Webchat with health secretary Andy Burnham

Andy BurnhamHealth secretary Andy Burnham joined us for a live webchat on Wednesday 22 July 2009. This is an edited transcript of the discussion.

He has been health secretary since June. He is also MP for Leigh in Greater Manchester, was born in Liverpool, has three children, supports Everton and, apparently, plays a mean guitar riff.

 
Swine flu | Swine flu and breastfeeding | Swine flu vaccine | Tamiflu and going abroad | Swine flu and the NHS | Swine flu and school closures | Miscarriage and pregnancy loss servicesGP appointments | NHS prescription charges | Cervical screeningSupport for breastfeeding | Formula feed advertising

AndyBurnham: I am very pleased to have the opportunity to be here and it's very good for me to communicate in a direct way with parents. As a parent myself of three children I can understand that everybody has questions and concerns but the first thing to say that this is proving to be a mild virus in the vast majority of cases. As a family we have made no changes to our weekly routine and while as parents we all need to take precautions it's very much business as usual in the Burnham household (utter chaos).

 

Swine flu

Q. SpookyJules: Could Mr Burnham tell us the proportion of pregnant women who contracted swine flu who have died? We've heard how many pregnant women have died but not how many pregnant women contracted it who only had mild symptoms and were OK. 

Q. LeninGrad: It'd be really helpful if we could get some clarity on if/how/why they think this strain may be disproportionally affecting pregnant women. Essentially, I think we need to know what other health conditions, if any, the pregnant women in intensive care or who died may have or have had, what actual complication it is that they are having (pneumonia?) and what, if anything, we can do to recognise deterioration in order to act quickly (if that helps). I'd like to see more info on Relenza as a prophylactic, not sure that message is getting through.

Also, some information on numbers of pregnant women hospitalised with complications from seasonal flu would be helpful too, along with outcomes, of course. Finally, is it thought that this strain can cross the placenta and what are the implications of that, if so? It seems to me either the media is being a bit irresponsible in its reporting, or the govt isn't doing enough to explain the risks or issues, or possibly a bit of both.

A. AndyBurham: It goes without saying that people should take extra precautions because of the extra risk of complication and infections. The best thing that people can do is read the Chief Medical Officer's advice.

I would want to say to people that I don't want to give advice, it's not the job of a politician to do that. We are adopting a policy of being as open as we can about information and facts and figures.

Experts tell me there is no evidence that this strain can cross the placenta. While we don't collect precise figures on cases amongst pregnancy women, we do know that many pregnant woman have had the virus and are now fine.

OhYouBadBadKitten: So it is the Chief Medical officer we should be taking advice from then? We really need a strong leader type figure to get us through this smoothly, not a myriad of different agencies each with their own agenda.

kathyis6incheshigh: You know, I suspect if you did collect figures on cases among pregnant women, most people would be very reassured by them. That could go a lot further towards stopping people panicking than just saying vaguely 'most pregnant women are fine'. 

Q. kathyis6incheshigh: Please can you ensure more information about sufferers with underlying health conditions is put out there to help reassure and inform people who have children with health conditions? It can't be very reassuring to be constantly told 'Oh, everyone without pre-existing health conditions will be fine' if the child you love more than anything in the world has such a condition.

A. AndyBurnham: On the subject of underlying health issues, I know that people don't like this particular phrase and find it too vague. In general, it does mean it relates to a serious condition such as HIV or leukaemia where the immune system is suppressed or it can mean that somebody is on chemotherapy for cancer treatment. It has been used because we don't want to give intrusive personal information on every person.

I am hoping that we will soon be in a position to give a breakdown of what illnesses have been underlying in all of the fatalities to date.

In the sad cases of fatalities, the underlying conditions have often been very severe. There are many people with mild underlying conditions who have made a full recovery. People must not worry unnecessarily, but if your child for instance has asthma and you think they have swine flu it is a good idea to get antivirals early.   

Q. Flumpity: The NHS Symptom Checker told me I had swine flu, even though I don't have a high temperature. Can you have swine flu without a high temperature? It struck me as unlikely despite having all the other symptoms. But it may explain all the panic when the symptom checker is diagnosing every normal cold as swine flu. Or can you, in fact, get swine flu without a temp?

A. AndyBurnham: I am not a GP, but it is nearly always the case that people who have swine flu have a temperature of 38 or more. 

