The fact the NHS survives by a kind of miracle is one of its endearing British features – so said former health secretary, Kenneth Clarke. Well, can that miracle continue?
As we approach the NHS’s 75th birthday in July, we’re launching a series of three podcast episodes setting out the big questions facing the health service. This first episode explores current pressures on the NHS, economy and wider society and what the future might hold.
What are the questions that policymakers may face as the population’s health and care needs change over the coming decade? How can the UK economy power the investment needed for health services to survive and thrive? And how can more long-term thinking help to foster good health and economic productivity?
To discuss, our chief executive Dr Jennifer Dixon is joined by:
Professor Jagjit Chadha, Director of the National Institute of Economic and Social Research and chair of the UK Productivity Commission
Anita Charlesworth, Director of Research and the REAL Centre at the Health Foundation.
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The fact the NHS survives by a kind of miracle is one of its endearing British features – so said former Health Minister Kenneth Clarke. Well, can that miracle continue? We're going to explore this question in the next three podcasts before July 5th, the NHS's 75th anniversary. This one looks at the current and future pressures on the NHS in the next decade.
With me to discuss all this, I'm very delighted to welcome two guests. Professor Jagjit Chadha, Director of the National Institute for Economic and Social Research, he also chairs the UK's Productivity Commission. And our very own Anita Charlesworth, who's also an economist and Director of Research and the REAL Centre here at the Health Foundation. Welcome both.
I thought the place to start would be just some brief contours of where you think we are now both on the NHS and also the wider economy.
Obviously the thing that people will be most aware of at the moment is that we are coming out a pandemic, but whilst we're coming out of a pandemic, COVID is not over. We are living both with the consequences of the pandemic in terms of big buildup of waiting times and waiting lists now of over seven million people and pressures on A&E and general practice, and also mental health, it's really important to think about that.
But we're also living obviously with the virus settling down to be part of our disease mix. People are in hospital with COVID. That's an added pressure, but I think perhaps more importantly almost than all of that, what we're seeing is that staff have been through an incredible experience and they're trying to get back to normal and they're trying to get back to normal when you've overlaid an economic crisis, cost of living crisis on top of that pandemic experience.
One of the biggest constraints I guess on our ability to get back to some kind of normal is how we get back to a new normal, I think because people you don't want to go back to just before pandemic. There were a lot of issues for the workforce there for staff.
That leads us to the economic question, Jagjit. I mean there's a cliche which says that if the economy sneezes, the NHS catches a cold and of course we wouldn't be under so much pressure probably if the NHS were invested in at European levels. Can you just say a little bit about the state of the economy and why it may not be powering up the NHS to the extent we might want?
What's interesting you say about the connection between the economy and health. I would also draw another line from the health back to the economy in the sense in which if the NHS sneezes the rest of the economy catches the flu. One thing we absolutely took away from the terrible period of COVID and the shadow in which we still live, is that there's not a trade-off between health and the economy. If you try and help people's health with lockdowns or some constraints on their mobility, that affects the economy in a negative manner. There were lots of calculations about the trade-offs, but actually we now know very well that there's no long run trade-off. The two snap together very, very clearly. A healthy economy and a healthy population are things that move in lockstep with each other, and that is something we shouldn't allow to be forgotten as we emerge from a COVID.
I would put that as the first principle on which we should guide policy planning both for the economy and in terms of health. If we take that as a principle and apply that to a particular problem that we're facing and that is of shortages across the board in many areas of the economy. We can talk about the private sector in terms of hospitality or recreation or the public sector in terms of teaching. But clearly there seem to be shortages in many areas of the provision of the NHS, and that's not only in terms of quantity, also in terms of composition. It could be that we've been losing more experienced people as there's been a gap developing between public and private sector pay.
That of course has been exposed very clearly as Anita mentioned, by the cost of living crisis that has raised inflation relative to wages and meant that the real value of what people are taking home has fallen quite markedly and it's hit hardest those in lower income brackets. Of course, the NHS employs many people in those lower income brackets who are struggling, I think.
Just on the economy itself, I mean clearly the performance has not exactly been exceptional, has it since the crash. We're kind of limping along behind quite a lot of other Western European nations in terms of our recovery from the pandemic. Why are we in such a weak state?
