Socialism and Health the magazine of the Socialist Health Association July 2011 Editor’s Opening This issue is largely devoted to our first attempt at a vision for a future health policy. The Labour Health Team has been completely pre-occupied with fighting the Health and Social Care Bill for the last year, and it will still be many months before the Party really starts to think about the policies on which we should fight the next election. Much may change before May 2015, and the leadership are understandably wary of committing themselves to ideas which might be used against them. The Director of the Socialist Health Association has a place on the Labour Party‟s Health Policy Commission and that is now starting to think about key policy areas, starting with social care and public health and moving on to the lessons to be learned from the successes and failures of Labour Government policy over 13 years. We have had long arguments over markets, choice and privatisation. The view of the majority is that patient choice of provider is helpful, where it is possible, but the amount of NHS expenditure which is susceptible to patients making choices is small, probably less than 20%. Few patients are enthusiastic about making such choices. We cannot make this the central principle of the NHS. Patients are more interested in how they are treated than in where they are treated. We are not against independent service providers in principle where they have something better to offer which the NHS cannot provide, but we do not see the commercial sector ever playing a large part . This isn‟t an agreed statement of Socialist Health Association policy, but a contribution to debate. There are many issues it does not deal with and a number of issues about which members will not all agree. The key points we need to stress are:
The futility of structural reorganisation
The importance of integrating health and social care
Active involvement by patients in their own care
Stress on prevention determinants of health
Commissioning to be under the control of democratically elected local authorities
Move towards Best Value
Shift resources out of hospitals and towards integrated services
Aligning the incentives for clinicians and organisations with the interest of patients
Genuine debate about the benefits of the service model adopted in Wales and Scotland
and
the
wider
Contents
P 2 The
Plot Against the NHS: book review P3 The Impossible Challenge: A Model for Future Care P7 Still Dark: The state of the Health Bill P9 Focus on Liberal Democracy P10 Timetable of Events Editor Irwin Brown 22 Blair Road Manchester M16 8NS 0161 286 1926 irwin@sochealth.co.uk
Please send contributions or ideas for articles
The Plot Against the NHS Merlin Press 2011 Colin Leys and Stewart Player This brief exposition of the situation facing the NHS is both clear and frightening. The first five chapters describe the changes made by New Labour during its period of office including the hugely expensive Private Finance Initiative projects, Independent Sector Treatment Centres, Payment by Results and the creation of Foundation Trusts. This marketisation laid the ground for the Coalition’s Bill to jump start their determination to fully dismantle and privatise the health service and leave the NHS as a ‘kitemark’ for those organisations commissioning and providing the service. These so-called reforms created a finance led system rather than one designed to meet health needs. The authors, Colin Leys and Stewart Player, show clearly with full references that it is private companies, required by law to meet shareholder returns, who benefit to the disadvantage of patients. Chapter 7 describes in detail the health policy lobbyists who have been such a strong influence on government, indeed to the point of showing how ministers, Labour and Conservative, have strong financial links to private companies driving this agenda. In the UK there is no register of lobbyists and therefore no public control. In dealing with how the market will operate the authors show in great detail the range of companies involved
and the influence of the US system of healthcare. But they also expose the real danger of competition, in reality based on price rather than quality of care. The costs of the market, borne by the taxpayer, are shown: huge transaction costs (up from 5% administrative costs in the ‘70s to 14% by 2003 and rising) plus shareholder returns and executive salaries. Removing the market (as in Wales and Scotland) would save £10 billion a year, resolving the problem of saving £20 bn over the next 3 to 4 years. This well researched book should be read by all those involved in and concerned about our NHS. It is a wake -up call. Whilst the NHS has never had a higher approval rate by the population, provides excellent value for money in comparison with most other countries and must be the highest on equity of provision, the proposed changes, even after the coalition’s marginal climb down, leave it seriously at risk. Of course, like any large and complex organisation, it needs improvement but this should be to the benefit of all. John Lipetz
Impossible Challenge The healthier we are, and the more we spend on care, the greater the demand for care services. Care costs rise faster than GDP, driven by expectation, technology and demographics. A free, comprehensive health service where there is equality of access and where the risks are truly shared through social solidarity is the mark of a civilised country. In our vision care remains free at the point of need and paid for out of general taxation. The aspiration of equal access and equality of outcomes remains and the gap between reality and aspiration must begin to close. Key problems faced by our NHS are unacceptable variation, increasing inequality, and fragmented services designed round organisations not patients. We know hospitals suck in resources and primary and community care is too weak to enable the shift of care closer to home. Public health, dealing with prevention and education, is sidelined. The market system still does not align financial incentives to the outcomes required. There are issues around “inefficiency�, poor productivity and a lack of focus on patient experience. None of these are new yet repeated attempts to deal with them through organisational change and financial incentives have largely failed.
