WELCOME ANNUAL GENERAL MEETING 2017 / 2018 Welcome from the Chairman Michael Fox Review of 2017 / 2018 and our priorities for 2018 / 2019 Jinjer Kandola Chief Executive Introduction First AGM as new Chief Executive

Thanks to Andy Graham and wider Team Thanks also to Michael, his last AGM as Chairman Will give a high level summary of achievements over the last year and priorities for this year and further ahead Context We operate in a system facing significant challenges: Increasing demand for services Continued financial pressures across health and social care o Underlying financial deficit

(costs exceed income) Major challenges in recruiting and retaining staff Successes in 2017/18 Despite these challenges, we continued to improve patient care: 91% of our patients say they are satisfied overall with their care 92% of carers say they are satisfied overall with the care we provide 95% of our patients say that they are treated with dignity and respect All improved since 2016/17

Successes in 2017/18 Progressed redevelopment of St Anns Hospital sold surplus land to GLA for residential use, work on new mental health inpatient building due to start soon Significant improvements noted in Care Quality Commission inspection, well on the way to Good then Outstanding Improvements in recruitment of permanent staff, significant reduction in use of temporary staff, but remains a challenge

Extended Quality Improvement Programme across the Trust. Major successes, such as reducing aggression and violence on mental health wards Successes in 2017/18 Developing our role as Lead Provider for Forensic services across North London

Additional contracts to deliver IAPT services in Barnet and drugs and alcohol services in Enfield from 2017 Very positive BBC documentary with Louis Theroux showing the work of our regional Eating Disorders service Trust Objectives for 2018/19 Our short-term objectives for 2018/19 are: 1. Excellent care 2. Happy staff

3. Value for money services Future Trust Strategy and future priorities With a new Chair and Chief Executive, and other new Trust Board members, we will be refreshing our overall Trust Strategy in 2018/19 We will be engaging with patients, carers, staff and local stakeholders over the next few months to help develop our future Trust Strategy

Our main priorities are outlined on the next few slides Future Trust Priorities Our main priorities for the next few years include: Getting the basics right o Improving our services and our CQC rating o Achieving long-term financial surplus Developing innovative models of care for our services o Managing increasing demand through more alternatives to inpatient admission / additional beds o Continuous improvement through our Quality Improvement Programme

o Extending our Enablement Programme to improve the health and wellbeing of our patients Developing our workforce for the future o Continuing to focus on staff recruitment and retention o Strengthening our support to and development of our staff Future Trust Priorities Developing the Trusts leadership o Developing leadership, including clinical leadership, at every level Stronger local integration and partnerships o Greater integration of our services at borough level, particularly with primary care and social care services o Stronger partnerships with other local providers o Strengthening our role as a local health and care system leader

Improving our IT o Using our new IT system and new mobile technology to support staff in delivering better patient care and working more effectively Future Trust Priorities Developing new services and business growth o Continuing to grow our services, particularly in areas of clinical expertise Improving our estate o Continuing to improve our estate for patients and staff o Redevelopment of St Anns Hospital is due to start this autumn

- new inpatient wards completed by late 2020 and full refurbishment works finished by 2022 8 Summary Lots of positive progress over the last year, which we will build on in 2018/19 and beyond, with new Trust Board soon in place Developing our future strategy for what kind of organisation we want to be in the future Positive and highly engaged staff, with great ideas and innovations Significant progress in developing our IT and our estate, particularly the redevelopment of St Ann's Hospital Quality Account 2017 / 2018

Jonathan Bindman Medical Director Our Quality Account 2017 / 2018 Reflects and reports on the quality of our services delivered to our local communities and our stakeholders Demonstrates our commitment to continuous evidence-based quality improvement across all services Demonstrates the progress we made in 2017/18 against the priorities identified and outlines our key priorities for 2018/19. Sets out for our services users, local communities and other stakeholders where improvements are needed and are planned Highlights areas requiring support from our stakeholder groups

Examples of quality performance and quality improvement initiatives, 2017 / 2018 Implementation of weekly Clinical Mortality Review Group to review all deaths reported to assess if further investigation is required North London Forensic Service selected to lead a new care model across the whole of north London for secure services Physical health care leads appointed in each Borough to support the Trust wide implementation of the Physical Healthcare Strategy priorities Quality Reviews of wards in response to a sequence of concerns highlighted through incident reporting, complaints, staff and/or the Freedom to Speak up Guardians Examples of quality performance and quality improvement initiatives, 2017 / 2018

