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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 1. - WAITING GAME
RADIO 4
TUESDAY 14/12/04 2100-2130
PRESENTER:
MARK PORTER
REPORTER: CLAUDIA HAMMOND
CONTRIBUTORS:
SUE JAMES
MARK FELDMAN
JULIE BEERMAN
MICHAEL CULLEN
CATHY HILL
MONICA DIGNAN
MARCUS LONGLEY
DAVID POWELL
CATHERINE THOMPSON
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about waiting.
Whether you want to see a doctor, consult a physiotherapist, get your teeth checked, have a scan, see a specialist, or get something surgically removed, repaired, or replaced - you are likely to have to wait, sometimes for a surprisingly long time.
But why have waits become part and parcel of NHS treatment? Waiting lists are almost unheard of in countries like France and Germany, yet there are currently 856,000 people waiting for operations in England alone. So is waiting an inevitable price of a free-at-the-point-of-access healthcare system said to be the envy of the rest of the world? Or are NHS patients, just too patient?
I'll be finding out why some of the longest waits are in Wales, and what one concerned father did when faced with a seemingly interminable wait for his daughter to see a specialist.
CLIP
I mean two years in the life of a child is - it's almost meaningless really, I mean so much happens and changes in two years that it's almost like being told you're not going to be seen at all.
PORTER
I'll also be asking what's being done to shorten waits, and finding out what patients can do to help themselves.
My studio guest is Sue James - she's chief executive at Walsall Hospitals NHS Trust.
Sue, are you one of those stern characters that walks onto casualty with a clipboard?
JAMES
Certainly not, no. NHS managers are like other NHS professionals - we all come into the service with a strong set of values about looking after patients. I think we're rather caricatured as people who know the cost of everything and the value of nothing. But that couldn't be further from the truth.
PORTER
And your background - the background of your team is?
JAMES
Well we're a mixture between clinical professionals and management professionals.
PORTER
So doctors and nurses ...
JAMES
Doctors, nurses and then we've got some businessmen on our board and we've also got a finance director, I've also got a background in general management in the NHS.
PORTER
Because it's a multimillion pound business.
JAMES
Oh yes, 拢120 million turnover in my organisation. We employ 3,000 staff.
PORTER
Right let's get to the - back to the waiting lists. Do you think the UK has a waiting list culture?
JAMES
Well I think there is an urban myth that there is a waiting list problem in the NHS. I think probably four or five years ago there definitely was a waiting list problem but because it was something that people were very concerned about the government really focused on getting waiting lists down. Now in fact numbers on waiting lists are almost immaterial - you talked about 800,000 patients earlier on but if actually everybody is seen tomorrow the number on the list is not something that really affects patients, it's the length of time they're on the list that really affects their own experience. And that length of time has dropped dramatically over the last few years. We' now, in my own area in Birmingham and the Black Country for example, only 500 patients at the moment, this week, are waiting more than six months for their surgery.
PORTER
But to be fair six months is a long, long time when you're waiting for something. I mean more importantly you can wait four to six weeks for an outpatient appointment is fairly good and that's still a long time when you're worried.
JAMES
It's a long time but actually a very small proportion of patients wait for six months, the majority of patients are seen much, much earlier than that.
PORTER
Well talk me through what happens to a referral. A patient comes to see me in my general practice, I think they need to see a specialist, for whatever reason, and I fire off a referral letter. Now in my practice that's an electronic referral, it arrives on the consultant's computer or desk that day, why is it three or four weeks sometimes before the patient even gets written back to?
JAMES
Well although the letter will come to - you'll send it to the consultant in fact it won't be the consultant that opens it and deals with it initially. What first happens is that a clerk will open it and they will then start the clock ticking, so they will feed all the information into the hospital computer system ...
PORTER
This is when the official waiting time starts?
