Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the Lancashire Care Association (DD 15)


  1.1  The LCA is the representative body of independent Nursing, Residential and Domiciliary providers in Lancashire. It is established as a limited company and has a board of directors, who are homeowners and domiciliary care providers, representing all areas of the County. Its aim is to provide advice and support to its 400 members, to represent its members at National, Regional and Local levels in political and officer forums. Its members currently provide over 7,000 beds in residential and nursing homes in Lancashire.

  1.2  The LCA members are committed to ensuring Older People and other Vulnerable Adults are provided with the highest standard of services to meet their needs. To this end it has promoted training for staff in the sector by accessing £2 million in European Funding over the last two years.

  1.3  The LCA is heavily involved across health communities in Lancashire in National Services Framework for Older People, Local Implementation Groups, Capacity Planning Groups and Intermediate Care planning groups.

  1.4  The experience of the LCA's officers and Board is considerable. The LCA's full time Chief Executive has 12 years experience working as Chief Officer for a local Age Concern Group and who has also worked on secondment to the Social Services Inspectorate and recently the Regional Health Authority "Change Agent" and older people's NSF Monitoring Team.


  2.1  The LCA welcomes the opportunity to comment on the area of delayed discharge from hospital. Our evidence will focus on what are some of the reasons why this is such a problem. Our views are the product of many years direct experience in and involvement in the Health and Social Care Sector, background documents such as the National Beds Inquiry, Audit Commission and Social Services Inspectorate Reports, Research Papers and reports of academic bodies such as Rowntree Foundation.

  2.2  In the time available we have only been able to raise what we see as the broad reasons behind the problems of delayed discharge. Much can be validated by detailed statistical and academic references that we are sure the Select Committee will have access to. We would be happy to elaborate on this evidence via direct questioning if the Select Committee so wished. We have shared this paper with the Independent Healthcare Association, Registered Nursing Homes Association and the National Care Homes Association and the British Medical Association.

  2.3  In order to understand the problem of delayed discharge we believe you have to take a historical perspective, over at least the last 20 years, and look at many factors, including socio-economic and demographic, that have culminated in what is seen as the problem of "delayed discharge". This includes the reasons why so many elderly people are admitted into hospital in the first place and what can be done to prevent this.

  2.4  Our evidence will focus largely on the problems of older people as the National Bed Inquiry indicated that this was the biggest group of consumers occupying acute hospital beds. It is the over 75s that have until recently, been counted as delayed discharges in the CITREP reports.

  2.5  There is no one reason but many inter-related factors that culminate in the problem of "delayed discharge" and significant pressure on acute beds in NHS hospitals.


  3.1  The Department of Health definition is "a person is delayed in discharge when they are medically fit to move from an acute bed". Reasons for delay can be related to:

    —  Delays in assessment by social services, allied health professionals or nurses.

    —  Delays in decision-making on commissioning community based or intermediate care services. (There are perverse incentives for Local Authorities to delay as many cases as possible to save money on their budgets).

    —  Budget blocks from local authorities—person stays in hospital because they are considered by the local authority to be "safe" and therefore not a priority case.

  3.2  It must be recognised that the numbers of delayed discharges as measured by the SITREP statistics are not an accurate reflection of when someone is fit for discharge.

  3.3  The point when someone is medically fit and do not need an acute bed will depend on the views of the clinician. Following this, the next question that needs to be asked is "what services are available to meet the patient's needs"? For example, if there is a good network of intermediate care facilities in the locality, that the secondary and primary care staff have confidence in, then a patient could be discharged much earlier than if no such facilities exist, or bureaucratic or professional barriers delay such action. This is the thinking that underpins the Government's strategy to manage the supply of beds by developing intermediate care service.

  3.4  There are also problems of delayed transfer that regional specialities face. They take a patient into a regional speciality, treat the patient to the point that they can be transferred to their nearest host hospital but that hospital has no bed for them—more often because they are blocked with older people who, as research has shown, simply do not need to be there.


  Delayed Discharge and Acute Sector Capacity is a relatively new phenomena. Prior to 1993, when hospitals had direct access to residential and nursing home care, there were not any problems with capacity and delayed discharge.

  The previous time in recent history was the 1970s, before the significant investment by the independent sector in the 1980s, when the main providers of residential care were Social Services departments. In those days swap systems often operated between geriatric beds as they were then and Local Authority Homes.