Suicide Prevention and Awareness Strategy developed and shared across the North Central London Sustainability and Transformation Plan Introduction of After Action Reviews to improve the timeliness of learning after an incident has occurred and the prompt identification of areas for improvement Links domestic violence project shortlisted for the Innovations in mental health HSJ award Experts by Experience (EbE) recruitment day attended by over 100 people. EbEs are already providing valuable input into a number of our services (part of our Enablement project) Quality Priorities 2017 / 2018 We identified three quality priority areas for 2017 / 2018.

They built on our quality priorities from 2016 / 2017, recognising the areas that required continued focus They were part of a broad programme of quality improvement work to improve patient safety, clinical effectiveness and patient experience Quality Priorities 2017 / 2018 1. Patient Safety - Improving the physical health of our service users 2.

Patient Experience - Dementia Care; improving end of life care 3. Effectiveness - improving systems for sharing learning within and between teams across the Trust Improving the physical health of our service users Examples of initiatives introduced in 2017 / 2018 which have led to improvements in the physical health of our patients New Physical Health Care Strategy A wide range of

physical health care training provided to all staff groups by a number of providers All nursing staff within Enfield Mental Health Services for Older People have received training in the recognition of the deteriorating patient

Physical health care leads appointed in each Borough Physical health care champions appointed in each ward and service Specialist nurse roles within Enfield Health to lead clinical physical health work and contribute to Trust wide clinical

leadership, in tissue viability, diabetes and falls Successful work on health promotion within North London Forensic Services; wards have pursued initiatives on exercise and diet Implementation of NEWS system for physical observation All wards compliant with NEWS audit (target 90%)

Diabetes competencies for nursing staff working in MHSOP; training and education in place Eating Disorders effective pathways implemented for working with acute Trusts to achieve high standards of physical care Specific physical health related audits as part of Trust wide monthly

Quality Assurance audit Regular visiting physician to ensure good standards of care on older peoples mental health wards Dementia Care; improving end of life care of our service users Examples of initiatives introduced in 2017/18 to improve the experiences, health and well being of our Dementia patients and their end of life care Dementia Strategy developed.

Associated work plan provides steer for implementation of aims Dementia (NHSI) self-assessment tool piloted on Magnolia ward with a view to rolling it out on other Trust wards Band 5 AHPs Interactive Training on Dementia,

Training for CHAT (Care Home Assessment Team) All 3 boroughs accredited with MSNAP (Memory Service National Accreditation Programme) Silver Birches dementia friendly improvements to environment All students in

clinical areas given dementia awareness training. Over 100 staff trained Six monthly audit of expected deaths evidence of optimal care for palliative care patients Quality Improvement project to implement the Magic Table in one ward. The aim of the

project was to enhance the lives of people with dementia by improving interaction and communication with them. Enfield MHSOP staff trained in End of Life care Dementia Awareness Dementia friends is essential training for all staff working

within Enfield MHSOP Forget me not meet and greet volunteer scheme started in Memory service, Haringey to ensure service users first contact with the service is positive Improving systems for sharing learning within and between teams across the Trust Examples of processes and tools introduced to improve and embed shared learning across teams to continually improve patient-centred, safe and effective delivery of care to our patients. Regular

programme of Trust wide Berwick Learning Events covering a range of including smoking cessation, physical health and suicide prevention. Over 100 staff have attended. After Action Reviews introduced enabling reflection and prompt learning by teams involved in

incidents. Development of Ward / team level Quality dashboard. Trust wide thematic reviews of specific incidents e.g. AWOLs shared with teams across the Trust Deep-Dive meetings: an emphasis on quality improvement for every agenda, with the aim of enhancing learning in

the Trust Reflective Practice sessions commenced in 2017 Complaints, safeguarding and patient safety meetings to identify common themes and learning Enfield Learning Forum open to all clinicians within Enfield Health services. Topics

include Diabetes and mental health management Learning from serious incidents and investigations shared via monthly Quality News to all staff Screensavers with messages from safety alerts for awareness by all staff A patient story with learning and positive outcomes shared

across teams at every Deep-Dive meeting Feedback from commissioners in relation to the robustness of serious incident investigations shared across all Borough SI groups BEHs Quality Priorities, 2018 / 2019 Our Quality Priorities for 2018 / 2019 continue to build on our quality priorities from previous years, recognising areas that require continued focus:

