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Health concerns

This guidance explains what types of information and evidence may require us to investigate whether a social worker’s fitness to practise is impaired by reason of ill health.

Guidance on health concerns

Last updated: 6 February 2020


About this guidance

This guidance notes what types of information and evidence may require Social Work England to investigate whether a social worker’s fitness to practise is impaired by reason of ill health. It also contains guidance on how we may take these investigations forward.

The guidance is intended primarily for social workers, employers, and Social Work England staff and decision makers.

What is health impairment?

A social worker’s fitness to practise may be impaired by reason of physical or mental ill health if, when practising, they are not adequately managing a health condition so as to protect the public from any risks posed by the condition.

Being unwell does not necessarily mean a social worker’s fitness to practise is impaired. The key question is the potential risk to public safety. This depends on the nature of the health condition and on the social worker’s level of insight, in particular their willingness or ability to self-limit their practice appropriately in light of their health condition.

A social worker who has full insight into their health condition, engages and complies with recommended treatment programmes, and either limits their practice appropriately or stops practising completely when unwell, poses no risk to public safety. There’s no need for Social Work England to be involved or even to know about it.

Very often health concerns can be managed locally through an employer’s occupational health scheme, without the need to engage with us at all. A social worker who self-reports their health condition to their employer and follows the recommendations of their occupational health department and/or treating physician for treatment and work arrangements, should not be referred to us by their employer on health grounds.

Even if a question of health impairment does arise, the best outcome involves us agreeing with the social worker what level of restriction is needed to protect the public while they recover their health. Ideally this should happen without the need for a fitness to practise hearing through what we call accepted disposal (disposal of a case without a hearing).

The fitness to practise process can be stressful, which in some cases may worsen a social worker’s health condition. We want to support social workers who are unwell and to work in partnership with them to protect the public while they recover their health.

Evidence raising a fitness to practise concern about a social worker’s health

A health concern may arise when:

  • There is evidence suggesting that the social worker has a health condition of a type that could impair their ability to practise safely and
  • There is evidence either that the social worker lacks insight into their condition and its potential impact on public safety, and/or they are unwilling or incapable of seeking or following recommended treatment programmes and practice limitations to protect the public

Physical ill health will usually reduce the capacity of the person to work and so is self-limiting in terms of potential risk to the public. Examples of exceptions might be where there is evidence of uncorrected deficient sight or hearing. However, in general it is very rare for physical ill health to warrant a fitness to practise investigation.

Mental health conditions and addictions are much more likely to warrant investigation, because of their potential impact on a social worker’s exercise of competent professional judgement, and consequently on public safety.

Any objective evidence of adverse incidents, even relatively minor, potentially arising from a suspected health condition, strongly suggests the need to investigate because this points to the social worker being unable to self-manage and control their condition. For example, a finding by a court that the social worker was drunk and disorderly may suggest that they are currently unable to limit their alcohol consumption. This might suggest an alcohol dependency which could be a risk to the public.

In the first instance it might be necessary to obtain further details of the court hearing to find out more background information, such as whether the court found the incident was uncharacteristic or isolated. If an employer is concerned that a decline in the standard of a social worker’s professional performance may be health related, they should first explore this through occupational health.

Whether a fitness to practise concern requires us to investigate may depend on the strength of the evidence suggesting a health concern, and the extent to which the social worker has engaged with the employer to explore and address this possible health concern.

There must be some evidence that is characteristic of an identifiable health concern before we can investigate further. Evidence of abuse of alcohol or drugs may be obvious indicators. Other signs might be confused or delusional thinking, symptoms of clinical depression, or irrational or excessive reactions to situations.

It is not possible to give an exhaustive list of health conditions or scenarios that could suggest impairment by reason of ill health. The key questions to ask are:

  • Does the evidence suggest a type of health condition that if not managed appropriately could mean the social worker poses a risk to public safety?
  • Does the evidence suggest the social worker may lack insight into their condition, is failing to engage with reasonable requests for information about their current health or recommended treatment programmes or practice limitations, or is otherwise unable to self-manage their condition so as to protect the public?

Initial consideration

Our investigations should be the minimum necessary to establish whether the social worker currently has a health condition of a type that might risk public safety (now or in the future), and whether the social worker is managing this condition in a way that fully addresses this risk.