  This evidence will concentrate on a wide range of factors which impact on delayed discharges and capacity problems in the acute NHS:

    —  Demographic and Social Change.

    —  NHS withdrawal from long term care.

    —  The care in Community Agenda as implemented by Social.

    —  Services Departments—including paying un-economical fee levels for residential and nursing home care.

    —  Over Stretched Primary Care Services.

    —  Differential priorities between Social Services and Health.

    —  Limited effective partnerships with Health, Social Services and Independent Sector.

    —  Failure of Social Services and Health to think laterally.

    —  Manpower Crisis.

    —  The Assessment and Care Management Process.

  The solutions are seen to revolve in many areas around:

    —  Developing Care Trusts for Older people's services.

    —  Developing effective strategic partnerships with quality Independent Sector providers.

    —  Paying realistic fees to residential and nursing home providers and managing the market more effectively.

    —  Streamline the assessment process.


5.1  Demographic and Social Changes

  5.1.1  It is a fact that the proportion of elderly in the population has risen significantly including the over 85s who tend to be in poorer health and have a wide range of disabilities and who require help to have their everyday needs for food, washing, dressing and cleaning met by informal or formal carers.

  5.1.2  Advances in medical care have led to people living longer.

  5.1.3  Family living patterns have changed over the last 50 years. There is greater mobility and fragmentation of families leaving many elderly people isolated.

  5.1.4  If they have sons or daughters they can often be in there 60s or 70s caring for an 80 or 90 year old parent.

  5.1.5  Family carers tend to be women. Changes have occurred in the workforce with over 50 per cent of women now working. These are often the main or a vital part of economic stability of a household. This leads to inability to care for family members or greater stress trying to juggle family and childcare, work and caring roles.

  5.1.6  In the last 30 years the role of organised care, via Local Authority Social Services Departments, has developed to try and fill some of the gaps created by social, economic and demographic changes.

  5.1.7  The percentage of over 85s is set to rise significantly over the next 30 years and if medical and nursing care continues to prolong life the number of over 90 year olds is likely to increase even more significantly.

  5.1.8  The focus of local authorities upon higher dependency needs people has caused the removal of many low level services which were supporting people at home.

  5.1.9  The trend to persuade more and more people that they can be cared for despite increasing dependencies at home has lead to a "revolving door" effect of older people going in and out of hospital on a regular basis.

  5.1.10  The effective removal in 1993 of the GP's option to transfer someone from their own home to a nursing home effectively means he/she has no option other than to refer to hospital any older person who needs a period of 24 hour care, ie, someone with a chest infection. This effectively soaks up masses of unnecessary NHS resource.

5.2  NHS Withdrawal From Long Term Care of the Elderly

  5.2.1  The Social Security changes in the early 1980s led to a major expansion of the independent sector residential and nursing home sector. Many NHS managers actively worked to close, often out dated and poor long stay wards or hospitals for elderly people. New people who required longer-term care were referred to the independent sector and their care was funded by Social Security benefits for those who met the income and capital rules.

  5.2.2  The growth in social security payments for people in long-term care grew exponentially during the 1980s from a few million to over £2 billion when Sir Roy Griffiths produced his Care in the Community Report in 1988.

  5.2.3  The resources released within the NHS were diverted to mange the wide range of new treatments, demands and cost pressures it was facing.

5.3  The Care in Community Policy Agenda

  5.3.1  The Griffith's Report published in the late 1980s heralded a shift from an over reliance on residential care to a more balanced policy of providing a range of options including more capacity to enable people to live at home. The ensuing Government response in the form of the Community Care Act 1990, gave Local Authority Social Services Departments the funds, currently in the Social Security budget, and the responsibility to assess and commission appropriate services including domiciliary, residential and nursing home care.

  5.3.2  Whilst the Care in the Community Policy agenda was initially driven by the Treasury's wish to cap the Social Security budget spend on residential and nursing home care it was broadly welcomed by Local Authorities. Social Services professionals, driven on by the Audit Commission and Social Services Inspectorate, have actively kept more frail and elderly people in their own homes. There is in reality a paucity of research based evidence to suggest that this is always in the service users best interests. Certainly isolation and other issues are given scant regard in the information put forward. It should be remembered that there was no real delayed discharge and capacity issues prior to 1993 when Social Services became the gatekeeper of the cash limited budget.

