Tuesday 11th December 2018

Overview

Representatives from various stakeholder groups were invited by the South Tyneside CCG to submit suggestions to a 'listening panel' formed by the CCG as part of their process of designing a legally watertight public consultation that is due to be implemented in 2019 as part of "Path to Excellence" phase-2, I.e. the second round of service downgrades at South Tyneside Hospital.

The following presentations were submitted to the 'listening panel'. They are listed in the order in which they were given, and the hyper-links will take you to the relevant position in the live-streamed video documenting the event:

Further down the page, this article provides the original transcript of the Save South Tyneside Hospital Campaign presentation. The main submissions and some further comments from the Keep Our NHS Public representatives have been bundled together in order to give a concise overview of their contributions. An abridged transcript of the submission by Councillor Angela Hamilton is also included.

Save South Tyneside Hospital Campaign

Full Presentation

Roger Nettleship
Chairperson
Save South Tyneside Hospital Campaign

First thing I would like to say is SSTHC came together with people from all walks of life and all political persuasions or none, from health staff to people in the community, to save our access to our vital hospital services, and right from the outset people from Sunderland also joined our campaign concerned about the deterioration of services in Sunderland as a result of these announcements.

Neither has this campaign just happened. Before that we had to fight to try and save our elderly care services in the borough, and the consequences of that being railroaded through - both here and nationally - is catastrophic, leading to the private nursing home companies ruling the roost, forcing councils and the NHS to pay exorbitant sums. Generations of people who had survived the Second World War and people from the post-war period had been promised health care from the cradle to the grave, now they have their finances bankrupted to pay for their long term care.

The consequences for care here are tragic. Palmer Community Hospital had NHS acute elderly mental health wards, elderly wards and day hospitals, this has all gone and now people have to be placed miles away. For example, a very elderly women from Jarrow said goodbye to her husband from Ward 1 of Palmer's EMI unit before it moved because she could not travel to Sunderland to see him.

Then we witnessed the destruction of local acute mental health services, in particular Bede wing. There was always a local safe place for acute mental health patients when I worked in the health service. That was so important for mental health patients to be treated locally near their home when they could not be at home. That service was closed despite our objections, claiming that people would be better cared for in the community, but for acute patients it is now a complete lottery as to where they will end up.

Then of course as you know we are still challenging your Path to Excellence, which wants the people of South Tyneside to have less equitable access to children's A&E, full maternity and stroke services. In that context you are ploughing ahead with phase-2 changes whilst we are still challenging phase-1.

So, this is the background to your Path to Excellence. Now you have phase-2, and can you wonder why thousands of people don't believe the very opening lines of your glossy document Working Together, stating that you are going to improve hospital services in South Tyneside and Sunderland, and that phase-2 aims to build on the strength and successes of our hospital staff.

Of course, the rest of the document raises very big questions. The real aim of this consultation is in the mantra that no change is not an option. Yes we hear the objections that 'nothing is decided yet' and 'all options are on the table', that there are 31 options, including one to build a new hospital - quickly dismissed of course - and then you say to us 'how can you dismiss change' and 'we need to go forwards'.

But what change are you talking about and in what direction is it going? We have very good reasons to believe from what your document says that this change is not going to restore proper public elderly care services. It is not going to restore local acute mental health services. It is not going to restore local walk in services. More specifically it is not going to improve our access to acute hospital services and it is not even going to improve the community services that are so flaunted in your documents. Over thirty years or so, many of those community services have disappeared especially since the days of the Primary Care Trust. So you are not talking to a ground zero public, you are talking to thousands of people in the borough who have seen this all before and know that when you say no change is not and option you mean to implement further drastic cuts to the diminishing services we have now, giving us less access to hospital and community services. Frankly, you even spell this out when you say we need to address the increasing demands on hospital services when community care is best care. Then you say we need to address the increasing demands on primary care when self-care is the best care. In other words, this whole direction is wrecking public acute and primary health care so that more people will have to rely on 'self-care', and that will mean - either now or in the future - paying for themselves whilst health corporations turn our NHS (both acute and primary care) into a chaotic sector to make profit - just as they did with elderly long term care.