JAMES
That's right, that's when the clock starts to tick. So very often a GP, not as organised as you, may well say to the patient yes I'll refer you but actually they've got to write the letter and that's got to be sent through the post etc. etc. But once the letter has been received in the hospital then the patient - the clerk will send all of the letters received that day, and there can be many - many, many - for individual consultants, and the consultant will read them all and decide what the relative priority is. So if he thinks that possibly a GP's done a lot of tests already for a patient and has a pretty clear idea of what the matter is and therefore there's an urgency about it, then he may give that patient a clinically urgent criteria. If on the other hand - again the GP's done some work but it's clear they need routine surgery, so there's not going to be any sort of immediate urgency about being seen, then they'll be given a routine appointment. Then they go back to the appointment's clerk who then allocates them - puts them into the system and in my hospital patients are then written to and told that they will - we'll be contacting them within four weeks of their appointment time to agree a time and date with them.
PORTER
So at least they know that everything's been processed.
JAMES
Indeed. If I was going to my hairdresser I wouldn't want my hairdresser to write to me and say you will come and have your hair done at 12 o'clock ...
PORTER
Next Thursday.
JAMES
Next Thursday - exactly. So what we're trying to do now is to say to people your appointment will be in the next couple of weeks, we'll ring you, make sure you still want to come and find a date and a time that's convenient for you.
PORTER
Now just quickly run through the targets because you've actually got targets that you have to meet on this.
JAMES
We do. There are national targets and there are local targets. As I say in Birmingham and the Black Country the local targets are actually more ambitious than the national targets. At the moment no patient should wait more than nine months for inpatient or day case surgery and more than 17 weeks for outpatients' appointment. Whereas in Birmingham and the Black Country we have no patients waiting more than six months, or at least that's what we're aiming to have.
PORTER
Just clarify this - if someone - is the maximum wait for nine months for surgery, so say I needed a new hip, the one everyone always talks about, I shouldn't have to wait anymore than nine months, is that from when my GP sends that referral letter, when the clock starts ticking?
JAMES
No there are two clocks at the moment. The first clock is for outpatients and the second clock is for inpatients.
PORTER
So the nine months is after the consultant has put me on the waiting list?
JAMES
Once the consultant has seen you and done all the tests and said yes this patient needs a hip replacement, he then makes a decision to admit and it's from that day that your operation or the timing is worked out.
PORTER
Well thank you for now Sue.
Well all journeys must start with a single step, and in the case of the waiting list, that first step is to get in and see your GP - which in itself often involves a wait. Dr Mark Feldman who works in Harold Hill in Essex has come up with simple but elegant solution, and one that allows him to see up to 20 patients an hour.
FELDMAN
Over the years that I've been here, which is about 20, I think patient demand has grown and grown and we would often find that we were seeing perhaps 20 unbooked patients in every surgery. At one stage we employed locums to do extra appointments and at the end of the year, having spent a considerable amount of money, we still had as long a wait to be seen as we did at the beginning and that was really most depressing. So we thought we had to do something quite radical. Finally I read an article - I have to confess, I'd love to say this was my idea but it wasn't, I can't even attribute the article because I can't remember who wrote it - but there was a wonderful article suggesting a three minute appointment and this is what we introduced into our surgery.
ACTUALITY - SURGERY
Good morning Julie. Come and take a seat. Here will be lovely, thank you. Okay what can we do for your today? This is a three minute appointment, Doctor will be joining us shortly.
Okay, it's just I've been having an ear - a really bad ear for the last couple of days.
Okay, so what ear are we talking about - your right ear?
Right ear.
FELDMAN
The way it works is during that appointment a doctor works between two rooms, with a nurse in each room, the nurse sees the patient, takes the history, and then the doctor comes in, checks everything's okay, problem solves and is gone. During that time a nurse in the other room has done exactly the same thing and a fresh patient is waiting. And in this way we can see 20 patients in an hour.
ACTUALITY - SURGERY
No sore throat either?
Nothing no.
No, good okay. This is Dr Feldman. Painful right ear, no discharge, left ear absolutely fine, no cough cold present. I've just noticed that her blood pressure hasn't been done for a few months and that she does in fact feel slightly giddy at times.
Okay if you could just check the blood pressure. Which is the one that's hurting?
The right one.
I'll just a have quick look. Ah yes and let's have a look at the other one if I may and if I can just look in your mouth as well - wide and stick your tongue out, that's lovely. No coughs or anything like that?
Nothing.
No, no cough and cold present.
Just worried because I'm going - I'm flying in a couple of weeks and I just wondered if I need it sorted before then.
It is a bit inflamed, you've got quite a nasty infection there, I think it might be best to give you a course of antibiotics. Are you allergic to anything at all?
