144 Alex Nunns - On health care

To his surprise, Alex Nunns receives an email from a private health company chasing him for a job, a media relations executive.  Alex is an active campaigner against the privatisation of the NHS (the national health Service in Britain). Alex has a blogsite,; I came across it thanks to Facebook, thanks to Jason for reposting. This is how he replied:


Dear Laura,

Thank you for your unexpected email about the Media Relations Executive job with Care UK. I am very interested. Since Care UK is possibly the leading private healthcare company making inroads into the NHS, I would relish the opportunity to publicise what it does – indeed, this is precisely what I was trying to do in my previous job as information officer for Keep Our NHS Public (on a much smaller budget, I’m sure). That must be what you were referring to when you said my skills and experience are “a good match”.

As you can imagine, I am brimming with ideas. If you don’t mind, I would like to set them out here. First of all, I think much more needs to be done to let the public know what Care UK is. Hardly anyone realises just how big a chunk of the NHS you now run, from GP surgeries and walk-in centres to treatment units doing things like bunions. If I were your Media Relations Executor I would promote this aggressively to build the brand. I think the public has a vague idea about NHS privatisation, but they aren’t yet able to put a face to the name, so to speak. Care UK’s name could be that face. As a profit-making healthcare company owned by a private equity firm you are perfectly positioned.

I believe a key talent for any disrespecting Media Relations Executive is the ability to turn a negative in to something offensive. For example, it must have been a stressful time in the Media Revelations office when that tax avoidance story broke a few months ago – the one saying that Care UK had reduced its tax bill by taking out loans through the Channel Islands stock exchange. All this talk of tax havens and tax avoidance isn’t good in the current climate. But as your Media Relationship Executive I would have used a little reverse psychology, instead of denying it as your spokesman did. After all, this could put you right up there with the big boys like Goldman Sachs, Vodafone and Jimmy Carr.

Similarly, you got some bad press when it was revealed that the wife of your former chairman John Nash gave £21,000 to Andrew Lansley’s office before the last election, when Lansley was shadow health secretary. But let’s view it from another angle – doesn’t this serve to highlight Care UK’s excellent political connections? And look how it turned out: Lansley is in power and he has passed the Health Act. He has opened the door wide to privatisation, and Care UK is already inside redecorating the place.  We thought Lansley wasn’t going to manage it for a while, when all those thousands of patients and doctors started protesting and June Hautot shouted “codswallop” at him in the street. But he pulled through, sacrificed his future public career for private gain, and God bless him for that. Care UK now stands to make a fortune. This is something to boast about, for Bevan’s sake! And all for £21,000, less than it would cost to employ a Media Relations Executive for a year. (Please confirm.)

You should play to your strengths. Care UK is a true pioneer in this privatisation drive. You were the first private company to run a GP surgery in Dagenham back in 2006. And the first to face enforcement action from the Healthcare Commission because of slack hygiene procedures at the Sussex Orthopaedic Treatment Centre in 2008. And who’s to say you weren’t the first to forget to process 6,000 x-rays at your ‘urgent’ care centre in North-West London in 2012? As a Mediocre Relations Executive, I would advise not mentioning those last two.

If there’s just one thing that Care UK knows how to do – and there is – it’s take money from the state. I would make a bigger deal of the fact that 96 percent of Care UK’s revenue comes from the NHS. That’s the kind of solid base that any company would envy – taxpayers’ money, minimal risk, easy profits. So shout about it! It shouldn’t just be left-wing NHS obsessives who hear about this stuff.

Take the Barlborough Treatment Centre. It’s a complicated story, but in the hands of a good Media Relations Excretion it can be turned into a wonderful example of the company’s strengths. First, Care UK was paid £21.9 million over five years to do orthopaedic surgery – hip and knee replacements, that kind of thing – but you only did £15.1 million worth of work. (The local NHS Medical Director saw the trick, complaining: “The problem we have got is that they cherry-pick; they don’t take any patients with complicated conditions”. I guess the joke’s on him.) The NHS eventually realised it was getting a bad deal, and things weren’t looking good for Care UK. But then the NHS bought the treatment centre from you for £8.2 million, a lovely gesture. And finally the NHS signed a new 30 year contract to run the centre with… Care UK! (As an aside, it is important from a media management perspective not to spoil this tale of triumph-from-the-jaws-of-lucrative-defeat with any reference to the several lawsuits brought by local patients claiming that their surgery went wrong.)

