RPP 18 3 Mark Lymbery Evaluation: the lost dimension of community care

Research Policy and Planning: The journal of the Social Services Research Group – Vol 18 (3) 2000

Evaluation: the lost dimension of community care

Mark Lymbery, BA MA MPhil CQSW and lan Shaw BA DPhil, Lecturer in Social Work and Lecturer in Social Policy, University of Nottingham

Abstract

This paper argues that the evaluation of service quality represents a lost dimension of community care. The Conservative government directed attention to the 3 Es ‘within public services, which led to a managerialist domination of the evaluation agenda where financial considerations took the highest priority. Although the rhetoric of the ‘new’ Labour government has changed, the ‘Best Value’ regime continues to emphasise the importance of the 3 Es’. This is linked to the more general development of managerialism within social policy since the 1980s, and to increased central control over local government. It has coincided with a period where the status and authority of the caring professions has weakened, which has given managers the opportunity to define what is meant by quality in service provision. It is argued that this creates detrimental effects in three ways: by decontextualising evaluation, by linking evaluation and funding too closely together, and by ignoring the perspectives of service users. The paper concludes that it is necessary to change the focus of valuation so that the context of community care and the views of service users and professionals become integral to the process, and suggests how this could be developed.

Key Words: evaluation, community care, social services

Introduction

Recent years have seen increased governmental concern over expenditure in the public sector. In the case of community care, the inadequacy of health and social care budgets has become evident (Neate, 1996). A key mechanism by which government has been able to maintain the illusion that funding levels are adequate has been through the wholesale adoption of the ‘3 Es’ – Economy, Efficiency and Effectiveness – which has ensured that social services departments (SSDs) have become adept at providing more for less (Butcher, 1995).

While the ‘3 Es’ were particularly associated with the Conservative government’s approach to public services, they remain influential within the ‘Best Value’ regime introduced by the Labour government in 1998 (DETR, 1998), even though this was heralded as a decisive break with the past. For example, ‘Best Value’ is defined as being the ‘… duty to deliver services to clear standards – covering both cost and quality – by the most effective, economic and efficient, means available’ (DETR, 1998 para. 7.2:64 -emphasis added). Although ‘Best Value’ also encompasses a focus on quality and fair access (Boyne, 1999), the ‘3 Es’ still form a dominant part of its processes, not least because issues like efficiency and economy are more easily measurable than quality. For this reason, it is still relevant to consider the impact of the ‘3 Es’ within social welfare.

Economy involves a judgement about how actual costs compare with planned or estimated costs. Efficiency means the reduction of the unit cost required to produce a service. Effectiveness refers to the extent to which the stated aims and objectives were actually achieved. This paper argues that the absence of a fourth ‘E’- evaluation of service quality -fatally compromises the ability of SSDs to meet the community care needs of the population successfully and therefore constitutes the lost dimension of community care.

Evaluation in Community Care

There has been a recent boom in academic interest in evaluation for social care (see, for example, Cheetham et al., 1992; Phillips et al., 1994; Everitt and Hardiker, 1996; Shaw and Lishman, 1999). This is driven by the need for social services organisations to be able to demonstrate the effectiveness of the work they carry out, in response to the increased levels of scrutiny and audit to which they are subjected (Everitt, 1998). In addition, the development of a ‘consumerist ideology’ (Sheppard, 1995) has ensured that the accountability of service providers to ‘consumers’ has also been enhanced, at least at the theoretical level. However, since fiscal accountability and accountability to service users are not necessarily compatible it is difficult to establish agreed criteria for evaluation.

The term evaluation has often been presumed to have strong scientific connotations and has consequently been defined as being concerned with establishing cause and effect (Phillips et al., 1994). By comparison, other writers have argued that evaluation is centrally concerned with establishing the merit of a project (Everitt and Hardiker, 1996). Either position raises difficult questions. How are the objectives of programmes defined? Who defines them? Who defines merit? If there are competing definitions, which one takes precedence? It would obviously be incorrect to assert that social services have never been evaluated. However, we would argue that evaluations have tended to focus on the measurement of performance (Adams, 1998), which has left issues relating to the appropriateness and quality of care services substantially unresolved.