Q. CathKidston: I am trying to plan the rest of my family and wondering if I should actively be avoiding getting pregnant? And if so, for how long? Do we know how long this pandemic is likely to last? I know you're not qualified to give medical advice but I would be interested to hear your views. 

A. AndyBurnham: Newspapers reports on the weekend about delaying a family were very unhelpful and I think brought a lot of unnecessary confusion. This has not been part of our advice. There was earlier advice relating to H5N1 (bird flu) but that would have been most likely a more serious virus. As we keep saying, this virus is mild in the vast majority of cases but undoubtedly very unpleasant for some.

Q. champagnesupernova: What do we say to our children who are worried sick [pun] by the scaremongering (or is it?) in the media? What is the best way to reassure them?

Q. thegrammerpolice: Andy, I would also urge you to try and persuade the media to report swine flu in a more responsible, less scaremongering way to limit the pandemic pandemonium that's going on. 

A. AndyBurnham: On the media, I think the coverage to date has been on the whole has been measured and informative. I was frustrated by the weekend coverage because this department has not changed its advice, but I appreciate that we need to work hard to provide as quick and clear answers as we can, if there is any sense of confusion.

We have to recognise that there are other non-government voices out there commenting and that is right and proper in a free country but I hope it won't always lead to headlines about confusion as that just increases anxiety. It is a fact that unbalanced coverage can put extra pressure on NHS staff by people making unnecessary visits to GPs or NHS Direct. I hope that the good media coverage so far will continue through the quieter summer months.

kathyis6incheshigh: Have to say I agree re non-government voices commenting. I wouldn't like it if RCM etc were prevented from giving their view, even if what they are saying is a bit dodgy.

Q. TallulahToo: Swine flu is not only a particular hazard to pregnant mums but also to the under-fives. Why then does the government not advocate closing of school nurseries when a case is found? 

A. AndyBurnham: TallulahToo, thanks for your question. We originally had a policy of closing schools and nurseries when we were in the 'containment' phase of our response to swine flu; that was when we were trying to stop the spread of swine flu for as long as possible so we had time to study the disease and make significant progress towards developing a vaccine. No one could stop the spread indefinitely and, following advice from scientific experts, we reached the conclusion that it wouldn't be right to close nurseries or schools every time a child or a member of staff fell ill with swine flu.

But we have said that nurseries and schools could close if local circumstances required it – for instance, if a number of staff all fell ill with swine flu. We've also asked nurseries to be particularly hot on cleaning hard surfaces, which can harbour the virus, and isolating children who show symptoms.

At the moment, swine flu is proving to be mild for most people, including the under 5s, so we do need to take a proportionate response. However, we are monitoring the situation closely and will make any changes to our position as and when we need to.

Q. Grendle: I would like to know what he thinks of the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) guidelines on swine flu and pregnancy. In particular, as access to homebirths can be so variable anyway, will their advice that if services are stretched generally then homebirth services may be cancelled be used as an excuse to deny women the choices they want in birthing? What will be done to ensure this isn't the case? Also, if services get really stretched due to staff illness, how will they make sure that breastfeeding and other postnatal needs are fully supported? Particularly if, as RCOG/RCM suggest, women may be encouraged out of hospital faster and not receive postnatal home visits from midwives. Will all hospitals be actively promoting referrals to the voluntary breastfeeding helplines as a backup?

Please could more information about Relenza and any flu vaccine and pregnancy be provided in order that pregnant women can make informed decisions about whether or not to take up these options. Simply saying "this is what we recommend, there's no evidence of harm" isn't really reassuring enough, nor enough information on which to make a judgement. Pregnant women are not sheep.

Q. blondieminx: Please could you also outline what continuity planning is being undertaken in hospitals to ensure that this country's already overstretched midwifery service gets support so that midwives are there when we need them when the time comes to deliver our babies? Also please could you confirm whether hospitals will be given guidance to offer reassurance scans to mothers-to-be who have taken Relenza (bearing in mind the lack of data about this drug)?

A. AndyBurnham: Thanks Grendle and blondieminx, you both hit on some important issues. I know swine flu is a big concern for expectant parents, which is why we've been working closely with the Royal Colleges to give joined up advice.