When concerns are first received about a social worker’s fitness to practise, we must make a triage decision about whether to open a formal investigation. Guidance to triage officers emphasises that an investigation is not required when a social worker is successfully managing their health condition and if necessary, limiting their practice so as to address the possible risk to the public arising from the condition.

If a condition is episodic and the ability of the social worker to recognise and act in response to an onset of a new episode has not yet been tested, or if the social worker has previously failed to recognise and act in response to an episode, then an investigation may be needed even if the social worker is currently well.

When we open an investigation

Consent

If we decide to investigate a health concern, we will first contact the social worker to let them know what information we have received and to give them the opportunity to add their comments.

We will ask the social worker for consent to seek further information about their health condition from their treating doctors or others who have been involved with their care such as occupational health. This will include medical records.

We will only seek information relevant to the health condition potentially affecting fitness to practise. We may also ask the social worker to consent to a health assessment and toxicology testing where drugs or alcohol use is a concern. There is more information about health assessments and testing below.

The social worker is entitled to refuse consent for us to get more information about their health condition. They can also refuse to take part in a health assessment and toxicology testing. However, without this consent, we may not be able to assess accurately the scale of risk the social worker’s current health condition may pose to the public.

This means we may need to consider the types of risk that could potentially arise from the relevant condition and seek a substantive order on this basis. Without further information into the presenting condition, it may also be necessary to seek an interim order that either prevents the social worker from working at all or limits their practice.

Our responsibility to protect the public means our decisionmakers might have to apply an order that protects the public from all possible risks including the most serious presentations of the condition in order to guarantee public safety, in the absence of accurate information about the health concern.

Our decision makers would also be entitled to take into account that social workers have a professional duty to cooperate with investigations by their employers or Social Work England into their fitness to practise. Again, this professional duty reflects that social workers should work in partnership with employers and their regulator to ensure the public is protected from risk of harm.

Decision makers will also be able to take into account a refusal to give consent or undergo assessment and testing when considering the social worker’s insight into their health condition.

Consenting to us getting more information and agreeing to health assessment and testing (where appropriate), enables us to fully understand the social worker’s state of health and the extent of any risk to the public. This means we can make well-informed decisions about whether the social worker’s fitness to practise is impaired, and what is the most proportionate level of restriction that we need to apply if so.

Health assessment

The fitness to practise rules include that ‘at any stage where the regulator is considering a case of fitness to practise by reason of the grounds of adverse physical or mental health, the investigators or adjudicators may request the registered social worker undergoes a medical assessment of their fitness to practise conducted by a healthcare professional nominated by the regulator’. For more information, see the fitness to practise rules (rule 36).

Part of this assessment may include the collection of samples for analysis when the health concern relates to drugs or alcohol abuse. However, a health case investigation can only be opened if there are reasonable grounds for investigating whether the fitness to practise of a registered social worker is impaired by reason of physical or mental ill health.

This means the purpose of health assessment is to find out what level of risk a social worker’s current health condition may pose to public safety, and to assess the social worker’s insight and understanding of the impact of the health condition on their ability to practise safely.

It is important to emphasise that health assessment is not a tool to find out if a social worker is unwell. There should already be sufficient evidence that the social worker is unwell in a way that might impact on their fitness to practise, even if the precise nature and scale of the presenting condition is yet to be confirmed.

This level of detail can then be investigated through health assessment and toxicology testing, where relevant. If the social worker is already under the care of a relevant specialist or general practitioner (GP) and is willing to consent to the specialist or GP providing us with regular reports on their current fitness to practise, then this may mean a separate health assessment is not required.

However, this may depend on the quality of the information the treating specialist or GP is able to provide and whether they are experienced in assessing fitness to practise for healthcare professionals.

The treating specialist or GP would also need to declare that they were fully aware of the concerns that had led to us opening an investigation. There is usually a fee for reports from GPs and specialists, which will vary between practitioners.

Identifying a social worker’s prognosis and treatment needs is different from assessing the risk their condition may pose in the professional setting of social work. This may mean a treating specialist or GP is not best placed to provide the sort of opinion that will help us decide about a social worker’s fitness to practise.

If in doubt, we will normally invite the social worker to a health assessment, because this ensures quality and consistency of approach in the opinions offered about fitness to practise concerns.

