YouGov Poll - 33 Point lead!

HolgateCorner

Well-known member
Can't keep it short and be thorough, it's an extremely complex topic.

When/ where did I ever say that I wanted a private NHS? Although saying that, I just want it ran the best way possible. It doesn't mean it couldn't be better than it is now, if they could hit better targets for less money (tendering) then it would make sense. Why wouldn't it? I wouldn't want it making obscene profits, but massive contracts like that are usually priced on 1-2% profit, or cost plus 1% etc. I'd rather have a company running it and hitting targets for less money, making 1% themselves, than spending more and not hitting targets.

Public-owned with heavy oversight by qualified people (not a politician), but privately ran or running it like a private company maybe, for some aspects, depends who the government is and who is running it. Absolutely must have minimum standards better than now, say to meet 2010 levels (which will also need a lot more funding and staff), and offer better value though, otherwise, it's pointless. Wouldn't trust the Tories to do it this way though, which is a problem when they're in power 2/3rds of the time. It would need to be locked out, so Tories could not funnel money into their mates (or own) private companies, and so we don't have companies/ people with zero skillset for what is required, like they did with PPE etc.

I don't think I've seen any good examples of something which is publicly owned and publicly ran, which is efficient and modernised, not in the UK anyway. It would be good if anyone had some good UK examples? I've got examples which are horrendous: rail, councils, construction (of public projects, private works fine/ very well), highways, utilities etc, and I expect the same continues with the NHS, seeing as anyone working in the NHS I speak to says it's so badly run.

Specific people or companies, for health? Which ones do you think work well, or are efficient? Which aspects have adequate management ratios and would hit budgets and performance targets, even if we did have more doctors and nurses? I've no idea, largely not my sector other than some utilities and construction on NHS sites, which they **** up as the client and as selecting or controlling main contractors. But the people will be out there, even if it meant recruiting from countries that were more efficient than us, which is not hard to find nowadays. Other countries just run public services better than we do, and that's not often due to more funding or people, whether that's health, energy, rail, highways etc. Hard to pinpoint that problem from our end/ level, so get someone top-level from places where their systems work.

Like I keep saying though, the NHS does need more funding and more nurses/ doctors etc, a lot more of both, everyone in the world knows this, but these are a million miles from being the only problems. Any company, service or workforce should embrace change if it could lead to better efficiency, and maybe even less cost, through modernisation. Every other industry can do it, if it has the right people running it, the right high and medium level management, right controls, right contracts etc.
I’ve worked in private companies for about 40 years.

They have been far from efficient or well run although you get pockets of things being done properly for period. The only difference is the money runs out after a while if they are not making a profit.

Look at Carrilleon, a private company spending public money, went down for billions and billions, I don’t think they’ve even got to the bottom of it.

Private or public, it’s the British way to run things chaotically, politically and inefficiently by often putting the wrong type of people in key positions.

Anybody thinking privatisation will somehow transform our health service into a panacea of efficiency is just wishful thinking, the Tories only want it for ideological reasons rather than making it better.
 

Laughing

Well-known member
I’ve worked in private companies for about 40 years.

They have been far from efficient or well run although you get pockets of things being done properly for period. The only difference is the money runs out after a while if they are not making a profit.

Look at Carrilleon, a private company spending public money, went down for billions and billions, I don’t think they’ve even got to the bottom of it.

Private or public, it’s the British way to run things chaotically, politically and inefficiently by often putting the wrong type of people in key positions.

Anybody thinking privatisation will somehow transform our health service into a panacea of efficiency is just wishful thinking, the Tories only want it for ideological reasons rather than making it better.
Just to row in with something I don't know much about. THe idea that private is bad and public is good isn't necessarily true. There are some private companies that are run excellently but their goal is a little bit different, both tactically and strategically.

Public owned companies, I suspect, will only be run if the folks at the top can learn to think in a different strategic way. Given the goal isn't profit but levels of service within a budget the thinking is clearly different.

A CEO of a privately owned organization has to think what the market will be like in 5, 10 years and how do you make a profit and stay competitive as the world market and your customer base changes. Someone running the nhs has to think strategically too, but their strategy should be very different. How do we ramp up for different health care needs in 5, 10 years, what assets do we need in place and how much will that cost over the short, medium and long term,. what are staffing needs and how can we best support an aging population.

