'Pharmacy is a rudderless boat drifting towards dangerous rocks'

Hemant Patel: Sector needs to adapt to NHS undergoing unprecedented transformation

Community pharmacists must find a new direction by overcoming political naivety and a myopic vision, argues Hemant Patel

Community pharmacy faces a real and urgent need to transform or be eliminated from the NHS equation.

The NHS is undergoing an unprecedented transformation to meet the future needs of very different populations. This has brought about seriously challenging developments in robotics and distribution methods, technologically empowered communities, multidisciplinary teams and virtual working, as well as artificial intelligence.

It has also prompted self-care and person, not patient-centred, care. But has the profession even considered the difference in provision of care with this small change in wording? I fear not, when we have people [at the local pharmaceutical committee (LPC) conference and other sector events] discussing how to tinker with the existing model.

Get to grips with new technology

The profession needs to get a firm grip on the NHS agenda, which is embracing powerful advances in technology. Cloud-based data management and devices which will make the 365-day-a-year, 24-hour-a-day personalisation of care possible – all while looking to improve care by significantly changing public engagement and personal responsibility for health and wellbeing.

Community pharmacists should be talking about how to make a contribution to multidisciplinary teams with integrated pharmacy care everywhere: in community pharmacies, GP surgeries, hospitals, care homes, and people’s homes, as a part of these teams.

New mindset needed

This requires a new mindset which recognises a need for collaboration between local pharmacists, and updated clinical and communications skills. It requires re-planning pharmacy layouts to ensure that space is allocated according to income – at present I estimate NHS services yield 90% of pharmacy income, yet they get 20% of space.

It will require community pharmacists to become experts in behaviour change to support lifestyle changes, to understand that simply giving information has limited impact, and to understand that to produce transformational care plans you also need to combine psychological support and clinical tools.

The sector will need to give pharmacy staff greater respect and responsibility from their employers, and a real stake in the system, to ensure that they feel part of it and are able and motivated to react to local changes. To make this happen, I would recommend that we look at creating associate status, to recognise the value of the knowledge, skills, relationships and time invested by our employee pharmacists.

Employers will need to act as local collaborators instead of competitors. In a world where Samsung makes phone screens and Microsoft writes software for [their competitor] Apple, it makes sense to review how we work with our competitors.

No place for division in sector

The creation of accountable care organisations as part of the sustainability and transformation partnerships will not permit a divided community pharmacy network, which attempts to work for divided owners instead of the public, the NHS, and increasingly value-for-money-minded commissioners.

The small thinking and lack of urgency demonstrated at recent conferences is not only depressing and mind-boggling, but indicative of a rudderless, engineless boat drifting towards dark and dangerous rocks.

Apart from lip service, I expect nothing from the Department of Health. So, what will save community pharmacy? Inward looking and short-sighted owners? Resentful and myopic employees? The pharmacy press, who are only interested in soundbites, rather than helpful policy analysis? Superman?

Whatever your view, the last remaining grains of sand in the hourglass will soon run out. We need a leader to turn the hourglass and restart the grain fall.

Hemant Patel is secretary of North-east London LPC

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63 Comments

Valentine Trodd, Community pharmacist

Mr. Patel, in fairness Shaun hit the nail on the head with his comment below. I too come from a technological background - programming, systems integration and web technology. In other words, I have a practical and in-depth understanding of how technology can enable businesses. With all due respect and kudos for coming on here and defending your views, I don't think you've described a single practical application of the technology you've spoken about. I've read the document you've referred Shaun to below and it's similarly fluffy - about a page or so which refer to, among other things (excerpt below to save people wasting their time downloading it) - 

* a range of technologies are being used to deliver or augment healthcare in different countries: e-health records, real-time counselling sessions, e-referrals discharge summaries

*robotics and algorithms being increasingly used by GPs along with dynamic clinical decision-making tools.

* IT is transforming practice, though not yet everywhere. In Sri Lanka, IT is used for medical education services

* AI will be huge asset to doctors

* big data

There are no 'big ideas' here. 'E-health records' sounds like SCR - this isn't revolutionary and has had a very minor impact on our practice. 'Algorithms and dynamic decision making tools' - Google? 'IT used for medical education purposes' - most of my flu jab training was done online.

