COVID-19 and Care Homes

[AM9]

Well it looks like the latest released figures of COVID-19 related deaths outside hospitals are far higher than previous reports have indicated. See here:
https://www.bbc.co.uk/news/health-52455072
snip:

The daily updates provided by government do not include care home deaths.

The ONS has been able to track these by looking at deaths certificates - but that means the data lags behind the hospital deaths provided by the government.

Up until 10 April just over 1,000 coronavirus-related deaths had been recorded in care homes so far.

A week later this had increased by another 2,000 to top 3,000 in England and Wales.

Projections for the following week - up to last Friday - suggest they rose again."

So in effect, the fall from the peak is nowhere as great as some commentators have stated. There was a newspaper report today talking of the death-rate 'plummeting', as a justification for getting back to normal life, (no reference as I can't remember which paper it was), it seems that printing about wishful thinking like that doesn't make it true, indeed quite the opposite, so the Government's cautionary approach to lifting some of the restrictions is rather more relevant than the clamour to open the floodgates.

 

[Bantamzen]

Well it looks like the latest released figures of COVID-19 related deaths outside hospitals are far higher than previous reports have indicated. See here:
https://www.bbc.co.uk/news/health-52455072
snip:
"How quickly are care home deaths rising?
The daily updates provided by government do not include care home deaths.

The ONS has been able to track these by looking at deaths certificates - but that means the data lags behind the hospital deaths provided by the government.

Up until 10 April just over 1,000 coronavirus-related deaths had been recorded in care homes so far.

A week later this had increased by another 2,000 to top 3,000 in England and Wales.

Projections for the following week - up to last Friday - suggest they rose again."


So in effect, the fall from the peak is nowhere as great as some commentators have stated. There was a newspaper report today talking of the death-rate 'plummeting', as a justification for getting back to normal life, (no reference as I can't remember which paper it was), it seems that printing about wishful thinking like that doesn't make it true, indeed quite the opposite, so the Government's cautionary approach to lifting some of the restrictions is rather more relevant than the clamour to open the floodgates.

Do we know how many of the deaths in hoispital originated from care homes?

 

[trebor79]

Without wishing to sound insensitive, would reopening the economy make any difference to care home deaths, given the virus is already established there? Point made in several articles that care homes require lots of different care givers to come and go, all potentially bringing the virus in so lockdowns don't really reduce infection rate in that setting as much as they do for the rest of society.

 

[AM9]

Do we know how many of the deaths in hoispital originated from care homes?

I've never heard that it expressed as a metric, but that doesn't matter anyway. One of the 5 qualifiers for relaxing aspects of the current quarantine conditions is the rate of deaths, so every death attributed directly or indirectly to COVID-19 is relevant in meeting that objective. So getting all excited about the falling daily headline figure of the number of deaths, (which is those in hospitals) is a bit premature. It's interesting to note that the briefings now show a chart that also has a line that shows the 7-day average number of deaths, which due to the delays, incorporates those that occur in care homes and private homes.
Maybe the next refinement to the data will be on the numbers of new cases. Improved reporting of cases outside of hospitals, may show that the new case rate is similarly skewed by only counting those in hospitals and through test results.

 

[chris11256]

Many care homes have banned visitors since before the lockdown started, outbreaks have come either from staff accidentally bringing it in or residents being sent from hospitals to care homes having caught it in hospital. The vast majority have been via the latter.

Just to add my wife is a senior carer in a smallish care home, so my post is based on her experience. Although thankfully her home has had no cases of Coronavirus at all.

 

[Bantamzen]

I've never heard that it expressed as a metric, but that doesn't matter anyway. One of the 5 qualifiers for relaxing aspects of the current quarantine conditions is the rate of deaths, so every death attributed directly or indirectly to COVID-19 is relevant in meeting that objective. So getting all excited about the falling daily headline figure of the number of deaths, (which is those in hospitals) is a bit premature. It's interesting to note that the briefings now show a chart that also has a line that shows the 7-day average number of deaths, which due to the delays, incorporates those that occur in care homes and private homes.
Maybe the next refinement to the data will be on the numbers of new cases. Improved reporting of cases outside of hospitals, may show that the new case rate is similarly skewed by only counting those in hospitals and through test results.

