ࡱ> ` Oxbjbjss 46ocNNNbIII8"JJdbthMM(FMFMFMNNNttttttt$vhixn>tNXN"NXX>tFMFM9St\\\X8FMNFMt\Xt\\rgT6NhFMM !QvIY0hdkit0t>hxZxhxNhN2QH\TUNNN>t>th\^NNNtXXXXbbb$CHdbbbHbbb CONFIDENTIAL ENQUIRY INTO MATERNAL AND CHILD HEALTH BUSINESS PLAN FOR 2008-11 Introduction This business plan covers the period from April 2008 to March 2011. Increasingly CEMACH is doing work funded by parties other than the NPSA. In 2008/9 total turnover is expected to exceed 2m, of which 75% will be provided by the NPSA and 25% by other parties. Part 1 below covers work carried out under our contract with the NPSA. Part 2 deals with work funded other than by the NPSA. Part 3 sets out the budgeted income and expenditure for 2008/9. The Board is requested to approve the business plan as a whole and to agree that Part 1 can be forwarded to the NPSA as part of our contract with them. PART ONE NPSA FUNDED WORK 1. Organisational Development CEMACH will continue to focus its organisational development work on implementation of the recommendations of the NPSA review, in particular: conversion to independent legal status as a company limited by guarantee and registered charityintroduction of single national advisory committee to replace current advisory structure with separate committees for children and maternal/perinatal. 2. Business Case Development In accordance with the NPSA Review, we are working to ensure that all work for the NPSA is covered by business cases and that these include:fully costed programmes analysed by budget head and year, statements of costs versus benefits and post-project review reports to assess action taken in response to recommendations. Progress to date and plans for completion of business cases as at March 2008 is as follows: Topic/ProgrammeOutline business case to BoardFull business case to BoardFull business case to NPSAObesity in PregnancyJuly 2007Oct 2007Nov 2007Maternal Death Enquiry-Oct 2007Dec 2007Head InjuryApril 2008July 2008*July 2008*Perinatal and Maternal Mortality Surveillance System-Jan 2008Oct 2008*Late Fetal Losses-July 2008*Oct 2008*Development of Child Health Enquiry-July 2008*Oct 2008*Intrapartum Mortality Jan 2008Oct 2008*Oct 2008*Further Child Enquiry topic tbctbctbc*gives the planned date for completion of the stage of business case development. This plan for business case development is based on the premise that we should prepare a strategy for the development of the child health enquiry following the publication of the Why Children Die: A Pilot Study report before we commence topic selection for a further child health enquiry to follow the proposed head injury project. Proposals to undertake a follow up study on the Child Death Review are also being developed. 3. NPSA funding for 2008/9 Recurrent funding received from the NPSA for 2008/9 is 1,426k. This represents a 3% enhancement for inflation over 2007/8. In addition a one-off sum of 50,000 was provided in March 2008 to assist CEMACH to meet a number of non-recurrent costs, particularly those associated with incorporation following the NPSA review. Of this 10k has been used to cover such costs incurred during 2007/8, so 40k will be available to meet costs due in 2008/9. In addition, because the NPSA provide our funds for the year in advance, we expect that 35k of the bank interest received will be directly attributable to the NPSA contract. Therefore, the total value of the funds provided by the NPSA for 2008/9 will be 1,501k and, of this, 1,461k will be available for work on projects and 40k to assist in the change programme required by the NPSA review. 4. Overall shape of work programme carried out for the NPSA: a key strategic issue for CEMACH 4.1 The shape of the NPSA funded enquiry programme in 2008/9 In return for its funding from the NPSA, CEMACH will seek, subject to resources, to run six concurrent pieces of work. These will be the ongoing maternal death enquiry and perinatal mortality surveillance work and four time-limited projects. The four time-limited projects will include two in the maternal/perinatal field and two in respect of the child health enquiry. The funding needed for these programmes in 2008/9 (at 2008/9 price levels) is set out in the following table: 000000Maternal Death Enquiry per business case340Perinatal Mortality Surveillance per business case 448Total ongoing work 788Obesity in Pregnancy per business case 302Intrapartum Mortality*89Total Maternal and Perinatal Topics391Head Injury*180Complete Child Death Review pilot study; prepare strategy