Saturday, 19 May 2012

Talk : Animal Testing

The latest in the Café Scientifique series of talks was presented by a member of the University of Nottingham’s animal ethics committee and was entitled "Exploring some myths on animal testing".

The speaker felt uneasy about publishing their name online, due to potential attacks by animal rights protestors, so let use call him “John Smith” for the purposes of this post.

John explained that he was a lay member of the committee, there to ask questions as a non-scientist His personal view was there was a need for a limited amount of animal testing.

At the outset of the talk, John stated that, for the most part, he had seen a lot of care of animals used in animal experiments. He added that that, at the University of Nottingham, there was a large team caring for the animals and that many scientists felt that “happy animals” resulted in “better data”.

Indeed, as soon as an animal showed signs of stress, such as going off their food or staying in a corner of their cage, some kind of action was immediately taken. This might range from removing the animal from the experiment to stopping the experiment to putting the animal down.

Indeed, there was an overall aim to reduce the level of animal testing in biological research, an aim that was encompassed in the “3 R’s”:

Reduce - the amount of animal testing required
Refine - animal experiments to reduce suffering
Replace - animal experiments with other forms of testing

John emphasised that animal testing was a time consuming and expensive process - certainly not something that researchers would embark on unless they felt they had to.

The animal testing at the University of Nottingham could proudly be broken down into testing involving small animals, such as mice, at the Science Park Campus - and testing involving larger animals such as sheep and pigs at the Sutton Bonnington Campus.

Small animals such as mice were generally used in medical research (e.g. cancer, hearing loss and alzheimers) whilst the larger animals were often used in farming related research (e.g. feeding trials and fertility testing)

It was pointed out that after the first animal ethics committee was set up at the University in 1998, the number of animals used in experiments started to decrease, but has now started to increase again. This is partly because of the increase in genetically modified mice in medical research and, surprisingly, partly because the breeding of these mice is itself classed as an animal experiment, with each bred mouse being counted in the statistics.

A measure the seriousness with which animal welfare is taken can be seen in the fact that the Home Office is copied into all meeting notes and can attend any meeting they wish.

John described how he would read each application and form his own view on whether the application was acceptable or not - he commented that, in his experience, if he had an issue with a particular application it was a concern that the rest of the committee usually shared.

Part way through his time on the University of Nottingham ethics committee, John took a sabbatical and spent some time in the US, visiting many University laboratories there.

In contrast to their reputation for having poor standards of animal welfare, John found that the US Universities had standards that were similar to those of the UK, with the possible exception that the physical environment of caged animals (such as mice) lacked the “natural” elements such as straw bedding and toys such as running wheels and cardboards tubes that were routinely provided at Nottingham. There was a feeling in the US that having very plain cages somehow made the experiment more “equal” and free from variability.

One other observation that John made was that, whilst the US is a single country, the costs of travelling around it mean that universities will sometimes only visit institutions within their own state, in order to minimise costs.

John also visited Huntingdon Life Sciences(HLS) in the UK, an organisation that had come close to collapse in 1997 after undercover footage shows dogs being treated very badly there. New management was brought in which stated an aim to make HLS a world leader in the humane treatment of animals. John commented that they have certainly made a lot of progress and a number of their initiatives (such as techniques to give injections to animals with minimal pain) have been adopted widely in the rest of the research community.

The broad animal rights movement has managed to make a real difference to the attitudes towards animal testing and has also caused companies to improve their standards dramatically.

One example of where the animal rights movement has caused problems to medical researchers, however, occurred recently in the case of a successful boycott of a US airline that was transporting laboratory mice. If transport of these animals (especially mice) by air becomes widespread, it will have a significant effect on research as scientists often wish to use mice from some specific breeding colony (to ensure their research is comparable to others in their field). If they are unable to obtain these easily, they may have to resort of less suitable animals or to breeding their own colonies - which takes time.

Moving on to explain the way in which animal tests were graded, John explained that there were three categories:

Mild : e.g. blood samples, minor surgery under anaesthetic

Moderate : e.g. small surgical procedures under anaesthetic, with post operative care, non-lethal toxicity tests

Substantial : e.g. major surgery, disease states

Whereas “substantive” testing was rare at the University of Nottingham, it might be much more common at other laboratories, especially those in the pharmaceutical sector.