My colleagues at the Institute did a bit of interesting work and they looked at our expectation of where the level of output would be, what economies call GDP, around now in the last forecast we did before the pandemic, so just at the end of 2019. By and large, economies had now recovered to the extent that they weren't that far away from where we anticipated them being. They'd been a large fall during the pandemic and then a recovery.
But what we did notice is that many European economies were significantly below, 2% to 3% below our expectations. It won't surprise you that the UK was the worst, five and a half percent below expectation and therefore you might ask why is that the case? I think there are a number of reasons that we are particularly exposed to the parts of the economy that were most affected by COVID. Hospitality, recreation that we just talked about. We have health service and that has struggled I think in this period.
As with many crises, they don't themselves do anything other than reveal existing problems and weaknesses that we have. I think the number of deaths that we saw is a reflection of an underlying lack of structural investment in our health and social care system. I think that is something that's held back the economy.
We can also point to the frictions with trade with Europe, otherwise known as Brexit, which hasn't helped as well. I think when we add all these things up, they're the things that we look at to try and understand why the UK has performed less well than it might otherwise have done.
Those things are fairly short run it seems. Are there any really long-term structural issues that are really quite unusual here, which might hamper our future recovery?
The breaking of relations with Europe in terms of economic trade and services is a long run factor. It's very much something that we've described as a slow puncture on the economy in the medium term until we've worked out a framework that's going to work for us as a very open economy.
Because what we're pointing to is a slowdown in our productivity. That means essentially the number of widgets we produce per hour at work. We look at that trend since the financial crisis and it's done very badly. That is the thing that underpins the reduction in relative living standards. That's the thing that means that we haven't got the capacity to fund directly the public sector infrastructure that we need. It's really the key issue facing the economy.
Related to that is a distributional issue in that those people fortunate to work in highly productive tradable sectors, the financial sector, of pharmaceuticals and other high value services, legal services or accountancy, have managed to maintain their standard of livings and improve them. But for the rest of the population, we've found income inequality increasing and many of those people falling into traps where even though they're working, they still can't afford to get by.
Let's just turn a little bit more to look at some of the future trends that are affecting the health service in particular and the wider economy. Start off with Anita. Can you just chart for us some of the big pressures you think in the next 10 years or so? What are the big contours people need to be thinking about? The headwinds that we're going to face.
People in the health system, who make policy in health system, do actually really need to think about that economic situation Jagjit was talking about. I think it's really important from two perspectives. The first is work that we did back in the autumn looking at how spending on the NHS compares to spending on housing in other large European countries found that on average we were spending over the decade preceding the pandemic, £40 billion less than we would've been if we'd been matching the average of the EU14 countries.
The main reason for that was not because the UK devoted a lower share of our national wealth to health. I mean some countries do do more, some of the Northern Scandinavians, Germany, etc. but actually we're about average in terms of the share of our national wealth that we devote to health. But the problem was that our income per head, our GDP, our national wealth was much lower. If we can't get that economic growth, it's really difficult to sustain the health service of the quality we need. That's always been true, but it'll be a particular challenge I think over the next decade or so for two reasons.
The first is that we are entering a period of rapid ageing of the population. That has a very big impact on health service because obviously people use more health care as they get into older age, and also in particular use more health care in the last year typically of their life. The ONS is projecting that by 2030, we'll have a third more over 85s compared to just before the pandemic, and a fifth more people in the last year of their life.
The other thing we're seeing is those real pressures in the labour market because we've got an ageing population, birth rate is falling, our working age population isn't growing. We've got people out of the labour market because of ill health, likely at the moment that's going to get worse before it gets better. The health service and the social care system, really importantly, if they're going to meet that need of a growing and ageing population are going to need more staff unless we can do some magic and I'll come to the magic in a minute, from a pool of potential labour that's got many more calls on it from other sectors of the economy.
Now the way as an economist, what that tends to mean when you've got more demand for staff and lots of people also competing for that scarce and very skilled resource is that generally speaking, wages go up. Although we've had a period obviously where one of the ways in the run up to 2019 that we tried to deal with funding for the NHS, not keeping up with pressures, was we sweated our system really hard. That meant not investing in new capacity, using that capacity really, really hard. Very high bed occupancy rates, our average stay at hospitals fall by the fastest rate in Europe by a fifth through that time.