It is not just us saying this, there are so many independent bodies, for one reason or another, saying these plans - which are based on the discredited Sustainability and Transformation Plans (STPs) - won't work, and criticise the government, NHS England and NHS Improvement for this whole strategy. Right now as you know the BMA is saying that the North has a shortage of 180 beds in our hospitals, and that the hospitals in the North cannot cope at this present bed capacity. Yet the favourite plan of the local CCG is to a impose the 'Canterbury Model' - which you guessed it - means closing more beds! In fact nobody talks about the beds that have been closed in phase-1. 20 stroke beds gone along with most of the experienced rehabilitation team, let alone the beds that will go with the closure of obstetrics if phase-1 goes ahead.

It seems to us that one thing we have in common is that neither of us have the power to solve these real problems facing the NHS. You have been told to paint a massive cut to health services as a Path to Excellence. You don't even have the power to challenge your bosses it seems. What is an economy for, especially a rich one, if it doesn't prioritise public services and especially the health service? What health staff do, is add the most essential value to society and its endeavours, but the government and their friends claim it is a cost and a burden to their other priorities for which you are the ones accountable to implement. Therefore your actually existing accountability is not to the people of South Tyneside and Sunderland but to these other priorities of the government - which are not ours.

However, although we don't have the power yet to change things for the better, the people in South Tyneside that have come together to form SSTHC and Sunderland KONP - like people everywhere - are doing everything they can to safeguard the future of the NHS despite the odds against us at this time. You on the other hand are prepared to dress up this disastrous path as a Path to Excellence, even though these days you have much less control of the public and private corporate market that is wrecking our health care system. If this is a listening exercise you need to consider that you are following a direction that in our opinion is wrecking the NHS as a planned and comprehensive public service with equitable access for all. This will lead to the deconstruction of our district hospital, community hospital, mental health services, and what is left of primary care. It will lead to the expansion of the private and public corporate model and increasing inequality of access - especially from poor and rural areas.

What we are witnessing today are hospitals that cannot cope with the numbers of patients that - everyday - are pressurising doctors and nurses to discharge sicker or less-recovered patients than before, but still the relentless ward and bed closures goes on.

What we are witnessing at the same time are fewer GPs and sicker patients being managed by those GPs, and a relentless workload for them, so that many are leaving the profession. We see the pressure not to refer these sick patients to hospital even for urgent tests and diagnosis that would enable them to make a full or partial recovery and live at home. Instead people can wait months for one test or another, or because there is no appropriate specialist to see them.

A friend I know had serious chest and heart difficulties in May this year, and for months had no diagnosis. He was managed by his GP at home, and when his family finally took him to A&E in July he was diagnosed with treatable C.O.P.D. but it was too late and he died in I.T.U. prematurely, and these clinicians were angry that this was left so late. People's lives ruined, and these are not isolated incidents. If you move services away from our communities both in South Tyneside, or in Sunderland, GPs will end up managing even sicker patients. Even the ambulatory care service, which as it should be is next door to the A&E, is not known about. At the last meeting of the CCG Board one of the GPs on the CCG complained that there is no publicity about access to this service and that GPs themselves did not know they could refer to it. Is this a Path to Excellence?

We know that there has been a review process and an ongoing engagement process. We have been involved in two stakeholder meetings and also, unlike phase-1, more staff have been included in a review process. However, the design teams are still working behind closed doors and reports to us suggest that staff are completely in the dark as to what giving their views means in reality. Matt Brown [South Tyneside CCG - Director of Operations] and others talk about 31 options developed by these design teams, but these are also behind closed doors undisclosed.

Our big impression from the stakeholder meetings is that this whole system works by fitting pre-conceived ideas about the changes that have already been decided in principle into what people are saying. This seems to be the case with the evaluation criteria. The reflected conclusions are all sanitised so that there is no emphasis on maintaining locally provided services at both our hospitals. People's priority for local health care services that are quick and easy to access gets changed into the criteria of Keep or improve health outcomes for local people. In other words, gone is the need to plan for local access to district hospital services that we have today and that provide quick and easy access to vital acute services that are an everyday need to the growing population of South Tyneside and Sunderland in our communities, and building on those successful services at both hospitals today. No, the criteria seems to be shaped to suit the mind of the beholder and not to discuss the societies requirement to have these services provided when and where they are needed. All the excuses and arguments are then found to justify services that are less accessible and less quick and easy to access for tens of thousands of people.