In answer to a question about the trends there at play in this area of research, John commented that increased globalisation and increased focus on genetic therapies and research were the two biggest trends that were likely to shape the way animal testing is performed in the future.

He added that forthcoming European legislation was likely to less strict than current UK legislation, which is some of the strongest in the world and that globalisation is already resulting in animal testing on larger animals and primates being undertaken in countries with laxer legislation such as India or China.

On the other hand, scientist want any animal testing to be performed in labs that are clean and well organised, and are aware that happy animals make better data, so some kind of balance has to be found.

In answer to another question about the way the animal keepers interacted with the animals, John said that whilst this was not such a big issue with small animals, it was certainly the case that dogs (for example) were profoundly affected by the degree of interaction they had with their keepers. As an example of good practice, John mentioned a (now closed) AstraZeneca lab in Loughborough where a a small army of handlers would arrive every day to walk the dogs and play with them and where the dogs had a large, feature filled, play area to enjoy.

Thursday, 10 May 2012

Interview : Prof Ian Shaw on the NHS

The BFTF radio show recently featured a fascinating interview with Prof Ian Shaw who is the Professor of Health Policy at the University of Nottingham’s School of Sociology and Social Policy, and is also (amongst other things) a Non-Executive Director of NHS Nottingham City Primary Care Trust.

The interview covered ground ranging from pandemic preparedness to Gujerati eating habits but focussed mainly on the NHS, and where it might be heading as a result of the recent Health and Social Care Bill.

This post contains a transcription of the key parts of the interview relating to the NHS, where is might be heading as a result of the recent changes and what you can do to influence it’s direction (the time-poor or attention-span deficient amongst you may wish to read an extra-condensed version here).

BFTF :So, Professor, what is your role at the University

Ian Shaw : The day job is as a Professor of Health Policy at the University of Nottingham. I have a personal chair which means that I can do, essentially, what I like in terms of research unlike some Professors who are tied to a particular activity because they are in a sponsored post. . .the day job is really about health service evaluation and my interest in that.

The Non-Executive NHS post sort of complements the day job, which is essentially why the University lets me do it. I spend one day a week working for the NHS as a public service duty and the University is very good to let me do that. “Non Executive” is a role that is there to advise on the strategy of the organisation but also to assure the organisation around quality, around performance, around risk management and around finance - to bring an independent voice to those issues.

I was appointed as a non executive director of Nottingham City Primary Care Trust in 2002 when it was first formed and it is coming to an end in April 2013 so it has been a good run and I have had 4 re appointments during that period so I must have been doing something right. And from August last year I was also appointed to the county PCT as part of the transitional arrangements for the Health and Social Care Bill.

QMC, Nottingham

BFTF: What is it like being on high level boards like these?

Ian Shaw : A: It is a particular sort of environment. Actually most of the work is done in the committees which is why the board is just one day a week. At board level non-executives are in the majority so the non-executive voice is strong in the PCT. That is changing a bit with the reforms but because of that if you are appointed you are generally bringing something to the table. Non executives are bringing different things, different sets of expertise so you can stand there and say “Does this make sense?”. You provide a challenge and they have to convince you that it makes sense

BFTF: How can people find out more about what the directors of the NHS are doing?

Ian Shaw : The best thing to do at the moment, because we are in a period of transition, moving from PCTs being in charge of the buying and selling of health services. . .to the clinical commissioning groups doing it. If you google “NHS Nottingham City” you’ll get the website with both the CCG and the PCT and all the board papers are on there, published at least a week in advance and the public is welcome to ask questions which are read out in board and to attend the board meetings as well. The other thing I’ll just mention is that the “gig” is coming to an end because of the reforms and the organisation (PCT) is ending in April 2013. The new organisation, the Nottingham City Clinical Commissioning Group is starting in 2013 and they are advertising today in the Nottingham Post for non-Executive Directors, or lay-members as they are called.

BFTF: How much to you get for being a non-Executive Director?

Ian Shaw : It varies from CCG to CCG, I think it is about £7,000 a year, which you are taxed on.

BFTF: And what kind of people do you think might be interested or would you suggest should think about this?

Ian Shaw : People with a degree of experience in community, academic or business organisations. Somebody who can bring something to the table. One of the new posts is on community engagement so people who are involved in community engagement might want to apply.

