National MS Guidelines - GM Benchmarking 2025

The network are benchmarking GM services providing MS care against a variety of national guidelines. The scoping will inform key areas of focus for our MS Pathway Development project. The form will filter questions depending on the service you provide. It has a "Save and continue later" function. NOTE: If you use this function it does not generate an email and you must copy the link generated and ideally email to yourself to keep safe (a new link is created each time it is saved). Please answer each question as follows: "Fully" if your service is fully compliant with the recommendation at least 90% of the time; "Partially" if your team complies with only part/some aspects of the recommendation all of the time, or fully complies but <90% of the time; answer "Not" if your team does not comply with the recommendation at all. There is also an opportunity to share further information under each section if you wish to do so. Deadline for submission is Friday 14th March.

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What best describes the service you provide to MS patients?

NICE Multiple sclerosis in adults: management NG220 (2022)

Available at: https://www.nice.org.uk/guidance/ng220/chapter/Recommendations#diagnosing-multiple-sclerosis

1.1 Diagnosing multiple sclerosis

Recognising multiple sclerosis

1.1.1 Be aware that people with MS may present with a wide range of symptoms affecting different parts of the body.

The most common are: loss or reduction of vision in 1 eye with painful eye movements, double vision, ascending sensory disturbance and/or weakness, altered sensation or pain travelling down the back and sometimes into the limbs when bending the neck forwards (Lhermitte's sign) and progressive difficulties with balance and gait.

Fully

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Not

1.1.2 Be aware that usually people with MS present with neurological symptoms or signs as described in recommendation 1.1.1, and:

are often aged under 50 and may have a history of previous neurological symptoms and have symptoms that have evolved over more than 24 hours and have symptoms that may persist over several days or weeks and then improve and do not have fever or infection.

Fully

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Not

1.1.3 Do not routinely suspect MS if a person's main symptoms are fatigue, depression, dizziness or vague sensory phenomena, unless they have a history or evidence of focal neurological symptoms or signs.

Fully

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Not

Initial assessment

1.1.4 Before referring a person suspected of having MS to a neurologist, confirm that this is a neurological episode by taking a history, undertaking a physical examination and excluding alternative, more common diagnoses.

Fully

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Not

Referral and diagnosis

1.1.5 Refer people suspected of having MS for diagnosis by a consultant neurologist or a specialist under their supervision. Contact the consultant neurologist directly if you think a person needs to be seen urgently.

Fully

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Not

1.1.6 Diagnose MS using a combination of history, examination, MRI and laboratory findings, and by following the 2017 revised McDonald criteria.

This should include: assessing that symptoms are consistent with an inflammatory demyelinating process e.g. headache is not suggestive of MS, excluding alternative diagnoses (targeted laboratory tests may be indicated if the history, examination or MRI findings are atypical), establishing that lesions on MRI scans have developed at different times and are in different anatomical locations for a diagnosis of relapsing–remitting MS, looking for cerebrospinal fluid-specific oligoclonal bands if there is no clinical or radiological evidence of lesions developing at different times and establishing progressive neurological deterioration over 1 year or more for a diagnosis of primary progressive MS.

Fully

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Not

1.1.7 If the McDonald criteria are not met but MS is suspected or the person has confirmed clinically isolated syndrome (see the 2017 McDonald criteria for a definition of clinically isolated syndrome):

Plan a review to reassess the possibility of MS. Discuss the timing of this and future reviews with the person (for example, annually). Provide information and ensure that the person knows who to contact for advice if they develop further neurological symptoms or if current symptoms worsen.

Fully

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Not

1.1.8 Do not diagnose MS on the basis of MRI findings alone.

Fully

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Not

1.1.9 Offer people with confirmed MS information and advice on resources and support.

Fully

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Not

Optic neuritis and neuromyelitis optica spectrum disorder

1.1.10 If a person has an episode of isolated, optic neuritis, confirmed by an ophthalmologist, refer them to a consultant neurologist for further assessment.

Fully

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Not

1.1.11 Diagnosis of neuromyelitis optica spectrum disorder should be made by an appropriate specialist based on established up‑to‑date criteria.

Fully

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Not

1.1 Diagnosisng MS - Additional information (optional)

1.2 Providing information and support

Information and support at the time of diagnosis

1.2.1 The consultant neurologist should ensure that people with MS, and with their agreement their family members or carers, are offered oral and written information at the time of diagnosis.