I want to conclude by saying that the Save South Tyneside Hospital Campaign is not going to accept the closure of vital acute and trauma services and A&E at our hospital, which seems to be the yet unstated aim of phase-2. We have always called on the hospital Executives, the Board and the CCGs to review their position and change this direction, because it will be disastrous for the people of South Tyneside and Sunderland and detrimental to their well-being. If you have already decided then we will fight those plans, if you really haven't decided then we call on you to listen. As we and our hospital staff say, it is our hospital, it is our workplace, it is our NHS, and we should decide.

Keep Our NHS Public - Sunderland & District

Submissions and Comments

Dr. Pam Wortley
Keep Our NHS Public - Sunderland and District

About the consultations you have already had, you talk about the views of hospital staff and patients having been considered, but there is no information about on what basis that consideration was made. What information was given to inform the decisions that were made?

Another point is to do with GPs and primary community care, where you say 'the plan is based on work to enhance primary community care with GPs and community health professionals', and then later on you say 'we will engage with professionals in primary care', so there is a dichotomy, it's not making sense. Either you have discussed it with them, or your going to discuss it with them in the future. It needs to be clear what's going on.

The other thing that I want to stress is this business about calling it a Path to Excellence. Please lets be honest, it's not a Path to Excellence at all. If it was a Path to Excellence, you would be expanding the services for the local people in South Tyneside, and you would be keeping the services in Sunderland but making them better as well. Even Matt Hancock has come out and said that 'CCGs and Hospital Trusts should focus on the most affected, to consider the impact on families and the well being of those who have to travel long distances'. So Government are recognising that 'local' is not what your planning at all, your planning a move.

How can you state that South Tyneside and Sunderland hospitals are definitely both going to continue? What would the purpose of South Tyneside Hospital be once you've moved all the acute services out of it. It will be [effectively] an empty building that needs £13 million spending to upgrade[/repair] it. [And that begs the question] why has that not been going on [over the years]? Why have we suddenly got a bill for an outstanding need for repairs in South Tyneside Hospital - which manager is responsible for allowing those appalling statistics to appear?

I would not want to move any of the services from the locality that they are in now, as I think they are a vital part of this area in South Tyneside, we know it has a very high level of deprivation, ...I would follow Matt Hancock and say why would you want to move services away from the local community. I would want to look at alternative ways of conducting [services], for example digital and I.T. For example with stroke services we know that at weekends, the scans were looked at by consultants at the R.V.I. So why did you have to move services from South Tyneside to Sunderland, when with digital technology you could have a consultant sitting anywhere looking at the scan. You had a good team at South Tyneside (which has now disappeared) with skilled senior nurses [meaning that] the treatment could be given.

...(01:58:25) It's really hard to get involved in [the consultation / pre-consultation process] in any meaningful way when we don't have any trust in the process. I can not believe you can sit there and think that it is OK for children to have to [potentially] get to Sunderland from South Tyneside in the middle of the night. ...You talk about that being a Path to Excellence, but it is cruel and inhumane. There are no women on your panel, where are they who would understand how awful it must be. I'm just making a plea from the point of view of general humanity, that it can't be right. It's difficult for us to [believe] that you really care about the patients. Your living in a different land if you like, as it is no object for you because you have cars, but it's not like that in South Tyneside, and not like that in parts of Sunderland. I make plea to you to stand up to government.

...You need to find ways to make the services better. [For example] I was a GP, and in my day we had functioning teams that you could turn to, but not any more. If you want a district nurse you have to ring a central number. They don't work with you any more, so you don't know what their skills are. How can you get the best for your patients when someone else decides who will come out and look at your patients. It's a crazy way of working. You need to get services back in place again to build up your teams. ...No wonder you are overworked.

What plans are you making for increased population in South Tyneside - 5 percent increase in population by 2025?

From the point of view of being part of a clinical team to look at how services are delivered, we've done that all our lives. You've looked at heart disease and ways of getting things seen quickly. The one-stop-clinic that is around for breast cancer for example is a great for patients so they don't have to travel.
Laura Murrell
Keep Our NHS Public - Sunderland and District

Your comments illustrate the assumptions being made about the whole of this process. There are lots of laudable aims in here. Who wouldn't want a better integrated service, joined up care etc. It's based on many assumptions, one of which is a better I.T. system, another is better self-care, and another is prevention and working with the local authority etc.