No.
Okay, right I'll give you some tablets, if you could just take one three times a day and I'm sure that will settle it down for you. If before you're flying you still have any pain then we might give you some nose drops as well to clear that but I'm sure it'll be - when are you flying exactly?
Just after Christmas.
Oh I think you'll be fine by then. Okay.
Blood pressure dropped to 125 over 80.
FELDMAN
Patients have an option - you can either book an ordinary 10 minute appointment or if you've got one single simple problem only you can opt for a three minute appointment. Now the beauty of this is that three minute appointments are always available on the day.
PORTER
Julie Beerman is one of the healthcare assistants helping Dr Feldman.
BEERMAN
It's the patients that have been here a long time and the elderly patients - they're the ones that are a little bit - can't quite get used to the fact they come in with the one complaint. But we accept that and we're quite used to that, if we can we'll obviously deal with a couple of things but 90% of the patients know - they know and they're made I think - I do believe when they ring reception they're asked if it's a one complaint and so they can be put on to the three minute list.
VOX POPS OF PATIENTS
Well I usually sort of see the nurse I think, she sort of takes all your details and then the doctor comes in and just sort of sees what you want. I need sort of blood pressure check for myself, that's all, but it seems to work quite well.
Oh well you can say more obviously when you have an ordinary appointment but when you have the three minutes you're really cut down, right to the base - it's what you want. And sometimes you come out and you feel that you haven't really said what you wanted to say. But with this three minute I've got at the moment it suits me because it's just an ongoing thing now that [indistinct words], so it's just something I wanted the results for. So that is alright I think but if you are ill and want to ask then three minutes I don't think - but the three minutes do come in handy because you can get in quick.
I only want to query about some pills I take for my TIAs I had last year, they're all going to run out at Christmas time, so the slot of three minutes is just a quick appointment, go in and out I come, that's all. Just a general - anything longer I normally take the 10 minutes.
PORTER
Some of Dr Mark Feldman's patients waiting for their three minute slot with the doc. And if any of my patients are listening don't be surprised if a similar scheme appears soon at a surgery near you.
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing waiting with hospital chief executive Sue James.
Sue, do patients in your area have access to waiting times - do they know how long they're likely to wait?
JAMES
They tend to discuss that with their GPs and the GPs have access to that information. And if a patient actually asks us we can give them information like that.
PORTER
Because we often have information that says how long you're going to wait to see the specialist but we don't know how long you might have to wait thereafter for your cataract or hip - that can be a bit tricky sometimes.
JAMES
Usually our specialists, when they're saying to a patient that they're going to need an operation, will tell them how long they're going to - the maximum that they can expect to wait.
PORTER
Now there is one fly in the ointment seems to rear its head a lot - it's if somebody goes to see the specialist and they need further investigations, typically a scan, typically an MRI scan - these complex scans of which there are very long waits, I think waiting lists can be more than a year in something like 1 in 12 trusts around the country and are more than four months in 1 in 3. It's no good having quick times to get to see the specialist and quick operating times if you have to then disappear off for 12 months in order to go and have a scan.
JAMES
No I think that has always been a bit of a flaw in the way in which we've been sort of judged in terms of our waiting times in the past. But the government has picked that up and as from 2008 the target will be from the day the GP refers you to the day you start your treatment, which includes your outpatient appointment and any diagnostic tests, then the maximum wait will be for 18 weeks. So it's very, very much telescoped.
PORTER
And one of the problems presumably with the MRI scan is that it's a relatively new piece of equipment, it's very expensive and there's a resource issue - there just simply aren't enough of them around.
JAMES
Yes that's the main problem. We're also - it's not just the MRI scanners, it's the staff who are trained to use them and the consultants who are trained to read the results of them. We've increased the numbers dramatically over the last two or three years but I think we're still on the upward curve...
PORTER
I was about to say you're going need to if you're going to meet that new 2008 target.
JAMES
Absolutely yeah.
PORTER
What about cancellations? If I get a phone call to say that yes you can come in now and have your cataract done, you can come in now and have your MRI scan done and it's 10 days away and I happen to be away and it's not convenient. I've had some complaints from patients who said well I said I can't make it and they say - well if you don't turn up you'll be at the bottom of the list again.