On Grendle's question about Relenza and vaccines, we do want to be as open as possible in the information available. The last thing I want to do is to tell pregnant women "you must do this, you must do that". It should be up to the individual to decide – but it needs to be an informed decision, based on an awareness of all the pros and cons. You can find a lot more information about Relenza on our website (www.dh.gov.uk), and I'd also urge you to speak to your GP or midwife if you have any concerns about taking Relenza.

On the vaccine front, I'm clear that we do need to make sure vaccinations are safe, and we're working with the licensing authorities to ensure the appropriate checks are carried out.

Turning to the issue of maternity services, I do want to stress that the NHS has been planning for a pandemic for many years, and this includes plans for how maternity services should respond.  The guidelines we've sent out to the NHS make clear that maternity units should do everything possible to allow women to choose the type of birth they want.

Equally, maternity services will make every effort to ensure swine flu does not compromise the quality of care and support that new mums receive immediately after giving birth.

As I say, there are detailed plans in place to minimise the impact this pandemic has on all kinds of health services. We're acknowledged as being global leaders in our preparations. But even so, I'm afraid I can't guarantee there won't be local cases where staff illness or short term pressures mean that some women will not have a home birth.

What I can guarantee is that we will do everything we can to keep those instances to a minimum – wherever possible, we need the NHS to function as normal during the pandemic.

Q. thegrammerpolice: I believe that there is vast over-diagnosis of swine flu going on in hot spot areas. Children who have the slightest temperature and any two other symptoms are diagnosed with it and handed Tamiflu which many of them probably don't need.

Surely this means the figures are over-estimates of the true spread of the disease? I'd like to know what proportion of swabbed suspected cases have actually tested positive for SF (I believe that small numbers are still being swabbed) and what proportion actually had other illnesses.

A. AndyBurnham: Grammerpolice, thanks. You're right to say that the figures we publish every week are an estimate. The reality is that at the moment there are thousands of suspected cases every day. That is why we stopped the policy of swabbing everyone who may have swine flu.

Instead, the Health Protection Agency swabs a small number of patients as a sample, and then we use this along with the number of cases reported by GPs to produce an overall estimate. They do this every year with seasonal flu so have experience in giving us a good picture of how the virus is spreading across the country. 

Q. studentmummy: Mr Burnham - The underlying causes theme seems to be one of the most dominant discussion threads here. If these details were released it would be helpful on a number of levels:

  • To help individuals assess their own relative degree of risk with regard to swine flu and promptness of treatment.
  • It would help dispel rumours that the underlying causes is all a government cover-up story to avert panic.

There seems to be real concern that almost anyone could be made retrospectively to fit into an underlying causes scenario and I am not altogether convinced by the tonsillitis story by the way.

A. AndyBurnham: I'm afraid patient confidentiality means we can't give out details of specific underlying conditions that people who have died with swine flu have suffered from. What I can say is that we have to put swine flu into some perspective. For the vast majority of people it is a mild illness, but in some cases the symptoms can be more severe, and in rare cases it can be fatal.

We do know that people with serious health problems such as heart disease, a recent history of serious asthma, and compromised immune systems (eg HIV patients, or those going through chemotherapy) and children under one are at greater risk. They should contact their GP and take Tamiflu as soon as they get swine flu symptoms.

Of course, pregnancy can also weaken your immune system, so it's important that pregnant women with swine flu also talk to their doctor or midwife who will be able to advise whether they need to take Relenza.
 

Swine flu and breastfeeding

Q. BoffinMum: Why is nobody giving advice about breastfeeding?

A. AndyBurnham: With regard to breastfeeding and swine flu, the department's advice is that women who are breastfeeding should continue while receiving antiviral treatment. If a mother is ill she should continue breastfeeding and increase feeding frequency. If she becomes too ill to feed, then expressing milk may still be possible. In short, carry on but it is important to keep fluid intake up. 
 

Swine flu vaccine 

Q. Stigaloid: I am quite nervous about swine flu as I am pregnant and have a two year old. Will vaccines be available to us and if so when? How do we know that vaccines won't hurt my unborn baby? How many of the pregnant women who have died did not have underlying health problems?

Q. atlantis: Are Mr Burnham's children going to be vaccinated in the first 'untested' wave to come from the manufacturer, or is he going to wait until the vaccine has been proven before allowing his children to have the shots?