Health assessment is undertaken by a medical professional nominated by Social Work England, usually a doctor registered with the General Medical Council with a minimum of ten years’ experience. For mental health and addiction concerns, we will usually nominate a psychiatrist.

For other types of concern, we will nominate a doctor with clinical experience relevant to the health condition. We will select the health assessor from a pool of experts provided by our health assessment supplier. The assessor will have been appointed to this pool for their experience in assessing the impact of health conditions on health professionals’ ability to work safely.

They are otherwise entirely independent of us. We will make every effort to nominate a health assessor close to the social worker’s place of residence. The health assessor will, in most cases, carry out a physical examination.

The assessor will also take a case history covering symptoms, past history, and previous relevant health episodes. They will also ask about family and personal history, including career, education, personal relationships, hobbies and interests, and usage of alcohol and drugs.

The assessor will carry out any other tests they think they need in order to assess the social worker’s fitness to practise. We will give the health assessor copies of any relevant information we have obtained including medical records. The health assessor will produce a report to be shared with the social worker and Social Work England. This report will include a diagnosis using an internationally recognised classification system and an opinion on whether the social worker is:

  • fit to practise
  • only fit to practise with restrictions or
  • not fit to practise at all

Where relevant, a recommendation will be given about how to manage the social worker’s fitness to practise case.

The health assessment is not intended to make recommendations about treatment options, it is not our role to manage or direct a social worker’s treatment. The social worker must pursue this with their treating doctors. Our role is to determine what steps may be needed in respect of the social worker’s professional practice to protect the public while they recover their health.

The social worker may of course use or share that report with their GP or treating doctors if they find that helpful.

Sometimes, the health assessor may be unable to make a definitive diagnosis and may suggest seeking a second opinion. This would involve setting up a second assessment with a different health assessor. We fully recognise the burden this might put on to the social worker, but it may be unavoidable if we are to ensure the outcome of the investigation is proportionate and fair.

Toxicology tests

Toxicology tests are used to better understand a social worker’s drug and alcohol use. These tests will only be undertaken where there is a concern that illicit (illegal) drugs are being used or alcohol is being consumed to an excessive level. They are not used for any other health concern.

If a social worker is asked to undergo toxicology testing, it could take a number of different forms including blood, hair, fingernails/toenails, saliva, urine or breath. Often only one type of test is needed but on occasion, we may carry out two different types. The most common tests undertaken are blood and hair tests.

If testing is needed, the social worker will be given a detailed donor sheet explaining exactly how the test will be performed. The appointment will be arranged by our independent laboratory. They will explain the process and look for a mutually convenient time and location for the test to take place.

The person who collects the sample is likely be a phlebotomist, they are trained to take blood and other samples safely and hygienically. They will ensure the sample is clearly labelled and safely transported back to the laboratory for analysis. They will ask for photographic identification to ensure they are taking the sample from the correct person and will take a photograph of the person giving the sample. The appointment usually takes around 30 minutes.

Depending on the sample taken, there will either be a report produced by a forensic toxicologist or a results script with norm referencing showing what the range of normal is. The outcome of the test should be available within 2 weeks of the sample being taken. It will then be sent to Social Work England and shared with the social worker.

Toxicology tests can be undertaken in advance of the health assessment so the health assessor can use the results to assist with diagnosis and their recommendation on fitness to practise. They may also be undertaken at the request of our independent decision makers as part of a conditions of practice order, either interim or substantive.

Completed investigations

When we have completed our investigation, including any health assessment or testing, we will invite the social worker to make any further comments on the evidence we have gathered and on their current state of health.

An investigation report will then be given to 2 case examiners (a lay case examiner and a professional case examiner which will be a social worker) together with any comments submitted by the social worker that has had the concern raised about them.

If necessary, the case examiners may consult with a medically qualified adviser.

Case examiner decisions: accepted disposal

The case examiners must decide whether there is a realistic prospect that the adjudicators would find the social worker’s fitness to practise impaired.

In health cases this means deciding whether the social worker has a health condition which may pose a risk to the public if not adequately managed, and whether there is evidence calling into question the ability of the social worker to manage their condition or limit their practice adequately.

If the case examiners decide there is a realistic prospect of a finding of impairment, they will normally first explore accepted disposal as an option. This involves inviting the social worker to agree to a proposed order on their registration.