Also did you notice - no mention of pharmacy anywhere?

Again, with respect, there are a lot of people with very little practical experience in technology expounding some big ideas - sound bites that come across well, but once you start poking around, you realise there is very little substance behind the swooping statements.

I'd echo Shaun's challenge, but I'll make it easier - can you describe a single specific and achievable technological innovation that would be practical for small contractors and large chains alike to implement, that would improve both the finances of contractors and be of benefit to patients and the NHS in general? What we need are practical achievable goals on a local level - our leadership has already comprehensively demonstrated utter ineffectiveness at delivering any innovation at a national level. 

Hemant Patel, Community pharmacist

Do I detect that there is an assumption that past pace of change will detect the future pace of change? And, that Digital world will have little or influence on community pharmacy if it remains a viable network for delivery of future NHS services? Change in technology, personal data and population health data will integrate and use predictive algorithms etc will happen and first place may well be NEL as we are ready to adapt to survive. We are not victims we are ready to change our predicted and projected future by active intervention and commitment.

 

 

Hemant Patel, Community pharmacist

Three quick points:

1 i am talking about the future not history; 2I also mentioned a conference (have you read the whole thread?) 3 see Press release below.

 

EMBARGOED: 09:00, Monday 11th September 2017
Media Contact: Rachel Fuller
Telephone: 07976 037576
Email: rachelfuller@pinpoint-events.co.uk

CARE CITY LAUNCHES LIFE-SAVING ATRIAL FIBRILLATION PATHWAY AT EXPO2017
Community pharmacists are working with their local hospital to find and treat AF and prevent stroke 

11th September 2017 – Care City launches its Atrial Fibrillation Pathway at this year’s EXPO 2017. The Pilot Model finds people with undiagnosed AF in local pharmacies, reduces appointments and waiting times to treat them, and offers a cost-effective way to prevent 1600 strokes across England.
An irregular heartbeat, clinically referred to as an Atrial Fibrillation (AF), is the most common heart rhythm disturbance. Half of people in London with AF are unaware they have the condition, or that they face a five times higher stroke risk as a result.

Care City is one of seven National Health and social care test beds funded by NHS England and is the only one in London. Working with local pharmacies, it is trialling early testing of AF using a Kardia Mobile handheld mobile device from Alivecor, which can spot AF in 30 seconds. Those with an abnormal result receive a rapid referral to a One Stop AF Clinic at Whipps Cross University Hospital where a patient will undergo minimally invasive diagnostic tests and meet with an Arrhythmia Nurse to discuss the result and, if appropriate, receive treatment. The whole process takes 2-3 weeks, compared to a national average of 12 weeks at present. The Pilot is a collaboration between Care City, North-East London Pharmaceutical Committee, Barts Health, Waltham Forest CCG and Sonar Informatics.

Nearly 700 patients have already been screened for atrial fibrillation as part of the Care City’s NHS England Test Bed since it launched last year. Of these, approximately 7% were identified to have Atrial Fibrillation. Independent evaluators from University College London, say “Preliminary health economic modelling indicates that combining innovative screening for atrial fibrillation in community pharmacies for the 65s and over with a rapid access clinic offers a cost-effective strategy, reducing strokes at a comparatively low cost. If replicated across England, an estimated 1600 - 1700 strokes would be prevented per year.”

The Health & Care Innovation EXPO taking place on 11th and 12th September at Manchester Central is the only major conference in England focused on innovation across all aspects of health and social care. It unites NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media and will explore the most important developments across health and social care.
John Craig, Chief Executive, Care City commented “We’re proud to launch our new AF Pathway at EXPO and show how we’re collaborating with technology and all levels of the health and care community with a common endeavour to assist patients to pro-actively manage their health and ultimately save lives. The data we collect from this testing, will indicate how many people use the service, leave with a diagnosis and start treatment. It will also help us understand whether the service is good value for the NHS and whether adopting this one stop shop approach further across the UK is an effective and viable option.”

