To be published as HC 694-iv

House of COMMONS



Communities and Local Government Committee

professor chris bentley

Monday 7 January 2013

the role of local authorities in health issues

Evidence heard in Public Questions 271 – 294



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Oral Evidence

Taken before the Communities and Local Government Committee

on Monday 7 January 2013

Members present:

Mr Clive Betts (Chair)

Simon Danczuk

Bill Esterson

James Morris

Mark Pawsey

Andy Sawford

John Stevenson

Heather Wheeler


Examination of Witness

Witness: Professor Chris Bentley, Independent Population Health Consultant, gave evidence.

Q271 Chair: Welcome to our fourth evidence session on the inquiry into the role of local authorities in health issues. Professor Bentley, thank you very much for coming this afternoon. For the sake of our records, could you indicate the capacity in which you are here this afternoon? That would be helpful.

Professor Bentley: I am an independent consultant, these days, and I was invited to give evidence to the Committee based on some work I have been doing with local authorities around the country.

Q272 Chair: Thank you very much for sparing the time to come and discuss these issues with us. Professor Bentley, there is obviously quite a lot of controversy over the Government’s legislation that brought in the Health and Wellbeing Boards, for matters not connected with them, but that was probably one of the proposals for which there was general support. Certainly the evidence we have had so far seems to be indicating quite a lot of hope and expectation that some really serious and beneficial improvements were going to come out of this. Your evidence is slightly less optimistic-slightly more cautious, at the very least-about what may be going to happen and whether things really are going to change and improve with these measures. Would you like to expand on that for us?

Professor Bentley: Yes. I go with the hope and less with the expectation at this stage. My take on the whole issue came through when I was heading up the Health Inequalities National Support Team under the last administration, and in that guise I was looking to work with the 20% of most deprived areas in the country. The very testing homework question that was set for that piece of work was, "How do you reduce the gap between those 20% and the national average by 10% in mortality terms?"

That is a very testing question. How do you make a percentage difference at population level? That target was added to by saying that we had to do it in a short timescale; we had to do it in just three or four years. How you manage to achieve a measurable change at the population level was a question that we explored quite extensively for five or six years as part of that initiative. It made you realise how difficult it was and what needed to be in place to achieve that. Armed with the knowledge and understanding that we gained from that, looking at the way the new arrangements are coming into place, I am a little bit worried that they do not have the firmness and stiffness of spine that will be necessary to drive forward measurable change at population level for our local authorities.

That is my concern. I am not saying it is not happening in places. It is happening, I would say, in a number of places where I have been working, but I would not say it is universal. There are some areas where I would say arrangements are a bit what I call "pink and fluffy", and will not necessarily enable people to drive forward those percentage changes.

Q273 Chair: We will probably come onto the precise ways in which you think some of those strategies and developments are not really satisfactory. What you are seeing, then, is a very patchy framework across the country, is it, with some areas doing quite well in terms of preparation, and others probably not really getting it at all?

Professor Bentley: Yes, I think that is right. Nowhere I have seen has got it perfect yet. As I put forward in my written evidence, there are 10 steps, and you would say that some have three or four of those going well, and others have a different three, and so on. It would be nice to find somewhere that has the whole set steaming away.

Q274 Chair: Are there some areas you think are at least doing better than most? It is always good to have one or two areas that seem to be making a real go of it, so that other areas can be pointed in their direction as to how it might be done better as far as they are concerned.

Professor Bentley: Yes. As I say, it is different for the different parts of the different steps, but the critical one at this stage-because it is early days-is to try to get the governance structures right. The thing that worries me is that a lot of places have Health and Wellbeing Boards that, when they are formalised and come out of shadow, are aiming to have four meetings a year, for example. If you are only going to have four meetings a year, you need to have some pretty durable structures that will do things between meetings. What are the governance structures that sit below the Health and Wellbeing Board and allow it to motor and produce stuff between the potential talkingshops of meetings?