The proposed order will normally be either a conditions of practice or suspension order. Conditions of practice orders will usually be the preferred course as they allow the social worker to undertake whatever level of practice is safe as and when they are able to do so. Further guidance on orders in health cases is set out below. Whether accepted disposal is an option may depend on the social worker’s level of insight. Further guidance about how we assess insight in health cases is set out below.

If the social worker does not accept a proposed order, or if they do not engage with us, the case examiners will refer the case to the adjudicators for a fitness to practise hearing. Social workers have a professional duty to cooperate with investigations by their employers and Social Work England into their fitness to practise.

The level of engagement during the investigation is likely to be seen by the case examiners as highly relevant to whether accepted disposal is a possible option.

Interim orders in health cases

If there are immediate concerns about a risk to the public or to the social worker themselves if they continue to practise, we may seek an interim order on one or both of those grounds. We can make a referral to the adjudicators at any point during an investigation if the risk to the public or the social worker is sufficiently serious. Read more about interim orders.

An interim order can be imposed for a maximum of 18 months. After this time, any further extension would need to be agreed by the High Court. The adjudicators can order either that the social worker be suspended from practice or that they practise with restriction–this is called a conditions of practice order.

In health cases, an interim conditions of practice order may require regular reporting from a GP, the requirement to submit to toxicology testing and abstinence of drugs or alcohol. They may also require that there is workplace supervision to ensure that people with lived experience of social work are not adversely affected or a requirement to ensure the social worker engages with treatment and medical advice.

Substantive orders in health cases

If the case examiners decide there is no realistic prospect of impairment or adjudicators decide the social worker’s fitness to practise is not impaired, they can issue advice about any aspect of the case. For example, they might offer advice about the steps to be taken if the social worker suffers a relapse of a health condition that is currently in remission.

If they decide not to issue any advice, the case will be closed with no action. If the adjudicators find impairment, or the case examiners determine there is a realistic prospect of the adjudicators finding impairment, then the likely outcome in health cases is a conditions of practice or suspension order.

In theory the outcome after an impairment finding could be no action or advice. However, any impairment finding must have been based on there being a current risk to public safety. It follows that these orders are unlikely to be sufficient to provide the necessary protection.

Conditions of practice orders would need to reflect the presenting condition and the consequential level of risk in the particular case but will usually include some or all of the following:

  • The social worker must appoint a medical supervisor for the case.
  • The social worker must remain under the supervision of the medical supervisor and should undergo any tests or assessments as and when requested or arranged by the medical supervisor.
  • The social worker must remain under the care of their treating doctors and must follow their recommendations about their treatment and their fitness for work.
  • The social worker should consent to the exchange of information and reports about their health between their medical supervisor, treating doctors, employers, and Social Work England.
  • The social worker must cease or limit their practice immediately if advised to do so by their medical supervisor or treating doctors.

Conditions of practice orders may not provide sufficient protection if there is evidence raising doubt about whether the social worker will be able or willing to comply with the order.

Decision makers should be slow to include conditions that are more about treatment and progress to recovery, rather than directly about managing risk to the public. For example, a condition to abstain from alcohol would require the social worker to be free from dependency. This may be a goal to be achieved in order to regain fitness to practise but may be challenging to the point of being unachievable while the social worker is still unwell and fitness to practise remains impaired.

The medical supervisor or treating doctor can require the social worker to cease practice if they relapse into abusing alcohol, and if necessary the case can then be listed for early review to see if more restrictive conditions or a suspension is required.

Conditions of practice orders should set the supervisory framework to protect the public and to support and monitor the social worker while they recover their health. Conditions of practice orders do not need to include drivers or goals in the treatment programme. That is for discussion and agreement between the social worker and their treating doctors.

A suspension order may be required if the social worker is not engaging, is not currently capable of complying with conditions, or there are no workable conditions that could be put in place to protect the public. Even if the social worker is engaging, in some circumstances suspension may be a supportive outcome in a health case because it removes the pressure on the social worker to return to work while they recover.

The social worker can ask for an early review of the suspension if they recover their health sufficiently enough to contemplate a phased return to work under a conditions of practice order. Although a suspension order cannot directly include requirements such as that the social worker remains under medical supervision, the reasons for the order should be clear about what a future reviewing panel will expect of the social worker, this is called a recommendation.