Terry Huff, Chief Officer, Waltham Forest Clinical Commissioning Group commented “There has already been a positive response from both professionals providing and patients receiving AF assessments in Primary Care. Patients are confident they are being looked after and are happy to have the opportunity to take actions to reduce their risk.”
Emily Hough, Director of Strategy at NHS England commented: “It is great to see combinatorial innovation in action in Care City as they bring together new technologies with changes in the way care is offered to patients.  This new enhanced AF pathway should lead to earlier diagnosis and treatment, ultimately offering improved outcomes for patients.  We look forward to continuing to support Care City, and thinking about how we can scale this approach if it does deliver improved outcomes for patients at the same or less cost.”
Kardia Mobile from Alivecor is one of a number of sophisticated innovations that the Care City Test Bed is collaborating with to support people with long term conditions, dementia and their carers.
•    The Canary Care monitoring and notification system aims to provide round the clock reassurance to family members whilst allowing older or vulnerable people to stay at home. 
•    GaitSmart’s gait analysis tool applies micro sensor technology to movement, identifies areas of issue in the patient’s mobility and provides personalised exercise programmes.
•    The HealthUnlocked Social Prescribing tool enables health professionals to signpost or prescribe local support services and other beneficial resources that relate to holistic needs or conditions
•    Join Dementia Research supports local people to register their interest in participating in dementia research and allows them to be matched to suitable studies in their area and wider afield. 

•    Kinesis QTUG™ is a fast and efficient tool for identifying older adults at risk of falling, using precise and accurate body movement sensors. 

•    St Bernard’s GPS based Emergency Location Service aims to reassure both the individual and their carer/s and family.
Care City will be exhibiting in the Test Bed Zone at EXPO 2017.

-ends-

 

 

 

 

Barry Pharmacist, Community pharmacist

This is old news and demonstrates that all you can respond to the question of Valentine Trodd is more "fluff". What is your plan to give us direction? From what I read of your comments here we will all be out of business before you crystalise any firm ideas.

Hemant Patel, Community pharmacist

There is going to be cull. 

In 2005, I opposed the so-called new contract. What did you do? So, with extreme reluctance and sadness I accept that the cull has started. I cannot stop it and my advice to contractors is start managing your finances with much greater care. For the survivors, there will be a network with fewer competitors and many more available pharmacists. From that, pick carefully pharmacists who are clinically trained, preferably undergoing a qualification for Independent Prescribing or already an IP. The days of the chemist are indeed limited. No one can save them. There is no raft or life jacket. The dispensing chemist is doomed. Yes, doomed.

Modern pharmacists will utilise their skills in remaining community pharmacies, work in surgeries, hospitals, care homes, and in administration. They are entrepreneurs of a different kind: knowledge brokers. They understand health literacy and go beyond CPD and are consummate learners. In their life time, unlike previous generations they will change direction at least three times. Best advice: things are heating up and you have simple choice. Get out and rebuild life as the NHS is ‘boiling a frog half a degree at a time’. Do you know what this means?

If you are a survivor contractor choose a team with a Pharmacist who is well respected, well paid, loyal, and enjoys new work. Don’t bother with the silly sods who do not like CPD, only want to do what their predecessors did, and want more money even when the government imposed cuts in re-imbursement and remuneration ( would they know the difference?). So, in short, if your boat is sinking start swimming. If the boat is not sinking yet, sail close to the shore at least for the time being but keep paddling and look for new opportunities. Be agile, be vigilant, be multi-disciplinary and develop relationships locally. Since 2005, Sue Sharpe of PSNC talked about ‘evolution’ which never materialised. Now, it’s red hot revolution. Now, you better have a sense of urgency otherwise you are DOOOOOMED. 

Aaaah! That feels so much better to get the truth off my chest. That’s why I write the piece. Now, you can brush off your CV and apply for Sue Sharp’s job and save community pharmacy.

Barry Pharmacist, Community pharmacist

Thank you. You could have saved us a lot of time and effort if you just said that before! That's what I think and a lot of others here. The boat is sinking, some of us - the strongest, will hopefully survive but we face a new life on a different island. 

Ilove Pharmacy, Non Pharmacist Branch Manager

Ever the politician. Why didn't you speak the truth at the begininning instead of all the other guff? hmmmmm.....

Locums and employees have known of this doom for quite some time but obviously it was not of wider concern as contractors were unaffected. Let the cull begin......
 

David Kent, Community pharmacist

Before critiscising Hemant please let us know what you have tried to do raise profile of the profession?

