November 2000

  • Main Speakers :
    • Rita Stringfellow, Chair of the LGA Health and Social Affairs Committee
    • Dr Linda Paterson, Medical Director, Commission for Health Improvement
    • Donna Covey, Director Association of Community Health Councils
    • Prof Aneez Esmail, President of MPU
    • Dr Guy Roath, NHS Consultants Association

    Account of 4 Workshops on Participation, Local democratic accountability, Two sorts of accountability, and Delivering an effective service

Democracy in decision making: new roles for local councils

Rita Stringfellow, Chair of the LGA Health and Social Affairs Committee

First a little history. In 1974 local government had elected members on health authorities as of right. The situation was one mostly of war, as they were not accountable to the health authority board. The quality of information was very poor, even from the local authorities. The issues raised at the 1990 Socialist Health Association conference, particularly around regional government, have now been kicked into touch, but there is still the question of coterminosity, for example, the North East local authority regional boundaries as compared with those of the NHS Regional Office.

The modernisation agenda for local government came out very quickly after 1997 and involves promoting the social and economic well being of local areas. A range of local agencies will be involved, so local government can no longer be all-powerful, although it can hope to have influence. Local authorities will exchange the right of power for the reality of influence.

There will be an executive that is separate from scrutiny, and local authorities will take on the community leadership role within the planning context. This all fits in well with the new health agenda. But how does health fit in with, for example, HAZs, HImPs, the Listen Up campaign, and the work of the Audit Commission? Look at the Health Development Agency report on HImPs – the lack of coterminosity will become more complicated.

The flexibilities within the 1999 Health Act propose a “can do” mentality in place of a “can’t do” mentality. This is a contextual change, and the introduction of NHS Direct and other changes such as access to letters to consultants, hand held records, etc. will also change people’s expectations.

The NHS Plan.

Rita was a member of the Modernisation Action Team, on which there was much good will but not much knowledge of local government.

Local government did not want social care to be taken over by the PCTs, as propounded by the NHS Confederation. Health is not just about the interface with social services, but also with housing, education, community safety and others, and the message got through, although local government was not really seen as relevant.

At the launch of the Plan there was a very strong response to the abolition of CHCs. This had been kept under wraps until then.

The scrutiny role is seen as one of the most significant issues for local government in the Plan, along with putting patients first, (although perhaps this should have been putting citizens first?). Scrutiny and patient empowerment must be linked, but how will scrutiny add value? If we are committed to reducing health inequalities, this is acceptable, but not if it is just about exercising the power to call chief executives to account.

There is also an issue around the unequal allocation of health authority resources that is difficult to unpick. It will be helped if PCTs make the process more transparent, but they are not really up and running yet. For example, with regard to the money for winter pressures, Rita has had no reply yet to her October letter about how the additional resources were to be allocated.

How will scrutiny operate in local government? Local government must not lose sight of the work and expertise of the CHCs. These must be picked up. The baby must not be thrown out with the bath water. There are important issues to be addressed, for example, around patient empowerment, equal access to services, equity in resourcing, and the role of the community in giving evidence.

Should the committees be able to scrutinise regional ?? ?? (this is not in the Plan). This is happening now in Rita’s area, through a Health Select Committee. Scrutiny must be got right, and it must not be adversarial on either side, or else it will fail. Resources will be needed to train councillors, officers and other personnel. The likelihood of conflict is a potential danger, but all those involved must go back to first principles and forget their prejudices.

Also, scrutiny must be tied to NHS performance mechanisms. The duty of Best Value in local government is an important issue (insert the fours ‘C’s – challenge, compare, consult, ) for local government, and also at the health and local government interface. So we need to address all these issues across the health and local government interface and translate them from scrutiny into performance management.

It will take time to build up trust, and this should be an evolutionary process. However, we do not have the luxury of much time. Colleagues in health find it difficult to discuss difficult issues in public, and tend to sort things out before going into the public arena. In future, this sorting out will have to be done in public.

There is a lot to be sorted out but the Plan recognises for the first time that local government has a role in health. A tier of elected government in England other than in Whitehall will be involved in scrutinising the local NHS. This is a package of radical reform. It will enhance and encourage the involvement of citizens in redesigning the health service from the patient’s point of view. This is about changing the culture, learning together and listening together. We must dismantle the Berlin walls but not replace them with others.