1. Improving the physical health and wellbeing of our service users 2. Improving the quality and timeliness of patient risk assessments 3. Improving GP communication between the Trust and primary care services BEH service user feedback about our care and services Financial Review 2017 / 2018 David Griffiths Chief Finance and Investment Officer Financial Highlights Key Duties Achievement

Notes Breakeven on Income and Expenditure Actual surplus: 35.0m Planned deficit: (4.5)m Operate within Capital Resource Limit Capital Expenditure: Less Disposals: Charge against Capital Resource Limit:

6.0m (34.4)m Capital Resource Limit: 6.2m Operate within External Financing Limit (28.4)m Net borrowing limit: 1.5m Actual performance: (59.5)m 2017 / 2018 Financial Performance

How was the Trust able to exceed its Financial Plan? Sale of part of St Anns Hospital site to the GLA generated a surplus on disposal of 17.1m Additional Sustainability and Transformation Incentive Scheme funding of 19.9m This also: Means we have secured the cash needed to fund the redevelopment of St Anns Hospital Allowed us to repay historic Working Capital Loans, saving 0.6m per year in interest payments to the Department of Health Strengthened our balance sheet Capital Investment Summary Statutory Compliance/Risk Management Projects

Backlog maintenance St Ann's Redevelopment IT Other Estates Projects TOTAL m 0.1 0.3 1.2 1.4 3.0 6.0 Financial Challenges Despite the headline financial performance the Trust ended 2017/18

year with an underlying deficit of c10m During 2017/18 an Independent Review of Trusts Cost and Prices concluded that around 50% of the Trusts underlying deficit was caused by commissioners (CCGs, NHS England and Local Authorities) not fully funding the current service model Agreement has been reached with local CCGs to address their element by 2019/20 and discussions continue with NHS England and Local Authorities Meanwhile the Trust continues to work hard to deliver further efficiency savings and provide value for money services: In 2017/18 we delivered 9.1m of Cost Improvement Plans against a target of 8.3m (equivalent to 4% of turnover) Continued to deliver efficient services our 2016/17 Reference Cost Index was 99 (100 equals average performance) Outlook for 2018/19 and beyond

We plan to reduce underlying deficit by half to 5m; and have been a Financial Control Total of 3.3m deficit, after receipt of Provider Sustainability Funding of 1.7m Our plan to achieve this requires us to: Maintain tight financial control over our income and expenditure, absorbing any unplanned demand or new cost pressures in year. Particular areas of concern are: The impact of the new Pay Award for NHS staff, which has not been fully funded Continuing challenges in recruiting staff, leading to high levels of agency spend than planned Managing the demand for our MH inpatient services which have risen over the first half of the year

Implement a Cost Improvement Plan of 8.1m 4.0% of our income Looking beyond 2018/19 we await further information as to how the increase in NHS funding announced in the Spring will be allocated; what new Service Priorities will be set, and the timescales/costs of delivering them. BEH Adult ADHD Service Achievements & challenges 2017-19 Dr. Ulrich Mller-Sedgwick (Consultant Psychiatrist) & Cathy McCaffrey (Team Manager &

Specialist Nurse Prescriber) What is Adult ADHD? Symptoms of inattention, hyperactivity & impulsivity persist into adulthood (prevalence of 1.5-4.5%1) 20-30% of our patients have a childhood diagnosis Adults with undiagnosed ADHD often have a long history of underachievement and contact with MH services Patients with ADHD live fast and die young2 Recommendations in NICE 2008 guideline resulted in increasing number of clinics (>70) and prescribing of ADHD medication (but still <0.1% in adults)3 Pharmacological treatment of ADHD reduces criminal offending, road traffic accidents, STDs, depression, substance use etc.4 1

4 Kessler et al. 2006; 2 Franke et al. 2018; 3 Renoux et al. 2016; Asherson et al. 2016 ADHD prescribing rates in the UK, 1995-2015 Boys/Men Girls/Women Renoux et al., Br J Clin Pharmacol 2016; 82: 858-68 Adult ADHD Service Our team