Shaun Steren, Pharmaceutical Adviser

For arguments sake, let’s assume he has done nothing. How does that influence the validity of his point? 

Ilove Pharmacy, Non Pharmacist Branch Manager

Childish circular arguing as the ship continues to surely sink. The likes of Mr Kent are very amusing nonetheless. 

Shaun Steren, Pharmaceutical Adviser

Mr Patel, I understand, that for many in the pharmacy establishment, it is very convenient to ignore the historical basis of our current predicament. I also understand, that for the ‘clinical visionaries’ who have been proven absolutely wrong in every single thing they predicted, it is very convenient to dismiss the sceptics (who have been proven absolutely correct) as people who wish to return to ‘compounding’. 

What you offer has not a single element of practical detail. Just using the terms ‘robotics’ ‘technologically empowered’ ‘virtual working’ and ‘artificial intelligence’ is meaningless. You may as well say ‘it’s computers innit’. It is very interesting to see how the pseudo-clinical prophecies of the mid 2000s have been quietly abandoned and replaced (by the same people) with a new ‘technological’ prophecy. 

As a technology geek myself, I would be very interested to hear you describe (in exacting practical detail) a single original and transformational technological innovation that could be implemented in every single pharmacy tomorrow. I request that you provide a substantial eivdence base (patient benefit) for this innovation and a full breakdown of its economic viability. I would also ask that you describe exactly how individual employee pharmacists would have complete autonomy in the use of this innovation and how it would, without exception, fit in with the current daily workload of any given pharmacist. Finally, I would ask how you would guarantee that a corporate monopoly would implement the innovation exactly as you describe and how it would be regulated to ensure it was used to benefit patients and not the bonuses of corporate directors. 

Hemant Patel, Community pharmacist

Final comment:where the future lies for GPs (especially see p 9_10) https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/policy%20research/education%20and%20training/the-changing-face-of-medicine-june-2017.pdf?la=en

Amal England, Public Relations

Pharmacy started to lose its rudders around the time you were president of the RPSGB. Since then only two things have changed and it has nothing to do with the population or technology, the government does not want to fund the NHS to the necessary level and pharmacy is leaderless.... There is no one controlling the rudders, Pharmacy has no power to even ask for the bare minimum. The result- pharmacies are closing because they cannot make ends meet. Yet GP surgeries are generally not facing closure for the same reason. I buy a medicine for £x but the NHS is only prepared to pay £x-y.... Try and see if you can make a GP provide a service at a loss.... Thanks to their leadership this is a no go area. The GPs are on the verge of getting the NHS to absorb professional indemnity costs (maybe it's done and dusted).... Can you do that for pharmacists?

Hemant Patel, Community pharmacist

IN in your mind community pharmacy contract is negotiated by RPSGB that was a professional and regulatory body. How absurd! But, then u r a Public relations chappie. Need for a bit of research. And, no! I can not negotiate professional indemnity for you and worse still for me! And, u know the reason why I cannot? As u appear not to know let me tell you: Gov does not negotiate with individuals. Now, find the right body and trying lobbying there and insure the whole profession would back you. Including me. 

Hemant Patel, Community pharmacist

I study history and wild life behaviour for a purpose: to learn and to apply that knowledge to help shape the future. To ignore history is a folly. But, to live in the past is a bigger folly. Anyone who feels we should be compounding or go back to the days where we made the pills and potions is a romantic. It will not happen in this country or anywhere else in the world. Those days are confined to pages of history, documentaries and minds of romantics. The future will require a very different skill set. You will not need a mortar, pestle, spatula or the weighing scales. It will require new knowledge of modern medicines, gene therapy, management of long term conditions and providing urgent care and behaviour change techniques. Computer skills, data set management, using near patient diagnostics and laying hands on patients is the future. Clinical visionaries are seeing 1 million pls vaccinations delivered in community pharmacy this year. They are seeing pharmacists in surgeries and hospital wards. And, they are seeing community pharmacists assessing patients for Atrial fibrillation and referring patients directly to a cardiology dept and getting paid for it. It is true we did not get there as quickly as we could have but then no one said PSNC is a visionary body. Virtually all innovation is local and from enthusiasts as the profession has no vision backed by coordinated practice research and development. 

