Sula(00:00.13) Thanks guys for joining me. I'm so excited to get into this episode. To begin, Angie, would you mind introducing yourself, who you are, what you do? Angie Rantell(00:08.236) Hey, it's lovely to join you. So I'm Angie Rantell. I am a consultant nurse in urogynecology and a senior lecturer in pelvic health at Brunel University. speaker-0 (00:18.35) Yeah, so you're busy, busy, busy. So we're going to explore all your multiple roles today. Keira, would you mind introducing yourself? Kiera 00:25.278) Yeah, hi, I'm Kiera. I am a psychological well-being practitioner in Aberdeen and I'm also a patient advocate with Convatech as well and a catheter user. speaker-0 (00:36.206) I thought maybe we could start with just the reality of your reality changing, if you wouldn't mind, Kiera, sharing a little bit about what life was like before your bladder started behaving differently. speaker-2 (00:49.78) I actually can't remember. So I started getting symptoms. I must have been about five when I got my first UTIs and they were they were constant. So I'd get a short course of antibiotics and then they would go away for a little bit, they come back again. the UTIs died down a little bit, but as I got through to my teenage years, early twenties, I just had different symptoms, so I needed to go to the toilet much more often than the people around me. There was a bit of pain as well and difficulty actually going to the toilet and that's still the symptoms I have today. speaker-0 (01:25.07) And it's interesting as well when you say you can't remember. So being that young and having bladder symptoms, that kind of, did that give you an awareness as a child of like, this is different and start to make you feel different about, you know, having to go to the toilet? speaker-2 (01:43.594) like as a child I didn't really notice it. Only when I had a UTI it was painful, I think. but when it was better I just went back to normal just day to day. I think I only really started noticing it when I was maybe coming into my teenage years and I was going to the toilet more often, then it started to become more of a problem, especially during the night. So I'd be up multiple times up and down. and that's when I started to move a question. Maybe that's not the same as other people. speaker-0 (02:11.512) And it's really hard at that point, because like you say, you've only got your own normal really, but you then start to see, maybe other people aren't experiencing this in the same way. And then do you remember, Keira, how you proceeded from there? How did you start navigating the healthcare system? speaker-2 (02:29.888) Yeah, so I I noticed symptoms as a teenager. It got quite bad at that age and then coming up to my twenties, but I didn't reach out at all. I actually I didn't although I knew that I wasn't doing the same thing as other people, I thought it was more of a habit rather than a physical problem. I thought I was just doing something differently just because it was a part of me. I didn't I didn't think there was anything actually physically wrong. so yeah, I didn't reach out for help until I must have been twenty three. and again I d I didn't reach out for my bladder. I I went to the doctor because I was bloated. and then she asked me questions about my bladder and it came out from there. speaker-0 (03:12.46) It's really interesting, isn't it, that it didn't feel like something that you necessarily should go to the doctor about. It's something to do with you, how you're doing things, that internal responsibility. I'd love to bring you in as a nurse, seeing people starting to present, I'm sure, at all different stages of life. How does kind Ciara's experience relate to perhaps some of the variation that you see? speaker-1 (03:39.918) To be honest with you, the sad thing is it's actually very typical. We know for women with bladder problems specifically, that help seeking behaviour takes years. And often, particularly those who say maybe a slightly different problem such as incontinence when they cough or sneeze or an overactive bladder. but most of them that have had symptoms for at least six years before they seek help because they try multiple different coping mechanisms or try and do things or think, maybe it's normal I've done this. And it takes some sort of catastrophic events such as a school mum completely wetting themselves at a school gate or having something that finally tips them over to that point of I can't cope with this anymore to actually go and seek help. I think It's changing. And I think one of the reasons people didn't seek help is because they often didn't know where to go, what was and wasn't normal. And with the internet, with a lot more resources available, there are more that people can do before they seek help. But I think it's a clearer path to seek help. But with challenges with access for time to see things, it's still not great. And it's still something that we need to work on from a healthcare perspective. speaker-0 (04:51.702) Yeah. And when you were talking about the different coping behaviors people might try, what sort of things do you hear about people trying? speaker-1 (05:01.88) First off, people will often try things like they might stop drinking or they might go and buy pads or something like that. What we then see is people start restricting activities so they won't travel to certain places, they won't wear certain clothes, they won't do certain activities. They then become a bit more isolated, it can affect relationships, they might refrain from sex, they change their behaviours and their activities to do things that they feel won't trigger the problem or... speaker-2 (05:29.142) Yeah. speaker-1 (05:31.052) will be in a place where you can manage it rather than being somewhere unfamiliar where you don't know what access to toilets are or that you don't feel comfortable being. So it can have an entire behavioural change as well as lifestyle changes. speaker-0 (05:45.944) Kira, can you relate to that? speaker-2 (05:47.438) Completely, yeah. yeah, then in terms of how you're planning your day. I I was very much like that, and this was before I even went to seek any treatment. I remember even at school is I would plan between you'd have your your lessons and I would deliberately plan in toilet breaks in between that time. but yeah, yeah, every everything that you you've mentioned there I can relate to. speaker-1 (06:14.296) Can I ask you, when you were in your lessons, know one of the, so for younger people particularly, there is a huge challenge with younger people, children, teenagers in schools and getting access to toilets. And that's a big problem about sometimes if you need to leave class, you have to get a key to leave school. And there's a lot of sort of work going on with the charities across the UK to try and help improve access to toilet for people in school with issues because it can then be. a problem amongst lessons, teachers, seen as disruptive and a behaviour that is often seen as problematic rather than actually trying to help them recognise and it's due to an issue. speaker-2 (06:55.318) Yeah, yeah. So I because I didn't have any sort of diagnosis at that time, in terms of the the behaviour change, I would sit in pain rather than ask for help or ask to go out. I deliberately try and avoid situations where I knew I'd have to be there for a certain amount of time where there was no escape, no toilet. I just wouldn't do it. I just yeah, so like you said, your world becomes so much smaller because of that. speaker-0 (07:19.99) And what you were saying there, and touches on something we had Claire Bourne, a physiotherapist on a little while back, and she was talking about, you know, how we learn. to toilet, you know, how we learn when we need to go and what's normalized. And one thing that she was saying was the problem in schools is you've got these set times and similar to your experience there, Kiri, you're thinking, okay, so I can't go between this hour and this hour. I have to plan. And I guess that feeds into this bladder vigilance of sorts and perhaps going when you don't need to go or, yeah, maybe forcing urine out and that kind of thing. Does that impact you think as well on symptoms? speaker-1 (07:59.778) that does impact on things. Now, there are some things to be said for doing things on sort of a schedule and there are some patients who are actually timed voiding at set times is a beneficial thing. I think being on a schedule that's not right for them is an issue. I think the other issue around schooling and toileting is not often the facilities