PALS and Forums – what we could lose if CHCs disappear

Donna Covey, Director, Association of Community Health Councils of England + Wales:

Donna is concerned that the process has led to a sterile debate. This conference is a good opportunity to be positive.

ACHCEW is a statutory body and has an overview of the concerns about CHC abolition. However, Donna will not be raising the appalling way CHC members and staff have been treated in the process. ACHCEW is also not sniping from the outside. ACHCEW is engaged in debating issues around the Plan. However, there has been no consultation around the decision to abolish CHCs and ministers say that there will be no discussion about abolition, the subject is not up for debate.

ACHCEW had concerns when the Plan came out. Four months later there are even more concerns. There is a lot of good stuff in the Plan, and CHCs have said so publicly. The patient and citizen focus, and the increased patient representation throughout the system, have been promoted for years by CHCs.

CHCs are not defending the status quo. CHCs had previously prepared a blueprint for change, but the government did not grasp the harder nettle of reforming CHCs. This was a real missed opportunity, especially given the work CHCs have undertaken to modernise themselves.

The key concerns begin from positive principles. Donna recently attended a Four Nations meeting. The NHS Plan is very much an English Plan. In Wales the Assembly is about to consult about how to make patient empowerment work before it produces any plans for change. The Assembly is facilitating a full stakeholder debate across Wales to identify the best model for public empowerment. In the wake of devolution very different ways of handling these processes have emerged.

The principles agreed at the Four Nations for the new systems are that they should be:

  • independent
  • integrated
  • have statutory rights
  • service wide
  • be people and patient focused
  • representative
  • transparent
  • and have a national body to co-ordinate standards.

The proposals in the NHS Plan currently meet these criteria even less well than the existing CHCs, and modernised CHCs would meet them even better.

The proposals in the Plan are all right as they go but they are isolated and fragmented. If an over-arching watchdog were included, then these principles could be delivered.

What is missing from the Plan are independence and perceived independence, especially of the PALS and Patients’ Forums. PALS seems a bit on the “meet and greet” level. The debate around advocacy is different again. PALS should have a consumer services role. The Plan uses the word hospital and trust as interchangeable. But what will happen to serious complaints? Will they be left to the lawyers? What happens when things go really wrong and cannot be resolved on the spot?

PALS based in health service premises are fine for consumer issues but not for addressing serious problems. If the new systems are not perceived to be independent, then people will not come forward with their problems, the problems will not be identified and they will therefore go unaddressed. If the mechanisms are not in place, then there could be life-threatening consequences.

Integration: there is no system in the Plan to link all the new systems, unlike the CHC functions of complaints work, scrutiny, and inspection, all of which feed into each other. Who would be able to notice patterns of complaints and do something about them? This will not happen under the proposals in the Plan. People don’t talk to each other, however much they should be expected to. Scrutiny cannot rely on informal networks. Complaints can emerge around the whole patient journey. How will these complaints be linked up, and by whom? Major referrals and changes can go to local authorities, but who will pick up the day-to-day scrutiny role? And what about incremental service changes done by stealth?

Statutory powers: these will go to local government, but to who else? Will ILAFs just be sounding boards? Patient’s Charter, Patients’ Forums, and PALS can negotiate, but they will have no statutory right to achieve a resolution.The right to negotiate an agreement means nothing if you have no power.

Co-ordination and a national structure: there is a need for a national association like ACHCEW to do things like the nationwide Casualty Watch, and pull together local experiences to identify national trends – such as the Hungry in Hospital report. There are also issues around training, minimum clinical standards, and the same level of scrutiny wherever, that must be built into the system through a national body. These are some of the issues of concern.

Other issues: how will primary care, ambulance services, dentistry, pharmacy become a part of scrutiny and patient involvement? CHCs are not alone in questioning this. The BMA has a deep concern, as does the GMC, and the NACABx conference opposed CHC abolition. All these bodies argue for modernisation and modernised CHCs.

There is already an Early Day Motion, and now a another one from the Conservatives. Over 100 MPs, mainly Labour, have signed the initial one, including New Labour loyalists. They are especially concerned at the lack of public consultation.

