The NHS has suggested that doctors should cease prescribing homeopathic medicine.
Simon Stevens, NHS England’s chief executive. asserted that “at best, homeopathy is a placebo and a misuse of scarce NHS funds which could better be devoted to treatments that work”.
Although the amount of money spent on homoeopathy is minimal at present, less than £100,000, the recommendation of the healthcare authorities is to phase it out completely.
Homeopathy utilises highly diluted doses of natural substances that some believe help the body to heal itself.
But there has been criticism of this controversial form of medicine, and some healthcare professionals assert that it ultimately does more harm than good.
Indeed, recommendations set out in a consultation document suggest that there is a “lack of robust evidence of clinical effectiveness” to supports the implementation of homoeopathy, calling on GPS to cease from prescribing it to patients.
“Often patients are receiving medicines which have been proven to be ineffective or in some cases dangerous,” the document states, noting there are often “more effective, safer and/or cheaper alternatives”.
Regardless of the effectiveness or otherwise of homoeopathy, it must be stated that the amount currently spent on it within the NHS system is so trivial as to be almost completely meaningless.
Indeed, 1.1 billion prescription items were signed off by doctors at a cost in excess of £9 billion in the most recent financial year; meaning that homoeopathy accounts for around 0.01% of the overall prescription budget.
New national guidelines outlined 18 treatments that should generally not be prescribed to patients from hereon in.
Other treatments that could soon be banned by the NHS include herbal treatments, lidocaine plasters, omega-3 fatty acids and unlicensed use of the painkiller co-proxamol.
Stevens went on to suggest that the new policy is intended to improve the efficiency of the healthcare system.
“The NHS is probably the world’s most efficient health service, but like every country there is still waste and inefficiency that we’re determined to root out. The public rightly expects that the NHS will use every pound wisely, and today we’re taking practical action to free up funding to better spend on modern drugs and treatments.”
Professor Helen Stokes-Lampard, chair of the Royal College of GPs, cautiously supported the move, while also asserting that eliminating some items currently available on prescription risks alienating some of the most vulnerable people in society.
“We know that a number of treatments are of little or no value, and are at best a placebo. We also know many other medications are available very cheaply over the counter and are much more readily obtainable than when they first became available on prescription, and both GPs and the public should be mindful of this. But imposing blanket policies on GPs, that don’t take into account demographic differences across the country, or that don’t allow for flexibility for a patient’s individual circumstances, risks alienating the most vulnerable in society.”
A new report suggests that pharmaceutical companies should be paid by the NHS depending on how effectively their products ultimately treat patients.
This approach is advocated by the Social Market Foundation, with the organisation asserting that drugs which satisfy a particular criteria should be made eligible to pass through a new purchasing scheme.
The Social Market Foundation believes that this would make medicines available for patients more rapidly.
Based on this new suggestion, the NHS would collaborate with the pharma company in question to jointly agreed on health outcomes to be achieved.
Other issues to discuss could include the basis on which manufacturers of the drugs will be paid, against certain performance yardsticks.
However, the Social Market Foundation also acknowledges that it is essential for safeguards to be built into the process, in order to protect smaller pharmaceutical and biotechnology companies.
With the financial climate of the NHS likely to be increasingly challenging in the coming years, such innovative attempts to make drug purchasing more efficient are almost requisite.
Yet Mike Thompson, chief executive of the Association of the British Pharmaceutical Industry, commented at an event earlier this year that patients in territories search as Germany and France are approximately 700% more likely to obtain a newly-launched medicinal product.
Clinical trials in the UK are already under threat, and this is only likely to be exacerbated by the Brexit process.
Meanwhile, policies intended to achieve outcome-based pricing are being increasingly embraced by both the pharmaceutical industry and the NHS.
Manchester health authorities have mooted paying companies for drugs based on how well they work, with several major players in the pharmaceutical industry having expressed support for the notion.
The Social Market Foundation has particularly cited Italy as a country implementing the approach suggested with considerable success.
And researchers, Nigel Keohane and Kathryn Petrie, said that as the NHS pursued efficiency savings of £22bn over five years, “how we procure medicines is too often left out of the equation”, despite the fact that £16.8bn was spent each year on treatments.
A shift to outcomes-based reimbursement would allow the purchase of medicines to be refocused on “value for money over the longer-term,” they argued.