Actually it does matter, especially if the data showed that care homes were a major source of spread. Yesterday's (27/04/20) NHS figures of deaths in hospital in England show that of 18,749 deaths in hospital with covid recorded, 9,770 (52.11%) were in the 80+ year old bracket, and 7,328 (39.08%) were in the 60-79 year old bracket, giving over 90% of recorded deaths as being over 60. This could mean that care homes are disproportionality represented in these figures (and keeping in line with WHO findings across Europe), which could drastically change how we should tackle the virus. I'm not sure if such data readily exists, but I'm fairly certain it could be extrapolated if needed, which I now believe it should. In fact with everything that we are starting to learn, it is would be negligent not to look more closely, to protect not just the elderly in care but their carers & healthcare staff.

Data taken from the NHS daily reporting:

Statistics » COVID-19 Daily Deaths

Health and high quality care for all, <br />now and for future generations

www.england.nhs.uk

 

[bramling]

Well it looks like the latest released figures of COVID-19 related deaths outside hospitals are far higher than previous reports have indicated. See here:
https://www.bbc.co.uk/news/health-52455072
snip:



So in effect, the fall from the peak is nowhere as great as some commentators have stated. There was a newspaper report today talking of the death-rate 'plummeting', as a justification for getting back to normal life, (no reference as I can't remember which paper it was), it seems that printing about wishful thinking like that doesn't make it true, indeed quite the opposite, so the Government's cautionary approach to lifting some of the restrictions is rather more relevant than the clamour to open the floodgates.

I’m seeing a difficulty, namely that the death rate (for hospital deaths) appears to be falling, but the infection rate is still higher than it should be, which has been officially acknowledged.

This would seem to indicate that shielding is working, simply by inhibiting high-risk groups from coming into contact with the virus, but that the lockdown has been less effective. So we’re still seeing infections, but this isn’t translating into deaths as the infected persons are less likely to be a member of a high-risk group. This would also square with the high care home figures as presumably care home residents are less likely to be effectively shielded due to needing care from people who will be going in and out.

This does seem to suggest that further lifting of the lockdown could prove disastrous for high-risk groups unless very strict shielding continues indefinitely, which will mean there needs to be a complete gear-shift in care homes.

I just cannot see a situation where we can shield the high-risk groups indefinitely. It’s not just a case of locking up the over-70s in their homes and allowing everyone else to continue economic activity, as it’s not just a young/old dividing line.

There will *have* to be a push at getting economic activity going again as quite simply none of us can live without it, however I can still foresee we’re all going to have to live with intrusive restrictions for the time being, and likewise we’re all going to have to continue to make an effort to observe these restrictions. I think some people are going to have to suck up the boredom or not being able to do certain things, unfortunately.

 

[AM9]

Actually it does matter, especially if the data showed that care homes were a major source of spread. Yesterday's (27/04/20) NHS figures of deaths in hospital in England show that of 18,749 deaths in hospital with covid recorded, 9,770 (52.11%) were in the 80+ year old bracket, and 7,328 (39.08%) were in the 60-79 year old bracket, giving over 90% of recorded deaths as being over 60. This could mean that care homes are disproportionality represented in these figures (and keeping in line with WHO findings across Europe), which could drastically change how we should tackle the virus. I'm not sure if such data readily exists, but I'm fairly certain it could be extrapolated if needed, which I now believe it should. In fact with everything that we are starting to learn, it is would be negligent not to look more closely, to protect not just the elderly in care but their carers & healthcare staff.

Data taken from the NHS daily reporting:

Statistics » COVID-19 Daily Deaths

Health and high quality care for all, <br />now and for future generations

www.england.nhs.uk

In respect of relaxation of restrictions it doesn't matter because however people contract the disease and whatever their age, they are a potential additional load on the NHS*. The load on the NHS is the main reason for the restrictions acccording to the Government, so that is why the COVID-19 attributable death rate is a key metric that determines the level of restrictions. Elderly patients are still people to most civilised persons.

* This is after the rumbled disgraceful attempt to get inadequately informed individuals (or their similarly unqualified relatives) to sign DNAR papers to reduce the inconvenience of treating some elderly patients.

 

[Freightmaster]

Without wishing to sound insensitive, would reopening the economy make any difference to care home deaths, given the virus is already established there? Point made in several articles that care homes require lots of different care givers to come and go, all potentially bringing the virus in so lockdowns don't really reduce infection rate in that setting as much as they do for the rest of society.