Quality

Service quality has long been an important aspect of community care, but there are competing understandings about how the term should be understood. Current meanings derive largely from the private market, where the establishment of quality standards should be achieved by reference to the consumer’s wants and needs. A simplified example of the operations of the private sector will illustrate this point. Consumer satisfaction in the market place can be easily manipulated. If the expectations of a service are high and the perceived quality of that service is moderate then consumer satisfaction will be low. On the other hand if expectations are low then a moderate quality of service may result in high levels of consumer satisfaction. One can attribute some of the perceived public failings of community care to the extent to which it has not met the raised public expectations that accompanied its passage into policy. In addition, the characterisation of service users as ‘consumers’ is inappropriate for public services generally, and community care more specifically (Ranson and Stewart, 1994; Farnham and Horton, 1996).

There are other ways in which the operations of the private sector do not readily translate into community care. For example, in a market the availability of a high quality service will tend to increase demand for that service; in turn, this should increase the profits for the company providing that service. There is a clear link between demand, supply and profit. In the public sector, if a high quality of service were to lead to an increased demand for that service this would create a pressure upon public finances, which would be likely to result in a reduction of quality as demand outstrips resources. In community care, therefore, service quality must be discussed within a context of resource limitations.

A key issue is that in a genuine market the consumer has a direct relationship with the goods available, and has a choice about what to purchase with her/his money. In community care, as Le Grand and Bartlett (1993) have recognised, such conditions do not apply for many service users. As the lead agencies in community care, SSDs mediate between the consumer and services and a range of factors, including the availability of public funds, limits free consumer choice. However, the passage of the Direct Payments Act in 1996 provided an opportunity to extend service users’ control over the services they receive, and reversed a long-established policy whereby such payments were prohibited (Mandelstam, 1999). However, relatively few service users have been able to access direct payments, which have been restricted to adults with disabilities under the age of 65. The government is encouraging SSDs to expand the uptake of direct payments, and intends to extend the scheme so that it will apply to those people over 65 (DoH, 1998). While direct payments are intended to give service users more control over their lives and the services they receive, they also confer additional responsibilities on them -notably in respect of recruiting and employing personal assistants (McDonald, 1999), and also in terms of monitoring the quality of their service.

Within the public sector there are differences of view about what constitutes service quality, and the significance and meaning of the term is affected by the context within which it is applied (Adams, 1998). For example, given the competing priorities at play within community care, it is reasonable to assume that there will be differences in interpretation between managers and service users. Managers are likely to be primarily concerned with the overarching financial priority of budgetary management, while service users are more interested in the process of service delivery and the extent to which services meet needs. A managerially driven focus on evaluation within the context of the ‘3 Es’ could serve to hide a reduction in service quality brought about by resource constraints.

Resources and Community Care

The 1989 White Paper Caring for People set out the government’s intentions for community care (DoH, 1989). It has been argued that the government would not have embarked on the reforms had there not been an overriding need to control the expenditure on independent sector residential and nursing home care, which was paid directly by the Department of Social Security (Lewis and Glennerster, 1996). This goal could not be met unless the sums transferred to SSDs were less than the current and projected level of social security expenditure.

However, the need for care services is increasing rather than decreasing. SSDs have had to give particular attention to ways in which they can ration services in order to manage their budgets, resulting in the increasingly stringent nature of the ‘eligibility criteria’ which limit the needs which the SSD intends to meet (DoH/SSI, 1991). There has been a process of ‘cost-shunting’ from health to social services throughout the 1990s, which has affected the ability of SSDs to manage their resources effectively. As the health service has disinvested in long-term care, SSDs are expected to meet needs that had previously been defined as requiring a response by health services. Because social services attract charges, this also means a transfer of more financial responsibility onto service users and their families (Means and Smith, 1998).

While welfare provision has always been characterised by some element of rationing, there is little doubt that community care has forced SSDs to think explicitly in terms of the targeting of services on those with highest ne s. in addition, the -has-beenpressure to expand the scope of services that attract charges and to increase the scale of such charges (McDonald, 1999). There are several key effects of this:

the manipulation of eligibility criteria means that each SSD has considerable flexibility to define which needs it will (and, by extension, will not) meet. Service users have relatively little legal power to contest this (Mandelstam, 1999);

the inadequacy of resources limits the scope of what SSDs will pay for, leading to priority being given to those service deemed essential to continuing safety in the home (Kestenbaum, 1999) with a consequent reduction in the low level support so valued by service users (Clark et al., 1998);

any reduction in such support, although it depends on the adequacy of funding (which is largely out of its control), is held to be the responsibility of the SSID. Any blame that attaches to rationing decisions accrues to the SSD, with the role of central government in this process effectively denied;

the overall impact of this on professionals is damaging for morale, as they question the purpose of highlighting needs that there is little possibility of funding.