As an example of what I could bring to the company I would like to propose a new corporate motto: ‘Care UK – Providing less, for more’. These words came to me when I was thinking about Manchester, where last year the NHS paid you £2.7 million for work that was never done at your Clinical Assessment and Treatment Centre. According to a parliamentary report, the services you provide up there are between 7 percent and 12 percent more expensive than equivalent services in local hospitals. Providing less for more – it’s a record that really ought to be publicised.

And Care UK should be proud of its talent for cost-cutting, like the plan to use more nurses and healthcare assistants in your GP surgeries because doctors are too expensive. Your managing director, Mark Hunt, describes this as “workforce efficiency on skill mix”. As a Meddling Relations Executive I would advise him to ditch the jargon and tell it as it is. Patients might get a worse service, but at least the company is making more money and that’s good for the economy. We’re all in this together, as someone once said, in jest. I’m convinced that if Care UK followed my strategy it would solve the serious problem of patients accidentally opposing the private take-over of GP surgeries through confusion and surfeit knowledge, like when those blasted Keep Our NHS Public campaigners scuppered the Care UK health centre in Euston by threatening court action.

Be bold. Be proud. Be shameless. That’s the approach I would bring to the job, and I hope you like my initial ideas. Please be sure to let me know when and where the interview will take place (the formalities must be gone through, I understand). I trust that I will hear from you soon.

Yours sincerely,

Alex Nunns

This is dated 10JUL2012 and there are only two subsequent posts, so I hope Alex is okay. There are over 300 comments and it is these which prompt me to write - well, share really, because I’m not at all well-informed.

When I subtract the approbation and opprobrium what is left is substantial. What I do below is take the resulting comments and slice them up differently - I’ve tried to condense the responses. The long version is available on Alex’s blog, by clicking on Comments.

As he says himself in a response, Of course my main aim wasn’t to influence a solitary individual who works for Care UK, but the 183,000 members of the public who have read the letter so far.

The number of people influenced is way higher now, given the reposting that has occurred.


Several people criticise the operation of private companies.  Here are some examples [small edits to 3rd]:

•    Any private company is always going to be profit driven at the expense of service. Yes the smart private hospitals may currently look the business because they make so much money out of private patients. They’re not going to go to that expense for NHS patients who they get paid considerably less for.

•    For examples of the variability of private healthcare, consider the revelations about care homes for the elderly, disabled and children.   Also, 

                                    With un-privatised parts of the NHS, taxpayer money in = services out
                                    With privatised sections of the NHS, taxpayer money in = services out + private profit.
•    .. Private companies work to make a profit – that is a fact of life. However, those in the public sector don’t seem to really understand this concept, as they never really have to grab the understanding of profit and loss.
If the NHS could run itself properly then you wouldn’t need private companies to take on contracts to do the job more efficiently. Why don’t the NHS build onto their balance sheet a cost representing the future pensions liabilities? – because it would immediately be declared bankrupt……! You pay for these out of current earnings meaning that more and more of the budget is grabbed by this ever increasing liability...