  5.3.3  Local Social Services, over the last eight years, have to a greater or lesser extent seen, a placement of an elderly person in residential and nursing care as a failure and have worked very hard to keep people at home. This is in stark contrast to what the vast majority of people and their families actually say about their experiences in care homes. They frequently report how their lives were transformed by the experience, how safe and inclusive they feel etc, etc. The comments are often in stark contrast to the fear and isolation experienced by many persuaded to stay at home (See Age Concern's research in this area). Despite academic and social workers fashionable spin on residential care, the verifiable reality is that for the vast majority of the millions of people cared for over the last 20 years or so and for the ½ million currently in care, the move to residential care has been a very positive experience indeed. Yet ironically nothing has been done to seek these positive views from the service users or their families, why?

  5.3.4  Whilst not decrying that many people want to stay at home for as long as they can it is the LCA's view based on experience of members who provide domiciliary and residential services to thousands of people, that a great many people are coerced into staying at home when they would prefer (and be far better cared for) to move to residential or nursing care.

  5.3.5  Social Services, for budgetary reasons, have set assessment criteria so that only a very small number of the most needy people qualify for full nursing care. The Department of Health and Laing and Buision statistics confirm that the placement rate in nursing homes has declined faster than residential and that the closure rate of Nursing Homes has been higher than residential care homes. Many Nursing Homes have also had to dual register and accept older people as residential customers just to survive.

  5.3.6  The policy of raising the threshold of who can enter a nursing home—in Lancashire they have to require more than five hours nursing care a day before they can enter a nursing home—means that many frail elderly are not having the specialist 24 hour nursing care that prevents many health problems occurring. (One does not receive five hours of nursing care on an acute medical ward). It has also placed greater demands on the GP and Primary Care Services. Are we surprised the knock on effect is being felt within the NHS?

  5.3.7  The policy of keeping more very frail elderly people in their own homes, often with limited domiciliary and health services support, has had an even greater impact. The fact that the commissioning agency (Social Services) only picks up part of the bill, Primary Health and Housing Benefit being the other components makes it superficially attractive. The elderly person's overall health is more unstable and they are vulnerable to illness and hence it is a very high-risk strategy in terms of admissions to hospital. For many, the real experience of domiciliary care amounts to an unpredictable service by definition. How can this possibly compare to the holistic experience in residential care of someone on hand 24 hours to attend to your every need?

  5.3.8  When frail elderly people do become ill the only option is for them to be admitted to an acute hospital. Their conditions—often multiple medical conditions exacerbated by dehydration, malnutrition and depression, in older people living on their own created through loneliness, all lead to longer admission times. Discharge home requires the starting or restarting of complex packages of care which takes Social Services more time to assess and commission. The "revolving door" effect of admission, home, readmission is a sad fact of life for substantial numbers of older people in England today. Simply because the right care is not being effectively accessed at the right place at the right time.

5.4  Over stretched Primary Care services

  5.4.1  The reduction in length of stay across all specialists in acute hospitals, the reduction in acute NHS beds and the Care in Community policy have all placed additional pressures and demands on GPs and the Primary Care Service.

  5.4.2  There is now an emerging crisis in Primary Care with increasing difficulty in training and recruiting GPs to replace those retiring or to meet increased demands. The shortage of District Nurses and Allied Health Professionals working in the community all add to pressures and patients not getting an adequate service.

  5.4.3  Intermediate Care—one of the key Government strategies to manage the capacity problem in the NHS—will also place additional pressure on GPs unless additional resources are invested here.

  5.4.4.  Given their inability to directly access nursing or residential home beds since 1993, the impact of the Care in the Community Policy, an increasingly elderly population on their lists, limited community care support services and the general frailty and complex mix of health problems presented, it is not surprising, that GPs seek a hospital admission when faced with a vulnerable and perhaps poorly supported elderly person in a home setting.

  5.4.5.  There are some indications that the compensation culture which has developed in Britain in the last 10 years may also impact on GPs decision making about whether to admit someone to hospital. The issues around defensive medicine clearly need greater exploration with the representatives of the medical profession.

  5.4.6  The bureaucracy and red tape which binds and ensnares all and costs professionals in this arena adds significantly to delays, frustrating GPs and de-motivating service providers at every level. The effect of this should not be under-estimated.

