Welcome And Why Rehab Matters

Dr Andrew Greenland 0:00

Welcome back to Voices in Health and Wellness, where we speak with practitioners who are redefining healthcare from the clinic floors of the community. I'm your host, Dr. Andrew Greenland, and today we're talking about something that affects almost every family at some point: rehabilitation after injury or illness, especially for older adults navigating neurological or physical challenges. My guest today is Susan Pattison, founder of SP Therapy Services, a specialist neurophysiotherapy clinic based in Greater Manchester. With over two decades of experience, Susan and her team help adults recover and regain independence after strokes, brain injuries, spinal injuries, and long-term neurological conditions like MS. So with that, I'd like to welcome you to the show, Susan, and thank you so much for joining us today.

Susan Pattison 0:43

Thank you for having me.

The Gap That Sparked SP Therapy

Dr Andrew Greenland 0:45

So to start us off, could you share a little bit about how SP therapy services came to be and what was the gap that you saw in the rehab landscape?

Susan Pattison 0:55

I have always been a very proud physiotherapist, and very quickly I identified that I wanted to work with patients with neurological conditions. I specialised very quickly and loved working with people on their journey, but even I found their journey and their access to rehabilitation was quite short-lived, and their journey was shorter than their potential, and I always felt that very, very strongly. And I took the opportunity to work into to move into a private sector rehabilitation unit where I had the opportunity to work longer with patients and see them gain their more of their potential. But being an inpatient unit, those patients were then discharged and they were being discharged almost into an abyss where there was no rehabilitation to support services to support them at home. And one day I said to him, you know, somebody's got to do something. I and he said, Aha, and I said, I think I'm going to do this myself. And he said, I wondered when you'd wake up and realize. And so that was the journey, that was the journey I took. It was it was it was understanding that patients had rehabilitation potential, understanding that physiotherapy and the other therapy disciplines had the capacity and the ability to change things, but not having the time or the service to do that. And I suppose I always hoped that maybe it would be a self-fulfilling prophecy and I wouldn't have a job because the services would be there, but 28 years later I am.

Dr Andrew Greenland 2:38

Thank you. Tell us a little bit about what you've created. What does your service look like?

Why Home Visits Change Outcomes

Dr Andrew Greenland 2:42

Who do you have working for you?

Susan Pattison 2:44

Well, we're we're community physiotherapists because fundamentally our homes, our communities where we live, isn't it? Um it's okay learning to walk across the gym floor. Um, that's a nice flat smooth service, but our homes are not like that. Our homes are carpeted, the kids' toys are there, the the um the dogs there. You've got to learn to um we've got to learn to live in our environment. And when people have survived complex injuries, complex brain injuries, complex strokes, uh, when they're living with MS, when they're living with Parkinson's, their physical abilities change, and I felt it was really important to empower them to be able in their own environments, and that's why we chose to start with home visits. Um, I was based in Bury in Lancashire, and I now have team members who are in Blackburn, Lancashire, Bolton, Stalybridge, Barnsley, Bradford, and Homeforth. So, really across that the whole of um just the northwest and into Yorkshire is how we've set our services up along the M62, that's how you like to say.

Dr Andrew Greenland 4:01

Thank you. So you talked about some of the kinds of conditions that you work with, but what does a typical care pathway look like for a patient with you?

Susan Pattison 4:10

I say there's two kinds

How Patients Find The Service

Susan Pattison 4:12

of um pathways that we are involved with. Um, unfortunately, we we I take phone calls from from daughters or sons who say things like, Um, my mum, my dad was admitted to hospital and they had a stroke, the hospital team have been amazing, you know, they've adopted this for the moment, they've had rehabilitation on the ward. Unfortunately, that you know, they have got as far as they can, they're struggling for beds, and um my mum is being discharged home. Can you help? So that's one way in which we see patients, and the other way in which patients are referred in to us is we work with case managers who are looking after complex needs, and that might be with because there's a compensation claim behind because it's been a catastrophic injury. So there's two routes really into our service.

Dr Andrew Greenland 5:00

Thank you. Um, we've talked earlier about the patient journey from acute to community care. You've kind of talked about the kind of the hospital starting point for this. Where do you see rehab often falling short for people in your experience and across the whole sector?

