Why do we need this programme delivered?
The main determinants of health are socio-economic.  If we want to promote good health, prevent ill health and reduce inequalities in health, we must act on the social determinants that are likely to impair people’s health (Marmot 2010).  Citizens Advice Bureau (CAB) provide advice, help and support to people on a wide range of issues that comprise many of the social determinants of health.  For example, income maximisation, debt management, homelessness and housing problems, employment problems and domestic abuse.Paris and Player (1993) found that placing CAB in general practice reached a group of individuals who would otherwise not use the CAB service.  This group was more likely to be ill and more likely to be entitled to welfare benefits that they were not claiming.  The authors concluded: ‘The provision of CAB in general practice is an effective way of providing advice on life problems and securing proper payment of benefits, particularly to patients with health problems.  This service complements rather than detracts from other CAB activities’ (p1518).The need for this programme has intensified since the economic downturn began in 2007/8. The Welfare Reform Act (2012) and the abolition of civil legal aid (MoJ 2012) will further increase the need and demand for advice on social and financial problems amongst low income groups.  Demand for advice in all settings is increasing.  GPs working in deprived areas report that:‘I cannot address medical issues as I have to deal with the patient’s agenda first, which is getting money to feed and heat.’

‘In my surgery I am hearing from patients who for 2–3 days a week cannot afford to heat their houses (many use metered cards which are more expensive than direct debit payments)’. Many patients are:

  • struggling to make ends meet
  • increasing contact with GPs and psychiatry
  •  increasing antidepressant/antipsychotic use
  • self-medicating with drugs and alcohol’

(Excerpts from GPs At The Deep End, University of Glasgow 2012)

Why Citizens Advice Bureau?  Citizens Advice Bureau has a 96% brand recognition (BMRB 2009) and came top in a survey of charities for its ‘ideal attributes’, which include being helpful, approachable, informative and reputable (nfpSynergy 2009).  It is the only County-wide organisation that provides advice on a wide range of issues with a strong reputation and which is recognised by the public as independent and free at the point of use.

In summary, provision of CAB in general practice is a practical way of reaching disadvantaged groups and helping them to resolve the social and financial issues that are likely to impair their health and wellbeing.  Derbyshire’s success at commissioning CAB in general practice is cited as an example of good practice in reducing health inequalities in the Marmot Review (2010 p122).

Currently, 94/102 practices in Derbyshire (including Glossop) have a regular CAB service.

How is this service performing against its key objectives and deliverables? Consider outputs, outcomes and KPIs. Note: the data in table 1 exclude Glossop
The service is exceeding its contractual targets.  The contract requires providers to achieve a cost per client of £175 or less.  For the last 2 years this target has been surpassed, as bureaux have become more efficient at provision in primary care.Table 1: Citizens Advice Bureau in GP Outputs 2009-2012                                   2009/10              2010/11                 2011/12Clients seen                 3,490                 5,587                     5,857

Contacts                       11,641              16,697                   17,138

Problems dealt with    18,589              26,141                   29,673

Financial gains             £4,545,623        £6,941,558           £7,698,310

Debt managed              £7,660,593        £8,098,016           £8,138,401

Cost per client             £187                £141                       £131

Cost per contact          £56                     £47                        £45

Cost per problem          £35                   £30                         £26

Cost to commissioners   £652,025          £790,000               £767,377

What key public health priorities does this service contribute to and how does it contribute? Consider the Public Health outcomes framework, JSNA, Health & well-being priorities, as well as value for money issues such as cost effectiveness, quality and performance.
The key public health priorities this programme contributes to are:1)   Improving the wider determinants of health (Public Health Outcomes Framework (DH 2012).  Specifically: children in poverty; people with a mental illness or disability in settled accommodation; employment for those with a long term health condition;  domestic abuse; homelessness; fuel poverty; social connectedness.2)   Reducing inequalities in health (Health and Wellbeing Strategy (DCC 2012).  Specifically income maximization p14.Value for money: Every £1 invested by the commissioner generates an additional £10 for clients and manages £11 of debt.  The cost per client, which includes an average of 3 contacts and the resolution of 5 problems, at £131, compares favourably with many health and social care interventions.  Case studies demonstrate significant potential savings to health and social care providers (appendix 1).

