The challenge there is because of the limited funding for substance abuse and mental health treatments for people who otherwise don’t have health insurance, we aren’t getting to a very high percentage of the population.  On the last estimate that I saw nationally was that drug courts get to about 1% of people on probation. They do very good work with those folks, but we’re not getting to jail.  It’s healthcare reform that gives us an opportunity to take these interventions to scale.

We also look a look at the parole populations.  Obviously, the number of people on parole are significantly smaller, but they are substantial.  In Illinois in 2009, we had about 33,000 people on parole.  In Indiana, it was about 10,000.  In Michigan, 22,000, and Ohio with about 19,000.  Much like for probation, there’s special parole supervision initiatives.  Individual officers make a lot of referrals.  There has also been other interesting initiatives in our region.  Ohio, recently, passed a reform legislation that will focus on putting more people on the street than the community.  Then, there are projects in Illinois where we have in Sheridan, Southwestern Illinois correctional center programs, which is on its way to becoming a jail because they’re a large institution.  There are, in both cases, I think 1,000 inmates, and most are treatment prisons.

So, most are medium-security prisons for people with substance disorders.  They get treatments there, and there are a lot employment programs to that initiative and also, post-release, treatment and case management in the community.  So, those are efforts that have shown benefits and recidivism among the parole population.  Given how expensive it is to put people back in prison, we pay a lot of attention to that here in Illinois, especially the last couple of years.  So, these are the kinds of things that when there is more availability of treatment in the community, they’ll be easier to expand these kinds of positive initiatives.

I’m going to shift now to talking about some of the current challenges and latest thinking on evidence-based practices, and Monica, if we want to take questions about what I presented.  Let’s give the people a chance to raise their hands.  We could do that. On your screen there, you have an option of raising your hand.  Right now I see Jimmy whose hand is up on this line.  Jimmy?

 

Jimmy:

Hi.  My question is more like will this presentation be available after the conclusion.

 

Monica:

Yeah.  For those of you would like to have a copy of the webinar, I’m actually recording the webinar, and we’ll be posting the webinar on our website.  I’ll make that announcement.

 

Maureen:

Will the slides also be available, Monica?

 

Monica:

Yeah.  The slides will also be available.

 

Maureen:

Okay.  Thank you for the question.

 

Monica:

Does anyone have any more questions? Are there any more hands raised?  We don’t, but we’ll have another opportunity to ask questions.

 

Maureen:

Okay.  Alright, good.  So, we’re going to go on to talking about the current challenges in both providing care and funding care for justice populations.  First of all, this slide may be a little bit hard to see on your screen, easier when you have the PowerPoint and you can blow it up much larger.  This is a chart that we use to talk about the criminal justice system and all of its on-ramps and off-ramps and the intervention opportunities that exist along the continuum, and when we’re talking about being able to take the intervention scale, we are really talking about the whole length and breadth of the national justice system.

So, there are opportunities for diversion to community days, mental health and substance abuse treatment and arrest on the mental health site.  The crisis intervention, you can see CIT is an intervention that’s been gaining a lot of popularity, and I definitely encourage people to pay more attention to that in the future.  There are opportunities for similar community-based supervision at the time when people are arraigned, but before I get into that, people who are held in jail and whose charges are dropped or dismissed, there’s an opportunity to do good re-entry services with them as well.  They just have to be short and quick and very effective.  So, there’s some models I’ll talk about a little bit later on that.

In terms of interventions and arraignment or sentencing, there are lots of opportunities to divert people to community-based substance abuse and mental health treatment.  With community supervision with the support of a community-based infrastructure that links support and the community, as well, to tighten up the supervision part of that so the court and the community could have confidence that people are supervised.  What this does is it allows us to have people supervised in the community and going to treatment in the community, which we know is very effective, rather than incarcerated and pulled out of the community for a period of time and, then, just face all of those issues, again, when they come out.

For people on probation, I talked a little bit earlier about specialty courts like mental health courts and drug courts. The opportunities to link people to substance abuse and mental health services once they’re more widely available exists all along throughout probation and parole.  We certainly, in the future after 2014, we should be considering every person in front of us as a person who could potentially be referred to the services that they need.  We’re not able to think that way now.  We’ll talk a little more about the reasons why now.  It is very frustrating, but it is a good thing that it may change.