I would say a couple of places have done that quite well. Recently I came across the example of Haringey, who have done a lot of work on trying to get their work right. They have concentrated on getting a set of substructures underneath the Health and Wellbeing Board. They have pared the Health and Wellbeing Board down to 12 good people and true, and they see it as a joint commissioning body. They then have an operational partnership group that sits below that, which really processes the work and drives it on. There are two or three committees that report through that operational group; they have a separate provider group, and a separate group for communities and patient input. That seems to be quite robust. Each of them has its own terms of reference and membership and the governance set out. And then they have an annual meeting set to open it up to a wide reference group, to help to guide at the right points in the commissioning cycle. That is a good, tight delivery mechanism, I would say, which allows you to have confidence that things could be processed in a way that is very businesslike and effective.

Q275 Chair: You seem to be implying that in other cases the structure is not being created to imbue the whole public health approach into the workings of the authority and service delivery. Indeed, to some extent it has been used as an opportunity to settle turf wars between the council and the Health Service about who pays what for elderly care.

Professor Bentley: That is certainly one of the agendas that will come up on those. There will never be any harm in getting both sides-the health service side and the local authority side-to come together in a forum. That will be beneficial. There is no problem with that. In quite a lot of places, they have arrangements to drive on some of the main priority areas already, derived through partnership. The question is how it will really add value-this whole business that is laid out in statute about having a joint strategic needs assessment leading on to a joint health and wellbeing strategy and so on.

The question I have to keep asking is: "If suchandsuch a place has chosen dementia as an important priority in its health and wellbeing strategy, how will anybody, including the public, see a difference in this particular borough in dementia, in three or four years? What will enable them to see a measurable difference?" That will not just happen by itself. It has to be organised and structured to happen. They are the things I am looking for, to try to see how we drive that better.

Q276 John Stevenson: You touched upon governance, which I take as a very important point. In many parts of the country there are twotier arrangements. Do you envisage problems there? There is quite clearly a division of responsibility between the different authorities, county and district. How do you envisage overcoming those difficulties, and what difficulties do you see?

Professor Bentley: I have seen a couple of different versions of this. It has always been difficult. I have seen it under the last jurisdiction, and there were problems there as well. I am doing work at the moment with Kent County Council, and it is a big county with a lot of difference across the geography. There is no doubt that the different parts of the patch-what is the district local authority and what is now the CCG-know each other much better than the county does. Therefore, where there are already relationships and understandings and histories between the two, it makes good sense to use that as the building block, to build upwards.

The question then comes as to what the added value of the countylevel organisation is, but I can see the value of it in Kent; it seems to be working on a good basis. I was exploring my test question with them the last time we met. Kent County Council-it is quite a welltodo county-has acknowledged the fact that there is a huge gap between the worst 20% of people in Kent and the second-worst 20% in terms of mortality, and then obviously other things as well. Kent County Council are saying, "Right, this has to be a priority for us. It has come out of our JSNA; we are taking it into our health and wellbeing strategy to say that we need to narrow that down."

The question then is, "How do we attribute the action that needs to be taken for Kent to narrow that down to each of the different district or CCG areas that they are using there-Ashford, Dover, Thanet and so on-and say what we expect from them and how their actions will add up to make a difference to Kent as a whole." That is the idea; that is what they are intending to work on, and I can see that that could work.

Q277 John Stevenson: But that demands a high level of cooperation between district and county. If that is not forthcoming, what do you think can be done?

Professor Bentley: The issue about the whole health and wellbeing strategy that we have all been talking about in the last week or so is: "What levers does it bring with it?" There are not that many. What you are doing is setting up a structure that then relies on the people within that structure to make it work. It does not bring powers. What it does potentially bring is relationships. That is what you are relying on: you are relying on the fact that those relationships, bringing people into the same place, giving them the same information and having the discussion, allows them to agree things together, which they can then take out to their separate places, either districts or organisations, and say, "Yes, we are all agreed on this. This is what we need to do in our particular place or organisation." That is okay, but of course it depends on the quality of leadership and relationship, which brings more patchiness into the system. When it works well, it works; but when it is not there, you’re stuffed.

Q278 Heather Wheeler: You have almost touched on where I want to go with this; it is a little bit about central direction from Government, but versus localism. How do you think that will marry up at all, if it can?