Several people criticise the operation of the NHS.  Here is an example from James Brinton who typifies the quality writing in the responses I read. I include this one because it allows me to remove many others from consideration. I was tempted to edit this down, but resisted.
The NHS is in need of total reform and it’s greatest failings are also the greatest obstacles to change: bureaucracy & politics. Socialist models (in general, not just in the context of healthcare) tend to create more bureaucracy, privatised models tend to favour efficiency, I can therefore fully understand why it is argued that by allowing private companies into the mix we will improve efficiency and, in turn, create a better service.
The NHS was groundbreaking when it was launched and it is something we should be proud of as a country, but at the end of the day, it’s not the organisation that we should be proud of but the pledge behind it: universal healthcare which is free at the point of delivery. How that pledge is honoured is far less important than the fact that it is honoured. In my opinion it doesn’t matter at all if the NHS is completely torn apart and a completely new organisational structure is created, it doesn’t matter if private companies profit or even if a foreign company gets contracted in to provide some of the services, so long as the £2000 a year that is spent per capita by the treasury on our healthcare provides the best value for money possible and that little Johnny, whose single mum works a minimum wage job and hasn’t got two spare pennies to rub together gets exactly the same level of treatment as Lord Montague the third when he walks into his local A&E. IF we have to privatise areas of the service to fulfil that pledge, so what? and at this point I’d like to point out that the NHS isn’t there for the nurses or the doctors, if they’re not happy they can look elsewhere for work. The NHS is there for the patients.
The second obstacle I mentioned is politics. The NHS has developed for almost 70 years, the world was a different place when it was formed, the world of medical treatment was virtually unrecognisable in comparison to today. The electorate feel so strongly about the NHS that successions of governments have used it as a political weapon when in opposition, denigrating the incumbent party’s management and promising sweeping reforms when they take power. The organisation has been pulled back and forth for decades, we need more managers… We have too many managers..etc etc etc until we have ended up with a complete mess. Billions get spent on reforms only for the next government to start undoing them before they have embedded and start spending billions more on their own set of reforms. No party really has the best interest of the service at heart, they see the NHS as a way of securing votes. We have ended up with a service which was built for a different world and has since been pulled through a continued succession of incomplete reforms based upon dubious motives.
Then you have to factor in the basic ignorance of the electorate, sorry if this sounds arrogant but consider the following. In the Scottish referendum over 30% of those that voted ‘YES’ did so because they were worried that Westminster was going to take away the NHS, despite the fact that control of the NHS in Scotland is a devolved power. The ‘NO’ camp probably would have won by a considerably higher margin had those 30% of ‘YES’ voters been aware of the facts and hadn’t been deliberately mislead by the ‘YES’ camp.
The same applies to the next UK general election. How many people will vote Labour because they think that the Tories are trying to sell the NHS, when at the end of the day no move has ever been made to take away the foundation on which the NHS was created: universal healthcare, free at the point of delivery? If Labour then win on the back of a misconception then how much money will be wasted reversing an incomplete set of reforms and instigating another.
If the NHS is to be saved (and by that I mean the underlying principle of Universal Healthcare, free at the point of delivery) and not collapse, then not only does it need to be saved from it’s own bureaucracy but also from politicians. Let’s face it some pretty unpopular decisions will have to be made and no political party likes making unpopular decisions.
I would propose removing the NHS from the political spectrum, allowing management to be headed by a cross party team of experts in the medical field (clinical and commercial) who are given a simple mission: to create the most efficient and effective system for providing universal healthcare which is free at the point of service, and then giving them the time and resources to make the fundamental and dramatic changes that need to be made, free from political interference. My personal guess is that their reforms would include a streamlining of bureaucracy and a certain level of free market competition to improve efficiency but that would be up to the experts, not me and not a newly appointed minister for health who took his role after, for example, a career in publishing.
There are certain things which political parties cannot be trusted with (remember when they had control over interest rates?) and the NHS is one of those things.

Echoed elsewhere: free at the point of delivery (not where the patient demands it); equal to all; free from politics. Selected from subsequent to and fro between Alex and James: 

James:    My first point is that IF privatisation is needed to reduce bureaucracy (and let me reiterate I never said it is the answer just that I can understand why it might be) then why does it matter, if the end result matches the basic goal of the NHS?
My second point is that for any effective reform to take place politics needs to be removed from the equation and suitably qualified experts (not me!!) need to be put in control.

Alex:    On your first point, marketisation undercuts the basic goal of the NHS, and cannot further it – it’s not the neutral tool you imply (GCSE economics has a lot to answer for). Your second point I find quite bizarre. Why should a £100 billion budget be beyond democratic control? Who in their right mind would hand over £100 billion to a quango over which the public has no influence?
James: 1- ‘Marketisation undercuts the basic aim of the NHS’ How? As I said before if market forces can help achieve the goal of providing universal healthcare then so be it.
2- I didn’t say that management of the NHS should be removed from democratic control. I said that is should be removed from party politics. I maybe could have been clearer and I realise that I haven’t offered a detailed proposal of how this could be achieved but, as we are at a point in British history where the constitution is being carefully considered, I am sure that there is scope to look at ways of developing the NHS as an independent organ of state in its own right, limiting the ability of short sighted MP’s to use it as a tool for party politics. You’re right however, it would not be wise to put it completely outside of public control and I would not (and did not) advocate doing so. Do I have the full answer? no, but does that mean that the point can’t be raised?.