Direction and Culture The NHS focus needs to change from providing episodic acute care in hospitals to managing long term conditions, where patients need social as well as medical care. Patients must feel they are cared for by one system not passed from one organisation to another. The inward looking culture must move to a patient orientated approach highly intolerant of poor care with systems for open reporting and rapid remedial action, tackled through leadership from care professionals. The top down prescriptive bullying management style must be replaced by genuine alternatives, the Empire broken up. Rather than some magic bullet solution we need to reach a broad consensus on what the problems are and then accept collectively the profound changes necessary to have an NHS fit for the current era. We need to get the improvements in outcomes and efficiencies to match the increased investment of the last decade. We have to do this during a period of reducing funding and do it without the constant upheaval and reorganisations that never appear to work.
A New Vision for Active Care
For at least two decades there has been a lazy and
evidence-free consensus that somehow competition is the only and best force for good. Our alternative to the market approach is based on a new version of clinical professionalism, on coproduction supported by information provision, integration, and democracy with a political settlement where there is an accountable Secretary of State for Care; not for Health. We need to move to active care. Active as patients feeling more confident to look after ourselves and share decisions with clinicians. Commissioners embracing a proactive approach to public accountability, co-production and community development. Active communities guiding the development of local services. Clinicians seeking actively to respond to needs and offering proactive care to people with long term conditions. Active providers working in collaboration (not in competition) and sharing best practice; working with patients and commissioners to develop the services required. Active regulation to ensure problems are identified early, support is provided where needed but firm action is taken if that is not enough.
Health Joins the Family – A National Care Service Health care, through the NHS, has always been a separate empire or rather a federation of powerful vested interests. It needs to be incorporated into the family of public services most especially ending the artificial barrier between social and health care. We need to move to a national care service so patients only undergo one needs assessment process on a national basis, with simple rules for eligibility and one national, and so portable, standard of entitlement. Over time personal social care should be made free as with health care; the argument that this is justified by risk pooling through social solidarity (as applies to health) is unanswerable. The rising costs of providing quality care for a growing elderly population should be met out of general taxation.
Involvement and Choice
We must all be encouraged, educated and supported to take more shared responsibility for our own wellbeing and the professions must be better trained in how to bring this about. The many barriers which face those most likely to suffer poor health need to be addressed in ways which encourage involvement. The principles of coproduction, where care professionals and patients work together, must feature more in medical training and professional development. Choice and involvement must be built on better access for patients to their medical records and on
simple, officially sanctioned, information about care and treatment options and care pathways. For the less able, such as the frail elderly or children, support and agency will be offered to enhance choice and involvement. An information revolution is still required, years after the “project” commenced. Portable electronic patient records, with access controlled by the patients, will not only drive process efficiencies but offer other avenues to personalise care and make it independent of organisational boundaries. Increasingly patients should be offered choice over where and when they can access advice, support or care, with the minimum of waiting. But this is choice about how care is provided as part of personalisation of care, not choice of provider organisation as a device to force market solutions.
Care Closer to Home
Increasingly care should be provided in the home or closer to home, making use of a much more dispersed model for care provision but also of the emerging technologies around telemedicine and monitoring, with knowledge transfer permitting patient-led processes. Over time investment in primary and community care and the merging with social care will accelerate the closure of acute facilities: less beds, less in-patient procedures, more ambulatory care and more day case surgery. This is not a cost cutting approach and indeed can only happen after considerable investment in capacity building outside hospitals. But it has to overcome the vested interests and political interference. Communities need a greater say in local services, especially when reconfiguration or closures are planned but based on engagement rather than one off and artificial consultations – but the trade-off is that the harder decisions can still be made in the wider interest. An alliance between clinical leadership and local involvement is essential for the extensive reconfiguration of services, such as closing an A&E or a birthing centre. All key decision making bodies must provide, as of right, places for patients and public. Health education and illness prevention has to be tackled at community level with leadership from local authorities; and tackled in ways which, for example, treat the issue of family breakdown as seriously as we once took public health issues around slum clearance and sewerage.