Susan Pattison 5:17

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Where Rehab Systems Fall Short

Susan Pattison 5:18

I think if you go, if your diagnosis means you go into hospital, you have the potential to me to physic therapist and an occupational therapist as an inpatient, and then you're discharged, and then there seems to be quite a gap in services between inpatient and accessing outpatient services. And I'm sure my my NHS colleagues would share my frustration in the fact that you know, if a drug was working, then a patient wouldn't be discharged without that drug continuity, but it seems unfortunately to be acceptable if physiotherapy or rehabilitation is working, that there is a gap before that starts again. Um, the other thing is that not everybody goes through AE with a medical diagnosis. You know, you can be perhaps living with MS or you can be living with um Parkinson's, and it almost seems that rather than us having a preventative role and looking after people from the start and empowering them to look after their own health and well-being, that we almost wait for it to be a crisis. Perhaps somebody falls and breaks the legs and goes in via the AE and then picks up the services that then gets referred. So it seems to me as though it's there are gaps in terms of when the patient is possibly at their most able to access rehabilitation because they're essentially well. Whereas if there is an inpatient, then fundamentally not well, are they? Because they're being looked after in hospital, or if they've fallen, again they're not well. If we could be in, I think we need to, or it's like prehab, isn't it? It's it's it's like in football, isn't it? Your physiotherapist prevents the injury, it's not sorts them out after the fact. And we spend a lot of time, um, certainly with our families, engaging in forge prevention.

Falls Prevention And Balance Realities

Dr Andrew Greenland 7:12

I was going to come to that as a as another thing. So, especially your work around balance training and force prevention, especially with older adults. What are the key challenges in that space?

Susan Pattison 7:22

I think the thing is, is as a physiotherapist, we're an evidence-informed profession and we we are learning more and more and more about balance. And the key thing about balance is the only way to challenge and improve balance is to use it. Um, but that presents us with a clear dichotomy, doesn't it? If you've got a loved one who is a little bit wobbly on their feet, then the carer in you, and not particularly me as a physiotherapist, but the the husband, the wife, it's like, don't do that, I'll do that for you. So we need people to use their balance to improve their balance, but the the dichotomy of that is that if somebody's got poor palents, they're at risk of falls. So the thing is we need to keep them going but reduce the risk of falls, and sometimes we can end up with with um well-intentioned people being disabled by love, that things are brought to them. You know, when you go and visit your your elderly relative, you know, I would always encourage you that rather than making a cup of tea for them, take them to the kitchen and chat to them while they make a cup of tea, help them look out of the out of the window. But we do tend to, particularly with our elderly, disable them with love by taking away the opportunities for them to be mobile and ambulant.

Rebuilding Confidence After A Fall

Dr Andrew Greenland 8:38

So disabling with love is one thing, but I guess there's a whole thing about patient confidence as well. So, how do you help someone who's lost their confidence after a fall or was afraid of moving too much?

Susan Pattison 8:48

Slowly, gently, with compassion, and allowing them literally to if it allowing them literally to move into the difficult space one centimetre at a time. Um and then and allowing them to actually use their balance mechanism. We don't have to be thinking about balance in terms of walking on a typerope or an elephant standing on a ball, you know, that is the very complexities of balance, but certainly reaching into a cupboard to get a cup out or reaching to clean your teeth, all of these will charge your background balance mechanism and encourage you to get involved in activities of daily living. So it's that's why I think when we've got somebody who is frightened of moving, and we have to improve their confidence that working with them in their home with the obstacles that confront them in their home is the most important because what we find otherwise is that patients bring their entire environment in so that they actually start to reduce their opportunities to move.

Dr Andrew Greenland 9:54

Thank you. And what about referrals in? So, do you feel that um GPS and acute care services are referring at the right time, or is there still in a gap? Is there still a gap in when people access the rehab?

Susan Pattison 10:07

I think there's a gap. I I think there's a huge, huge gap, and sadly, listening to my NHS colleagues, listening to the magazines that come through with regards to my professional network, it's getting bigger and bigger. Um the staffing issue with regards to rehabilitation within our NHS sadly is is not good. Is not good. Um, I do welcome the fact that we seem to be thinking now about rehabilitation in terms of neighbourhood networks, and that seems to be part of the 10-year plan, but that's a it's a long, a long way away, and we're not in a good place with regards to rehabilitation at the moment. And from what I understand, and my NHS colleagues can correct me, is that often services are limited at the output in terms of their actually dictated to in terms of how many sessions they can provide, not necessarily what the need of the individual is.