So, this slide is borrowed from a presentation that Doug Marlow gave.  If you don’t know Doug’s work, he is the research director for the National Association of the Drug Court Professionals and a university professor, and he does very good work on thinking about how you use graduated sanctions in drug court to influence behavior, what the timing is on these kinds of things.

This slide is from a different perspective.  He wrote a great paper called “Evidence-based Sentencing Practices”, and he talked about the continuum of risk and need.  Risk, in this situation, is public safety risk, and need is need for a clinical intervention; so, mental health and substance abuse treatment.  In particular, when you look at people who are in the low risk, low needs in the bottom right box, they aren’t posing much threat to public safety.  They don’t have very high need for formal, structured substance abuse and mental health treatment, but they’re doing some stuff that’s getting them through the attention of the criminal justice system.

So, what do they need?  He talks about that as prevention.  We might, in the substance abuse treatment field, we might talk about it as early as intervention.  So, motivational intervention structured like an expert, screening, brief intervention, and referral to treatment project, which is a strong methodology that’s been demonstrated on the public health side and in the substance abuse treatment side to make a difference, as well as what kind of life skills interventions and good supervision that are offered through community safety officers.

So, then, if we go up to the next, high need, low risk box, this is the classic box for low-level drug offenders who’s continuing involvement with the criminal justice system is driven by their alcohol and drug use.  They have a very high need for good structured intervention, but because they pose low risk to the community, they don’t need a very high level of supervision from probation and parole officers.  They could conceivably be good candidates for diversion programs at the far end of the criminal justice system as well.

Then, when we look at the high risk column, we are really dealing with a different profile of offenders.  Also, if this box represented offenders in the criminal justice system, the high risk column would be much narrower and smaller and the row risk column would be much larger.  The high risk, high need folks are people who, and Doug has come to talk about these folks.  These are the folks that need the resources of a drug court and a mental health court.  They need to be very accountable on short timeline for whom treatment compliance is absolutely essential, and also, a lot of habilitation is needed.

So, when you think about the previous slide of the continuum of intervention, we just don’t want to spend our resources willy-nilly.  We want to prioritize where our somewhat limited resources go, and so, focusing the highest intensity of resources on the high risk, high needs people makes a certain amount of sense.

Then, the last box is the high risk, low need people.  These are people who are less likely to be impacted positively by mental health and substance abuse treatment and for whom accountability and habilitative services are the priority.

So, that’s how he broke out this thinking, and it’s a helpful way.  There’s a lot of talk in probation these days about evidence-based probation strategies, and triaging and spending resources where they’re most needed is obviously a budgetary reality as well as a professional reality.  So, this is the kind of thinking that helps us figure out what to do.

So, just a minute.  For folks who aren’t familiar with mental health and substance abuse treatment, I’m just going to say a few things about what treatment actually is.  High quality treatment is used as evidence-based strategy.  Different kinds of treatment modalities that we know have been proven over the years to actually make a difference in people’s subsequent behavior, their arrest behavior, their work behavior, their continued use or not continuing use, which is the goal.

In substance abuse treatment in particular, behavioral therapies are used.  We use counseling.  We use cognitive therapies like DVT and MRT.  We use psychotherapy as well in various combinations.  You may become more familiar with hearing terms like residential treatment, inpatient treatment, outpatient treatment, and basically, we call those modalities and their levels of intensity and also structure and also determine whether housing is a part of that intervention strategy or not.  What goes on in these settings is the same general activity.  We just relate it to what the setting is in which the person will most benefit.

Physician-prescribed medications are increasingly a part of substance abuse treatment.  Methadone has been around for many years.  There are a number of new medications that have come to prominence in the last decade.  Many of them have been around for a long time but not applied to addiction in this particular way.

