H&F Council still refuses to take practical action over poor shingles vaccination rates

Cllr Lukey: Refusing to take practical action.

Cllr Lukey: Refusing to take practical action.

Last week I reported on the terrible news that Hammersmith and Fulham has only half vaccination rate for shingles as the national average.

I suggested that the Council could make a difference by using a relatively modest amount from its £22.7 million Public Health budget with practical measures to increase the take up of the jab.

The Council could write to all qualifying residents to urge them to take the jab. They should back this up with visits. They could fund the NHS to make it as easy as possible – for instance offering the vaccination on site in sheltered housing accommodation and indeed in residents’ private homes. They could also pay for the vaccine itself for borough residents aged 73-77? (At present those who were 70, 71, 72, 78 or 79 years old on the 1st September, 2015 qualify for a free vacine from the NHS.) Preventing elderly residents from getting this very unpleasant disease would actually save the Council money in terms of the adult social care budget.

I have wrote to Cllr Vivienne Lukey, the Cabinet Member for Health and Adult Social Care urging her to take action. I’m her reply read to me like a collection of excuses for doing nothing very much at all. She rejected my proposals – but didn’t offer any very tangible alternative – apart from holding lots of meetings. Here is her reply in full:

“Dear Cllr Phibbs,

Thank you for your email. Shingles is a horrible condition – you may have had family experience of this, as I have. Prevention is better than cure and I am determined that we get our health partners to improve on past performance.

I am unclear as to whether you have misunderstood the letter from Stuart Lines or have chosen to disregard what he has explained. NHS England has both the duty and the budget to commission GPs and NHS providers to carry out immunisations . There is no funding for this within our Council Public Health budget, which (as you well know)  is being cut by the Government. Given the other pressures on our funds, it makes no sense to me to attempt to take on a job which other bodies are paid to do so I cannot accept your original suggestions. I realise you put forward  these ideas before you had been briefed about statutory duties and am sure you were trying to be helpful.

But of course we will want to do the best we can to reduce shingles in our borough. We have an absolute commitment to defend our NHS services and improve health outcomes for our residents.

What we will do is to use our health and wellbeing leadership role to hold our partners to account and use our Council , voluntary and independent sector communication channels to encourage take up by educating residents about the consequences of getting shingles and signposting them to immunisation. I have asked for further work to be undertaken about eligibility for the vaccination (since it is restricted to older people) so we can see whether we need to lobby the Government for wider access.

We  set up a multi agency partnership group last summer which is led by the Council, and attended by myself and Cllr Holder. It has developed new ways of publicising  immunisation across the sectors and increasing take up in a wider range of venues and at weekends. This has proved a very effective forum for pressing NHS London Public Health officials and GP management for a proactive and sustained programme , which the Council can in turn promote. As Stuart Lines explained to you in his letter, this  will be our vehicle for driving up performance.

Thank you for taking an interest in what we are doing.

Best wishes

Cllr. Vivienne Lukey
Labour Councillor for Fulham Reach Ward
Cabinet Member for Health and Adult Social Care”

I have replied as follows:

Thanks, Vivienne.

I do think that your reply is quite disgraceful.

Just because we do not have a statutory requirement to do something does not preclude us from doing it. Nor do I accept that there is not the funding available given that there is £1.8 million unallocated from the Public Health budget for this year and that much of the total £22.7 million budget is ineffectively spent at present.

While you say that you wish to reduce the level of shingles in our borough you fail to back any practical measures for doing so but instead offer bureaucratic waffle.

Best wishes,

Cllr Joe Carlebach: H&F Labour councillors reject plea to engage with vulnerable residents

joecarCllr Joe Carlebach is a councillor for Avonmore and Brook Green Ward and the Hammersmith and Fulham Vulnerable People’s Champion

It’s a mad world!

The words of the song by Tears for Fears ( a band of the 1980s for those of you who are too young to remember them!) came to mind last week at the Hammersmith and Fulham full Council meeting. If you have never been to one of these meetings, they are usually three hours of solid political banter with occasional glimpses of debating prowess on the part of both parties.

My approach to Council meetings has always been one of constructive engagement. It is an opportunity, when in power, to listen to what the opposition has to say and, when in opposition, to constructively hold the administration to account. This is what I believe residents would expect. So it was with sadness and surprise that in a debate on a motion about the Administration’s new Area Health Forums I tabled what I thought was a constructive unpolitical amendment, and it was voted down!