I will share details of a conference about technologically driven models in due course. I am confident that pharmacy in this country and abroad will become more clinical (in NE London pharmacists are doing clinical work in cardiology, mental health, respiratory and diabetes) and use technology (detection of AF, diabetes, BP etc). Go to the bit starting at 11:47 Https://www.england.nhs.uk/our work/innovation/test=beds/

AF work can be done in every community pharmacy and watch out for the big news in the coming months.

Ask me do to the possible and i certainly will try. I do not run the corporate or independent pharmacies; I have influence in a limited sense at a local level and no control. Each company behaves as it feels fir within the regulated environment and wider societal requirements. We should give complete autonomy with respect to clinical independence to not only pharmacists but all health professionals who should work within their competences. 

I have no idea how to control the behaviours, policies and employment conditions of the corporates and it is not my job either. I refer you to the excellent PDA of which I’m a proud member.

I urge people to consider thinking about what changes we want in our profession  to reposition itself in the refashioned NHS. Dispensing only has a limited future and high streets are seeing closures everyday. Number of pharmacies, GP surgeries will decline and digital solutions will have greater access and use. I will not give false hope of engaging the ‘reverse gear’ or safety in ‘status quo’. Future is uncertain, precarious and with risks. Future is also in some areas clear, offering virgin territory to those who head the warnings and take action, and rewarding. So, for some it will be a ‘wind down and retire time’ and for others a ‘roll up and have a go time’. 

Delectable Skeptic, Community pharmacist

 

"Anyone who feels we should be compounding or go back to the days where we made the pills and potions is a romantic. It will not happen in this country or anywhere else in the world."

Quote from WebMD:

"How many compounding pharmacies are there?

According to the IACP, there are 56,000 community-based pharmacies in the U.S. About half of them directly serve local patients and doctors. Some 7,500 compounding pharmacies specialize in what the IACP calls "advanced compounding services." Some 3,000 of these pharmacies make sterile products. "

I don't think compounding will take off in the UK in the least but wanted to correct your statement regarding the rest of the world.

Hemant Patel, Community pharmacist

Thank you. I stand corrected. I should also say that we have hospital pharmacies which do compounding and of course the specials labs. But, the future is without the compounding skills and soon the undergraduate courses will reflect what i said is the future if they are not doing it already. Technology and clinical pharmacy will engage with behaviour change and new practices will be born.

 

 

John O'Neill, Pharmacy Buyer

How about the foundations of the application of chemical medicines in terms of ANY actual existing validated independent long term effects of many of these substances.

Now science is aware of epigenetic effects this brings a whole new area of potential benefits and dangers to these medicines.

Has this been properly researched? 

Is a 3-10 year lead in time sufficient to suitably assess the potential hazards posed by these compounds?

The whole industry needs to take a long hard look at itself.

We as independent and learned experts in Medicines should consider whether there is long term damage in terms of genetic expression in the long term.

And the above is ignoring the massive hazards that have already been played out in the numerous casualties of COC's, HRT, VIOXX, CELEBREX, CO-PROXAMOL. 

These are the more obvious disaster stories.  There will be more. 

Meanwhile any pharmacist who makes a small mistake can expect to loose their liveleyhood, hopes and dreams.

WAKE UP.

You ARE SLAVES.

Hemant Patel, Community pharmacist

If we liken meds to hardware and knowledge/advice to software it seems to me that value of hardware is measured and value of safety, effectiveness, patient experience, and cost-effectiveness is devalued. Value of Pharmacist input needs to be recognised by the Gov and employers. MURS has not increased in financial value for 12 years so effectively devalued. Tomorrow and everyday after that each pharmacy will let through 0.4 serious errors which harm patients and cause NHS to spend more. NHS must consider creating ‘heat maps’ to identify areas and reward pharmacies for reducing errors. So, I agree safety needs to improve and can be improved with use of pharmacists skills.

Ilove Pharmacy, Non Pharmacist Branch Manager

Come on Hemant, you can't mention MURs in any serious convo about Pharmacy. 

Hemant Patel, Community pharmacist

read my statement again. I was talking about the a fact: decline in monetary value of MUR. Every pharmacist should be engaged in full medication review as the meds expert. MUR service is unsustainable and of limited clinal value. Clinically competent pharmacists should be paid $30 per hour and global sum adjusted accordingly.