Dr Andrew Greenland 11:11

Thank you. Now

Referral Timing And Capacity Pressures

Dr Andrew Greenland 11:12

I think about um neurological patients specifically. I don't know how it works in inpatient institutions, but I'm guessing there's a certain amount of structured rehab protocols that people are following. How do you balance that with perhaps what you want to do with them when you see them and create something which is more individualized and adaptive?

Susan Pattison 11:32

I think when somebody's in an institution, there are a lot of controlled structure, isn't there? Breakfast comes at a certain time, drugs come at a certain time. There is a structure within which then it is easy to put. There's there's specific holes, isn't it, in which you can put things, but real life's not like that. Real life's not like that at all. Um, so and the other thing is is that when somebody is in an inpatient institution, for example, when I've been at when I personally have been as an inpatient, I stay at my bed and I stay still. Yes, whereas when you're in your home, you have so many more opportunities to move and engage. So it's it's making every movement opportunity therapeutic. So it's it's using cues. So you have your physiotherapy session, but homework is key. So it's it's using cues. So for example, um, great fan of post-it notes, post-it notes above kettles with reminders to stand on your tiptoes whilst the kettle boils. Great fan of a strip of tape down the middle of a mirror that if somebody has got difficulties with their balance and their alignment, that it's prompting them whilst they're cleaning their teeth. Um, a great fan of engaging family members such that when grandchildren come round, there's a uh a bucket of activities within which grandchildren can engage with grandma, such that it's not a structured exercise, but that what we're trying to do is at the end of the day, we're trying to engage people in their everyday activities. Um, if we talk about neurorehabilitation, the key to neurorehabilitation, the principles of neuroplasticity, and that means that um rehabilitation has to be salient, so it means it has to be meaningful for the brain to learn. So it's really important that when particularly when we're working in the home with people, that exercises are not abstract, but they're actually integrated into their everyday activities.

Dr Andrew Greenland 13:44

And on that note about neurorehabilitation, which I'm imagining is probably quite a slow process for a number of conditions, how do you measure progress? Because the improvements can often be quite subtle or non-linear, but how do you track things when you're working with people?

Susan Pattison 13:58

I think the most important thing when you're tracking progress is to work out what the patient wants to do. Because at the end of the day, that's what's going to motivate them. And if if you're wanting to motivate them, they've got to engage. I might be able to track progress in terms of an outcome measure. Very lovely. My patient doesn't really care for an outcome measure, they're not bothered how long they can stand up for, what they're worried about, or what they want to be able to do is to stand up long enough to put their shirt on without losing their balance, or they want to stand up long enough in order to make a cup of tea. It's only physiotherapists that actually get excited about the ability to stand and balance. Um, patients are driven by wanting to do something. So often it's about setting realistic goals. So if I'm working with somebody and they've perhaps recently been discharged from hospital and they're living downstairs, it could be that they want to walk sufficiently far to get to the toilet independently rather than use the commode in the lounge area. So that's a really valued goal, isn't it? And if you achieve that, that's progress. Yes. Often that then leads to, you know, well, what I'd really like to do is go into the kitchen for my breakfast. So then you work to go into the kitchen to do breakfast, and then you say, Well, what do you want to do after that? Well, breakfast, dinner, and tea. So it's breakfast, dinner, and tea. And so it's a cumulative set of goals that are all based on the fact that it's the functional representation

Making Rehab Meaningful At Home

Susan Pattison 15:32

of what improvement means to that patient rather than an objective measure, because I'm not measuring populations, am I? I'm trying to make a difference to that individual in terms of their life and their engagement. And I find as a physiotherapist, when you've got a motivated agent, it's cumulative. You know, it's then, well, it's my grandson's christening, I want to go down the steps so I can get in the car. So it's each meaningful goal that we tick off one after the other. I am realistic, I am I am a physiotherapist, I don't cure the problem, I don't take it away. I am a movement expert and I analyse movement and function, and I make that movement easier for the patient.

Dr Andrew Greenland 16:17

Got it. So, with your pacing, because you're essentially pacing and trying to help patients with their goals, do you often find that patients are underchallenged or over cautious in their recovery before you get to um do your thing with them?