for development of child health enquiry; commence topic selection for second child health enquiry topic.102Total Child Health Enquiry282GRAND TOTAL 1,461*These are estimated figures subject to full business case development 4.2 The future shape of the overall enquiry programme Shortly after commencing on 1 April 2003 and while the national enquiry programme was still being commissioned by NICE, the Board gave consideration to the overall shape and prioritisation of the enquiry programme. At that time, the national child health enquiry was new and we did not know whether it would be a feasible or beneficial use of scarce resources. Further, the brief provided to the new organisation by NICE was to ensure the completion of all work in progress by its predecessor bodies, CESDI and CEMD, and no new funding had been provided for the new enquiry into child health. Indeed, the creation of CEMACH was accompanied by a large funding reduction by NICE, thus complicating the development of the new child health enquiry. The Board therefore decided to take an incremental approach to the funding of the new national enquiry into child health, releasing resource where this was possible from the work programmes inherited from CESDI and CEMD. The resources committed to the child health enquiry have since that time typically been around 20% of the total funding provided, the remaining 80% being committed to the traditional areas covered by the previous enquiries. Given that it is some time since the Board previously gave consideration to this issue and that there has been significant change since then, it is now both necessary and appropriate for the Board to review its position in respect of the place of the child health enquiry within the overall programme. This is considered to the key strategic issue for the Board to address in respect of the business plan for 2008-11. There are a number of reasons for this. First, the Child Death Review pilot study has shown that national confidential enquiries on child health, whilst challenging, are both feasible and worthwhile. Second, the development of business cases for the maternal death enquiry and perinatal mortality surveillance programmes has, for the first time, entailed the calculation of detailed cost estimates. This has shown that these ongoing programmes will, in 2008/9, absorb approximately 54% of the total resource available for the enquiry programme. This means that less that 700,000 per year is available for project work for an enquiry programme that covers mothers, babies and children. Of the funding being provided for projects, the investment on the child health enquiry projects in 2008/9 of 281k represents 19% of the overall funding provided to CEMACH. This underscores the relatively low priority presently attached to the child health enquiry by CEMACH, at least in terms of the funds provided for it. The result is that CEMACH is currently investing more in investigating approximately 125 maternal deaths per year, where there is already a good understanding of the causes and avoidable factors, than on 3000 deaths of children aged from 28 days to 18 years, where the level of understanding of the causes and avoidable factors is much more limited. This suggests that the CEMACH programme may be unbalanced and that an undue weighting may be being provided both to ongoing work as against short term projects and to maternal and perinatal work as against work on children. It will clearly be preferable for CEMACH to obtain additional resources for the development of the child health enquiry than for it to reduce the resources available for its other work streams. To achieve this will require a business case to be prepared for the NPSA and the Department of Health. A necessary part of the business case will be set out options in relation to the existing CEMACH programme if the development of the child health enquiry were to be funded by reducing the resource committed to our maternal and perinatal work. It will also be appropriate to consider whether there are parts of the enquiry programme that could be funded other than by the NPSA. 4.3 Business case for development of national enquiry child health: identification of options The Board is recommended to confirm that its management team should prepare a business case for the development of the national confidential enquiry into child health. In doing so, a range of options will need to be considered. These will include the possibility that new funding will be provided without the need to reduce other CEMACH work and the possibility of alternative funding streams for existing work. It would also be necessary to consider options for funding the expansion of work on children by reducing the resource currently provided for the existing maternal and/or perinatal enquiry programmes. The identification of the full range of options should assist the NPSA and the Department of Health in deciding whether and how the development of the child health enquiry should be supported. 