Any model adopted “should be designed with simplicity in mind — to send clear signals to investors and to retain diversity in the market where small providers can participate fully,” according to the foundation.
The report, funded by Novartis, also included suggestions on how to protect smaller drug companies from competition difficulties.
As the British Medical Association seeks a replacement for the outgoing GPC chair Dr Chaand Nagpaul, the organisation has confirmed that two candidates are currently being strongly considered.
No further GPs have chosen to put themselves forward ahead of a major vote on the appointment.
The two candidates understood to be vying for the post are current acting GPC chair Dr Richard Vautrey and current GPC executive team member Dr Mark Sanford-Wood, both of whom will be a extremely familiar to all healthcare professionals.
Members of the BMA’s GP committee will vote to elect a successor to Nagpaul, after a process in which candidates are not permitted to campaign publicly.
Nagpaul has been a general practitioner in Stanmore since 1990, and is stepping down as GPC chair after being elected chair of the BMA.
In addition to this BMA duties, Nagpaul is a BMA Council member, a member of its Political Board, and GPC member on the BMA Public Health Committee and Consultants Committee, as well as being Honorary Secretary of his local BMA Division.
Dr Vautrey has served as deputy to two GPC chairs – Dr Nagpaul and his predecessor Dr Laurence Buckman.
The Leeds GP was also a negotiator under Dr Hamish Meldrum’s chairmanship of the GPC and has been a GPC member since 2001.
Devon GP Dr Sanford-Wood had been a GPC member for five years when he was appointed to the GPC executive team last year.
Both candidates have spoken out strongly about the crisis facing general practice.
Vautrey spoke strongly on the matter at the BMA annual representative meeting in Bournemouth earlier this year.
While Dr Sanford-Wood wrote ahead of this year’s LMCs conference in Glasgow that there was no margin for error in delivery of support for general practice promised in the GP Forward View.
The significance of this position cannot be underestimated, as it is undoubtedly one of the most important within the healthcare system in Britain.
Nagpaul was ranked as the 25th most powerful person in the English NHS in December 2013, and in a list of the 100 top clinical leaders in 2014.
The aforementioned Porter, meanwhile, has been a strong critic of government policy towards the NHS.
In December 2013 he warned the British Medical Association that “the financial outlook is dire. The NHS is struggling just to keep pace. A growing and ageing population, public health problems like obesity, and constant advances in treatment and technology are all contributing to push NHS costs well above general inflation. The numbers overall are so bad that if the NHS was a country, it would barely have a credit rating at all.”
Several prominent GP leaders have thrown their weight behind the proposed industrial action that is currently being balloted on by the British Medical Association.
A letter is currently being circulated among general practitioners, which argues that this approach is “the best choice to cause maximum disruption for government, but minimal harm to patients”.
BMA deputy chair Dr David Wrigley, chair of BMA London regional council Dr Gary Marlowe, GPC members Dr Jackie Applebee, Dr Louise Irvine, Dr Stephanie deGiorgio, Dr Zoe Norris, GP Survival chair Dr Matt Mayer, and LMC representative Dr Susie Bayley have all signed the letter in question.
The indicative ballot currently being undertaken by the BMA questions practices on whether they would be prepared to temporarily suspended new patient registrations or apply to local commissioners for formal list closure.
This industrial action is intended to heap pressure on the government, at the time when there is a huge amount of discontent and discourse regarding the climate of general practice.
LMC representatives agreed the measure at the annual conference in Edinburgh.
And it is particularly deemed to be a response to what is considered to be a fundamental failure of NHS England’s GP Forward View to deliver adequate resources to frontline services.
With the ballot closing on 10th August, the GPC will ask the BMA council to review the results and consider a formal ballot on the subject.
This new conflict is just the latest in a series of industrial action that has been carried out by healthcare professionals in response to government policy.
Advice published by GPC last week alongside voting instructions warned that practices could face breach notices if any action is deemed a breach of contract.
But the letter advises that list closures can be allowed under the terms of the existing contract if they are carried out on the grounds of patient safety.
“Any action by medical professionals is only done with a heavy heart. In advising practices to consider list closure, our representatives are clear that this is a way of causing maximum disruption to the government’s plans for the NHS, registering our disdain at their failure to adequately fund general practice, whilst causing no harm to our registered patients,” the letter argues.