Susan Pattison 16:30

Yes, yes, um people are frightened of making a situation worse. Um, and I think we're all beginning to understand that exercise itself is a great panel, is it is a great medicine for a lot of things, isn't it? Physical activity lowers blood pressure, improves mood, helps modulate um blood sugars, all of these things that are very medically orientated, that as a physiotherapist I wouldn't wouldn't particularly be looking at, let alone what it does in terms of muscle function, balance training, all of those skills, those skills that I am interested in, we are now understanding much, much more that that um exercise is important for brain health, as is brain health is for exercise, and that the the body and brain are much more linked than we ever thought they were. And so, yes, I think the tendency is to not do enough, and again, that comes back from a fear of doing too much and hurting yourself.

Dr Andrew Greenland 17:36

When you think of all the patients that you've seen and continue to see, what do you think is the biggest barrier to someone regaining their independence after a fall?

Susan Pattison 17:45

After a fall, I think every environment represents a different challenge. So it's not that you recover from a fall, is it? It's that um if you've recovered from a fall, then differ then confidence and and the well, we know that fear of falling is one of the biggest predictors of falls. That's something else that we now know. But that fear is environmental specific, isn't it? So maybe um you have learned and become confident to move in your own home downstairs. The stairs represent a separate, separate challenge. The steps outside your back door represent another challenge. You know, walking down your drive represents another challenge. The uneven pavements in your community represent a different challenge. So I would say that whilst fear is a huge indicator of people's potential to fall again, that fear translates, it's almost the better they get the person gets, they move around the monopoly board if you like, but there's the next challenge around the corner. So if we just treat um if we just treat mobility and falls in terms of the context of um being able to walk six metres or or something like that, we are vastly underestimating. We're what we're trying to do, isn't it, is people need to live in their communities. That's where they that's where we all live, isn't it? To go to their shops. You cannot be a prisoner in your own own home being fearful of falls. I think that's very wrong.

Dr Andrew Greenland 19:21

Thank you. What about the really complex cases? Because I'm sure you have those as well, where you've got patients with multiple conditions or multiple comorbidities. How do you help them or put something together for them?

Susan Pattison 19:34

It comes with the nature of the person, doesn't it? They are these comorbidities do exist, don't they? It often somebody who has had a stroke has also had high blood pressure for a long time, has also been suffering with diabetes, potentially is overweight, potentially has not had a particularly good lifestyle. And when I'm working with complex brain injuries, um sadly, if perhaps somebody's gone through a windscreen, they've also broken their leg and fractured their ribs and what have you on the way through. As a physiotherapist, then my job is to look at the movement skills that the person has, to look at the potential that they feel I have, they have, and then to build the gap between the two. Um, I have met as many couch potato 40-year-olds as I have enthusiastic 70-year-olds, so I think you learn not to judge the book by the cover. Um, and you just have to take every individual and the problems that they present and their own. And my patients amaze me every single day. You know, they they have so much resilience, they have so much potential. They're brilliant.

Dr Andrew Greenland 20:46

So moving on to the business

Measuring Progress Through Real Goals

Dr Andrew Greenland 20:48

side, because SP Therapy Services is a business. Um, what are you most proud of and what's working really well for you from a business perspective?

Susan Pattison 20:57

I think I'm still here after 28 years. Um, I don't know if that makes me proud or sad. Um, perhaps sad that rehabilitation is not recognised as a need, and I'm still here in the private sector. Proud that um as a business I said that's needed and I'm still here providing that. Um proud that um I've provided jobs. I have eight staff currently. I've had um number of physiotherapists that have joined us over the years, a number of newly qualified physiotherapists who've who've joined us over the years, and have been very proud to set up on their on their journey. Um I've always been an incredibly proud physiotherapist. Having a business has allowed me to do it my way, and that's what I'm proudest of.

Dr Andrew Greenland 21:52

I think you should be proud, and you know, you're clearly fulfilling a very important need. And like you said, you've got people working for you, you're providing service. To a good chunk of the country, by the way, you described the M62. So I think you're doing great work. So well done. On the other side of the coin, what are the um challenges or bottlenecks that are most impactful to the business at the moment in your space?