These new forums do, on the face of it look like a positive development. I would support any opportunity where residents have the chance to express their concerns and views on all aspects of health care in our borough to health care providers.

I know from painful experience that residents from vulnerable groups have a disproportionately difficult time gaining fair access to health care. I have worked on many cases where this has happened and I am confident there are many cases out there that I do not know about with exactly this experience. It was in light of this that I tabled the following amendment to the motion, expecting (perhaps naively) that all Councillors would feel able to support it.

For your information here is the exact text of my amendment. For those well versed in the intricacies of Council life, this was an addition to the Administration’s text, not altering it in any other way:

Amendment to Special Motion 7

– The Council recognises that the health needs of our vulnerable residents are often complex and diverse requiring specific detailed multi disciplinary care solutions.

– The Council will make every effort to ensure that invitations are extended to the Neighborhood Health Care Forums to groups representing our vulnerable residents and in particular those representing and working with children and adults with all forms of disabilities as well as the frail elderly.

I am still at a loss to understand why this amendment was voted down.

One of the main reasons given on the night was that these forums are for individuals not groups. I have to say, having worked with many of the groups representing vulnerable people for many years, they are almost entirely made up of service users and families of people with disabilities, complex needs, the frail elderly etc. So for me this reasoning is not correct nor does it sound reasonable. Our residents will make their own judgement.

I would like to end with the statement that I started with which is in opposition I have done my best to take a constructive approach to ensure that the needs of vulnerable people are addressed. However (I say again) I also believe it is the role of the opposition to hold the Administration to account when the situation merits it. That is how good democracy works.

The rejection of my amendment was very disappointing and I would go so for as to say incomprehensible. The real losers of this disagreement will be the very people we are all trying to help, namely the most vulnerable residents in our borough and that is deeply regrettable.

Ever the optimist I am hopeful that the administration will experience a change of heart and see sense. As Martin Luther King said “We must accept finite disappointment, but never lose infinite hope.”

H&F Council rejects allowing electric cars to use bus lanes

A Nissan Leaf

A Nissan Leaf

I wrote last week about the urgent priority to encourage motorists to switch to electric cars. At present air pollution kills 72 borough residents a year – as well as diminishing the quality of life for the rest of us. A big switch to electric cars would be transformational. A significant incentive could be allowing electric cars to use bus lanes. So it is disappointing that Hammersmith and Fulham Council has rejected the idea.

Edward Stubbing, a Transport Planner for the Council’s Transport and Highways Department writes to me to say:

“Modelling suggest that there is a eight fold increase in fully electric vehicle ownership year on year, as such the bus lanes are likely to quickly become congested with electric vehicles over time as the level of ownership quickly rises. Bus lanes are currently used by both buses and Taxi’s in recognition of the shared mode of transport they represent. Introducing other vehicles into these priority lanes would likely damage the effectiveness and advantage of these modes of travel.”

He concludes:

“As such at present it is the view of officers that the benefits of allowing electric vehicles into bus lanes, does not outway the disadvantages it would cause other road users.”

Now there can be a more general argument about whether bus lanes are an overall benefit in terms of traffic congestion and passenger journey times. In Liverpool most bus lanes have been abolished to ease traffic congestion for motorists. The length of time for bus journeys only increased fractionally and the number of bus passengers actually increased. At Holborn tube station passengers were asked to stand on both sides of the escalators – instead of walking on the left and standing on the right. This meant congestion was eased as capacity increased. One can see the same logic provides a case for getting rid of bus lanes.

On the other hand perhaps Mr Stubbing is correct and that allowing electric cars to use bus lanes would increase overall journey times. I think he’s wrong – but let us suppose he is right. What is more serious? That a bus journey takes a minute or two longer or that air pollution continues to cause us to die an year earlier than we otherwise would and means we are wheezing and spluttering before it finally finishes us off?

H&F Council is failing to protect elderly residents from shingles

shingles250,000 people a year in the UK suffer from shingles. It is a very unpleasant illness. Victims can die from it, although that is rare – about one in a thousand cases.  But what is commonplace – approximately 100,000 cases a year – is to develop “postherpetic pain” when the virus damages a nerve. The pain is typically excruciating. 20 per cent of shingles patients remain in pain after three months. For those admitted to hospital the average stay is 14.6 days. More often the infection means the elderly can stay at home but are unable to look after themselves.

