Above all the freedom of the Press is paramount. Censorship or severely restrictive legislation is not an acceptable alternative. We sometimes have to accept the consequences and tolerate a Press that can be wrong, unfair, misleading or more interested in selling newspapers than in the public interest. The Press are our protectors and not out enemy. But there are times when we have to stand back and consider what is being said. Reporting occasionally differs so much from any concept of balanced coverage that questions must be asked. Journalists must search their consciences over what has happened to their principles and ideals.
Unreasonable reporting has arisen with the Health and Social Care Bill to an extent that has played a role in turning both members of the Pubic and medical professionals against the Bill. Normally responsible newspapers and broadcasters, including the BBC, have sometimes been misleading and have contributed to prejudice against the reforms. In this blog I do not have space to consider every case. I therefore focus here on one example that provides a flavour of what I mean. Taken as a one-off situation the implications of this one example are not enormous but the overall pattern is disturbing.
If at the time of writing the words “BBC Health Bill” are fed into Google the first search result listed is:
BBC News – ‘Planned 49% limit’ for NHS private patients in England
The relevant BBC story was released on 27th December 2011 and was featured prominently on BBC Television News. The first three paragraphs of the BBC summary reached through the above link read:
“NHS hospitals in England will be free to use almost half their hospital beds and theatre time for private patients under government plans.
A recent revision to the ongoing health bill will allow foundation hospitals to raise 49% of funds through non-NHS work if the bill gets through Parliament.
Most foundation trusts are now limited to a private income of about 2%.”
These opening paragraphs gave the impression that the Government had just proposed a new increase in the limits for non-NHS income in NHS hospitals. In fact, the Bill as passed by the House of Commons to the Lords included no limit at all. The new proposal was therefore to introduce a safeguard ensuring that no NHS hospital will end up principally servicing the non-NHS sector.
The proposed limit of 49% (or, to be precise, below 50%) does not in fact relate directly to hospital beds or theatre time but rather to total non-NHS income in each hospital. Some potential non-NHS income derives from services not relating directly to medical care and should be strongly encouraged as a way of raising funds for the NHS. Certain other non-NHS medical income relates to services that would not be available to NHS patients without the contribution from private patients (e.g. by helping to fund facilities that would otherwise be unavailable such as costly diagnostic equipment). On the basis that hospitals are likely to charge more to private patients than the funding received per NHS patient, it is mathematically hard to see how a hospital can get anywhere near to 49% of hospital beds or theatre time going to private patients unless the hospital provides other important non-NHS services (e.g. for the pharmaceutical industry or in research contracts or as discussed on pages 10-12 of my submission to the Department of Health downloadable here ).
The BBC article goes on to say (paragraphs 4-9):
“The Health Secretary says the move will benefit NHS patients but Labour claimed it could lead to longer waiting lists.
The amendment to a clause of the Health and Social Care Bill was made shortly before Christmas by Health Minister Earl Howe.
Commenting on the move, Health Secretary Andrew Lansley said lifting the private income cap for foundation hospitals would directly benefit NHS patients.
‘If these hospitals earn additional income from private work that means there will be more money available to invest in NHS services,’ he said in a statement.
‘Furthermore services for NHS patients will be safeguarded because foundation hospitals’ core legal duty will be to care for them.
‘But Labour’s shadow Health Secretary Andy Burnham claimed the move could mean longer waits for NHS patients.’ “
Under the Government’s proposals hospitals are required to ensure that NHS patients benefit from non-NHS income and to explain why they do so. It would therefore be illegal for NHS hospitals to increase waiting lists as a result of the provision of non-NHS services unless there were some greater benefit to NHS patients in other ways.
The article from the BBC then quotes Andy Burnham as saying:
“This surprise move, sneaked out just before Christmas, is the clearest sign yet of David Cameron’s determination to turn our precious NHS into a US-style commercial system, where hospitals are more interested in profits than people.
“With NHS hospitals able to devote half of their beds to private patients, people will begin to see how our hospitals will never be the same again if Cameron’s Health Bill gets through Parliament.”