aren't all that private. Often people, they're accused, they're not all that clean and it's that, you know, In some schools, toilets are seen as a place where, you know, it's not the place people want to be. They don't feel comfortable. And in order to be able to empty your bladder properly, A, you have to be sitting on a toilet, but B, you have to be comfortable to relax your pelvic floor and your sphincter. And if you're anxious and worried and the door won't lock or you're worried someone's going to come in or something's going to happen, that's not an environment that's conducive to emptying your bladder. and wanting to empty your bladder. So you then get them withholding and holding on until they're in pain or they're sort of moving past that. And the withholding can then lead to problems later down the line. And it is something that goes through life. It then can cause problems all the way through. speaker-0 (09:12.246) It's really interesting actually because I use a type of therapy in my practice called eye movement desensitization and reprocessing. So EMDR for short, which was initially developed for people with post-traumatic stress disorder. the research suggests that what it does is help people's brains update from extreme stress and trauma. And... A lot of the time when I've been working with people with bladder issues and bowel issues, there tends to be these significant memories from being younger, not always in childhood, but younger and there's standout experiences around toileting where there's a lot of shame. And so I remember being told about... this scenario of being in, like you say, the unsafe environment of the school toilet. I even, this really thinking back to my school toilets, I can picture them, I can picture how quickly I wanted to be in and out of there. And you could kind of preempt that somebody is gonna put their head over and look at what you're doing or bang on the door or say something. speaker-1 (10:12.472) and the tracing paper, toilet paper that you had to wipe with afterwards that was always on play. speaker-0 (10:17.198) And then people are throwing like wet toilet paper. it's, yeah, it's not a place that's conducive to relaxing one's bladders. But the other interesting thing is that there does seem to be this hanging on to those experiences that the brain does. And naturally that then... stores memory, I suppose, this connection between the brain and bladder to be like, it's not safe. You need to be in the ultimate safe environment to relax. And it interrupts, I think, the default of you can just relax when you need to go to the toilet and that creates problems long-term. Keira, I'm interested as well when you were saying your life becomes smaller automatically and this assumption of speaker-1 (10:55.694) Absolutely. speaker-0 (11:07.034) it's probably something that I'm doing. I know there was the Convitex survey which was looking at how people saw continence issues and health issues more broadly. And there was this statistic of 59 % of people would mask, similar to what you were saying, Angie, and not share their symptoms for fear of burdening other people. Is that something that you've experienced as well? speaker-2 (11:32.648) Yeah, yeah. And I think the way I've done that has changed over time. I still do it. but it's definitely changed. I think when I was a teenager, my reason for doing it was more social. the fear of judgment, the fear of what people might think of me. and it would be more, yeah, friendship groups if I was to leave my group to go to the toilet more than once in a in a particular time though, they'd start to notice them, maybe talk about me. Yeah, so I say as I've maybe grown up it's still there. Maybe the way that I think about myself has changed a little bit, but still in those probably more social environments of I'm maybe sitting at dinner or in an environment where it would be noticeable if I got up and and moved around more than other people. yeah. speaker-0 (12:23.726) And you were saying you've seen multiple people wee today. So as a continence nurse, you're particularly desensitized to people's toileting, right? What do you think is that makes us so aware of how people might be thinking of us going to the toilet? speaker-1 (12:43.48) think there are so many different views on it. You know, I look after women with bladder issues all day. I do bladder tests where I'm sitting them and asking them to pee and filling their bladder up and making them cough. And I'm actively trying to make them leak and recreate symptoms. So yes, I'm desensitized to it. And then I'm very much that, you know, if I need a wee, you just have a wee and I'm, you know, I think you go to the toilet with friends. I've not got a problem peeing in front of a friend. I've got friends. who can't pee if there's someone in the toilet next to them because they just have this fear that someone's going to listen to them or feel that it's not normal. I think there's very much a nurture part. depends within families. Some families talk openly about it, some don't. If people have had issues and they don't want to do it, there are a huge different outlook on it. I think one of the big things from a continent's world that we're trying to do is actually just normalise discussions about peeing and pooing, you know, because it's something that everybody does and needs to do. But actually getting people to talk about it, recognise it as a normal bodily function in the same way as needing to have something to drink or something to eat. It's just about, as with everything, breaking that taboo to start the topic, to get it a bit more normalised. speaker-0 (14:04.142) Yeah, it's really interesting the different cultural things, isn't it? Because I've, you know, I thinking about how able I am to be like, I need a weight and just announce it and go off. Whereas other people might slip off and yeah, be worried about that and how that then shapes your... well, not just yourself, but the group around you. If it's not talked about, it perpetuates this idea of we need to hide it. Considering that, how automatic these things are, how we absorb these ideas around whether it's normal, whether it's not, whether people are gonna judge us. When you got then, was it your early 20s when you started to think, maybe there's something going on here? What was that healthcare journey like when you started to talk with healthcare professionals? speaker-2 (14:58.428) it's been a long one. It's been about ten years now. so when I first went, I was sent up to Uralgy quite quickly actually, to get a scan and at that time they did a scan, they had a look inside and I was told that there was actually nothing there, that there was nothing wrong, and I I came away feeling quite deflated. And it confirmed what I thought. I thought there was nothing wrong anyway, that was just in yeah, in my head. so I went back to that GP and I I was just really was quite put off in seeking further help because it confirmed that yeah, it was just it was just a me problem, really. but after that I had a had a great GP and she popped me back into urology and then from there did different tests and it it came out that there was actually something. that they could see when they did a procedure where they popped in a camera and had a look around. and that was a huge relief because up until that point I was having these symptoms and I thought it was just, yeah, just a habit, just a really bad habit, an irritating habit that I had. so although they'd confirmed that there was something physically not right, to me it felt really validating because they had an answer eventually. and then from there I had a I think I had about three, four years of treatment. in Aberdeen some of them worked a little bit, some of them didn't work at all, some of them made me worse. and after I'd I'd completed all the treatment that was available in Aberdeen, I was sent to Glasgow where I had in-depth murodynamics and then from there is when I started to use catheters. And I think that's when things shifted because I had the freedom to actually empty fully. And that was about five years ago now. And since then things have changed massively. speaker-0 (16:56.046) I'd love to explore that turning point with you in a moment, but it's really interesting to me, Kiera, about the tests telling you there's nothing going on and that automatic assumption of, it's in my head. know, you know, we've talked about this before and it's why I wrote the book, It's All in Your Body, because it's so interesting how automatic our brains are to tell us this is a you