National Health Service

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NHS logo in England
NHS Wales logo
Logo of Health and Social Care in Northern Ireland, the equivalent in Northern Ireland

The National Health Service (NHS) is the name used for each of the public health services in the United Kingdom – the National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland – as well as a term to describe them collectively. They were established together in 1948 as one of the major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery.[1] Each service provides a comprehensive range of health services, free for people ordinarily resident in the United Kingdom, apart from dental treatment and optical care.[2] (The English NHS also requires patients to pay prescription charges with a range of exemptions from these charges.)

Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government; Welsh Government; Northern Ireland Executive; and the UK Government, responsible for England's NHS. NHS Wales was originally part of the same structure as that of England until powers over the NHS in Wales were firstly transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly as part of Welsh devolution. Some functions may be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and depends on hospitals in Great Britain, routinely at Carstairs hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients.[3] Similarly, patients in North Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester Hospital. There have been issues about cross-border payments.[4]

Taken together, the four National Health Services in 2015–16 employed around 1.6 million people with a combined budget of £136.7 billion.[5] In 2014 the total health sector workforce across the UK was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland.[6] In 2017, there were 691,000 nurses registered in the UK, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008.

Although there has been increasing policy divergence between the four National Health Services in the UK, it can be difficult to find evidence of the effect of this on performance since, as Nick Timmins says: "Some of the key data needed to compare performance – including data on waiting times – is [sic] defined and collected differently in the four countries."[7][8] Statistics released in December 2017 showed that, compared with 2012/3, 9% fewer patients in Scotland were waiting more than four hours in accident and emergency, whereas in England the number had increased by 155%.[9]

History

Aneurin Bevan, who built on Sir Henry Willink's vision of a National Health Service with the establishment of the NHS

The National Health Services began their work on the 5 July 1948. This put into practice Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's 1947 Public Health Services Act.[10] (NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales before transferring to the Welsh Executive and Assembly under devolution in 1999.[11])

Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909,[12] but it was following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease" that cross-party consensus emerged on introducing a National Health Service of some description.[13] When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took.[14] The NHS was born out of the ideal that good healthcare should be available to all, regardless of wealth. At its launch by Bevan on 5 July 1948 it had at its heart three core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.[15]

Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures and glasses.[16] The following year, Winston Churchill's Conservative government introduced prescription charges. These charges were the first of many controversies over reforms to the NHS throughout its history.[17]

From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature. The NHS had a prominent slot during the 2012 London Summer Olympics opening ceremony directed by Danny Boyle, being described as "the institution which more than any other unites our nation".[18]

Eligibility for treatment

UK residents are not charged for most medical treatment though NHS dentistry does have standard charges in each of the four national health services in the UK. In addition, some patients in England have to pay charges for prescriptions though most are exempted.

Aneurin Bevan in considering the provision of NHS services to overseas visitors wrote, in 1952, that it would be "unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody." [19]

The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.[20]

Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can get emergency treatment without charge.[21]

The NHS is free at the point of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents.[22] People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment.[23][24] Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.[2][25]

People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance or to sign a written undertaking to pay, except for emergency treatment.

People from outside the EEA coming to the UK for a temporary stay of more than six months are required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. This includes overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa.[26] In 2016 the surcharge was £200 per year, with exemptions and reductions in some cases.[27] It is to increase to £400 in 2018. The discounted rate for students and those on the Youth Mobility Scheme will increase from £150 to £300.[28]

From 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK is fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas.[29] This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development and other work.

Those who are not ordinarily resident (including British citizens who may have paid National Insurance contributions in the past) are liable to charges for services.

There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.