5. The Individual work programmes within the NPSA funded programme 5.1 Introduction The sections below briefly set out the plans for 2008/9 in respect of the work programme on individual topics with a forward look to 2010/11 to the extent that this is possible at the current time. 5.2 Maternal Death Enquiry The plan will be to continue the maternal death enquiry, whilst implementing the developments set out in the draft business case for this work. Key features of the maternal death enquiry are expected to be to: continue to be the unique source of data on causes of death and extent of avoidability of maternal mortality in UKcontinue triennial report with epidemiological and case study analysescommence annual reporting of key surveillance dataimplement the Memorandum of Understanding with the Healthcare Commission. The draft business case has identified that the cost to the NPSA of this programme at 2008/9 levels will be 340k, 309k and 366k in 2008/9, 2009/10 and 2010/11 respectively. The higher figure in 2010/11 will enable the extra costs associated with publishing the triennial report for 2006-8 to be met. 5.3 Perinatal Mortality Surveillance 5.3.1 Continuing to develop the perinatal mortality surveillance system CEMACH is the only reliable source of data on perinatal mortality at trust and neonatal network level. It is used by trusts to monitor their own performance. We intend as far as we can to continue to refine the analyses to enable, in time, trusts to compare their perinatal mortality against expected levels. We are working with the Healthcare Commission to incorporate this work into our regular data exchange under the Memorandum of Understanding with them. We will continue to analyse major national trend data on causes and risk factors associated with perinatal mortality, whilst increasingly integrating these analyses with our data on maternal mortality. At a national level, the annual perinatal mortality surveillance report will continue to provide information on major trends. In addition, focused analyses on particular issues will be reported. We will continue to monitor the impact of changing lifestyle and demography on perinatal mortality. We will assess variations in outcome by place of delivery, including the impact of greater choice. We will issue reports specific to each trust and neonatal network within 12 months of the end of each year. We will issue the national report within 16 months of the end of the year. We will also see whether there is scope for obtaining income to reduce the net cost to the NPSA of the perinatal mortality system by obtaining funding from PCTs to obtain analyses specific to them. CEMACH has developed a new data collection instrument to enable more information to be collected on those perinatal deaths that have hitherto been ascribed to unascertained causes. It is expected that this will produce valuable information on a number of issues including the significance of intra-uterine growth restriction in perinatal mortality. Use of the new form commenced on 1 January 2008. 5.3.2 Late Fetal Losses We have prepared an initial proposal for the NPSA to fund us to recommence collection of data on late fetal losses at 22 and 23 weeks gestation, stopped in 2007/8 due to funding cuts. This would enable England to recommence reporting on perinatal mortality rates according to the WHO definition, a matter raised by the Chief Medical Officer for England in his 2006 report. It will also enable CEMACH to produce analyses of differences in outcomes by place of delivery and identify risk factors for what is increasingly becoming the new boundary for fetal viability. The full year cost of recommencement of data collection on late fetal losses is 62.5k at 2008/9 levels. We will prepare a full business case on the recommencement of late fetal loss data collection by October 2008. 