The questions and solutions are different and just employing a commercially successful ceo into public owned companies, won't necessarily work. Publicly owned companies have, if I recall, been run quite poorly and perhaps that is the reason why. or of course, it could be poor government setting that agenda. Public services should be taken out of parliamentary remit, ringfenced and run themselves with the best people available with the previously alluded to ring-fencing in place.
 

Andy_W

Well-known member
I’ve worked in private companies for about 40 years.

They have been far from efficient or well run although you get pockets of things being done properly for period. The only difference is the money runs out after a while if they are not making a profit.

Look at Carrilleon, a private company spending public money, went down for billions and billions, I don’t think they’ve even got to the bottom of it.

Private or public, it’s the British way to run things chaotically, politically and inefficiently by often putting the wrong type of people in key positions.

Anybody thinking privatisation will somehow transform our health service into a panacea of efficiency is just wishful thinking, the Tories only want it for ideological reasons rather than making it better.
Carillion wasn't well run, they cooked the books and hid their debt, which loads of people apparently realised before they went into liquidation, they were broke long before this. They also had the wrong business model which was inevitably going to come back and bite them, which it did. They're similar to Interserve, those two are probably the worst "large" construction companies I've come up against as a sub-contractor. I mean against too, as when working for them, you have to actually cover/ remind yourself that they're working against you, as your PC, when they should be working with you.

The Carillion example is a good one though, they relied heavily on government/public sector contracts, which was a bit nieve during a recession recovery, headed by a Tory government known for shafting the public sector. They also took on all the risk, which is extremely naive when working for a client who does not know what they're doing. This coupled with their model of ******* off (bankrupting/ shafting) subcontractors, effectively left them with crap work, for a crap client, with a subcontractor base (nearly all of their work was sub-contracted) who either massively overcharged (insurance against Carillion) or would not work for them.

They Carillion/ Interserve had all risk contracts, yet took on subcontractors who would not/ cannot do all risk, it's not how construction works. You cant price low, take all the risk, assume subbies will absorb those risks (which they're contractually not obliged to do) and then shaft the same subby with under and late payment. Word gets around, and inevitably a company which 100% relies on subcontractors has nobody who will work for them for a fair price, with a fair contract. Towards the end, when they asked us to price work for them I would always stipulate settlement of the outstanding debt, before I even sent any e-mails related to the job they wanted us to tender for, then any new jobs our terms were payment up front. This partially worked and we were getting our outstanding debt back, at a low trickle, it was the only way to trickle that money back.

In the end Carillion went down owing me about 50k I think (better than the 80k it was), and Interserve still owe about 30k which has been going on about 7 years, although they're still sort of going somehow. I won't price Interserve work "normally" now though, last job for them was at James Cook, the new secure treatment section, the whole job was a joke, and took about 6 months to get paid all of it.

Everyone knew what Carillion were all about or, or learned this between 2008 and 2015, the only ones who didn't were new sub-contractors, new to the industry or those scrapping for any sort of work after the recession (this was plenty of companies mind, we were the same in 2010/11).

Oh I didn't say it would work (running it all private, but as a publicly owned company), as it relies on a competent client/government, which we currently don't have (we've had 13 years of bad, who dug a big hole), and won't have for 2/3rds of the time (going historically). It could work under Labour, if they got competent people in, to look after it, but I'm not sure I would even want to take that risk, as it's coupled with the risk of losing to the Tories. It could (and should) really work, but I'm not really saying it would.
It doesn't mean the private aspect is wrong, it means we have a control problem. I think some smaller sections of it (to start) could maybe run private but mainly needs to be on the low-risk, easier areas (not construction), and areas where budgets can be forecast more easily. It's certainly not easy, but controlling that sort of budget never is. It also doesn't mean we can't make big changes, to streamline things, pre A&E/ GP Triage, bring back walk in centres for minor injuries, not suitable for A&E, pharmacies taking on more responsibility etc. I imagine some things need breaking down, to take the load away, dealing with smaller, should make it easier, but some areas need better integration, like between the NHS and social care, as they're so reliant on each other, and one can sink the other.
 

Andy_W

Well-known member
Just to row in with something I don't know much about. THe idea that private is bad and public is good isn't necessarily true. There are some private companies that are run excellently but their goal is a little bit different, both tactically and strategically.