Dr U Mller-Sedgwick Consultant psychiatrist 0.9 WTE C McCaffrey Team manager / Nurse prescriber 0.5 Dr L Moodley Specialist doctor 1.0 Dr V Alonge Specialist doctor (locum) 1.0 Dr J Kustow Consultant psychiatrist 0.1 Dr B Perera Consultant psychiatrist 0.1 P Ellis Logan Graduate mental health worker 1.0 S Cutting Graduate mental health worker (locum) 1.0 E Peston Peer support worker 1.0

M Jeffrey, G Macken, S Okafor Administrators 3.0 Adult ADHD Service Service user involvement Team members with lived experience of ADHD Peer support worker Patients & team members campaigning for Adult ADHD Close liaison with ADDISS (founded in Edgware in 2000), ADHD Foundation, ADHD Action and ADHD Europe Team members on executive, training and service user panels of UKAAN (UK Adult ADHD Network) New pathways for students with ADHD (collaboration with local universities; including nursing & medical students) Planned collaboration with NHS Practitioner Health Programme (service for doctors with ADHD)

BEH Adult ADHD Service Achievements 1 Waiting list recovery plan (agreed in Apr 2017) Updated Service specification (signed off in Feb 2018) Referral form (introduced in Feb 2018) Admin SOP and template letters updated Waiting list down to 6-12 months (from 18-24 months in Apr 2017) Team building (up to 9.6 WTE, from 2.5 in Mar 2017) CBT / psycho-education group (started in Jun 2018) Draft webpage, information leaflets

Adult ADHD Service Referral & activity data Outcomed appointments Referrals per month 35 200 30 180 160 25

140 20 120 100 15 80 10 60 5

40 20 0 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 r-1 ay-1 un-1 Jul-1 ug-1 ep-1 ct-1 ov-1 ec-1 an-1 eb-1 ar-1 pr-1 ay-1 un-1 Jul-1 ug-1 p A M J A S O N D J F M A M J A 23.5 (14-34) referrals per month New New admin

admin team team Move Move to to SpringSpringwell well New New admin admin team team

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 108 (36-178) appointments per month active case load >800 Adult ADHD Service home made info leaflets Booklet for GPs Leaflet with links Leaflet for students BEH Adult ADHD Service Achievements 2 Adult ADHD training for BEH clinicians (& all around UK)

Supervision of five NCL ST4-6 trainees and one UCL Mental health sciences student Organisation/chair of ADHD in Intellectual Disability meeting (bi-annual, at RCPsych headquarter) Contribution to UK wide campaigns for better services for adults with ADHD Contribution to NICE 2018 (& other) guidelines Audits of prescribing & frequent attenders Research activity & publications BEH Adult ADHD Service Challenges Workforce development (recruitment, retention, training) Developing IT capability (mobile working, Dragon etc.) Growth of clinical space Psychosocial interventions Navigating complexity (pathways for complex & risky

patients with ADHD) Working with commissioners on service development and continuity (NCL considerations and further growth) Thank you for your attention ! Barnet CAMHS in Specialist Schools Dr Amina Tareen Child Psychiatrist Specialist Schools Pupils who are unable to attend mainstream school either because they have been temporarily or permanently excluded from school due to behaviour problems, or due to depression or anxiety or specific learning needs or specific medical needs.

Compared to the general school population Exclusion rate of pupils with identified SEN needs was 6 x times higher than the rate for pupils with no SEN Exclusion rate of pupils claiming free school meals is 4 times higher Ethnic backgrounds: Traveller of Irish Heritage, Gypsy/Roma, black Caribbean and mixed white/black Caribbean In 2014 Key Stage 4 (KS4) in alternative provision make up 1% of all KS4 pupils but 4% of all NEET (not in education, employment or training) 16 year olds Starting the journey-co-production with Staff Key Themes: Pupils had unidentified mental health needs such as ADHD, depression, anxiety, autism Unidentified learning difficulties and no EHC Plans

Families - Disengaged families/parenting issues/cultural issues/belief systems 3 broad groups behavioural/anxiety/medical illnesses Starting the journey co-production with young people Their view of CAMHS- waiting lists, travel time to appointments, confidential information may be shared with others Might not be able to talk/think when angry, some people might use it to get out of lessons, might be a queue to see the person and it would be hard to wait Good to have someone to talk to, helps develop thinking/maturity, strategies given can help