problem. And you must see that. often in patients, how does that present and how do you spot it happening? speaker-1 (17:29.87) So I think there's a couple of different challenges with this. When it comes to bladder symptoms, there's a huge variety of bladder symptoms and we have a huge variety of different tests that we can do and they're all looking for slightly different things. And whenever we're planning what investigation we should do, we're working number one on a process of elimination because whenever we're diagnosing something, we're eliminating things to get to something rather than doing a test to pinpoint a problem. But we're also working on a spectrum of the least invasive to the most invasive. We have to work on a spectrum of costs because we're not going to go jump in straight in with the most expensive, most invasive test when sometimes we can do it. But sometimes you have to work through a spectrum and a variety of different tests to get to the point where you've eliminated certain things, got certain answers to make that diagnosis. The other thing to remember is There's a phrase that's always been used in the Eurodynamics world, that the bladder is an unreliable witness and bladder symptoms vary. For some women one day they may be fine and another day they might be bad. It can have links to sort of psychological wellbeing, anxiety. It can have links to hormonal cycles. It can have links to when you're more stressed. It can have links when to when you're more constipated, when your bowels are more full. So a test on one day. might have a different result than a test on another day. Filling out a bladder diary and a sort of chart on a week when you're at work may be very different to a week when you're on holiday. And so sometimes just because a test has been negative at one point, repeating it again at another time point or in another circumstance is incredibly valid. And the challenge is often people think, well, I've had that test before and it didn't show me anything. And it's understanding that rationale of why actually sometimes we do repeat things again, because things might be different on a different day at a different time of day. speaker-0 (19:36.302) I mean, that makes so much sense, doesn't it? When you think about all of the different factors that would influence it and getting a bit more data to capture that variability. But as you say, I can imagine how quickly you might conclude, well, I've done it and that didn't show anything, especially if a patient's in a hopeless place and it feels like, you speaker-1 (19:59.532) And I think the challenge is, Kira said, not every place can offer every single investigation. Some of them are more labour intensive. They require equipment that's expensive. They don't have the expertise. And so often, for the majority of patients, most places, most specialist services could see a lot. But there are a group of people that once the specialist services have reached the end of what they can offer, they then do have to go to a bigger service that has a a wider range of specialist investigations that can be performed that then may give different options and open up different treatments that can't be available everywhere. speaker-0 (20:38.22) I'd like to ask you a bit about that access option in a moment, but just to stick with that sense of it's all in my head if the tests come back normal. I know you do a lot of training of healthcare professionals and continence nurses and doctors and all sorts. Do you ever, in fact, I'm remembering we were away together, think, in Nice at some... research presentation and a colleague in common, I was standing up to talk about how when I'd had that experience, similar to you, Kira, of being told, well, the tests come back negative, and how disappointing that was. And I thought I'd explained it adequately, but the consultant there was confused and said, but weren't you happy that it wasn't cancer or something really serious? And I think that can be the default for a lot of healthcare professionals to be like, well, you know, be reassured by that. But of course it's disconcerting to not have an explanation for suffering that you're still experiencing. So do you touch upon that in how you mentor people, talk about it in training? speaker-1 (21:52.814) We do to an extent. The challenge is when we are teaching people about investigations, the level of training they get varies because certain investigations may be performed by multiple different healthcare professionals. So a set of Euro dynamics, like you said, a bladder function test might be performed by a nurse. It might be performed by a junior doctor. It might be performed by a consultant. It might be confirmed, confirmed, performed by a clinical scientist. It could, and they all have. different levels of training and baseline understanding of why. I'm so predominantly when I'm teaching in my own unit, I'm training doctors, nurses, physios and midwives. And at the university, it's midwives, physios and nurses predominantly. So when we are doing the training, my main focus is understanding why we're doing the test, what information it may give us, more importantly, what information it won't give us, but also why it may be an unreliable test because not every test we have is perfect. There is a nuance in certain tests that don't pick things up or this certain problem won't be picked up or actually this test for, know, it does it in 90 % but there's 10 % where it's not going to pick it up. So a lot of the education we do is about when this won't pick it up. For us, sometimes it can be frustrating when we're doing lots of tests and we can't find something wrong as well. Because it's not that we don't want to believe people, we don't want to believe that people are just sort of, can recognise the stress and the anxiety, but sometimes for us, when we're not getting answers, it gets quite frustrating for us and quite stressful because we're thinking, well, what aren't we doing right? And what the new reality is, is we can rule out certain things. We are looking to say, well, it's not this, it's not this, it's not this. If we've ruled out conditions or problems, We're then just left with symptoms and we then have to go back to symptom management. But the problem is certain treatments that we offer are only for conditions, not for symptoms. So it then just makes it slightly more difficult and nuanced to figure out how to help. speaker-0 (24:07.918) for you then, Kiera, because it's an interesting process to go from tests are normal, there's nothing wrong. Then I think you said you had a good GP that said, let's take another look at that. Could you explain or share a little bit more about what that was like? speaker-2 (24:23.38) Yeah, so that original experience I had, I think you've got a a great attitude too to how you kind of communicate with people. that doctor that I had maybe was not quite the same. It wasn't as yeah, understanding. so I think I don't know if it was because of my age at the time as well. I I didn't fall into the category of having the typical person who would maybe have the problems that I have. so I was I was the way that this doctor maybe tried to reassure me with saying that his His sister had problems similar and it's just typical women's problems. So that and so I went back to my GPO, I was like, I'm not doing it anymore. I'm not I'm not I'm not seeking help again. so yeah, that kind of made her a little bit more passionate about helping me to get help. so yeah, when I went back in the second time, I was really nervous. I remember I was away, it's my first operation, so it was a big deal for me, quite scary. I was away to be put to sleep and I I said to the doctor, whoever was up on this side, I was like, I'm really sorry if you find nothing. It was I I genuinely thought they were gonna put me to sleep and spend all this money and just find nothing. So I apologized. I feel it now. and I and then I remember when I woke up, they told me they were like, We found something. And the the relief, the wave of relief, I just Amazing. And I mean it's it's something it's a problem that I'm still living with. It's not it's it's not a good thing. But at that time it felt yeah, amazing to hear that. speaker-0 (26:00.002) Yeah, what a strong reaction, know, apologizing to the doctors, that sense of responsibility so strong, but also how powerful to recognize the relief of getting some clarity on what's happening. And at that point, of course, you've got clarity and then there's a lot more to figure out. And how do you experience, you must again