We asked staff to bear a lot of the brunt of that. Their real earnings fell. We didn't increase staff at the same rate as activity and we asked them to work ever harder. Even before the pandemic, it looked like that strategy of just run your system ever hotter had run a road and it certainly now has done.
We need to look to new sources of productivity gain, because productivity gain matters in the whole economy, also matters in the health service. That's one of the reasons why I think so many of us are really interested in and think it's really important that the health service starts to get its head round and get ahead on the potential of new technologies. That if it's to do that, it's got to invest in the capital. It's got to invest in the R&D.
One of the tragedies of the way that we've run the NHS, which is I think one of the root causes for some of our problems, is that we run it just in this firefighting short term mode. Through that last decade, not only have we been spending less on day-to-day care, but to cope with the pressures on day-to-day care, we've been raiding capital investment and we see that actually today the share of capital investment in the NHS is lower than it was before the austerity squeeze.
You've done lots of work looking at the real terms increase in investment in the NHS over the last 75 years of its history. Can you say something about what kind of real terms growth is manageable, comfortable and what is low?
When you look at the longer term, it looks like somewhere between 3% and 4% increase a year over and above inflation is the amounts of money that you need to go in it. It depends partly on how well you can do on productivity, depends partly on what's going on in wider labour markets and so just what the wage pressures are. It depends also on some of those population demographics. If you go back to the sixties, we had a period in which probably the working age population was growing relative to the elderly population, so your health pressures were a bit moderated. We're in a period now where your elderly population is growing more than the working age population, so your pressures are going to be higher.
Given economic trends, Jagjit, if the NHS finds it comfortable to have its long-term run rate of 3.9% real terms growth to survive and thrive, that sounds like a tall order for us in terms of economic growth of the same magnitude.
The trend rate of the UK economy growth has been successively revised down. We're now thinking about one to one and half percent. If we're going to try and achieve the health targets that Anita's outlined that are very sensible, that of course means that health expenditure takes an increasingly large share of GDP and the limit would take it all. That's clearly not a sustainable position in an economy.
If we're going to increase productivity, I think there's two parts to this problem. One is to be very clear, it can't be done quickly. A secular decline in relative productivity over the last 15 years is not something that can be reversed quickly. I have to mention this. That was definitely the lesson in the mini budget in September last year. Any radical attempt to increase productivity quickly and inject a large amount of expenditure in the economy will come up against an inflationary problem and a concern that we're trying to run the economy too fast.
Once we accept that, then we have to adopt a different approach which is nurturing the economy over a longer period, five, 10 or 15 years that then asks questions of our institutions, political commitment and the targets that we're going to have to adopt to get there over that generational timeline. We need commitments to the level of public investment far above where we are at the moment. We've been somewhere between 1% and 2% over the last 40 years. That has to go to 3% to 4% if we're going to help.
Doing things that encourage FDI, foreign direct investment. The idea of foreign direct investment is that internationally competitive firms bring their skills and ideas into a country, employ people at the productive frontier, so people with using the best skills and technology available, potentially using AI as well. That tends to help our domestic firms become more productive, raising wages and incomes in local areas and providing economies core spillovers, jobs for other people servicing those in that part of the country as well.
It looks like it's dried up somewhat over the last five or six years. That would be an important part of building up the economy. But I think it's something that we think of as being in conjunction with a clearer strategy on public investment, which of course incorporates research and development about half of which comes from the public sector and around half from the private sector.
I think one of the things that's really interesting is just how strongly interconnected the economy and the NHS is and how close the parallels are around what the policy need is going forward. Just to explore that interconnectedness. Exchange rates might feel like something that have absolutely nothing to do with the NHS. But actually they are really important over the longer term, given our reliance on international recruitment.
There's a global shortage of nurses at the moment projected to get much worse and nurses who speak English have an enormous choice about which country to go to. They tend to come for a period with the aim of saving money and sending it home. Obviously if our exchange rate is getting worse, then why would you pick coming to the UK where then your money just doesn't buy as much when you send it back to your home country, compared to other countries where actually that exchange rate is much better. Actually, exchange rates do affect our ability to secure those international recruits.
But Jagjit's phrase about policy that's nurturing seems incredibly important and avoiding these silver bullet magical almost transformation processes, very, very pertinent to the NHS as well.