JAMES
I think that is the old approach. As I said earlier what we're trying to do nowadays is to book an appointment that's convenient for patients. We can't just say come on Christmas Eve and if you don't come on Christmas Eve we'll put you to the bottom of the list. We try and negotiate a time that's appropriate for people. But obviously there is only so much play in the system and if people - if we offer two or three dates and none of them are convenient then they will go to the bottom of the list.
PORTER
What about paying for scans privately - what happens if I have a problem with my knee, the orthopaedic surgeon wants to see the MRI result before he operates but it's a nine month wait on the NHS list, can I go and have it done privately and then come back into the system?
JAMES
Yes you can. We do actually arrange for the two systems to work in parallel with each other.
PORTER
Well one common bone of contention among patients that I have referred to hospital is how long they have to wait in outpatients to see the specialist. An experience that the Queen Elizabeth Hospital in Birmingham is hoping to improve using an unusual approach. The QEH actually has a good track record on waiting times but, if patients need lots of tests, some hanging around is going to be inevitable. So, does employing musicians to play live in the waiting room help? Claudia Hammond went along to find out.
BRIAN THOMPSON
A period of two hours feeling terrible you know because one's waiting and I think you are really concerned well what's going to happen, what's the doctor going to say?
NOOR THOMPSON
We've been here till 6 o'clock some nights, haven't we, waiting and you just sit and the time - and you read a paper and you do the crosswords and you come to the point that you think oh just so weary.
HAMMOND
Brian Thompson and his wife Noor arrived at the cancer unit in the morning to be told they would have to wait for an extra two hours, but they also found something rather different going on in the waiting room ...
MUSIC
The idea of incorporating the arts into the cancer centre came from Michael Cullen,
consultant medical oncologist.
CULLEN
When the musicians are here we get a lot of comments - very positive comments from patients and we do also get very positive comments from the staff.
HAMMOND
What sort of music do they play?
CULLEN
All sorts - serious classical music, to Moon River and all that kind of stuff. So we had little old ladies coming in here with tears in their eyes saying how lovely it was.
MUSIC
POWELL
I'm thrilled with the idea that us musicians go out into the community and actually affect the communities in which we live and work.
HAMMOND
Cellist David Powell has come from the City of Birmingham Symphony orchestra to perform with harpist Catherine Thompson.
POWELL
I didn't quite know how it was going to work in a waiting room of the oncology department but this is such a beautiful setting - this place - with the sort of glass roof and there's space - isn't there - for the sound to disappear and for people to chat or just let it mull around them.
CATHERINE THOMPSON
We've got quite a wide range of music and we tend to play all of it actually but just tone it down - play the loud bits quieter and play the faster bits slightly slower. And people seem to enjoy kind of the lively music and the slow music because you don't want to play slow music all of the time. So we just play anything actually. They clap and they applaud, which is really nice, so that you know they're listening actually and they look as if they really enjoy themselves and then it's really lovely at the end of a session when they come up and have a talk - you know chat to us. We do requests and everything and people do come up and ask, which is always quite nice. Well today a lady asked from some Schubert, we played something called Edelweiss from the Sound of Music, it could be absolutely anything.
MUSIC
BRIAN THOMPSON
To have this, it's tremendous, we don't mind how long we wait now.
NOOR THOMPSON
In fact we're hoping now we're not going to be called until 4 o'clock [LAUGHTER] - we don't mind waiting, it's unbelievable, just to sit and listen to this is just wonderful and to watch the musicians.
HAMMOND
You were sitting where you can get quite a good view of them, it's nice isn't it because you can be so near.
BRIAN THOMPSON
We moved across in fact in order to be in a better position to listen to and to see the musicians. My congratulations to whoever arranged it. I can't say how much - how different it is, I mean before I could read but now for various reasons I can't read quite properly.
HAMMOND
I sort of hope they don't call you yet.
MUSIC
CULLEN
Patients of course can't choose not to come here, it's not really a voluntary experience. Here patients are here because they're seriously ill and they have to be here for their treatment, so we have to take this very much into account when selecting the sort of artistic experience and programme that we offer to patients.
HAMMOND
Now some people might argue that although it's all very nice it might be more important to spend money on treatments or seeing people faster and things like that.