Commissioning Care
Commissioning is the process where decisions are made about how public money is spent and on what priorities are set and what standards apply,
since we can never fully address all care needs. It is also about how we get best value for our public spending. In the general view health commissioning has been largely weak and ineffective in bringing improvements. Across all local and central government commissioning has been separated from providing so decisions are not unduly influenced (though they must be informed) by provider power or conflicts of interest. This is hard to achieve in health care as the only place much of the necessary knowledge and expertise can be found is within the providers, so a more collaborative style to plan and then procure services is needed. Increasingly care commissioning should be the responsibility of local government, through elected representatives, as it is (directly or indirectly) for all other local public services. They take responsibility to provide a comprehensive universal local service with specific access guarantees, reinforced by the NHS Constitution. Some specialist services, rare conditions, will be commissioned either regionally or nationally – nothing new for authorities. Population needs analysis and the strategy for wellbeing is already the responsibility of local authorities. Public health responsibility will soon (rightly) go back to local authorities. There is already a good basis for this approach as mental health and learning disabilities show many excellent models for a shared, partnership approach to care provisions across NHS and local authorities. The shift to comprehensive local authority responsibility could only be achieved over time but should start with local NHS commissioning bodies being coterminous with authorities, collocated and sharing back office functions. Many local initiatives which deliver better integrated care should be encouraged through shared posts, pooled budgets, and the success of approaches like Total Place can be built on. Funding systems must encourage and incentivise local integration. The bottom up approach should lead the organisational change rather than the other way round.
Integrated Commissioning With integrated commissioning there is clear responsibility for whole populations, and consideration of protection and prevention resides alongside remedial care. All services in community, primary, social and acute care are in one structure; physical and mental health; all informed and directed by the clinical professionals in combination with patients and citizens - with public health, actuarial and health economics expertise resident in the same structure.
The key to effective commissioning would still be having the right information and evidence on which to base decisions, which would include accurate information about the actual cost of service provision and the reasons for its variation across providers. Getting this information is best advanced through investment in a Care Information Centre, with involvement of clinical professionals and the professional bodies, with all providers to the care system having a duty to provide data. For greater strategic coherence there would still be a regional structure (as there always has been) dealing with rare conditions, overseeing major reconfigurations, looking at major capital schemes and arbitrating on disputes. They could also play a leading role in training and development and research, and host functions such as the Deaneries.
Service Design and Procurement Care pathway redesign, prioritisation of services (and restrictions), and clinical service specifications are best undertaken by the appropriate mix of clinicians at whatever is the appropriate population level; which varies by condition. It should be seen as a normal part of a clinician‟s professional role to be involved in these decisions when required but not as full time managers. Some of this work could be done once as a national template; and it is work that only needs to be done periodically (in reality much of it has already been done). The financial systems must be aligned so that they do not inhibit good pathway and service design and in many cases this will imply a move away from the constraints of a fixed tariff and payment by results (volume). In stark contrast other components of commissioning - procurement, contracting, market management and contract management processes are more effective at a higher level, and apply continuously, and must be informed by the clinical models. It is unlikely that clinicians would want to work full time on these functions, and most experts on procurement and contract management are not clinicians. The separation of these functions should be explicit and would mitigate conflicts of interest.
Preferred Provider – Best Value
Commissioning will continue to be based on the implicit assumptions that the NHS is the preferred provider and that integration of services is best achieved through partnership and collaboration not competition. The best value approach long ago adopted by the rest of public services allows the risks and wider considerations of using non NHS
providers to be objectively taken into account. The best value approach still requires an objective approach and should deal with issues where third sector providers are denied opportunities to offer services or to get a fair assessment when services are required. Best value starts with consultation and engagement of service users. There should be best practice guidance, and exploitation of the many opportunities to leverage the vast scale of care procurement. The general rule would be that commissioners are free to use whatever methods are appropriate, without any fear of a regulator, the Courts, or prescriptive performance managers interfering. We could identify care services which should not be subject to economic competition – most mental health care, long term conditions, and most emergency and urgent care. For commissioners relationships with providers must be strong and there must be flexibility to bring stability through longer term or block contracts for service, even though this might limit competition. Integration of services takes priority with, for example, commissioning of whole pathways or for whole periods of care. Lead providers would be free to subcontract parts of the pathway or aspects of the service, but how they achieve this need not be prescribed. Some services would be simple enough to have a “tariff” and payment by volume, but this would not apply to all or even most services. The level of tariff would be set nationally based on objective evidence on real costs experience by good quality providers; and price based competition would not be permitted.