Ilove Pharmacy, Non Pharmacist Branch Manager

£30 per hour. My ribs are aching with laughter. For all the hassle, crap and possible prosecution most would prefer to do something else. Many are simple marking time, counting the days.

Amal England, Public Relations

I think it would be much better if every GP surgery had a pharmacist and the MUR and NMS be transferred to the GP practice. The GP would not be paid any extra and it should form part of their existing remuneration package, I understand they get quite enough. The MUR/NMS funding would remain in the global sum.... Maybe it could fund a real and comprehensive minor ailment scheme. Pharmacy can only become stronger with strong leadership fighting for its corner.

Hemant Patel, Community pharmacist

Is this not fanciful thinking? Getting paid for work that counter assistants can do and the real work of a pharmacist is sent to the surgery? This would be funny if it did not have serious implications in the real world of the New cash stricken NHS.

 

 

 

Valentine Trodd, Community pharmacist

>>This would be funny if it did not have serious implications in the real world of the New cash-stricken NHS.

It would indeed have serious implications for the 'cash stricken' NHS. Scrapping MURs and NMS would save them close to £100 million!

Ebers Papyrus, Pharmaceutical Adviser

Community pharmacy over the years has been incredibly resilient and very quick to adapt and deliver. It will of course survive and ultimately thrive again in the future, pharmacy is a winner.

We should also be proud of the healthy competition and service levels delivered through pharmacies, patients certainly recognise it. PSNC and NPA however urgently need to align a structure that gives the profession a clear voice and authority.

 We also need motivation, incentive and direction from those in positions of authority (CPO, DH). This is sadly lacking, it’s worth noting that the barrier to change doesn’t come from Pharmacy just examine : Call to Action; Murray report; CCG directives; BMA rhetoric. When these folks wake up we can move on, until then we’ll keep banging the drum.

Overworked Pharmacist, Community pharmacist

Some good points, and I’ve throughly enjoyed reading all the comments in the thread. There is a future for community pharmacy, but what? We’re all in the dark about what that may be. But as with any industry, margins are lower, and there is a high expectation from the end user of that service. But there is a fine line between healthy competition, delivering an excellent service whilst working under what can be extreme pressure sometimes (especially if you genuinely care about your patients). There is no voice for community pharmacy. Fair enough if we had the same pressures of working in a supermarket delivering a persons weekly shop. But like them, we cannot simply substitute Mrs Johnson’s favourite Granny Smiths apples for Royal Gala if they were out of stock. Stock shortages are very real. So why aren’t patients aware of this nationally? Lives are potentially at risk in this current climate. Yet we’re expected to either source/contact the prescriber/ or let that patient try elsewhere only to be told the same thing. How much time is wasted? Yet still no one seems to raise these questions. Unless you have the resources and man power and genuine compassion and care of the individual patient, this industry will continue to suffer. The government seem to be quite happy for stock to be short, pharmacies to overpay for it when available. Failure to do so, is breach of our contracts yet I hear pharmacists refusing to dispense because they’re at a loss on an item!! This is in my opinion a way of squeezing out all the small item dispensing contractors to panic and sell or close there doors for good, because all the effort involved leaves you on less money than being employed for one of the ‘big boys’ I just wish more people voiced this, and created the government to change the way we’re treated, rather than sat on their hands waiting for a miracle...

Hemant Patel, Community pharmacist

There is a change in the air: the future is going to be locally negotiated and multi-disciplinary. Battles will be fought in the meeting rooms of the STPs and ACOs. What national bodies do (most often reactions) will have marginal influence at best. If community pharmacy does not engage in shaping views of STPs work to redesign care pathways then in that area they will be spun off to the most outer circles of healthcare provision. So, you will need well informed and committed LPCs to have a future. Influence of PSNC and other bodies will be like that of a lone football fan left in the stadium after a 8:0 defeat. Obligatory encouragement.

Ilove Pharmacy, Non Pharmacist Branch Manager

I'm more than happy to inform patients that shortages are engineered by manufacturers for financial gain and to screw extra money out of the NHS. 

Chemical Mistry, Editorial

, To be fair to you aleast you come and interact with the great unwashed that is grassroots pharmacist unlike others, ivory tower academics, fellows and the who one's who say to us we know best just suck it up!.

 

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