Current issues

The NHS is underresourced compared to health provision in other developed nations. A King’s Fund study of data from 21 nations, which the OECD collected reveal that the NHS has among the lowest numbers of doctors, nurses and hospital beds per capita in the western world.[30] Nurses within the NHS maintain that patient care is compromised through lack of nurses or lack of nurses with the necessary quailfications. Lives are put at risk. Cancer patients and patients needing surgery are noted as not getting enough qualified nurses. Experienced nurses maintain shortages are the worst in decades.[31] 74% of the UK public believe there are too few nurses according to a YouGov poll.[32]

Funding

NHS Spending 1948/49–2014/15[33]

The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services.[34][35] About 10% of GDP is spent on health and most is spent in the public sector.[36] The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 per person in the UK.[37]

When the NHS was launched in 1948 it had a budget of £437 million (roughly £9 billion at today’s prices).[38] In 2008/9 it received over 10 times that amount (more than £100 billion). In 1955/6 health spending was 11.2% of the public services budget. In 2015/6 it was 29.7%.[39] This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. Under the Blair government spending levels increased by around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year.[39]

Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.[40] Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care.[41] The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut.[42] NHS staff resort to high interest payday loans in large numbers.[43] The House of Commons Library did research showing that real-terms NHS funding per head will fall in 2018–19, and stay the same for two years afterwards.[44]

There appears to be support for higher taxation to pay for extra spending on the NHS as an opinion poll in 2016 showed that 70% of people were willing to pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS.[45] Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS.[46]

The Guardian has said that GPs face excessive workloads throughout Britain, and that this puts the GP's health and that of their patients at risk.[47] The Royal College of Physicians did a survey of doctors in England, Wales, Scotland and Northern Ireland. Two thirds of doctors surveyed maintained patient safety had deteriorated during the year to 2018, 80% feared they would be unable to provide safe patient care in the coming year while 84% felt increased pressure on the NHS was demoralizing the workforce. Jane Dacre said, “We simply cannot go through this [a winter when the NHS is badly overstretched] again. It is not as if the situation was either new or unexpected. As the NHS reaches 70, our patients deserve better. Somehow, we need to move faster towards a better resourced, adequately staffed NHS during 2018 or it will happen again.”[48]

62% of Intensive Care Units function below normal because there are not enough nurses, a survey of ICU consultants by the Faculty of Intensive Care Medicine (FICM) stated. The survey found the 210 intensive care units throughout the UK were short of 12 nurses each on average and nurses are vital caring for critically ill patients.[49]

Theresa May is under pressure from MP's of both the main political parties to increase funding for the NHS and for social care, also to consider tax rises to achieve this. 98 signatories to a letter maintain the NHS, public health and social care are “overstretched, poorly integrated and no longer able to keep pace with rising demand and the cost pressures of new drugs and technologies”. Without action, patients will experience a serious further decline in services.” One possibility is a NHS tax where the money would be earmarked for the NHS.[50] 61% of voters favour higher taxes to pay for improvements to the NHS. The NHS is a major concern for voters and consensus for finding more money exists.[51]

Effect of Brexit

The plan to exit the European Union will affect physicians from EU countries, about 11% of the physician workforce.[52] Many of these physicians are considering leaving the UK if Brexit happens, as they have doubts that they and their families can live in the country.[52] A survey suggests 60% are considering leaving.[53] Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left in 2016. The figures, put together by NHS Digital, led to calls to reassure European workers over their future in the UK.[54] EU nurses registering to work in the UK are down 96% since the Brexit vote aggravating shortages of nurses. Janet Davies of the Royal College of Nursing, said, “We rely on the contributions of EU staff and this drop in numbers could have severe consequences for patients and their families. Our nursing workforce is in a state of crisis. Across our health service, from A&E to elderly care, this puts patients at serious risk.”[55] 3,962 nurses and midwives from the European Economic Area (EEA) left in 2017 and 2018.[56]

There is also concern that a disorderly Brexit may compromize patients' access to vital medicines. Many medical organizations are diverting resources from patient care to managing a possible worst case Brexit scenario.[57]

Rising social care costs

Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.”[58]

