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In praise of Old Father Thames

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At the end of last week I was able to take a couple of days off to walk part of the Thames Path with my son, starting in Wandsworth and ending up in Cholsey in Oxfordshire. Blessed with some lovely summer weather it was a thoroughly enjoyable and refreshing break but it also made me reflect on rivers and, in particular, the Thames.

From a modern perspective it is easy to underestimate the significance of rivers in previous ages. While the Thames is at the heart of London’s identity and its most important cultural reference point it is hard today to imagine how completely central it was in the past to all aspects of London life. Since the invention of the railways at the end of the 19th century, we have been used to travelling, with relative comfort, to all parts of the country by land. Before then, however, water was by far the most important means of transporting both people and goods. Even the Romans with their fabled reputation for roads were heavily dependent on river transport.

The Thames has had a particular significance which has been central to the dominance of London, connecting, as it does, the capital both to the agricultural heartland of Southern England and to the sea. The Thames path, largely based on the original towpath, is itself a testament to the importance of the river as an economic highway.

A string of royal palaces: Hampton Court, Richmond, Windsor, to name but those we walked past, are a tribute to its political importance. Now, as in the past, the rich and powerful have chosen the Thames as the place to settle and display their wealth, and in many but not all cases, their taste.
Its economic importance may be diminished but the Thames remains a busy place with the river full of pleasure boats of all shapes and sizes. Our first day included the course of the Boat Race, our fourth that of the Henley Royal Regatta (with its elaborate village of restaurants, bars and other sources of riverside entertainment in the process of being taken down). We passed tens of rowing clubs on our journey and many rowers: the very serious and those just messing about on the river.

The Thames is a now an ecological success story. 50 years ago it was a dead and dirty river but as in other cases where our industrial past, has faded nature has fought back and reasserted itself. As we walked down the river we saw a wealth of birdlife, some of it familiar some more exotic. All sorts of fish now live again in Thames where only too recently nothing could survive. A series of nature reserves along the route such as the London Wetland Centre provide the opportunity to see and learn about some of the rare wildlife which has remerged around the river.

A river makes a brilliant companion for a long walk. It remains beside your side while slowly changing in its own character as it casts off its urban regalia and puts on my comfortable country garb. A particularly attractive discovery of the trip was the succession of aits or eyots (an old anglo-saxon term) small islands which bedeck the river like jewels along its course.

Then there are the bridges, the most obvious landmarks for progress along the river and each with their different character. Some like the bridges at Hammersmith, Richmond and Chertsey provide some of the most elegant viewpoints on the route; others like those which carry the M3 or M25 across the river are a less welcome intrusion of contemporary things onto the more tranquil world of the river. The private toll bridge between Pangbourne and Whitchurch on Thames (in the course of being rebuilt) was a lovely discovery and an interesting reminder that private enterprise has a long track record in the control of means of transport. In the past, as well as bridges, as series of ferries would also ply the river. Few now survive but it was good that our journey included one from Weybridge to Shepperton, a touching reminder of times past.

The river has its literary associations. We followed in the steps of some of Dickens’ characters, ambled along stretches of the river in which Kenneth Grahame set Wind in the Willows and were often reminded of Jerome K Jerome’s hilarious Three Men in the Boat.

I have often thought that a river provides an apt metaphor for the passing of history and one’s own life. Much of the character of England is played out along the Thames . A few days walking along its banks are a good and peaceful way of reflecting on both.

 

It’s all about relationships

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One of the best insights I took away from the recent NHS Confederation conference was the point made by Rob Webster in his keynote speech that it was time that we saw the NHS, less in terms of buildings and kit, and more in terms of it being a collection of people: clinicians, volunteers, patients and carers.  I’d like in this blog to take that point a stage further and to focus on the issue of relationships and why investing in good relationships may be one of the best things we can do to help transform the NHS.

That is not to belittle the logistical aspects of healthcare delivery.  In a system as complicated as the NHS, it is crucial that we become better at understanding the optimal approaches to deploying what are often expensive resources to deliver the best outcomes for patients within the finance which is available at any given time.  But if we focus exclusively on those issues, as we often seem to do, then we are missing a big deal because effective relationships between the different players is, in my view, key to high quality and sustainable healthcare.