Professor Bentley: The first thing is that there is a difference between diktat and guidance, of course. The move to localism certainly has its pros. It does have some cons with it as well, of course. You can look at different slices of action coming into the Health and Wellbeing Board. I still think the NHS Commissioning Board will be giving quite a lot of topdown direction, and that will still play in. It is not Government; it is slightly separate from Government, but I know a little bit about the players in the NHS Commissioning Board, and they have quite a topdown feel to the way they run things. There will still be some of that coming in.

Q279 Heather Wheeler: So more than NICE?

Professor Bentley: With NICE, I think, it is always guidance. We have backed off slightly from saying, "You have to follow NICE." Now, it is, "Here’s the evidence, and if you want to disregard it, you can, but you have to say why." The difference in this setting is how good NICE will be in working with local authority evidence. They have a good track record with health, and we can see that. It has had some of its rough edges knocked off now, and it is functioning okay. However, to move into an area where we are moving less into randomised controlled trials and all that sort of thing into a different kind of evidence that local authorities are used to using, how good will it be at that? How will it bridge across between those different types of evidence and still come up with the type of product that people will be able to follow well? The same will apply for Public Health England. A lot of the resources in Public Health England are coming from the health service, and I think the question is how much local authoritybased evidence do they understand and will how they take it on board to be able to be the advisors on it?

Q280 Heather Wheeler: All of that is very interesting, and thank you for that. If the Health and Wellbeing Boards have somebody from the National Health Commissioning Board on the board, how do you think the relationship will play? The Health and Wellbeing Board will feel that they represent their people, and that they know their people even better than the National Health Commissioning Board does.

How do you think the relationship between the 11 and one who makes the twelfth will work? The National Health Commissioning guy will be the one with all the historical power and information, but the Health and Wellbeing Board will be made up of people who think they know their area very well. How do you think that will work? Who will listen to whom?

Professor Bentley: There are a lot of different angles on that one. As I said before, the Health and Wellbeing Board is not really about powers; it is about influences. We had an interesting discussion in one of the places I was working with where we had reached the point where we had decided some priorities, and then the CCG said, "So are you saying that the Health and Wellbeing Board is going to tell us what to do? We have been deciding what our plans are going to be. Are you saying that the Health and Wellbeing Board is going to tell us what to do?" I said, "The Health and Wellbeing Board are us. You are the Health and Wellbeing Board. You are a core part of it. It is not telling you what to do. You should be, as a group of people, making joint decisions and then taking away the findings to implement them. It is not a question of one person telling another what to do. One of the members of the Health and Wellbeing Board will be people from the LAT, the local area team, of the NHS Commissioning Board. The question is how they then play it-whether they see themselves as an inspector sitting there watching what is going on and being judgmental, or whether they will pitch in there, bringing their resources to the table, and then helping to make decisions that will fit all the systems. That will be an interesting question.

The second answer to it really depends on how much the whole system is driven by outcomes, because there is a lot of faffing around that can be done, but at the end of the day it is about how we change the health and wellbeing of our local population in measurable ways. That is in the interests of the NHS Commissioning Board, which will have its outcome targets through the NHS outcomes framework, etc, and in the interests of the Health and Wellbeing Board working perhaps more with public health outcomes frameworks. They should both be looking at outcomes, and if they are not being achieved, then they both need to work on why that is and how they can change things to make it better.

Q281 James Morris: Professor Bentley, you are quite disparaging about the capacity of the Health and Wellbeing Boards to produce a good joint strategic needs assessment. I think you said in your evidence that "the transfer of public health professionals and practitioners into local authorities has been very variable, and some do not have the critical mass to do other than minimalist churning out of an annual JSNA report." I am wondering how you think that situation might be improved. How can Health and Wellbeing Boards produce a genuinely strategic assessment?

Professor Bentley: I have some genuine concerns about this. Information and data is the stuff of my profession, and I have to state a concern that quite a lot of analytical capacity is being moved into something called commissioning support units. These are there to support CCGs in their commissioning, and the intention is that by 2015 they will become independent and will become some kind of social enterprise being, slightly outside the system, and will therefore enable CCGs to have a marketplace to choose where they will get their support from. In the meantime, that means that some of the analytical support we have currently in the public sector is going off into that sector, which means we are concerned about whether local authoritybased public health will get sufficient access to that resource.