CULLEN
Right from the very start of this whole programme a few years ago we were very clear that any money that we spent on the arts programme was money that was identified purely for the arts programme, so we have money from the Arts Council, which you can't spend Arts Council money on chemotherapy drugs or radiotherapy machines or nurses, it has to be spent on art. We have had right at the start some comments from staff who under a misunderstanding believed that we would be using NHS money for the arts programme. But once one had resolved that we've not had any complaints since, in fact quite the opposite.
HILL
I was a bit sceptical actually when it was first suggested, I wasn't sure a. what the patients would think, you worry about things like is it going to be too loud, is it going to interfere with the clinic, are the consultants going to get cross because they can't hear what's going on.
HAMMOND
The sister in outpatients, Cathy Hill and auxiliary nurse Monica Dignan both look forward to the days the musicians play.
HILL
It chills them out listening to it, they get talking, they come into the clinic, they're much less stressed I think and we have people come from other departments and have a crafty listen for 5 or 10 minutes, so word gets around and they come and join us.
DIGNAN
We have some of the older generation, they'll get up and have a dance, they'll have a little bit of a waltz or whatever music we've got on at the time, they enjoy it.
NOOR THOMPSON
Sometimes the anticipation is worse than the actual sort of realisation of the treatment you're going to have. I mean we've had this now for four years and it doesn't get easier, you don't sort of get blas茅 about it, you think oh what are we going to again. But it's just been superb this morning, in fact I was just saying I think you said they were going to do it about every month or something, I said how are we going to get them to fit the treatment in [LAUGHTER]...
MUSIC [CLAPPING]
PORTER
Brian and Noor talking to Claudia Hammond. Live music has also been used in the waiting room of a high risk ante-natal unit at the Chelsea and Westminster Hospital where researchers found that it significantly lowered women's blood pressure - a benefit, interestingly, not shared by the piped version, which women tended to treat as background noise and ignored after 10 minutes. So there you go.
Sue, initiatives like that obviously improve the waiting experience but we wouldn't need them if waits in outpatient departments weren't so long. It's a problem I think we've got around in general practice - my patients would lynch me if I ran a couple of hours late - and then I get a bit worried myself if I'm running more than 15 minutes late. Why is there a problem in hospital?
JAMES
I think again this is a perception that there certainly used to be a problem in hospital and it used to be largely around the fact that patients were batched booked, so ...
PORTER
Which they never knew about did they?
JAMES
No you think you've got there at the appointment at 2 o'clock but so do the other 15 who've also got an appointment at 2 o'clock. Now we don't do that, we give everybody an individual appointment. Things can still go wrong, we make assumptions about the numbers of doctors who are in an outpatient clinic and with all the changes in the way which junior doctors work those assumptions are not always easy to fulfil. So sometimes if clinics are running with a doctor down but the numbers are still the same then people can wait.
PORTER
But it's a priority for you to give appointments on an individual basis so you will get quarter past two, you will be the only one at quarter past two.
JAMES
That's right yes.
PORTER
And it's important to you that people are seen quickly.
JAMES
It's ...
PORTER
Do you monitor that in some way?
JAMES
We do and - I mean there's two ways of doing that, we every so often sample the clinics to see how long they're going but for me a more important way of monitoring it is to actually pick up the numbers of complaints we have and they've tailed off dramatically over the last few years.
PORTER
What about people who don't turn up - because it's a problem in general practice, is it a problem in the hospital too?
JAMES
Oh a huge problem, yes. About 10% of our patients just fail to turn up. One in every 10 appointments is a wasted appointment. We try and deal with that, as I said earlier, by giving people the option of choosing when they're coming to clinic and we're hoping that that's going to change the approach but actually there's no evidence of it changing it yet sadly.
PORTER
But if you can't make it for heaven's sake please ring up.
JAMES
Please do let us know, yeah.
PORTER
Well, one sure fire way to shorten waiting times is to go down the private medical route - something Marcus Longley - who's associate director of the Welsh Institute for Health and Social Care at the University of Glamorgan - thought he would never do.
Ever since devolution, NHS services in Wales have been autonomous and the total annual spend is now 13% higher per head of population than in England. Sadly more money has not meant shorter waits, as Marcus discovered when his daughter needed to see a specialist and had to join the back of a very long queue.