I'd say probably 80% or more are extremely well ran, in my sectors anyway, but they pay a high price for the best people. This pays back by many orders of magnitude though.

Public services should be taken out of parliamentary remit, ringfenced and run themselves with the best people available with the previously alluded to ring-fencing in place.

200% this!
 

HolgateCorner

Well-known member
Carillion wasn't well run, they cooked the books and hid their debt, which loads of people apparently realised before they went into liquidation, they were broke long before this. They also had the wrong business model which was inevitably going to come back and bite them, which it did. They're similar to Interserve, those two are probably the worst "large" construction companies I've come up against as a sub-contractor. I mean against too, as when working for them, you have to actually cover/ remind yourself that they're working against you, as your PC, when they should be working with you.

The Carillion example is a good one though, they relied heavily on government/public sector contracts, which was a bit nieve during a recession recovery, headed by a Tory government known for shafting the public sector. They also took on all the risk, which is extremely naive when working for a client who does not know what they're doing. This coupled with their model of ******* off (bankrupting/ shafting) subcontractors, effectively left them with crap work, for a crap client, with a subcontractor base (nearly all of their work was sub-contracted) who either massively overcharged (insurance against Carillion) or would not work for them.

They Carillion/ Interserve had all risk contracts, yet took on subcontractors who would not/ cannot do all risk, it's not how construction works. You cant price low, take all the risk, assume subbies will absorb those risks (which they're contractually not obliged to do) and then shaft the same subby with under and late payment. Word gets around, and inevitably a company which 100% relies on subcontractors has nobody who will work for them for a fair price, with a fair contract. Towards the end, when they asked us to price work for them I would always stipulate settlement of the outstanding debt, before I even sent any e-mails related to the job they wanted us to tender for, then any new jobs our terms were payment up front. This partially worked and we were getting our outstanding debt back, at a low trickle, it was the only way to trickle that money back.

In the end Carillion went down owing me about 50k I think (better than the 80k it was), and Interserve still owe about 30k which has been going on about 7 years, although they're still sort of going somehow. I won't price Interserve work "normally" now though, last job for them was at James Cook, the new secure treatment section, the whole job was a joke, and took about 6 months to get paid all of it.

Everyone knew what Carillion were all about or, or learned this between 2008 and 2015, the only ones who didn't were new sub-contractors, new to the industry or those scrapping for any sort of work after the recession (this was plenty of companies mind, we were the same in 2010/11).

Oh I didn't say it would work (running it all private, but as a publicly owned company), as it relies on a competent client/government, which we currently don't have (we've had 13 years of bad, who dug a big hole), and won't have for 2/3rds of the time (going historically). It could work under Labour, if they got competent people in, to look after it, but I'm not sure I would even want to take that risk, as it's coupled with the risk of losing to the Tories. It could (and should) really work, but I'm not really saying it would.
It doesn't mean the private aspect is wrong, it means we have a control problem. I think some smaller sections of it (to start) could maybe run private but mainly needs to be on the low-risk, easier areas (not construction), and areas where budgets can be forecast more easily. It's certainly not easy, but controlling that sort of budget never is. It also doesn't mean we can't make big changes, to streamline things, pre A&E/ GP Triage, bring back walk in centres for minor injuries, not suitable for A&E, pharmacies taking on more responsibility etc. I imagine some things need breaking down, to take the load away, dealing with smaller, should make it easier, but some areas need better integration, like between the NHS and social care, as they're so reliant on each other, and one can sink the other.
Sorry to hear you lost money with Carrilion, I was just using them as an example but there are plenty more examples of badly run big private companies. As you allude to above many of the problems are rooted in the system we have put in place in this country which is largely a no trust, exploit weaknesses in the contract or claim your way out of trouble culture. And that’s without looking at the ‘human capital’ shambles currently being masqueraded as good people management. The likes of PWC are in the middle of it all and they are clueless but listened to because they are accountants and our system is run on shareholding and finance.
Like I said, the British way, chaos but ok if somebody can make a quick buck here and there.
 

The Ruthsayer

Well-known member
I’ve worked in private companies for about 40 years.

They have been far from efficient or well run although you get pockets of things being done properly for period. The only difference is the money runs out after a while if they are not making a profit.

Look at Carrilleon, a private company spending public money, went down for billions and billions, I don’t think they’ve even got to the bottom of it.