Interventions offered 1. Work with young peopledrop in sessions, individual sessions, group sessions 2. Work with parentsweekly coffee mornings for peer and professional support ( parenting support, dealing with their childs exclusion, information about benefits, housing, general signposting ) 3. Work with teachersconsultation, staff de- briefing, staff training in mental health issues CBT for anxiety group for children and parents Parallel group of children and parents ensures that parents are able to support their children in dealing with anxious thoughts and feelings Running the groups jointly with a teacher from the Pavilion ensures the transfer of knowledge and skills into the school.

Children benefit from peer support Feedback from parents Table 3: Experience of service questionnaire completed by 10 parents who completed the CBT for anxiety group during Summer 2017 and Spring 2018. Certainly True I feel that the people who saw me listened to me 10 It was easy to talk to the people who saw me 10 I was treated well by the people who saw me

10 My views and worries were taken seriously 10 If a friend needed this sort of help, I would suggest to them to come here 10 Overall, the help I received here is good 10 Partly True

Not True Dont know Feedback from young people Table 2: Experience of service questionnaire completed by the 10 CYP who completed the CBT for anxiety group during Summer 2017 and Spring 2018. Certainly True Partly True I feel that the people who saw me listened to me

7 2 It was easy to talk to the people who saw me 9 I was treated well by the people who saw me 9 1 My views and worries were taken seriously

9 1 If a friend needed this sort of help, I would suggest to them to come here 8 Overall, the help I received here is good 8 Not True

Dont know 1 1 1 2 1 Support for Parents Involving parents and carers helps counter negative perceptions of alternative provision, enabling better support for yp and improved outcomes (Evans 2010, White 2012)

CAMHS staff hold a weekly coffee morning together with a member of the school staff , providing peer and professional support Group Parents Coffee Morning Therapeutic relationship 9 Goals & Topics set in group 8.3 Approach/Method of therapists

9 Overall session rating 9.2 Support for teaching staff 1. Consultation (1 to 1 consultation slots) 2. Staff de- briefing : CAMHS staff join end of the day de-briefing to provide mental health perspective, understanding behavioral incidents / mentalising and providing advice and support Behaviourist techniques ( teaching pupils through positive reinforcement and sanctions) is effective in short-term, but more therapeutic interventions help students develop self-management skills for successful transition to work or further education. (Thomson 2016)

Activity 2017-2018 Over the past year the project has offered: 264 drop-ins with students; 91 staff consultations. 2 Cognitive Behavioural Therapy (CBT) for Anxiety Groups 2 Solution Focussed Groups 14 Girls Group sessions 27 Coffee Mornings held with parents Training Sessions for staff Feedback comments CYP 1 - I was able to share thoughts and feelings CYP 2 - People are very supportive and helpful Parent 1 I was really happy at the service I received at the anxiety group. If it wasnt for the anxiety group I dont know what I would have done

Parent 2 Useful strategies and tools to use going forward. Helpful advice and guidance and understanding Parent 3 I really liked that what I said was respected but if they gave advice it was always non-judgemental. Felt good to talk in a safe space and the kids respected each other too The Assessment, Management and Treatment of Stalkers: Stalking Threat Assessment Centre & National Stalking Clinic Sara Henley, Frank Farnham, and Alan Underwood What is stalking? Repeated attempts to impose unwanted communications and/or contacts on another in a manner that could be

expected to cause distress and/or fear in any reasonable person. A convenient term for a set of behaviours Not one homogeneous entity May result from a range of very different motivations and mental states Legal Framework Protection from Harassment Act 1997 Harassment Protection of Freedoms Act 2012 Stalking becomes a crime Examples of stalking in the act

Following a person, Contacting, or attempting to contact, a person by any means, publishing any statement or other material relating or purporting to relate to a person, or purporting to originate from a person, Monitoring the use by a person of the internet, email or any other form of electronic communication, Loitering in any place (whether public or private), Interfering with any property in the possession of a person, watching or spying on a person. Stalking Risks

Violence Persistence Recurrence Psycho-social damage to the perpetrator Classifying Stalkers Motivation Categories of motivation (Mullen et al., 1999): False beliefs about a relationship Trying to start a relationships A relationship ending