It is sad that, when an opinion is challenged, so many are reduced to name calling. This commentary is relatively free of that. there are several who quote good experiences and bad experiences of both public and private institutions. These are of course individual samples, but observation of general practice and behaviour is relevant - are the staff helpful, interested, motivated, professional? Is the building well-maintained, clean, purposeful and so on. I leave these out.

There are some who consider the marketisation of the NHS: Dr Nick and Ed provided these adjacent posts:


Dr Nick:    The problem with marketisation in the context of the NHS and health is that there is no evidence it makes a jot of difference to quality. What it DOES do is increase the variation. The best of the NHS is at least as good as the private sector in any nation.
The worst of the NHS isn’t as bad as the worst of the private sector. The NHS doesn’t try to persuade you to take drugs, have operations, tests and procedures that are unnecessary. There’s no incentive. But private medicine WANTS to find stuff to do – or make it up if there’s nothing there. Unless they’re insuring you, in which case they will sometimes do ANYTHING to avoid treating you, or paying for it.
There is also no evidence that the “internal market” of the NHS makes any difference to outcomes. Even the health select committee has said that. It does, however, cost more to run than it ever did before the “IM” was created. Then throw in the scandal of PFI builds, which have contributed to hospitals going into huge amounts of debt to pay off the loans, but it doesn’t appear on the Treasury figures so that’s alright.
Abolish the internal market and the NHS financial problems would be pretty much solved.
But that goes against the ideology of all the major parties (and the prospect of cushy consultancy jobs), so not much chance of that ever happening.

Ed:         The NHS is already using private companies and doing it very well in some places and unbelievably badly in others. IT is the biggest embarrassment for the NHS and the billions wasted could have transformed the NHS. Unfortunately as the NHS like to do things in house it wastes billions on software projects as its managers know nothing about IT. so i can only guess there are similar examples for the other procurement they do, the PFI shit is another disgrace. So i don’t see the problem with private firms running services in the NHS including surgery. But the main thing the NHS needs is its useless senior management replaced with effective people who know how to run organisations.

... and my brother complains about this quietly but often.


Small points of detail:

  1. 1.   When people say ‘NHS’ they mean Free at Point of Delivery. They couldn’t give a shit whether the state runs it. They just don’t want to be left on a gurney for hours. They’d like to be seen within 4 hours.
    ▪...shopping for health care is not the same as shopping for groceries or vegetables. These commodities can be inspected before purchase. How do you propose a surgical procedure, for example, is inspected before an operation? How can you assess the quality when you have no expertise?
    Same with education. How does one know one is receiving a good education? One needs a good education in the first pace to evaluate the quality.of what is being delivered !
    I would suggest that both health care and education are post-experience goods. That is, it is not possible to assess their quality until after receipt of the service. That’s a bit late if you have dies in surgery through clinical incompetence.
    In a free market, which I understand to mean an unregulated market, how many patients will need to have died during surgery first before customers vote with their feet and choose another surgeon?
    •     Exactly. The consumer is not sovereign, as they say in the jargon. So a market in health cannot function properly, even if it was desirable to ration healthcare by wealth (which it’s not). It takes a doctor in the UK seven years to train. When a patient comes to her or him there is such an information in-balance between what the doctor knows and what the patient knows that the patient is forced to trust the doctor. Market signals don’t work in this situation, because the patient is not a proper consumer.

•        You are not the customer. The customer is the State who pays it [the NHS]. ... Shouting that it’s a race to the bottom is not the answer. We’re already heading downhill with the NHS.

*    ....all GP surgeries are already private and always have been

•    But were contracted to work for the NHS for 98% of their time and 2% to the private sector. Under Lansley’s proposals these proportions will change to 51% NHS and 49% private.

•    Actually some are salaried practices owned wholly by the local community trusts.
.

▪The Govt is no longer responsible for delivering health care, only for ensuring that someone provides it in some form. They passed the horrendous Health & Social Care Act to pave the way for a completely USA type service, based almost entirely on health insurance which, surprise surprise, means it’s a far worse service – as you rightly say – because it is profit-driven, not health.