Susan Pattison 22:14

Me. I'm a physiotherapist at the end of the day, and um running a business takes other skills, and you know, I love reading about balance, I love reading about neuroplasticity. Oh, I could you know take a book on holiday, I'm happy. Um, but as a business owner, I have to learn about employment law, GDPR, all the other things that come with being responsible. Um, recently SEO optimization was my latest um thing that I've been learning about and reading into the middle of the night. So I think it's that the hardest thing is accepting that, and it's Amy, you know, accepting that being a skilled, hopefully a skilled physiotherapist, hopefully an enthusiastic physiotherapist, hopefully a physiotherapist you could see a gap in the market was not enough.

Dr Andrew Greenland 23:09

I mean, for for you, because you wear lots of hats and you mentioned some of them already, what is your biggest time drain?

Susan Pattison 23:22

Useless worrying. Yeah, use um, yeah, I I think it comes with um I may I was brought as a physiotherapist up to be an evidence-informed practitioner and reflective. And being reflective is good. It's really, really good, but you have to watch yourself that that doesn't turn into an oring guilt that you've forgotten something. It's a bit like when you walk outside the door, isn't it, and you worry that you've left the you've left the oven on and you've not. Um and just just wanting to do wanting to do the best by my patients and wanting to do the best by my team, um, you know, but just accepting that I I can't know everything all of the time.

Dr Andrew Greenland 24:13

Thank you. Um if you had a sudden influx of new referrals next week,

Fear Of Falling And Complex Cases

Dr Andrew Greenland 24:18

which sounds like a nice problem to have, it might be, I don't know, what would happen?

Susan Pattison 24:23

It's a difficult problem. It's a difficult problem because you want to provide the best for everybody, don't you? Um we I think managing the ups and downs of business as is possibly another big challenge because if you had a crystal ball and I understand you work in an A and E department half the time, I'm sure if you could regulate the flow through the front door, um you know, regulate the flow through the front door, then um that would help. Um, I understand you have triaging practices um in an A and E department, we would have to delay the rate at which we could respond. We pride ourselves in being out as soon as the patient needs us, because often when when we actually find, you know, patients find us, they've got themselves in quite a pickle, or families have got themselves in a pickle because they've been waiting a long time. And whilst their need is not desperate, as in when they come through AE, emotionally, they're in a really, really bad place, and we try to get out as quickly as possible, it would delay that.

Dr Andrew Greenland 25:33

Right. And are there patients you'd like to spend more time with, but for the reason you've just said, you don't necessarily have the capacity to do so?

Susan Pattison 25:42

Um you would always like to do more, I think. You'd always like to do more, you'd always like to know more, you'd always like to do more. Um, I think if you work in healthcare, you're pretty much a born rescuer, a little bit. So um I think it's the nature of the beast.

Dr Andrew Greenland 26:05

I guess I'm I'm guessing at the sort of the tension that can sometimes exist between delivering ideal care, which is I'm sure what you want to do, but but also what's realistically scalable within the resources that you have.

Susan Pattison 26:18

Um well, I think the thing is is that ultimately I'm not in charge of the resources, the patient's in charge of the resources, and that's quite a you know, isn't it, that the patient is in charge of the resources, we don't come free. We're honest and upfront about how much we cost, um, we're honest and upfront with regards to our patients about what we think can achieve, we can achieve. Um, and at the end of the day, I have to be respectful of the patient that the patient's funds are their funds and it is their decisions to what they do. So it's a very different resource. The resources are held by the patient, aren't they? They're not held by me. So I'm not making a service delivery decision based on populations. I'm not saying there is a population of X number of thousands of patients with Parkinson's that I need to deliver, which is how I understand it in the NHS, have to work their budgets out. A patient is coming to me and is in they are in control of their own budget. So I think we're coming at it from the service delivery challenges, I think, are different.

Running A Clinic And Wearing Hats

Dr Andrew Greenland 27:39

Do you have a take on um group programs or digital tools or hybrid care models or tool? I don't know how it would work in a community setting, but I just wonder whether it's something you'd ever looked at or had a view on.

Susan Pattison 27:49

Yes, yes, I think um we ran for quite some time and it's now run we've handed over to our local university a hydrotherapy exercise class for people with neurological conditions. Um, but I think there's a difference, isn't there? When we talk about community, there's community as outpatient, and there's community as in home visits. And where we work is community as in home visits, so we go into people's homes. I mean, we need to have group exercise sessions that people can go to, but you have to have a set of skills to get to the group exercise class. So, you know, if you've if you there's a lot of work at the moment about um false prevention classes, great, but you've got to get to the false prevention class, and if you're too frightened to get out of your front door, we've got a problem. So we've got to go back again and go back into pick where people's homes are and where within their homes, such that yes, group exercise is fantastic, but you've got to get out of your front door, you've either got to get to your bus stop or get to the taxi or get out the other side, and all of those things can prevent can lead to barriers to people actually being included in in group activities. But yes, they absolutely have their place.