This should include, but not be limited to, information about: what MS is, treatments (inc. disease‑modifying therapies), symptom management, how support groups, local services, social services and national charities are organised and how to get in touch with them, online resources, legal requirements such as notifying the Driver and Vehicle Licensing Agency and legal rights including social care, employment rights and benefits.

Fully

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Not

1.2.2 Discuss with the person with MS and their family members or carers whether they have social care needs and if so refer them to social services for assessment. Ensure the needs of children of people with MS are addressed.

Fully

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Not

1.2.3 Offer the person with MS a face‑to‑face follow‑up appointment with a healthcare professional with expertise in MS to take place within 6 weeks of diagnosis.

Fully

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Not

Ongoing information and support

1.2.4 Explain to people with MS that they should have a comprehensive review of their care at least once a year and what this should cover. Advise them to ask their healthcare professional for a review if it has not taken place.

Fully

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Not

1.2.5 Review information, support and social care needs regularly. Continue to offer information and support to people with MS or their family members or carers even if this has been declined previously.

Fully

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Not

1.2.6 Ensure people with MS and their family members or carers have a management plan that includes who to contact if their symptoms change significantly.

Fully

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Not

1.2.7 Explain to people with MS that the possible causes of symptom changes include: another illness such as an infection, further relapse and change of disease status (for example progression).

Fully

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Not

1.2.8 Talk to people with MS and their family members or carers about the possibility that the condition might lead to cognitive problems.

Fully

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Not

1.2.9 Provide ongoing information and support tailored to the person's changing needs or circumstances, for example, when planning to have children, if their MS is changing to a more progressive phase or as their MS becomes more advanced.

Fully

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1.2.10 Explain to carers (including young carers) about their right to a carer's assessment and tell them about other sources of information and support that may be available

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Information and support for people planning to have children or who are pregnant

1.2.11 Ask the person with MS soon after diagnosis and at regular intervals if they have any plans for starting or extending their family now or in the future, either through pregnancy or adoption.

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1.2.12 Explain to people with MS that they should discuss with their healthcare professionals if they are planning to start or extend their family or become pregnant. In particular, ensure that people taking disease-modifying treatments understand that they should tell their healthcare professionals straight away if they are trying to become pregnant or if they become pregnant.

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1.2.13 Explain to people with MS, and their partners if appropriate, that MS should not stop them from planning a family. Offer the opportunity to talk with a healthcare professional with knowledge of MS to answer any questions they have.

For example, this may include discussing the following: that fertility is not affected by MS, that pregnancy can be well managed in people with MS, the risk of the child developing MS, taking vitamin D and folic acid supplements before and during pregnancy, possible changes to medicine use before and during pregnancy, that pregnancy does not increase the risk of disease progression, that relapses may decrease during pregnancy and may increase 3 to 6 months after childbirth before returning to pre-pregnancy rates, that birth options and pain relief choices available (including epidurals) should not be affected by MS, that breastfeeding is safe unless the person with MS is taking certain disease-modifying treatments and support that may be available with caring for and supporting children.

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1.2.14 Discuss caring for a child and the possible impact of MS symptoms, such as fatigue, and how these could be managed.

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Not

Information and support for people as MS becomes more advanced, including those approaching the end of their life

1.2.15 Give people with MS that is becoming more advanced and their family members or carers information and support covering: social isolation and feelings of depression, mobility aids and home adaptations and other support available, such as legal rights including social care, employment rights and benefits, and the right to a carer's assessment

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1.2.16 Explain to people with advanced MS and their family members or carers about the services available (for example, occupational therapy, palliative care and social services) and give them support to access them if needed.

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1.2.17 For advice on identifying people who may be approaching the end of their life and providing information and support, follow the recommendations in NICE's guideline on end of life care for adults.

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1.2.18 When appropriate, explain to the person with MS (and their family members or carers if the person wishes) about advance care planning and power of attorney.

Think about discussing advance care planning early if you expect the person's ability to communicate, cognitive status or mental capacity will deteriorate. Follow the recommendations on advance care planning in NICE's guideline on decision making and mental capacity.

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1.2 Providing information & support - Additional information (optional)

1.3 Coordination of care

1.3.1 Offer the person with MS an appropriate single point of contact with knowledge of MS services to coordinate care and help them access services.

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1.3.2 Care for people with MS using a coordinated multidisciplinary approach.