see a whole range of different reactions when people start to find out everything from we can't really figure it out right now. And I'd love to explore a little bit with you about the symptom management aspect outside of diagnoses, but through to, we have found something from the kind of patient, broader patient lived experience as a human perspective, how do you work with that as a healthcare professional? speaker-1 (26:52.782) So I think there's real different ways, there's so many variances within this. So within my clinical practice, I see a real range of women. So I see from teenagers all the way through to end of life care, but I also work within a tertiary referral unit. So I see a lot of women for whom it's their first time they're ever seeking help, all the way through to women that have had multiple investigations, multiple surgeries elsewhere. that have been unsuccessful and are sort of coming as a last ditch. I think the perspective between the two is very different. I think the women that have been on a long road and had either treatment failures or treatment success for a while and then a recurrence of a problem or have had lots of investigations or treatments elsewhere with no response, their reaction is always very different. And it is often a pure relief that There's a name, there's a diagnosis, there's something that that's tangible problem that can then do something. For some of the first time patients coming through when you're doing something and then you give them a diagnosis potentially, sometimes for them, that's almost more a fearful factor or a bit more. I don't want to, the word crushing isn't the right word, but it's that they've been given a diagnosis, what does that mean? Because the people have gone through years of trying to get answers, that's what they want. The people that are at the start of their journey, then they get an answer. That's not necessarily what they want. And so there's this real differential view between where on your individual journey you are. I think it also depends on some people come looking for answers. Some people come wanting to rule problems out. some may have symptoms, but actually they're not all that bothersome. And they just want to know that there's not a serious problem, underlying things. And they just want tests to rule things out. And then they're like, okay, I don't want anything more from here. As long as I know it's nothing bad, that's it. And so I think that perspective of what that individual wants from the consultation, from their management. speaker-1 (29:17.304) then depends on how we would respond. speaker-2 (29:20.172) find that so interesting hearing the difference there. It makes a lot of sense because when I find out that there's something wrong, I then had hope because you know there's something wrong. Now we can do something about this. that that perspective has changed over the years. But at that time I I that gave me hope definitely. speaker-0 (29:38.838) Yeah, so it's kind of the timing of the journey and the experience of the journey, plus the degree of impact, I suppose, of symptoms that informs the headspace of the individual going through it. And then that theoretically, hopefully informs how the healthcare professionals relating to the person to support them. speaker-1 (30:00.994) You'd hope so. As healthcare professionals now, we are trained and we are taught to try and individualise. We've gone away from trying to do everything the same. It's all about individualised care. And when we're individualising care, it's not just about to that symptom, it's about to that patient, it's about managing expectations, it's about how we communicate. And in order to that, there has to be a level in which that healthcare professional can gauge. And often now, as a lot of the doctors are taught, when we're seeing someone for the first time, we no longer go in with this is what we can do. It's like, and what would you like from today? Because sometimes it's some people just want to chat, some people want tests, some people want treatment. It's about what would you like to achieve from today? And is that realistic and attainable? And so we've changed that perspective on how we start conversations and how we plan what we're going to do. speaker-0 (30:57.334) Yeah, that patient-centred care. And I know that's variable, as we heard just from your experience, Kieran, I know I've shared from mine, but it makes such a difference, right, to know what the patient's goals and hopes are. speaker-1 (31:10.86) Because often the challenges, those goals and hopes aren't necessarily realistic or appropriate. know, lots of people say, well, I have a friend that's had this or I've tried this or someone else. I know someone who's had this and I want this. And it's justifying actually why that may not be appropriate for them. So we need to manage expectations before we start anything else. speaker-0 (31:35.086) because I was thinking about this the other day. That must be a really hard thing to do as a healthcare professional and a human to be like, oh, they want this and that's just not possible and have to give that truth. How do you manage that and how do you help your colleagues to manage that so that they can do that in a safe way for their patients, but also, I guess. for it not to impact them quite so much, because it's a hard position to be in. speaker-1 (32:07.086) Absolutely. And it's a challenging one because there's not really a good set up for that. As healthcare professionals, we're taught some communication skills, but a lot of it's learnt on the job. Some people have better communication skills than others. And although you can try and teach someone, there are some people that you're never necessarily going to be able to teach that way. A lot of it now focuses around patient education because if we can... educate and inform and create expert patients and understand why. That's how we then rationalise things. But if people don't understand why we're saying what we're saying and the rationalisation behind it, that's why there were challenges. In some healthcare professions, so people like physiotherapists are really great because they have lots of clinical supervision, they have debriefing, they have time to sit down and chat and work through the challenging cases. nursing and medicine aren't so great at that. And, you know, we'll have MDT team meetings where, so a multidisciplinary team meeting where we'll sit and we'll chat with other colleagues and we can discuss it with other people. Have you ever had something like this? How do you do it? But we're not as good as debriefing and having those supervision as in others in psychology situations and bits. So I think that's something that within a classical sort of healthcare physical healthcare setting we're not good at and we're not supporting staff well at doing. speaker-0 (33:38.688) I was talking the other day with some friends about before the pandemic as a psychologist, we were set up in a really lovely way in my service in the NHS where we would have these communal rooms and then when we go have therapy with people, we'd go off obviously in individual rooms when we come back. you'd come back into this group room of people and if it been a challenging session or if there'd been something come up that was interesting or that you were reflecting on or difficult, you had like this room of different people. It wasn't all the same profession either to just discuss it and debrief whilst people are doing their notes and they're doing their different bits. And what was really interesting was when the pandemic hit, obviously everything changed. When you could then go back into work and you could be in that setting again, this is an individual experience, the building had changed. So everyone was still in these siloed rooms. and the mental health of the staff just plummeted. We had such a big turnover of staff, obviously the effects of the pandemic more broadly, but I also just thought a big part of it is we're not getting the opportunity to debrief. And I'm thinking about the realities of the NHS, everyone being very busy, but do you have ideas and about how that could be better for nursing staff and doctors? speaker-1 (35:05.464) So I've got ideas, but I think one of the biggest challenges, yes, we would love time to debrief. We would love time to sit down. Sometimes the challenges is particularly in specialist roles, there aren't many around. So you may be the only specialist nurse specialist in that thing in your hospital. Now, you'll have doctors or a physio to work