is complex, dynamic and context sensitive.  Therefore, a number of viewpoints or lenses are useful in order to make sense and apply this knowledge.  Knowledge from science and the humanities are both important in order to apply it in the real world.  The application of this knowledge, therefore, must be grounded within an ethical framework that is coherent within its setting.  In this case, within Physiotherapy, I argue for a humanistic framework which leads us to a philosophical perspective of Emmanual Levinas and the fundamental ethics surrounding Others.

Levinas and the Other:

Filip Maric and Dave Nicholls wrote a paper ‘The fundamental violence of Physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for Physiotherapy theory and practice’.  The paper briefly introduces the background of Emmanual Levinas of which I will summarise below.

Levinas was born in 1906 in the Jewish community of Russian-occupied Kovno (now Kaunas, Lithuania).  He went on to study philosophy in Strasbourg where he read classical philosophical works from Plato and Other Greek philosophers through to Descartes, but also modern philosophy.  Subsequently, Levinas studied under the famous phenomenologists Edmund Husserl and Martin Heidegger, who were significantly influential in the development of his future method and thought.  The influential tensions that Levinas experienced during the Second World War alongside Heidegger’s affiliation with the Nazi party strengthened his insight towards an alternative fundamental ethical way of being that contrasted with the phenomenological focus on the self.

Much broader, Levinas felt that much of Western philosophy tended to subvert the ethical relation to the other by placing persons within the unifying system of ontology (the nature of being), hence denying persons their right to be themselves or their otherness.  The inherent tendency of a culture based in a philosophy that seeks to overtake a person’s otherness into the same as themselves is one of power, control, oppression and even tyranny.  Levinas makes a phenomenological claim that an ethical relationship, which is founded upon respect for the other’s radical alterity (or difference), exists prior to the ontological relationship, which is based on knowledge and comprehension of the other.

Put in another way, one’s relation to the other is the foundation of human knowing, not the other way around.

When I encounter someone else, I experience a difference between the other and myself. This initial difference is the first moment in ethics, in the acknowledgement of another who obligates me. The foundational nature of the ethical relationship is one that may be neglected in Western philosophy and its branches. The influential work of Heidegger, for example, treats ethics as secondary to ontology (the nature of being) and epistemology (the nature of knowledge).  Levinas suggests that it is the ethical perspective, in the experience of the other, that should be the norm, and that this creates the standard to which other Western philosophical perspectives are seen relative to.

“Indeed, the objectifying thematization inherent to the Western logos as ontology does not do justice to the way in which the Other exists. The only adequate response to the face is my being devoted to the Other. If I reduce the Other to an interesting topic for my observation or reflection, I am blind to the claim that is constitutive of the Other’s coming to the fore.” (Peperzak, 1997, p. 34)

Simply put, the implicit use of objectification that is dominant in Western philosophical reasoning does not do justice to others.  Rather, in Western philosophy, if we attempt to reduce others to our observations or reflections of ones-self then we are at risk of causing potential harm to others.

Emmanuel_Levinas

What implications might this have for Physiotherapy?

Although I have not read around a large amount of Levinas’ work that would place me anywhere near as an expert, the reading that I have done has resonated.  Levinas’ work calls forward the need to embrace diversity, cultural and social differences.  It engenders a mind-set change to hesitate and consider others first and foremost.

In clinical practice this elevates communication and interpersonal skills as a priority because it is through our embodied way of understanding others that we seek to appreciate and comprehend through sense-making, on an equal footing, with others.  We, as clinicians may have knowledge of the body, of physiology, of anatomy or whatever, but first and foremost we are people making sense of each other with the acknowledgement that, in our difference, we are both human beings with different sources of knowledge and experiences.  In all cases, my patients are far wiser than I am, in many ways, but certainly in regard to themselves.  This nurtures a sense of epistemic humility, for example, I could have a huge amount of knowledge and understanding around the latest randomised controlled trials, systematic reviews, narrative review and qualitative papers surrounding a condition like low back pain, but unless I am able to engage and understand others and placing themselves first within the clinical encounter, the sense-making process of each other will be lost.  The inter-subjectivity, or sense making process, using body communication, language and insight to the other uplifts the therapeutic encounter.  A genuine curiousness of the other places them truly at the centre of comprehension that comes before all considerations of being or knowledge of the condition that the other person presents with.   Carl Rogers, the American Psychologist, embodies this perspective in his book, ‘On becoming a person’, wonderfully:

“…I find that the more acceptance and liking I feel toward this individual, the more I will be creating a relationship which he can use.  By acceptance I mean a warm regard for him as a person of unconditional self-worth-of value no matter what his condition, his behaviour, or his feelings.  It means a respect and liking for him as a separate person, a willingness for him to possess his own feelings in his own way.  It means an acceptance of and regard for his attitudes of the moment, no matter how negative or positive, no matter how much they may contradict other attitudes he has held in the past.  This acceptance of each fluctuating aspect of this other person makes it for him a relationship of warmth and safety, and the safety of being led and prized as a person seems a highly important element in a helping relationship.” (Rogers, 1961, p. 85)

Levinas and the face to face encounter

Levinas felt that the human face was of fundamental significance in encountering others.  The face is not considered as a physical or aesthetic object.  Rather, the first, usual unreflective encounter with the face, is as the living presence of another person and, therefore, as something experienced socially and ethically.  The face looks towards others, which both at the same time overwhelms and resists the existential experience of the human encounter. If one refuses the existence of the another’s face, it causes an overflowing experience that calls to the other in a fundamentally moral way.