Security breaches

In 2001 the NHS entered into a licensing deal with Microsoft, ignoring the advice of some of its own IT specialists that had recommended investing in Linux instead.[59] Concerns about the vulnerability of NHS computer systems to cyber-attack have been expressed since at least 2016.[60] NHS computer systems have been subject to cyber attacks of which one in May 2017 was notable.[61] The May 2017 attack lead to the cancellation of at least 6912 appointments including operations, 139 suspected cancer patients had urgent referrals cancelled. The number of GP appointments cancelled, the number of ambulances diverted from A&E departments unable to treat some patients, the number of delays in receiving information like test results are unknown. North Korea is strongly suspected of starting the attack. The attack happened on a Friday in May. A cyberattack on a Monday in winter would be even more damaging.[62] NHS computers have been vulnerable because a minority still use or used Windows XP, an outdated system that originated in 2001, and one which Microsoft stopped supporting with security patches. Complacency among NHS staff and among government departments that pay for computer security are blamed. Unless systems are upgraded, more cyber attacks are feared.[63] Dr David Wrigley of the British Medical Association said, “It’s been known about for years, that the software isn’t up to date across the NHS, so it’s not unpredictable that this situation should have arisen. But it’s disappointing that funding hasn’t been given to upgrade the system. It needs urgent action by politicians.”[64] In April 2018 there was concern that insufficient had been done to improve cybersecurity and protect against future possible cyber-attacks.[65]

Internal mail lost by part-privatised subsidiary

In 2017, it was reported that NHS Shared Business Services, a part state-owned, part-privately owned company tasked with internal mail delivery for NHS England, had lost 864,000 documents relating to patient healthcare.[66]

