Proposed Government Plan 2022-2025 (P.90/2021): fifteenth amendment. Health Insurance Fund funding

STATES OF JERSEY

PROPOSED GOVERNMENT PLAN 2022- 2025 (P.90/2021): FIFTEENTH AMENDMENT

HEALTH INSURANCE FUND FUNDING

Lodged au Greffe on 30th November 2021 by the Health and Social Security Scrutiny Panel

STATES GREFFE

2021  P.90 Amd.(15)

PROPOSED GOVERNMENT PLAN 2022-2025 (P.90/2021): FIFTEENTH AMENDMENT

____________

1  PAGE 2, PARAGRAPH (I)

After the words "as set out at Appendix 3 to the Report" insert the words–

"except that, on page 168 under "Health Insurance Fund" the following words be inserted:

The following safeguards and transparency measures will be put in place in relation to the establishment of the Jersey Care Model:

• The independent non-executive board (establishment of which was approved in P.114/2020) will be supported to publish a review of the Tranche  1 and  the  use  of  2021  funding  by  the  end of March 2022 at the very latest; and

• The  digital  health  team  within  Modernisation  and  Digital establishes  a  protected,  separately  resourced  sub-team  (that includes a Manager grade role), to focus solely on the delivery of the  Jersey  Care  Model  digital  systems,  and  the  Digital  Care Strategy. Regular  updates  on  these  workstreams  should  be regularly reported on to the independent JCM programme board and the Health and Social Security Scrutiny Panel.

The following safeguards and transparency measures will be put in place in relation to the operation of, and any transfers made out of, the Health Insurance Fund:

• The Minister for Health and Social Services will annually publish a report, which will also be presented in advance to the Health and Social Security Scrutiny Panel, to detail the information provided to the Minister for Social Security relating to the costs incurred on the  Jersey  Care  Model  that  require  a  transfer  of  funds  from the HIF;

• The Minister for Social Security will publish a report, within 2 weeks of any transfer, to detail how any funds transferred out of the HIF  for  the  purposes  of  the  JCM  or  its  related  digital strategies costs have been verified;

• An  actuarial  review  of  the  Health  Insurance  Fund  (HIF)  is prioritised in 2022 and will include:

• specific analysis of the use of the HIF for the purposes of the Jersey Care Model and its related digital strategies;

• Consideration of the impact of all withdrawals on the fund since 2020; and
• The future of the HIF, should withdrawals take place as per envisaged by P.130/2020.

• As part of the wider review of sustainable healthcare funding to be undertaken in 2022, there will be a specific consideration to repaying the HIF (from the Consolidated Fund) for funding withdrawn for the establishment of the Jersey Care Model and its related digital strategies if no sustainable healthcare funding is operational by 2025.

HEALTH AND SOCIAL SECURITY SRUTINY PANEL

Note:  After this amendment, the proposition would read as follows –

THE STATES are asked to decide whether they are of opinion

to receive the Government Plan 2022 – 2025 specified in Article 9(1) of the Public Finances (Jersey) Law 2019 ("the Law") and specifically –

1. to approve the estimate of total States income to be paid into the Consolidated Fund in 2022 as set out in Appendix 2 – Summary Table 1 to the Report, which is inclusive of the proposed taxation and impôts duties changes outlined in the Government Plan, in line with Article 9(2)(a) of the Law;
2. to approve the Changes to Approval for financing/borrowing for 2022, as shown in Appendix 2 – Summary Table 3 to the Report, which may be obtained by the Minister for Treasury and Resources, as and when required, in line with Article 9
   2. of the Law, of up to those revised approvals;
3. to approve the transfers from one States fund to another for 2022 of up to and including the amounts set in Appendix 2 – Summary table 2 to the Report, noting that the transfer from the Consolidated Fund to the Technology Fund is subject to the Assembly's approval of a proposition to create such a Fund in 2022, in line with Article 9(2)(b) of the Law;
4. to approve each major project that is to be started or continued in  2022  and  the  total  cost  of  each  such  project  and  any amendments to the proposed total cost of a major project under a previously approved Government Plan, in line with Article 9(2)(d), (e) and (f) of the Law and as set out in Appendix 2 - Summary Table 4 to the Report;
5. to endorse the efficiencies and other re-balancing measures for 2022 contained in the Government Plan as set out in Appendix