There’s buprenorphine, which also goes by the name Suboxone®.  There’s Vivitrol®.  That’s the trade name for a medication that’s been promoted for treating alcoholism as well as opiate addiction.  Buprenorphine is a treatment for opiate addiction, and the good news about all these medications is that they really help people who, otherwise, don’t really stand a great chance of being able to control their own craving and get through the first part of establishing early recovery without some assistance.

What we hear from our treatment partner is folks who are using these kinds of medications actually stay in treatment, and they’re to benefit from the psychosocial rehab and the counseling and the other things that the person has to do to get their life together.  If they’re not able to stay in treatment, they can’t manage their cravings, and they feel overwhelming urgency to go back and use and we’re not getting anywhere.  So, that’s increasingly the value we see in medication-assisted treatment.  Treatment is often a combination of one or more therapies.  They’re not mutually exclusive, and people are stepped up and stepped down in different levels of care based on their progress.

Now, mental health is often organized in a different way, and community mental health centers do a great deal of work around the country.  There’s also a certain amount of this work that’s done in community health centers where physicians are prescribing medications and doing some counseling with people.  In our experience, at least in Illinois, the challenge for the mental health system, even before the budget cuts that have hit since 2008, is that they’re really restricted to working with the most disabled people and a pretty limited number at that because the money will only go so far.

See the video: http://vimeo.com/30743539

There we go. I work at a company called TASC.  We are Treatment Alternatives for Safe Communities.  We are a statewide organization in Illinois, and for the last 30 years, we’ve been providing direct services and doing policy advocacy and policy development and research to help advance this tremendous opportunity to provide behavioral health interventions for people who are involved with the criminal justice system.

So, annually, we serve about 20,000 people who are involved in the justice system, mostly, today, people who are on probation and people who are on parole, and we have designed and managed a number of many kinds of projects that that connect the criminal justice system and community-based care.  We participate extensively on state and national planning on health care reform with this particular interest in mind.

So, our goals today in this webinar are, trying to advance this slide here.  There we go.  The goals of the webinar are:  To provide an overview of the current challenges in providing substance abuse and mental health services for justice-involved populations, which is essentially to provide the background, to understanding how the Affordable Care Act can, then, change this situation.  Then, further, how can we use evidence-based practices and services expansion to actually move the whole field forward and move our efforts to reduce recidivism and build community recovery dramatically forward.

There are certainly planning steps that we would recommend will be happening now.  We’ll talk about that towards the end of the presentation, and we’ll look a little bit at the financial and practical implications for the criminal justice system, specifically, of taking on these challenges.

So, first of all, what is the Affordable Care Act?  This a law known as Health Care Reform passed on March of 2010 and signed in March of 2010.  It’s hard to believe that’s almost a year and a half ago, but it is.  The goals, broadly, of the legislation are to extend access to underserved populations, to improve health outcomes, and to maximize efficiency of public health expenditures.  The Affordable Care Act, itself, is 2700 pages long.  I don’t know anybody who’s actually read all pages although I’m sure there are people who have, and there’s quite a bit of federal guidance.  Then, when you multiply that by every state in acting their own required processes, there’s quite a bit of administrative rule on this.

So, what we’re going to focus on for the Affordable Care Act is the one particular aspect that creates this big opportunity in the criminal justice system and the community substance abuse, mental health system, and that is the expansion of access to care for low income populations regardless of disability.  This expansion shifts us from planning on a program level to planning on a system level and creating enduring linkages between the criminal justice system and the community behavioral health system for purposes of good re-entry, good diversion programs, and reducing, ultimately, the number of people whose ongoing untreated mental health and substance abuse by bringing them into contact with the criminal justice system.

So, where are we in implementation?  The federal and state governments are currently in the planning processes and early implementation phases.  There were a number of requirements that took effect a year ago in September that, for example, the limitations on, the conditions of coverage to young adults up to the age of 26 being covered on their parent’s health insurance.  So, those are already in process.  There’s a number of things the state has to get done by 2013 in preparation for the expansion of coverage in 2014.  Those include building things like health insurance exchanges, setting up expedited enrollment procedures.