Levinas insists that science, technology and other theoretical systems of knowledge cannot function independently.  Human existence does not form the basis of knowing in and of itself. Rather, ‘‘…it is the epiphany of the Other’s face and speech rupturing the homogeneity of my universe and breaking its totality’’ (Peperzak, 1997, p. 12).

Modern technology, however, has allowed novel forms of interaction that have permitted clinicians to see others at distance.  During the current Covid-19 crisis, the use of video consultations has transformed the usual clinical encounter.  By seeing the other, in their own environment and communicating as if one where with them has been a revelation.  Those, like myself, now find the telephonic clinical encounter distancing, devoid and stale in comparison.  One can truly see that the healthcare encounter has forever been changed as a result.  The new telehealth system of care will bring both excitement and scepticism resulting in both revolution and disruption. Only time will tell how the future landscape of Physiotherapy care will end up.  Either way, how the profession evolves through considered conversation with others both within and outside of Physiotherapy will determine its own future success.  Educational institutes will have to adapt as well, once again, highlighting the importance of person-centred communication and ethical considerations causing us to hesitate on our own traditional practice and hubris.

The recent months have indeed caused me to seriously reflect on the Physiotherapy profession and perhaps, if you have managed to get this far, I hope this blog has created a space for you to reflect.  Once again, I would like to thank everyone that attended the HAN International learning week that triggered my thoughts.  If there was any time to consider others, I think the time is now. Please, continue to be kind to yourself and more importantly, others.

 

References

Kerry R, Maddocks M & Mumford S (2008) Philosophy of science and physiotherapy: An insight into practice. Physiotherapy Theory and Practice. 24:6, 397-407.

Laplane et al (2019) Why science needs Philosophy. PNAS 116 (10) 3948–3952.

Andersen, Anjum and Rocca (2019) Philosophy of Biology: Philosophical bias is the one bias that science cannot avoid. eLife; 8: e44929.

Kerry, R (2017) Expanding our perspectives on research in musculoskeletal science and practice. Musculoskeletal Science and Practice. 32. 10.1016/j.msksp.2017.10.004.

Tonelli, M.R. (2010), The challenge of evidence in clinical medicine. Journal of Evaluation in Clinical Practice. 16: 384-389.

Maric F and Nichollls D (2019) The fundamental violence of physiotherapy: Emmanuel Levinas’s critique of ontology and its implications for physiotherapy theory and practice. Open Physio Journal.

Peperzak, A (1997) Beyond – The Philosophy of Emmanuel Levinas. Illinois: Northwestern University Press.

Rogers C (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. Boston: Houghton Mifflin.

“Tis the season to be jolly”

A couple of thoughts about this year and the year ahead for MSK Physiotherapists

by Neil Langridge, NHS Consultant Physiotherapist

At this time of year it’s a great time to look back as well as looking forward. To do this personally and professionally I think is a great way to re-set the scene for oneself, and it also to develop goals and aims for the coming year. I like to look back at the previous year, and this year in particular I think has been a shift in the MSK world that really we should be “jolly” about as well as mindful that there is so much work ahead for the profession.

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There have been some real advances in what might be available for the physiotherapists of the future. Advanced practice has really taken off, it’s just the start but there have been some enormous leaps forward. Work developing the “Multi-professional  framework for advanced clinical practice” although published 14 months ago, will certainly begin to influence many opportunities for physiotherapists and AHPs. This is now driving advanced practice models such as the apprenticeship model which was approved in 2018 which will see employers, Universities, and clinicians working together to gain improved care, careers, and clinical practice.

Education

First contact work has gained further credibility with more data, more service transformation and courses being developed in Universities to support this work. It has seen its own framework underpinning it, data tools to help monitor it, cost calculators to help plan for it as well as clinicians coming together to help drive it. Health Education England working with partners in NHS England and the CSP have driven this to the table where STPs (Sustainability and Transformation Partnerships) are discussing it as part of remodelling and CCGs were mandated to provide pilots across England.

These pieces of work were well presented in the fantastic piece of work “AHPs into Actionand this document will help continue to inform how AHPs can continue to re-design and transform. Physiotherapists within the MSK field were used as examples in this document and once again highlights the national profile of what we do and can do.