2 Summary Table 6 and reflected within each gross head of expenditure in Appendix 2 – Summary Table 5(i):

6. to approve the proposed amount to be appropriated from the Consolidated Fund for 2022, for each head of expenditure, being gross expenditure less estimated income (if any), in line with Articles 9(2)(g), 10(1) and 10(2) of the Law, and set out in Appendix 2 – Summary Tables 5(i) and (ii) of the Report;
7. to approve up to £480 million to be appropriated from the Consolidated Fund for the Past Service Pension Liabilities Refinancing head of expenditure, subject to the availability of funding, which may include, in full or in part, use of the borrowing/financing referred in paragraph (b);
8. to approve the estimated income, being estimated gross income less expenditure, that each States trading operation will pay into its trading fund in 2022 in line with Article 9(2)(h) of the Law and set out in Appendix 2 – Summary Table 7 to the Report;
9. to approve the proposed amount to be appropriated from each States trading operation's trading fund for 2022 for each head of expenditure in line with Article 9(2)(i) of the Law and set out in Appendix 2 – Summary Table 8 to the Report;
10. to approve the estimated income and expenditure proposals for the Climate Emergency Fund for 2022 as set out in Appendix 2 – Summary Table 9 to the Report;
11. to approve an amendment to the policy of the Strategic Reserve Fund to enable that Fund to be used as a holding Fund for any or all monies related to the repayment of debt raised through external  financing,  with  the  monies  used  to  offset  the repayment of debt, as and when required; and l. to approve, in accordance with Article 9(1) of the Law, the Government Plan 2022-2025, as set out at Appendix 3 to the Report.
12. to approve, in accordance with Article 9(1) of the Law, the Government Plan 2022-2025, as set out at Appendix 3 to the Report except that, on page 168 under "Health Insurance Fund"the following words be inserted:

The following safeguards and transparency measures will be put in place in relation to the establishment of the Jersey Care Model:  

• The independent non-executive board (establishment of  which  was  approved  in  P.114/2020)  will  be supported to publish a review of the Tranche 1 and the use of 2021 funding by the end of March 2022 at the very latest; and  

• The  digital  health  team  within  Modernisation  and  Digital establishes  a  protected,  separately  resourced  sub-team  (that includes a Manager grade role), to focus solely on the delivery of the  Jersey  Care  Model  digital  systems,  and  the  Digital  Care Strategy. Regular  updates  on  these  workstreams  should  be regularly reported on to the independent JCM Programme board and the Health and Social Security Scrutiny Panel.

The following safeguards and transparency measures will be put in place in relation to the operation of, and any transfers made out of, the Health Insurance Fund:  

• The Minister for Health and Social Services will annually publish a report, which will also be presented in advance to the Health and Social Security Scrutiny Panel, to detail the information provided to the Minister for Social Security relating to the costs incurred on the  Jersey  Care  Model  that  require  a  transfer  of  funds  from the HIF;  

• The Minister for Social Security will publish a report, within 2 weeks of any transfer, to detail how any funds transferred out of the HIF  for  the  purposes  of  the  JCM  or  its  related  digital strategies costs have been verified;  

• An  actuarial  review  of  the  Health  Insurance  Fund  (HIF)  is prioritised in 2022 and will include:  

specific  analysis of the  use  of  the  HIF  for  the purposes of the Jersey Care Model and its related digital strategies;  

Consideration of the impact of all withdrawals on the fund since 2020; and  

The future of the HIF, should withdrawals take place as per envisaged by P.130/2020.  

• As part of the wider review of sustainable healthcare funding to be undertaken  in  2022,  there  will  be a specific  consideration  to repaying  the  HIF (from  the  Consolidated  Fund) for funding withdrawn for the establishment of the Jersey Care Model and its related digital strategies if no sustainable healthcare funding is operational by 2025.  

REPORT

This amendment seeks to establish several political commitments in relation to the use of the Health Insurance Fund (the HIF') as the source of funding for the Jersey Care Model (the JCM').

The Panel has the following concerns, and will set out its report in sections to cover the below:

• The establishment of the independent oversight board, that was originally intended to be put in place as a safeguard during the establishment of the JCM has been delayed in 2021;

• The JCM digital systems and Digital Care Strategy workstreams have not progressed as planned in 2021, and require prioritisation in 2022 -2024; and

• Despite assurances provided in 2020, the reviews of healthcare funding and the HIF that were due to be undertaken in 2021 before the 2022-2025 Government Plan debate, have not happened.