The federal government is in the process of determining what’s called the essential benefit plan, which will be the minimum services that have to be included in any expansion plan, whether it’s a Medicaid expansion plan or it’s a subsidized insurance plan that will be sold on the exchange.  The Medicaid expansion and the expansion of subsidized insurance actually takes effect January 1^st of 2014.  So, that is the target that we’re working towards in our state and many other states are working towards.  A lot of things have to come together at that point.

I do want to acknowledge the general error of uncertainty and concern that’s been generated by how we will pay for this and where this is going to go.  That got particularly intense this summer during the discussion.  We had to address the debt ceiling and what would be required, and I would expect that conversation to intensify, given that we’re heading into a national election next year.

I think what’s important to remember is that we actually have the slot on the books that it does currently point us in the direction of doing these things, and states are moving forward to do implementation.  Many states are moving forward in implementation, and for us, as people who have been working on this for many years, this is the best shot that our clients and people like them in other states and other communities have at getting their untreated health conditions actually treated.

So, our position is we need to continue to explore what could happen and to figure out how to broaden this conversation so that even if the Affordable Care Act doesn’t proceed as we all hope it will that we’ll have gained some ground in this conversation.  So, I offer that to you as a framing and acknowledgment that the political reality of the current situation, but we’re still very optimistic about this.  The rest of those presentation will be about why:  Why aren’t we optimistic?  Why aren’t we thinking this will make a difference?

So, a little bit of background, a little bit of epidemiology and numbers of people that we’re talking about.  First of all, this won’t be a surprise to anybody on this phone call, substance use disorders are nearly universal in the criminal justice system.  We know because of 30 years of research conducted by the Department of Justice, the National Institute of Justice, the National Institute of Drug Abuse, and many, many prominent national researchers that the criminal justice population include people who are both addicted to drugs and alcohol and people who abuse and misuse drugs and alcohol.  It may be in combination with a co-occurring mental health disorder.  It may be in combination with lots of other medical issues, but we know this is the consistently documented reality.

The National Institute on Justice’s research on jail inmates, they do quarterly testing in a number of cities around the country.  They consistently find that over 70% of jail inmates test positive for some illegal drug, and when you add alcohol into that mix, it goes up to nearly 100%.  So, this is a test within 3 days of arrest, and the prevalence is very, very high.  So, then, the next question we want to ask is what is the level of intensity and severity of those issues?  Are we talking mostly about people with risk use? Are we talking about people with ongoing problem use, or are we talking about people whose lives are like when the wheels come off the cart where their lives are run on their dependence on alcohol or illegal drugs or both?

The research on that shows that about 48% of prison inmates and about 44% of local jail inmates meet criteria for substance dependence, and that’s seven time greater than the general population.  So, we’re definitely looking at an area of concentrated, untreated addiction.  We are also looking at an area of untreated, risky use and abuse that has never been there.  So, both of these things can be addressed through healthcare reform.  Through the expansion of services, that’s possible through health care reforms in 2014.

Most of the remaining groups, the dependent group demonstrated significant substance abuse that has various consequences, obviously, including the legal consequences of their being in jail or in prison at the time.  When you think of how we manage this problem right now, we manage it by incarcerating people and putting them in community supervision, which can be expensive, especially the [10:08] Report and the public safety portfolio.  So, about 90% of the criminal justice dollars, corrections are actually spent on incarcerating people, and 10% is spent on all community supervision and other management population efforts that go on.  So, that’s really the big ticket item, and we have the opportunity to shift that a bit here.

Other chronic conditions in addition to substance abuse are very much more widespread than in the general population.  There are much higher rates of serious mental illness.  There was a very good study that was done by 1046 and other folks in the last couple of years that show the cross site analysis of jail populations consistently demonstrated serious and persistent mental illness.  So, schizophrenia, bipolar disorder, major depression, those are the ones that they looked at at over 15% of men, and about 30% of women who were in jail demonstrated that level of serious mental illness.  It’s also pretty high in the parole population, and it’s less high among the probation population.  So, that’s why I have over 10% on this slide.