LONGLEY
There are in Wales now about 8,000 people waiting more than 12 months to get into hospital or about 7,000 waiting to see an outpatient consultant for more than 18 months. And those figures - well there are no figures really for England because they've stopped having to count that long because nobody waits that long in England anymore. So the situation on waiting times in Wales is quite poor, although getting better it has to be said now.
PORTER
Why has it been such a problem in Wales?
LONGLEY
I think because for a while Wales took a slightly different attitude. Following devolution the Labour administration came in and said what we're concerned primarily about is the health of the population of Wales and not about statistics like waiting times. So a lot of attention was given to health promotion and building healthy communities and so on - all good stuff but that shifted people's focus off waiting lists. And they continued to rise at a time when in England the Health Secretary, Alan Millburn, was taking a much, much more proactive and tough line and they started to fall in England, whereas in Wales for two or three years they continued to rise until finally the pressure became too much and the politicians finally started to take it seriously.
PORTER
Of course people can vote with their own feet and I know that you yourself fed up with the long waiting lists in Wales decided to go private, to take a short cut, before - I think it was your daughter wasn't it?
LONGLEY
There was a particular drug really that it had come down to was the only way forward and that can only be prescribed and monitored by consultants. So we were referred to hospital and two or three weeks after the referral I phoned up to see what was happening and was told oh yes she's on the waiting list it'll be at least two years, sorry mate put up with it.
PORTER
So what was your - did you decide then immediately that that was unacceptable and you would go privately or did you try and bring forward the appointment within the NHS?
LONGLEY
I tried to bring forward the appointment in the NHS and the procedure was the consultant looked again at the letter to re-evaluate its urgency and within a fairly short period of time the answer came back - no he's looked at again and I'm sorry but it's not a life threatening case and therefore your position on the waiting list remains where it was.
PORTER
Did you have an ethical dilemma deciding to go privately or was that the obvious next course of action?
LONGLEY
For me it was a very difficult decision, I've never been involved in private medicine at all in the past and to me it's something of an anathema really, it seems almost a contradiction of what the health service is all about and the sort of civilised values that that encompasses. But when faced with your own child in that situation it was an acute dilemma but for me there was only really one thing I can do, I had to put the interests of my child, as I saw them, first. I could afford it and therefore decided that that's what I had to do.
PORTER
So you'd been given a two year wait on the NHS, how quickly was she seen privately?
LONGLEY
Two weeks and it would actually have been earlier but the consultant was on holiday that week, so potentially it could have been two or three days really but it was actually two weeks.
PORTER
Did you feel guilty about jumping the queue?
LONGLEY
Yes I did. Not so much when we're in the private consultation with the consultant because you can forget about that sort of thing but it came home to me when a few days later we had to go to the GP's surgery to collect the results of a blood test. And walking into the waiting room and seeing maybe a dozen or so people sat in the waiting room waiting patiently and I couldn't help wondering how many of these people actually are waiting to see - not to see the GP but to see a consultant because they simply can't afford it. And that just I find deeply offensive that people should be discriminated against on something as profound as their health on the basis of do they have a few hundred quid spare cash to pay for it.
PORTER
Marcus Longley, talking to me earlier from our studio in Cardiff.
Sue, is there anything else patients can do, other than go private, to reduce the length of time that they wait?
JAMES
Yes they can talk to their GPs about other consultants who may have a shorter time and ask to be referred to them. They can actually tell the hospital when they're on a waiting list that they're prepared to come in on short notice, so that they - if a vacancy comes up they can use it straightaway. Most patients want to be treated locally, they know how to get to the hospital and their relatives can visit them at the hospital, in fact we found that recently we had 25 operations that had been bought in another hospital which we could actually offer to patients much earlier than we could offer them in our own hospital ...
PORTER
To get your waiting list down.
JAMES
To get our waiting list down, we had to ask 150 patients before we'd find 25 who were prepared to travel.
PORTER
So people are prepared to wait to get the treatment in their local hospital.
JAMES
They are indeed yes.
PORTER
That's all we have time for - Sue James thank you very much. Next week's programme looks at female urinary incontinence - I'll be finding out if the world's first pill for stress incontinence is as good as it sounds.
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