Unfortunately, the only way to completely eliminate risk/deaths in care homes seems to be
for the staff and residents to 'self isolate' as a group, as per this example:

'Amazing' staff praised for St Annes care home lockdown

No-one has been in or out of Fairhaven Lodge for five weeks since staff chose to isolate with residents.

www.bbc.co.uk

But while the St.Annes example is commendable, how many care home workers elsewhere in the
country would be willing to make a similar sacrifice, especially as it would have to be maintained
for an indefinite period??

Perhaps a more workable alternative would be to insist that care home workers can only come to
work is they are willing/able to self-isolate while at home and do not have to use public transport
to get to and from the care home?






MARK

 

[AM9]

... It’s not just a case of locking up the over-70s in their homes and allowing everyone else to continue economic activity, as it’s not just a young/old dividing line. ...

The "young/old dividing line" has come up for severe criticism today, especially in the context of whatever restrictions are extended beyong the next review. David Blunkett, writing in the Telegraph, and interviewed on World At One today, is putting across just how unacceptable such a move might be considered. His main point was that as it has been noted, some (B&ME) ethnic groups seem to be hit much harder by COVID-19, but if they were singled out in law to stay at home or otherwise be severely restricted, there would be an uproar, so expect there to be a massive response from those who just happen to be over 70 years old. As others here have commented, because most people in that age group tend to be more aware of the risks and are generally more compliant with the rules, they hardly represent as much of a risk as some of the younger adults who seem to think that they are immune and it isn't their problem anyway. Add to the fact that there are those who are just under 70 but in real terms no more healthy and often a lot less healthy than many of those say under 75, makes such a rigid dividing line pointless. There are over 1/2 million working over '70s so any specific age-realted restriction preventing them from working might result in a claim for full pay whilst they sit at home being compliant.

 

[mpthomson]

Do we know how many of the deaths in hoispital originated from care homes?

Last reported estimate was 3500-4000.

 

[bramling]

The "young/old dividing line" has come up for severe criticism today, especially in the context of whatever restrictions are extended beyong the next review. David Blunkett, writing in the Telegraph, and interviewed on World At One today, is putting across just how unacceptable such a move might be considered. His main point was that as it has been noted, some (B&ME) ethnic groups seem to be hit much harder by COVID-19, but if they were singled out in law to stay at home or otherwise be severely restricted, there would be an uproar, so expect there to be a massive response from those who just happen to be over 70 years old. As others here have commented, because most people in that age group tend to be more aware of the risks and are generally more compliant with the rules, they hardly represent as much of a risk as some of the younger adults who seem to think that they are immune and it isn't their problem anyway. Add to the fact that there are those who are just under 70 but in real terms no more healthy and often a lot less healthy than many of those say under 75, makes such a rigid dividing line pointless. There are over 1/2 million working over '70s so any specific age-realted restriction preventing them from working might result in a claim for full pay whilst they sit at home being compliant.

I agree. There’s a difference between “let’s try and resume as much economic activity as we can because there’s no realistic alternative” and “let’s lock up the over 70s and let everyone else continue happily ever after”, the latter seeming to be the line one or two are advocating. As you say, even is we disregard the ethics it doesn’t work on practicality as the dividing line is *very* blurred.

I wonder if we shouldn’t have had a shorter but much stricter lockdown, which in theory should have got the case rate down to much lower than is, allowing us to restart from a much lower level of active cases. The problem is now we’re almost totally reliant on social distancing to maintain the infection rate low, and we *have* to get that right if the death rate isn’t going to climb again.

 

[mpthomson]

Many care homes have banned visitors since before the lockdown started, outbreaks have come either from staff accidentally bringing it in or residents being sent from hospitals to care homes having caught it in hospital. The vast majority have been via the latter.

Just to add my wife is a senior carer in a smallish care home, so my post is based on her experience. Although thankfully her home has had no cases of Coronavirus at all.

As a senior manager in this area, it's not possible to say where anyone's case of COVID 19 came from and there's zero evidence to support the claim that the vast majority of transmission is from people sent back to care homes. I suspect the large majority will be brought in by staff from home but there's no way of proving or disproving that currently, and there's likely never to be.