5.5  Policy agendas of Health and Social Services

  5.5.1  It is only relatively recently (circa last three years) that the Health and Social Services Policy agenda has been looked at in a combined manner. Only in the last year have the two arms of the Department of Health been integrated.

  5.5.2  The focus of the National Services Frameworks, "whole systems" thinking and planning, Health Promotion and linking health to the wider community agenda of housing, income, employment etc has brought the NHS and Local Government closer together.

  5.5.3  "Working together" and "developing strategic partnerships" is still rather embryonic in many areas and is a process that will take considerable time and effort to ensure it happens. In particular, whilst some of the barriers between public and private sector partnerships have been broken down, attitudes and the lack of positive incentives are preventing this rolling out across the Country in the way the Government might wish. Without a fundamental reform, the whole policy shift runs a high risk of stagnation.

  5.5.4  Meanwhile it should not be assumed that the implementation of Government Policy on, for example, minimising delayed discharges will be given the same priority by Local Authority Social Services Departments as the NHS.

  5.5.5  It will not work if Local Authorities cap budgets and only allow so many placements in residential and nursing homes (two-out one-in schemes, etc) or very limited domiciliary packages of care a week or month.

  5.5.6  The Government realised the problems of under-funding when it announced the £300 million Building Capacity money in October 2001. This had two objectives—1) to stabilise the residential and nursing home sector by increasing placements and starting to address the problems of grossly inadequate fee rates and 2) eliminate delayed discharges by 2004. The response to this by Local Authorities has at best been patchy and inconsistent.

  5.5.7  Local authorities are struggling to cope with the demands of people already at home, as well as other budget pressures on child care services, so when someone is in hospital it actually relieves pressure on staff and budgets.

5.6  Limited effective partnerships between Local Government, the NHS and Independent Sector

  5.6.1  Whilst there has been exhortation at a Government Policy level for Health and Social Services to plan and work together for 30 years the results have been patchy and broadly at the margin of each organisation's main independent agenda.

  5.6.2  Joint planning and joint finance was introduced in the early 1970s. However, evidence suggests that real joint working only developed in areas where there were champions willing and wishing to work closely together. In 90 per cent of the country what joint working there was, centred on the relatively marginal activity of spending "Joint Finance" monies.

  5.6.3  The Community Care Act 1990 was supposed to see greater joint working between health and social services but the results have again at best been tentative. Indeed cost shunting (deliberate or un-intended) still occurs between health and social services. Local Authority policies of placing increasing proportions of people in residential care has cost the District Nursing service dearly as they have to visit to assess and provide nursing care to an increasingly dependent group of residents.

  5.6.4  The policy of keeping severely disabled elderly people in their own homes, even sometimes against their wishes, has cost the NHS dearly.

  5.6.5  Bizarrely nurses in dual registered nursing homes have had to stand by waiting and watching a District Nurse give an injection or change a dressing as it is not legal for them to undertake this task on residential clients. This may change with the implementation of the single Care Home under the Care Standards Act from 2002 but only if realistic and sustainable fees are paid to such homes.

  5.6.6  It is only in the last two years that a new attempt has been made to promote partnership working between Health and Social Services. Apart from PFI initiates, using private sector resources to build hospitals, the independent sector has only featured in policy guidance from the Department of Health in the last year or so.

  5.6.7  The political debate about the role of the independent sector in the NHS has not helped develop effective partnerships although Concordat 1 and 2 has helped the process in the last 18 months. Actual evidence of new contracts is however extremely sparse in percentage terms.

  5.6.8  Two to three years ago Members of the LCA were knocking on doors of both NHS Commissioners and Trusts offering partnership proposals only to be told they were not interested. Even now, relatively few partnership schemes exist, why? One of our members in 1997 built a six-bedded extension to specification having been selected as the "preferred provider". The trust prevaricated and the home still awaits its first "continuing care" patient.

5.7  Failure of Social Services or Health Authorities to think laterally or use expertise in Independent Sector

  5.7.1  It is clear that the National Beds Inquiry, the NHS Plan and the Modernisation agenda have started to focus manager's minds in both Health and Social Services. There is embryonic broadening of thinking and whole system approaches, but it is thinly spread and significantly hampered by the massive organisational changes affecting the NHS at the moment.