A. AndyBurnham: With regards to vaccines, yes I would give it to my children but I would want to be sure that it had been properly tested so, you can all take heart that I won't be taking any risks there.

On the timing, we have contracts in place to see the first doses arrive at the end of next month and then build up significantly over the autumn. Sixty million doses are contracted to arrive in 2009. Enough to vaccinate half the population.

Overall, we have an order placed for 130 million doses (people may need two doses). Because we had advanced purchased agreements, we are at the front of the queue for vaccines.

Q. Frasersmum123: So are you sure it will be properly tested?

A. AndyBurnham: Of course, the vaccine has to be properly tested. The licensing process will be carried out by the European Medicines Evaluation Agency. It will get under way as soon as possible. It is important to remember that there is long experience of providing safe flu vaccines. Every year, the seasonal flu virus can mutate a little and require a new vaccine, so we are well used to dealing to situations of this kind.

Q. PM73: So who decides who gets the vaccine and who doesn't get it?

A. AndyBurnham: On prioritisation for vaccine, I will meet my counterparts in Scotland, Wales and Northern Ireland in Cardiff tomorrow and we will discuss this very issue. Our scientific advisors have given us advice about the priority higher risk groups and we will take a decision on whether to take this advice soon. Of course, as soon as we do we will make that information public.

A lot depends on the speed of delivery and the licensing process. We also need to consider when we should vaccinate health and social care staff, alongside the priority risk groups.

Q. blondieminx: C4 News reported earlier that they've only just started the testing process and it takes seven months. So by my reckoning that takes us to early next year. Once testing has finished, the vaccine still needs to be licenced for use here.

A. AndyBurnham: We do not know where Channel 4 could have got their information from. It was news to us and sounds inaccurate. I have spoken to the manufacturers and I am led to believe that it will not take anything like that long.

studentmummy: Can you tell me why 'under threes' do not make it onto Professor Salisbury's priority list for the vaccination program in the autumn. I completely fail to comprehend the reason for this given that 'under-fives' are the highest risk group in terms of being the most affected category, possessing highest proportional number of hospitalisations and highest projected mortality rates? According to Salisbury's priority list, 'under threes' come at the very end of the queue together with the rest of the population instead of amongst other children (three and over) who are somewhat near the top of the list. Is there an explanation for this? If so it might need disseminating to the parental population to help us make informed choices.

Frasersmum123: How will you insure that those who are at most risk will get the Vaccine? Will it be the case that you will have to prove hom asthmatic you are for example, or will it be a blanket vaccination for everyone that has a condition that puts them in the 'at risk' category?

BrightShinySun: Just two simple questions really..
1. Are the under fives (as they seem to be hit the hardest when they do contract swine flu) going to be priority when the vacination does arrive?
2. Bearing in mind it does not seem to be affecting the elderly as hard as the young why is there still talk of them being priority (no offence to the elderly of course) would it not make more sense to prioritise the 15-50 (ish) year olds that make up most of the country workforce and basically keep the country moving?

A. AndyBurnham: Thank you all for these questions on vaccinations, which I'll respond to together. And I'm afraid the honest answer is that we haven't yet reached a decision on who is going to receive the vaccine first. The list that studentmummy refers to was not in any order and was simply a list of possible groups that had been identified to assist the NHS with its planning.

There will be limited supplies of the vaccine at first, and prioritising vaccinations is going to be a very tough call. However, we are discussing this with scientific experts and we'll make a decision, using the most up-to-date evidence about the severity and spread of the disease, once we've got a clearer idea of exactly how much vaccine will be available in the months ahead.

There is not enough experience of swine flu in children under the age of five in the UK yet. Other countries have not yet included young children as an at risk group but we have decided to take a precautionary approach and consider children under five as being at increased risk until further information makes this clearer. If a child under five has flu-like symptoms you should contact the National Pandemic Flu Service.
 

Tamiflu and going abroad on holiday

Q. norwood: I accept the UK government have enough Tamiflu for everyone, but is that the case everywhere in Europe? If we fall ill with it while we are abroad, is it guaranteed that we will be prescribed it? Or is it more prudent to take some with you? 

A. AndyBurnham: My best advice for people going on holiday in Europe is to get a European Health Insurance Card for each member of the family. If you're travelling further afield you may want to consult the Foreign Office website, but it is important to say that we do not plan to issue Tamiflu on a speculative basis. It is for people with symptoms.