Social care is a separate budget to health care, and it relies a lot upon the funding of the local authority, which as we all know has been cut to shreds. So how can you guarantee that [these mitigating assumptions] are going to help your overall program of this Path to Excellence?

If you want to gain the confidence of people, and you want to bring people along with you on this, then you need to be able to show how you arrive at your solutions. For example, you use a lot of modelling, which most people don't understand, but you quote it as though it is without criticism, when we know it can be criticised. You take that as the basis for a lot of your decisions. You make assumptions about improvements in public health, where is all the evidence. ...You need to be able to justify those assumptions to people.

Elected Representative of Beacon and Bents Ward

Abridged Transcript

Angela Hamilton
Councillor
Beacon and Bents

My name is Councillor Angela Hamilton, I represent Beacon and Bents ward in South Shields. It is geographically one of the largest wards in the borough and has high levels of deprivation. I've been asked to come here by residents of that ward to put forward their thoughts, opinions and experiences about the use of the hospital and what it will mean for them if and when services are moved away from the hospital to Sunderland, and to raise some concerns about the process that's been undertaken, both now and previously.

Just to give you a bit of background about myself, I work for Newcastle City Council in a policy and communications role, so I am well aware of communication and consultation. I represent disabled members nationally on Unisons National Executive Council, and I'm a disabled person myself, so I have knowledge and experience about using the hospitals. I previously worked for the Disability Rights Commission, so I have understanding of the issues faced by some of those who are most excluded and isolated within our society. I think it's those people more than anyone else that I am here to speak on behalf of today, those people who can't always speak on behalf of themselves.

I am aware that this consultation is about phase-2 of the proposals for the hospital. I received a presentation in my role as a Councillor approximately six weeks ago at a community area forum meeting. I raised a number of concerns there, and I'm going to raise very similar concerns here.

My first concern is that your progressing with this before the outcome of the judicial review, which is being heard next week on [phase-1]. I feel that it is inappropriate to be moving forward when you don't know the outcome of phase-1. You may have to halt everything. I understand how judicial review works, I have a background in law, so it's about the procedure not necessarily about the outcomes. If the procedure was not carried out, you have to go back and start at the beginning. So to begin implementing phase-1 and to start consulting on phase-2 seems very premature, almost presupposing what the judge is going to say at the hearing next week.

Moving on to phase-2. I am well aware that there has been a consultation amongst members and Unison staff at the hospital, and overwhelmingly they are opposed to the merger of the two hospitals. The reasons behind that are numerous, but include things like the inability to get to work, a belief that all issues have not been considered, that neither hospital will be able to deliver the services that will be expected going forward, and that there are a wide range of alternatives that are apparently being considered, but nobody has been given any information or evidence about what they are. In the presentation I sat through, I was told that there are 31 potential options, but nobody would tell us what those 31 potential options are.

So to be ploughing ahead with this is premature because people can't respond to proposals that don't exist. We aren't clear what your plans are for the hospitals, expect that it will mean the downgrading of services in South Tyneside, and services that people don't feel are appropriate to downgrade. Accident and Emergency is essential, changing the hours or reducing accident and emergency cover is not appropriate.

At the council meeting I used my own situation as an example. I have asthma, which I have not suffered from for about 15 years, but this year it increased significantly with the hot weather. I had to go to hospital because I could not breath. I could not have got to Sunderland hospital, and I completely and totally believe that if I had not been able to go to A&E in South Tyneside, I would be dead. The doctors were brilliant, and we [South Tyneside] have some of the best ratings in the country for A&E, higher even than Sunderland, so the thought of moving services to Sunderland is not acceptable to people in the borough.

I have nothing against Sunderland hospital, I have M.S. and I receive most of my treatment for M.S. at Sunderland City Hospital as it's the most appropriate place. Nobody is saying that things can't change, nobody is saying the everything has to be delivered in every single hospital, we all know that's not possible, [for example,] you could not have heart transplants in every hospital, but there are some services that need to be delivered in every single hospital, and that includes accident and emergency, it includes maternity, it includes all of the services that you are considering moving at this stage.

I asked people to let me know what they wanted me to say. Someone from my ward came back to me with this:

"I see lots of different specialists, eleven at the last count, and all but the physiotherapist are now in Sunderland. I basically have to prioritise who I can see, because of the cost and hassle of getting there."