Evidence of effectiveness: this intervention is effective at reaching disadvantaged groups, increasing the income of between 25-46% of people who use the service and helping them to manage debt and other problems (as per Paris & Player 1993).  In terms of health outcomes, Liverpool University tried to measure the impact on health of advice in general practice.  They did a longitudinal study using the SF-36 with clients before and after advice was provided.  The report concluded that, for patients who received additional income as a result of advice received in primary care settings, there were statistically significant improvements in two of the eight SF-36 health domains: mental health and vitality (Abbott and Hobby, 2002).  These health gains remained evident at six and 12 months.

More recently, the University of Sheffield took a logic modelling approach to measuring the health impact of advice in primary care (Allmark et al 2012).  The authors concluded that, while it was impossible to say with certainty that advice improves health because of the complexity of causal pathways, it is plausible that it does so.

Quality: CABx are subject to rigorous assessment and validation by their national association, Citizens Advice.  This includes regular audits of quality of case work, social policy work and client satisfaction as well as the management and governance of the bureau as an organisation.

Performance: all our CAB providers are performing to a high standard and exceeding their targets.  When the programme was rolled out across the County in 2008/9, High Peak CAB was used as the benchmark for performance as it has been delivering in general practice since 1995. Bureaux which were new to this work took a while to become as efficient as High Peak. The outputs above show that all bureaux are now performing efficiently and effectively.

Identify options for change or continuation.  Outline the impact that these changes would have both on the service and patients and the wider pathway. Consider options such as redesign, consolidation with other existing contracts/services, or commissioning a different volume of activity.
There is a regular (mainly weekly) CAB service in 94/102 practices including Glossopdale.  Note: all costs except 1b exclude inflationary increase.Options1)  a) No change: May result in small decline in outputs as operational costs of CABx rise each year. Cost = £802,557
b) An uplift in line with inflation @ 2.7% will enable current outputs to be maintained.
Cost = £824,247.2)  Increase provision in general practice: demand outstrips supply in many practices.  Waiting lists have developed and this increases DNA rates and exacerbates clients’ problems.  The unmet need could be met with two extra weekly sessions per locality.   Cost of extra provision = £140,800.
Total cost of this option = £943,357.

3)   Maintain provision in general practice and extend CAB to all children’s centres: DCC currently funds an income maximisation programme delivered by CAB in some of its children’s centres.  This produces similar outputs to the GP setting.  DCC investment in this is £114,000 in 2012/13.  CAB in children’s centres reaches a different but important audience and complements CAB provision in other settings in the County.  Extension of CAB to every children’s centre may emerge as a priority in the Child Poverty Strategy that is in development.  Cost of weekly session in all 53 children’s centres = £466,400 (£352,400 if existing provision in CCs is maintained).  Estimated additional outputs at this level of investment = 3,560 clients/families helped; £4.6 million additional income generated; £5 million of debt managed.  This option epitomises Marmot’s proportionate universalism.
Total cost of this option is £1,268,977
.

4)   Reduce provision: outputs would reduce proportionate to funding.  This would weaken Derbyshire’s commitment to reduce inequalities in health and is likely to push the problem ‘downstream’, resulting in higher social and healthcare costs (see case studies for examples).

5)  Stop provision: Pros: this would release £802,000 to spend on other things.

Cons: 6,000 disadvantaged people not advised; £8 million less income into poorer   people’s pockets (and the Derbyshire economy); £9 million more debt unmanaged; 30,000 problems unresolved and their consequent impacts on health, wellbeing and health inequalities (estimates include Glossop).  Significant destabilisation of CABx in Derbyshire.

What proportion of the population does this service deliver to?  Is the service equitably available by geography, age, vulnerability etc?  Is it to an appropriate scale to have population impact?
CAB in general practice is available to everyone in the practice populations of those who have the service so theoretically most of the County population has access to it.  During the expansion phase (2008-10), funding was systematically distributed using a weighted formula so it is equitably distributed.  In practice, the nature of the service means that it is used by the most vulnerable groups in the community, for example, people who are unemployed, in poverty, in debt, at risk of homelessness, with employment problems etc.  This is illustrated by the nature and volume of ‘enquiries’ that clients present with,Table 2: CAB in GP number of enquiries 2011/12