Let’s start with the most fundamental relationship of all – that between those providing and receiving care.  Despite all the wonderful developments in science and medicine, human relationships are still a crucial therapeutic ingredient.  It is perhaps easier for us to appreciate this in the world of mental health with its tradition of talking therapies but I would argue that it is of great importance in other areas of care too.  Medicine is not always an independent agent and patients, especially those with long term conditions, have a major role in their own recovery or, at least, in the management of their own condition.  Clinicians who work on relationships, who listen and treat patients with respect, who involve patients in decisions about their care, who coach them effectively in the skills of self-care will, in my view, be more effective.

 This is not just about being nice or having good communication skills, important than though those things are,  it is the recognition that therapeutic relationships are fundamental to good clinical practice.  Many clinicians do this instinctively but it seems to have little place in clinical training and the way in which we organise care on an increasingly fragmented basis serves to discourage the development of such relationships.

The second area is the relationships between practitioners.    Much healthcare is delivered in teams.  Good teams are greater than the sum of their parts.  They share their knowledge and they often share the practical and psychological responsibility for patients.  I was very moved in a recent meeting with one of our clinical teams to hear the intensity of a collective sense of pride and relief of how they had successfully supported a young person in a period of acute crisis.

Bad teams are dysfunctional.  It would be an interesting piece of analysis to identify in many occasions poor relationships and a lack of effective joint working had been a root cause in a patient safety incident.  Poor relationships also help engender a poor culture in organisations.  It was very powerful hearing Helene Donnelly, a whistleblower at Mid Staffordshire, and now an Ambassador for Cultural Change at Staffordshire and Stoke NHS Trust, describing how poor relationships undermined the relationships between professionals which should have supported a collective interest in good standards of patient care.

Sadly as a particular factor in healthcare, relationships can be undermined by examples of tribalism between different groups of professionals or what Freud described as the “narcissism of small differences”.  The diversity of professional perspectives can be a very positive force for good in healthcare but when energy is narrowly focused on defending a profession’s own ideology or resources it is less so.   

The last crucial strand of relationships are those operating across organisational boundaries.   The integration agenda and the challenges of meeting the needs of patients with the most complex requirements has highlighted the need for us to find effective means of developing effective models of care which can operate across organisational boundaries.  So often the NHS reaches for structural solutions to issues which, like integration, are fundamentally about relationships, between senior leaders and between practitioners on the ground.  It is striking, in my book, that some of the best progress on integration is being made in places where continuity in leadership has allowed relationships to develop over a period of time.

So what does all of this mean.  Again three things.

It means the NHS should recognise the importance of relationships both in the heart of the therapeutic process itself but also in how it mobilises itself with its partners to deliver complex goals. 

Second it highlights the needs for skills around relationship management and systemic thinking to have a much bigger role in the training of clinician professionals and NHS managers.

Third it points to the case for investment in building, maintaining and repairing human relationships as just as an important an element of service transformation as buildings and technology.

Good relationships are indeed at the heart of better care.

 

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Ferry cross the Mersey

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Let’s not be a nation of idiots

 

 

 

 

 

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One of the advantages of having a classical education is having some insight into the origins of words in our own language.  The term “idiot” is an interesting case in point which originates from the Greek word for “private citizen.”  In its linguistic journey to modern English it has acquired the meaning of somebody who is stupid and uneducated.  It’s worth dwelling though for a moment on the insights provided by the original Greek meaning.

Despite its different meaning the ancient Greeks, and especially the democrats of ancient Athens, were no greater lovers of idiots than we are today.  In his famous funeral oration for the first victims of the Peloponnesian War, and still one of the best bits of political oratory you can read, the Athenian statesman Pericles says:

“We do not say that a man who takes no interest in politics is a man who minds his own business, we say he has no business here at all.”

For the first democrats the active participation of citizens (or at least male citizens – a whole other story there!) as equals in the business of the state was an essential characteristic of the model of government they had created.  