See also

References

  1. ^ Choices, NHS. "The principles and values of the NHS in England". www.nhs.uk. Retrieved 2016-11-23. 
  2. ^ a b "NHS entitlements: migrant health guide - Detailed guidance". UK Government. Retrieved 6 June 2016. 
  3. ^ "Guidance on the Transfer of Mentally Disordered Patients August 2011". 
  4. ^ "Breakdown of cross-border agreements is costing English trusts millions". Health Service Journal. 14 February 2008. Retrieved 19 January 2016. 
  5. ^ "10 truths about Britain's health service". Guardian. 18 January 2016. Retrieved 19 January 2016. 
  6. ^ Cowper, Andy (23 May 2016). "Visible and valued: the way forward for the NHS's hidden army". Health Service Journal. Retrieved 28 July 2016. 
  7. ^ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Retrieved 27 January 2016. 
  8. ^ Timmins, Nick. "The four UK health systems: Learning from each other,". Kings Fund. Retrieved 2 February 2016. 
  9. ^ "Scottish A&E bucks trend on long waits". BBC. 7 December 2017. Retrieved 10 December 2017. 
  10. ^ Ruth Barrington, Health, Medicine & Politics in Ireland 1900–1970 (Institute of Public Administration: Dublin, 1987) pp. 188–89.
  11. ^ Wales, NHS. "NHS Wales | 1960's". www.wales.nhs.uk. Retrieved 2016-11-22. 
  12. ^ Brian Abel-Smith, The Hospitals 1800–1948 (London, 1964), p.229
  13. ^ Beveridge, William (November 1942). "Social Insurance and Allied Services" (PDF). HM Stationery Office. Retrieved 3 March 2013. 
  14. ^ Charles Webster, The Health Services since the War, Volume 1: Problems of Health Care, The National Health Service Before 1957 (London: HMSO, 1988), p. 399.
  15. ^ "The NHS in England - About the NHS - NHS core principles". Nhs.uk. 23 March 2009. Retrieved 27 June 2017. 
  16. ^ Kenneth O. Morgan, 'Aneurin Bevan' in Kevin Jeffreys (ed.), Labour Forces: From Ernie Bevin to Gordon Brown (I.B. Taurus: London & New York, 2002), pp. 91–92.
  17. ^ Martin Powell and Robin Miller, 'Seventy Years of Privatizing the British National Health Service?', Social Policy & Administration, vol. 50, no. 1 (January 2016), pp. 99–118.
  18. ^ Adams, Ryan (27 July 2012). "Danny Boyle's intro on Olympics programme". Awards Daily. Retrieved 27 November 2016. 
  19. ^ Bevan, Aneurin (1952). In Place of Fear. Retrieved 2 April 2018. 
  20. ^ "Guidance on overseas visitors hospital charging regulations". UK Government. 6 April 2016. Retrieved 6 June 2016.  Links to many relevant documents: Guidance on implementing the overseas visitor hospital charging regulations 2015; Ways in which people can be lawfully resident in the UK; Summary of changes made to the way the NHS charges overseas visitors for NHS hospital care; Biometric residence permits: overseas applicant and sponsor information; Information sharing with the Home Office: guidance for overseas patients; Overseas chargeable patients, NHS debt and immigration rules: guidance on administration and data sharing; Ordinary residence tool; and documents on Equality analysis.
  21. ^ Nardelli, Alberto (11 August 2015). "Are foreigners really gaming the NHS to pay for their medical treatment abroad?". the Guardian. 
  22. ^ "Visiting or moving to England? - How to access NHS services (see "Hospital Services" section)". NHS Choices. 26 June 2015. Retrieved 6 June 2016. 
  23. ^ "NHS charges for people from abroad". Citizens Advice. Retrieved 2010-11-16. 
  24. ^ "Non-EEA country-by-country guide – Healthcare abroad". NHS Choices. 1 January 2016. Retrieved 6 June 2016. 
  25. ^ "Categories of exemption - Healthcare in England for visitors - NHS Choices". NHS England. 18 August 2015. Retrieved 6 June 2016. 
  26. ^ Bruno Rodrigues, "Important NHS charges in visa applications", "Immigration Media", 18 March 2015
  27. ^ NHS Choices (18 August 2015). "Moving from outside the EEA – Access to healthcare in England". Nhs.uk. Retrieved 6 June 2016. 
  28. ^ "Increase in health charge paid by temporary migrants". OnMedica. 6 February 2018. Retrieved 2 April 2018. 
  29. ^ National Health Service (Charges to Overseas Visitors) Regulations 1989
  30. ^ Shock figures from top thinktank reveal extent of NHS crisis The Observer
  31. ^ Danger to patients revealed in reports by 18,000 NHS nurses The Observer
  32. ^ 'Three-quarters of public worried about nurse staffing' BBC
  33. ^ "Health spending". 
  34. ^ "How the NHS is funded". TheKing'sFund. 15 January 2016. Retrieved 6 June 2016. 
  35. ^ "Underfunded, underdoctored, overstretched: The NHS in 2016". 21 September 2016. 
  36. ^ "Health care spending compared to other countries". 
  37. ^ NHS Choices The NHS in England: The NHS: About the NHS: Overview. Retrieved 22 June 2010.
  38. ^ "The NHS in England". NHS choices. 28 January 2013. Retrieved 27 July 2014. 
  39. ^ a b "10 charts that show why the NHS is in trouble". BBC News. 8 February 2017. Retrieved 10 February 2017. 
  40. ^ https://portal.rcem.ac.uk/LIVE/docs/International/6.5.2%20Part-2---The-structure-and-funding-of-the-NHS.pdf
  41. ^ Health unions urge Theresa May to ditch NHS pay cap The Guardian
  42. ^ NHS staff suffer pay cuts in real terms as salaries rise by one per cent The Independent
  43. ^ NHS workers top list of those applying for payday loans The Guardian
  44. ^ Conservatives will break NHS funding pledge, Labour claims The Guardian
  45. ^ editor, Rowena Mason Deputy political (30 December 2016). "People may be ready to pay extra penny on tax for NHS, Tim Farron says" – via The Guardian. 
  46. ^ Two-thirds support higher taxes to maintain NHS funding The Observer
  47. ^ Family doctors working 'beyond safe levels', says GPs' leader The Guardian
  48. ^ Patient safety getting worse, say two-thirds of NHS doctors The Guardian
  49. ^ NHS intensive care units sending patients elsewhere due to lack of beds The Guardian
  50. ^ May must consider tax rises to fund NHS and social care, say MPs The Guardian
  51. ^ Majority of voters back tax rises to bolster NHS The Guardian
  52. ^ a b mamk (February 23, 2017). "Brexit gelungenn, Patient tot" (in German). Der Spiegel. Retrieved February 23, 2017. 
  53. ^ O'Carroll, Lisa; Campbell, Denis (28 February 2017). "Poll shows 60% of European doctors are considering leaving UK" – via The Guardian. 
  54. ^ Marsh, Sarah; Duncan, Pamela (30 March 2017). "Record number of EU citizens quit working in NHS last year" – via The Guardian. 
  55. ^ 96% drop in EU nurses registering to work in Britain since Brexit vote The Guardian
  56. ^ Brexit blamed as record number of EU nurses give up on Britain The Guardian
  57. ^ Brexit deal delay could put NHS patients at risk, Tory MP warns The Guardian
  58. ^ NHS faces staggering increase in cost of elderly care, academics warn The Guardian
  59. ^ Rogers, James (October 2001). "Is Microsoft deal best medicine for NHS?". Computer Weekly. UK. Retrieved 16 June 2017. 
  60. ^ Murdock, Jason (23 March 2016). "NHS hospitals are 'ripe and vulnerable targets' for ransomware cyberattacks". 
  61. ^ "NHS hospitals in England hit by massive crippling cyber-attack". NursingNotes. 2017-05-12. Retrieved 2017-06-01. 
  62. ^ NHS 'could have prevented' WannaCry ransomware attack BBC
  63. ^ "The ransomware attack is all about the insufficient funding of the NHS". 13 May 2017 – via The Guardian. 
  64. ^ Warning of NHS cyber-attack risk was not acted on, says cybersecurity adviser The Guardian
  65. ^ NHS ransomware attack response criticised BBC
  66. ^ Syal, Rajeev; Campbell, Denis (16 October 2017). "NHS data loss scandal deepens with further 162,000 files missing". The Guardian. Retrieved 17 October 2017. 