  • Benefits          16,976
  • Employment     1,281
  • Consumer           229
  • Health                514
  • Debt                6,616
  • Housing           1,060
  • Education            94
  • Other             2,903
  • TOTAL        29,673

Use of the service by age roughly reflects the population:

Table 3: Use of CAB by age 2011/12

  • 0-16    = 0.06%
  • 17-24  = 6.24%
  • 25-34  = 11.84%
  • 35-49  =  30.47%
  • 50-64  = 33.92%
  • 65+      = 14.4%
  • Not recorded   = 3.31%

The intervention reached 0.8% of the County PCT population in 2011/12.  It is unlikely to have a population impact at this scale but it will mitigate the impact of social and financial inequalities experienced by the 5,857 individuals and families that used the service.  Extension of the programme to children’s centres would reach 1.3% of the population.  Although the proportion of the population reached is small, outputs show that it is successful at targeting and reaching some of our most disadvantaged and vulnerable groups.

Is the patient feedback positive for this service?
CABx conduct annual client satisfaction surveys.  These surveys sample a significant percentage of users in all their settings – usually around 5% per annum.  Non-responders are not recorded but low (could be audited).  An average of 98% of respondents report that they are satisfied or very satisfied with the service.  99% say that they would use the service again.  99% report that they found the advice they received useful. Most clients when asked report an improvement in their wellbeing, but CAB do not always ask questions around this and the responses are, of course, subjective.Qualitative research conducted by the University of Sheffield in a sample of Derbyshire practices found that patient and health care professionals’ satisfaction with this service was high, see excerpt below:‘Key positive service features were seen by all groups as: the confidential and familiar GP surgery environment; ability to make appointments; experienced advisor availability and continuity.  Outcomes for service users were described as financial gain and managed debt, along with beneficial social and mental health impacts.  Staff benefits were perceived to be appropriate referral, and better use of GP consultation time.’  (Burrows et al 2010).
Outline the reputational, clinical and wider financial risks of redesigning, decommissioning or reducing this service? Include details of potential destabilisation if service reduced or decommissioned.
Reputational risk: The CAB service has been provided in some practices since 1995 and in all 94 since 2010.  It is regarded as a core primary healthcare service in some of these practices.  GPs have been known to ring the CAB to thank them for the work they are doing with patients.  At least one GP has been moved to become a trustee of his local CAB and many are prepared to act as advocates for the service.  Without surveying GPs it is impossible to gauge their reaction to a reduction or cessation of this service but it is likely to be an unpopular decision.As an embedded community service, decommissioning CAB in general practice is also likely to come to the attention of local MPs as well as constituents and other local agencies concerned with the welfare of their population.  It would be difficult to present a convincing case for disinvestment at this time, given the outputs, reputation and goodwill that this service has generated, and in the current context of increasing need, demand, the Welfare Reform Act and the Legal Aid Bill.Potential destabilisation: This programme comprises a substantial proportion of the income of Derbyshire CABx.  Decommissioning would poleaxe the service and have the following consequences:For clients:

  • Loss of 90 advice outlets
  • At least 30% reduction in CAB service
  • Many users and potential users unable to access the service
  • Many communities would lose access to advice, especially in rural areas
  • Impact on health and wellbeing, health inequalities
  • People with chronic health and social problems particularly likely to suffer

For bureaux and partner agencies – and indirectly for communities:

  • Massive pressure on remaining services
  • Reduced referral options for practices and other agencies
  • Around 20 redundancies
  • Loss of expertise / skills base
  • Financial destabilisation of bureaux
  • Existing CAB services not directly funded by GP project funding will have to be re-shaped and possibly reduced
  • Negligible likelihood of replacing this funding

If the panel decides to continue the programme, dialogue with districts and boroughs, which traditionally provide core funding to CABx, is recommended, to ensure that core funding remains the responsibility of these second tier authorities.