They text of the letter goes on to encourage GPs to ask patients to provide support for the action with petitions and letters to MPs.
“Our patients are the strongest weapon we have in fighting for general practice. Tell them what you are doing and why,’ it says. It adds that the risk to patients is greater if GPs do not take action to stop the collapse of the service. ‘If this list closure happens nationwide however it causes a significant increase in workload for NHS England, as well as public embarrassment to the government”.
A major academy intended to train radiologists and imaging professionals has been announced in Wales.
£3.4 million of funding has been invested in the project by the Welsh government
And the new National Imaging Academy for Wales will be based in Pencoed, Bridgend.
It is hoped that it will be fully operational by the mid-point of 2018.
Health Secretary Vaughan Gething announced the plan, indicating that the academy will “play an important role” in the training of radiologists, increasing the number available to the Welsh healthcare system.
Specialist training will be provided by the new academy, with partnerships being struck with the existing provision for training at hospital sites throughout Wales.
State-of-the-art workstation suites, simulation training and lecture theatres have all been earmarked for the new initiative.
While consultant radiologists from across Wales will deliver the seminar involved, also supervising trainees on imaging studies.
This will include information on the interpretation of X-rays, CT and MRI scans.
While the initial focus of the academy will be on training radiologists, the programme will eventually be extended to include radiographers, sonographers and other professionals involved in imaging.
Although the Welsh healthcare system has been successful in recruiting and training more radiologists in recent years, the fact that 42% of professionals in this niche are over the age of 50 means that further training is essential.
It is notable that Britain has one of the lowest proportions of radiologists of any European nation.
There are seven radiologists per 100,000 people in the UK, as opposed to a European average of 12 per 100,000.
This is reflected in the fact that UK survival rates for cancer, particularly lung cancer, are among the worst in Europe.
There have also been increases in demand for radiologists in Britain in general, and Wales in particular.
Commenting on the issue, clinical lead for the academy, Dr Phillip Wardle, consultant radiologist at Cwm Taf University Health Board, suggested that the new plan will have a massively positive impact on the treatment of cancer in Wales.
“The academy will enable a significant increase in the capacity of radiology training, emulating successful academy models in other parts of the UK,” Wardle commented.
And the aforementioned Gething stated that radiologists and imaging workers were “crucial” in helping medical and clinical staff to deliver the best care.
“The new academy will play an important role in allowing us to increase the number of trained radiologists in the Welsh NHS to ensure a sustainable, high-quality workforce for the future”.
It is also hoped that the academy can become a keystone for research on cancer in Wales.
A major reorganisation of the ambulance service will fewer 999 calls classified as a life-threatening.
The shake-up is considered the largest in 40 years of this critical aspects of the healthcare system, with the aim of reducing the number of incidents requiring a particularly rapid response.
NHS England has approved the new approach, with ministers signing off the new arrangement.
It is presumed that the new guidelines will result in approximately 8% of callouts being classified as requiring the quickest response from ambulances.
This is a massive reduction from approximately 50% currently.
And the authorities conclude that the majority of these incidents are in fact not particularly serious, and could be delayed until paramedics arrived on the scene.
NHS bosses suggest that the new approach will enable ambulances to respond to the sickest people and most serious cases with more rapidity.
They claim that the targets being used are “blunt” and “dysfunctional”, meaning that too many ambulances are dispatched to meet these targets rather than dealing with patient appropriately.
Medical experts have supported this change in policy, after a pilot scheme dealt with 14 million emergency calls over the last 18 months.
Evaluation by Sheffield University discovered that the new initiative will enable 999 calls to be dealt with more swiftly.
Prof Keith Willett, of NHS England, asserted that one of the problems with the current system was that crews were being unnecessarily dispatched to “stop the clock”.
“This has led to the inefficient use of ambulances, with the knock-on effect of hidden waits,” Willett explained.
It is expected that it will be possible to deal with 90% of calls within 15 minutes as a result of the new policy.
College of Paramedics chief executive Gerry Egan indicated that he was “fully supportive” of the move.
“It is vital to patient care that paramedics are targeted to the most appropriate patients,” Egan commented.
And Juliet Bouverie, of the Stroke Association, also suggested that the new initiative should be beneficial for patients.