CHCs and ACHCEW are not perfect but they have been constrained by a lack of government will to modernise them. There is so much radical work going on in CHCs that is not dreamed of in Milburn’s philosophy. Abolition is, in reality, now only three to four months away, with nothing concrete to replace the gap.

At last we have a government that is putting money into the NHS, so why this little nastiness? The public will have no voice in the interregnum between the demise of the CHCs and the introduction of the new arrangements.

We can develop an independent network of local bodies to deliver the Plan, and if the government is really serious about patient empowerment, it will enable that to happen.

Quality control as part of accountability, locally and nationally

Linda Patterson, Medical Director, Commission for Health Improvement:

CHI was set up by the Health Act. It is now one year old, and went live in April 2000. It is a non-departmental public body, independent of the health service and government, although publicly financed. It has 14 members, predominantly lay, from patients’ groups and the public, with a minimal number of health professionals. The executive are not members of the board, which demonstrates a strong commitment to the patient and public voice. The aim of CHI is to bring a demonstrable improvement in patient care, to make a difference.

It operates only in England and Wales. England and Wales have very different cultures, language, political processes, and CHI has to be sensitive to that.

CHI is the voice of the patient, is patient centred, independent and perceived to be fair. It wishes to be developmental and rigorous, not located at either end of these two poles. It recognises that NHS staff want to do their best but are very hard pressed and dissatisfied But CHI also needs to be able to say “this is not good enough”.

CHI is evidence-based, not opinionated. It is open and accessible, holds its meetings in public, has a website, produces hard copies of its reports, has a hearing culture, and as a new organisation is open to evaluation and public feedback. It must focus on the quality of care, not just the cost of care, just as trust and other chief executives now have the responsibility for clinical governance as well as corporate governance. This is the first time that the NHS has quality as a statutory function.

Many recent cases have damaged public confidence in the NHS, so CHI is timely. It considers performance variance in the NHS and also in access to services. The aim is to iron out some variations but also to engage in continual quality improvement, so it will not just concentrate on the worst performers. Everyone can improve, so the line will shift further towards quality.

CHI is aware of other players in the field, such as the HSE, the bodies responsible for training health care professionals, the NHS litigation body, the Audit Commission, and it must link into that network and commit to a two way flow of information and communications.

The work programme is:

  • clinical governance reviews of quality across the whole NHS
  • investigation of severe service failures, for example, the John Radcliff Infirmary report
  • national studies within the National Service Frameworks, this year concentrating on the Calman Kline cancer framework jointly with the Audit Commission
  • leadership in quality issues through the publication of guidance.
  • Major work – clinical governance reviews

CHI will look at NHS staff accountability for the patient care framework, including provision of a patient centred approach, up to date care, high safety standards, and constant improvement, involving an independent assessment of systems within the NHS and processes for continual review – seeking a consistent approach across England and Wales. CHI will also identify good practice and share it across the NHS. There is good quality work out there.

Three levels will be considered:

  1. the patient experience at the heart of care
  2. how the patient is delivered to the clinical teams
  3. the corporate strategy of management systems to support this delivery.

How will CHI get to the patient experience? CHI has piloted the use of patient diaries, questionnaires, observational studies, access, complaints, talking to advocacy groups and to individual patients. It is also looking particularly at how more marginalised, vulnerable groups can have a voice – and has a commitment to take this work forward.

Clinical governance reviews have started at the acute stage, and will be moving to primary care through health authorities and PCTs, then mental health reviews. CHI is working on a methodology. Ambulance trusts and specialist hospitals will come later, then the MoD, NHS Direct and other services, so the workload is expanding.

CHI will be looking at the components of clinical review, the process of patient care, the strategy, the culture, the use of clinical information, staffing, staff management, education and training – across all the strands. The first four reports are into the Southampton University Hospital Trust, North Norfolk Health Authority, Redbridge NHS Trust and Bedford Trust, which was brought forward because of concerns raised by the local CHC. It will be going to Poole, Nuneaton, and Chester, and then more will be announced.

The NHS Plan traffic light system requires CHI to review red light trusts every two years, and CHI is working out how to do this. CHI did not know that it would have this responsibility until the Plan was published.

There will be a 24 week cycle for each clinical review, involving a lot of preparation. Trusts will be asked to supply their existing data (which they often don’t use), then CHI will go in at a high level and do a hard quantitative data analysis. There will be trust self-assessment (including the health authority and PCGs in the area). CHI will then select two or three areas to look at out of all the information received – either very bad or very good areas.