On general availability, ministers had to take a decision a couple of weeks ago about whether it should be restricted to at-risk groups or made available to everyone with symptoms. We decided that it should be offered to everyone and we could take this cautious approach because we have built up such a large stockpile over recent years. I cannot stress enough that there is enough for everybody. 
 

Swine flu and effect on health services

Q. alittlebitfat: I'm an HCP, I'm already aware of the strain on critical care beds during a normal winter, I feel extremely anxious about this winter as there will simply not be enough ITU/HDU beds available.

A. AndyBurnham: On critical care beds it's important to say that the NHS is wonderfully resilient and has long experience of dealing with the extra pressure that comes with any flu season or outbreak of flu. In the winter of 1999/2000, there were very high levels of seasonal flu, much above the current levels that we are seeing and, as always, the NHS rose to the challenge and sufficient capacity was available.

People should take comfort from the fact that our health care system is nationally organised and that capacity can be planned centrally to meet demand.

alittlebitfat: Thank you for answering, although I must disagree. We got by... just. On Millennium eve I travelled with a seriously ill patient from Hertfordshire to Derbyshire. This was the last ITU bed in England at that time. We will not get by this winter with current numbers.

Q. studentmummy: Will we have enough for all the anticipated child swine flu sufferers who need hospitalisation over the course of this pandemic (estimated up to 20,000 worst-case scenario) when number of paediatric beds available is somewhere between three and four hundred?

A. AndyBurnham: On paediatric intensive care I would want people to be reassured that there are contingency plans in place in all English regions to meet increased levels of demand. We issued planning guidance to the NHS last week with worse-case scenarios. Whilst this produced some awkward headlines for us, we think it was the right thing to do, so that the NHS was clear about the extra pressure it could face in the most extreme scenario.

Swine flu and school closures

Q. megcleary: I have read that it would be best NOT to close schools in September and allow children to get immunity before the the winter version of a flu appears. Do you have any comment on this? 

A. AndyBurnham: There are no plans for widespread school closures. There were closures in the early phase but that was when all our efforts were focused on containing spread so that we could buy time to learn more about the virus.

Again, it is important to keep it in perspective and adopt a business-as-usual approach. School closures may be considered on a local basis, but that would be a matter for the head teacher and the chair of governors. Obviously, we will keep things under review and have to see how the virus develops in the autumn, but there are no widespread closure plans under discussion at the moment. 

Miscarriage and pregnancy loss services

Q. CMOTdibbler: When Alan Johnston came to visit us, he promised that there would be a review of miscarriage and pregnancy loss services, having heard the heartbreaking stories here of how women were mistreated by the NHS. I know you are a bit busy at the moment, but could you let us know the status of this ?

A. AndyBurnham: Thanks CMOTdibbler. Yes it is a busy time! But I'm still very keen to pick up where Alan left off because I know the NHS can do a lot better in helping women deal with the physical and psychological effects of miscarriage.

Since Alan's appearance on Mumsnet last year, we've been working very closely with the RCOG and the RCM, and there has been some progress. We've put money into RCOG's new Standards for Gynaecology, which now sets out clear standards on how the NHS should help patients who have experienced miscarriage, ectopic pregnancy and recurrent miscarriages.

Last August, we also published advice on how the NHS needs to improve facilities for families suffering pregnancy loss – at such a traumatic time, hospitals should do everything they can to ensure women can have their loved ones around them, and that's where things like overnight stay rooms become very important.

I think it is encouraging that 97% of maternity services now have an Early Pregnancy Assessment Unit to manage problems in early pregnancy, such as vaginal bleeding and abdominal pain, and to provide ongoing advice and support.

But I'm under no illusion there's more to do – and over the coming months, we'll be working with the Royal College of General Practitioners to improve the role that GPs can play in pregnancy care, and this should include bereavement counselling and building long term relationships with families who suffer the loss of a pregnancy.
 

Difficulties getting a GP appointment

Q. 1dilemma: I was disconnected from the GP four times this morning in an attempt to get my next antenatal appointment and I have pretty much given up trying to get my kids their routine jabs. I am fed up of being told there are no appointments left and I have to phone back between 8.45 and 8.50am in 3.5 weeks time on any day except one with a y in it!