We have no criticism of Andy Burnham at a personal level. He is simply doing what politicians often do in showing political bias. However, the impartiality of the BBC can be criticised because of the prominence to given to his remarks without providing the information necessary to put them in context. The only surprise was in the Government restricting non-NHS income at all. The prime directive of the NHS is to achieve the best clinical outcomes for NHS patients and is not to make a profit. As explained above, hospitals will not normally be free to devote anything like half of their beds to private patients, because to do so would generally breech the total non-NHS income limit and also not be in the interests of NHS patients. In addition, the Government’s proposals will not directly increase the number of private patients. Far too few private patients exist to fill half of NHS hospital beds.
The proposed Government amendment was announced on 15th December 2011 but not reported by the BBC until 27th December. The amendment was agreed by the relevant House of Lords Committee on 15th December after considerable debate involving Shirley Williams (Liberal Democrat). If the Labour Party truly felt the proposal to be as harmful as Andy Burnham has implied, press coverage would have been obtained well before Christmas. A Labour plot to sneak out biased criticism between Christmas and New Year fits the facts better than a Conservative plot to release the news shortly before Christmas, although we have no strong evidence that either has occurred.
The House of Commons debated the non-NHS income limit on 16th January 2012 when Andy Burnham (Labour) moved the following motion:
“That this House believes there is an important role for the private sector in supporting the delivery of NHS care; welcomes the contribution made by private providers to the delivery of the historic 18-week maximum wait for NHS patients; recognises a need, however, for agreed limits on private sector involvement in the NHS; notes with concern the Government’s plans to open up the NHS as a regulated market, increasing private sector involvement in both commissioning and provision of NHS services; urges the Government to revisit its plans, learning from the recent problems with PIP implants and the private cosmetic surgery industry; believes its plan for a 49 per cent. private income cap for Foundation Trusts, in the context of the hospitals as autonomous business units and a ‘no bail-outs’ culture, signals a fundamental departure from established practice in NHS hospitals; fears that the Government’s plans will lead to longer waiting times, will increase health inequalities and risk putting profits before patients; is concerned that this House has not been given an opportunity to consider such a significant policy change; and calls on the Government to revise significantly downwards its proposed cap on the level of private income that can be generated by NHS hospitals.”
The wording of this motion is much more accurate and precise than the media coverage. The Labour Party supports a role for the private sector in the NHS. The debate is about how large that role should be and what limits should be imposed. The motion refrains from repeating the false claim that the Government proposals would allow most hospitals to allocate 49% of beds and theatre time to private patients. The Bill clearly makes it illegal for non-NHS income to be accepted that would be expected to lead to an increase in NHS waiting times or NHS health inequalities or to a move towards putting profits before patients. However, Andy Burnham is entitled to fear that the law will be broken. The Conservative view is that the non-NHS income cap is a “belt and braces” safeguard and not something that will in practice affect many hospitals. I do not propose to cover this topic here but the true debate between the three major UK political parties is about more subtle matters than the media appear at times to recognise.
2020health's Blog 
“In fact, the Bill as passed by the House of Commons to the Lords included no limit at all. The new proposal was therefore to introduce a safeguard ensuring that no NHS hospital will end up principally servicing the non-NHS sector.”
Yes, that’s right, the government’s original policy was to have no limit at all, so we may have been in the bizarre situation of FT hospitals having the NHS logo on the outside and no NHS patients on the inside. What incompetent fool allowed that into the Bill? The 49% rule is no better than the original 100% rule (the effect will be the same), but it keeps the hapless Lib Dems happy.
“it is mathematically hard to see how a hospital can get anywhere near to 49% of hospital beds or theatre time going to private patients”
It *is* mathematically possible via patients (in fact, this is the only way). All you have to do is build a private hospital, like Moorfields have done in Dubai. In fact, that is the only way for there to be significantly more private patients because, frankly, when people are paying for the treatment they will not want to be in a bed next to someone who doesn’t pay, or waiting in the clinic waiting room next to someone who does not pay, or indeed, fight for a place in the car park with someone who’s not paying for their treatment.
“unless the hospital provides other important non-NHS services (e.g. for the pharmaceutical industry or in research contracts or as discussed on pages 10-12 of my submission to the Department of Health downloadable here ).”
Sorry, it is not mathematically possible to do it by increasing those other services. Have a look at the finance reports of any FT, the VAST majority of their income come from treatment of patients, not from services. Also bear in mind that the number of private patients is tiny compared to the number of NHS patients, so there is a finite limit on how many services that can be provided to the private sector. No FT would get more than a few %age from services. If you don’t believe me, have a look at what work hospitals do (private or NHS): it is treating patients.