That's not a criticism of the staff in any way, it's just the most likely method of transmission when looked at logically. COVID 19 positive people sent back to homes should continue to be barrier nursed until symptom free, which can be a couple of weeks. In these circumstances the chances of them affecting others are relatively limited, whereas staff do all the things that the rest of us do, put fuel in vehicles, go to supermarkets etc.

 

[mpthomson]

Unfortunately, the only way to completely eliminate risk/deaths in care homes seems to be
for the staff and residents to 'self isolate' as a group, as per this example:

'Amazing' staff praised for St Annes care home lockdown

No-one has been in or out of Fairhaven Lodge for five weeks since staff chose to isolate with residents.

www.bbc.co.uk

But while the St.Annes example is commendable, how many care home workers elsewhere in the
country would be willing to make a similar sacrifice, especially as it would have to be maintained
for an indefinite period??

Perhaps a more workable alternative would be to insist that care home workers can only come to
work is they are willing/able to self-isolate while at home and do not have to use public transport
to get to and from the care home?






MARK

My bold, a significant proportion of the lower paid care staff don't drive, so that is impractical unfortunately. This can be 50-60% in many homes.

 

[3rd rail land]

Unfortunately, the only way to completely eliminate risk/deaths in care homes seems to be
for the staff and residents to 'self isolate' as a group, as per this example:

'Amazing' staff praised for St Annes care home lockdown

No-one has been in or out of Fairhaven Lodge for five weeks since staff chose to isolate with residents.

www.bbc.co.uk

But while the St.Annes example is commendable, how many care home workers elsewhere in the
country would be willing to make a similar sacrifice, especially as it would have to be maintained
for an indefinite period??

Perhaps a more workable alternative would be to insist that care home workers can only come to
work is they are willing/able to self-isolate while at home and do not have to use public transport
to get to and from the care home?






MARK

Would care home staff really be willing to self isolate just so they could continue to go to work? If they refused to self isolate what would be the outcome? If they got sacked I suspect it might end in an employment tribunal and end up being quite costly for the employer.

As for not using public transport not everyone drives. Care workers are typically on low pay and may not be able to afford their own transportation. What would be the outcome if this rule was implemented and the care home end ed up with insufficient staff to run the home? Its not as if you can just close the care home and turf out all the residents.

 

[Bantamzen]

In respect of relaxation of restrictions it doesn't matter because however people contract the disease and whatever their age, they are a potential additional load on the NHS*. The load on the NHS is the main reason for the restrictions acccording to the Government, so that is why the COVID-19 attributable death rate is a key metric that determines the level of restrictions. Elderly patients are still people to most civilised persons.

* This is after the rumbled disgraceful attempt to get inadequately informed individuals (or their similarly unqualified relatives) to sign DNAR papers to reduce the inconvenience of treating some elderly patients.

The capacity of the NHS is on the increase, which was one of the primary drivers of the measures. As the hospitalisation rates fall, and a better understanding of how the virus is spreading & affecting people means strategies can be adjusted. This is why this kind of data is invaluable, a shorter lockdown means less revenue loss, which can mean better funding aimed where it is needed most.

Last reported estimate was 3500-4000.

Thanks, that is a significant proportion then. Do you happen to have a link, just for reference?

Would care home staff really be willing to self isolate just so they could continue to go to work? If they refused to self isolate what would be the outcome? If they got sacked I suspect it might end in an employment tribunal and end up being quite costly for the employer.

As for not using public transport not everyone drives. Care workers are typically on low pay and may not be able to afford their own transportation. What would be the outcome if this rule was implemented and the care home end ed up with insufficient staff to run the home? Its not as if you can just close the care home and turf out all the residents.

Self isolation won't automatically be necessary. If at is seems care homes represent a significant part of the spread, then care workers there need to be given access to the same level of PPE that we would expect at hospitals, and perhaps resources needed to be shared where possible so that both patients in hospital and in care homes get the same level of treatment.

 

[AM9]

... I wonder if we shouldn’t have had a shorter but much stricter lockdown, which in theory should have got the case rate down to much lower than is, allowing us to restart from a much lower level of active cases. The problem is now we’re almost totally reliant on social distancing to maintain the infection rate low, and we *have* to get that right if the death rate isn’t going to climb again.