5.3.4 Business Case on the overall mortality surveillance system The first draft full business case for the perinatal and maternal mortality surveillance system was submitted to the January 2008 CEMACH Board. This has not as yet been submitted to the NPSA. It is recommended that the review of options outlined in 4.3 above should be completed before submission of this business case to the NPSA as it may impact significantly on future plans for the funding of this work. 5.4 Maternal and Perinatal Topics 5.4.1 Obesity in Pregnancy In response to the knowledge we have gained due to maternal and perinatal mortality surveillance work, we are undertaking a national enquiry into obesity in pregnancy. Our Saving Mothers Lives report published on 4 Dec 2007 identified the role played by obesity in increasing the risk of maternal mortality for a range of conditions, including thromboembolism and cardiac disease. Our forthcoming perinatal mortality surveillance report for 2006 will identify a sharply increased risk of perinatal mortality where the mother is obese. This is a major health issue in the UK. It impacts significantly on pregnancy outcomes. All the indications are that this is going to become an increasing problem. Our study will produce prevalence data for the first time on obesity in pregnancy. This will be important to provide denominator data. We will review how services are organised to manage the care of women who are obese in pregnancy. We also intend to identify standards of care and assess services provided against those standards. Good progress is being made on this project. The draft business case was presented to the CEMACH board at the end of October 2007 and was subsequently submitted to the NPSA. The organisational survey is expected to be distributed to health providers throughout the UK in April 2008.The project should be completed in the financial year 2010/11 with a post-project review report in 2012/3. We are planning on the basis of a project cost of 774k from 1 April 2008 and at 2008/9 price levels, as follows: 2008/9 302k2009/10 335k2010/11 116k2011/12 -2012/13 21k. 5.4.2 Neonatal Encephalopathy- Intrapartum Mortality Damage to babies during birth is the largest source of clinical negligence claims against the NHS at some 300m per year. It is also an important cause of disability and death. The Chief Medical Officer in his 2006 report considered this issue under the heading 500 missed opportunities. By enquiring into intrapartum deaths where neonatal encephalopathy is identified as a causal factor, CEMACH aims to add to knowledge about how it should be defined, its prevalence, the extent to which services are organised to respond to its occurrence, adherence to clinical standards for its prevention and treatment and the extent of avoidability. By doing this we aim to take valuable steps in setting out how clinical negligence claims in this area might be reduced and to address the 500 missed opportunities referred to in the CMOs report. An outline business case on this was presented to the CEMACH board at the end of January 2008. The target date for the full business case to be presented to the board is October 2008 and the NPSA shortly thereafter. 5.5 Child Health Enquiry 5.5.1 Child Mortality Studies Some 3000 children between 28 days and 18 years die each year. We are reaching the end of our pilot Child Death Review (CDR) study. This has demonstrated that there are major gaps in knowledge about why children die, the extent to which those deaths are avoidable and the reasons for their avoidability. The report will be published at the end of April 2008. Proposals are being prepared to obtain additional funding for a follow-up to the Child Death Review. This would enable firmer conclusions to be drawn on a number of the issues identified in the Why Children Die pilot study report. The current intention is that this would focus on hospital deaths. In addition to this, CEMACH will give priority to the preparation of a business case to develop the child health enquiry following the publication of the pilot study report. Any decisions on future topic selection on the child health enquiry will be made using an open call and the national advisory committee. The aim has always been however to develop a new topic based on the findings of the pilot study report. Costs of child mortality studies in 2008/9 will therefore include bringing the CDR report to publication, dissemination of the CDR report, business case preparation for the development of the child health enquiry and, possibly, the commencement of topic selection for a new child