The Athenian democracy was not a perfect institution and, as in all cases of human behaviour, some of its fine words were followed more in the breach than in the observance.  However this vision of active citizenship still has a resonance today. I would like to use this blog to set out 5 characteristics which set us apart as active citizens and not idiots:

Voting

At the heart of our democracy is our right to use the ballot box to elect those who govern us.  While having sympathy for the frustrations which many have with conventional politics we cannot expect more of politicians if we cannot be bothered to vote.  A turnout of 36% in this year’s local elections or even the 65% at the last General Election shames us.  The ability to change the Government through the use of the ballot box, rather than at the point of a gun, is aspect of civilised life which many brave people have given their lives for in the past and which some parts of the world still do not enjoy today.   Think of the Suffragettes or of the queues patiently waiting in South Africa in 1994 to cast their ballot for the first time.

 Informed debate

A healthy democracy is distinguished by an informed debate of the issues of the day in which citizens themselves are able and have bothered to participate.  Not everything has gone backwards, but it is disappointing to see how often it is portrayed as a virtue not to be interested in politics and how trivialised aspects of public debate have become.  Television has a lot to answer for but I would also point a finger to a general shift in our values and, in particular, the values of our educational system which increasingly stress economic usefulness over the skills which contribute to the active citizen.    The Internet and social media with their democratisation of debate offer a chance to redress the balance and give ordinary people a vehicle to influence debate and decisions.  Of course with debate comes the need for tolerance.  At times we need to remember the words of Voltaire:

“I do not agree with what you have to say, but I’ll defend to the death your right to say it.”

 Meeting our obligations

In the Funeral Oration Pericles also says:

We are free and tolerant in our private lives but in public affairs we keep to the law”

At its best Britain lives up to this adage but there are also many worrying signs of the idiotic tendency to look after own interests above any respect for the common good.  Whether it is cyclists jumping lights, MPs and expenses or rich people and corporations looking at how they can avoid taxes there are growing areas of life where the bonds of common life are undermined by a sense that it is justifiable to see “what we can get away with”.  In a democracy it is possible to have a debate about what laws we are governed by and what level of financial contribution we are asked to make.  Once made as active citizens we should respect the laws or campaign for their change.

Making a difference

The same spirit of participation in Pericles’ eyes also stretches to private relationships between citizens.

We make friends by going good to others, not by receiving good from them.”

Beyond public debate active citizens can also find ways to make a difference directly.  It is definitely one of the positive things about this country that it has such a rich tradition of charitable and other kinds of voluntary endeavour.  Charity should not be an alternative to what the state should provide but it is a powerful channel for those who believe that the best way to change the world is to do something about it yourself, today.  For a more eloquent account of what I mean, look at the Independent on Sunday’s  List of  100 Happy People published today.   

Courtesy

My final plug for the active citizen relates to good old fashioned qualities of courtesy and friendliness.  If we find the energy (yes London I am talking about you) to recognise each other as human beings rather than irritating obstacles in the way of us achieving our next personal objective then that will be one small step to making the world less idiotic.  

 

For the full text of Pericles Funeral Oration look up Book 2 of Thucydides’ History of the Peloponnesian War

Picture courtesy of @journodave

For the link to the Independent on Sunday’s  2014 Happy List:

http://www.independent.co.uk/news/people/news/independent-on-sundays-happy-list-2014-not-the-rich-list-the-full-list-of-people-who-make-life-better-for-others-9423410.html

 

I lift my eyes to the Hills

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 As I get older, inevitably it is harder to attain that sense of excitement at things which is a natural part of being young.  However there remains for me a very special feeling whenever I get the chance to look at or, even better, climb a hill.  A feeling which I don’t necessarily look for but which nonetheless catches me firmly as I first catch site of a hill or mountain in the distance or, when climbing, a grander or wider vista, opens before me.  My wife, who is more a person of the coast, is prone to tease me for my love of the hills and argues that if I were to disclose my religious affiliation on the census it should really be “peak worshipper.”

There are many aspects of the hills which engender a sense of awe and excitement.  There is something about their scale and grandeur, often reinforced by the weather, which challenges our human presumptions.  Our race has often tamed the plains but it has not subdued the high places in anything like the same way.  They remain, to a greater extent, Nature’s preserve which man can visit but not own. 