The problem there is that the restriction came too late, there was a considerable volume of spreaders already moving about the UK which is why the increase in cases rose so fast. Had the tracing and testing capability matched the rising demand, the peak would have been much later and much more suppressed, which means that we would now have been tweaking a reduced amount of restrictions to keep the level well within the NHS capability. About the only thing that the government really got right was the very rapid acquisition of space, the fitting out and the opening of the Nightingale resources, - albeit by scraping ventilators and other kit from every possible source, even from some places where it was still needed. The dearth of PPI is probably partly down to the hollowing-out of many places that never thought that it would be needed. I wonder sometimes whether switching-off of most other acute services in the NHS was in part because liberties could then be taken with their stocks of PPI etc..
I suppose that by the end of June, there will be a quietening down of the desperate scramble for PPI and supplies from whoever can provide it (fashion manufacturers, charities etc.), will keep it ticking over.
Ideally from a logistics point of view, all new cases should be transferred to Nightingale hospitals as soon as that level of support needed becomes apparent, which would remove those patients from the 'spreading' environment. That would allow general acute hospitals to become generally COVID-19 free and resume normal services. It would also reduce the onward spread to care-home staff and then onto other residents. Given the distances involved, there might be resistance from relatives of the sick residents but AFAICS, once things get that serious, the patient becomes part of an intensive care 'worksite' and family interaction in a physical sense becomes both a negative asset as far as the patient is concerned and very difficult to administer by intensive care staff, if further infection is to be avoided. If that sounds insensitive, I apologise, but big decisions are made to deal with big problems, and there are likely to be many heartbreaking measures as a result of them.

 

[mpthomson]

Thanks, that is a significant proportion then. Do you happen to have a link, just for reference?

The CEO of one of the large care companies (CIC, a not for profit )who's on the board of a larger care home trade organisation, interviewed on BBC Breakfast I have to say that I recognise those figures from my own workplace discussions.

 

[mpthomson]

The problem there is that the restriction came too late, there was a considerable volume of spreaders already moving about the UK which is why the increase in cases rose so fast. Had the tracing and testing capability matched the rising demand, the peak would have been much later and much more suppressed, which means that we would now have been tweaking a reduced amount of restrictions to keep the level well within the NHS capability. About the only thing that the government really got right was the very rapid acquisition of space, the fitting out and the opening of the Nightingale resources, - albeit by scraping ventilators and other kit from every possible source, even from some places where it was still needed. The dearth of PPI is probably partly down to the hollowing-out of many places that never thought that it would be needed. I wonder sometimes whether switching-off of most other acute services in the NHS was in part because liberties could then be taken with their stocks of PPI etc..
I suppose that by the end of June, there will be a quietening down of the desperate scramble for PPI and supplies from whoever can provide it (fashion manufacturers, charities etc.), will keep it ticking over.
Ideally from a logistics point of view, all new cases should be transferred to Nightingale hospitals as soon as that level of support needed becomes apparent, which would remove those patients from the 'spreading' environment. That would allow general acute hospitals to become generally COVID-19 free and resume normal services. It would also reduce the onward spread to care-home staff and then onto other residents. Given the distances involved, there might be resistance from relatives of the sick residents but AFAICS, once things get that serious, the patient becomes part of an intensive care 'worksite' and family interaction in a physical sense becomes both a negative asset as far as the patient is concerned and very difficult to administer by intensive care staff, if further infection is to be avoided. If that sounds insensitive, I apologise, but big decisions are made to deal with big problems, and there are likely to be many heartbreaking measures as a result of them.

Sorry, we simply don't know what effect the date of lockdown had yet and it's not possible to say what would have happened if it had been done earlier at this point. There are a whole host of demographic and sociological factors that differ from country to country, and even in the UK between London and the rest of the country, to be considered alongside that and no one will know for a significant period of time, once the epidemiologists and public health research wonks have done their analysis.

And your analysis of the purpose/usage of Nightingale hospitals isn't correct. No ventilators were taken from settings that already needed them. Most COVID patients don't warrant ICU admission so the idea of an intensive care 'worksite' makes no sense, especially as there is significant spare UK ICU capacity (c3300 beds, not including Nightingales) from the latest figures. Families can't visit patients in hospital in any case at the moment, moving them un-necessarily tens of miles to a Nightingale doesn't alter that in any way, and ties up valuable ambulance resource as well.