with, but it's about wider networks. We try to do it for certain things. but it's then actually having dedicated time within your job plan. know, time is a massive factor. Time is an issue in having the consultation. If we're doing sort of a clinic and we only get 20 minutes per patient in which you're meant to do the consultation, do all the plan and all your documentation. Having difficult conversations, having conversations where you need to provide the education, the counseling, it's difficult. And then if you then end up taking 40 minutes with one patient and then you're running late and it then your next patient start getting a bit antsy and sometimes you can understand. But it's when we're only getting a short space of time. I think that's one of the challenges we have to be able to provide everything now. Yes, in an ideal world. Some again, some healthcare professionals like a physio for a first appointment get an hour. Now, I would love an hour as a first appointment for a new patient, I get 20 minutes, you know, and the time and the education and the counselling and the communication you can get through in that time would be so much better. But when you've got people waiting a year for a first appointment, if you're seeing three patients now versus one, you're going to think of the time the waiting list would be. We don't have the specialist staff. So the focus within a lot of it at the moment is just to get patients in and be seen. And the longer people are waiting, the more symptoms they're having, the more frustrated they're becoming, the more challenging that is. But if we've not got enough specialists to be able to see them, then the debriefing almost becomes, yes, we'd love to set up a perfect service where we have everything set up. But sometimes the focus is just getting patients in and seen. speaker-0 (37:14.434) Yeah, the pragmatics and yeah. And Kira, just thinking about that, because I know we've spoken about this as well, the difficulty of time and consultation. From your experience, what have been the ways that healthcare professionals have communicated with you? So you've been navigating this in, know, short periods of time, as well as perhaps if you've ever had experience for longer consultation. what sorts of things have made a difference and perhaps maybe a contrast between things that have been particularly unhelpful and things that have garnered a sense of hope or support. speaker-2 (37:56.404) Yeah, yeah. so actually what you'd said they're the way that you start a conversation, asking an open question. And as I think you might notice this as well. If somebody's had treatment for a long period of time, they maybe come in with their guard up a little bit. And I do that and I don't mean to, but you go in thinking the worst sometimes and you just don't know what you're gonna get, if it's gonna be helpful, you've waited on the waiting list for so long. so you go in ready. and if somebody just gives you that space to Just say a little bit about what's been happening. It's it's it's to me that's really yeah, really useful because it feels like they care. Even if it's five five minutes, I just get to say my bit and then they come in and then we talk together. It feels much more collaborative rather than just being told, This is what I think you should do. So speaker-0 (38:47.598) And I guess it feels much more relevant to you having felt like you've been heard at some point. Yeah. Do you think then, and not to put you on the spot as a spokesperson for Continence Nursing and care, but do you think that there could be feasible ways of supporting healthcare professionals to incorporate a bit more of that interpersonal element? speaker-1 (39:16.088) So NHS wide, it's, you you'd hope that all healthcare professionals would have that and it should be part of undergraduate training. Now, yes, there's an element of communication skills within undergrad training, but actually until you're out there on the shop floor doing things, I think one of the challenges is communication skills vary differently between different groups. And for me, working with someone with a continence problem that is a very personal problem that has a significant impact on daily life would be very different to the communication skills that you need for someone that's looking after someone with end of life care or very different to someone working with a paediatric population. So I understand why at undergraduate level you have a core because you never know what area you're going to go into and you have to learn to adapt your communication skills to the needs of your population. The problem is postgraduate education is so varied and a lot of people don't have access to it. There's no sort of mandatory communication training. You know, if you're in certain roles, they give you access to things on breaking bad news. If you attend certain external courses sponsored by companies, they're starting to recognise motivational interviewing skills, things like that. But getting time out to do study days. It's impossible. There's no money for postgraduate education at the moment. So there is a sort of a focus within the NHS to try to invest in some education. But the reality is, again, the focus is on the more specific skills that people need and training specialist skills rather than actually being able to create a holistic practitioner. speaker-0 (41:05.518) I mean, I'm obviously very biased here, but do you think there's a bit of short sightedness there in terms of recognizing that those sorts of skills actually could enhance the physical health outcomes? I'm thinking very specifically around perhaps even the training, how somebody might catheterize when they realize that they have to. What difference does it make? And I'm sure you see this a lot between someone that... learns the technical skills of catheterizing, but whether or not they go on and do it is a different story. speaker-1 (41:39.128) think it makes a huge difference. And I think the really sad thing is it's practitioner dependent and it depends on their experience. It depends on their knowledge and it depends on, think, sometimes their own life experiences. And I think a lot of people that go into a specialist field, something like continence, have often had an issue or have experience of a family member with an issue because the reality is it's not a sexy area that, you know, people think, I want to work with P or Poo when I grow up sort of thing. It's something that you've had a family member thing or developed an interest in because there's a link to it. And often that's how people develop their style. Well, actually I've had something similar and you can, there's that shared understanding. It's not generally something that you just go to because it's a job, you know? And I think, but there are some people that particularly when it comes to catheterizing, their job is just to teach catheterization rather than dealing with the whole thing. they don't recognize the life beyond the catheter. And the catheter is, it's a skill, it's a technique. But actually, the skill is not in performing catheterization. The skill is in adapting it into your everyday life and managing it in social situations in life, not a process of take this out, put this in this whole weight and pull it out. And I think people have missed that view sometimes because we have gone, is a procedure, not a way of managing everyday life. And I think that's where we are missing. But again, it comes back to education, access to education and time to start exploring all those things again. Some places it varies. Some people get 20 minutes to learn to self catheterise. Some people, I'm lucky I block out an hour if I'm going to teach. But you know, I can, it depends on some people get 20 minutes or half an hour to do that all in. It depends on your local processes and what people are doing. And that's the challenge, the variation and what some people will and won't challenge and can and can't challenge to know any different. speaker-0 (44:03.064) Kiri, you said wow when you heard that and she has an hour. Could you share a little bit about what that would be like in that hour, how you would go about helping someone learn to catheterize? speaker-1 (44:16.28) So first thing I want to say is though, I've been teaching people to catheterise for nearly 20 years. And actually in the last few years, I have hugely changed what I do. The first thing I do is I actually teach far fewer patients to catheterise. And the reason I do that is not just because of the service pressure on clinics. It's that