Second there are issues of perspective.     From the summit of a hill it can be possible to see fifty or hundred miles around you while on the ground the view might be limited to a mile or two or most.  When admiring such a view I can agree with the poet Shelley who said: 

I love all waste

And solitary places; where we taste

The pleasure of believing what we see

Is boundless, as we wish our souls to be…”

On the top of a hill there is no limit to our imagination and no constraints on our hope.

However as well as the grandeur of summit views there are the wonderful moments when, on higher mountains, it is possible to walk above the clouds or other occasions, when walking in mist,  that the clouds can, in a moment, blow away revealing a panorama on all sides.

Finally hills are the most personal, and in a way the most human, of landscape features.  Once acquainted with the distinctive shape of hill it is instantly recognisable as would be the face of good friend, however long not seen.  Yet at the same time hills offer infinite variations.  There are mountains I could climb every day and have a different experience of them each time, with different seasons, different vegetation, and different light, different vistas.

To finish off this piece, and inspired by the Guardian’s excellent “6 of the best” series I would like to have a go at choosing and explaining my list of favourite hills.  It is meant to provoke controversy amongst other hill lovers (after all I could hardly agree the list with myself!).

 

So here goes:

Pen y Ghent – Yorkshire

The most striking of the famous 3 peaks of Yorkshire, its name a legacy of when this part of the world was part of the Celtic kingdom of Elmet. A distinctive summit often clad with snow in the winter months, which demands some effort.  It is, though, well worth the exertion in terms the views it offers to those who reach it.  Climbed for the first time on my first weekend living in Yorkshire it became the symbol of my connection with God’s Own Country.

Watzmann – German Alps

The Alps are very special place for the mountain lover and it is invidious to choose one area of them let alone one peak.  However Watzmann made a special impression when visiting the Bavarian Alps a couple of years ago.  Germany’s second highest summit epitomises the grandeur of height, towering above its neighbours and dominating the views from the town of Bertchesgaden.  Local legend has it that Watzmann is a cruel ancient king buried under a mountain of stones.    

Tryfan – North Wales

Tryfan is a near perfect mountain in the Nant Ffrancon Valley in Snowdonia.  It has a beauty of proportion, a craggy exterior and, unlike its neighbours, Glyder Fawr and Glyder Fach it stands proudly on its own.  For the keen walker it is a fun climb with a bit of scambling which adds some excitement to the expedition.  On a good day the views from the top of the mountain kingdom of the Princes of Gwynedd are sublime. It is one of the oldest of my mountain loves, remembered from the drive up to Bangor on childhood holidays.

Worcestershire Beacon – The Malvern Hills

The Malverns are not very high but in virtually every other respect they are beautiful set of hills, perfectly in scale with the landscape around them.  Brought up in the south of Birmingham they were an obvious destination for a day out and for many years I walked on them as part of sponsored event for a local charity.  Edward Elgar’s muse, they command a brilliant panorama on both sides, across to the Cotswolds to the East and to the hills of Wales to the west.  Worcestershire Beacon is the highest peak standing above the town of Great Malvern.

Great Gable – Lake District

There had to be a choice from the Lakes where, Wainwright in hand, I first learnt to walk in the hills independently.  Again there could be many choices but Great Gable is the one I have gone for.  It is a well-shaped, independent mountain, offering an interesting ascent from a range of starting points and offers an excellent vantage point for many of the other star attractions of Lakeland.

Y Eifl – North Wales  

Not surprisingly I return to North Wales for my last choice.  Again not the tallest, these hills are perfect in form and beautifully situated on the edge of the sea along the windswept North Welsh coast between Clynnog Fawr and Nefyn.  Their name (an old Welsh word for fork) describes their shape – three peaks on one ridge and it is often mistranslated, but not inappropriately, into English as “The Rivals”.  Although remembered from childhood holidays it is only in recent years I have climbed them.  One of the summits is an iron age hill fort (Caer y Cewri –  Fort of the Giants) and its ancient choice as a symbol of authority and protection is  as natural as the day is long.

So I have put my head above the parapet and named my six.  Let other peak worshippers be as bold to counter my judgement and share their own selections. I am more than happy to be persuaded, especially if it means another day in the hills!