Other than that, there is a lot of patchiness about how much analytical support there was and therefore will be. The history of JSNAs shows that in quite a number of places they commissioned a JSNA from outside the sector. They asked consultancy organisations to do them a JSNA, which was most unsatisfactory, because they were dead documents. Nobody knew the origins of the information and how to take it forward and on. They did not have the data. They were not living, working documents that helped the local organisations, and the danger is that you have more of that kind of, "Do me a JSNA."

Q282 James Morris: Do you think there is a capacity gap, then, in terms of fully understanding how you create a fully comprehensive strategic needs assessment in local authorities?

Professor Bentley: I think it is a quality issue, rather than a quantity issue. It is not so difficult to produce a nice big JSNA with lots of data in it. I have seen quite a number of those. The proper JSNA is supposed to take it on beyond that and say, "So what? This is what our finding is, and what does that mean in terms of what people might need to do about it?" One of the ones I have seen recently had 10 pages of findings and recommendations-10 pages of them tightly in the executive summary.

The question then is, "How do we turn that into a health and wellbeing strategy?" You end up-and did end up, in that health and wellbeing strategy-with three priorities. If the Health and Wellbeing Board is the beating heart of health and wellbeing improvement in a particular area, it must be more than that, I would say.

Q283 James Morris: The other area you identified in your evidence was that in order to create this beatingheart strategy, we need to drive activities by sharing data across different Departments-the NHS, local authorities, maybe DWP, other relevant functions. That is a big barrier to getting the strategic assessments in place. What could be done in order to make data-sharing better? We have had submissions from Sheffield City Council and Kent County Council already, saying that one of the things that is hampering them is a lack of ability to share data with other agencies.

Professor Bentley: I think someone was suggesting: "Is this is an area where we could get guidance from Public Health England?" I think that would be a good idea. This has gone on for years and years, and my original contact with it was through a thing called health action zones-I don't know whether people remember those. They were quite a few years ago now-2000. What happened in the health action zone programme was that when you were signed up to the health action zone you were allowed to appeal to the centre where there were difficult bits of legislation and regulation getting in the way, creating barriers to you moving on. You were allowed to appeal and say, "Could you hold these back for us to make progress?"

It was very interesting; I cannot remember the statistic, but the large bulk of what was asked for in terms of leniency, as it were, was something that could be done already. Quite a lot of the barriers are perceived barriers, as opposed to real. I am not saying that there are not real barriers, but, for example, if all the organisations you are working with have Caldicott Guardian status, you are allowed to transfer quite a lot, with the confidence that it will be handled safely and securely. That gets over some of the barriers. It is a question of saying, "What is left, when you pull that all away, that would be a barrier?" I think you can share quite a lot.

I have seen examples: somewhere like Islington, a couple of years ago, had reached the stage where they had moved on further than most on the single assessment process, which was allowing social care and healthcare to share information about their clients and patients. Other people were claiming that there were big barriers to that happening.

Q284 James Morris: Could I just ask one final quick question? You also talk about the importance of the public in all of this, in terms of the public easily understanding what it is that the public health strategy is for their particular area. "How will it affect me? What does it mean?" In your evidence, you talk about, "the presentation of the resulting information has not been converted into userfriendly formats, to inform and tell the story to a range of audiences." Could you just elaborate a little more on what you mean by that, and how the public could be more engaged with the information that is at the heart of some of these strategies?

Professor Bentley: The first part comes back to your earlier question about the resources to do the JSNA. Quite a lot of the resources for the JSNA do the analysis. You come across some very clever analysts who do very clever things that an epidemiology person like myself will appreciate the skill of, but then it is left there. A lot of people will not understand what the story that is emerging from the information is.

I am not just talking about the public; it starts earlier than that, with a lot of the frontline staff who do not get it, because it is not being presented to them in ways they can follow and understand. That is true in the health service, with health service information. You have to try to get that information into, for example, local elected members, some of whom will not have a technical background. You cannot expect them to pick up on some of that. It needs to be laid out in different ways for different people.

Just as an example of that, which I push a lot, is moving away from rates. "We want to reduce the mortality rate from heart disease from this to that." I don't know what that means. I do not feel it. Change it to people. How many fewer men will die in 2015 if we hit this target? How many fewer women? People can then get into that discussion. They can say, "How many in my practice? How many in my constituency? How many of those would be South Asian?" You can begin to have a conversation with people who are not technical in nature about what this really means. It takes a little extra resource, and a different type of almost marketing skill to take the initial analysis and turn it into something that will affect decisions. That, again, is somewhere we often fall short.