Are there gaps in provision of services in your programme area?  Please identify how this might be filled by redesign, reduction in activity, alignment with county and district council services, in house transfer to the county council or additional funding.  Please note that the ring fenced public health budget is only known until March 2015.
Gaps: there are a few gaps in coverage, i.e. no CAB offer in 8 practices in the County.  This occurs for one of two reasons: (1) limitations in surgery infrastructure (i.e. building) means that an advice session cannot be run or (2) the surgery doesn’t want CAB.  This may change with the advent of CCGs.Waiting times for CAB appointments in some of the busier practices can be too long, leading to a higher rate of DNAs.  This happens more frequently in more deprived areas where a higher proportion of people are living more chaotic lifestyles.  Some practices have requested more CAB time and others have requested home visits which cannot currently be provided due to lack of resource. See option 2 for solution.Appeals: the presence of advice in primary care and other settings helps to prevent claims reaching the appeal stage. Despite this, the number of social security appeals is rising exponentially, due to the work capability assessment, and other changes to welfare, such as sanctioning benefits.  The introduction of personal independence payments on 8th April 2013 is certain to exacerbate this trend.  To ascertain the impact of this increasing demand on providers’ time and expertise, a prospective audit of appeals resulting from CAB advice in primary care will be conducted from April to June 2013.  The results will be available in July.
Are there gaps in provision of public health programmes against population health need that you would recommend that the panel consider? These may be outside your programme area. 
  1. The Health, Wealth and Wellbeing programme would complement this programme.  It takes an outreach approach in highly targeted neighbourhoods so reaches people who don’t/won’t come to services.  It combines a ‘wider determinants’ approach with a lifestyles approach and has worked well in Tameside.  Costs have been requested from the Tameside provider.
  2. The Family Loan scheme run by Chesterfield and NED Credit Union is helping families who may otherwise go to payday lenders or loan sharks.  A modest investment (£50k) has been lent to 120 families (average loan = £400) and is paid back via a direct debit from clients’ child benefit.  Repayment rates a high and the money is repeatedly recycled, offering the commissioner good value for money.  Contact with a credit union has other positive outcomes such as clients being encouraged to save and financial capability developed.  This model could be extended across the County via local credit unions for a relatively modest investment.

 

Political implications A Scrutiny Review of Advice Services across Derbyshire was conducted in 2008 and a Total Place Review of advice services was done in 2010.  Both were strongly supportive the CAB in GP approach.The CAB in GP programme is popular with patients, GPs and partner agencies.  It epitomises a social model of health which is what Derbyshire has committed to. Cessation or reduction of this programme is likely to be a difficult decision to defend to patients, GPs and partners in the current socio-economic context.
Impact on partners & public The outputs demonstrate the impact of cessation or reduction of this programme on vulnerable groups and on local CABx as organisations.
Provider & market stability   There is a significant risk that cessation or reduction may destabilise some bureaux. This would significantly impede their ability to help the most vulnerable members of our population.
Reputational issues The service has a high standing in the community and with its partners.  Significantly reducing or stopping this work is likely to have a negative impact on the Council’s reputation.
Legal/contractual Parameters  
Financial implications   18 years of experience has shown that investment in this programme will generate 10 times the amount of money invested by commissioners and channel it into the poorest pockets in Derbyshire.  The same investment helps people to manage £millions of debt. Additionally, it is likely to have an economic development effect as poorer people spend their money and they spend it locally.

References

Abbott S and Hobby L (2002) What is the impact on individual health of services in  primary health care settings which offer welfare benefits advice?  Health and Community Care Research Unit (HACCRU) Liverpool University Research Report 87/02

Allmark P, Baxter S, Goyder E and Guillame L (2012) Assessing the health benefits of advice services: using systematic review and logic model methods to explore complex pathways Community Care vol

Burrows, J, Baxter, S, Baird, W, Hirst, J and Goyder, E (2011) Citizens advice in primary care: A  qualitative study of the views and experiences of service users and staff Public Health 125: 704-10

British Market Research Bureau (2009) cited in ‘The Citizen’, Citizens Advice summer 2009.

Marmot et al (2010) Fair Society, Healthy Lives IHE

Ministry of Justice (2012) Legal Aid Bill

nfpSynergy (2009) cited in ‘The Citizen’, Citizens Advice summer 2009.