mortality topic. These activities are estimated to need 102k in all in 2008/9. CEMACH will continue to strive to work supportively with the Department for Children, Schools and Families (DCSF) and to develop networks with Local Safeguarding Children Boards (LSCBs). The role of these bodies as set out in Working Together to Safeguard Children will be of critical importance and the future success of the national enquiry into child health will depend on positive engagement with them. 5.5.2 Head Injury in Children The national advisory committee for the child health enquiry selected head injury as the topic to immediately follow the CDR study because of its significance as a cause of death and disability in children. We have been seeking to develop an enquiry that enables review of the care provided from the scene of the accident for children whose head injury leads to intensive care. We have conducted a feasibility test to see if it is possible to match the records created at these two ends of the care pathway. This indicated that the project should be feasible but would be highly challenging. We anticipate that it will only be possible to match the records of the scene of the incident with intensive care for a proportion of cases. Fulfilment of this project on a national level will be resource-intensive because it will involve the development of substantial networks across ambulance services, accident and emergency departments and paediatric intensive care services. Whilst CEMACH has begun the development of networks in these areas, there will need to be substantial further investment to establish a national study. The outline business case for this project is due to be presented to the Board in April 2008 and if approved for full business case development, the aim will be to prepare this by July 2008. PART TWO WORK AND FUNDING OTHER THAN FOR THE NPSA Other UK nations and non-UK subscribers to enquiry programme The NPSA contract covers England and Wales. Other subscribersto the enquiry service, with the detail of what is covered and the amount paid, are set out in the table below: Northern IrelandFull programme26,346ScotlandMaternal death enquiry and maternal topic26,884JerseyMaternal death enquiry, perinatal mortality surveillance, perinatal and maternal topics 6,135GuernseyAs for Jersey 5,065Isle of Man As for Jersey 4,624TOTAL69,054The Republic of Ireland has expressed an interest in joining the maternal death enquiry from 2009. Now that we have demonstrated the feasibility of confidential enquiries into child health it may be appropriate to see whether the Channel Islands and Isle of Man wish to subscribe to this service too. Conferences CEMACH conducts a programme of conferences to help to disseminate its work. The intensity of this in any one year varies with the number and subject of major reports being issued. The major report expected for 2008/9 is the Why Children Die pilot study report on 30 April 2008. There will be a major conference in London to launch the report and a number of regional conferences. These are expected to be as follows:16 May: Newcastle4 June: Birmingham12 June: Cardiff In addition to conferences in respect of the Why Children Die report, we will hold a number of conferences on the enquiry programme in general, including the perinatal mortality surveillance work. At the present time, these conferences include: 15 April: Glasgow23 June: Manchester 27 June: Cambridge 3 July: Leicester6 November: Sheffield It is also planned to arrange regional conferences in London, the South East and South West of England. Delegate fees from the conference programme in 2008/9 are expected to be in the order of 105K. The basic premise behind the financing of the conference programme is that it will be at least self-financing overall and that this will include a contribution to the administrative costs involved in organising the programme. This reflects the fact that its underlying purpose is to help spread our findings so the aim is to keep prices low and attendance high. Free or discounted places will be available to those who assist the enquiry programme, for example as assessors. Interactive Workshops The main purpose of our interactive workshop programme is to promote the recommendations in our reports. A secondary aim is to assist in providing evidence for demonstrating the impact of our work. The intention is that each strand of work which gives rise to recommendations, i.e. basically all our work other than perinatal