CHI will select the team, set up common stakeholder meetings, including the patient and the public, the health authority, CHCs and the regional office, advocacy groups, carers and the general public, to discuss their experiences of the trust. They will validate individual views against trends, which is very different from the previous inspection methodology.

Site work will take about a week, with a multi disciplinary team from the health authority, again including patient representatives, all of whom will be carefully selected, trained and supported. The team will be led by a CHI review manager. Interviews and a lot of observation will take place during site visit. Verbal feedback will be given to the trust, followed up by a written report. CHI will ask for the trust to do some objective setting, prepare a detailed action plan, and report performance to the regional office.

The four reviews done so far show there is variation. Trusts may major on one area and be poor on others. There must be a board-led commitment to excellence, and CHI will be looking for evidence of board involvement, strong clinical leadership on the ground, patient input, and the impact of organisational change as a consequence of recent mergers, which is an issue that is emerging from reviews already undertaken. The importance of input from local groups, which produces invaluable information, is stressed.

There has been a lot of publicity this week, demonstrating that CHI can undertake investigations where concerns are brought to it, for example, around persistent failures. This is not the same as undertaking a review. The North Lakeland Trust was just such an investigation of the abuse of patients, in primary care, where a GP in Loughborough had been convicted of paedophile offences, and cardiac transplants at St. George’s NHS Trust.

CHI produced guidance to support North Lakeland, which highlighted the failure to ask for whistleblowers’ reports. Now there is a commitment to go forward. At Carmarthen there was a very good action plan, but it had not been implemented. This highlighted poor joint working following a merger, with different policies and agendas being followed.

CHI does not investigate individuals as procedures are already in place for that, nor one-off complaints, because that is the responsibility of the NHS Complaints Procedure, and CHI is not able to remove staff.

What to expect from CHI? It will be challenging, independent, fair, evidence based and focused on patient care and improvements, with a hope of achieving visible improvements. Delegates should invite CHI back to a similar conference to report back on its successes or otherwise in one or two years’ time.

DEBATE AND DISCUSSION

* Maggie Shineton: The demise of CHCs will leave nothing in rural areas to represent patients, so if an independent monitoring group were set up, would CHI recognise it?

* Dr Richard Taylor: Democracy is entirely disregarded in Kidderminster – is it our fault that CHCs are to be abolished because we gave the CHC money for a judicial review?

* Donald Roy: CHCs are not unelected. The relationship between scrutiny and the partnership role in local authorities offer scope for particular new problems, scrutiny must involve some criticism otherwise it will not be effective, but, for example, the ALG wishes to combine the provision of care with scrutiny.

Responses:

1. Linda: CHI cannot revisit configurations that have received the approval of the Secretary of State. It can look at the consultation processes, and transparency and whether the reconfigured services deliver good quality care.

2. Rita: Best Value reviews can be challenging, but there is no need to fall out, unlike previously, but this will require a culture shift and being very open.

3. Donna: The executive role must be separate from the scrutiny role. Scrutiny must not replace public involvement. The public must be involved in scrutiny and consultation.

* Dr Dipak Ray: Scrutiny is a balancing act between costs and providing care, because most trusts are bankrupt.

* Intermediate care will overwhelmingly be delivered by the private sector – who will scrutinise that?

* Joan Penrose: How do users and carers get plugged in, and into what?

* David Spilsbury: Scrutiny seems to be constructed with a London Borough in mind. How do you scrutinise where there is a plethora of trusts?Birmingham City Council has 20 to scrutinise.

Responses

Rita: There will have to be regional variation in scrutiny arrangements. There are training implications

Linda: Scrutiny will have to be disciplined and cohesive to make sense – and shared learning experiences and training are also crucial.

Donna: The private sector should be scrutinised as rigorously as the public sector – this was an opportunity missed in the NHS Plan. It is not clear who will guide local involvement strategies if CHCs go, nor how there will be any regional co-ordination

* Mike Turner: Our organisation, Community Voice, is independent of Community Health Council. CHCs are very variable. Patient forum might be an improvement

* Maureen Smith: Urban thinking may not work in rural areas. Labour Party Policy Forums are a useful place to raise these issues.