Paris J and Player D (1993) Citizens Advice in General Practice BMJ 5th June 1993 Vol. 306 pp 1518-1520

Appendix 1

CAB Case studies (names have been changed)

Case study 1

Jade was referred to the service via the Health Visitor attached to her GP surgery. Jade is aged 21, she is a single parent living in local authority accommodation; she has a 4 year old daughter. Jade recently became unemployed and she suffered with severe depression. She had multiple debts (priority and non-priority) totalling approximately £21,000 and she was struggling financially. Her home was not adequately furnished with limited appliances and she relied on her father who lived nearby to wash clothes, cook meals etc. However her relationship with her father broke down which contributed to her depression and she tried to take her life resulting in her being sectioned and sent to hospital whilst her daughter went to stay with family.

Upon her discharge from hospital we identified that Jade was not receiving full benefit entitlement. Since coming out of part time work she was just receiving Child Benefit/Child Tax Credits and due to low income she was accruing housing and council tax arrears. The local authority was threatening possession proceedings against her. We were able to assist Jade with a claim for Income Support and Housing/Council Tax Benefit. The council agreed to backdate her housing/council tax benefit which reduced her priority arrears and we were able to negotiate an affordable amount for Jade to pay a minimum amount towards her rent and council tax arrears.

We referred Jade to our debt team who assisted her with a debt management plan. Regarding the problem she had with not having any appliances, we made an application for a Community Care Grant to purchase a washing machine, cooker, bed for her daughter (who had outgrown her cot but was now sleeping in bed with Jade) and carpet for her living room floor. The CCG was refused and CAB assisted with a review of the decision which was also refused. Following this we made an application to two charitable trusts that between them provided all of the requested items.

As a result of CAB intervention Jade was financially better off (claiming housing and council tax benefit with a backdate) and her debt was rescheduled and managed. We were able to prevent possession proceedings on her home and bailiff action for council tax arrears. We assisted Jade to deal with all of her debt which eased a lot of her pressure and stress and we assisted her to furnish her home adequately making it a safe and healthy environment for Jade and her young daughter to enjoy. Jade has since been discharged from Mental Health Services.

Outcomes/Gains

Weekly Benefit Gain: £76.30

Debt Rescheduled/managed: £21000

Charitable lump sum: £900 (cash equivalent)

Case Study 2

Ryan’s mother, Janet, approached CAB after she saw the service advertised in her GP surgery. Ryan is 16 and has had 2 operations to remove a brain tumour. The operations have been successful however he does still experience severe headaches and nausea. Since the operations Ryan has developed severe depression and anxiety. There was some tumour that they were unable to remove which Ryan is anxious about, however the neurologist did not want to scan again for a year. Janet was struggling financially as Ryan had no income of his own and did not qualify for automatic help with prescription costs. Janet had even lost child benefit and child tax credit as Ryan was 16 and no longer in education. Janet’s husband worked full time and due to this they were not entitled to any means-tested benefits.

We suggested that Ryan applies for Incapacity Benefit (incapacity in youth rules) as due to his headaches, nausea and depression he may be found incapable of work. We also assisted with the completion of a HC1 (help with prescription costs for people on low income). Janet was very grateful for this as it meant that she no longer had to pay for Ryan’s regular prescriptions, sight tests, glasses and they reclaimed travel expenses for hospital appointments.  Janet described Ryan as extremely withdrawn with low self-esteem. He hardly ever left his bedroom and stopped seeing his friends. His family only saw him for about 10 minutes per day. He came out of his bedroom at night when no one was around. Janet left him meals to re-heat however due to anxiety about food-poisoning he refused to re-heat anything and as food was cold and unappetizing he hardly ate. He often refused to get dressed and washed, he could not sleep and side effects of his operations caused memory loss and poor concentration. Ryan only went outdoors at night with his mother to walk the dog (therapy suggested by psychiatrist). He avoided people and experienced panic attacks in crowded places. Ryan’s anxiety and depression were due to him thinking he had no future and so was not motivated to have friends, consider finishing year 11 or take career advice. The neurologist had said that most children whom undergo the surgery that Ryan had return to school within 4 weeks. The depression appeared to be preventing this. Ryan was referred to a psychiatrist for therapy.

Based on Janet’s description we assisted her to complete an application for Disability Living Allowance on behalf of Ryan. Ryan was awarded low rate mobility and middle rate care and we were able to assist Janet with a claim for carers allowance. His Incapacity Benefit was also awarded and due to advice on time limits he got his claim in just before Employment Support Allowance took over from IB (ESA is less money and does not increase over time).