The good news is that there is a shingles vaccine (called Zostavax) that is available. There is a phased introduction. It is currently available free on the NHS for those who were 70, 71, 72, 78 or 79 years old on the 1st September, 2015. If you are eligible – or you know someone who is – it is something to be contact your GP about.

Apparently it costs the NHS around £55 a shot – which is rather high for a vaccine. But not only will it avoid a lot of misery, it is also good value for the taxpayer.

The bad news is that the take up in Hammersmith and Fulham is less than half the national average. Between September 2014 and May 2015 it was 27.7% in Hammersmith and Fulham for the routine vaccination at age 70 years. The uptake for England was 52.8%. For 78-year-olds it was 25.5% against 53.8% nationally, 21.0% against 52.5% nationally.

These figures are a disaster. The statistics represent a terrible human toll. There will be vastly more misery for the old people of our borough from this disease than for the country as a whole. This is avoidable.

Hammersmith and Fulham Council is doing nothing about it. The Public Health Department tells me:

“The shingles vaccination programme is commissioned by NHS England (NHSE), who is responsible for the commissioning of local provision of immunisation services and the implementation of programmes through general practice and other providers. As this is not a local authority responsibility no financial contribution has been allocated from the H&F public health budget specifically to increase the shingles vaccination uptake rate.”

Remember the Council spends £22.7 million a year on Public Health – most of this spending is currently wasted. Also consider that this is a Council that spends £88 million a year on adult social care – including providing carers for those residents unable to look after themselves due to shingles. So the Council’s indifference is not only callous but financially inept.

Other councils have been active on this – which may partly explain the higher vaccination rates.

The Council should use Public Health funds to write to all qualifying residents to urge them to take the jab. They should back this up with visits. It should be made as easy as possible – for instance offering the vaccination on site in sheltered housing accommodation and indeed in residents’ private homes. What about also paying for the vaccine itself for borough residents aged 73-77?

Cllr Lukey: Indefensible

Cllr Lukey: Indefensible

According to the last census the borough population is 183,000 with around 3% of us aged 70-79.  So perhaps 5,000, and perhaps 2,000 aged 73-77.  Of course not all of them will take the jab – it is a matter of personal choice after all. But supposing half of them did at a cost to the Council of £50 a time and thus a total bill of £50,000. I suspect that would be money rather better spent that most of current £22.7 million current Public Health budget – with teams of people writing reports for other people to file.

I have written to Cllr Vivienne Lukey, the Cabinet Member for Health and Adult Social Care, asking for the policy to change. She has a wide remit and I actually think it is understandable if she was not aware of the current policy on shingles vaccination. But I do hope that having been made aware of the policy she will not seek to defend what seems to me to be indefensible.

Ravenscourt Park Ward leads the way on proton beam therapy

ravenscourthospRavenscourt Park Hospital closed in 2006 but now there are exciting plans for it to reopen in 2017.

It is to become the first in the UK to offer proton beam therapy for cancer patients.

The treatment involves firing beams of proton at a tumour to destroy cancerous cells. The beams stop once they hit the cancerous cell, causing less damage to surrounding tissue than conventional radiotherapy, which makes treatment is especially well suited to children with brain tumours.

The Mayor of London Boris Johnson said:

“This is a tremendous vote of confidence in London’s thriving life sciences sector as well as the skills and talent of our amazing healthcare professionals.”

VPS Healthcare plan this as their first hospital in Britain. There will be 150 beds and around 2,000 new members.

Dr Shamsheer Vayalil, an Indian entrepreneur who founded VPS, says:

“The UK has one of the strongest and most productive medical research sectors in the world, contributing to patient well-being, as well as supporting breakthroughs in science and driving economic growth.

“It has a worldwide reputation for excellence in innovation within its universities and is recognised for producing world-class scientists and clinicians.

“VPS Healthcare has been encouraged by the UK government’s ongoing policy to support health and pharmaceutical companies and we believe that our investment in this dynamic sector will not only ensure that we play a key role in supporting this initiative, but will also help to grow and develop the next generation of medical breakthroughs.”

The hospital was opened by George V in 1933. It won an award for RIBA as the best building that year – despite that I don’t think it is too bad.