  5.7.2  Until recently there has been a paucity of imagination in much of local government and health service planning. Whilst some local partnerships have developed between health and social services or with the independent sector they are the limited in number and scope.

  5.7.3  Many managers and clinicians have not been brought up in a culture of thinking "out of the box". Hence the majority of solutions to problems have been limited to the tried and tested with the inordinate request for new money rather than any thinking laterally and analysing whether existing resources can be re-engineered or used more appropriately. A good example has been how local authorities like Lancashire have held onto their stock of Old People's homes (some 48 of them) when many are well past modern standards and are significantly more costly to run than services provided in the independent sector and run at low occupancy.

5.8  Failure by Social Services to Properly Understand and Manage the Independent Residential and Nursing Sector

  5.8.1  Social Services were handed a poisoned chalice in 1993; they had to cash limit the out-of-control social security budget and develop new ways of commissioning services rather than providing them. Very few had any experience of working in business; few had knowledge or any interest in the economics of business including rates of return. There was not a culture of planning based on aggregating assessed needs and setting out clearly what the new commissioners of services wanted. The culture had been built up around largely managing and protecting in house services.

  5.8.2  Social Services in many areas of the country have singularly failed to work effectively with the large residential and nursing home market. (Remember there are still more beds—379,200 beds for older people—in the independent sector than the whole of the NHS).

  5.8.3  Social Services have suppressed fees and restricted placements to the point were many homes have become un-viable. Little building is going on to replace the old converted stock to achieve the standards that are set out under the Care Standards Act 2000. The economics of a new build home, on the majority of fee rates paid by local authorities, are simply not viable nor sustainable—banks will not lend! Exceptions to this are occurring around the London area where fees are being set at a level where operators will build and run homes.

  5.8.4  The result is that many homeowners have shut their doors and sold for the price of the land or building to be used for alternatives. In areas of the South East, South Coast and the North there are now insufficient places for the needs.

  5.8.5  Social Services, whilst stimulating the Domiciliary Market (to some extent artificially), have again tried to force providers to accept fees that do not enable providers to meet the challenge of providing quality training and the infrastructure to develop effective care services.

  5.8.6  The LCA is of the view that some of this has been created by mismanagement of social services budgets but it must also be recognised that demand has grown far in excess of any real increase in their base budgets.

  5.8.7  Other pressures on social services in particular on their child care budgets has led to cross subsiding of children's services from monies allocated in the SSA process to elderly services. The reluctance of Local Authorities to have ring-fenced budgets enables this to occur.

5.9  Manpower crisis

  5.9.1  There is a national shortage in qualified nurses that is well documented. The Government projections for the numbers of new nurses are woefully inadequate given the expansion of the NHS currently underway. Currently each new initiative—NHS Direct, Intermediate Care, Intensive Care Beds, Improvements to A&E all lead to existing nurses moving to new jobs and their existing wards or community posts denuded.

  5.9.2  Whilst the LCA do not like the use of agency nurses, not least because of the cost but more importantly because of the effect on quality and continuity of care, even the agencies are struggling to supply the NHS and Independent sector needs.

  5.9.3  Whilst the LCA welcomes the general health of the economy it is clear that both the NHS and residential and domiciliary services are struggling to find sufficient care assistant staff who wish to work in such demanding and yet relatively poorly paid jobs.

  5.9.4  Few Local or Health Authorities have undertaken a detailed manpower projection of the impact of their Care in Community policies. However, given the projected rise in very frail elderly who will require significant amounts of care it is expected that there will need to be a significant increase in the numbers of paid carer workers.

  5.9.5  There are many examples locally of an inability to recruit care staff to work in the community or residential homes. In other areas with a more buoyant economy the problems are more intense. Whilst some of this could be remedied by local authorities paying more realistic fees, thus enabling providers to pay more competitive rates this alone will not solve the problem.

  5.9.6  The LCA believe that the shift in demographics and the rise in the 85 years plus population coupled with near full employment will mean that the overall policy of keeping very highly dependent people at home will have to be reviewed. The challenge faced by politicians is, will this be done sooner or later?