Q285 Simon Danczuk: In your submission, you have made the point about inequality targets not being achieved, you say, "by a series of small but eye–catching projects." You also outline the example in Oldham, however, which is a relatively small, defined pilot project. I was wondering how you square the two there.

Professor Bentley: What we are saying there is that a lot of people including Oldham were doing work, but had not calculated what was necessary to produce the percentage change. It is a question of getting the dimension of the change right. A population health approach to alcoholrelated heart conditions, for example: "We are going to have 56 extra places". You say, "What difference will that make at a population level? How could we measure that? Could we?" The answer is, "Probably not". The question is, "How do we get the right dimension of change into the system to know that we will make a difference?" The Oldham example was showing how you can do that. You can work it all through and work out exactly how much of what you need to achieve that level of change. It was an example- it was probably one of the lowerhanging fruit, one would have to say-but it is showing the mechanism that would be necessary to get a handle on these things for population work.

Q286 Simon Danczuk: On that, from what little I know about the Oldham example, it appears that language is important. In the Oldham example, you talk about people dying; that is the reality. A lot of this stuff, particularly around health, seems to be steeped in terminology that ordinary people just do not relate to, and that is part of it.

Professor Bentley: That is exactly true, and that comes to an important issue for Health and Wellbeing Boards. It is a question of demystifying the whole thing. When I was trekking my way round the 70 most deprived areas, in a large majority of those you would go in there and you knew that the chief executives and directors and whoever thought that if you were to change the inequalities agenda thing, it would be some kind of white magic that public health would achieve with partners somewhere off there somewhere, whereas when you had finished, and you had dissected it out and shown what actually needed to be done, what people were dying of, what the extras were, what would make an impact on that and how much of it you would need, you could boil it down, and chief executives would then say, "But we can do that," and you would say, "Yes, that is absolutely right."

The question is how we translate that over to Health and Wellbeing Boards, so it is not some vague mystery: "Oh yes, we are very committed to reducing this or that, or making that better", but saying, "Yes, but how do we pin it down? How do we demystify it as an issue, and therefore how do we take it on as a programme to make a measurable difference?"

Q287 Simon Danczuk: The BMJ published a report relatively recently that showed that unemployment is directly related to life expectancy. Should all authorities include employment initiatives in their public health work, do you think?

Professor Bentley: I would not say all, because we are not being topdown; we are doing localism. However, a good guide is the Marmot Review, which most people will know about. This basically picked out six sets of objectives that cover the life course. It started with early start, and employment and employment issues were there about number three or four, but we are talking about moving across the life course. I think that all local Health and Wellbeing Boards should appraise their own system against that checklist and say, "Where is our weakest link? Where should we be working?"

For me, the key one is about early start, because if you miss children in the first five years of life, when their cognitive abilities are developing, it means they are playing catchup for the rest of their lives. It is not just then a question of giving them equal opportunity, because they will not have the skills to be able to capitalise on those opportunities. It is really a question of saying, "We must put some emphasis on early start". Yet Health and Wellbeing Boards seem to be neglecting that, on the whole.

Q288 Simon Danczuk: That is interesting.

Professor Bentley: I am not saying they necessarily need to be doing it, but you need to have the driver coming from this beating heart of health and wellbeing, saying, "We need to have stuff on early start, or employment", and then making sure that part of the system is dealing with it, so that we can keep taking stock through you, and saying, "Yes, we are the guardians of this, and we will make sure it is being done appropriately."

Q289 Simon Danczuk: A quick question about funding: you said in your submission, "systematically scaledup public health intelligencedriven, evidencebased programmes". That sounds expensive to me. How will this be funded? What about the cuts? Do you think they will have a big impact?