“Under the current system, the first responder to a stroke patient could be on a motorbike – but this vehicle can’t transport the patient to hospital meaning they have to wait even longer for an ambulance to arrive. By allowing ambulance call handlers a little more time to determine what is wrong with a patient, it ensures that stroke patients can be identified and the right vehicle sent out immediately to get the patient to a stroke unit.”
The Parliamentary Under Secretary of State at the Department of Health, Lord O’Shaughnessy, has revealed a new package of support worth over £85 million, intended to assist British businesses with developing medical innovations.
It is then hoped that the technological breakthroughs will be utilised within the NHS system.
The funding can be considered the first step in the implementation of recommendations made in the Accelerated Access Review.
This document was intended to ensure that patients gain access to innovations in medical care more rapidly.
The cash stream is being provided jointly by the Department for Business, Energy and Industrial Strategy (BEIS) and the Department of Health.
And £56 million of funding is being provided by the Industrial Strategy Challenge Fund, with £30 million siphoned from existing Department of Health budgets.
It is believed that this initiative will have a particularly strong influence over the ability of small and medium-sized enterprises to test and ultimately deliver new healthcare technologies in the NHS system.
Additionally, the rapidity with which such technologies can be delivered from the laboratory to a real-world of setting will also be improved by this new approach, according to the government.
The Department of Health has already broken down how the funding will be distributed, with £39 million available to Academic Health Science Networks (ASHNs), £35 million for Digital Health Technology Catalyst for innovators, up to £6 million to support SMEs in gathering evidence they need through real-world testing; and a £6 million Pathway Transformation Fund.
It is hoped that collectively this will have a real impact on the way that technology is delivered within the NHS.
“The Government’s ambition is that NHS patients get world-leading, life-changing treatments as fast as possible. That can’t happen unless we support medical innovation and tear down the barriers – like speed to market and access to funding – that can get in the way, especially for SMEs,” Lord O’Shaughnessy commented.
And the Ethical Medicines Industry Group believes that the new initiative represents a positive step.
“We will continue to work with the Government to find ways to make significant improvements in patients’ access to medicines,” chairman Leslie Galloway com themented.
Dr Richard Torbett, executive director of Commercial Policy at the ABPI, suggested that the new investment for AHSNs is “an important first step in pulling industry and the health service together to realise the Review’s ambition. Turning the rest of the AAR’s recommendations into reality now relies on a full, positive Government response to the Review – and an effective Life Sciences Industrial Strategy.”
The AAR, which was developed in partnership with the Wellcome Trust, made a total of 18 recommendations that could propel a step change in access and uptake of innovation in the country.
It is hoped that the government will respond to this before the end of the calendar year.
Around 90% of GPs believe that the NHS should fund the cost of indemnity, according to an authoritative survey.
Indemnity costs are proving to be an increasing difficulty in this critical part of the healthcare system, while evidence also suggest that NHS claims related to clinical negligence are escalating.
Indeed, in the most recent financial year, the NHS shelled out around £1.7 billion on this issue.
Meanwhile, the MDU – the leading medical defence organisation in the UK – has warned that GPs “simply cannot afford” professional indemnity as costs continue to rise higher.
And a poll conducted by the organisation discovered that 88% believed that the NHS should fund indemnity costs, as is currently the case for hospital doctors.
Official figures published by NHS Resolution indicate that there was a 15% increase in clinical negligence claims in the most recent financial year.
And the figure of £1.7 billion has doubled since the 2010/11 financial year, with around 40% of this figure invested in legal costs.
Dr Matthew Lee, MDU professional services director, believes that indemnity is one of the most serious issues facing the healthcare system and its workers.
“The spiralling cost of claims is something society cannot afford and neither can our GP members, who pay for increasing costs via their professional indemnity. We are already seeing large GP claims heading towards settlement at £15-20m. If GPs aren’t supported, many won’t be able to pay the increased indemnity costs. There would be a crisis in the GP workforce that which would leave patients at risk.”
Lee called on the authorities to address this issue with direct action.
“The government needs to act fast to protect GPs from further indemnity cost increases as it is facing a looming crisis. GPs clearly want the same arrangements for NHS indemnity their hospital colleagues enjoy.”
While Emma Hallinan, director of claims at the MPS, indicated that a legislative solution to this problem is a necessity.