Involve professionals who can best meet the needs of the person with MS and who have expertise in managing MS including: MS nurses, consultant neurologists, physiotherapists with expertise in MS and occupational therapists, speech and language therapists, psychologists, dietitians, social care, continence specialists and specialist neuropharmacists or specialist MS pharmacists, consultants in rehabilitation medicine, primary healthcare team.

Fully

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1.3 Coordination of care - Additional information (optional)

1.4 Modifiable risk factors for relapse or progression of MS

1.4.1 Encourage people with MS to exercise. Advise them that regular exercise may have beneficial effects on their MS and does not have any harmful effects on their MS.

Fully

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Not

1.4.2 Advise people with MS not to smoke and explain that it will increase the progression of disability.

Fully

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1.4.3 Offer vaccinations in line with advice from the Joint Committee on Vaccinations and Immunisation and the Green Book: Immunisation against infectious disease for people with MS and their carers.

Fully

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1.4 Modifiable risk factors for relapse or progression of MS - Additional information (optional)

1.5 MS symptom management and rehabilitation

1.5.1 Determine how often the person with MS will need to be seen based on: their needs, and those of their family and carers and the frequency of visits needed for different types of treatment (such as review of disease‑modifying therapies, rehabilitation and symptom management).

Fully

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1.5.2 When prescribing medicines for symptom management in people with MS, ensure that local arrangements for prescribing, supply and treatment review follow NICE's guideline on medicines optimisation.

Fully

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Not

Fatigue: Assessment and non-pharmacological management of fatigue

1.5.3 Ask people with MS if they are experiencing fatigue, sudden tiredness or a change in their energy levels affecting their daily living.

Fully

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Not

1.5.4 Do not assume that the person's fatigue is always caused by MS. Assess for other causes and manage these or refer the person for management if indicated.

Other causes of fatigue may include: sleep problems, symptoms of MS, such as pain, spasticity and bladder dysfunction, side effects of medicines, illnesses, such as infections, anaemia and thyroid dysfunction, anxiety and depression

Fully

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Not

1.5.5 Explain that MS‑related fatigue may be brought on by heat or biological, physical and emotional stress.

Fully

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1.5.6 Offer people with MS and fatigue a personalised discussion about how they can be supported to self-manage their fatigue.

This could include: identifying goals and priorities, advice on conserving their energy, reviewing lifestyle factors such as diet and exercise, using stress management and wellbeing approaches such as mindfulness and cognitive behavioural techniques to help with day-to-day activities.

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1.5.7 Advise people that aerobic, resistive and balance exercises, including yoga and pilates, may be helpful in treating MS‑related fatigue.

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1.5.8 Explain to people that there is no evidence that a specific diet will improve fatigue in people with MS, but that a healthy diet will benefit their general health.

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1.5.9 For people with MS with moderately impaired mobility (an EDSS [Expanded Disability Status Scale] score of greater than or equal to 4), consider a combination of: a programme of supervised aerobic and moderate progressive resistance activity and cognitive behavioural techniques.

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1.5.10 Do not use vitamin B12 injections to treat fatigue in people with MS.

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1.5.11 Do not offer hyperbaric oxygen to treat fatigue in people with MS.

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Pharmacological management of fatigue

1.5.12 Discuss with the person with MS whether a medicine to treat fatigue might be an option for them. Explain that there are potential risks, benefits and safety concerns for the possible treatment options.

Fully

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Not

1.5.13 If a person with MS wishes to try a medicine for fatigue, refer them to a specialist to fully discuss the treatment options.

Fully

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1.5.14 Use shared decision making to decide whether to try a medicine for fatigue and which would be most suitable. Taking into account the needs, priorities and preferences of the person with MS, and the risks and benefits of each treatment.

Consider any of the following: amantadine, modafinil (except in people who are pregnant or planning pregnancy), SSRI

Fully

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1.5.15 Regularly review treatment to monitor effectiveness, safety and acceptability, adjust the dose, and decide whether to continue or stop the medicine:

Agree the frequency of review with the person with MS, taking into account the medicine that they are taking, the need for dose adjustments and the person's preferences and circumstances.

Fully

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Not

1.5.16 When the person with MS is on a stable dose of a medicine for fatigue, subsequent prescriptions may be issued by another prescriber as part of a shared-care agreement under the direction of the initiating specialist prescriber.