Further reading

  • Brady, Robert A. Crisis in Britain. Plans and Achievements of the Labour Government (1950) pp. 352–41 excerpt
  • Gorsky, Martin. "The British National Health Service 1948–2008: A Review of the Historiography," Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp. 437–60
  • Hacker, Jacob S. "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy," Studies in American Political Development, April 1998, Vol. 12 Issue 1, pp. 57–130.
  • Hilton, Claire. (26 August 2016). Whistle-blowing in the National Health Service since the 1960s History and Policy. Retrieved 11 May 2017.
  • Loudon, Irvine, John Horder and Charles Webster. General Practice under the National Health Service 1948–1997 (1998) online
  • Rintala, Marvin. Creating the National Health Service: Aneurin Bevan and the Medical Lords (2003) online.
  • Rivett G C From Cradle to Grave – the first 50 (65) years of the NHS. King's Fund, London, 1998 now updated to 2014 and available at www.nhshistory.co.uk
  • Stewart, John. "The Political Economy of the British National Health Service, 1945–1975: Opportunities and Constraints," Medical History, Oct 2008, Vol. 52 Issue 4, pp. 453–70
  • Valier, Helen K. "The Manchester Royal Infirmary, 1945–97: a microcosm of the National Health Service," Bulletin of the John Rylands University Library of Manchester, 2005, Vol. 87 Issue 1, pp. 167–92
  • Webster, Charles. "Conflict and Consensus: Explaining the British Health Service," Twentieth Century British History, April 1990, Vol. 1 Issue 2, pp. 115–51
  • Webster, Charles. Health Services since the War. 'Vol. 1:' Problems of Health Care. The National Health Service before 1957 (1988) 479pp online

External links

  • NHS Choices official website for England's NHS
  • Health and Social Care in Northern Ireland official website for Health & Personal Social Services in Northern Ireland
  • NHS Scotland official website for NHS Scotland
  • Health in Wales official website for NHS Wales
  • Birth of the national Health Service archive collection of programmes and documents
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