This points to long-term policymaking, doesn't it? Over a 10, 20 year period cross-party agreement, more of a technocratic agenda agreement that there are some big things that need to be done and some of those things I think on the productivity side, Jagjit, presumably the Productivity Commission you lead is addressing some of those. There may well be parallels because obviously the NHS doesn't just receive public funds, it's also got to become productive itself. Just when you say nurture the economy, what are the big headlines of that nurturing apart from a long-term strategy?
It's a very important question. The Productivity Commission is having another evidence session and we're particularly focusing on that session in the need for public investment. One thing that I've observed while being director of the National Institute is that Treasury does a great job of guarding expenditure and looking for savings. We've heard something about the improvements in public sector productivity in the NHS since the global financial crisis. Rather than trying to spend more money per se, and it's been trying to see how can we get more for the money that we've spent and that's a reasonable thing to be done.
But it could very well be we've come to the end of that process, and what we actually need is more capital and expenditure and big amounts of capital to be spent. That's where I think the Treasury have some issues in terms of understanding the multipliers, and by that I mean how a pound of expenditure in another part of the country might benefit that in the long run by more than that pound spent. I think the Treasury has some problems with, and maybe to some extent that also reflects the quality of the institutions we might have. Whether they're local authorities or the local organisations running hospitals in areas, maybe local politicians. There are a bunch of things that need to be addressed so that money can be channelled effectively in local areas.
I mean I think we discovered during the pandemic, we didn't have enough local knowledge always to understand what the impacts were at the local area, from why in particular areas we had such a large increase in deaths and in certain other areas we didn't. I think there's a number of things there that we have to think about in institutional design to ensure that even if we started to turn the taps on public investment, that it was effectively carried out at the local level and connected. But part of that as well is getting people in Whitehall to understand that there are significant multipliers there.
I just give one brief example is that in general, if you spend a pound of money in the way that these things get analysed, it is measured to have more impact in places where income is already high and where there's high levels of employment. Because it looks like it'll be spent by those people and increase income there. On the other hand, if you do it in an area that's sparsely populated where income is low, the multiplier because of the structure of that economy will look low and that makes less likely the money will be spent there.
It's not very good at what the economy's call the counterfactual. What might happen in that region or in that place if that pound was consistently spent. How many more jobs might be created, how many high income people might work there, and how will that then generate prosperity locally? That counterfactual imagination is often missing in this kind of analysis and that's where I think we have to go with this work.
I was looking at some work by John Van Reenen and Nick Bloom, and looking at the difference between productivity in organisations, and of course the big multinationals have higher productivity partly because they invest a lot more in technology and as you know, there's a long tail of companies that have small amounts of capital investment and have low productivity and just rely on the workforce labour to low wages. That's one factor, the size and exposure to international markets as you're saying.
But another factor is not just the technology but actually the quality of management, which I think Van Reenen said was actually a more active ingredient. I'm just turning to Anita now. I mean just say the Treasury as Jagjit says did turn on the taps for good capital investment across the NHS. Far more than less than half the OECD average that we're getting at the moment. How on earth do we up the productivity of the NHS, if there is an analogy with the private sector that I've just described?
We've tended to think about the quality of management within individual institutions and clearly that matters, hospitals or whatever it is. But actually we think an awful lot of the productivity gains that are available for the NHS going forward are about pathways, about running the system as a whole really well. I guess it's been health policy for at least the last 20 years to think that what we need in the UK is to move care upstream. Earlier intervention, more prevention to reflect the fact that we've got multi-morbidity, treat people holistically rather than body parts with services that are able to do that. Fewer handoffs between them, which is often a point of inefficiency and poor quality.
To do that, we need to look across our system. Obviously that's why we are moving from a model that we had then in the nineties and the 2000s of quasi markets, independent institutions optimising for themselves with a view that that would lead to significant improvements in productivity, and there's some evidence that it did. Individual institutions and certainly the NHS as a whole became more productive through that time, did very well compared to the economy as a whole through things like much more effective throughput, theatre utilisation, all those sorts of things.