Q. JimmyMcNulty: Why can I not get an appointment to see a GP at my local practice (except for WEEKS in advance) except by ringing up at 8am on the dot for an 'emergency' appointment on the day? This was the same at my last GP practice as well before we moved area and I'm told it's so that they hit targets. Are you looking at fixing this?

A. AndyBurnham: I'm really sorry to hear about your experiences. I've made it very clear to local health authorities that everyone should be able to see their GP at a time that fits around their lives. That doesn't just mean accessing appointments at short notice, but also being able to book them in advance.

The latest figures suggest that about three-quarters of those who wanted to book ahead for an appointment with a GP said they could do so. This is an improvement on the past, but it's still not good enough. I want to aim for a situation where all GPs can offer patients an appointment within the next two days, and allow them to book further ahead. If this isn't happening in your area, you should take this up with your local Primary Care Trust, who are responsible for overseeing GP services.

 

NHS prescription charges

Q. herbietea: Why are those of us in England still having to pay for prescriptions when the rest of the UK don't?

A. AndyBurnham: We want all NHS services to be affordable and accessible – and that includes prescriptions. From April this year, cancer patients became eligible for free prescriptions, and we are currently looking into extending this exemption for people with long-term conditions – we're expecting to make a decision on this in the autumn.

And help is already available for people who need extensive or frequent prescriptions. If you need more than four prescription items in any three-month period or more than 14 items during a period of 12 months then it's worth getting a Pre Payment Certificate. This means you can then get as many prescribed items as you need for £2.00 per week – and the cost can be spread by direct debit.
 

Cervical screening

Q. Herbietea: Is it only English women's cervixes that show changes between 20-25? It must be, as Scotland and Wales pay for the smears to be done during this time.

A. AndyBurnham: On cervical screening, I'm afraid we have taken a different view to our counterparts in the devolved administrations. Last year, we asked an independent panel of experts to review the pros and cons of offering cervical screening in women under 25. They unanimously concluded that the screening age should not be lowered. Treating women for abnormal cervical cell changes can increase premature birth. Cervical cancer is very rare among women under 25 and they are over three times more likely to produce false positives so it is the committee's advice that screening at this age causes more harm than good.

This is a view that's shared internationally. The World Health Organisation has recommended that screening starts at 25 since 2005. France, Belgium and Italy also begin screening at this age while the Netherlands start at 30.
 

Support for breastfeeding

Q. elkiedee: What do you think the government could do to improve support within the NHS for those women who want to breastfeed but give up much earlier than they expected or planned to? Could someone ask about breastfeeding in public and protecting the right of all women to feed their babies/young children in public (and not just up to six months either).

A. AndyBurnham: I agree with you that women should get all the advice and support they need to encourage them to breastfeed. There is clear evidence that breastfeeding your baby does have health benefits.

In terms of what we're doing, the Government has put a lot of money behind the Baby Friendly Initiative. This is helping maternity units and other community settings like Sure Start Children's Centres to provide help to mothers to start breastfeeding, and continued support in the community to sustain breastfeeding for longer.

I also agree with your point about protecting mother's rights to breastfeed in public. There's already strong protection for mums under the Sex Discrimination Act, which makes it unlawful to treat someone less favourably because she is breastfeeding – and this is the case whatever the age of her baby.

So a woman should have complete confidence that it is unlawful for a café owner or restauranteur, for example, to ask them to leave the premises because they are breastfeeding.
 

Formula feed advertising

Q. grendle: Why has all formula advertising, including follow-on formula, not yet been banned? These products are used and needed by lots of people, but they don't need to be advertised. Impartial information on formula and bottle feeding would be better than marketing.

A. AndyBurnham: Grendle, there is a review already under way to look at whether we need to take further action on the way infant formula and follow-on formula is presented and advertised. It will also explore whether babies under six months are being fed follow on formula, and if so why. This report is due at the end of this year, and we'll take a decision once we've looked at the evidence. So rest assured, this is something that's on our radar!

AndyBurnham: I am sorry but I have to sign off now. I know I haven't answered many questions, particularly those not about swine flu, but will come back soon to do another webchat. Enjoy the summer and enjoy your holidays. Thanks for having me.

Last updated: 05-Nov-2013 at 11:13 AM