Feeling mistreated by an organisation/service Classifying Stalkers Motivation False beliefs about a relationship Stalking arises out of a context of loneliness Motivation is to establish an emotional connection/ intimate relationship Victims are usually strangers or acquaintances who become the target of the stalkers desire for a relationship. They believe they have a relationship with the victim where there is none

Frequently behaviour is fuelled by a severe mental illness , delusional beliefs about the victim, belief that they are already in a relationship, even though none exists Classifying Stalkers Motivation Trying to start a relationship Stalks in the context of loneliness or lust and targets strangers or acquaintances. Motivation is to establish contact in the hope of a friendship/ sexual relationship. They attempt to form a relationship in an appropriate context but do so in an unskilled and inappropriate way very poor communication and social skills Often related to autism spectrum disorders or intellectual disability. Stalk for brief periods if persist usually because they are blind or Indifferent to the distress of victim.

Classifying Stalkers Motivation A relationship ending Rejected stalking arises in the context of the breakdown of a close intimate relationship. Victims are usually former sexual intimates; Motivation is either attempting to reconcile the relationship, or to take revenge for a perceived rejection. Behaviour is maintained because stalking becomes a substitute for the past relationship - allows the stalker to feel close to the victim /

iI allows the stalker to salvage their damage self-esteem Classifying Stalkers Motivation Feeling mistreated by an organisation/service Stalker feels mistreated or a victim of some form of injustice or humiliation. Victims are strangers or acquaintances who are seen to have mistreated the stalker. Stalking can arise out of a severe mental illness when the stalker develops paranoid beliefs about the victim and uses stalking as a way of getting back at the

victim. Motivation is the desire for revenge or to even the score and maintained by the sense of power and control Often present themselves as a victim - justified in stalking to fight back against oppression Why split stalkers into types? Risk factors in each domain of risk differ according to motivation. An ex-intimate is ALWAYS a rejected. Rejected should not to be confused with intimacy seekers intimacy seekers feel a sense of rejection when there was no relationship Intimacy seekers should not be confused with incompetent suitors - both can be awkward and incompetent but intimacy

seekers because they believe there is a relationship without any evidence of such Prevalence Stalking is highly prevalent in the England and Wales, will impact approximately 5.3 million people each year. (3.5 million women, 1.7 million men) Impact on Victims Family life

Working life Social life Well-being and mental health Impact on perpetrators Family life Working life Social life Well-being and mental health

Dealing with Stalking National Stalking Clinic (NSC) 2011 Stalking Threat Assessment Centre (STAC) 2018 National Stalking Clinic (NSC) The National Stalking Clinic (NSC) is a specialist service for the assessment and treatment of stalkers, and of stalking victims. The NSC provides: Detailed assessment of stalkers and of risks in stalking cases Guidance as to the appropriate management of risk in stalking cases Individual, structured, psychological treatment programmes for stalkers to reduce reoffending Assessment and treatment of stalking victims Guidance to police, MAPPAs and other agencies on problematic cases which have yet to lead to conviction or re-conviction

Stalking Threat Assessment Centre (STAC) Part of the The Multi Agency Stalking Intervention Program (MASIP) funded by the home office. v Stalking Threat Assessment Centre (STAC) The Stalking Threat Assessment Centre is a multi-agency

collaboration between the MPS, Barnet Enfield and Haringey Mental Health NHS Trust, Probation Services, CPS and the Suzy Lamplugh Trust. Based at a London Police Station and will cover pan-London providing support to colleagues on borough and Basic Command Units (BCUs). Included the development of a psychological behaviour change programme. The team make up is as follows Police = DI X1, DS X1, DC X4, PC X2

NHS = Forensic Psychiatrist X1, Forensic Clinical Psychologist X 1, Clinical Psychologist X 1, NHS MH Nurse X1, NHS Mental Health Worker X1, Assistant Psychologist x1 Probation Services = Probation Officer X1 CPS = Lawyer (consultation & advice) X2 One North and one South. Suzy Lamplugh Trust = stalking advocate X1 nationalstalking[email protected] [email protected]

Table discussion The Chief Executive set out a number of priority areas that we will be focusing on over the next few years . What are the top three priorities you think the Trust should be focusing on?

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