Other Provider Models
Some services, where these is enough information to be able to judge quality, and where there is a high degree of independence from other services, could be open to an „any willing provider‟ approach. A patient could choose to get the service from any provider which had demonstrated it could meet the required standards (like eyes and teeth and pharmacy). When an existing provider is unable to deliver a service to the required quality or where a new service is required then there could be formal procurement and either a single supplier or a framework panel awarded the contract. There would be an overriding requirement to ensure that the interdependence of care was considered; simply awarding a contract for one service whilst ignoring the possible consequential impact would not be permitted. Private providers would play a part, as they always
have, but the share taken would be small, as now, based on niche provision and adding capacity. All providers would be subject to the same level of scrutiny and could not hide anything behind commercial confidentiality. Supplying required information and paying a fair levy to cover their opting out of NHS training development and research would be part of the contract. A social solidarity model with most commissioning and provision within the public sector will keep the care provision parts of the NHS outside the scope of domestic and EU competition Law.
Integrated Providers
Benefits should come from the rise of integrated providers, such as a single provider for all urgent and emergency care and this could extend to a whole population approach where one organisation effectively accepts a block payment and delivers all care for a defined population. Whilst such arrangements are obviously anti-competitive, competition is a tool to be used when appropriate and no more than that.
New Professionalism
Change has to be led by clinicians. There should a greater role for Royal Colleges in improving practice and in supporting, but if necessary retraining or deregistering, professionals. Colleges could lead on the definition, collection and analysis of meaningful and accurate information to allow variations to be identified and peer support deployed.. Use of peer support, National Service Frameworks and the National Clinical Advisory Team would be delivered through the colleges. The combined colleges should be required to use their role to drive up quality in a more general manner, rather than just in professional silos.
Public Health – Keeping us Well Looking after our wellbeing and ensuring decisions are based on good evidence requires public health professionals to be at the highest levels of decision making within local authorities, leading on joining up services, on predictive support, and on wellbeing - linking together housing, education, and environmental health issues. There is a significant strategic role leading on needs analysis and guiding prioritisation of resources, working with other clinicians, actuaries and economists. Over time the balance of funding for public health would increase as investment in future health overrides paying for remediation of past underinvestment.
Providers of Services
Health care provision is badly fragmented and would be made worse by further competition. The organisations which manage hospitals are separate and wield disproportionate power: power which often prevents a rigorous approach to poor performance. Organisations set up to deliver primary or community care are generally smaller and less visible. Previous attempts at integrated trusts saw acute services swamp the rest. These cultural barriers must be removed but only clinicians can bring this about, working collaboratively and ignoring any artificial organisational barriers; impossible if competition is the driving force. Realigning financial incentives towards collaboration will help. The “Foundation Trusts� which provide NHS care will be all shapes and sizes; from specialist tertiary providers to integrated care providers covering all needs of a defined population. They would be part of the NHS whilst under moral ownership of the local community, not set up as an excuse for a different business model led by accountants and marketing experts. They would work with commissioning colleagues to help develop appropriate pathways and services. They would be able to merge, demerge, federate and partner, if they had local support and their local owners (governors) agreed, (but not be free to dispose of NHS assets). As now they would be subject to local overview and scrutiny arrangements. If these organisations get into trouble as most do from time to time they would be able to call on support and even additional resources. There may be conditions attached to support and there may be changes in management but this is not supporting failure: it is ensuring continuity of vital services. The alternative, that they are business entities which should be left to go into insolvency and ad-
ministration, is unacceptable. Alongside these trusts would be many other forms of providers to the care service; social enterprises, third sector and private sector. Given a high degree of autonomy in exchange for effective stakeholder governance trusts would still be subject to ultimate intervention and in extremis could be taken back into being directly managed
General Practice
There will be our quaint but effective system of semidetached GPs but with the local authority as commissioner carrying out the performance management; something both will find uncomfortable but essential to the eradication of poor performing GPs effectively outside any proper performance or contract management. There is considerable variation in performance but little understanding of why. GPs have mostly become office hours providers. A more active model for primary care requires a genuine 24/7 service which is far easier to access, and a model of the GP at the heart of a local community (with a defined practice area) rather than just the gateway into other services. Support and guidance to authorities from the Royal College, supporting a clear determination to drive up standards, would be invaluable.