Establishment of the independent oversight board

The Jersey Care Model (P.114/2020) was debated on 3rd November 2020 and was approved (as amended) by 39 votes to 7.

The  Panel  was  supportive  of  the  Jersey  Care  Model  proposition,  but  lodged  an amendment, which was further amended by the Minister for Health and Social Services, that would see:

the establishment of an independent, non-executive board, that will keep under continuous review the delivery of the Jersey Care Model and report to the Minister and the Health and Social Security Scrutiny Panel and that will be responsible for agreeing monthly progress reports and the publication at the end of Tranche 1 of a detailed analysis of progress against set targets and a detailed look ahead to the delivery of Tranche 2'1

The Panel has received regular updates from the Department about the progress of the JCM work in 2021 but has been concerned to note the time taken to progress the establishment of the independent, non-executive board (the Board'). In a letter to the Panel, dated 20th September 2021, in response to a query about the establishment of the Board, the Minister for Health and Social Services explained that:

The process has taken longer than anticipated due to the lengthy process that had  to  be  undertaken  to  keep  the  recruitment  independent.  To  ensure independence, officers and scrutiny panel members agreed to ask the Jersey Appointment Commission (JAC)to oversee and lead on the recruitment. The resulting process was longer than anticipated'.2

1 Jersey Care Model (P.114/2020): amendment (P.114/2020 Amd.) – amendment (gov.je)

2 Letter to the Health and Social Security Panel from the Minister for Health and Social services, dated 20th September 2021

The letter also confirmed that the process for the appointments to the Board should be complete by the end of November 2021 and that officers were working towards the Board's first meeting in December 2021.

The Panel's amendment to P.90/2021 seeks to ensure that there is support provided to the Board to ensure that it can publish a review of Tranche 1 and the use of approved 2021 funding by the end of March 2022 at the very latest.

JCM digital systems and Digital Care Strategy

The workstreams for the JCM - digital systems and Digital Care Strategy are not under the management and control of Health and Community Services, these projects are run centrally by Modernisation and Digital (M&D').

In a hearing held on 28th October 2021, the Minister for Health and Social Services explained that the management structure was with M&D rather than Health and Community Services in order to reduce silo working. However, the Panel has concerns that the centralised management of this project has slowed down progress on the Jersey Care Model related work and led to other workstreams being prioritised.

In a letter dated 25th November 2021, the Minister for Health and Social Services outlined the 2021 underspend on the JCM - digital systems and the Digital Care Strategy. The letter states that:

The discovery of the replanning has shown that there are greater levels of dependencies on other projects such as demographic, EDMS & Our Hospital. So far, circa 20 workstreams have been discovered hence the need of re- prioritising'[3].

The Panel considered a recommendation that the management and control of the digital systems and digital care strategy projects should return to the remit of HCS, however, for practical reasons have acknowledged that this could not be the most efficient approach. Therefore, the Panel's amendment requests commitment that the digital health team within M&D establishes a protected, separately resourced sub-team (that includes a Manager grade role), to focus solely on the delivery of the Jersey Care Model digital systems, and the Digital Care Strategy.

Furthermore, the Panel seeks a commitment that regular updates on the digital care strategy and the digital systems for the JCM will be reported on to the independent board and the Health and Social Security Scrutiny Panel.

Reviews of Healthcare funding and the Health Insurance Fund (the HIF)

The Panel refers to the States Assembly's approval of each of the following in 2020:

• P.114/2020 – Jersey Care Model'(as amended);

• P.130/2020 – Government Plan 2021-2024' (as amended); and

• P.156/2020 - Draft Health Insurance Fund (Miscellaneous Provisions) (Amendment No. 2) (Jersey) Law 202-'.

The Panel notes that at the time each of the above was approved by the States Assembly, the assurances provided and information available indicated that that there was a commitment to design a sustainable funding model for primary care costs in 2021, for approval by the 2022-2025 Government Plan. This would be informed by a review of the structure and use of the Health Insurance Fund also undertaken during 2021.