A social worker may be able to present positive evidence of insight and engagement to a review hearing where they have successfully followed these recommendations. This could include that the social worker undergoes a health assessment shortly before the end of the period of suspension. View our guidance for suspended social workers

While orders are in place

Where the social worker is under a conditions of practice order, we will keep in touch with the social worker’s medical supervisor or GP. The medical supervisor may invite the social worker to a further health assessment.

In cases of addiction, medical supervision will usually include repeated toxicology testing. The type and frequency of assessments and testing is a matter for the medical supervisor’s professional judgement. It may also be set out by the case examiners or adjudicators in their decision.

The medical supervisor may arrange for unannounced blood or hair testing, if there is concern the social worker may otherwise only abstain from alcohol or drugs use in anticipation of a scheduled test. This can also be arranged by Social Work England.

Reviews of orders

Orders for conditions of practice or suspension must be reviewed before they expire. We can direct an early review if circumstances change, for example if the current order is no longer sufficient to protect the public, is no longer workable, or is no longer necessary and can be reduced or removed.

We will consider whether to direct an early review as and when we receive further evidence about the social worker’s current state of health and how this affects any potential risk to the public. It’s therefore very important that the social worker keeps us informed of any such evidence and continues to allow us to engage with treating doctors and medical supervisors.

Where the social worker has been subject to a conditions of practice or suspension order imposed by the adjudicators for more than 2 years continuously, the adjudicators can consider directing a removal order. In health cases this is the likely outcome if the social worker has failed to engage during the life of the case.

Publishing decisions

We are required to publish decisions in fitness to practise cases, including those agreed through the accepted disposal route. As far as possible, any information capable of identifying the nature of the health condition will be put in a confidential annex to the decision and will not be published. This might include some conditions in a conditions of practice order, for example a requirement to be under the care of a treating psychiatrist, or to undergo toxicology testing for drug or alcohol abuse.

We may need to share the confidential annex with current or prospective employers or medical professionals. We will not share it with any complainant in the case. We will inform the social worker if and when we share the information with others.

Convictions for driving while under the influence of alcohol

Driving while under the influence of alcohol is a criminal offence and as such will result in an investigation of impaired fitness to practise by reason of the conviction. Any abuse of alcohol that contributes to a social worker’s criminal conviction must raise the possibility that the social worker is not able to control their use of alcohol within safe limits. This in turn raises questions about possible risk to the public.

Such questions also raise concerns about public confidence in the profession. The public would expect us to inquire into the health of a social worker who has abused alcohol to the extent of committing a criminal offence. Therefore, a conviction for driving under the influence of alcohol gives grounds for us to investigate whether the social worker’s fitness to practise is impaired by reason of health.

The level of alcohol reading that led to the conviction is generally of limited help in assessing fitness to practise and we will take steps to investigate the possible health concern, such as a health assessment and/or toxicology testing.

Cases with other grounds of impairment

Very often, health is one factor in a case where there are other grounds of impairment. In many of these cases there will be a direct link between these grounds. For example, a conviction for driving while under the influence of alcohol points to grounds for impairment by reason of conviction and health.

In conduct or capability or competence cases, health may be a factor which has contributed to the events giving rise to the other grounds of impairment. A key consideration in deciding what order may be proportionate is whether the ill health caused the other concerns. For example, lack of capability or competence might be as a result of an impairing health condition, especially mental illness.

Investigation of health in these cases may need to explore whether recovery from the ill health is likely to result in remediation of the capability or competence concern. In some exceptional cases, it may be that the lack of competence or capability is entirely explained by ill health, in which case a finding of impairment on health grounds alone may be appropriate.

However, in conduct cases, the presence of a health condition is very unlikely to explain misconduct such as to remove the need for us to investigate it. Illness is not usually accepted as a defence to offences of bad character. Furthermore, maintaining public confidence in, and the professional standards of, social workers requires that we act in response to serious misconduct, even if the misconduct is linked to ill health.

In some cases this may even require a removal order for the conduct element. An example might be stealing drugs from a service user for personal use. The issues of dishonesty, abuse of trust, and risk to the safety of the service user would mean that a removal order might be inevitable, even if the social worker’s drug addiction explained the behaviour.