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Mobility problems

1.5.17 Ensure people with MS and mobility problems have access to an assessment to establish individual goals and discuss ways to achieve them. This would usually involve rehabilitation specialists and physiotherapists with expertise in MS.

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1.5.18 Do not offer fampridine to treat mobility problems in people with MS. Fampridine is a clinically effective treatment for some people, but it is not cost effective at the current list price.

This recommendation does not apply to people who have already started treatment with fampridine in the NHS, who should be able to continue treatment until they and their NHS clinician think it appropriate to stop.

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1.5.19 Consider vestibular rehabilitation for people with MS who have fatigue or mobility problems associated with limited standing balance.

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Not

1.5.20 Consider supervised exercise programmes involving moderate progressive resistance training and aerobic exercise to treat people with MS who have mobility problems or fatigue.

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1.5.21 Help the person with MS continue to exercise, for example, by referring them to a physiotherapist with expertise in MS or to exercise referral schemes.

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1.5.22 If more than 1 of the interventions recommended for mobility or fatigue are suitable, offer treatment based on which the person prefers and whether they can continue the activity after the treatment programme ends.

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1.5.23 Encourage people with MS to keep exercising after treatment programmes end for longer-term benefits

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Spasticity

1.5.24 Suspect spasticity when a person with MS presents with any of the following:

involuntary muscle movements (spasms), muscle stiffness, pain and restriction with certain movements or positions causing difficulty in performing various activities, a change in their mobility or upper limb function.

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1.5.25 Assess people with MS and suspected spasticity for factors that might worsen spasticity, for example, pressure ulcers, bladder and bowel dysfunction and infections, poor posture or positioning, and pain. Provide support and information to help people with MS, and their families and carers if appropriate, to prevent and manage these factors.

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1.5.26 Discuss with the person the balance between the benefits and harms of treating spasticity. In particular, explain that some people use their spasticity to maintain their posture and ability to stand, walk or transfer, and that treatment with muscle relaxants may adversely affect this.

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1.5.27 Consider oral baclofen as a first-line drug treatment to treat spasticity in people with MS who have specific treatment goals such as improving mobility or easing pain and discomfort. Take into account any contraindications, comorbidities and the person's preferences.

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1.5.28 If oral baclofen is not tolerated or does not provide adequate relief, consider gabapentin as a second-line option to treat spasticity in people with MS.

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1.5.29 When using oral baclofen or gabapentin to treat spasticity in people with MS, explain to the person that they should:

increase the dose gradually in at least 2‑week increments to optimise symptom improvement or until they reach the maximum dose they can tolerate, stop taking the medicine if there is no benefit at the maximum tolerated dose (explain that baclofen can cause harm if stopped suddenly and that special precautions may be needed when stopping specific medicines), have their medicines reviewed at least annually once the optimal dose has been reached.

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1.5.30 Consider a combination of oral baclofen and gabapentin for people with MS if: individual medicines do not provide adequate relief or side effects from individual medicines prevent the dose being increased.

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1.5.31 If spasticity is causing significant impairments in mobility, posture or function and initial treatments are unsuccessful, refer to a multidisciplinary team experienced in the management of spasticity for assessment and treatment planning.

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1.5.32 For guidance on THC:CBD spray for treating spasticity in people with MS, see the recommendations on spasticity in NICE's guideline on cannabis-based medicinal products.

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Oscillopsia

1.5.33 Consider gabapentin as a first‑line drug to treat oscillopsia in people with MS.

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1.5.34 Consider memantine as the second‑line treatment for oscillopsia in people with MS.

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1.5.35 Refer the person with MS for specialist advice if there is no improvement in oscillopsia after treatment with gabapentin and memantine or if side effects prevent continued use.

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Emotional lability

1.5.36 Consider amitriptyline to treat emotional lability (involuntary laughing and crying related to a frontal lobe lesion) in people with MS.

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Pain

1.5.37 Assess and investigate the cause of pain to establish a diagnosis and offer treatment specific to the cause of the pain.

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1.5.38 Be mindful of the impact of pain on the mental wellbeing of people with MS, and provide advice and support.

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1.5.39 Treat neuropathic pain in people with MS and refer people to pain services according to NICE's guideline on neuropathic pain in adults.