There are higher rates of chronic medical conditions, including, we definitely see these in our patients, diabetes, heart disease, asthma, cancer, and HIV among the most prevalent ones.  There are also that only about 10% of these folks have insurance, whether that is Medicaid already through mental health or physical disability.  You have access to the All Kids Program. They call it something slightly different in other states, but it’s the subsidized Medicaid program for youth under 19.  Occasionally, folks have work and have private insurance, but because folks don’t have access to consistent health care, all their chronic conditions including their behavioral health conditions get treated episodically and get undertreated, essentially.  S

So, we see the effect of that in the behavioral health side with repeated cycling through problematic conditions, repeated arrests, but we also see the impact of that with chronic medical conditions.  So, undertreated diabetes and heart disease have much worse complications.  People are affected by those complications sooner, and they may die significantly younger as a result.  So, it’s a very large population group with a very high rate of untreated disease.

When we look at what this looks like in Illinois, this next slide is just a snapshot of the jails in Illinois.  In 2008, there were almost 367,000 jail booking.  We weren’t able to get an unduplicated number for those jail bookings, but if you just assume that, on average, everyone has two jail admissions, knowing that a lot of people have a lot more and some people have fewer.  I think it’s a conservative amount, about 180,000 in Illinois, and fewer of those jail admissions report to using drugs regularly.  So, two-thirds of the 180,000 would be about 120,000 unique people or 240,000 admissions.

So, about 14.5% have psychiatric disorders.  That’s 53,000 admissions, and of those, most have a co-occurring substance abuse as well.  With very highly variable lengths of stay and not a lot of organized re-entry services in jail, which are organized for people to come in and out of largely, it’s very difficult to coordinate care around case processing.  There’s not a lot of post-release care and a very high likelihood that people will return to jail if their behavioral health needs, in particular, are not addressed.

We also took a look at what are the numbers in probation across the four states at the area.  In Illinois, there were about 144,000 people in probation in 2009.  Indiana was a few less, 130,000.  Michigan, quite a few more at 175,000.  In Ohio, quite a few more at 260,000.  There are a number of very good, quite organized projects to link people on probation into substance use and mental health treatment programs.  They tend to be called like special probation supervision, specialty courts like drug courts and mental health courts, and certainly individual officers make a lot of referrals.

It’s a shame, I think, because Dental Protection and MDD US, they probably got billions invested in assets to underwrite what they do.  So, I think they should start paying out some sort of terminal bonus.  I think if you’ve been a customer of theirs and you retire, I think you should get a little bit of a share of the company back.  At the moment, they just go, “Thanks very much.  That’s the members’ money.  We’re putting it in, and we’re keeping it for the members.”

When you cease to become a member, I don’t see why you shouldn’t get a bit back, some sort of share.  They could do that and still maintain sufficient reserves, but at the moment, they’re saying, ”We have ways.  That’s going in the reserve.  We’ve had to put that into building the reserves.” I mean, how many billion pounds do you need?  They just save this money up for the sake of saving it.  It’s a bit addictive, I suppose, if you’re getting hundreds of millions of pounds in all the time.  When is enough, enough?  When do they say stop?

Chris Ritchie:      Well, they have to employ someone to count all the money, don’t they?  They’d have to sack people, presumably.  People would be made redundant.

Derek Watson:   Well, they can probably take on the people from the BDA then to help them count the money.

Chris Ritchie:      That is a very good idea.  What I’m more concerned about is the Scott advice, and he mentioned to me, some years ago, that he found out dental nurses, as you just told me, do not necessarily need indemnity insurance, but is the GDC still telling them that they do?

Derek Watson:   I think the GDC is pretty careful to steer clear of the argument.  Let me put it this way.  Dental nurses, I am pretty sure, and I’m looking for the reference here.  I think it’s fairly early on in the review that says that dental nurses are covered by NHS indemnity or their employer.

Now, a self-employed nurse would need indemnity, but there are very, very few of those.  The sort of people that need indemnity are hygienists, therapists, dental technicians, and stuff like that.

Now, if you’re a dental nurse and you’re worried, and you’ve been told, “Now, you’re already with the General Dental Council.  You may get reported to the General Dental Council.  You may have to appear before the General Dental Council,” then I can see why you might think you need some sort of insurance possibly to cover that and to pay for representation because you couldn’t pay for a barrister if you’re a dental nurse if you got a complaint.