There have been various incarnations as a Masonic, private and NHS hospital.

Let’s hope the best is yet to come.


Cllr Andrew Brown: Chelsea & Westminster merger with West Middlesex Hospitals – what are the risks?

andrewbrownCllr Andrew Brown writes

Earlier this summer I wrote about the proposed merger of Chelsea & Westminster Hospital Foundation Trust with West Middlesex NHS Trust. Since then Chelsea & Westminster (C&W) have given evidence to the Health, Adult Social Care and Social Inclusion Policy and Accountability Committee. At that meeting we heard senior clinicians and hospital directors strongly argue for the clinical rational behind the proposed merger. This aspect of the merger was heavily scrutinised by the committee, however missing from this was any financial details whatsoever.

This was a serious obstacle to proper scrutiny of a merger that’s origin was due to financial difficulties faced by West Middlesex NHS Trust. Representatives of C&W explained that this was due to confidentiality reasons. Whilst that is to an extent understandable, in my view it was misguided, as it cast further doubt onto the validity of the merger proposal. To their credit, C&W directors extended an offer to members of the committee to meet with their financial director to review the full business case for the proposal.

I have recently met with C&W’s finance director, Lorraine Bewes, and their strategic director, Dominic Conlin. On the condition that I signed a confidentiality agreement, they discussed with me in detail and showed me the financial case behind the proposed merger. I of course intend to honour the agreement I signed, and for full disclosure, have shared this article with Ms Bewes and Mr Conlin before publishing it.

My areas of concern regarding the merger have always been primarily on its effect on residents of Hammersmith and Fulham. For the residents who are primarily served by West Middlesex, it is fairly clear that the merger will be of benefit, as without a merger with a strong, viable trust, there would be a significant risk that West Middlesex Hospital could cease to function. For these reasons, it is understandable why the Department of Health, the Trust Development Authority, Monitor and the Secretary of State, will most likely support the merger.

I want to therefore focus on my concerns for the people of Hammersmith and Fulham, and share some of the answers that I received from C&W.

Financial Burden of West Middlesex’s existing deficit and PFI contract

One of my concerns, shared with colleagues, was how the combined trust would be able to manage the deficit and PFI costs associated with West Middlesex. It was explained to me that compared to other PFI contracts at hospital across the NHS, the West Middlesex contract was comparatively small. The money that the new trust would receive from the NHS to help manage the merger would more than cover this. The NHS are also funding a new electronic patient record system for the new trust, which will see it become one of the most advanced in the NHS.

This will hopefully speed up how the trusts communicates with patients and other parts of the NHS to reduce time and costs associated with referrals and making appointments, and ultimately improve care. I have also seen that the business case plans for a current deficit over both trusts to be turned into a significant surplus over 10% in several years. It will be challenging to turn around the hospitals’ finances to that extent, and the trust should be judged on whether that is achieved.

Managerial Challenge associated with the merger

One of the criticisms laid at C&W by the CQC report was that their leadership requires improvement. That is not an ideal position to be starting such a challenging organisational change. C&W has been led by Elizabeth McManus, as interim Chief Executive, since the departure of Tony Bell in November last year. Ms McManus is to be replaced as Chief Executive by Lesley Watts, who will start in mid-September. With the merger with West Middlesex expected if final approvals are given, on the 1st of September, this is a particularly challenging time to be taking on such an important role. It is critical for both hospitals that Ms Watts hits the ground running, and that the whole management team supports her in taking the hospitals forwards and making the changes agreed with the CQC. It has been explained to me that many of senior management team from C&W have already been spending some of their time at West Middlesex in advance of the merger, and that the proposed larger merged trust is already helping to attract senior clinical and management staff. That is all well and good, however the challenge facing the management team at the new trust if the merger goes ahead is an extremely significant one. It is critical for patient services and outcomes that they are successful.

Risks Associated with merger plan’s assumptions not turning out as expected

The business case for the merger trust is based in part on increasing the number of patients seen on the West Middlesex site. This will depend on whether significant numbers of patients choose to come to West Middlesex; on whether local clinical commissioning groups commission new/expanded services at West Middlesex; and that large neighbouring trusts, such as Imperial, do not successfully compete for these additional services.