“Legal reform is required to strike a balance between compensation that is reasonable, but also affordable – this includes the introduction of a limit on future care costs based on a tariff agreed by an expert group and fixed recoverable costs for claims up £250,000 to stop lawyers charging disproportionate fees.”
Hallinan also suggested that the indemnity issue could impact on the NHS system as a whole.
“While the report does not cover GP claims, the challenges posed by the rising costs of clinical negligence affect the healthcare system as a whole. We recognise the pressure this places on our GP members and this is why we have launched our Striking a Balance campaign – to tackle the root of the problem.”
The Royal College of General Practitioners has warned that GP practices could miss out on over £250 million worth of funding that was previously promised by the Scottish government.
The RCGP warns that there is considerable risk of practice closures in the current climate.
While waiting times for patients’ appointments are also set to increase, according to the authoritative organisation.
The Royal College thus calls on funding funding for the service to be increased, having accused the government of allowing confusion to reign over delays related to new funding.
Previously, the Scottish government indicated that around half of a £500 million package of support may no longer be diverted into general practice.
Nicola Sturgeon promised to increase the share of NHS funding in Scotland spent on general practice to 11%, as demanded by the RCGP.
“By 2021, an extra half billion pounds will be invested in our GP practices and health centres,” Sturgeon commented.
Yet ministers and officials now assert that just half that will be used “in direct support of general practice”, to fund multidisciplinary working, workforce and practice investment, which they state was agreed with the BMA.
The college has said the term ‘in direct support’ is “too broad and lacks sufficient clarity”.
It is believed that the £250 million which is not specifically destined for practices will instead be invested in primary care.
However, this could include general practice or services related to the support of GPs.
In a submission to the Scottish parliament’s health committee consultation on NHS innovation, the RCGP warned that over a decade of cuts to general practice’s share of NHS funding was a barrier to innovation.
Responding to the issue, a government spokesperson outlined the policy of the Scottish authorities.
“As the first minister announced last year, a further £500m will be invested in primary care by the end of this parliament. This spending increase in primary care, to 11% of the frontline NHS budget, will support the development of a multi-disciplinary approach, with increased staffing as well as investment in GP services and health centres.”
The statement went on to outline some of the policies of the government towards general practice in Scotland.
“Health secretary Shona Robison recently set out that £250m of this new investment will be in direct support of general practice, helping to transform the way services are delivered in the community – an approach that was agreed with the BMA. In this financial year, over £71m of that funding is to support general practice by improving recruitment and retention, reducing workload, developing new ways of delivering services and covering pay and expenses.”
The NHS has once more been ranked as the world’s best healthcare system, having been rated against 11 comparable nations.
It was particularly praised for its safety, affordability and efficiency.
There is clearly room for improvement, though, as the service did not perform so well on issues such early death and cancer survival.
Research was conducted by the Commonwealth Fund, a US think tank, and examined countries across the world, including the United States, Canada, Australia, France and Germany.
The United States healthcare system also finished bottom of the pile in common with the last survey.
This was a conducted three years ago, at which time the UK also finished top of the pile.
And this is despite the fact that the NHS currently faces some of the strictest financial restrictions in the history of healthcare in Britain.
Evidence has also indicated that waiting times for Accident and Emergency have been consistently increasing.
In compiling the final report, the NHS was praised for the safety and quality of its care, the systems in place to prevent ill-health, such as vaccinations and screening and the speed at which people get help.
It is also notable that equitable access to healthcare services regardless of income was delivered in a superior fashion in the NHS to any other healthcare system.
The overall rankings were as follows:
4 = New Zealand
4 = Norway
6 = Sweden
6 = Switzerland
Commenting on the report, England’s Health Secretary Jeremy Hunt welcomed the performance of the NHS.
“These outstanding results are a testament to the dedication of NHS staff, who despite pressure on the front line are delivering safer, more compassionate care than ever. Ranked the best healthcare system of 11 wealthy countries, the NHS has again showed why it is the single thing that makes us most proud to be British.”
But Kate Andrews, of the Institute of Economic Affairs, conversely suggested that the NHS was “far from being the envy of the world”.
“The UK has one of the highest rates of avoidable deaths in western Europe, and tens of thousands of lives could be saved each year if NHS patients with serious conditions such as cancer were treated by social health insurance systems in neighbouring countries, such as Belgium and Germany. It is not just low-income earners who receive poor care, the NHS’s provision of care is equally poor for everybody, irrespective of income,” Andrews commented.