Nobody should have to prioritise which medical conditions they are able to have treatment for, because they can't afford to get there on the bus, or because there is no transport for them to get there. Some people from the ward I represent have to get three buses to get to Sunderland, when your not well, its really not acceptable. I'm not saying things should stay as they are, but we need to look at options.

There is very limited access, especially public transport. The staff in Sunderland don't think that they will have the capacity to deal with the additional number of patients. Staff from South Tyneside don't want to move to Sunderland, there is now talk of a recruitment crisis. What will you do when those staff go to Gateshead or Newcastle, which are much easier to get to, or they decide not to work any more in the NHS, how are you going to recruit the staff you need in Sunderland? How are you going to ensure that people are not dying because of the changes? Your proposals are absolutely horrific. Someone sent me something this morning raising the point about a young patient who died at Sunderland from sepsis. If Sunderland hospital is struggling now, how will it cope with more patients?

Over the last 20 years our services have been downgraded significantly, and the way things are going South Tyneside Hospital is going to be little more than a 'cottage hospital', and we deserve so much more than that. The people of this borough deserve a real hospital with real services. There should be no reductions to A&E, maternity and [other vital services].

We have been asked to submit evidence today, but it's very hard to submit evidence when you don't know what the proposals are, when you've only heard outlines. We have been told that a small clinical design team are designing or looking at these options. I don't think it should be a small clinical design team, you need patients involved in that. You need people from the public involved in that. A clinical design team may only see one side of the issues. Representatives of the Save South Tyneside Hospital Campaign probably know more about the impact of the proposals than anyone else. They have spent two years (at least) gathering evidence on all the issues, and I think they could point you in the right direction... [you need to include] trade unions in the hospital, cleaners, nurses, everyone, not just clinicians. ...It's the people at the bottom, the people on the ground who are front-facing who see what is going on, it's amazing how many ideas that they come up with that are so simple yet so innovative at the same time. ...[You should also consult] community and voluntary sector organisations, especially those representing vulnerable adults, as they will find it hardest to get to services. Also include young people as it's their future. Include people who use the hospital on a regular basis. ...If you have a design team of 30 clinicians, you should have a similar number made up equally of staff and lay people, and they should be part of the design team right from the beginning so it's not all driven by senior clinicians.

...The response times - if you have a poorly child in South Tyneside and they have to get to Sunderland - it's going to be pretty bad! Especially with all the cuts to the ambulance service. I know it's not directly linked, but it looks like we are going to have cuts to the fire service in South Tyneside, but that will impact. Road accidents will also impact upon people getting [to Sunderland in an emergency]. [There is a transport working group] but no solutions have [been generated]. ...There are a lot of people in this borough who don't drive. You might manage to get a taxi to South Tyneside Hospital, but a taxi to Sunderland is [potentially too expensive]. Try getting to Sunderland Hospital if it's match day in Sunderland! Its not safe.

You have staff that are going to be TUPE'd across to a different employer and they don't want that. Are you planning on selling any of the land at the hospital? ...Telling people that there will always be a sustainable hospital delivering the best care does not tell people anything. It does not tell people what services are going to be delivered and that is what people want to know. They want to know - particularly around things like A&E - that it is not going anywhere, and right now everyone thinks it is. We've been told too many times in this borough that hospital services weren't going, or medical services weren't going - and then they did! So nobody believes it any more when you say there will always be a hospital in South Tyneside, because when I was a kid there was 5-6 hospitals in South Tyneside, now there is one.

Times change, and people know we are living longer and potentially more services may be needed... Your starting point should be which services have to remain in both locations, some services have to remain in both locations [South Tyneside and Sunderland]. ...Everything is being talked about being moved to Sunderland. Nothing is being moved to South Tyneside, and there does not seem to be any reason for that?

If you want to take people with you, you have to let people know what the real challenges are. You need to stop with the language that excludes people. Path to Excellence - what does it mean? It means nothing does it?

Extra Highlights for Campaigners

The whole event was live-streamed over a period of nearly 3-hours. The following list highlights other potential moments of interest (beyond the core presentations) for campaigners:

(01:49:12) The listening panel acknowledge their poor track record with regard to gaining the trust of citizens in relation to their proposals. They ask what can be done to gain trust?
Roger Nettleship (SSTHC)

During phase-1 you had 3 or 4 options, but keeping the services as they were, or improving them was not an option. I picked this up in the stake holder meetings. Every time you come along, it's as though you are inventing the wheel again, but nobody is looking at what you have now, which is good and is functioning very well. Some services may have staffing problems, but they've had that for decades, and as has been said, there are other ways of working.