  5.9.7  The National Statistics Office have recently published a report that suggests that to meet the needs of the rapidly increasing over 85s in the next 30 years some 65 per cent more beds in residential and nursing homes will be required! This is a significantly more cost effective and less staff intensive solution. If the solution is to keep them at home or in extra care housing schemes, then this will be both more costly and more staff intensive and probably unsustainable. Moreover, it is far from proven that this is what people actually want.

  5.9.8  Whilst the NHS and independent sector are currently recruiting qualified nurses to fill vacancies, it may be, given the balance of our population, that we have to look to recruit care assistants from abroad to fill the labour gap.

5.10  The care assessment and commissioning process

  5.10.1  The joint assessment procedures recommended to implement the Care in Community legislation have in the main not been implemented. Indeed the Department of Health's NHS Plan has focussed again on a "Single Assessment Process" which has to be in place by 2004.

  5.10.2  The community care assessment and commissioning process can be overly complex, not started soon enough when someone enters hospital or is close to discharge. If assessments only start when a doctor says someone is fit for discharge then by definition delayed discharges will occur however speedy the subsequent assessment.

  5.10.3  Allocation panels can be used as a means of slowing down the commissioning of a community or residential package. If panels sit weekly and papers miss the deadline for consideration then another week goes by with the patient taking up an acute bed when they do not need it.

  5.10.4  Rigid budget setting by Local Authorities which bear no relation to demand create delays. In an area which borders Lancashire but affects Lancashire hospitals there are around 140 delayed discharges some of whom are waiting months for a community placement. The mismanagement of the care market in Cumbria has led to a contraction of the market and now money has been released through Building Capacity Grant there are not the places available to purchase. The fees are still too low for providers to start building and there is no surety that the Local Authority will purchase beds on a longer-term basis if they are built.


  6.1  Given the experience of the failure in Lancashire, and many other areas, to develop effective strategic partnerships and any semblance of pooled budgets the LCA would like to see urgent direction by the Secretary of State for Health to create "Care Trusts" for Older People.

  6.2  This would create one organisation, under the leadership of the NHS with an accountable Chief Executive, with one agenda and the ability to make things happen. This would reduce duplication and waste and lead to more innovative solutions being developed more quickly. Currently the blame culture can shift responsibility between health and social services, and local politicians can also blame central government for not funding their budget adequately. Arguments abound about the real year on year increases provided to local authorities with the Government telling us that there has been a 3-4 per cent real increase in funds and the local authority saying they have lost money. The outcome has been eight years of the care sector suffering major cost pressures that have simply not been recognised by appropriate fee increases. The current agenda is not totally shared—the emphasis still varies between health and social services.

  6.3  Develop strategic partnerships with Independent Sector with significant block contracts over a minimum of three years for new Intermediate Care services at prices that are independently shown to be economically viable.

  6.4  Raise fees for domiciliary, residential and nursing home care to rates which are viable and enables providers to attract staff and retain them. The National Care Coalition estimated that the residential and nursing home sector needed an injection of £1.5 billion in 2002-03. In 2001 the Rowntree Foundation estimated the social care sector needed £700 million just to stem the crisis in social care provision.

  6.5  Develop strategies and plans based on clear understanding of need and projected increase in demand, which are sustainable both financially and in terms of manpower.

  6.6  NHS Trusts to charge Social Services or other Trusts when awaiting a transfer back to a hospital of origin, the actual cost of the acute bed when a patient is delayed more than one week after a decision is made that they are fit for discharge or transfer. (It is understood that a hospital trust in Bristol is about to implement such a policy due to frustrations over social services delayed discharges).

  6.7  The recently established Change Agent Team be enabled to impose on Health & Social Care systems with significant problems of delayed discharge the solutions they must follow. Failure to achieve target reductions be utilised as a trigger to establish a Care Trust or replace NHS managers who have failed to implement changes.

  6.8  Streamline the assessment commissioning process and abolish allocation panels. Delegate decisions to front line managers to commission services quickly and efficiently.

  6.9  Implementation of Best Value within HA's/Trusts.

  6.10  Creation of real incentives towards the achievement of joint working.

  6.11  Transparent and wider publishing of areas of good practice and those poorly performing in terms of partnership working, with far greater use of internet technology for these purposes.

  6.12  Finally, the older people we serve, deserve the development of a system that will brush aside the old excuses for inaction and facilitate real action in time for them to enjoy better and more integrated services now.

18 January 2001

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