We also offered to refer Janet and Ryan to our Macmillan caseworkers who may be able to assist in the future with a grant.

Actual weekly Benefit Gains

Incapacity Benefit = £63.75    DLA = £62.60  Carers allowance         = £50.55 Total: 176.90

+ free prescriptions, sight tests and refund on travel care.

Case study 3

A practice Health Visitor referred Katie and David to our service after they received an eviction notice for from their letting agents after only 6 months of living in the property due to the Landlord suffering financial difficulty, and as a result selling the property.  Katie and David have two young children with a third on the way.  They are presently living on a low benefit income after both being made redundant.  Katie also suffers from depression and anxiety.

They have been through similar circumstances previously and had to vacate their previous home through no fault of their own.  The CAB caseworker assisted David and Katie in securing another property with a social landlord which will give them greater protection and a longer term tenancy agreement.

The house that Katie and David were living in benefited from built in appliances and partial furnishings. We were able to secure £200 financial assistance from Bolsover District Council to assist with the removal costs and also assisted Katie and David in securing a community care grant for £600 to pay for essential items for their home. In addition the CAB caseworker also approached a children charity trust (Glasspool) who kindly provided them with a grant for a fridge / freezer.  The caseworker also assisted Katie in gaining both a Sure Start Maternity Grant and Health in Pregnancy Grant.

Benefit Gains:

Financial assistance from council £200

Charitable Trust Fridge Freezer – £250

Community Care Grant of £600

Social Fund Payments of £690

Case study 4

Sarah came in to see us (CAB) last December.  She agreed to write down her story for us.

I am 14 and live with my Dad.  My Mum died three years ago.  The two of us live in a small rented house.  It’s cold and damp, but it’s home and we get by.  Dad lost his job about six months ago after he became depressed and found it hard to work.  He’s tried to get more work, but he’s got a criminal record and this makes it hard.  I’m terrified that he will take to robbing again to try and pay the bills.  He’s all I’ve got.  If he goes to prison, I don’t know what I’ll do. 

We have also fallen behind with the rent.  Last week our landlord sent us court papers.  He wants us out.

Sarah took the day off school and virtually dragged her father in to see us.

Over the next few weeks we were able to do the following:

  • Reach an agreement with the landlord for Sarah’s dad to pay off the rent arrears over an affordable period
  • Get the court proceedings withdrawn
  • Persuade the landlord to carry out essential repairs to the property
  • Prevent the family being made homeless
  • Help Sarah’s dad set up arrangements to deal with his other debts
  • Check his benefit entitlement and increase the family income
  • Talk to Sarah’s dad about voluntary work as a way of building self-esteem and making him more employable
  • Put him in contact with a support group
  • Give the family some hope

I am so pleased at the way things have worked out.  We won’t be moving after all and I am staying at the local school with all my mates.  Dad is much happier without the worry of all the debts piling up.  He’s still not got a job, but I think he will do soon. 

I am thinking of becoming a social worker or solicitor when I leave school.  I want to help people.  I’ve seen the difference that this sort of help can make to people’s lives.  Dad says I’d be good at it.  I got into trouble for taking the day off school to drag my Dad into the CAB, but it was one of the best things I ever did.

Julie Hirst

Public Health Principal Derbyshire County Council

Systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings

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2 Comments

  1. During the last recession I was managing a holistic clinic in Tunbridge Wells that provided a wide range of natural therapies to improve peoples’ health but we recognized many patients were suffering ill health brought on by stress due to financial problems. We realized that they could not get the necessary help from their GPs (a pill wont solve such a problem), they dare not go to their bank in case they were were to lose any help they had, our therapies were not a solution so we engaged a financial advisor who could. I agree with the above but would add that a health service that fails to teach people how to improve their health is the other major factor. Good health is about good diet (nutrition), adequate exercise (physical activity) good mechanics (osteopathy/chiropractic etc), good breathing (breath training), good mental state ( relaxation etc) yet our modern medical system ignores most of these factors. No wonder we have an escalating sickness bill. Just as you cannot buy happiness with money so health is not the result of increased income, there is a bit more to it than that.

  2. Julie Hirst says:

    I agree with you Michael. I was trying to redress the balance of the usual public helath focus on lifestyles which is important but not that important to people who can’t pay their rent or feed their children.
    Julie

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