It is largely for budgetary reasons that the National Health Service and Community Care Act, 1990 contained little that was prescriptive. For example, the government did not want to establish central criteria for service eligibility as this would have created an obligation for SSDs to have sufficient resources to carry out their requirements. Therefore, while SSDs have the duty to assess the needs of people who may require community care services, it is up to each SSD to define what level of need calls for an assessment, and what level and type of service – if any – may be subsequently provided (Mandelstam, 1999). Due to the lack of detail in the Act concerning how this duty -amongst many others – was to be managed, -recent years have seen a deluge of government guidance explaining the minutiae of implementation (Lewis and Glennerster, 1996). The legal status of this guidance is uncertain; even if it does not contain legally binding obligations it represents evidence of the general intentions of government and will be used in cases of dispute. However, courts can and do disagree about the precise legal import of guidance (Mandelstam, 1999). While this appears to give considerable flexibility to SSDs, such an interpretation ignores the extent to which the guidance represents a form of centralised control.

The Rise of Managerialism …

Pollitt has defined managerialism as a ‘…set of beliefs and practices … that better management will provide an effective solvent to wide range of social and economic ills’ (Poilitt, 1993:3). The growth of managerialism is testimony to the impact of the political New Right, associated particularly with the Thatcher administrations (Lawson, 1993; Pollitt, 1993) and represents a preference for the ‘rationality’ of managerial processes over professional decision-making. Ciarke and Newman (1997) argue that managerialism became the ideological force to bring about a transformation in public services from the supposed inefficiencies of the past to a more flexible and responsive organisational form of the future. There was an assumption that the more state welfare was forced into a private sector mould, the more efficient its organisations would become (Clarke, 1998), and the more they would be ‘… customer-d riven, flexible, quality-oriented and responsive’ (Clarke and Newman, 1997:38). It is interesting that the development of ‘Best Value’ by the Labour government includes a parallel managerialist invocation to replace the outdated ‘old’ culture and framework of local authority services with the ‘new’ (see DETR, 1998).

Community care gave a significant boost to managerialism in SSDs. The Conservative government used the legislation to introduce some key elements of New Right theory into the welfare state. This included a preference for private sector managerial approaches and ‘the 3-Es’, a consumerist perspective, a belief in the benefits of competition and the social care market, and an underlying mistrust of public service professions (Lawson, 1993; Sheppard, 1995). As a result, the priorities for SSDs have become more financially driven.

Although the Labour government is seeking to develop a new agenda for social services, (DoH, 1998), they are doing this in the context of maintaining previous spending levels (Balloch, 1998; Burchardt and Hills, 1999); this limits both the extent and pace of change. However, consistent themes are emerging. The government is emphasising partnership, prevention, the promotion of independence and the need to develop rehabilitative services (DoH, 1998), which places continued stress on the need for effective management within SSDs. It also has implications for the role and functions of professionals within those organisations.

… and the Fall of Professionalism?

The extent to which caring occupations can be classified as professions has long been contested. Johnson (1972) has argued that social work is ‘state-mediated’, and that external conditions effectively deny it a full measure of ‘occupational control’. Building on this perception, Parry and Parry (1979) have argued that social work is a ‘bureau-profession’, holding the elements of autonomous professionalism and bureaucratic hierarchies in balance. The implementation of community care – and the development of care management in particular – has arguably involved a shift of this balance, increasing managerial control of practice and hence decreasing professional control (Sheppard, 1995; Sturges,1996; Harris, 1998; Lymbery, 1998).

However, this is a more complex debate than the above summary would indicate. Most social services managers are themselves trained as social workers, and there is no necessary disjunction between the ‘professional’ values of social workers and their managers. However, many managers have willingly accepted the role of ‘technicians of transformation’ (May, 1994) within community care; in effect, therefore, managers are developing a revised conception of ‘professionalism’ which extends and transforms their own identity (Pahl, 1994). This creates a conflict between two versions of professionalism, as Pahl’s research makes clear; those people who have a responsibility for shaping and managing community care policy are more enthusiastic about the changes and their own roles within them than those people who carry out the policies. Due to the ideological force of managerialism, managers have been able to capture and control the activities of professionals (Harris, 1998).