A review of clinical commissioning groups discovered that levels of remuneration can be inconsistent across the NHS system.
This has forced NHS England to update its guidance, after it was discovered that the level of pay is significantly high at Liverpool CCG.
Complaints have been made by local MPs in order to instigate the review, and the investigation discovered that remuneration was set at an inappropriate level, and that governance procedures had been disregarded.
Vice-chair, Professor Maureen Williams, resigned as a result of the review, which had discovered that she was paid a salary of over £100,000.
The CCG has now published NHS England’s full report within its July board papers.
“Remuneration of NHS Liverpool CCG’s governing body members, excluding GP members, in financial year 2015-16 was significantly higher than a peer group of 10 other CCGs selected based on allocation,” the report notes.
And the document goes on to outline some of the higher salaries within the organisation.
“The chair, chief finance officer and chief nurse had the highest pay in their peer group; the chief officer had the second highest pay in their peer group; the two lay members were paid significantly more than any of their peer group; the practice nurse and secondary care doctor were paid significantly more than any of their peer group.”
With problems within the CCG quite evident, the report indicates that NHS England will liaise with the Department of Health in order to ensure that payment guidance for clinical commissioning groups includes appropriate population measures.
Katherine Sheerin, chief officer of the CCG, commented on the matter, indicating a tacit acceptance that executive pay has been inappropriate.
“We’ve accepted that we got some of our decision making processes wrong, and we are happy to share that and put things right. We will learn from this and move forward. It would be very helpful if the [NHS England] guidance was clearer, so that it’s clear which population measure should be used and whether there should be a weighting for complexity.”
Guidance in this matter was written five years ago, and suggests that pay should be “in line with non-executive director payments in other NHS organisations”.
The report found that several prominent individuals working within the clinical commissioning groups were paid extortionate salaries.
NHS England’s review was initiated after criticism from West Lancashire MP Rosie Cooper.
“It is not sufficient for the chair of the remuneration board to simply stand down, the governing Body should resign and pay back the monies they’ve grabbed,” Cooper had commented.
General practices across the country have been sent a critical letter on an indicative vote.
The text of the letter question surgeries on whether they will be prepared to participate in a collective closure of practice lists.
This headline-grabbing activity would be a response to the perceived failure of NHS England’s GP Forward View to provide adequate resources.
And the British Medical Association is now asking doctors whether they would temporarily suspend patient registrations, or apply to local commissioners for formal list closure, as an industrial action measure.
LMC representatives had agreed on the ballot at the annual conference in Edinburgh, which took place back in May.
In a letter to the profession, acting GPC chair Dr Richard Vautrey outlined how the process will unfold.
“GPC England has been asked to ballot practices as to whether GPs in England are prepared to collectively close their practice lists. Such action would constitute industrial action, and with significant implications on GPs as independent contractors.”
Vautrey also reminded healthcare professionals to submit their responses to this ballot as soon as possible.
“GPC England needs a clear understanding of the views of all GP practices on this issue, and I would therefore urge you to ensure that your practice takes part in the ballot by Thursday 10 August 2017.”
Should an affirmative vote emerge in the indicative ballot, the General Practitioners Committee would consult with the British Medical Association council in order to review the results and consider a formal ballot.
An accompanying FAQ document explains that the ballot is aimed at practices rather than individual GPs, and recommends partners meet to agree their vote.
While liability for any decision lies with partnerships, the BMA encouraged practices to involve sessional GPs in the decision.
The document warned that, as contractors, practices could face breach notices if any action is deemed a breach of contract.
“There is a risk that temporary suspension of new registrations for the purposes of taking industrial action may be deemed as a breach of contract. However there is no case law in this regard, which means definitive advice is difficult to offer.”
London GP Dr Jackie Applebee was central to the LMC conference motion, calling on her fellow doctors to accept the industrial action.
Evidence was particularly cited indicating that around 80% of GPs assert that their workloads are unmanageable.
While practices collectively closing their lists would undermine access for some patients in the short-term, Applebee suggested that it is currently impossible for the majority of doctors to accept more patients and provide adequate, and even safe, service.
Recent polls have suggested that around 60% of GPs would be willing to participate in a collective closure of practice lists.