But now we think alongside what we really need to do is get much better at how do we deploy resources and redesign care across pathways and across systems? That's why we're moving away from that quasi market model towards this system level with the integrated care systems. But these are organisations that are in their infancy and the task of management is very different. It's not so much a technocratic task but much more of a relational task because this is about persuading lots of different organisations with different types of accountability. Private sector providers in social care, local government, local businesses, all those NHS organisations, GPs and all the independent contractors, to work together and to work in a different way and to move resources around.
I think one of the issues when you start to look at this is very few people don't think that that is the right direction of travel, but actually as is so often in the parallels with the wider economy, UK management in the 1960s etc. was seen as not as good on average as many comparative countries. We invested much less in management training. We were so amateur about management and we've put the ICSs in, but it's quite interesting. There's really very little support to ICSs around the leadership and management challenge and how different that is and where that comes.
Then you think the other big opportunity going forward is to move to system and then to design a new system that has technology at its heart and is really fit for the 21st century rather than the 20th. But where is the real, again, support offered to people and the advice and guidance and infrastructure for improvement around how you properly embrace technology. Huge amounts of effort going in obviously on innovation. Wonderful examples that we can all go to, in many cases with our Foundation, from some of those examples of people doing brilliant things. But scale and adoption is just so challenging, and so we have this absolute beacon of shining light, but we are not taking system advantage of that quickly enough. In that regard, the NHS is just a microcosm of some of the problems of our economy as a whole.
Does that ring bells, Jagjit?
It very much does. To think about something as a system is of course is what we do as economists. We think of the whole of the economy. First, I'm not an expert on health economics, so I should be careful what I say. But I was just thinking about one example that was brought to my attention by a colleague at the Institute who was looking at the impact of making it easier for GPs to provide their services to patients out of hours and his work that suggested that then reduced demand for A&E. There's a spillover there from the way that GPs are arrayed and the impact it has on local hospitals.
Now I'm not saying, I'm not suggesting that that should be done. I'm simply saying there are from different parts of the system, there may well be spillovers that are positive or negative that we need to think very carefully about so that we ensure that the unit that's working on its own doesn't just focus on minimising its costs and therefore sloughing those costs onto other parts of the system. I think that's where Anita's point about system, thinking about the thing in the whole is incredibly important.
Whether that's a management question or structural question, it's really important that where there are these links, we make sure that they benefit the patient, not cause problems for the patient. That would be my guiding principle. Maybe less about thinking about managers, but thinking about the patient. How easy it is for them to get the service that they need in the way that they want given the constraints they might face? They might have problems with using the internet as they get older. Disabilities themselves that make access to health service more difficult. I would think about it if I were allowed to from the perspective of the patient who is him or herself, a heterogeneous being with very different requirements and very different approaches to accessing health care.
My last area of question really is what you've both said is that there needs to be consistent national thinking for a wider strategy and a long-term plan for thinking about upping productivity in order to help the economy, but also then to help sustain the National Health Service. But there are lots of factors as we all know that mitigate against that kind of thinking and that kind of initiative. You have a ideology that is anti any kind of industrial strategy or productivity strategy. You've got a centre of gravity in science, which give good people money but don't direct it and they will produce the goods, and there's a lot of money going into science as we know. We also have the political short-termism, not least because we're in election year, which mitigates against a long-term focus.
Given those headwinds, I guess the final question is how do you think we're going to overcome the centre of gravity at the moment to get much more progress on this wider strategy that you've both indicated we need both in the NHS and the wider economy?
It's incredibly interesting this issue about market versus public sector and it's something I've grown up with as an ongoing debate in economics and in the public arena. I think it's up to those of us who purport to understand some of this. I don't think any of us fully understand anything. Being honest about the fact we don't understand everything is a really, really good place to start better than some of the Chancellors we've had if I'm allowed to say that.
But I think if we can understand that where the fault lines have emerged since the 1990s. The model was free trade, an open economy. People get some skills, find a job. The financial sector is dominant and from that it will trickle down to the rest of the country, provide sufficient taxes to fund what we need in public services, and that was the end.
It seems to me that there is enough evidence to suggest that didn't work, that we need a much broader based economy than just the financial sector. Absolutely nothing wrong with the financial sector. I've worked in it myself, but it's not the only thing that should dominate the economy as neither should fintech and neither should AI. I think we need to make the case that a broader based industrial strategy is important and point to the obvious failures of the model that we've had.