The Impact of Quality Assurance

One of the mechanisms for limiting the role of professionals in determining service quality is in the use of performance measurement. Some writers (see Temple and Brereton, 1999) have argued that the development of explicit performance measurement tools has brought about improvements in service quality and a more flexible approach to the meeting of need. However, as Sanderson (1998) argues, the growth of performance measurement within the public sector is based on a mistrust of concepts such as ‘professionalism’ and ‘public service’, and represents a direct challenge to both. As a result, it should be regarded with some caution.

Various writers (Walsh, 1995; Boyne, 1999) have noted the distorting effects of performance measures, as organisations have to accommodate these priorities over any that they may develop independently. It is also argued that they oversimplify complex problems, have little impact on the quality of life of service users and tend to focus only on those elements that can be easily measured (Sanderson, 1998). Of parallel concern is the way in which the measures are being used to regulate local authorities. For example, when the results of the first performance assessment process were published many senior officers of SSDs were appalled at the element of ‘naming and shaming’ that underpinned the government’s response (Community Care, 1999). They also suggested that much of the data was one-dimensional and of insufficient quality to justify the sweeping judgements that resulted. In some instances the information was misinterpreted by the media, compounding the problems of SSDs (Railton, 1999).

Performance measurement can be used to control professional activity and can therefore have serious consequences for professional groups. Various writers (Parton, 1994; Everitt, 1996) have focussed upon the ways in which managerialist evaluation has become an integral part of the control of professional practice across welfare organisations. Managers have therefore become the primary definers of good quality in service delivery. The professional values of quality of practice and service are in decline, as noted by Lipsky (1992), who remarked that these values constitute the last bastion of welfare ideals, and are a clear expression of the public service ethic (Farnharn and Horton, 1996). Lipsky also argued that increased managerial control of professional practice, when combined with high workloads and limited resources, would lead to a reduction in service quality as professionals struggled to reconcile their practice standards with the performance measures imposed upon them.

Reasons to be Anxious …

These changes give rise to three major issues when examining the development of evaluation within community care:

the context within which evaluation takes place;

the purposes to which evaluation can be put;

the process of evaluation.

The context within which community care evaluation is carried out is critical. Community care is being driven by budgetary priorities, and there are great inequalities in the distribution of scarce resources. The managerialist dominance serves to transform the essentially political question of resource allocation into an administrative concern with how best to manage the reduced budget. The assumption that community care can be evaluated outside of its political context serves to decontextualise and depoliticise it, with the end result being the unquestioning acceptance of practice as though it existed within a policy and social vacuum (Everitt, 1996). The caring professions should attempt to enable service users develop a greater understanding of the impact of social and economic policies on their lives. It is therefore vital for evaluation to focus on the extent to which community care policies affect the levels of social inequality experienced by service users. Managerially controlled evaluation would not provide an opportunity to learn about the discriminatory effects of social and economic policies, and may serve to preserve the status quo by denying the existence of the social and economic forces that shape community care.

Another consequence of the managerialist dominance of evaluation can be seen in the uses to which it can be put. For example, when establishing Citizens’ Charter targets for community care, local authorities needed to take several factors into consideration. The first is that the local authority may simply have avoided setting targets – in this way it could not easily be accused of missing them! For example, one Community Care Charter contains only a single item to which a timescale is attached (Nottinghamshire County Council, 1996). The second is that working practices may be amended to give an impression that the target is being met, even though services may be inadequate; the primary importance is more to claim success than it is for services actually to be more successful. In view of the governmental response to the publication of performance assessment data this approach can be understood, if not justified. The linking of success to continued funding compounds this problem; in circumstances where funding for a project may be reduced by reports of apparent failure, it is almost inevitable that any internal evaluation of that project will concentrate on its strengths rather than its weaknesses.