I’ve read your document and I am afraid you don’t have a grasp on the situation. For example you list services that you say that hospitals COULD charge for when in fact they DO charge for them (entertainment, internet use, meals for visitors). The other things you list are minor and will not return much return on investment. For example “accommodation for visitors”: how many visitors travel long enough distances to need accommodation? A few perhaps, but not enough for a hospital trust to invest in providing hotel facilities. “Collaboration over clinical trials”, huh? Do you really think patients will want to be treated as guinea pigs as a revenue stream for the trust? I suggest you talk to some NHS patients. Even if trusts took part in clinical trials with big pharma, the income would not be significant since there are huge liabilities to be addressed over the trials going wrong and if big pharma foots the bill for that insurance they would not pay much to a trust. I am an elected FT governor, by the way.
“Certain other non-NHS medical income relates to services that would not be available to NHS patients without the contribution from private patients (e.g. by helping to fund facilities that would otherwise be unavailable such as costly diagnostic equipment).”
This is plainly deluded. If the NHS needs the equipment, they get it. It is not the case that the private sector in some way sponsors it. The fact is, it is the NHS that funds the expensive equipment not the leprechaun gold of private patients. If there were so much leprechaun gold in private patients why isn’t it the private hospitals that has the expensive equipment and the NHS rents usage off them? The scandal of Independent Sector Treatment Centres shows that it is the NHS that takes the risk and the private sector who creams off a profit (cf the agreement that the NHS would buy back ISTC assets if they fail to have their contract renewed).
REPLY BY AUTHOR (BARBARA ARZYMANOW) TO COMMENTS BY RICHARD SMITH @richardblogger
THE FOLLOWING IS THE FULL TEXT OF RICHARD SMITH’S COMMENTS ON MY LATEST 2020HEALTH BLOG TOGETHER WITH MY REPLIES, WHICH ARE IN UPPER CASE.
“In fact, the Bill as passed by the House of Commons to the Lords included no limit at all. The new proposal was therefore to introduce a safeguard ensuring that no NHS hospital will end up principally servicing the non-NHS sector.”
Yes, that’s right, the government’s original policy was to have no limit at all, so we may have been in the bizarre situation of FT hospitals having the NHS logo on the outside and no NHS patients on the inside. What incompetent fool allowed that into the Bill? The 49% rule is no better than the original 100% rule (the effect will be the same), but it keeps the hapless Lib Dems happy.
I AGREE THAT THE 49% RULE WILL HAVE MUCH THE SAME EFFECT AS THE 100% RULE I.E. VERY LITTLE. THE REASON IS THAT HARDLY ANY NHS HOSPITALS WILL REACH ANYTHING LIKE 49%. THE 49% RULE IS JUST A “BELT AND BRACES” WAY OF BEING ABSOLUTELY CERTAIN THAT OCCURRENCES LIKE HAVING THE NHS LOGO ON PURELY PRIVATE HOSPITALS CANNOT HAPPEN AND THAT NHS HOSPITALS GET MOST OF THEIR INCOME FROM THE CARE OF NHS PATIENTS. THE 49% RULE WAS PROPOSED BY THE CONSERVATIVES AND ONLY ACCEPTED BY THE LIBERAL DEMOCRATS IN THE HOUSE OF LORDS AFTER CONSIDERABLE DEBATE. THE 100% RULE DID NOT ENCOUNTER HIGH-PROFILE OPPOSITION IN THE HOUSE OF COMMONS. IT IS INTERESTING THAT THE LABOUR PARTY SEEM MORE WOUND UP ABOUT THE 49% RULE THAN THEY WERE ABOUT THE 100% RULE. A CYNIC MIGHT SUGGEST THAT THE FORMER IS EASIER TO MISREPRESENT AND FOR THE MEDIA TO MISUNDERSTAND EVEN THOUGH THE EFFECT IS ESSENTIALLY THE SAME.
“it is mathematically hard to see how a hospital can get anywhere near to 49% of hospital beds or theatre time going to private patients”
It *is* mathematically possible via patients (in fact, this is the only way). All you have to do is build a private hospital, like Moorfields have done in Dubai. In fact, that is the only way for there to be significantly more private patients because, frankly, when people are paying for the treatment they will not want to be in a bed next to someone who doesn’t pay, or waiting in the clinic waiting room next to someone who does not pay, or indeed, fight for a place in the car park with someone who’s not paying for their treatment.