Private or public, it’s the British way to run things chaotically, politically and inefficiently by often putting the wrong type of people in key positions.

Anybody thinking privatisation will somehow transform our health service into a panacea of efficiency is just wishful thinking, the Tories only want it for ideological reasons rather than making it better.
It’s not just the British way. I’ve done business pretty much all over the world (apart from Sub-Saharan Africa), I have met incompetence from public and private entities everywhere I have traded. Oddly, given their reputation efficiency, the worst was probably Japan, with a ridiculously ossified hierarchical structure. The one common theme was the smaller the company, the more efficient is was.
 

exiledinboro

Well-known member
People can't get a doctor's appointment as the doctors are over-subscribed and loads of the appointments are taken up by people who could be sorted at a pharmacy, or with a one-minute online consultation.

Seriously 🤨

And we have a pharmacist shortage believe it or not 🤷🏻‍♂️
 

Andy_W

Well-known member
Sorry to hear you lost money with Carrilion, I was just using them as an example but there are plenty more examples of badly run big private companies. As you allude to above many of the problems are rooted in the system we have put in place in this country which is largely a no trust, exploit weaknesses in the contract or claim your way out of trouble culture. And that’s without looking at the ‘human capital’ shambles currently being masqueraded as good people management. The likes of PWC are in the middle of it all and they are clueless but listened to because they are accountants and our system is run on shareholding and finance.
Like I said, the British way, chaos but ok if somebody can make a quick buck here and there.
Ah it's not a big problem, that's construction, it's ruthless, they were not the first by a long shot, and won't be the last. We know it's going to happen, so make allowances for it.

Totally agree with what you're saying, we have many broken systems, we need a reset and to start to think outside of our box (or just like successful services/ countries do). The fight was hard before (comparing ourselves to other countries), but it's going to be even harder now, as we're going to struggle to compete outside of the EU.

We absolutely have to be as efficient as we can be, in everything we do, throwing resources at problems won't fix problems, picking the right thing to fix the problem will (will also likely need more resources).
 

Andy_W

Well-known member
Seriously 🤨

And we have a pharmacist shortage believe it or not 🤷🏻‍♂️

Why couldn't pharmacies/ pharmacists sort out some (even 20%) of the potential GP appointments, if they were given more power? Especially in winter when flu/ colds absolutely pummel GP's? The load imbalance from summer to winter is a problem, which needs assistance, and the method of treating the load needs to be flexible, to be efficient.

I'm not talking life or death, or anything close to that, which certainly needs a GP, or even to be able to bypass that to more specialisation. The majority of younger/ 9-5 working folk would likely get 90% of their needs met, by a basic/ quick 5 minute online triage by a doctor (I would absolutely love something like this, for my family). This triage would take less time than it does to try and get through to the GP, and they could then be directed to the Pharmacy/ GP/ A&E/ Minor injuries/ X-Ray dept/ physio etc. I'm not saying send old people with chest pains to the pharmacy, I'm saying not cram up GP appointments with those who won't need them, if there were alternatives, so those with bigger problems can actually get an appointment. The triage system could even allocate drugs out from central hubs, and courier them around, to save people who may not need physical appointments/ contact from taking up time from those who do need the contact. Could also stop viruses etc spreading around, reducing the load. The system of people sick with flu, chest infections or whatever, going to the same places/ waiting rooms as vulnerable people with bigger issues is absolute madness.

I'm not surprised there's a shortage or pharmacists, just like there is with everything, maybe we need some sort of fast track/ leaner qualification, which is more specific, and less padding, and which can be later built on with more experience. Same with GP's, maybe less General, and more targeted to specific areas, and then people get sent to specific GP's which cover that band of issues. This cold work in towns and cities, but would be more difficult in smaller places, but there's no reason why it has to be the same everywhere.

I think most Pharmacies are private too, which I don't like and wouldn't want, if they were given more of the load, I'd rather this was in public ownership and may help with the ludicrous prices the people and the NHS are paying for drugs/prescriptions etc. Any drug which can be bought by the public, should not have to go via NHS prescription (or even a private pharmacy), which adds on massive cost, and wastes the trained medical staff's time.