mortality surveillance, will be supported by an interactive workshop programme. This will involve the use of extended case studies to prompt discussion about the recommendations in workshop groups and to invite attendees to identify actions needed in their units to implement the recommendations. It is currently planned to hold workshops in 2008/9 as follows on the major reports recently released by CEMACH, i.e. Diabetes in Pregnancy, Saving Mothers Lives (SML) and Why Children Die (WCD): DiabetesSMLWCDTotal London & South East2316West Midlands & North West268South West11 2 East of England1214East Midlands and Yorkshire1214Wales11 2TOTAL615526 The CEMACH offices in Northern Ireland will organise its own workshop programme. Arrangements for this programme in Scotland and in the North East of England where the CEMACH service has hitherto been provided by the local Regional Maternity Survey Office have yet to be decided. Charges for workshops are intended to be made on the same basis as for conferences. We have currently set this so that income from a full day workshop should be a minimum of 3000 and 2500 for a part-day workshop. This will be kept under review to ensure that the charges are both attractive to delegates and cover costs. Sponsorship CEMACH and its products have a strong brand image, potentially of value to commercial sponsors. Sponsorship is already accepted within the NHS as a way of supporting educational activities. Whilst this could provide a useful source of revenue for activities which support the enquiry programme, it will be important to balance this against any potential risks of tarnishing the brand. On the other hand, the fact that we seek sponsorship will be visible evidence of our concern to ensure that we make best use of the resources available to us. It is therefore intended to gradually develop opportunities for commercial sponsorship of the Enquirys products. Target sponsorship income for 2008/9 will be 25K. Local audits CEMACH has entered into a total of 4 agreements with individual health commissioners and/or providers to support local clinical audits. We are still developing the know-how to do this to a quality comparable with our national studies within a level of cost sustainable at a local level. As a result, the availability of this service has not yet been advertised and there are no current plans to do so, although this is seen as an area where CEMACH may in the future be able to provide valuable expertise in helping local services. Income associated with local audits in 2008/9 is expected to be circa 52K. Externally funded projects To date, CEMACH has entered into two contracts with bodies other than the NPSA to carry our projects relevant to its mission. These are the contracts with BLISS in respect of a project on dissemination of study findings in a clinical context and with Novo Nordisk on diabetes in pregnancy. Total income in 2008/9 from these contracts is expected to be 80K. Consideration is being given to possible future bids for third-party funding of projects on cardiac disease in pregnancy and neonatal encephalopathy. Working Together As described in Part 1 section 5.5.1, the development of relationships with the DCSF and LSCBs in relation to Working Together will be very helpful in ensuring a successful future for the national enquiry into child health. With this in mind we are developing services to promote to LSCBs in connection with their new responsibilities under Working Together with a particular focus on chapter 7 of that document. In this they are required to collect data on all child deaths using a nationally determined core data set. We have entered into contracts with the North West Government Office and Hertfordshire LSCB to support them in meeting their requirements under Working Together. Income from these contracts in 2008/9 is expected to be 104K. We intend to promote these services to other LSCBs during 2008/9. Sundry income CEMACH derives sundry income from sources such as bank interest and book sales. Bank interest derivable from the advance payment made by the NPSA in respect of its contract with us has been credited to their programme and is used to enhance the amount of work we can do for them. Other sundry income provides a useful source of revenue for other areas which can be difficult to recover through normal contract income, e.g. the need for once-off expenditures and to ensure that the organisation holds a sufficient level of reserve to meet its reserves policy