Is this the time to rewrite Bevan’s settlement?

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The boundary between health and social care created as part of the 1948 settlement is dysfunctional.  There is nothing new in that conclusion but there may be a growing argument that now is the time to do something more radical to address it in a way which unifies the resources committed by the state to care on an equitable basis.

That was the conclusion of the Kings Fund’s Barker Commission whose, well-argued and eminently readable interim report was published before Easter.  For many years I have thought this issue undoubtedly worthy but in the too difficult pile.  I am starting to think that it is worth grasping the political and financial nettle of such a bold step.  The reasons for doing so are not the traditional ones relating to the injustice of people losing their homes to meet a care need which is deemed to be “social care” which would be free at the point of delivery if it was categorized as “health care”, distressing though this is for many individuals.  The measures identified by the Dilnot review and, which somewhat slowly and reluctantly, the Government are implementing, are probably sufficient to address this.  Instead I would argue that the rationale for the change sits with a deeper challenge that if we not take an integrated approach to health and social care the NHS itself will become both unsustainable.

I have some personal history on this subject.  In the 1990s I worked on developing the guidance to define NHS Continuing Care which came out in response to a very critical report from the Health Ombudsman – an interesting if ultimately thankless task. While at that time the dominating question was that of financial equity the exercise gave me an insight into how the health and social care systems could work against each other with service users and carers the inevitable losers on all fronts.

During the years of plenty at the start of the century the issue didn’t go away but was undoubtedly softened by the development of a positive strand of joint commissioning activity between the NHS and Local Authorities.  Mental Health had a particularly good track record which was furthered boosted by the money which came into the system through Supporting People.   However, since the start of austerity things have got worse as organisations have been forced to look inwards to balance their own books.  The disproportionate pressure on local authority budgets has exacerbated a growing divergence between health and social care.   

The issue is brought into focus by the changing nature of demand within the NHS.  40% of the NHS costs relate to 10% of patients, often but not exclusively the frail elderly, with complex medical and social care needs.  As work around integrated care highlights the needs of this group cannot be met effectively without a joined approach across health and social care.   The Better Care Fund  is trying to recognise this fact but there is a danger that, as the Barker Commission suggests, it is a sticking plaster when a more fundamental alignment of health and social care is required.

There is a political dimension to this.  Over the years sadly social care has, in general, failed to harness anything like the same political capital as the NHS.  It staggered me in the midst of the debate about the Dilnot reforms how difficult it was to secure media and public interest in the issues – VAT on pasties and caravans fared much better!   For reasons I am not sure I fully understand, given the numbers of individuals and families affected, the public do not seem to understand or engage with social care.  However when the public do engage they can see no sense in the artificial boundary between the two systems.  Needs are needs and care is care.  Bringing the systems together simplifies the political debate about how we look after the most vulnerable members of society and how much we are prepared to pay collectively to do so.  It would give social care the welcome protective shield of the public’s support for the NHS and create a better chance that people who need support will have their needs met in a more effective manner.

So what of the cost of such a change?  The Barker Commission’s interim report sets out the options clearly.  There are two choices. We have to be prepared to pay more tax which the Commission also does a good job in explaining is more affordable in the long term than many doomsday commentators would argue.    If we are not prepared to pay more tax we have to be prepared to accept a greater level of charges which might apply equally to areas which we currently class as health care. A mixture of the two may be required although the impact on health behaviour should be thought carefully about before imposing further charges at the point of use.

We also have to consider the political implications of such a change.  We have had for 65 years a national administered health care system which, at least in theory, is meant to deliver common standards of access and care while social care spending is, in general, subject to local political decision making.  If a single budget and system of entitlement was created there would have to be a clear view on who made the decisions about how it was spent.  Perhaps that could be done within existing structures such as Health and Wellbeing Boards but this issue would need careful thought.  Even if there were no major changes in organisations or decision making structures the unification of health and social care would have major implications, in particular for local government.

But as the Barker Commission highlights, hard choices are not always a good reason to put off difficult decisions.  I am beginning to feel that Bevan’s decision to run and fund social care on a separate basis might put his great legacy, the NHS at serious risk in the future.  That is probably a reason to act.   