Like I say though, I'm very much not a specialist in medicine, but I'm good at making things efficient and problem solving/ spotting, so just putting ideas out there. I'm certain there are plenty of people good at this sort of thing with much more expertise in the field, we just need to be open to changes and embrace the technology we now have. Ultimately the idea is that people with less risk, and lower level problems do not need to be taking up time/ space/ cost/ resources, which causes those with bigger problems delays and further decline of health, which ultimately requires more time, space, cost and resources to treat them.
 

exiledinboro

Well-known member
So we have a pharmacist shortage and you still want them to take on referrals?

Do you know how many serious issues I can think of alone with the that suggestion? Probably at least 20
 

Laughing

Well-known member
So we have a pharmacist shortage and you still want them to take on referrals?

Do you know how many serious issues I can think of alone with the that suggestion? Probably at least 20
It's one of those solution that seems to have some merit but only until you start to look into how it might work. I didn't know there was a shortage of pharmacists, for example so it sounded like an idea worth exploring. It maybe still is, I don't know, but until you do feasibility studies, you dont know.
 

Unravel_Morrison

Well-known member
So we have a pharmacist shortage and you still want them to take on referrals?

Do you know how many serious issues I can think of alone with the that suggestion? Probably at least 20

My local pharmacy takes on referrals and it seems to work okay.

I understand that getting every pharmacy to be forced to take on referrals wouldn't be suitable but if it can be utilised well I don't see a problem.
 

Andy_W

Well-known member
So we have a pharmacist shortage and you still want them to take on referrals?

Do you know how many serious issues I can think of alone with the that suggestion? Probably at least 20
Of course, the idea would be to increase the number of pharmacists, which I expect is easier than adding more GP's, and still crippling them with issues which could be solved with much simpler care/ treatment.

There are issues with everything, the NHS has thousands, if this adds 20 issues and saves 100 then that's a positive.

You have to be open to change, we're using a similar system to what we always have, and it's not really modernised, where there's clearly the ability to do that for some appintments.
 

exiledinboro

Well-known member
We have a multi disciplinary team here in Teesside where doctors, nurses, physios and mental health professionals and pharmacists work in a team. So it is in place now

What Stretting is referring to as doctors being gatekeepers is what’s called the single point of access. The problem is some areas have self referrals already in place for things like physio which is what he and Starmer are referring to

Let’s put it this way if a patient needs a new hip and an online referral is sent in you’re already legally responsible for that persons medical care. Secondary care won’t accept those referrals NOW without the patient being seen and a pharmacist is never going to have patients. They’re just not, nor are they going to be able to be qualified to do any investigation work such as XRs for the patient that secondary care may request before accepting the referral

They can say see a Doctor or Physio which happens now which means we’re actually not getting anywhere with pharmacists being a solution to the problems in the NHS
 

Andy_W

Well-known member
What Stretting is referring to as doctors being gatekeepers is what’s called the single point of access. The problem is some areas have self referrals already in place for things like physio which is what he and Starmer are referring to

Let’s put it this way if a patient needs a new hip and an online referral is sent in you’re already legally responsible for that persons medical care. Secondary care won’t accept those referrals NOW without the patient being seen and a pharmacist is never going to have patients. They’re just not, nor are they going to be able to be qualified to do any investigation work such as XRs for the patient that secondary care may request before accepting the referral

They can say see a Doctor or Physio which happens now which means we’re actually not getting anywhere with pharmacists being a solution to the problems in the NHS
Doctors still can be gatekeepers, but they don't need to be gatekeepers for all of it, and the aspects they do, some of that could be done online to streamline the process.

I'm not saying for a pharmacist to have a register of patients, I'm saying anyone should be able to go there for very basic care, anyone from any area to any pharmacist who signs up for it, and if it's treatable with basic care, treat them, give them some drugs and send them on their way. Put the liability on the patient, I'd happily take liability if I thought my problem was basic, if it meant easy in/ out. If I thought I had a big problem I'd go to the GP, or ideally someone who specialises in my problem, or a department which covers it.

Nobody is saying send someone who needs a new hip to a pharmacist, but equally, maybe they don't need to be seeing a GP if they're old and know they have a hip problem, things like that are so common we could have someone dedicated to that role alone, bypass the GP, or people just go to a department handling that and wait (straight to musculoskeletal, X-Ray dept or whatever). Same with many other things.