The Panel highlights that a review of sustainable healthcare funding, or a review of the HIF as part of Jersey's Social Security scheme, has not been completed in 2021. Therefore there is no further information about future options for healthcare funding available for the Assembly to consider at this time in advance of the debates on both P.90/2021 – Proposed Government Plan 2022-2025' or P.102/2021 – Draft Health Insurance Fund (Miscellaneous Provisions) (Amendment No. 3) (Jersey) Law 202-'.

A brief background is detailed below: The Health Insurance Fund

The Health Insurance Fund (HIF) was established by the Health Insurance (Jersey) Law 1967 and it receives allocations from Social Security contributions from employers and working-age adults and supports the wellbeing of Islanders by subsidising GP visits, the cost of prescriptions and other primary care services. Under the law, the HIF is under the control and management of the Minister for Social Security.

Further amendments have been made to the law which have made specific provision for the withdrawal of money from the HIF for reasons other than that which was provided for in the 1967 Law, these are set out in the table below, for reference:  

P.130/2020: Government Plan 2021-2024, which was lodged on 12th October 2020, indicated that there was a commitment from Ministers to undertake a review of the Social Security schemes, of which the Health Insurance Fund is a part:

Ministers  are  determined  to  make  sure  that  the  [Social  Security]  fund continues to serve future generations and, as a priority, will undertake a full review of the various components of the Social Security scheme ahead of the

next Government Plan to ensure the future balance is maintained at a fully sustainable level'[4].

During a Hearing with the Minister for Social Security on 13th October 2021 the Panel was advised that no reviews had been undertaken of either the Social Security Fund, or the HIF in 2021[5].

Transfers from the HIF in 2022

P.102/2021: Draft Health Insurance Fund (Miscellaneous Provisions) (Amendment No. 3) (Jersey) Law 202-' seeks approval to transfer £13 million in 2022 from the Health Insurance Fund to the Consolidated Fund for the purposes of the Jersey Care Model and its related strategies. This is as a consequence of what is proposed in P.90/2021 and is in line with what was proposed in P.130/2020.

For reference, a breakdown of the approved and proposed funding from the Health Insurance Fund for the Jersey Care Model and related digital strategies is detailed in the table below:

The Panel was advised in its Government Plan Review hearing with the Minister for Social Security on 13th October 2021 that the transfer of £11.3 million approved for 2021 (in P.156/2020) had not been made but was expected to be completed towards the end of 2021 once the activity costs had been verified[6]. If approved, P.102/2021 would also permit any of the approved £11.3 million funding that is not transferred in 2021, to be transferred in 2022 instead, subject to the requirements set out in the Public Finances (Jersey) Law 2019.

The Panel's amendment seeks further transparency in this process and will require the Minister for Health and Social Services, and the Minister for Social Security to publish reports to detail the information sharing and verification process.

The Jersey Care Model

P.114/2020 specified that sustainable healthcare funding would be operational by 2025, and, in the accompanying report it was indicated that, in the more immediate term, investment of £28.1 million in the next Government Plan would be required, it was stated that this included £17 million of non-recurrent investment over a 5-year period7.

During the opening speech of the debate of P.114/2020 on 3rd November 2020, the Minister for Health and Social Services stated:

The Government Plan we will be debating in a few weeks recognises the need for quick action. It brings forward the need to deliver a solution to make sure that health costs are funded sustainably and it commits to undertaking a full review, which will include taking proposals to this Assembly ahead of the 2022 Government Plan to determine an appropriate model for future health and care funding.'8

During his closing speech, the Minister for Health and Social Services stated:

Each year we will have a Government Plan. Each year there will need to be money put into the Government Plan for up to 2025 for the costs of this. Each year up to 2025 Members will be able to debate the vote proposed. There are plenty of opportunities for reviewing this and I have no doubt Members will continually ask me questions and, of course, I have the opportunity or any future Minister has the opportunity to bring a debate to this Assembly.'9

And

Yes, there is concern about we will not be in a position to debate sustainable funding but we are going to be working on a sustainable funding measure over the next 9 months and the commitment is to bring it forward in the 2022 Government Plan. That is what the proposition asks for, that is in the present Government Plan that commitment to do so.'10

It was confirmed in a public hearing with the Minister for Social Security on 13th October 2021 that work had started on the wider review work on sustainability of healthcare  funding,  with  cross  department  consultation,  and  that  this  would  be completed by the end of 202211.