a requirement under the Charity Commission as well as for proper financial management of an independent legal entity. Excluding bank interest assigned to the contract with the NPSA, total sundry income in 2008/9 is expected to be 23K Summary of non-NPSA funded Enquiry activity The total income expected for 2008/9 from sources other than the NPSA against the categories identified above can be summarised as follows:  KOther UK nations and non-UK subscribers 69Conferences 105Interactive workshops 77Sponsorship 25Local Audits 52Externally funded projects 80Working Together 104Sundry 23TOTAL  535 PART THREE BUDGET FOR 2008/9 INCOMEK KNPSA grant (including 35K bank interest1,501Other income 535TOTAL INCOME2,036EXPENDITURECentral Office pay by section: Chair, Chief Executive & Central Services 252 Medical 201 R & D 359 Programmes 137Total Staff 949Central Office Non Pay costs   362Regional Offices costs  723Contingency for miscellaneous expenditure 2TOTAL EXPENDITURE2,036    Page  PAGE 1 of  NUMPAGES 11CEMACH Board April 2008 Business Plan 2008-2011 45DEGOP^`f m s y " | } ~   ()*Abdenoش櫧ЧЧh1h hc5 h,5h,hw h;5h_kghH}5hh5h}Mh)hV&hch4hH} haN5 hH}5 hw5 hI75jhG%j5UmHnHu956PQ^_e f ~  *gd, & Fgdwgdw$a$gdH}gdH}$a$gdw$a$gdI7wJxNx*e>?On $Ifgd1gd1 & Fgd, ^UUUU $Ifgd#kd$$Ifl\ 0T& t0644 la^UIUU $$Ifa$gd1 $Ifgd1kd$$Ifl\ 0T& t0644 la&1^ULUU $Ifgd> Y $Ifgd1kd$$Ifl\ 0T& t0644 la12gir|^UIUU $$Ifa$gd1 $Ifgd1kd$$Ifl\ 0T& t0644 la2rvz{} 69:=>ADE(BCDGKST`Ni h)5 h;5h8kh)h*_ h]w5 hc5 h,5h]whLhXh,hmCJaJh,h,CJaJh,CJaJh<h,h1h> Y?|}^UIUU $$Ifa$gd< $Ifgd1kd,$$Ifl\ 0T& t0644 la^UIUU $$Ifa$gd< $Ifgd1kd$$Ifl\ 0T& t0644 la^UUUU $Ifgd1kdB$$Ifl\ 0T& t0644 la6:>B^UUUU $Ifgd1kd$$Ifl\ 0T& t0644 laBCDCD_^YPKFFAgd]wgdmgd,h^hgd,gd1kdX$$Ifl\ 0T& t0644 la_`MN./05: $$Ifa$gdND $Ifgd]wgdwgd;gdm8LM ,./049Qefij  5679:;KLÿϻǴǿǴǿǬǥǴh3iEh*_h)- hNDh#h6|h*2 hNDh}Mh;h}MhNDh#hmhwhQhQ56 h6|56 hQ56 hQ5 h)5 h85 h;5<:;fjkqh\\ $$Ifa$gdND $Ifgd]wkd$$IflF&0  g t06    44 laklqh\\ $$Ifa$gdND $Ifgd]wkdX$$IflF&0  g t06    44 laqh\\ $$Ifa$gdND $Ifgd]wkd$$IflF&0  g t06    44 laqh\\ $$Ifa$gdND $Ifgd]wkdB$$IflF&0  g t06    44 laqhXX$h$If^ha$gd]w $Ifgdwkd$$IflF&0  g t06    44 laqhXX$h$If^ha$gd]w $Ifgdwkd,$$IflF&0  g t06    44 la67;qhXX$h$If^ha$gd]w $Ifgd}Mkd$$IflF&0  g t06    44 la;<=>?qhhh $Ifgd]wkd$$IflF&0  g t06    44 la?@MQRqhXX$h$If^ha$gd]w $Ifgdwkd$$IflF&0  g t06    44 laLMOPQS !',-/24678~-CT`5 < Žŧ񜔜hhh=hb- hQ56 hb-56hI7h)-h)-CJaJh)-CJaJh[ h)5 h#5 h6|5h]wh}M5 h}M5h6|hoh}Mh*_h3iE hNDh}M8RSqhXX$h$If^ha$gd]w $Ifgdwkd $$IflF&0  g t06    44 laqhXX$h$If^ha$gd]w $Ifgd}Mkdu $$IflF&0  g t06    44 la qhXX$h$If^ha$gd]w $Ifgd}Mkd $$IflF&0  g t06    44 la !./5qhXX$h$If^ha$gd]w $IfgdNDkd_ $$IflF&0  g t06    44 la567~_`+!,!!!qlllllllllllgd[kd $$IflF&0  g t06    44 la < J p !!!!!K"`""""###$$$8$d$u$z$$$$$$$$ %,%&.&8&X&Z&[&>'E'((Y)))))?*A*D*****,,e- h5 h5 he5 h35h=hIuW5 h56 hIuW56hIuWh$hA^hQHhheh3iEh)-h;hh8kh8h_1c hb-hb-hchhb-9!##[&\&='>'))@*A*f-g-----....s/t//.0a0 & FgdM  & Fgd=gdwgdgd;hgd[e-f-g-h-j----....../n/q/r/s/t//////70a0k0o0000011"1#1-1R1\1x1111111ĺwhehSeY56hehe56h0IhYohYhBjhSeYhtXhM h8kh=hw hw56h=hw56h=h=56 h=h=heh= h=56 h=5 hqX5 hND5h}Mh=hQH5.a0001122K2L24444q6r6779999;<<<<<<<>gd3dgd=gdM  & Fgd=11222J2K2L2R2U2z2222222344444-525>5a5555T6p6q6r667(777S8o8969Q9c9k9l999999999+:ĸȰȬȬёёhlhlh3d6h$h~X heheh> Yh8kh3dhhSeYh;hhM he h3d5hlhl6 hl6 hl56 h=56heh=56hehSeY567+:R:^:m::;/;l;;;;;;<2<8<:<;<<<<<<<<=$=1=N=R==>>>>>>>>>>>#?A?t???@@AAAAણ쟚hiOhm hmhmhlJ h~X6h~X h~X56hlh[6 h[5hlh[56hlhl56h[h: h8k6hlh3d6hlhl6h3dhlhXhh8kh;4>>>>>>@@AABB\D]DDDDE"E Yh"Gh3iEh$hBj h=56h3iEhm6 h$6h3iEh3iE6hiOh=hmqh U(hlhIhlJhmh2^DHHHHIIIIIIYKZKLL5M6M(N)NOO.Q/QNQOQUUvVwVyVgd=IIIIIIIIIIIiJoJJJJJ4KXKYKwKK?LLL5M6M;MBMzMMMMMMNN!ONOPOOOOPEPMPQ"Q.Q/Q0Q1Q3Q5QNQOQQQNRĸĸĴİפןhiO h9o56 hI/j6h3iEh9o6hI/jhPWh9ohy6h> Yh2hhb hT56h3iEhT6h3iEh3iE6 hT5h3iEhT56h3iEh3iE56hThBj:NRTRvRRR3SuSSMTuTUUuVvVwVxVyVVVVVVVVVVVVxWyWWWWWWWWWWWWWWWXX X XbXiXkXsXtXXXXXXXXXXXXXƽ h=ghh=ghR $htxh h5 hR $5 htx5 hm5 h_kg5 hm56hI7hBj h9oh3iEh9ohiOh3iEh"G@yVVVVVVVV*WWWWWW $$Ifa$gdtx $IfgdR $ & FgdR $gdR $$a$gd_kgWWWWWqhhh $IfgdR $kdI $$IflF t  t06    44 laWWWWXqhhh $IfgdR $kd $$IflF t  t06    44 laXX XbXjXqhhh $IfgdR $kd3 $$IflF t  t06    44 lajXkXtXXXqhhh $IfgdR $kd $$IflF t  t06    44 laXXXXXqhhh $IfgdR $kd$$IflF t  t06    44 laXXXXXqhhh $IfgdR $kd$$IflF t  t06    44 laXXXXX"Y#YYYYYYZZZ[[[[[[[[[[[[[[[[[\\\\\\\ ]]]]#],]9]:]D]]]]]]^^^ ^ ^^^+^<^^x_ؽй̵汭ررh=gh=hV/hy6hOh$hYhphp6 hevhevhph41hevhE& htx5 hE&5hhhtx h=ghtx h=gh=g?XXX#Y$YYYYLGGGGG? 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