* Donna: Why abolish CHCs if you can improve them? PALS have the right to negotiate, but this will only work if there are provisions for enforcement. Their role is also to service, not to lead, the Patients’ Forums. Despite public assurances there is no formal consultation going on about the process of setting up PALS.

* Rita: Both independence and integration are important.

* Dr Ramkissoon: Patient satisfaction is a very downstream measure. Laboratory staffing structure is a shambles and must be addressed now, not in the future. This is a problem that is not obvious to the public.

* Sally Brearly: Contrast the rigorous role of CHCs with two meetings per annum and not just with CEOs, together with local government secrecy – local authority HIMP boards meet in private. Who will speak for out of borough patients?

Responses

Donna: There is a big shift in the Plan from collective scrutiny to individual patient experience, and this is not an alternative. There is too much scope for the “you wouldn’t understand” attitude.Making information accessible and comprehensible will also be crucial. Random selection for Patients’ Forums will not work. The government will have to put serious money into training Forum members, and we need to have national minimum standards.

Linda: There is a tension between the individual patient experience and information from a representative patients’ group, and CHI wants to hear both. CHI has a role in the private sector when NHS patients are treated there. The National Care Standards Commission will monitor private care, but is not yet up and running.

Rita: I am not here to defend poor practice in local government.

* Joan Davis: Scrutiny will just be rubber stamping, based on officers’ advice, and will have a political motivation and bias. Councillors will not have the time to do it properly.

* Ian Syme: Is local government democratic? Many local authorities are officer-led and everything is done behind the scenes. £60 allocated to pay for dealing with each complaint through the PALS is a recipe for disaster. Who will look at continuing care?

* Maggie Mansell: We should not have CHC abolition but CHC enhancement, with the Patient Forum mechanisms added on. Many of the problems are due to lack of resources. Local government can support the scrutiny function and develop it. There must also be national standards, statutory responsibilities and national benchmarking for all CHCs or whatever replaces them, to ensure they are all up to standard.

Responses

* Linda: CHI has an interest in continuing care but most of it is delivered in the private sector. North Lakeland was about continuing care, and the lesson learned was that this affects often the most vulnerable people, who are hidden from view. Expect the health service to look at high mortality areas, not CHI, and the health service must learn to use public health data better.

*Donna: Some local authorities do not have specialist health staff and will give it no priority to enable serious scrutiny. PALS and the money available does not add up. PALS cannot just operate during office hours. Often most of the problem emerge out of peak hours, so £10 million plus £23 million does not add up.

* Rita: There will be no whipping on scrutiny committees, the legislation is very clear on this. Codes of practice will apply. For scrutiny, local authorities can bring in experts from outside, not use council officers. Lead councillors will have to explain why decisions are made, and write them down. Not to do so will be a criminal offence, so this will mean the end of officer-led local authorities. We must not have a postcode lottery as far as scrutiny is concerned.

* The HAZs are directed at health inequalities. Also, urban and rural White Papers promise renewal funds. We will need to avoid a postcode lottery in scrutiny.

Aneez: summing up

  • There is an election coming up. The government needs the MSF/MPU, the SHA and the NHSCA to keep it in line and to demonstrate that it can do things differently.
  • We can build and learn from scrutiny, and we must end the blame and secrecy culture in the NHS
  • We must recognise the history of CHCs and acknowledge that their key principles of independence and integration. We need something democratic and accountable to oversee the replacement processes.

FINAL PLENARY

Panel:  Dr Paul Walker, Dr Guy Routh, Dr Aneez Esmail.

How to increase democracy accountability in the NHS in the short and the long term?

Sally Brearly: A succinct message should go out to public that CHCs are their mechanism. How about a postcard campaign for the public to send to the government requesting an effective, independent mechanism for public and patient representation?

Mike Turner: The SHA should write to government suggesting that CHCs remain to set up and manage all the new involvement and patient organisations within the Plan.

Helen Groom: Most PCGs will have no idea about these issues. In the headlong rush to PCT status, they will need this information. They want to have a base in the community, to be accountable and to make the necessary changes in culture, so send this information to the PCGs and discuss it with the PCGs, especially around the need to change cultures.

Aneez: There is a need to engage PCGs and not to reinvent the wheel.