A&E Department, QMC, Nottingham

BFTF: Moving on the Health and Social Care Bill, and the NHS generally, you have a very interesting blog that is hosted at the University of Nottingham website and one of the posts was about the “Kidderminster Effect” and how competition doesn’t always pan out to be a good thing. Can you give a little more information on this.

Ian Shaw : Kidderminster was a district general hospital, a bit like the QMC only a lot smaller, in Worcestershire. And Worcestershire had three district general hospitals serving around 526,000 people. Now Nottinghamshire has two big district general hospitals - Nottingham University Hospitals Trust, which runs the QMC and City hospital; and Sherwood Forest up in the north of the county. And the population of Nottinghamshire is about a million, so you can see that they [Worcestershire] didn’t really need three district general hospitals so they decided to beef up two and Kidderminster.

And they did it BADLY.

They didn’t tell people WHY they needed to close Kidderminster, there was an A&E department at Kidderminster there so people were thinking “Oh my goodness, I’ve now got to travel further, if something happens to me I’m going to die in the ambulance”. . . they just announced that they were going to do it , it was a way of rationalising resources and for the Health Service to save money - they could save £20million by selling the site - but, to use a cricketing analogy, they didn’t roll the turf before they bowled the ball and if you don’t do that then the ball can bounce all over the place.

Harltey Road Medical Centre, Nottingham
BFTF: How could it have been done better? How could they ever have got the staff at the Kidderminster hospital on board?

Ian Shaw : Well, you need to explain to the staff why you are doing the changes that you are doing. You don’t need to get them on board but you need to explain that there are going to be jobs elsewhere, that they aren’t going to get laid off.

It is the community which is the big effect. You have got to flag up to the community at an early stage and explain why. The community doesn’t like to listen to me, or NHS managers - it likes to listen to doctors, and if they are GP’s, if they are the leading doctors in their community and they tell the community that this is a good idea, they they’ll listen.

But [in Kidderminster] it wasn’t explained to the doctors in the communities, they just decided to do it. And it was a misunderstanding about who owns the NHS. The managers thought they owned it. They don’t - the people own it.

BFTF: Just to pick on one point there about people thinking they are going to die in the ambulance - your local hospital 500yds down the road closes and you are now, by definition, further away from treatment. How can you ever pitch that as a good thing?

Ian Shaw : Well, this is getting topical because the QMC is going to be turning into a trauma centre so people from all over the East Midlands are going to be travelling into Nottingham.

The question is - is the journey time worth the benefit of the treatment at the end? So there is going to have to be very good triage by the paramedic in the ambulance- telemedicine, whereby there are videolinks with consultants at the hospital, can help with that and decide where that person goes. Do they go to their local District General Hospital or do they go to the QMC and how do they get there. . .

In north London at the moment, there are four A&E departments that are going to close - that is going to take an awful lot of “rolling of the lawn”.

But it’s not just the big services, it’s the small services as well, like GPs relocating into one unit, as you have in West Bridgeford, for example, which is an eminently sensible idea because you can get more resources in there. . . but wasn’t necessarily explained to the practice community very well and there has been some resistance.

MEMS, Nottingham

BFTF: One thing I perceive is that when you have these centres of excellence, the doctors there get a critical mass of cases that they see and they see more of the rare cases. Is that a significant factor in having these kinds of centres of excellence?

Ian Shaw : Yes, there are two things - economies of scale but also centres of excellence. If you are having an operation you don’t want someone coming along and doing the operation who says “Oh I haven’t done of these in a while”, you want someone who is doing it day in and day out [as is the case in centres of excellence].

BFTF: That feels, as a layperson, to be quite a good argument- your local hospital is being scaled back but you will have these better facilities a bit further away.

Ian Shaw : You have to explain that it is a movement, that there are costs and benefits but overall the benefits are better. There is some concern about Ambulances sites closing for example. But Ambulance stations are different because ambulances are strategically placed, in laybys and supermarket car parks for example at all times so that they can respond quickly to an incident. So it doesn’t matter where an ambulance station is, it’s not like a Fire Station, which is where the fire trucks are, so if you move the Fire Station 3 miles you have a longer response time.