“unless the hospital provides other important non-NHS services (e.g. for the pharmaceutical industry or in research contracts or as discussed on pages 10-12 of my submission to the Department of Health downloadable here ).”
Sorry, it is not mathematically possible to do it by increasing those other services. Have a look at the finance reports of any FT, the VAST majority of their income come from treatment of patients, not from services. Also bear in mind that the number of private patients is tiny compared to the number of NHS patients, so there is a finite limit on how many services that can be provided to the private sector. No FT would get more than a few %age from services. If you don’t believe me, have a look at what work hospitals do (private or NHS): it is treating patients.
AGAIN WE SEEM TO AGREE ABOUT MANY OF THE FACTS.
MY MATHEMATICAL POINT ARISES BECAUSE PRIVATE PATIENTS PAY MORE PER PERSON THAN THE REVENUE ATTRIBUTABLE TO AN NHS PATIENT. CONSEQUENTLY, IF 49% OF REVENUE AROSE FROM TREATING PRIVATE PATIENTS AND 51% OF REVENUE AROSE FROM TREATING NHS PATIENTS, THE PROPORTION OF PRIVATE PATIENTS WOULD BE MATHEMATICALLY LOWER THAN 49%. FOR EXAMPLE, IF PRIVATE PATIENTS PAID TWICE AS MUCH EACH, 49% OF REVENUES WOULD CORRESPOND TO 32% OF PATIENTS BEING PRIVATE. THE MEDIA IS MISLEADING IN SAYING THAT 49% OF BEDS AND THEATRE TIME COULD BE USED BY PRIVATE PATIENTS BECAUSE SUCH A POSITION WOULD BREACH THE 49% REVENUE LIMIT. THE 49% CAP RELATES TO REVENUE, NOT PATIENTS OR HOSPITAL BEDS. THE 49% LIMIT IN FACT APPLIES TO ALL NON-NHS INCOME AND NOT JUST TO INCOME FROM PRIVATE PATIENTS. HOWEVER, I TOTALLY AGREE THAT THE DIFFERENCE (NON-NHS INCOME OTHER THAN FOR TREATING PATIENTS) IS GENERALLY SMALL AND THAT NATIONALLY THERE ARE FAR MORE NHS PATIENTS THAN PRIVATE PATIENTS. THESE ARE REASONS AS TO WHY THE 49% NON-NHS INCOME LIMIT WILL HARDLY EVER BE REACHED. IF IN FUTURE ANY HOSPITALS DO REACH THE LIMIT IN A WAY THAT IS CONSISTENT WITH THE OBLIGATIONS IMPOSED BY THE BILL, THE MOST LIKELY WAY WOULD BE BY OFFERING SERVICES OTHER THAN TREATING PATIENTS. PROVIDING THAT THIS DOES NOT INTERFERE WITH TREATING PATIENTS AND IS SOUND COMMERCIALLY, IT SHOULD CLEARLY BE ENCOURAGED AND NOT PREVENTED BY A LOW CAP.
I’ve read your document and I am afraid you don’t have a grasp on the situation. For example you list services that you say that hospitals COULD charge for when in fact they DO charge for them (entertainment, internet use, meals for visitors). The other things you list are minor and will not return much return on investment. For example “accommodation for visitors”: how many visitors travel long enough distances to need accommodation? A few perhaps, but not enough for a hospital trust to invest in providing hotel facilities. “Collaboration over clinical trials”, huh? Do you really think patients will want to be treated as guinea pigs as revenue stream for the trust? I suggest you talk to some NHS patients. Even if trusts took part in clinical trials with big pharma, the income would not be significant since there are huge liabilities to be addressed over the trials going wrong and if big pharma foots the bill for that insurance they would not pay much to a trust. I am an elected FT governor, by the way.