In that, structures haven't changed. The same parts of the country that were well off 30 or 40 or 50 years ago are the ones that are well off today. Those that suffered scarring from de-industrialization are also the ones with more poverty and more health problems than the others. I think it's up to us to continue to make the case and try to move the policy agenda in the direction of understanding that it's not public or private. It's both. Public supports the private sector and the private sector by thriving provides the tax base for the public sector to succeed. I think we have to move in that direction in the national dialogue in order to get at these answers.
Anita, do you think we can overcome the short-termism to have some more of a bigger plan, particularly on the productivity side in the NHS?
I think there are some grounds for optimism in this, not least because I think the public in all the polling work that we've been doing with Ipsos are very clear that actually I think they do understand and have very good diagnosis of the root causes of the problems that we face at the moment, substantial part of which is a lack of capacity. I think we'll rightly be very sceptical of political arguments which are just magical thinking that everything can be fixed in an instant with one initiative and really do want to focus on fixing the fundamentals. I think there's a strong appetite and need for a long-term perspective that is focused on those fundamentals.
I think there are also some things that we've learned from other areas of policy that could help us to try to shift the dial towards more of a longer term focus. Obviously, Bank of England independence is one of the things, the creation of the critical climate change. One of the ideas that a lot of people are interested in at the moment at the Resolution Foundation and NSC have been talking about is a National Infrastructure Act which tries to lock in a commitment to public sector investment. Within that, we could have a commitment to health investment.
But I think alongside that, what we should also think about if we were going for that sort of institutional change, is adding to that not just capital investment, which is incredibly important, but also across the NHS, but also wider public sector being much clearer about distinguishing between spending on day-to-day services now and spending on prevention.
We are very familiar with this categorization of capital investment and day-to-day spending. I want to argue for a new category of spending which we identify, which is prevention spending and creating long-term commitments and reporting and ringfencing of capital investment, but also of prevention spend. I think those two things combined with a big push on increasing the pipeline in training on the workforce so they've got the health care workers. Those three things could help to shift the dial towards a more productive, more appropriate upstream health service.
Given all of that, how optimistic are you both that the NHS will be able to reach its hundredth birthday given the need of this longer term wider strategy and approaches that you've both mentioned?
The NHS is a national treasure and we don't want to see national treasures lost so I think it will see its hundredth birthday. The question we're all trying to answer is what state will it be in at that time and what will it look like? Will it be able to provide the services that our population needs?
One thing we didn't touch on is that we don't have to treat an ageing population as a problem. It's not necessarily problematic if we can maintain our health and our vigour for work that doesn't necessarily provide a drag on the economy. I think that's one thing the NHS might want to focus on as well. We're not talking about people going down the minds at 80. There are things that they're able to do. Pass on knowledge, experience. Contribute to firms at a different level than an executive position that would maintain their standard of livings and able to participate in the broader society. That's possibly one thing the NHS might want to focus on as well. The idea of longevity rather than just ageing.
It's always worth separating it out. The issues that are specific to the NHS model and the issues that all countries are facing in order to secure universal health care coverage, which is incredibly important in and of its own right. That's what society exists for in very many ways, but also actually it's in our economic interest to come back to where Jagjit started.
We need to make sure that we've got universal health care coverage delivered as efficiently and effectively as we can as an enabler of individual flourishing, community flourishing and economic flourishing. All the evidence is that tax funded universal health care system is as good as any other option. Actually when you've got an ageing population, it has some advantages over things like social insurance, which put a lot of the burden on the employed population.
I think the important thing here is sometimes we have such a problem with English exceptionalism, and we can do that also in saying the NHS is some miracle outlier. Actually, these are very consistent problems across high income countries and actually problems that middle income countries in many ways aspire to have.
I started off the podcast by quoting Ken Clarke, a former Health Minister, and perhaps I can end with quoting another, Frank Dobson, where he said rather pragmatically, ‘It doesn't get any cheaper for not being free at the point of use’. All health systems are expensive regardless of whatever model that you have.
We must leave it there. Big thanks to Anita and Jagjit for their insights today. Next time, we're going to be looking at some areas for hope to face these headwinds successfully, so do join us then. Meantime, thanks to Kate, Leo and Tatjana at the Health Foundation, to Paddy and co at Malt Productions. And it's goodbye from me, Jennifer Dixon.
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