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1.5.40 Be aware that musculoskeletal pain is common in people with MS and is usually secondary to problems with immobility, spasticity and posture. Assess musculoskeletal pain and offer treatment appropriate to the cause

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Cognitive and memory problems

1.5.41 Be aware that the symptoms of MS can include cognitive problems, including memory problems, that the person may not immediately recognise or associate with their MS.

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1.5.42 Assess cognition as part of the person's comprehensive review. Tailor the assessment to the person's needs, for example, use a clinic interview or brief formal assessment, or consider referral for a full neuropsychological assessment if needed.

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1.5.43 Be aware that anxiety, depression, difficulty sleeping, fatigue and medication can affect cognition. Assess for and offer management appropriate for these issues in people with MS and cognitive or memory problems

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1.5.44 Consider referring people with MS and persisting cognitive impairments to an occupational therapist and/or a neuropsychologist to assess and manage these symptoms according to the person's needs.

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1.5 MS symptom management and rehabilitation - Additional information (optional)

1.6 Comprehensive review

1.6.1 Ensure all people with MS have a comprehensive review of all aspects of their care at least once a year.

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1.6.2 Ensure the comprehensive review is carried out by healthcare professionals with expertise in MS and its complications. Involve different healthcare professionals with expertise in specific areas of the review if needed.

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1.6.3 Tailor the comprehensive review to the needs of the person with MS assessing:

MS symptoms, MS disease course, General health, Social activity and participation, Care and carers

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1.6.4 Refer any issues identified during the comprehensive review of the person with MS to members of the MS multidisciplinary team and other appropriate teams so that they can be managed.

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1.6.5 Ensure people with MS are offered a medicines review in line with NICE's guidelines on medicines adherence and medicines optimisation.

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1.6.6 Ensure people with MS have their bone health regularly assessed and reviewed in line with NICE's guideline on osteoporosis.

Fully

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Not

1.6.7 Ensure people with MS and severely reduced mobility are regularly assessed and reviewed for risk of contractures

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1.6.8 Check people with MS and severely reduced mobility at every contact for areas at risk of pressure ulcers

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1.6.9 Discuss the care provided by carers and care workers as part of the person's care plan. Ensure that carers (including young carers) know about their right to a carer's assessment

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1.6.10 Refer people with MS to palliative care services for symptom control and for end of life care when appropriate.

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1.6 Comprehensive review - Additional information (optional)

1.7 Relapse and exacerbation

Recognising a relapse

1.7.1 Diagnose a relapse of MS if the person: develops new symptoms or has worsening of existing symptoms and these last for more than 24 hours in the absence of infection or any other cause after a stable period of at least 1 month.

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1.7.2 Before diagnosing a relapse of MS: rule out infection – particularly urinary tract and respiratory infections and discriminate between the relapse and fluctuations in disease or progression.

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1.7.3 Do not routinely diagnose a relapse of MS if symptoms are present for more than 3 months.

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Treating acute relapse of MS

1.7.4 Develop local guidance and pathways for timely treatment of relapses of MS. Ensure follow up is included in the guidance and pathway.

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1.7.5 Assess and offer treatment for relapses of MS that affect the person's ability to perform their usual tasks, as early as possible and within 14 days of onset of symptoms.

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1.7.6 Non‑specialists should discuss a person's diagnosis of relapse and whether to offer steroids with a healthcare professional with expertise in MS because not all relapses need treating with steroids.

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1.7.7 Offer treatment for relapse of MS with oral methylprednisolone 0.5 g daily for 5 days.

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1.7.8 Consider intravenous methylprednisolone 1 g daily for 3 to 5 days as an alternative for people with MS: in whom oral steroids have failed or not been tolerated or who need admitting to hospital for a severe relapse or monitoring of medical or psychological conditions such as diabetes or depression.

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1.7.9 Do not prescribe steroids at lower doses than methylprednisolone 0.5 g daily for 5 days to treat an acute relapse of MS.

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1.7.10 Do not give people with MS a supply of steroids to self‑administer at home for future relapses.

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Information about treating a relapse with steroids

1.7.11 Discuss the benefits and risks of steroids with the person with MS, taking into account the effect of the relapse on the person's ability to perform their usual tasks and their wellbeing.

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1.7.12 Explain the potential complications of high‑dose steroids, for example temporary effects on mental health (such as insomnia, depression, confusion and agitation) and worsening of blood glucose control in people with diabetes.

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1.7.13 Give the person with MS and their family members or carers (as appropriate) information that they can take away about side effects of high‑dose steroids in a format that is appropriate for them.