actually what we now have is far more company nurses working in the community that will go to someone. home and teach them to catheterise at home. Because me teaching someone a procedure in a clinic room, in a room that's well lit with a hard couch with a person sitting there, it's very different to you going home and doing it in your own toilet or in your own bedroom. And one of the biggest challenges was people then being able to, yes, fine, it's easy doing it in a procedure room, but going home and working out how you're going to do it in your own environment is half the challenge. speaker-2 (44:58.368) It is speaker-1 (45:12.364) So the recognition is, actually from an anxiety and usability point of view, you're far better to be taught at home. So wherever possible and wherever they consent, I will always send a patient to be taught at home rather than in my clinic. And I tend to see more the patients that are maybe having issues and then need a bit of troubleshooting, tweaking with other bits rather than knowing actually which position am going to sit in my bathroom? Where am I going to put this on? Which side am I going to put this on? Because Half the time, I'm guessing if you were taught in a clinic room, that was the biggest challenge back there. But actually what I tend to start my conversation is, is an understanding of why you need to catheterise and what I hope a difference it's going to make. A bit about anatomy. And then I'd start to get someone to hold a catheter, trial it, feel different ones, generally try variety, see which ones you like, which ones you try. And then my next question is... When are you going to be catheterised and what's your normal life? know, do you work from home? Do you work from an office? What's the set up there? You know, sometimes I have one patient that's an air hostess. So actually when I told her to catheterise, I told her off in a boxed off corner in a clinic room that would mimic an aeroplane toilet standing up knowing that actually, and so it's about when are you going to be using it and what environment it is. And I think that's the change I've made with years of experience, because when I started off doing it, definitely never did that. I definitely was very much, this is a procedure, I'll teach you how to wash your hands, I'll teach you how to part your labia, I'll teach you how to look at where you're going and grip a catheter. But actually, my learning and my progression, that's what's changed over the years when I've seen that actually, if I don't deal with that bit, that's why people don't do it or can't do it because you haven't worked out how to put it into life for them. speaker-0 (47:05.218) that translates from research we have in psychology, revising in a particular context when it matches up to the environment that you're gonna then be tested on, you do much better because the context matches up and it makes so much more sense in this context as well when it's procedural sort of memory stuff. And Kira, can hear, was that very different to your experience of learning? speaker-2 (47:32.342) Makes me so happy to hear that you do it that way. That's that is just amazing. So I had a very different experience. so I actually started to learn to use the catheter during COVID times. and I was living in Aberdeen, but I was being treated by Glasgow at that time. So it was through phone call actually. speaker-1 (47:50.51) There was a lot of virtual learning, phones, video calls during COVID. speaker-2 (47:56.266) Different time. so the nurse that she she was lovely, but she was just so limited on what she could do because we the distance and yeah. so what happened with me is they sent up a pack of various catheters. I there's about six in them. She was like, try them all and then pick your favourite one. and she did warrant me pick it pick it based on how it feels and not how it looks. So that was good advice. so yeah, I had only used a catheter before and it was years prior to do bladder installations, which is a much longer catheter, putting it in and putting medicine in. And that was lying down on a on a bed. having to transfer that skill to then trying to do it over a toilet was really, really difficult. So hearing you actually go into people's homes or having someone go into someone's home and teach someone how to do that at home is just amazing because I struggled and I made so many mistakes and Like even understanding your body where to aim, where so it's really hard. It's speaker-1 (48:58.456) Something that, you know, it's often the companies that break the catheters are providing these home care nurses that will go out and do it. And it's to take the burden off hospitals because people are waiting a long time. There's not the time. But actually the evidence shows that it's better. So I can't go to someone's home and teach them there. But I have to say that this is not an NHS nurse. They're a qualified nurse. They are specially trained to do this. I have to give your personal details to a medical company. Get consent to do it. speaker-2 (49:12.664) So much, yeah. speaker-1 (49:28.088) So much better. speaker-0 (49:31.148) And so, you know, I'm interested in what you were saying, Keira, there about learning your body. What was that process like? Because, you know, going from my bladder works this way to now it works this way and I have to have some involvement. What was that process like for you? Just broadly speaking. speaker-2 (49:50.862) frustrating because my body wasn't working in the way it wasn't it didn't feel like it was working with me. so at the point when I started to use catheters, my I was already having a lot of symptoms. My my biggest problem was during the night. So I think at that time before using catheters, I'd get up eight to ten times in a night and that was fairly normal for me. I was shattered but that was the incentive to try and learn how to do this so I could drain properly. But the first few months, maybe six months or more, was just awful because I was learning how to do this new skill, but I just kept getting infections. and it felt like it was making things worse, much, much worse. I was I was unwell so so often. so yeah, I I questioned whether I should keep going if if it is doing more damage to my body rather than actually something that's helpful. But yeah, trying to be persistent with it and and push through when it was hurting was hard. speaker-0 (50:52.238) That's really hard. Yeah. How would you talk with a patient about that experience? speaker-1 (50:59.406) So I think it's a case of trying to understand what we were aiming for the catheter to do because people catheterise for many different reasons. For some people it's because they are not emptying their bladder completely. For some people it's because they can't empty at all. For some people it's to put medicines in. Some people catheterise seven or eight times a day. Some people catheterise once a day. So it's understanding that individual why they're catheterizing and what the aim of catheterization is. Because for some people, if they're just not emptying the pee to catheterize before bed helps them sleep for the night versus they cannot pee at all and they have to do it to protect their kidneys. I'd then look at what it was and wasn't helping and what new symptoms it had created. Because it's then going well, if it's created recurrent infections, then I would start looking at the technique. that you're using to make sure you're not introducing infection. I would look at potentially the catheter and the coating if it was causing pain. I would look at the length of the catheter because sometimes the shorter catheters, although they look lovely, don't actually get all the way in and drain your bladder. I would look at when you're catheterizing, how you're catheterizing. I would look at what else you're doing around it because catheterization is great for many things, but it doesn't mean that you can then change all of the other things that we're doing for general prevention and health if you're still not drinking enough, if you're getting constipated, if you're not having the hygiene in the right way, it's not going to help things. So it's looking at the bigger picture around it as well. speaker-0 (52:38.648) Did you make sense of what was making you unwell and figure that out and what was that like? speaker-2 (52:43.778) I'm not sure. I think like what you'd said there, I think it was my technique, probably. this some of it was technique, some of it was maybe the catheter that I was using as well. I'm now on a different one that's much better