Linden House Neuro-Stabilisation Unit, City Hospital, Nottingham

BFTF: Moving on a little to talk about competition. On the one hand superficially you can understand it, people are competing, they’ll try harder. But then you think about within an organisation - suppose you have an engineering company with five engineers - if they are all each keeping their good practice to themselves, they are hoarding their secrets, they don’t want to co-operate with the other engineers - that company isn’t going to last very long. How do those two drivers relate to the NHS?

Ian Shaw : There is what’s happened historically and there is what is going to happen in the future - so I’ll handle those separately.

What has happened in the past is that going back to 1997 when the Labour Party came in, although I don’t want to get political, at that time there were people waiting for nine months on waiting lists - and that wasn’t uncommon so what the NHS did was say, here are some more resources, we want more facilities but also, if you can use the private sector sensibly where there are large queues to take the pressure until this new money in the NHS can build capacity then that is a sensible way to do it. It was also useful in that it corrected one of the original conflicts of interest that was built into the formation of the NHS in the first place. In order to get the NHS formed, Bevan told the doctors that they could do private work as well as their NHS work. Now if you have that situation then the length of your waiting list interacts with the likelihood of people to want to go private so where was the incentive to want to reduce the waiting list? Giving the commissioners, these new primary care trusts, the power to buy services from the private sector where these waiting lists were long essentially took the power off the consultants to manage these waiting lists for the benefit of their private income and brought the waiting lists really down and what we saw was private insurance going really down as well because why would people have private insurance if they can get good quality free care on the NHS.

So that was the situation before the introduction of the NHS and Community Care Bill. The situation after its introduction, which is now is that all significant contracts are going to have to be put on open tender. That means that the private sector can compete with your local community NHS service for example or your out-of-hours doctors service to compete for that service. They will compete on costs and on quality and it is up to the primary care trust at the moment, CCG’s soon, to procure those services through a contracting procedure and monitor them once the contract has been done.

Nottingham Radiography Centre, City Hospital, Nottingham
BFTF: How does European competition law and the wish to balance cost and quality affect how decisions might be made?

Ian Shaw : If - IF - the contract continues to be based on quality so that it is the same quality going across and what you are doing is competing on quality then that is not necessarily a bad thing. The problem is that you have in some areas - In fact Virgin has just taken the NHS to court and lost for predatory pricing i.e. they [the NHS] weren’t taking a profit out of the system so therefore he couldn’t compete against them. It’s get into difficult waters if you start competing price, if you compete on price you are goinf to be driving the quality levels down. Competition has got to be done on quality and at the moment the safeguard is still there for competition to be done on quality but it’s literally a very small safeguard. At the moment all conditions have a price based on the average cost of doing something, so for example the average cost of doing a hip replacement. So everyone [providers] gets paid that price and so long as everyone [patients] gets the full range of work then that price is fair. . . The problem is that the NHS, because it has accident and emergency centres and all this acute care in case something goes wrong, can take more serious cases and the private sector can’t. So the private sector says “we can’t take these more expensive cases, these more serious cases because something might go wrong so we’ll only take the easy cases. Which means they are not playing on a level playing field, they are cherry picking the best cases on the basis of clinical risk.

BFTF: Do you think that might end up with the private sector saying “Look, we can do hip operations for x pounds whereas the NHS operations are costing twice as much”. Is there a possibility of that argument being made?

Ian Shaw : Well, because the NHS is doing the full range of work and if you give the easy work to the private sector then yes the NHS is going to have the harder work, will take longer to do it and will be more expensive. So they will be getting the same pay for more difficult work so they start running into cost problems. So the contracting is going to have to be careful to state that the full range of work should be available, all the different types of cases.

Sign, City Hospital, Nottingham
BFTF: Outside of this interview, you have mentioned a House of Commons report that stated that transaction costs were 14% of NHS total costs, but that there was no evidence that these transactions delivered 14% more productivity. Could you just elaborate on that a little bit?

Ian Shaw : At the moment, this was House of Commons select committee report in 2009, which showed 14% of the total budget going transaction costs - they buying and selling of goods and services in the market, the contracting and the monitoring of these contracts

BFTF: Admininstration essentially

Ian Shaw : Exactly, and there was no evidence at all that this was creating 14% of added value in terms of productivity or quality. Indeed in Wales and Scotland there is no contracting. . .Scotland started to do contracting and then realised that they were not getting any benefit from it. There is some evidence that competition works between trusts and teams within the health service, aiming to get a better status or reputation. But bringing in the private sector doesn’t seem to have any positive impact as far as the NHS House of Commons Select Committee was concerned. And that committee was run by conservative MP and ex Secretary of State for Health Steven Dorrell.