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1.7.14 Ensure that the MS multidisciplinary team is told that the person is having a relapse, because relapse frequency may influence which disease-modifying therapies are chosen and whether they need to be changed.

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Medical, therapy and social care needs at time of relapse or exacerbation

1.7.15 Identify whether the person having a relapse of MS or their family members or carers have social care needs and if so refer them to social services for assessment.

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1.7.16 Offer inpatient treatment to the person having a relapse of MS if their relapse is severe or if it is difficult to meet their medical and social care needs at home.

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1.7.17 Explain that a relapse of MS may have short‑term effects on cognitive function.

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1.7.18 Identify whether the person with MS having a relapse or exacerbation needs additional symptom management, rehabilitation or consideration for disease-modifying treatments.

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1.7 Relapse and exacerbation - Additional information (optional)

1.8 Other treatments

Disease-modifying treatments: NICE has published technology appraisal guidance on disease-modifying treatments for MS. For full details, see NICE's technology appraisal guidance on multiple sclerosis.

1.8.1 Vitamin D: Do not offer vitamin D solely for the purpose of treating MS.

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1.8.2 Omega fatty acids compounds: Do not offer omega‑3 or omega‑6 fatty acid compounds to treat MS. Explain that there is no evidence that they affect relapse frequency or progression of MS.

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1.8 Other treatments - Additional information (optional)

NICE MS Quality Standards QS108

Available at: https://www.nice.org.uk/guidance/qs108

Statement 1: Adults with MS are given support at the time of diagnosis to understand the condition, its progression and the ways it can be managed, by the consultant neurologist making the diagnosis.

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Statement 2: Adults with MS are offered a face‑to‑face follow‑up appointment with a healthcare professional with expertise in MS, to take place within 6 weeks of diagnosis.

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Statement 3: Adults with MS have a single point of contact who coordinates access to care from a multidisciplinary team with expertise in MS.

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Statement 4: Adults with MS who have problems with mobility or fatigue are offered support to remain physically active.

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Statement 5: Adults with MS who have a relapse that would benefit from treatment are offered treatment as soon as possible and within 14 days of the onset of symptoms.

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Statement 6: Adults with MS are offered a comprehensive review at least once a year by healthcare professionals with expertise in MS.

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NICE MS Quality Standards QS108 - Additional information (optional)

MS Optimal Care Pathway (2024)

Quality Standards 4&5 covered in previous sections. Available at: https://www.nnag.org.uk/optimal-clinical-pathway-adults-ms

Quality Standard 1: Diagnosis of uncomplicated MS to be confirmed and communicated to the patient within 12 weeks of reciept of GP referral by specialist MS team

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Quality Standard 2: A face to face follow up appointment with a specialist MS Nurse is offered within 4 weeks of reciept of referral post diagnosis

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Quality Standard 3: People with a confirmed diagnosis of MS who are elegible and want to start DMT within 12 weeks of shared treatment decision

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Quality Standard 6: Response to any unscheduled contact by a patient, MDT or GP reporting a patient problem within 3 working days

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Quality Standard 7: Formation and evaluation of a care plan within 1 week of the patient, a member of the MDT or GP reporting a problem

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Quality Standard 8: Every person with MS has been offered comprehensive education within the last 2 years

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Quality Standard 9: Every patient with complex rehabilitation needs should have a Rehabilitation Prescription

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Quality Standard 10: Every MS service should maintain a current database of people with MS

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Quality Standard 11: Every patient should be offered the opportunity to take part in research, including clinical trials (where egilible)

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MS Optimal Care Pathway (2024) - Additional information (optional)

MS Society - My MS, My Needs Report 2022

Several recommendations covered in previous sections. See below for others. Available at: https://www.mssociety.org.uk/about-us/how-we-work/our-evidence/my-ms-my-needs

Emotional Support: Address patient's, their families and carer's emotional support needs during reviews.

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Bladder & Bowel Support: Ask about any changes to bladder and/or bowel routines during appropriate patient contacts. See below for signposting information if issues identified in any patient contact:

In GM, if patient has bladder and/or bowel issues refer to the GM Neurogenic Bladder & Bowel Service. For more information contact Clare Crossley: gbccro@coloplast.com

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MS Society - My MS, My Needs Report (2022) - Additional information (optional)

This field is for validation purposes and should be left unchanged.