It is very important that if social workers believe health to be a factor in cases of conduct, capability or competence, they indicate this at the outset of a fitness to practise investigation and submit any supporting medical evidence to us. Decisionmakers may give submissions about ill health less weight if these are only made at the time they are making a final decision on disposal of the case.

Insight

Insight is a very important factor in a social worker’s fitness to practise, because the level of insight is directly linked to the risk of repetition. Insight usually requires full acceptance of the alleged facts that support a ground of impairment, including an understanding of what circumstances led the social worker to act as they did and how this might be avoided in the future.

A social worker may be asked to produce a reflective piece to demonstrate their insight. Insight is especially relevant in cases of accepted disposal, which will not normally be available if the social worker does not accept the facts that are core to the question of impairment. However, in health cases, the social worker may have limited or no control over the onset of or relapse into a health condition, so the question of insight is less relevant to the risk of repetition.

In some health conditions, the very nature of the condition may also compromise the capacity of the social worker to have full insight. Particularly in mental illness, the social worker may be unable or unwilling to accept the diagnosis or the severity of their illness. Because insight may be a function of the social worker’s health condition, it may be unrealistic to demand that the social worker displays complete insight into the facts of their illness while they recover their health.

The important factors in terms of future risk are whether the social worker has sufficient insight to recognise the onset of symptoms of their illness, to act appropriately by limiting or stopping practising as necessary, and to fully engage with whatever protective and supportive measures are in place to manage their condition.

In other words, a social worker may be capable of engaging with the regulatory process including agreeing the primary importance of public protection, identifying and accepting when they may need to limit or stop their practice, and following any recommendations and directions about managing their condition.

This might amount to sufficient insight even if the social worker may not accept the diagnosis or description of their condition. For example, a social worker may be unwilling to accept that they have a drug dependency but may nonetheless be willing to submit to medical supervision, toxicology testing and limitations on their practice.

In conditions of an episodic nature such as bipolar disorder, it is important the social worker is capable of recognising the symptoms at the onset of an episode and of taking the necessary steps to limit or suspend their practice and to seek help. This might include agreeing to colleagues being made aware of the position so that they can help the social worker into the support systems when these symptoms appear. Whether or not the social worker accepts the bipolar disorder diagnosis is of less importance than whether they accept these supportive and protective measures.

Health conditions in remission

Whether a social worker whose health condition is in remission is fit to practise will depend on the risk of relapse and whether the social worker has demonstrated sufficient insight to seek help and support and to limit their practice where necessary in response to a new episode.

As this guidance has emphasised throughout, being unwell is not the defining factor in whether fitness to practise is impaired. The core issue is the capacity of the social worker to self-manage their condition and to limit their practice as necessary to protect the public.

If the social worker has previously not been able to manage their condition adequately, or if this has not yet been tested, for example by returning to work, then we may need to maintain a fitness to practise order on the social worker’s registration until this can be assessed further, even if the health condition is in remission.

Updated health assessments may help guide any decision on whether the social worker has sufficient insight to self-manage their condition and their practice in response to a new episode.

Pausing the process

If a social worker’s illness is so severe that it prevents them from engaging with us, then we will not progress a fitness to practise case until they are well enough to do so. We will usually need a medical report to confirm that the current health condition means the social worker is incapable of taking part in the fitness to practise case.

We will usually need to seek an interim suspension order to protect the public while the case is on hold. In some cases, engaging with us may add to a social worker’s stress and may make their condition worse.

On request we can consider pausing a health investigation to allow time for a social worker who is not currently practising to recover enough to engage with us. Again, we will probably need to seek an interim suspension order. We will not usually be able to pause an investigation if there are other grounds of impairment in the case, because of the public interest in us determining those other grounds, and because of the risk that evidence about those other grounds could go stale.

These can be complex decisions, and we will need to assess each case on its facts. However, we are committed to being as supportive as we can of social workers when they are ill, while meeting our responsibility to protect the public.

Voluntary removal

Voluntary removal is where a social worker requests for their name to be removed from the register. There are specific circumstances where this may be available. 

Support

We acknowledge the pressures that social workers face and we appreciate the impact that the fitness to practise process can have, particularly for those in ill health. We would encourage social workers to access dedicated support services. View details of services that may be able to assist.

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