Dr Andrew Greenland 29:08

You've talked a lot about your team on this call, and I just wondered how you've managed to build a team that shares your values and clinical standards, and how easy is it to find the right people.

Susan Pattison 29:19

Um physiotherapists are quite a weird bunch, and you know, we can we can get really excited about things like balance and standing very, very easily. Um, I think you can always, I think there are different types of clinicians, aren't there? There are there are people who qualify that are born to be teachers, there are people that are qualified that qualify that are born to be researchers, and then there are people that are qualified that just are born to be with people, and I think you can tell that very easily, and I think I'm very skilled at getting that out over a cup of tea, to be honest with you.

Dr Andrew Greenland 30:01

So if you were starting your business again tomorrow, would you do anything differently with everything that you know and the journey that you've been on so far?

Susan Pattison 30:08

Employee business manager. I I think for somebody to um to take to take that side away, because you can you can hear the bit I love. You know, I love people, I love, I love working with patients, I love crawling around on floors, sorting out balance, you know, that's where I'm happy. Um I understand as a business owner I have to do the other stuff. But it doesn't like my fire.

Dr Andrew Greenland 30:43

And if you had a magic wand and you could fix one thing in the business tomorrow, what would that be?

Scaling Care And Group Options

Susan Pattison 30:53

Can I say something very selfish?

Dr Andrew Greenland 30:55

Yeah, please do. It's a free floor.

Susan Pattison 30:57

I'm 60. I haven't got enough time left to do everything I want to do. So I'm going to I'm going to be Doreen Grey and stick my stick my my uh picture in there and come back at 20, come back at 20 and and and do it again with all the life experiences, the life experiences I've learned. If you ask me anymore, if I can suggest if I would like one thing to happen with big ads, do not necessarily my business but rehabilitation, um is the one thing I that drives me absolutely potty is when I come across a patient that's labelled as having no rehabilitation potential. That drives me potty. We cannot identify what rehabilitation potential is. So how dare we label somebody as having no rehabilitation potential? Rehabilitation potential to me is content, context, and time specific. We have to put the person in the right environment in order for them to be able to access rehabilitation. You can't say somebody hasn't got rehabilitation physically potential if they can't see a physiotherapist. That's a service limitation. So I don't think I answered your question there. I think I got what I wanted to say through the background.

Dr Andrew Greenland 32:15

You definitely answered it, you made a very good point, and I love your Dorian Grey analogy as that was excellent. But yeah, the rehabilitation potential um issue you mentioned is a very interesting and worthwhile one pointing out. So thank you for that. So, what about the next 12 months? What does um the next 12 months look like for you? Do you have any particular plans for the business? Where do you want to be in a year's time?

Susan Pattison 32:36

We've very excitingly just taken on a new graduate physiotherapist again. We when we feel we have the structure within the business in terms of the right support from the right senior members of staff, we can take on a new graduate. We've very excitingly taken on a new graduate. So I'm really excited to see how she evolves. I think bringing a new graduate in is just such a fantastic opportunity

Hiring, Training And The Next Year

Susan Pattison 33:02

for everybody, isn't it? They they arrive with their spaniel-like enthusiasm to learn and turn everything upside down with their questions. Um, and also I think it gives the rest of our clinicians a real opportunity to reflect on what they've learned as they as they teach. So I always find that when we we bring a new staff to in, it's a very exciting, um, it's a very exciting part of the journey, isn't it? Obviously, and my business has time enough to sort out a case label for her to secure her mortgage, which will entertain me on the other side. But that's the best I'm looking forward to.

Final Reflections And Thanks

Dr Andrew Greenland 33:44

With that, I'd love to thank you so much for joining me today. It's been a really interesting conversation. Thank you for your insights. Thank you for telling us a little bit about your work, what you're seeing in the space, some of the challenges of the work, and how it all works from a business perspective because I think that's important for people listening as well. So thank you very much.

Susan Pattison 33:58

You're very welcome.