In phase-2 you have gone the other way [with 31 possible options], but you still discount the services that we have now, stating 'change is not an option'. This creates an atmosphere where you are ostensibly listening, but ignoring huge concern as nobody knows what these 31 options are, but we do know that the services we have now are not on the table. You have denied this, but in all the presentations that have been made, that is what comes across.
(02:02:00) Coming back to the issue of trust, Dr Matthew Walmsley sitting on the 'listening panel' asked what they could do to convince us that the fate of our services has not already been decided, the following conversation ensued:
Dr Pam Wortley (KONP Sunderland)
You've decided that what your proposing is a "Path to Excellence", which I find really objectionable. Why aren't you honest and just say that you have no money or resources, and so you have to make the most of what you've got? I could live with that, although I would then want you to make sure that services don't go into private hands etc. ...You should also be considering the detrimental effects of marketisation, which has raised NHS administration costs from 5 to 14 percent.
Roger Nettleship (SSTHC)
The point is that you are the ones that have the responsibility, you are the ones who are accountable for these services. You should be listening to what people are saying and empowering them to shape the future of services, and opposing those who are trying to wreck our services.
Dr Matthew Walmsley (Listening Panel)
Politically we have to remain neutral. I would not object to lots of money being spent on the NHS, but we can't be political campaigners as you can.
Laura Murrell (KONP Sunderland)
But as managers you should be able to point out that your not being given the resources to deliver the service that your being asked to, that's non-political, that's good management!
Chair (Listening Panel)
If I jump out of this local context for a minute, and look at this from the perspective of working with people across the UK, not just in England but in Wales and Scotland, and sometimes Northern Ireland, as someone who oversees what everyone is going through, it's very difficult for people to be seen sticking their head above the parapet when their involved in a programme, because there is the risk of the accusation of bias, in one way shape or form, and it is not always that they have already made up their minds, but they come under pressure for stating a perspective. That means sometimes people who would be valuable and see things - probably in a manner that you do, working within it and trying to shape things accordingly - might end up getting removed from the equation, and I have seen some scenarios like that. I have also seen people with their own personal views working behind the scenes to try and change that, but obviously in the context of the project they are working on it is difficult. I think that you need to be a little bit flexible with people in that respect. What they might personally feel is not what they can always bring to the table in the context of what they are doing here. From what I've seen throughout the country, I've seen a lot of people very torn about some of the things that they are asked to do.
Roger Nettleship (SSTHC)
They should not do them then.
(02:37:30) In response to suggestions raised by Peter Bower of Healthwatch South Tyneside, Dr Shaz Wahid reminds us of the overarching (repeated nationwide) strategy to sell service closures and restructuring (that will ultimately benefit private corporations) to the public, by promoting "Prevention" - a theory (without evidence) that the general health of the population can be improved to such an extent that hospitals are needed far less - so enabling the "Path to Excellence" (the downgrading and closure of our hospital services). This dovetails with "Integrated Care" STPs -> ACOs -> ICOs -> ICPs. In 2006, the NHS National Leadership Network produced a document stating that "Integrated Care" is not just about the shift of hospital care towards the community, but the reconfiguration of NHS infrastructure. This means a radical reduction in the number of NHS hospitals and the development of new facilities to house "Integrated Care" services that are decoupled from the NHS, enabling the expansion of the private sector, therefore actually not restoring the integrated public health service that existed before fragmentation began in the 1980s, but rather integrating services in a market context leading to increased charging and the possibility of wholesale privatisation.
Dr Shaz Wahid (Listening Panel)
When we have our "Clinical Service Review Group", we have everyone around the table and that includes "Out-of-Hospital". The out-of-hospital "Prevention" work is getting traction. It is like a bud. It is flowering, we are talking. We are considering that if "Path to Excellence" is going to change [things] here, then we need to figure out what is going to happen to out-of-hospital. We must not forget "Prevention", if we make the population more healthy, it would make a big difference. We have thought about how we actually sell that work, the ICP, we have to start looking at how we describe that in layman's terms, and see how that links in to the "Path to Excellence".