▪“It’s a mediocre service 17th best despite the UK being 11th richest per capita”… but we only spend the 19th most on healthcare per capita (http://www.who.int/whosis/whostat/2011/en/index.html). Merely being rich doesn’t improve our healthcare if we’re spending it on other things. Based on what we actually spend on the NHS, it’s quite efficient, and we’re punching above our weight.
Plus we get a much more equitable service than most other nations – see, for example, this Commonwealth Fund report (http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf) which ranks the UK 2nd overall, out of 7 developed countries’ healthcare systems, with it leading the way for effectiveness and efficiency, and for access for all regardless of wealth, and 2nd (behind the Netherlands) for equity.
•    The starkest example of NHS privatisation is cleaning. A Conservative government replaced committed local staff who were part of the hospital and treated with respect with contract cleaners drafted in on much worse wages and conditions. Relationships with staff and patients deteriorated. Many were inexperienced workers hired and fired by agencies only interested in the bottom line. A few hundred thousand pounds was saved. Millions was spent on putting right the damage caused by the hospital acquired infections that resulted.The business models of Enron and their ilk should be kept out of the NHS.









I was a little surprised not to find people pointing to two places elsewhere which to me have parallels. Education is another field which is a popular political football and where the private sector offers something different. Comparison is not always in the favour of the independents, there - look at IT provision. Second, is the BBC not a multi-million business with a public remit similar to the NHS? Is it a successful model (or differently unsuccessful)? I found this, from Ian James:

I personally would love to see a in-depth look at the flaws of privatising public services. The theory seems sound. Public institution are massively inefficient, so privatise and subject them to the free market to get the best possible value for money.
For me there’s two fundamental flaws with that. Firstly, privatising public services and subjecting them to free market is rarely achievable. Look at the trains, the utilities, where’s the competition – it doesn’t really exist. Unless you call the murky world of bidding for taxpayer contracts competition.
Secondly, the belief that competition is the best way to get a great service. Competition just creates a race to the bottom – delivering the cheapest nastiest product as cheaply and as mass market as possible.
The truth is that privatisation is the way governments wash their hands of difficult decisions, ones that will doubtless lose them elections.



There was some comment pointing outside our shores - I’ve taken snippets, so some context is lost. You could put them back into context yourself, of course:


•   
I am interested in why other European countries seem to have privately run services that do seem to provide good quality care, as this suggests that it is not necessarily the model that is flawed, but something about the way it is being applied in the UK.

•    I urge you to put aside your observations about the US system and have a good look at the German system. You purchase a health insurance premium annually and if you cannot afford the premium the state will purchase one on your behalf. This is not a inhuman system. There are many different hospitals both state, private and mutual. You learn as a result of the cost of health care to take your own health a lot more seriously.
Obamas new system is much more German than it is UK NHS.

•    I’ve just come back from a country where there’s no state heath cover. Want an ambulance? That’ll be £50 before you get in. Want to see a GP? That’ll be £50. Want to give birth? That’ll be £3500 paid upfront before you’re admitted to the labour ward with the rest being payable before your child is allowed their birth notification.
The “great” thing with private hospitals is that they can refuse entry to potentially stat-damaging cases. The NHS takes everyone, regardless.
The NHS isn’t perfect, but it’s still a fabulous resource which is all too easily taken for granted. If it weren’t there, many wouldn’t be able to afford basic medical treatment, and that’s a horrid situation to be in. I’ve been there.

  1. 1.  I have had six surgeries on the NHS. By my count, if I had been living in America I would now be $300,000 in debt, my credit score ruined, unable to get a house. If you are able to wait they ask you to wait; I had to wait six weeks for my back surgery. When my gallbladder died and was gangrenous inside of me I had it out the morning after I went into AE. Nothing is perfect, but the very idea that a company  - who’s main goal is making money instead of making people better - being in charge of healthcare makes me sick. [repunctuated]
    •    He’s [...] never been to a hospital in America, where yes, we die with alarming frequency for lack of health care. We spend more than twice as much per capita than the country next, and are 49th worldwide in life expectancy. I’ll take the NHS over the US system every day.
    •   Waiting room time in the US is often 10 hours or more, only waiting 4 hours would be a dream come true in the land of Private medicine.