In  a  quarterly  hearing  with  the  Minister  for  Health  and  Social  Services  on  17th November 2021, the following update was provided about the sustainable healthcare funding review:

7 P.114/2020 Jersey Care Model (gov.je), page 23 of Report

8 Hansard, 3rd November 2020, page 54

9 Ibid, page 79

10 Ibid, page 80

11 Transcript, Hearing with the Minister for Social Security, 13th October 2021, page 14

The review will be undertaken over the course of next year, as it is a commitment in the Government Plan 2022 and it will inform the next Council of Ministers. The aim is to have the review maybe by the beginning of 2023 so it can feed into the Government Plan 2024.'[7]

The Panel was also advised the following in relation to the timeline (relevant part highlighted in bold):

There was the commitment in the Government Plan and in the Jersey Care Model proposition at the end 2020 that a sustainable funding mechanism will be in place by 2025 and that is what we are working towards too. It might be even earlier in place, beat the current timeline as explained, it will go into the Government Plan to 2024, so it is even a year earlier. The actual proposal of options was anticipated to come back this year but due to COVID that just was not possible to achieve in that timeline. The proposal is being undertaken, this has started and will be undertaken probably next year but it is still in the timeline, as proposed initially and agreed by the States Assembly.[8]

There is an acknowledged overlap between the review that is required for the assessment of sustainable healthcare funding and the review of the HIF as part of the Social Security scheme. At the Panel's Quarterly Hearing with the Minister for Social Security on 21st October 2021, it was clarified that the HIF was not due to have an actuarial review for another couple of years (a review every 5 years is required by law). Officers advised that:

We need to make a decision about the Health Insurance Fund. Given the significant changes that are planned for it, it may be not very good value for money for the public to do an actuarial review while the fund is in such a state of flux'[9].

Whilst the Panel acknowledges the above, given the uncertainty about the future of sustainable healthcare funding, the Panel feels that it is prudent and reasonable to request this review to consider the impact that the withdrawals from the HIF are having on the future health of the fund.  

The Panel's amendment seeks to ensure that a separate actuarial review of the Health Insurance Fund (HIF) is prioritised by the Minister for Social Security in 2022 and that this should include; specific analysis of the use of the HIF for the purposes of the Jersey Care Model and its related digital strategies; consideration of the impact of all withdrawals on the fund since 2020; and consideration of the future of the HIF, should withdrawals take place as envisaged by P.130/2020.

The Government Plan 2021-2024

As referenced above, the Government Plan 2021-24 (lodged on 12th October 2020), indicated that there was a commitment from Ministers to undertake a review of the Social Security schemes and had the additional commitment to undertake a review of

sustainable healthcare funding in relation to the JCM. This was specifically stated in the Government Plan:

After investments, the JCM is forecast to save £23 million per year by 2036. However, it brings forward the need to deliver a solution to make sure that health costs are funded sustainably and we will undertake a full review – which will include taking proposals to the States Assembly - ahead of the next Government  Plan  to  determine  an  appropriate  model  for  future  health funding.'15

Furthermore, the transfer of funds from the Health Insurance Fund to the Consolidated Fund as a consequence of the approval of the Government Plan 2021-24 was approved by the States Assembly in P.156/2020. In the Minister for Social Security's opening speech proposing P.156/2020 on 17th December 2020, it was stated that (relevant parts highlighted in bold):

The 2021 Government Plan sets out further transfers in 2022 to 2024. I again will only put these forward after Ministers have completed the planned review of sustainable health funding and brought proposals back to the Assembly during  2021.  The  next  transfer  will  be  proposed  next  year  after  States Members have considered the proposals for sustainable health funding and the future direction of the Health Insurance Fund.'16

In the closing speech on 17th December 2020 the Minister said:

I understand the Deputy 's concerns. I do not share them because we will not be taking any more money out until we find that sustainable model. It will come back to the Assembly. It needs to come back to the Assembly and it will be amendable but it has to be done, as I said, before we can just carry on taking money out of the Health Insurance Fund.'17

The above indicates that there was a clear commitment made, on a number of occasions by both the Minister for Social Security and The Minister for Health and Social Services, to a review of sustainable funding in 2021 ahead of further decisions required for the next Government Plan and transfers out of the HIF. The planned review has not been undertaken in 2021.