The dearth of PPE, not Payment Protection Insurance, is mainly down to worldwide demand and a limited number of suppliers, plus NHS logistical and distribution problems in the UK. Some time ago (ie a couple of decades) the NHS made the decision to stop using UK PPE suppliers as their prices were significantly higher than those offered by (particularly but not exclusively) China and Turkish suppliers, so to use overseas suppliers offered the NHS, and therefore UK taxpayers, much better value for money. Lots of other countries also source from these same suppliers.

So when C19 kicked in outside China lots of countries were suddenly all trying to buy the same stocks at the same time and the suppliers prioritised those with significant outbreaks, so China and then Italy. In addition some governments where this stuff is manufactured suddenly made it much harder or impossible to export these items. There were instances of the US trade department taking literally suitcases of cash onto the pan at an airport in Turkey and offering more money for plane loads of masks originally intended for France, as just one idea of how desperate it got.

Germany is in exactly the same position as the UK regarding mask and other PPE provision, mainly because their sources are the same as ours. Over the last couple of weeks I'll have had just into double figures of UK companies contacting me regarding trying sell the hospital I run PPE as a new provider. When we've done due diligence on these only one has been able to provide remotely near the quantity that we actually need, the rest were either far too small, trying to broker supplies from the same Chinese suppliers that we already use at inflated prices (£50 for 50 masks, don't think so....) or were bordering on or completely in the realms of being scammers. Most of the new British providers can only provide amounts that are a drop in the ocean compared to the actual requirements, so this was never going to be an easy fix.

And to finish, just an interesting note, the UK has managed to significantly increase the number of ventilators and CPAP machines available to the NHS, mainly through the efforts of VCUK and some other companies, whilst the EU ventilator procurement scheme that the government was criticised for not being part of hasn't yet managed to even order a single one of either.

 

[Bletchleyite]

Precisely; and this is exactly the root cause of most of the problems we now face.

We had decided as a nation to adopt an approach of natural herd immunity, which is an effective approach provided that you shield away those who are most vulnerable and likely to die from the virus (ie care homes locked down, those who are currently shielding would have been advised to do so). We didn't do this effectively enough and the virus spread through the vulnerable quickly meaning that, in order to prevent any risk of the NHS being overwhelmed, we had no choice but to enter a national lockdown.

With respect to care homes, what should have been done was to fully lock them down - staff to live in and be tested before starting and after ending their (week or 2-week) shifts, the only exception being e.g. emergency plumbers, electricians etc who would have to wear full PPE and anyone dealing with them the same, and any goods inwards to be sanitised before use. One care home did do this off its own back (at a fairly considerable cost) and had no cases - it was featured on a podcast.

Matt Hancock's comment about a "protective ring" is what should have been done, not what was - it was an outright lie to suggest it was.

 

[Yew]

I don't even think that we'd have to be that dramatic, not discharging patients from hospitals back to a care home without a test (or some form of quarantine) would have done a lot towards protecting them.

Slightly off-topic, but I also think we need to re-evaluate the role of care homes, a few years ago a hospital pharmacist friend described some hospital wards it as "like we're farming old people". I think we should also have some grown-up discussions about voluntary end of life, the importance of years of quality life, and our obsession with keeping people technically-not-dead for as long as possible.

 

[Bletchleyite]

I think we should also have some grown-up discussions about voluntary end of life, the importance of years of quality life, and our obsession with keeping people technically-not-dead for as long as possible.

That too, though it's not really for this thread so maybe needs a new one if we will go further with it. I'm terrified of the idea of being that dependent on others, myself. We'd never allow a dog to continue living in that sort of state; in many ways we treat our pets better than our family.

 

[Llanigraham]

With respect to care homes, what should have been done was to fully lock them down - staff to live in and be tested before starting and after ending their (week or 2-week) shifts, the only exception being e.g. emergency plumbers, electricians etc who would have to wear full PPE and anyone dealing with them the same, and any goods inwards to be sanitised before use. One care home did do this off its own back (at a fairly considerable cost) and had no cases - it was featured on a podcast.

Matt Hancock's comment about a "protective ring" is what should have been done, not what was - it was an outright lie to suggest it was.

Except that many care homes do not have space to allow staff to live-in nor the facilities for them to "stand down" when not on duty.
And follow that to it's logical conclusion; should staff in hospitals have done the same thing?