The third issue concerns the general process of evaluation, and specifically the role of service users. In one sense, service users can be considered as ‘stakeholders’ (Smith and Cantley, 1985; Powell and Goddard, 1996) whose needs and wishes have to be accommodated to some extent. However, it should also be recognised that service users’ struggle for greater control over their services is connected with their wider aspirations to participate more fully within society. It is tempting for managerialist versions of evaluation to negate the perspectives of user groups and to carry on hearing the views of unpoliticised, preferred individuals, in the interests of maintaining a ‘balance’of perspectives (Barnes et al., 1996). One of the key consequences of this is to concentrate maximum decision-making power with those managers who are responsible for the service, so that they can ensure in advance the ‘acceptability’ of the views of people who are consulted. However, the development of active social movements (Taylor, 1993) has increased both the visibility and selfconfidence of a range of service user groups. This makes it much more difficult for them to be sidelined, simply because they are no longer prepared to accept such marginalisation. However, they remain in a relatively weak structural position, particularly when compared with the organisations with which they interact (Croft and Beresford, 1998).

The Problem of Evaluation

This paper has criticised the managerialist appropriation of evaluation within community care, and the use of performance measurement as the means to ascertain service quality. It has argued that managerial priorities dominate community care, and that this has led to evaluation becoming disconnected from its social, economic and political context -reflecting the limited ability of the welfare state to impact upon disadvantage and poverty within society. In practical terms the focus of evaluation has tended to move away from considerations of effectiveness and the achievement of organisational goals towards the use of criteria of economy and efficiency.

The proposition that every organisation has a goal, or set of goals, has often become a taken for granted assumption (Clegg and Dunkerley, 1980). Empirical investigation has shown that what Georgiou (1973) referred to as ‘… the classic goal paradigm’ has flaws. For example, many social services goals will be set centrally by government departments rather than by SSDs themselves. The Performance Assessment Framework is a good example of this. Whether or not the assessment criteria represent the most important issues for an organisation they have to be pursued to the exclusion of others, a classic example of the distorting effects of performance measurement (Walsh, 1995), which is now ubiquitous within much of British welfare. Increasingly, services are judged by ‘league tables’ that illustrate relative positions against narrow sets of performance criteria. With schools it is exam results, with universities it is research income and publications, and with social services it is achievement against the Performance Assessment Framework. In the case of welfare, externally imposed goals are often too narrow to be meaningful; alternatively they may be pitched at too ambitious or generalised a level, leading to problems in judging organisational success.

However, organisations do have some – albeit limited – capacity to establish goals that are autonomous of central government. Etzioni (1964) recognises that the targets an organisation sets itself are not necessarily the ‘real goals’ but are the result of a process of negotiation and conflict between groups both within and outside the organisation and are the outcome of process rather than formal function (Ciegg and Dunkerley, 1980:305). This issue has not been successfully addressed in the traditional literature on organisations, although new approaches to organisation theory have shown the negotiated basis of any organisational goals. There has been a sharp line drawn between the study of social and formal organisations (Benson, 1977). Formal organisations were seen as rational and goal oriented, and stressed a system of rules for the pursuit of those goals (Blau and Scott, 1963). However, as Strauss (1982) has emphasised, organisations are characterised by endless processes of negotiation. This is the starting point of ‘new’ organisation theory, which acknowledges the importance of situational influences (Dingwall and Strong, 1985). However, advocates of this approach have failed to address methodological questions on how organisations can best be studied and evaluated – although Dingwall and Strong (1985) argue against outcome based measures and in favour of ethnographic approaches.

Evaluation: Changing the Focus

It is critical that evaluation for community care be more broadly focussed than has hitherto been the case. In particular, the following factors should be addressed.

1. Context: for community care, the purpose of evaluation must be to inform judgements about the merits of particular projects, which requires a sophisticated level of understanding about the context within which those projects operate. A narrow focus on cause and effect is inadequate here, since it ignores the reality that the context may determine the direction of a project. Successful forms of evaluation for community care must be rooted in clear understandings about the social, economic and political milieux within which community care is carried out.

2. Inter agency approaches: community care is not delivered solely by social services, but is the product of different agencies working in collaboration. Evaluation needs to recognise the costs and benefits to different organisations of a particular policy, and to develop a framework that can take these specific circumstances into account. This is made particularly complicated by the fact that the products of inter agency work are often intangible and therefore difficult to measure.