There will of course be other risks, both known and unexpected, that could derail plans. It has been explained to me that if the merger does not go ahead, C&W will face risks perhaps greater than those of the merger. Not being able to turn the deficit around, and compete with larger nearby trusts to attract patients as well as leading clinicians are valid concerns.

Concern that services based at C&W could move to West Middlesex

C&W have said that they have no plans to move services from C&W to West Middlesex. Residents of Hammersmith and Fulham have heard that before however, following the creation of Imperial College NHS Trust. We have been assured that services will not be moved, and that if such a proposal was put forward it would have to undergo full public consultation. That in my mind is not sufficient, so I have written to the Chair, Chief Executive and Governing Body of Chelsea and Westminster to ask for their guarantee that patient services will not move away from Chelsea and Westminster.

In conclusion, I still believe that this merger carries significant risk, but as argued by C&W there is significant or greater risk by not going forward with West Middlesex. The combined trust will be strongly incentivised by the NHS to take over West Middlesex, as well as invest in a new IT infrastructure.

My biggest concern is that services for patients in Hammersmith and Fulham could suffer through either being moved to West Middlesex or through the management of the trust being distracted by the merger and away from what counts patient care and outcomes.

Finally from a local authority perspective, Labour councillors on the scrutiny committee and members of the administration have not been to C&W to meet with their finance director and scrutinise the business case. This is in addition to there being little to no contact between C&W and the leadership of Hammersmith and Fulham council since the Labour Administration took over last year. For a council that put such electoral stock in local healthcare issues, they have serious questions to answer. Do they not care about a hospital that provides services to a significant majority of patients in Fulham, and most families across the borough with children? Or do they only care at election time?

Proposal to reopen Ravenscourt Park Hospital

ravenscourtparkhospTim Harvey the Chairman of the Ravenscourt Gardens Residents has made the following query with me about Ravenscourt Park Hospital:

“As you know this has now been empty for some years. Is the planning consent for conversion to a specialist cancer centre still valid – by now it may well have expired? As the years tick by it would seem that the possibility of converting this beautiful Grade II* building to a modern facility gets more and more remote. On costs, the last I heard it was £100m, with no takers. What powers do the council have to force the issue here, or even to reconsider its use, with reference to its sister building Ashlar Court, for instance?

Under a general heading of ‘regeneration’ isn’t it time that something creative was done to this huge building and very large area of the RP ward?

The buildings behind the hospital in the roadway between Ravenscourt Gardens and Ravenscourt Square continue to be a particularly squalid part of our conservation area. The Chiswick Nursing Centre have now been forced to lay huge concrete blocks on the pavement alongside the very dilapidated boiler house to prevent illegal parking and flytipping. It is a really horrible area, and we tend to avoid it at all times, especially at night.”

The Council has responded as follows:

“With regards to Ravenscourt Park Hospital, we have been advised that negotiations with a new investor and operator that runs a number of hospitals are at an advanced stage, in fact heads of terms have been exchanged. The agents are of the opinion that works were carried out on site to implement the earlier planning permission and they hope to be on site in the near future to complete the development. They have advised us that some minor alterations (mainly internal) may be required to the planning permission, and these would be part of a further planning application in due course.”

So good news.

Although I will still pursue Tim’s point about the dilapidated old boiler house and surrounding area.

Cllr Andrew Brown: Proposed merger of Chelsea & Westminster with West Middlesex Hospitals – Good for patients or a huge risk?

andrewbrownA guest post from Cllr Andrew Brown, Conservative spokesman for Health and Adult Social Care

Yesterday evening I attended, with my colleague, Cllr Joe Carlebach, a public meeting arranged by Chelsea & Westminster Hospital Foundation Trust. The purpose was to engage with local residents and councillors. The Chair, executives and governors of the hospital spoke initially about the challenges and also successes of the hospital, including the CQC report, but also the excellent A&E waiting times and world class HIV & sexual health services. The white elephant in the room however was the acquisition of West Middlesex NHS Trust, by Chelsea & Westminster.

There has been a serious lack of local scrutiny of this decision, and to give credit to the hospital’s Chair and executives, they gave a full, and in my opinion, genuine apology about the lack of communication on this issue and in general. It is refreshing to see that from an NHS body. But it is unfair for Chelsea & Westminster (C&W) to take all the responsibility for this lack of scrutiny, a point made by several people at the meeting.