For a while, people like Dental Protection said, “No, it’s not a problem.  If you’re a dental nurse working in the practice of a dentist who’s a member of the house, we’ll include in our scope of advice and care because basically it’s going to be the same complaint.  I mean, the complaint will probably reach to the dentist.  Then, they’ll name the nurse, but basically, we’ll be doing the paperwork anyway.  So, we might as well put your name down on the list of people that we are representing.”

This one organization in particular, the British Association of Dental Nurses, did come up with this scheme whereby they sold nurse’s indemnity insurance, and I’ve had many an argument with Pam Swain, their chief executive, about this, and underwriter, Sharon, who underwrote both Shield and Farras and I know underwrites the BDNA end scheme.

It’s money for them because they know damn well that the nurses aren’t going to get complained about, and they’re paying a premium, which £10 or £15 pounds a year, but even if it’s £2 a year, it’s £2 a year for not much.  The problem with this in the society in which we live is that this is seen as good business by some people, and there are an awful lot of nurses.  So, the numbers multiply.  There are profits to be made.  If 30,000 people pay £10, then you booked £300,000 haven’t you?  You don’t have to do much.  That’s good business.

I would say bad business.  Whenever our nurses have asked us if they need indemnity insurance, we’ve always told them no, but at the back of their mind, “Perhaps I’ll get it just to be on the safe side.  Perhaps I’ll get it just to be sure.”  Are you sure?  It’s always more difficult to say to someone, “No, you don’t need something,” than to say, “Yes, you do,” because you can’t prove it.  You can’t prove to them that they don’t need it.  All you can say is that you’ve looked at the Scott review, which most of them will never have heard of, let alone see, and say, “We’ve looked at it.  It’s our opinion. You don’t need it.”  I’m pleased to say, we’ve never regretted giving that advice.

Chris Ritchie:      Does the GDC have any knowledge of the Scott review?  According to the GDC website, “Once registered as a dental care professional, you must have professional indemnity to practice in the UK,” and they’ve helpfully blued out professional indemnity there.  So, you can follow the link.  If you click at that, “We’re sorry, we couldn’t find that page.”  I think it needs to spend a little bit of that new money it’s got on sorting its website out, perhaps.

Derek Watson:   Their website terrible.

Chris Ritchie:      Also, this advice is not right, is it?  It says you must have professional indemnity to practice in the UK, and as it turns out, that’s not exactly true.

Derek Watson:   Well, I’m on their indemnity page, and it says, “We expect you to have the appropriate arrangements in place in order for patients to seek any compensation, which they may be entitled to.”  Now, if you’re vicariously indemnified by your employer, then I would say that’s the end of it.

Chris Ritchie:      What about technicians?  Why should dental technicians need indemnity?  Would they?

Derek Watson:   Well, as I say, it’s really designed to protect you against financial claims, which arise out of claims for damage for loss as a result of negligence.  Now, how many times have technicians had claims of that nature?  It’s always the dentist isn’t it?  It’s always the dentist that gets sued.

Chris Ritchie:      It’s a big business, I think, built up around, and I think there’s a little bit of unscrupulous activity going on.  I think that it needs to be clearer.  I think who needs indemnity and who doesn’t should be made absolutely clear.

Derek Watson:   I wish I could find this thing in the Scott review.  Wait a second.  I got it.  Conclusions and recommendations number four.  It says, “My conclusions have taken into account that employees in the NHS and independent sector will be able to satisfy the condition of registration by dint of the corporate cover that arises from an employer’s vicarious liability for the acts or omissions of employees.”  Basically, that’s the employer’s support.  It’s like whatever goes wrong is my fault around here.  Whatever goes wrong with the nurse, it’s the nurse’s employer’s fault.

It says, “Personal cover, from a defense organization, trade union or other body, will not be required on relation to practice as an employee.” So, as an employee—

Chris Ritchie:      Completely covered.

Derek Watson:   “Personal cover will only be required in relation to self-employed practice.  In my judgment, this is the correct approach.”