3. The political choices underpinning evaluation strategies: Trinder (1996) has argued that the selection of a research strategy is a political and value-ridden activity. One of the successes of managerialism in community care has been to present its version of events as natural and uncontested, although other views may have equal or greater value. The preference for easily quantifiable targets within the Performance Assessment Framework is not, therefore, politically neutral. Neither is such an approach inevitable – there are alternative traditions of social research and evaluation that would lead to a quite different approach (Dullea and Mullender, 1999)

4. Service user perspectives: the views of service users are not incidental but are integral to successful evaluation. Managerialist evaluation might pay lip service to the empowerment of service users, but this conception is concerned with the increase of the service users’ consumer power, not the increase of their ability to exercise their ‘rights’ (Means et al, 1994). Increased ‘consumer’ power will lead to greater calls on the limited community care budget, which would directly conflict with managerialist priorities. This fact serves to militate against the perspectives of service users becoming an integral part of evaluations of community care.

5. Professionals: the implementation of community care has subordinated professional to managerial priorities. However, social workers and other caring professions operate at the intersection of private needs and state resources and must manage the unequal balance between the two (Langan and Clarke, 1994). This gives the professional an unique insight into the practical workings of community care; any process of evaluation that does not accommodate this insight is likely to be fundamentally flawed.

6. The possibility of failure: that an evaluation of a project highlights weaknesses or problems should not be the sole criteria for judgements about whether or not that project should continue. Yokeing evaluation and funding too closely together denies the possibility for projects to try new approaches to meeting need; the risk of failure may simply be too great. For innovation to continue there must be greater incentives than are currently available to try new approaches to problems, and to learn from mistakes.

Evaluation must contribute to ongoing policy and service development in a manner that is denied by managerially dominated approaches. This process should involve a flexible combination of both qualitative and quantitative approaches. Chen’s (1990) concept of ‘Theory Driven Evaluations’ may be one means whereby a more flexible and responsive approach to evaluation can be developed. Chen argues that it is theories about services that should be evaluated, rather than the services themselves, and that policy making is essentially a set of hypotheses that connect a project to its broader context. The key to successful evaluation is to test the validity of the hypotheses. It is not possible, therefore, to evaluate a service simply through an examination of information taken out of context. Instead, one must evaluate the service while taking full account of how that service reflects a wide range of interests. One cannot do this without taking account of the power differentials between those interest groups. In recent years, managerialist perspectives have achieved precedence – but there are viable alternatives that professionals and service users should be enabled to articulate.

There are research projects that have accommodated the criteria we have identified; two are discussed here. In the current climate, many researchers accept the need to produce data that bears directly on the ‘3 Es’. As Powell and Goddard (1996) indicate, it is possible to combine evaluation methodologies so that effectiveness can be addressed as well as issues of economy and efficiency. Drawing on Smith and Cantley’s groundbreaking work [1985] they argue that effectiveness can only be judged in the context of ‘… a multiplicity of interests and concerns’ which lead to the ‘… plurality of legitimate criteria for success’ (Powell and Goddard, 1996:95). In terms of the factors we have identified, this strategy enables the significance of the inter-agency context to be addressed, and actively seeks to accommodate the views of service users and professionals.

The choice of evaluation strategy is always significant. In carrying out an evaluation of the impact of a new policy within a day centre for people with learning difficulties Baldwin (1997:952) consciously selected an approach that was “participative to the greatest possible degree”, building on the framework of co-operative inquiry (Heron, 1996) as a research approach. This was to ensure that the perspectives of all participants in the day centre, notably service users, did not get lost. A key contextual issue that the methodology aims to address is the oppression routinely experienced by people with learning difficulties. Therefore, the approach taken is an attempt to place service users’ perspectives at the centre of the process, within a broader social context. More generally, Dullea and Mullender (1999) believe that participatory models of research can enable the formulation of challenges to social, political and economic structures. Therefore, the choice of evaluation strategy represents an attempt to address a key contextual issue, while highlighting the concerns of service users.

Conclusion

Community care policies should aim to bring about positive benefits in service users’ lives. This must therefore be the starting point for any evaluation strategy. The approach to evaluation that we have advocated would enable the perspectives of service users to be placed at the centre of the evaluation process, and would also place social workers and other professionals in strategically important positions. This process would provide a contextual framework for evaluation that could enable the focus to be shifted away from managerialist models to approaches that genuinely reflect the needs and wishes of service users.

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