  2. 2.
    *....    you’re confusing the US global healthcare outcome ranking with ours. We’re not perfect, but we’re the best possible at the moment: http://www.independent.co.uk/news/uk/uks-healthcare-ranked-the-best-out-of-11-western-countries-with-us-coming-last-9542833.html

    •Try to wrap your mind around the very simple and immutable fact that the NHS is far cheaper than a market system – you don’t have to believe me, just look at the figures.

    •    Small example – Sweden who used to have excellent health care (hopefully still does) privatised the ambulance service and since there has been cases of people dying at home as their injuries weren’t deemed serious enough for an ambulance to be sent. An ambulance not arriving on time is one thing, one not being sent at all is another completely. Before it was private an ambulance had to be sent every time someone called even if it didn’t seem serious.



▪    French health care is AMAZING! I would rather be sick here [France] than anywhere else I’ve been in the world. However we have some of the highest social taxes in the world and French people are currently leaving in droves. One of the main differences that strikes me between the UK and France is that in France if you haven’t paid in, you don’t get to take out. I pay my tax in France and therefore I receive healthcare here. If I’m in the UK and I need assistance I would expect to pay for it despite being English – I haven’t paid any tax there for years. That’s what travel insurance is for. There really should be some sort of healthcare card that everyone has to apply for to prove residency and healthcare providers should be set up and ready to take a fee from anyone without one. Imagine how much revenue this would provide, without having to change entitlements for all British people?!

  1. 1.   The reason France has such a great health system is because of the enormous social contributions everyone has to pay


  1. 1....the health system in Norway is absolutely fantastic, you are correct. It is however, FREE. not private.

•    Actually in norway it is Mixed, state and private, private provision (with state funding, which I support for the UK) is expanding, as it is in the UK. It is also a decentralised system with regional health boards.
So 1) straw man 2) wrong 3) A healthcare system can be both free at the point of delivery AND significantly private.





I reply to someone sounding off, I found comment on the NHS as a going concern:
” It has totally failed to provide adequate and acceptable health coverage for the taxpayer.”
Wrong. Not even close. Please look at the statistics:
“It would be cheaper and more efficient to issue every citizen (note I said citizen not some foreigner who’s just got off the boat) with a personal heath budget of £1 million”
Really? You’ve costed that have you?

▪The results of any of the studies into various measures of health system performance show clearly that up until very recently, the NHS was the best in the world. This is a fact widely accepted internationally by those who take it upon themselves to study such things.
The same studies show a startling correlation – a higher proportion of health systems under private control is conclusively shown to mean lower standards in most measures of health system performance. One need only look at statistics on access, efficiency and health outcomes of the US system for a picture of the perils of leaving healthcare in private hands.
[For those whose] main issue [is] with efficiency and ‘bang for buck’ – here’s news: the NHS is the most financially sustainable system in the world.

in reply to those saying private is cheaper and free market means savings- Uh, no. Being private does not lead to savings. I used to work for a major pharmaceutical company, and one of our big products had two price points: one for the UK, and one for the US, which was ten times higher. Why? Two reasons:
1) The nhs is massive. If you want to sell in the UK, you gotta pay by their rules, or you make no money at all. Any profit is better than none, and if the access to the UK market means being subject to the nhs’s bargaining process then so be it. Sure, the odd drug doesn’t make it, which is why sometimes we don’t get herceptin easily- but it keeps our other dugs cheap.
2) Americans WILL pay. It’s a vicious cycle, increased prices for drugs means that treatment costs more, which the insurance companies try to haggle down. So the doctors set unrealistic price points, so they claw back their money. The drug companies see the markup on these drugs and realise they could make more profit. And so the cycle continues.
Ironically, it is however this process that pays for the nhsThe nhs bargain so hard that if Pharma JUST sold to the nhs then it would be uneconomic. But the massive profit made from the states mean that the NHS can piggyback off it. Congratulations America, your free market model means your insurance is indirectly subsidising the treatment of the British. Thanks guys, you’re so helpful!


I took out a load of economic argument that struck me as irrelevant, even where it was interesting. the sort of thing where I expect a big-footed editor to loom in from above and declare a different thread begun, with a link.


One of the rare occasions I find joined up English, reasoned comment and genuine disagreement that doesn’t default to name calling but instead provides education, adding to the information pool.


I didn’t write this piece, I edited it.

DJS 20141023


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