Quality at the Heart
The fundamental importance of quality should be accepted through the powerful role assigned to the independent quality regulator, one adequately staffed with clinical expertise. (There would be no “economic” regulation, as this is not an economic system!) Better definitions of what quality means, greater public access to accurate, timely and relevant information, active involvement of patients and communities, and clinicians intolerant of poor performance will drive quality and improve outcomes.
A Better NHS
Such an NHS, within a care system, would be faithful to the founding principles and values, a genuinely national service. It would shift care from acute settings, integrate all care in one system, use competition and non NHS providers only where they add value, and the focus would be on continuing the improvement of NHS providers especially through better information, greater clinical involvement and leadership. Patients would have the central role but not as consumers nor as the product which is competed for.
Still Dark Briefing on the Health Bill Amendments The Health Bill still rests on the view that competition is the answer and it must be allowed to flourish, free from anti-competitive behaviour. The Bill sets out the framework which brings in a regulated market system, and all the necessary components to do this remain. The timetable, constrained by reality, has been slowed down. The role of the Secretary of State has actually been weakened further. The amendment 174 says the Secretary of State “must exercise the functions .... so as to secure that services are provided”. This replaces the current duty “to provide or secure the provision of services”. The end of the comprehensive NHS is signalled as the current duty that the Secretary of State “must provide (NHS services) throughout England” is replaced by “A commissioning consortia must arrange for the provision … to the extent as it considers necessary”. Local commissioning is fragmented. There is even greater scope for confusion now between the roles of the NHS Commissioning Board, The Quality Board, the NHS Constitution, Monitor and the Care Quality Commission. The system architecture is now far more complicated than it has ever been. The NHS Commissioning Board represents major centralisation. It is the biggest quango in the world and gets additional powers, contrary to the concept of autonomy. It retains the role of commissioning local services such as GPs, Dentistry, Pharmacy, contrary to any idea of local control. The role is not changed except to introduce some new duties around promoting the NHS Constitution, involving patients, carers and representatives, and around integration (not defined). The preferred provider approach is outlawed. There must be no exercise of functions for the purpose of causing a variation in the proportion of services provided by the public or the private sector. However, the clause is impossible to apply as no definitions or measures of current proportions exist and the “purpose” is different to any outcome. The issue of coterminosity with local authorities is not addressed. Consortia should not cross local authority boundaries but need not be coterminous (but not in the legislation). GP practices have to become members, there is no opt out.
Top down prescription for consortia. Consortia must now have a governing body which will be the subject of guidance by the NHS CB and many regulations . They could also have Boards making them like Foundation Trusts. It appears that GPs still have to be regulated by Monitor as providers, as well as consortia. There is no formal provision for clinical networks or senates and no requirement (apart from a very general one) to have regard to what they might recommend. The hierarchy between NICE, Networks, Senates and Health and Wellbeing Boards all of whom may have different views and all must be taken into account by consortia, is not addressed. A wider range of consortium board members. There will be a mandated role for two lay people, a nurse and a secondary care clinician and scope to involve others, but subject to unseen regulations. There are now members of the consortia and members of governing body which is confusing. Money can still be distributed to members, including the lay members. The quality premium, which allows payment for effective financial management, is retained but subject to further rules.
250 plus consortia has become more likely. The issues raised by the Health Committee are not addressed. Nothing has been said about the commissioning support suppliers which are being developed. Patient and public involvement is strengthened with a new requirement for commissioners to consult over any changes in services (which is unworkable). The full role of scrutiny is not restored but could be if as suggested designation is removed from the Bill at a later stage. Choice and competition are reinforced. The duty to promote competition is replaced by a duty to prevent anti-competitive behaviour. The involvement of the Competition Commission and the competition acts remains, as does the licensing regime which allows Monitor to regulate the system. The intention to continue with the current rules around cooperation and competition and to keep the Cooperation and Competition Panel has been stated. No changes are made around designation or the failure regime (insolvency provisions) – but further changes later are likely. The end of “designation�,
which is where a service cannot be closed down because there are no reasonable alternatives, has been signalled.