I DID NOT MEAN TO SUGGEST THAT HOSPITALS NEVER CHARGE FOR ANY OF THE ITEMS THAT I LISTED. SOME HOSPITALS DO NOT PROVIDE SOME OF THE SERVICES FROM WHICH THEY MIGHT BENEFIT OR COULD PROVIDE THE SERVICES MORE EFFECTIVELY. I WAS SUGGESTING GREATER ATTENTION TO THE WHOLE RANGE OF POSSIBILITIES. THE SOLUTIONS VARY FROM HOSPITAL TO HOSPITAL AND I AM CERTAINLY NOT SUGGESTING THAT MANY HOSPITALS SHOULD BUILD HOTELS. I HAD IN MIND NATIONALLY IMPORTANT HOSPITALS, LARGELY IN LONDON, AND WAS MINDFUL OF POSSIBLE JOINT VENTURES WITH HOTEL COMPANIES USING SURPLUS HOSPITAL LAND IN PRIME LOCATIONS. THERE ARE MANY OPTIONS THAT COULD BE CONSIDERED BY OTHER HOSPITALS E.G. ARRANGING A DISCOUNT AND COMMISSION FROM A LOCAL HOTEL. I AM AGAIN NOT SUGGESTING THAT NO HOSPITAL CURRENTLY DOES THIS.
MANY HOSPITALS, PARTICULARLY TEACHING HOSPITALS, DO TAKE PART IN CLINICAL TRIALS FINANCED BY THE PHARMACEUTICAL INDUSTRY. INDEED SUCH TRIALS, HERE OR ABROAD, ARE A LEGAL REQUIREMENT BEFORE A DRUG IS MADE AVAILABLE FOR PRESCRIPTION BY DOCTORS GENERALLY. WHILST THE PATIENTS ARE GUINEA PIGS, THEY CAN ONLY BE GIVEN AN EXPERIMENTAL DRUG IN A TRIAL AFTER GIVING INFORMED CONSENT. TRAGEDIES DO OCCASIONALLY OCCUR BUT THERE IS ABUNDANT EVIDENCE THAT PATIENTS IN CLINICAL TRIALS ON AVERAGE DO BETTER THAN THOSE OUTSIDE THEM. MANY PATIENTS- I DO NOT KNOW WHAT PROPORTION- ACTIVELY SEEK TO GET INTO TRIALS. THE ENTIRE TREATMENT COSTS OF PATIENTS IN CLINICAL TRIALS ARE USUALLY MET BY THE PHARMACEUTICAL INDUSTRY, WHICH ALSO MEETS THE INSURANCE COST. THE UK WOULD BENEFIT FROM DOING MORE CLINICAL TRIALS, NOT LESS. THE BUSINESS IS QUITE LUCRATIVE TO HOSPITALS REGARDED AS WORLD LEADERS IN THEIR STRONGEST FIELDS.
“Certain other non-NHS medical income relates to services that would not be available to NHS patients without the contribution from private patients (e.g. by helping to fund facilities that would otherwise be unavailable such as costly diagnostic equipment).”
This is plainly deluded. If the NHS needs the equipment, they get it. It is not the case that the private sector in some way sponsors it. The fact is, it is the NHS that funds the expensive equipment not the leprechaun gold of private patients. If there were so much leprechaun gold in private patients why isn’t it the private hospitals that has the expensive equipment and the NHS rents usage off them? The scandal of Independent Sector Treatment Centres shows that it is the NHS that takes the risk and the private sector who creams off a profit (cf the agreement that the NHS would buy back ISTC assets if they fail to have their contract renewed).
WHY DO PEOPLE LIKE ME HAVE TO MAKE CHARITABLE DONATIONS SO THAT LOCAL HOSPITALS CAN BUY EXPENSIVE EQUIPMENT IF THE NHS WOULD PROVIDE IT ANYWAY? SOME OF THE BEST EQUIPMENT USED IN AT LEAST ONE UNIT IN MY LOCAL HOSPITAL HAS COME FROM CHARITABLE DONATIONS. OBVIOUSLY IF HOSPITALS HAD MORE PRIVATE INCOME, THEY COULD RELY ON CHARITY LESS AND HAVE MORE CERTAINTY OVER THEIR OWN FINANCES.