Moving forward the issue is that there is going to be more contracting, so more and more transaction costs and particularly in terms of monitoring the quality. Now we’ve seen problems in the quality of the private sector recently with care homes, learning disability homes, mental health and you cannot just give people contracts, you have to monitor what they are doing in the contacts to make sure they are delivering because you have patient care and patient experience as a strong moral duty if you are commissioning. A big worry for me is that the level of management costs in these new commissioning groups is capped so it is going to be challenging to do all of the monitoring of the contracts, the quality assurance that they are going to have to do with increased numbers of providers.

Departments, City Hospital, Nottingham
BFTF: Can ordinary citizens challenge their local Conservative or Lib Dem parties or the Dept of Health and say “Can you assure me, as a Citizen, that these contacts are going to be monitored adequately?”

Ian Shaw : I can’t see the Bill getting changed, it’s in so it’s going to be in until this government ends. The big thing is the Health and Wellbeing boards which are set up by local authority area and decide the health and social care strategy for the communities which they serve. The elected representatives, councillors, form a large group on that board so that the attitudes of the councillors are REALLY important for how this is going to role out within a locality. Now, the national politicians know this - the Labour party is campaigning in local elections on this issue, and that is really them saying that they want their councillors in the Health and Wellbeing boards and we want to see that this competition isn’t working adversely.

BFTF: Why am I hearing these clearly defined points from you? Why didn’t I hear it on the news? Why didn’t I hear it from the MPs? Why has it taken getting you into this studio to hear all this stuff?

Ian Shaw : That is a long argument. Twitter has been alive with criticism over the BBC particularly on their reporting of the NHS reforms and particularly the protests against the NHS reforms. There is not one single Royal College or Union which has not stood up to these reforms. They are trying to impose reforms on the NHS when all the Royal Colleges and unions are against it, so it is going to be interesting to see how that plays out. And that is why the Health and Wellbeing boards become important because there is resistance in the system against this which is why getting a policy through at government level is not necessarily the same as it happening on the ground.

The BBC has come under criticism. . .Al Jazeera covered the NHS protests far better than the BBC. The fact that the chairman of the BBC has large shares in private health companies probably has nothing to do with it.

It is very strange, it is a national institution, of national importance, health is crucial but it has not been fully covered by the BBC and there have been hundreds of complaints against the BBC over this.

Services at Mary Potter Centre
BFTF: One other point about the Bill, perhaps a bit of a technical point, but one that is often mentioned is that the Bill allows Trusts to take up to 49% of private work. What is the concern here?

Ian Shaw : The concern is two fold. Firstly, most of the big NHS Trusts are working at full capacity anyway, so where are they going to get 49% of free space to bring in private patients.

And the second thing is, why on earth would someone want to go privately when they can have things done free, to a good quality, in a timely manner within the NHS where they also have choice. Why would they want to do it? The concern is that it signals what might be about to happen to happen to the NHS in terms of limiting its budgets, in terms of cutbacks to services and if you get to a stage where waiting times start to get political, if you get to the stage where people are thinking “Well, I might have to go private to avoid these things” or some costs become privatised then that is the worry. It’s not what’s happening now, it’s what that signals is going to happen down the track.

BFTF: And how does that 49% compare with how the legislation stood last year?

Ian Shaw : It was a cap at 3%

BFTF: Again, I’m just gobsmacked that I’m hearing this for the first time, quite unbelievable. Before we wind up the interview, is there any key message you want to get across to the public.?

Ian Shaw : There is concern about the direction of travel of the NHS. I don’t think anything is going to happen now. I don’t think anything is going to happen this parliament. I think it depends on who gets in next time and what sort of platform they are on for the NHS. But I am concerned that the “free at the point of use” bit - which is there now, it’s there with these new reforms but I think it might be under threat in the future. Bevan said that the NHS would be there so long as people defend it and I think that people need to be aware that it needs defending.

BFTF: Do you think it might go the way of dentistry has gone?