The Panel's amendment also seeks a commitment that, as part of the wider review of sustainable healthcare funding to be undertaken in 2022 that there should be a specific consideration to repaying the HIF, from the Consolidated Fund, for funding withdrawn for the establishment of the Jersey Care Model and its related digital strategies if no sustainable healthcare funding is operational by 2025.

Conclusion

The Panel has lodged this amendment to the Government Plan in order to obtain commitments to change certain matters relating to the JCM work and its funding from the  HIF.   The  commitments  sought  are  all  achievable  measures  and  reasonable safeguards that will provide confidence in this use of public funds.

15 Government Plan – 2021-24, Appendix 3, page 22 16 Hansard 17th December 2020, page 34

17 Ibid, page 35

Issues such as the delay to the establishment of the independent oversight Board and the lack of priority for JCM digital projects from M&D are significant concerns for the Panel relating to the successful delivery of the JCM. The Panel seeks a commitment for support to be provided to the Board in order to complete its report no later than March 2022. Furthermore the Panel feels that, to make acceptable progress, the JCM digital work should not have to compete with other priorities in M&D, therefore, the creation of a protected, separately resourced sub-team (that includes a Manager grade role), which can focus on the delivery of the Jersey Care Model digital systems, and the Digital Care Strategy is vital to the JCM's success.

The Panel also wants further safeguards and transparency measures to be put in place in relation to the operation of, and any transfers made out of, the HIF. There have been a number of publicly voiced concerns about the use of the HIF to fund the JCM and the Government's unfulfilled commitment to review funding has not assisted with this perception.

Therefore, for transparency purposes, the Panel seeks commitments from the Minister for Health and Social Services and the Minister for Social Security to publish reports to detail the information sharing and verification process following any transfer of funds from the HIF.

The Panel is concerned that the HIF, as the current source of the funding for the JCM is being depleted without: i) a review being undertaken to understand the impact that the withdrawal of funds will have on it in the long term, ii) an alternative sustainable funding plan in place; or iii) further detail readily available about the future of the JCM. The Panel therefore requests that the actuarial review of the HIF is prioritised in 2022. The Government should also consider (as part of the sustainable funding review) whether refunding the HIF, of money used to fund the JCM, would be suitable in order to provide long term support for the benefit directly provided to Islanders (for example, subsidised G.P. visits and free pharmacy prescriptions).

Financial and manpower implications

The Panel has received the following feedback about the financial and manpower implications of this amendment:

• Confirmation from the Minister for Health and Social Services that additional staffing time would be required to support the board to undertake and produce the review, however that this would be provided from existing project management resources working on the JCM. A board secretary is currently being recruited who could help with future requests[10];

• Regarding the creation of the protected, separately resourced sub-team (that includes a Manager grade role) in the digital health team in M&D, the Minister for Health and Social Services has confirmed that:

To an extent, there is a separately resourced and managed team within M&D that are responsible for the digital health projects, although this

is not separated between projects within the Jersey Care Model Digital Systems business case and the Digital Care Strategy business case. They are together in that sense, although as we have discussed, there is cross over and interdependencies between projects across the two.

When the digital health team came into M&D, we did not disperse the team within the other M&D teams, but retained them together as a unit to keep the "domain knowledge" and "domain focus" for health. There have been vacancies within the team, but we have recently been able to recruit successfully to two new project managers and a programme manager at management grade 13 on a permanent basis, and others to fulfil the needs of various projects on a contract basis.'19

• The Minister for Health and Social Services has confirmed that there are no additional resources involved in the Minister publishing a report in respect of the HIF transfer. These details will be included in the ministerial decision as a matter of course20.

• Customer and Local Services has confirmed in officer correspondence that there are no additional resources involved in the Minister publishing a report in respect of the HIF transfer. These details will be included in the ministerial decision as a matter of course.

• Customer and Local Services has confirmed in officer correspondence that the cost of an actuarial review will be met by of the HIF itself. The last actuarial review (undertaken in 2019 as at 31st December 2017) cost less than £50,000.

• Regarding the work to consider a repayment to the HIF (from the Consolidated Fund) for the JCM work as part of the wider sustainable healthcare review, the Minister for Health and Social Services has confirmed that this could be included in the scope of the project and would therefore not require additional

resources.21

19 Ibid 20 Ibid 21 Ibid