The system just doesn't work (as well as it could, even with low manpower), but it's just as much a policy, high-level management, organisational and waste problem as it is a staffing problem for those on the front line. It's also an education problem for the public, most don't know where to go for what, so go to the wrong place, taking up resources and appointments from people who went to the right place.

Here's one recent example (I've got a few). I had an impact injury to the outside of my knee, which for some reason caused foot problems, which was odd, rang 111, got passed onto someone else and within an hour I'd spoken to a specialist over the phone who talked me through some tests and said I've almost certainly got nerve damage, and need to get an MRI and see a knee & never specialist ASAP, but need to start via GP. 1 year later after getting passed around from the GP, physio and other areas (maybe 20 appointments, loads of drugs and various equipment), I finally got to see the knee & nerve specialist and it was confirmed I needed that MRI and some nerve tests and they would arrange an appointment. For some reason that never happened over the next year, and I got a call asking if I had my MRI, said no and the specialist went banana's (not at me, at their systems). Had the MRI the next week, the damage was confirmed, yet hadn't been treated for two years. It made the whole thing a waste of time and resources. I should have just been put straight on the MRI list. I'd have even went at 3am out of hours, or driven 100 miles for it, and done away with most of the 20 appointments in between. Almost every appointment said this isn't my speciality, and was all about dealing with the symptoms, not the cause. I feel guilty for how many resources I took up, by going to the wrong place over and over, before they let me go and see the person I knew I needed to see on day 1.
 

HolgateCorner

Well-known member
Doctors still can be gatekeepers, but they don't need to be gatekeepers for all of it, and the aspects they do, some of that could be done online to streamline the process.

I'm not saying for a pharmacist to have a register of patients, I'm saying anyone should be able to go there for very basic care, anyone from any area to any pharmacist who signs up for it, and if it's treatable with basic care, treat them, give them some drugs and send them on their way. Put the liability on the patient, I'd happily take liability if I thought my problem was basic, if it meant easy in/ out. If I thought I had a big problem I'd go to the GP, or ideally someone who specialises in my problem, or a department which covers it.

Nobody is saying send someone who needs a new hip to a pharmacist, but equally, maybe they don't need to be seeing a GP if they're old and know they have a hip problem, things like that are so common we could have someone dedicated to that role alone, bypass the GP, or people just go to a department handling that and wait (straight to musculoskeletal, X-Ray dept or whatever). Same with many other things.

The system just doesn't work (as well as it could, even with low manpower), but it's just as much a policy, high-level management, organisational and waste problem as it is a staffing problem for those on the front line. It's also an education problem for the public, most don't know where to go for what, so go to the wrong place, taking up resources and appointments from people who went to the right place.

Here's one recent example (I've got a few). I had an impact injury to the outside of my knee, which for some reason caused foot problems, which was odd, rang 111, got passed onto someone else and within an hour I'd spoken to a specialist over the phone who talked me through some tests and said I've almost certainly got nerve damage, and need to get an MRI and see a knee & never specialist ASAP, but need to start via GP. 1 year later after getting passed around from the GP, physio and other areas (maybe 20 appointments, loads of drugs and various equipment), I finally got to see the knee & nerve specialist and it was confirmed I needed that MRI and some nerve tests and they would arrange an appointment. For some reason that never happened over the next year, and I got a call asking if I had my MRI, said no and the specialist went banana's (not at me, at their systems). Had the MRI the next week, the damage was confirmed, yet hadn't been treated for two years. It made the whole thing a waste of time and resources. I should have just been put straight on the MRI list. I'd have even went at 3am out of hours, or driven 100 miles for it, and done away with most of the 20 appointments in between. Almost every appointment said this isn't my speciality, and was all about dealing with the symptoms, not the cause. I feel guilty for how many resources I took up, by going to the wrong place over and over, before they let me go and see the person I knew I needed to see on day 1.
More emphasis and resources should be put into preventative measures - you touched on education above. Start with schoolchildren - teach them how to stay healthy.
 

Trug

Well-known member
Of course, the idea would be to increase the number of pharmacists, which I expect is easier than adding more GP's, and still crippling them with issues which could be solved with much simpler care/ treatment.

There are issues with everything, the NHS has thousands, if this adds 20 issues and saves 100 then that's a positive.

You have to be open to change, we're using a similar system to what we always have, and it's not really modernised, where there's clearly the ability to do that for some appintments.
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