Professor Bentley: No, it is not. I think that that is given as an excuse. A lot of the stuff that we saw that needed to be done at population level was a question of working on quality, for example-quality of provision. You have very patchy quality within primary care. I have graphs-I put some in the evidence base there-about how variable it can be simply managing blood pressure for someone with heart disease. That is not rocket science, and yet they are all over the place in some of those places. Getting to the point where that evens out is not something that is grossly expensive, and yet it has a real impact, so we are making sure that we know, "This stuff works, and we’ll apply it to as many people as possible who can benefit from that, and we will get the results from it."

There is a lot to be gained from that way, and there is a lot to be gained from the workingtogether component, with which the Health and Wellbeing Boards should really help. That is one of the real pros of Health and Wellbeing Boards. Things like integrated care services and things like single infrastructures working into communities, where at the moment we have a whole plethora of them, all separately funded and adding up to chaos rather than a smooth interaction with communities. There are also things like community budgets, and working with troubled families. They are all things where there are huge inefficiencies and overlaps and difficulties for the user, and we can smooth that out by working on it together. That will make the whole thing much more efficient and therefore more costeffective. It is those sorts of things, in this austerity environment, that we need to be working on first. We need to get that sorted out: "What can we do when we go in in the morning?" and then we can start saying, "If we had a bit more money, how would we invest it to make even further change?"

Q290 Simon Danczuk: My final quick question: Westminster Council cannot be accused of being "pink and fluffy" or, as you said earlier, "faffing around". They have come out and said, in my interpretation, "Fat people will not get benefits if they do not get in shape". That is the general idea of what they said in terms of benefits and being incentivised to get healthy. What is your take on what they have said?

Professor Bentley: I think it depends on how much support they will give people to make the change. It does not mean, "We are not going to intervene. We wash our hands of you until you sort yourself out." That would be a dire thing to be doing. However, if they are saying, "We have a range of other things we can do to support you to get yourself in a position where you can benefit from these interventions", I think that is perfectly sensible.

Q291 Mark Pawsey: You have talked a lot about the challenges faced by Health and Wellbeing Boards. To sum up, are you confident that Health and Wellbeing Boards will make a significant difference in the area of public health, and how much time would you give them? How long do you think it will take to get to where we might want to be?

Professor Bentley: I think Health and Wellbeing Boards, in some places, will make a difference quite quickly. I have seen some evidence that gives me confidence that that is true.

Q292 Mark Pawsey: What timeframe is "quite quickly"?

Professor Bentley: It has to be within an electoral cycle, has it not? You have to make a change. In reality, you have to do that. Aiming to make a difference by 2015, I think, is the what they should do. There should be some outcomes they could achieve by then, and some indicators of change they could have achieved by then, to show that they are making a difference. I would hope that they would do that. That will be the point at which we can say how patchy the delivery is.

Q293 Mark Pawsey: Are you of the view that in some places they will not make any difference at all, but will end up being elaborate talking shops, unable to deliver; or do you think that, in time, those that are struggling to get their act together will be able to do that?

Professor Bentley: I would imagine that it will always be a bit patchy, because that is the way systems are unless you regulate them, and this is not a system that will be regulated very hard.

Q294 Chair: Finally, Professor Bentley, will you be doing a review in due course of how things have progressed? Is that something you intend to do, to keep your eye on the situation? I think that exactly what you have just said now is likely to happen; some areas will do it better than others, and it would be very good for someone to be looking at it and saying, "There is some really good practice out there that ought to be shared and disseminated."

Professor Bentley: It is not me, because I am an independent person. I will do it if someone employs me to do so, but I would like to be. I think that where we need to be looking for this initially is Public Health England. It is the new player on the block. When Public Health England was set up I heard the Secretary of State talking about it, and he said he was looking for a worldclass public health system, delivering worldclass outcomes. I have been trekking around the country, and I have seen some worldclass public health, but it was the patchiness of it that meant it was not nationally worldclass. The idea was that the system-this would be the Public Health England system-should enable us to get rid of some of that patchiness, and have a better and more consistent use of the evidence base, better drivers on quality, and so on and so on. That is where I would think the expectation is. We do not know yet, because they still have not got their knees under the desk. They will do in the next month or so. That is where the hope will be: that Public Health England will provide a spine on which quality and outcomes can be driven.

Chair: Thank you very much indeed for coming this afternoon. It has been very interesting to have evidence from you.

Professor Bentley: Thank you very much.

Prepared 11th January 2013