IN CONCLUSION, YOU AND I DO HAVE DIFFERENT POLITICAL OPINIONS AND I RESPECT THAT. HOWEVER, I THINK YOUR COMMENT THAT I “DON’T HAVE A GRASP ON THE SITUATION” IS UNCALLED FOR. THIS REPLY HAS COVERED MUCH MORE THAN MY CRITICISMS OF MEDIA REPORTING ON THE HEALTH AND SOCIAL CARE BILL. TO REITERATE MY THREE MAIN POINTS IN MY MOST RECENT 2020HEALTH BLOG, THEY ARE:
1. THE CAP OF AROUND 49% RELATES TO TOTAL INCOME AND NOT TO HOSPITAL BED NUMBERS OR THEATRE TIME.
2. VARIOUS MEASURES IN THE BILL MEAN THAT HARDLY ANY HOSPITALS WILL GET CLOSE TO THE 49% LIMIT, WHICH IS SIMPLY AN ADDITIONAL SAFEGUARD.
3. THE RECENT GOVERNMENT AMENDMENT IS REDUCING, NOT INCREASING, THE SCOPE FOR PRIVATE MEDICINE PERMITTED BY THE BILL (EVEN THOUGH THE PERMITTED LIMIT WILL RARELY BE REACHED ANYWAY).
I THINK ANY REASONABLE PERSON WOULD ACCEPT THAT SOME MEDIA COMMENT, FOR EXAMPLE BY THE BBC, GIVES A DIFFERENT IMPRESSION. I WOULD MENTION THAT I GENERALLY SUPPORT THE BBC. MY COMMENTS ARE MEANT NOT AS AN ATTACK ON THEM BUT AS A CORRECTION OF MISCONCEPTIONS OVER THE BILL. I HOPE THAT WE CAN FIND SOME COMMON GROUND IN SUPPORT OF THIS OBJECTIVE.
@barbararesearch
http://www.researchideas.co.uk
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What you don’t mention is that the 2006 Act had placed a much lower limit on the percentage of a Foundation Trust’s income that could be generated by private work.To quote the NHS Act 2006, s 44: “… the proportion of the total income of an NHS foundation trust which was an NHS trust in any financial year derived from private charges is not greater than the proportion of the total income of the NHS trust derived from such charges in the base financial year” (ie 2003). The H&SC Bill strikes out this old cap.
I have to agree with Richard’s assessment about the gaps in your knowledge on these matters, and why do you use capitals in your response? Perhaps you are the kind of person who likes to shout.
David Hughes
REPLY TO PROFESSOR DAVID HUGHES FROM BARBARA ARZYMANOW
Your comment on what was in the 2006 Act is correct but was not highlighted by Richard Smith or me in our exchange because it is not very relevant to what we were discussing. However, in my original article I did quote from the BBC, “Most foundation trusts are now limited to a private income of about 2%.” In my criticisms of the BBC’s reporting I did not challenge this comment in any way. I also mentioned the current restrictions in my tweet of 21st January from @barbararesearch
The Bill as originally passed by the House of Commons to the House of Lords, as both Richard and I agree, completely abolished any direct limit on private income. MPs had accepted this change. The House of Lords later passed an amendment moved by the Government to impose a 49% (or, more accurately, under 50%) limit on the private income of hospitals. The BBC gave the impression that the amendment represented a surprise relaxation in the limits on private income in NHS hospitals. In fact, the House of Commons had previously agreed to the removal of all limits and the Government’s “49%” rule was tightening the proposed restrictions on non-NHS income.
The BBC also gave the impression that a dramatic increase in private patient numbers would be possible by contrasting the current private income limit of typically around 2% of income with the future “49%” number. In fact, if ALL private health work was done in NHS hospitals it would take up only 11% of the total. The factors limiting the private income of nearly all NHS hospitals will be the availability of patients and regulations requiring that private income can only be accepted when NHS patients benefit. The “49%” rule is intended purely as a safeguard which will affect very few, if any, hospitals.
I could go on about media bias but I think my original article, my replies to comments and my tweets (@barbararesearch) make my views clear. You can also refer to my website at http://www.researchideas.co.uk .
The reason for using capitals in my previous response to Richard’s comment is that I wished to distinguish between what I had written and what Richard had written. The blog host, WordPress, does not allow the use of italics or coloured fonts except in the original article. Only normal black letters are allowed and therefore the only way to distinguish between Richard’s comments and mine is to use capital letters for one of us. I do not think I can be fairly accused of liking to shout. My text only appears once whereas Richard’s appears in full both in his comment and in my reply to it.
If you think there are gaps in my knowledge, perhaps you could give me an example. I am very happy to continue this discussion.
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