Focus on Liberal Democracy
The intention to prevent price competition and cherry picking may or may not be resolved. There are many changes to the proposed Tariff system and around setting prices, the impact of which will depend entirely on how they are implemented. There is no mention of the use of “best value” in relation to contracting for non tariff services.
Now the Health Bill has completed the committee stage it's time we started asking Liberal Democrat MPs whether they are going to support it when it comes back to the Commons on 6th September. Though the Liberals have succeeded in making the structure more complicated the essential dismantling of a planned National Health Services and its replacement by a regulated market still appears to be the central policy.
No change is to be made to Health and Well Being boards. The ability to disagree over commissioning plans is retained but there is no dispute resolution process or any requirement to reach agreement. The many-to-many nature of the relationship between consortia and Health and Well Being board remains. New clauses have been introduced the purpose of which is unknown. The duty of the Secretary of State to keep the effectiveness of the system under review links to the reduced duty only to exercise functions so as to secure that services are provided. There is a new requirement that appears to force choice of any provider which would also include choice of GP Practice. Any willing provider is enhanced. A new concept of a “fair level of pay” for providers gives scope to vary payments according to the different costs profiles of providers, but how this might be operationalized is unclear. The same clause also seeks to enforce moves to standardisation of health care specifications – all of which looks to be supportive of the drive to any willing provider type models. There is no recognition of the role of the Cooperation and Competition Panel. Although this may be there by inference, it is not put on a statutory footing. The duty of candour is not brought in, and other assurances given in response to the Future Forum are not implemented.
Can you help? We need local activity in the places where Liberal Democrat MPs are. We need their constituents to raise questions, and we want letters in their local papers. It will also help if people contact Liberal Democrat councillors. There is clearly a battle going on inside the Lib Dem party over this and we might be able to affect the outcome. If you live (or can pretend to live) in a place where there are Liberal Democrats would you like to write to them, or to the local papers? Or go and talk to them? We need members in Wales and Scotland to help too even though the legislation doesn't apply to them because the Government will rely on Welsh and Scottish Lib Dem votes to get this through. The obvious issues to raise are:
NHS no longer comprehensive....
Waiting times up....
It‟s a mess.
People have to pay....
Some concessions have been made to improve accountability, down play the role of competition, reduce the active role of the regulator and to stress the need for greater patient and public involvement, for integration of services and for proper regard to the NHS Constitution.
There will be a market & consequences..
Your local hospital will be allowed to shut...
EU competition law will apply...
But there is far greater bureaucracy, little cohesion in the architecture, a very prescriptive regime for the consortia and still the emphasis on moving to a market system with many providers competing for the patients.
But don't restrict yourself to those issues. Local and personal stories are what make a difference.
Timetable of events 2011 6th & 7th Sept 17th Sept 24th Sept 25th Sept 2nd October 5th October 30th Nov 2012 10th Jan
Report and 3rd reading of Health Bill in the commons Lib Dem conference in Birmingham SHA Council Liverpool Labour Party conference Liverpool Conservative conference Manchester Lords resumes. Health Bill goes to Lords. NHS Commissioning Board established in shadow form. SHAs to be clustered NHS Alliance conference Parliament returns. Lords concludes discussion of Health Bill and it goes back to the Commons. (date not yet known) Any Qualified Provider starts Local Elections England, Scotland, Wales. London Mayor, GLA Labour Party Conference Manchester NHS Commissioning Board is established Monitor starts to take on its new regulatory functions. HealthWatch England and local HealthWatch established
April 3rd May 30th Sept October
2013 April 2nd May September
Commissioning groups established. SHAs and PCTs abolished NHS Commissioning Board takes on its full functions. Public Health England established Local Elections English County Councils and Unitary Authorities Labour Party Conference Bournemouth
2014 Jan June September
Value-based pricing for new drugs. European (and probably local) elections and London Boroughs Labour Party Conference Manchester
2015 May 7th
General Election, NI, Scottish and Welsh parliament elections, English districts
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