The NIHR document “Moving forward – physiotherapy for musculoskeletal health and well-being” highlights some of the wonderful research that has led our practice and continues to inform the future.

Whether you agree or disagree with the messages the CSP have been driving many new initiatives in the promotion of the profession and activity. The wonderful campaign video that supported “Rehab matters” was very well put together, and really emphasised the need for rehab to be at the heart of our medical futures and values. The “Love activity, hate exercisecampaign had some controversy but it certainly once again brought home the importance of activity within our communities. PhysioUK 18, was in my opinion, a great success and was sensibly priced to encourage those who had not networked and gained CPD at this event in the past, the opportunity to experience a varied and interesting programme.

At a more local level, the” BigRs” movement continues to create conversation and developments. I have been fortunate enough to attend these, speak at them and also be part of the ongoing strands of work around trying to help develop the profession. I really like this model of critical enquiry, development, and challenge, but it’s done in such a way it encourages those involved via the winning of hearts and minds, building a model around respectful dialogue and leaving emotion and personal conflicts at the door. The “Physio Matters” team and “Connect Health” should be congratulated on their work so far with this and I look forward to the future work from this group.

From a personal and professional point of view, I am aiming to try to see how our MSK team can start to impact on the health and well being of the population we serve. Our main challenges this year are to try to improve our public health outcomes, look to engage with schools, local community groups and just widen the impact of physical exercise and good health models for our communities. This is something I am particularly looking forward to. We also have the challenges of supporting staff in tough environments; we have therefore looked to support staff at MSc levels, build improved local educational opportunities, seeing staff progress into specialist roles.

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I am looking to drive a Band 8a clinical lead in physiotherapy only, not as an Orthopaedic triage specialist, but as someone totally focussed on rehabilitation. I have witnessed these discussions across SoMe and want to act on them within my service. We have a Band 4 sports rehab role near ready to be advertised, this is something I am really keen on, the old style remedial gymnast, leading some of our classes and using skills in class taking and rehabilitation to complement what we do across all the services to de-medicalise where appropriate and where we can. The changes in CCG directives in many surgical options means we as a profession are ideally placed to resolve these lines of practice, it will be a matter of getting houses in order to achieve this.

These initiatives have been massively helped by the information I have received on SoMe and the discussions have prompted my local conversation, driving plans for 2019, so thanks to those I have learnt from.

I am looking forward to seeing the HEE funded FCP e-Learning programme to be completed. This was initially started by just asking SoMe colleagues for help and the interest and comments were staggeringly helpful. I now have an amazing team of contributors and all of the modules have a person-centred approach underpinning them.  The modules will, I think, be a valuable free to access resource. SoMe will be the platform to support its launch.

As in any reflections, there are concerns and worries, as it can’t be all “jolly”, things we wish we had done better, I certainly spend time thinking on this. I know we must continue to move forward and not harp back to historical philosophies.  We cannot ever really rest in developing an evidence-base that makes sense and change practice for the physiotherapists of tomorrow, in so doing, challenging the out-dated practice of today and consequently place our profession in the most professional light possible. I always look back in how I could have managed situations, people, working relationships and patients better and these are always my constant wishes to improve on.

The balance in being brave, critical and balanced in thinking whilst engaging change is a tough one to make, but one I will always strive for. I will continue in 2019, to push my service forward, see staff flourish, improve my own practice, be critical where necessary, and challenge those who I feel hold those processes back with personal, emotional views that inhibit the profession on the multi-professional and national stages. In my opinion being critical is an absolute must for development, offering an alternative view an absolute, but most importantly, do so in a way that commands respect from multiple perspectives through the skill and mastery of facilitating change that as a profession, I believe, we must develop further.

We have a fantastic profession and there are loads to be proud (and jolly) about, however, I don’t see things through rose tinted glasses, and I do know there are HUGE changes to make, but I still see the glass as half-full and I remain happy and positive (most of the time) about the future. In any culture there will be a mix of people and views, and I through 2019, will keep developing my knowledge of these, engage with those who offer different views, and challenge those whose values I just cannot find concordance with, as it is the professional values and behaviours of some that can at times influence the many. As well as being critical of the evidence base, I think the many should also develop and be confident enough to enhance critical enquiry across multiple mediums, sadly I know many who just feel inhibited through fear of reaction in SoMe and how they might be labelled.

So, in conclusion 2018 for Physiotherapy and the MSK arm of the profession has been a really advancing year in my opinion, there are loads to get involved in within the national new models of care, SoMe driven initiatives, evidence-based programmes, and local clinical practice progression, and so perhaps if you take those on they may aid your 2019 goals, like they have mine, good luck therefore with whatever you hope to achieve in 2019.

I wish anyone who is good enough to take the time to read this, my best wishes and kindest regards for the coming year.

Neil.