Whilst C&W could have asked to present to our Health, Adult Social Care and Social Inclusion Policy and Accountability Committee – catchy title isn’t it – that is not really how the committee functions. The vast majority of attendees are asked to give evidence by the committee. There have been numerous occasions over the last year when important NHS issues have been discussed, such as A&E waiting times, or Shaping a Healthier Future, where C&W’s presence would have been welcomed and could have provided valuable information and the opportunity to discuss and scrutinise the proposed merger/acquisition.

Cllr Carlebach and I had to argue for Chelsea & Westminster to be called before the committee, as they are a very important provider of acute hospital services, especially paediatrics to a significant proportion of LBHF, but especially the south of the borough. It was revealed this evening that Labour’s cabinet member for health, Cllr Lukey, has not until last night, met the acting chief executive of Chelsea & Westminster, who has been in post for some time. This is concerning to say the least.

Onto the merger/acquisition itself. C&W were approached by West Middlesex NHS Trust a couple of years ago to investigate a merger. As a foundation trust, C&W have to acquire West Middlesex. This has to be agreed by the TDA, the Trust Development Agency. So far the acquisition has been approved by the Competition and Markets Authority. It is now being reviewed by Monitor, the NHS financial regulator, and then final approval is needed from the secretary of state for health.

Worryingly, this is all due to happen within the next few weeks, with the final acquisition proposed for September.

What I find most alarming is that we have so far, despite asking for it, received no in-depth clinical case, outlining how this will improve patient care, improve outcomes and save lives, and no financial case at all. We do not know what services will move between sites, or what additional services will be offered other than a brief suggestion of cardiology cath-labs, bariatric surgery (to tackle morbid obesity) and ophthalmology.

The Chair, pointed out the challenges facing NHS trusts due to increasing demand from an aging population and increased chronic disease, and how trusts have to work together and specialise to cope with demand, improve outcomes and reduce backroom costs.

At a time when there is great uncertainty in the NHS, especially in North West London, he conceded that this is a risk, but that it would also be a risk not to proceed with the merger. Chelsea & Westminster’s budget is currently in surplus but forecasted to fall into deficit.

Without the key clinical case and financial case it is impossible to scrutinise this decision or believe the risk is worth taking. Especially when we consider that C&W is soon to appoint a new permanent chief executive, needs to make significant changes to improve its CQC rating of requires improvement, and needs to improve its own leadership structure. There are also significant leadership challenges at West Middlesex, and hanging over that hospital is a PFI contract, a disastrously managed policy of the last Labour Government, that is a significant reason for the financial challenge facing the NHS.

We will hopefully have the opportunity to scrutinise this decision in great detail on the 7th July at the next health scrutiny committee. Only then will we be able to come to a conclusion on whether this will be good for patients’ outcomes and experiences, and save lives, and something that we should support, or whether the risks are too great. I hope that residents interested and concerned about changes to healthcare in our borough will attend that meeting.

If the acquisition is given the final go-ahead by the regulators and government, it is ultimately the decision of Chelsea & Westminster’s governors whether to go ahead. If there is significant uncertainty and local opposition against this proposal they will have a difficult decision to take. However if this proposal had received greater scrutiny during its process, we could have a lot more confidence that the decision was the right one. The fault for that has to be shared by Chelsea & Westminster and Hammersmith and Fulham Council, and its Labour administration.

The silence of Andy Burnham

The Hammersmith Labour Party are fighting the General Election campaign with a promise to “save” Charing Cross Hospital. The claim that the hospital – or it’s A&E – face closure is dishonest. But leave aside, for one moment, that way of characterising the NHS proposals. Would a Labour Government block the changes?

I have asked the Shadow Health Secretary Andy Burnham:

 Thus far there has been no reply. Of course he will be busy but he has has sent various other “tweets” in the interim. He might also decide to ignore me given that I am a political opponent. But his own Labour colleagues might also be interest in his clarification.

Not least Cllr Stephen Cowan, the Labour leader of Hammersmith and Fulham Council, who made just such a plea in the left wing weekly Tribune.

I believe the NHS proposals would mean an improvement for Charing Cross Hospital and that they would save lives. Some will agree, others have made very clear they disagree. But before Thursday next week shouldn’t we be told whether or not a Labour Government would allow those changes to proceed?