Guy: Consultants have even less idea about these issues. CHCs have a lot to offer. It would be a mistake to hang on to their name – but we need to keep their skills and abilities, rather than necessarily the CHCs themselves.

Paul: The point of today is for the SHA to feed into its policy development processes and then to respond to the government through the policy which it will develop arising out of this conference.

Michael Varnam: There are a million health care workers in the country, which means that 1 family in 5 is involved. If they are all democratically accountable then they could change what we do at work.

Ali Syed: It is important to communicate with consultants.  We will get more in co-operation than by acting alone. The CHCs should be improved, not abolished.

Joan Penrose: The GLA has set up a London Health Commission chaired by Trevor Philips, which is currently looking into models to replace the CHCs in London. This will help us who live in the London area.

Aneez: We should spread these models around. At the moment the NHS is too hierarchical and secretive, so it is good suggestion to engage more with NHS staff.  We need to start democracy inside the NHS.

Fiona Campbell: The DHN has sent out a survey to all local authorities asking them how they will use the health scrutiny function. Some innovative proposals are coming back, including using CHC members in a new way. The DHN is happy to share this information.

Maureen Smith: Social services now have to draw up service needs assessment for each user in conjunction with the user, then produce a care plan with outcomes, identifying who will be involved in delivering it. This is a good collaborative model.

Malcolm Cooper: Re openness in the health service, our local staff have been told not to speak to the media.

Guy: This happens everywhere, as an attempt to put the frighteners on staff, but management has absolutely no authority to impose any penalty.

Martin: There has been a lot on CHCs today. There is still an issue around lay members, NEDs, etc. They are told they are there to represent the Secretary of State. This needs addressing. They should have some notion of accountability to their local community, otherwise they might as well just be paid civil servants.

Julia Knight: As a lay PCG member, she was told by the Health Authority that the role of the PCG is to carry out government policy, not to be a campaigning organisation. She has had training in corporate responsibility and cannot match this with the lay member job description and the statement that she is there to represent the interests of local people.

Angela Young: It is possible to do a course in public involvement at the Public Health Resource Centre at Oxford University, to NVQ standard. There is a need to learn and understand the importance of talking and listening to the people lay members are supposed to speaking up for. This training could be rolled out to all local universities.

TONY JEWELL SUMMARY:

Questions to ask of lay members, NEDs:

  • who agreed you?
  • who do you represent?
  • what do they ask of you?
  • how much do they pay you?
  • how do we get rid of you?

“Questions for quangocrats” devised by Tony Benn.

Donna: the abolition of CHCs was a sudden idea to meet an immediate need. There is now a struggle to put it into practice. “Dangerous watchdogs” like the farce of the Dangerous Dogs Act. It was policy on the hoof, a bright idea at 2.00 a.m. Why should customers have to shop around for their rights?

Rita: Importance of strategic planning and partnership.  Linking performance review to scrutiny.

Linda: Will CHI make a difference this time? We had similar institutions in 1961, in 1963, with investigations into hospitals. CHI is a carrot and stick development, and the jury is currently out.

Reports from the four groups

Local democratic accountability

There are unresolved issues, with no easy answers. There is a need for clear structural processes. Do local authorities have the skills for the scrutiny role? How do you empower local communities?

Participation: patients or citizens?  Consultation – active or passive?

If CHCs are to be replaced, the core principles underlying the replacement services must have:

independence, integration, accessibility, transparency, and proper resources.

Delivering an effective NHS

We must recognise the complexities with the different professional groups that we cannot control and direct. There is a need to value staff, to look for success in health outcomes, and to involve all staff, from primary to acute to tertiary care and build a culture of openness

Two sorts of accountability – health authorities, trusts and local authorities

  • We need a context of co-operation
  • There should not be a HImP and a Community Care plan – they should be integrated into one plan
  • We must listen to people
  • Communities need to have the ability and processes in which to stress their needs
  • We must go out to engage excluded communities
  • Should scrutiny committees be televised?

NEXT STEPS

Circulate bullet points within a longer report of today’s conference.

The three organisations must consider:

  • in the short term, the need to respond to CHC abolition and the need for the gap to be properly filled
  • in the longer term, the complexity of defining what democracy is, what health and social care is, and what structures and processes are needed to deliver democracy to health and social care.

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