suited to me. but yeah, I don't I never got an answer. I actually I was put on antibiotics for two years at that time because it was happening so often. and then it yeah, it just it stopped after a while and I don't I don't really know why. speaker-0 (53:12.8) intrigued because that's a really hard experience to have to persevere with. How did you manage that I guess from like a psychological well-being point of view? speaker-2 (53:25.802) For a while I did I just didn't manage. I just it was just but yeah, pushing through. lots of sleepless nights because with when I get a UTI when I get a bad one, it is you're up all night. Some nights you are taking the duvet into the bathroom and you're just camping out in there. Yeah, and it was just exhausted because it did it had a massive impact on my sleep as well. I think begin with I didn't talk about it but eventually when I was maybe a a bit more used to using it I I opened up a little bit more and that was helpful actually just speaking to people. I did a lot of research at that time in the middle of the night I remember online just trying to figure out what's wrong trying to find an answer but I was googling things and that was just taking me in all different directions and then I would get more stressed because I didn't know what I was doing. Yeah, it just felt like I was firefighting the whole time. And eventually it settled and I I got more used to my new way of living. I think it was adjustment in in how I was living. And that fear of having to l do this out with the home as well. That was a whole new step. It was just learning at home was hard enough. speaker-0 (54:41.612) Yeah, because I can imagine then being confronted with the impact of exhaustion, infections, feeling unwell, that builds fear understandably. And then as you were saying earlier, and when you when you have fear around urinating or empty on your bladder that also can create difficulties. So you must have done a good job then, Kira, somehow of like helping your body to kind of let go of that fear or reduce it so that you could carry on. you have some kind of reflective insight? Maybe it wasn't, you know, on purpose necessarily, but you found your way to it. speaker-2 (55:21.976) think I noticed patterns of the way I was that maybe wasn't entirely helpful. So I would go in I'd I'd swing between this is going to be something that's going to help me and then something that's actually really harmful. And if I approach I remember looking at them and thinking, I'm going to try it now. And I had to really psych myself up to put one in because it was scaring me. and I had to stop I had to stop approaching it quite negatively because when I did my f my whole body was tense. And if you try and put in a catheter when you're tense It hurts. so I recognized that and I started to change that. I was like, I'm gonna try it and see what happens. And if it doesn't work, if it doesn't go in, it's it's fine. And even just tell myself that was so powerful because before, if it didn't work, if it didn't go in the first time, I'd be quite harsh towards myself. So maybe just that little shift in mindset was helpful. speaker-1 (56:13.902) only try distraction techniques. I sometimes get women to listen to music in the bathroom or have an audio. Like that, just to have some sort of distraction to try and... speaker-2 (56:27.192) That's helpful because I put so much pressure on myself to I need to I need to do it right. And when I didn't, it was disaster. speaker-0 (56:35.15) Yeah, it's so interesting to think about the mindset and the almost harsh critical nature of do it right or versus it's okay if this doesn't work now and how much that actually changed things for you. And also then thinking about that context. I might say it's not necessarily distraction, but it's enhancing the environment, you know, so that things can calm slightly and it can help the system. Can I ask you, Ange, about the UTI fear in the context of catheterizing, because obviously it can be a big issue with catheterizing and something that you've experienced, Keira, but also just broadly, we were talking before we started recording about UTIs, recurrent UTIs and that kind of thing. How do you navigate that when people are fearful of... catheterizing maybe because they know that it'll give them an infection or when people are presenting with recurrent UTIs, what would you be looking at? speaker-1 (57:41.282) And so I think, again, it's two perspectives. There are a group of people with recurrent UTIs and it's because they're not empty in their bladder. So the aim is you're teaching them to catheterise with the aim of emptying their bladder to prevent the UTIs. But then you also have the group of people that can't pee and weren't necessarily getting infections that then worry about that risk. We know that for people catheterising when they're catheterised at least a couple of times a day, from the evidence most will get, two to three UTIs a year for most women. And that is just a pure process. And the problem is UTIs are so multifactorial, trying to pinpoint it just to the catheter. Often it's a dysuria, it's a discomfort, and that makes it feel stingy like you have symptoms of cystitis. And so then we think about alternative catheter coatings, alternative sizes, styles, different tips. There are different product characteristics that we can use for discomfort. The reality is we need to be honest with people, you know, we can never promise no UTIs any treatment for recurrent. We can't promise no UTIs because actually that's not normal. Women are prone to UTIs. It's about trying to reduce and risk assess and prevent. So it's then teaching them about the hygiene, the positioning, technique. And it's about trying to say, we're trying to prevent this. Look at all the things you're doing. If you get one, we need to manage it. But actually, maybe one UTI a year compared to six that you used to have. We know it's not pleasant, but it's a lot better than it was. Or yes, there's been a UTI, but actually look at what we've protected and we don't always want to spin it in that way because we'd love to say well you're never going to get a UTI but there are things that we can look at differently and try to reduce risk and prevent. speaker-0 (59:45.144) So Kira, were put on long-term antibiotics, you were saying. Would that be something that you would see in your practice that people might get, or would there be other? speaker-1 (59:56.088) There are some schools of thought that think that there are alternatives and we come again to the there is no one treatment that is right for everybody. And again, we're working through that spectrum. For me, if I've got a woman that's postmenopausal, I'd always be looking at vaginal oestrogens and hormone replacement therapy vaginally, as that is one of the most effective things to prevent recurrent UTIs in postmenopausal women. There's also a drug called methamphetamine hipuret or hipregs that is The only sort of non-antibiotic thing we have, it's a urinary antiseptic that prevents bacterial colonisation. And NICE guidelines now actually puts that above sort of long-term antibiotics. If it's just a one-off antibiotic for sex or post-trigger, they use a single dose. But rather than continuous antibiotics, NICE say we try hip racks first as a treatment to prevent infections. We have vaccines now available to prevent recurrent urinary tract infections. Now, they only work for certain bacteria, but if there have been more than certain number, but again, it's working through treatments. We start off with the simpler ones. We then might do a prolonged course of antibiotics. If that's not working, we then might look at the vaccines. People are doing installations into the bladder. either with drugs to prevent infections or with antibiotics. Gentamicin installations is something that's used in a lot of places now. But again, that's not going to be the first thing we start on. We have to work with the simplest and work our way through. And we get it that it gets frustrating when problems aren't being managed with one thing. But if you throw everything, could it begin with, A, from a cost point, but from a side effect perspective from a thing that doesn't work either. So it's finding that balance. speaker-0 (01:01:43.064) think people will be surprised to hear that there are vaccines for UTIs. Will you share a bit more about that? speaker-1 (01:01:50.094) So they've been around in Europe for sort of a while now. We've been using in the UK for sort of about five to six years. Lots of places still aren't using it. It