Chris Ritchie:      So, this could be like the misspelling of PPI.  You know you get stung.

Derek Watson:   Oh, I haven’t thought about that.

Chris Ritchie:      You could get some recorded voice at the end of your phone, you know, saying, “Press 5 now and—

Derek Watson:   We were missold indemnity insurance by the PADN.  Holy cow.  Holy cow.

Chris Ritchie:      Yeah, that’s what it is.  This is what it boils down to.  This could be a PPI scandal in dentistry.

Derek Watson:   You know, it hadn’t occurred to me about that, and I’d been banging about this for years.

Chris Ritchie:      Well, you just need to talk to someone clever occasionally, that’s all.

Derek Watson:   You know, I think they’ll say that even if you are covered by vicarious liability, you might still need someone to represent your interest and help you handle the correspondence and everything, and that what we would do.

Oh well.  That seems like a fairly good note to end on.

Chris Ritchie:      We’ll be talking to Pam Swain next time, of course.

Derek Watson:   Pam Swain will be a guest on the next netcast, no doubt, explaining what she spent all the money on.

Chris Ritchie:      Buying Richard Leishman a new car, perhaps.

Derek Watson:   Right, we need to wind it up now because I think I’ll just have enough time to cover the list together.  As I said, the video’s working again this week.  That’s great.  We might have this up on YouTube as well, as a netcast, a podcast.

We’re going to the BDTA.  Now, I’ve got a problem because Farida is stuck in Iran.  My staff is stuck in foreign acclaims and therefore, cannot man personnel, workforce, whatever the word is, stand.

So, I don’t know what I’m going to do.  Ask me on the next podcast how it goes because 2 three-day exhibitions, and there’s nobody to help me.

Chris Ritchie:      Aw, diddums.

Derek Watson:   So, by the time people listen to this, the exhibition’s going to be over anyway.  So, they don’t care.

Chris Ritchie:      Does anyone care?

Derek Watson:   But if you do, if you’re listening to this in the two or three days before the BDTA.  It’s the 17^th and 19^th of October.  We’re on stand R and J [55:06].  Now, the next netcase is going to be on Monday, the fourth of November.  That’s they day for a bonfire date, and as usual, just either e-mail us at info@dentalfusion.org or go to the website dentalfusion.org.

If you’re a member, you’ll be able to get in.  If you’re not a member, there’s still some stuff there for you, including the address to the podcasts and stuff like that.  Please do consider joining because we have, for many years, relied on the support of the profession to keep going.  Unlike the British Dental Association, we don’t have much of the way or reserves, and we do need your help and support more than ever.  So, go and have a look.  See what we offer.  If you think it’s worth what we’re charging for it, then sign up, and try us out.

So, I think that’s it.  Anything else?

Chris Ritchie:      No.  I was just going to suggest, as it’s the day before Bonfire Night, we could have a mass burning of all the indemnity certificates.

Derek Watson:   Yes, there’s going to be a mass burning of Leishman unless we find out that he’s got a bloody excuse for not being on this week, but as you said, I think he did mention that he wasn’t going to be around one week.

Chris Ritchie:      This is that one week.

Derek Watson:   Possibly, he’s taken his blood £81,000 Mercedes abroad, and he’s gone on a driving holiday hasn’t he?

Chris Ritchie:      Probably.  That man seems to take holiday every week.  I just don’t know what’s going on.  Shocking.  We have to work for a living.  He’s some sort of playboy, gallivanting around Europe.  I don’t know.

Derek Watson:   First of all, can I just say, if you’re going to be a presenter on this podcast and you don’t turn up, expect the piss to be taken off you mercilessly.  That is one of the conditions.  If I ever miss one of these, and Chris has certainly missed these in the past, that is just a condition of joining in.

Chris Ritchie:      Yeah, that’s fair.

Derek Watson:   Secondly, read rule one.

Chris Ritchie:      Thirdly, I’m hungry.  Thanks very much.

Derek Watson:   Alright Chris.  Talk to you next time.

Chris Ritchie:      Buh bye.

Derek Watson:   Bye.