 Read the Barker Commission’s interim report available at the link below:

http://www.kingsfund.org.uk/publications/new-settlement-health-and-social-care

      

Hadrian’s Wall – the grandeur and intimacy of the Roman Empire

 

 

 

 

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The fact that most of Britain was part of the Roman Empire is one of the defining aspects of our past and nothing epitomises that episode of history more than Hadrian’s Wall.  Started in 122AD on the occasion of the visit of his to Britain it was part of Hadrian’s plan to establish fixed and defensible limits to the Roman Empire.  It is not a wall.  It is the Wall which, even if it is through a mistaken piece of translation, has given us the word in the English language.

In a nation with an ambivalent attitude today to grand public works, its ambition and scale are breath-taking.  72 miles long and built across a landscape which, even today, can still be forbidding and desolate, the Wall makes few compromises to geography in its aim to furnish the best defensive positions.  Follow the Wall today around Walltown Crags or Steel Rigg and you cannot fail to be taken back by the boldness and determination of the Roman engineers and soldiers who constructed it.

Built by the legionary soldiers of the 2nd, 6th and 20th Legions over a period of around 5 years the Wall was built of stone, except for its western reaches which, initially, were constructed from turf.  In addition to the Wall itself, the legionaries constructed a series of milecastles, a network of forts such as those which can still be seen at Housesteads, Chesters and Birdoswald and an enormous ditch or “vallum” running in parallel to the Wall.  The Wall was, by any standards, an enormous logistical exercise. By one estimate it might have taken 30,000 vehicles, 6000 oxen and 14,000 horses and mules to transport the materials required.  Its  scale is highlighted by the extent to which so many subsequent buildings in the area are constructed from stone robbed from the Wall.

The Wall was occupied for 300 years.  In the period after Hadrian the Romans tried to extend the boundary of the Empire northwards to the line of the Firth of Forth where they built the Antonine Wall as an alternative frontier defence.  It didn’t last much more than 20 years and for the rest of the life of Roman occupation they relied on the defences of Hadrian’s Wall to protect the Empire from incursions from the northern tribes of Scotland.  The Wall was garrisoned by around 9000 auxiliary troops drawn from different parts of the empire, Romanians, Spaniards, Belgians, Dutch, Germans but with their strength made up over time form more local recruits.  It is a classic image of the Roman occupation of Britain to imagine soldiers, drawn from sunnier climes in the Empire, shivering on sentry duty on the windswept Wall.

But the Wall and the forts and settlements which grew up are not just about military expediency.  As well as forbidding fortifications, the Romans were determined to bring the comforts of civilisation to the northern frontier of the Empire.  Forts such as Chesters had their bathhouse blocks; there was access to fine pottery, literature, decent wine, fine clothes and all the other accoutrements of civilised Roman life.    

 Nowhere is this more on display that at Vindolanda, a fort behind the lines of the Wall. Thanks to excavations starting in the 1970s which uncovered a fascinating series of wooden tablets, preserved in damp anaerobic conditions, recording many of the details of everyday life at the fort.  The tablets, now mainly held at the British Museum, are a unique and wonderful historical source, their everyday character making them particularly special.  The tablets cast light on many of the practical everyday features of how the Roman army went about its business and how it was supplied.  They include quotes from Vergil, an insight into how the Romans view the natives (there is a tablet which patronisingly refers to the Britons as “Britunculi” – “little Britons”), a reference to the disastrous day on which the Fort ran out of beer.   

One tablet stands out as particularly lovely.  It is an invitation sent by Claudia Severa the wife of the commander of a neighbouring fort to Sulpicia Lepidina, the wife of the Flavius Cerialis the commander at Vindolanda inviting her to a birthday party.  As well as being the oldest surviving writing by a Roman woman, it is an artefact of heartrending beauty connecting us in such an intimate way with the lives of those who have gone before us.

So when you next wonder what the Romans did for us make your way up to Hadrian’s Wall.

If you are interested in reading more about Hadrian’s Wall I would recommend for starters:

The Wall – Alastair Moffat

Life and Letters on the Roman Frontier – Alan Bowman

 

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