Ian Shaw : Well that is one of the scenarios on under this direction of travel. You might get the basic service free but they might say, “well, you’re in a bed, we’re changing your sheets, we are going to charge you hotel fees and we’re feeding you so we are going to charge you for food”. You can see the ways in which a cash starved service might keep to the letter of free-at-the-point-of-use but actually the add-ons become very expensive and in the US almost half of all bankruptcies are because they cannot afford to pay their medical bills and I would hate to see Britain move to that situation - nobody is suggesting that they are moving to that situation at the moment but I think that really we need to be alert to the possibilities that the direction of travel is moving.

BFTF: I guess we all have a role, we can all lobby and tell our elected politicians what we want and what we don’t want.

Ian Shaw : Exactly

BFTF: Ok, we’ve come to the end of the interview and the final question, that is asked of all guests is quite simply “What do you think is the best thing about living in the UK”?

Ian Shaw :. . . I think it’s two things. One is that there is a degree of security here, you can walk the streets and you can live fairly peaceably. I think the other thing is that there is a degree of social justice and I think that some of the institutions of social justice, like the NHS, help to frame that - but you see this, community spirit occasionally like if you are on a train that has broken down, it’s hot, there’s no water and people start sharing, start chatting and all of a sudden you know why people are doing visits, why they are on the train, that grandchild they are going to visit. You scratch the surface and there is a good community there and that’s what I like.
NHS Flag, QMC, Nottingham

Notes:Prof Shaw was interviewed on the Buidling for the Future show (Wednesdays at 5.15pm ish) on Radio Dawn 107.6FM, one of Nottinghams community radio stations.

Image Sources: All BFTF's own.

Monday, 7 May 2012

Booing the National Anthem

Apparently, Liverpool fans were booing the National Anthem as it was played just before the FA Cup Final this year. So fas as BFTF can see, this was covered only by Chris Warburton on his Radio 5 Live show (Sat 5th May, around 9.40pm). During the show, Chris asked two people who had booed the anthem their reasons for doing so. Their responses are shown below:

"Paul" commented that he had booed:
"Because the transport situation today was a disgrace, the late kick off time made it impossible for Liverpool fans to get home on the train . .. How else do you make a protest. . nothing against the national anthem. . there was no internet conspriacy, no premeditated action, it was something spontaneous, everyone felt the same and how else do you show your displeasure."

While "Mark" said that the booing was
"Representative of a general feeling of anti-establishmentism really amongst Liverpool supporters. . .a lot of it is to do with a lack of justice after Hillsborough. . the national anthem and flagwaving, patriotism, any kind of gesture like that is associated with the Royal family. . .you very very rarely see a flag in the Liverpool end with a union jack with the name Liverpool written across it, that's what other clubs do but Liverpool are different. . I don't think it means that Liverpool fans aren't proud of where they come from or anything like that, in fact its the complete opposite. . there is also an alienation, I know so many Liverpool supporters who don't support the English National team"

What can be done to integrate these communities into British Society?

In addtion, Chris read out a few texts that had come in:

A text from "Ted" stated that:
"I would never agree with booing our national anthem but Liverpool fans feel consistently let down by their own country's rulers to acknowledge how their own were killed at Hillsborough . . .Chelsea were allowed to boo a minutes silence for people who had dies at the FA cup semi final without serious criticism"

Another had texted in to say "come on, we are not all Royalists"

Whilst "Jo" felt that "The national anthem isn't relevant to todays society so why sing it. . .don't play the anthem and then it won't get booed."

BFTF suspects that, had it been Muslims booing the National Anthem at a major sporting event, the coverage would have been a lot greater, a lot harsher and with a lot less time spent asking the people concerned for the nuances of their motives.

In fact just thinking about what the coverage might look like is leaving BFTF with a knot in the pit of its stomach.

Update Apr 2014
Recently read a CRE report on "Britishness" in which the CRE interviewed people from white and BME communities to ask them about their feelings about nationality. The report says that, regarding flags :
Across all groups, the Union Jack was immediately mentioned as one of the most potent symbols of Britishness. This was seen positively, by most, as a force for unity (as opposed to the St George’s flag, for instance, which both white and ethnic minority participants saw as having been appropriated by the far right, and therefore as being divisive)

By The Way. . .

If you likes this post, you might like some of these popular posts from the BFTF archives:

This is what is wrong with the NHS Bill

Interview with Mohammed Yaseen about the Emmanuel House project

Interview with Himmah and Citizens UK

MSC certified fish fingers