tends to be in the specialist centres. So you often have to go through a process of multiple investigations and multiple treatments first. The important thing to know is it's not that you have a vaccine and then that you save for life. Often in the same sites of other things like the flu vaccine and things like that, most of them generally say to be for about 18 months to help prevent. Some of them only work for, so there's one vaccine that's just for E. coli and it's 19 strains of E. coli. It's a tablet that you take for 90 days. The problem with that one is there are far more than 19 strains of E. coli. So if the recurrent infections you're getting with a different strain, it may not work for you. The other one covers is called Euromune. That covers E. coli, enterococcus faecalis, Proteus miribelis and Klebsiella. But again, if your infections aren't due to one of those infections, it's not going to work. And often it can be that you don't tend to get resolution. It's sort of 90 days of treatment and it's not going to start preventing things straight away. But with 90 days of treatment, there are good results. There have been clinical trials in the UK. And like I said, in specialist centers, it's something that can be available. But you have to, for us, in that it may be a fifth or sixth line treatment rather than something that we'd be starting with. speaker-0 (01:03:20.878) And I think even that is quite hopeful for lots of people, similar to what you were sharing earlier, Kira, when at the outset it can potentially feel quite hopeless, especially if you get a no or this isn't quite what you'd expected. Our brains quite easily shut down and think, well, nothing's going to change. I know I experienced that as well. But just hearing you speak, Angie, about, well, actually there's quite a lot that we can explore and try. speaker-1 (01:03:49.368) There are. I think at that point as well, one of the most important things to do is go back to basics because often, sometimes the simplest things that were started with have then been forgotten along the way and missed. And I think it's really important that I want to stress that even when we get to gay these bits, one of the things that I'm going to be doing starting these is going back to basics of are you sitting on a toilet? What are you using to wash with? How are you wiping? and doing the basics of prevention. Because if we don't look at the whole picture again, it's no one thing is gonna make it better. It's the whole package that aims to get you to be managing symptoms well. speaker-0 (01:04:31.896) Has that been helpful to you, Keira, to think about it in that way? And I guess an extension of that question, as we come to the end, is just thinking about what do you think from your journey and experience have been the things that have helped you expand a life that got smaller and maintain a sense of hope and connection with yourself? speaker-2 (01:04:58.094) So I think that that idea of the whole package really resonates with me. because it is it's more than just the product that you're using. It's that life adjustment as well, but it's also building confidence in what what I what I was doing at the time. I was scared to do things for a really long time and it was a little bit of trial and error and pushing myself out there, maybe pulling back a bit, doing something new. and over time you really do build confidence. You learn that you can do things that me five years ago just wouldn't have even considered. It would have been an absolute no. but now, yeah, so many things have been possible. I can travel public transport, I can travel to different countries. running, I can run I can run. I kinda can try and run. but different types of exercise that I just wouldn't have been able to do or I I thought that just wouldn't have been possible before. but that hasn't come instantly. It's come from years of trying something maybe it didn't work out trying something else and yeah that's yeah alongside the physical treatment in the in the product that I've been using it's a combination of everything. speaker-0 (01:06:07.086) There is a tenacity there, isn't there, of, this doesn't quite work out, let me try something else, or let me go back to it. What's helped you do that? Because I know that's hard thing to do. speaker-2 (01:06:17.848) So that's a very that I had to push myself a little bit to be more like that because before if I tried something and it didn't work, I'd feel like I'm never doing it again. It didn't work. I'd be quite negative about it. But it's giving things a chance, I think, and doing things more than once as well and learning that if I do something once and it doesn't work out, well that doesn't mean that I can't ever try again. I'm just being a little bit less black and white about things. speaker-1 (01:06:42.446) this in combination with this because often things work well in combination rather than in isolation. speaker-2 (01:06:48.682) Yeah, yeah, and trying different combinations as well. speaker-0 (01:06:52.296) It's hard balance, it? Because it's like, we must try multiple things, but we don't have to try everything. We need to give ourselves balance. It actually is hard to navigate, but it's so important. And, you know, just to reflect that. is such a hopeful picture to paint, Kira, of how you've managed to do that because thinking about the beginning of your journey of not wanting to even talk to the doctor about it and now you're on a podcast discussing it, you've done lots of work with ConvertTech and in big presentations at conferences, sharing your experience. So what a big transformation personally, as well as having such a rich, life. speaker-2 (01:07:32.074) Yeah, yeah. And it's improved areas of my life that are nothing to do with my bladder as well, just confidence overall, I think. yeah, because the experiences that I've been able to do but even just having the freedom of using the catheters is just changed me as a person, which thinking back five years ago, me then would be like you're you'd never do anything like this. So yeah, it's it's it's amazing. I I wouldn't have believed it if you'd told me that back then. speaker-0 (01:07:58.146) That's incredible, isn't it? To think about what's changed from something that's actually really difficult. And Ange, I guess, just to finish on a sense of hope from a nursing professional in this area, how would you make people who are navigating these issues, maybe around continence, maybe just around bladder health difficulties, what would you want them to know to feel hopeful and a sense of... I don't know openness about what's going to come next. speaker-1 (01:08:31.768) So I think there's some hopeful points, but I also want to do a cautionistic thing. So from a hopeful thing, we're here. We want to talk to you. We want to try. Yes, may be vast differences in experience and views. There's sort of different things, but that's why there are options that if things aren't being sorted in a local area, there are specialist services that you can go into. And so just because you may not get the answers first time, there are... second opinions, there are other services with more in-depth things. I think the other thing to say is we're all still learning. I know my own style has changed very much over the years, like I said, with my journey on how I teach catheterisation. And I still don't get it right for everybody. There are still some people that my communication, that my way doesn't work for. And that's just sometimes we can't always. And as much as I'd love to be able to help everybody, I've had to learn that actually from my reflection is that I can try my best and I can try and do it, but I may not be able to do it. And I think that we are trying for the NHS as a whole is struggling and we're trying, but we can't always do everything as we would like to for everybody, which, you know, I get isn't great, but we are here and we're trying and there are lots of things we can do. speaker-0 (01:09:56.45) Yeah, and we'll get the details as well, you just maybe to give people some insight about. the access in the pathway to specialist services if they are a bit stuck, if that's alright as well. But yeah, thank you both so much for such a rich conversation and I think there's so many different angles that we've hit that people never get to really think about or discuss. So it's been so valuable having your perspective, Keira, with yours and from the professional point of view. So thank you very much. speaker-2 (01:10:26.038) Thank you for having us. speaker-1 (01:10:27.97) Thanks.