Meeting date: Wednesday, November 25, 2020
Meeting of the Parliament (Hybrid) 25 November 2020
Agenda: Portfolio Question Time, Covid-19 (Roll-out of Testing Programme), Policing (Complaints Handling, Investigations and Misconduct Issues) (Independent Review), Legal Advice (Publication), Business Motion, Parliamentary Bureau Motions, Decision Time, Inverclyde Royal Hospital (Intensive Care Provision)
- Portfolio Question Time
- Covid-19 (Roll-out of Testing Programme)
- Policing (Complaints Handling, Investigations and Misconduct Issues) (Independent Review)
- Legal Advice (Publication)
- Business Motion
- Parliamentary Bureau Motions
- Decision Time
- Inverclyde Royal Hospital (Intensive Care Provision)
Inverclyde Royal Hospital (Intensive Care Provision)
The final item of business is a members’ business debate on motion S5M-22984, in the name of Jamie Greene, on the intensive care unit at Inverclyde royal hospital. The debate will be concluded without any question being put.
That the Parliament is significantly concerned over reports that the ICU provision of the Inverclyde Royal Hospital’s critical care offering, in Greenock, is closing and that patients requiring that type of critical care will be transferred to the Queen Elizabeth University Hospital in Glasgow for treatment; believes that Inverclyde has been disproportionally impacted by the COVID-19 pandemic; considers this closure to be ill-advised given the continuing prevalence of COVID-19 and need for intensive care in the surrounding region; notes the considerable hardship and stress that it believes this will place on local families who visit their loved ones in hospital; understands that, in the seven days leading up to 3 October 2020, Inverclyde recorded 34 new cases of COVID-19 at a rate of 43.7 per 100,000 people; notes the calls on all political parties represented in the Scottish Parliament to collectively raise these concerns with the local NHS board and the Cabinet Secretary for Health and Sport, given the current national health emergency, and further notes the calls on the Scottish Government to look into this matter immediately with a view to a substantial rethink of this action.18:03
I thank the members who have supported the motion and helped to bring the debate to the chamber. Saying “save our hospital” is one of those perennial but powerful tools in the political toolkit that strikes at the heart of communities as an emotive subject, because hospitals are places of worry, sorrow and joy, illness and recovery, and life and death—things that are the essence of politics and public policy.
I accept that change is sometimes difficult to accept, understand or even communicate. Patient safety is, of course, paramount, but it should not be used as a smokescreen to make unpopular changes that are the by-product of systemic problems of resource, finance or governance.
There is nobody in Inverclyde, Renfrewshire, North Ayrshire or Argyll who does not have an Inverclyde royal hospital story to share. It is a truly ominous building, and it has sat at the heart of our community since the year before I was born.
I was a youth volunteer at the hospital radio station in my teens. I had a weekly show there, the highlight of which was a Christmas Day request show. I am not sure that we had many listeners, but I recall that, one year, the phone rang in the studio—I nearly fell off my chair.
It seems serendipitous that, one day, that same hospital would serve as a place of care and love for many of my friends and family. Some of them walked proudly back out of its front door, others, sadly, did not. I have spent many a night in the intensive care unit family room, sleeping on its uncomfortable floor, with kind nurses bringing me cups of sugary tea. We do not always remember the names of folk in those situations, but we never forget their faces.
The strength of feeling locally to protect the intensive care unit in the interests of all patients who need it, for as long as they need it, is not just palpable but entirely justified. On 1 October this year, shocked staff were told that level 3 ICU patients would be moved to Glasgow. That type of care had been under threat for much longer than that, because, in December last year, the Government confirmed in writing that its two funded level 3 care beds were already at risk, and said that challenges and risks existed that might impact the unit’s on-going sustainability. Guess what those challenges and risks were. It will come as no surprise to members that they involved workplace issues and skills shortages. That was a year ago. It is there in black and white.
Following that, Covid came along, and temporary changes were made to patient pathways. People get that—I get that. Inverclyde was hit hard by Covid, with the death rate twice the national average. People understand the need for temporary changes in response to a temporary health emergency. However, what they do not appreciate is that fact being used as a cover to make permanent changes. The rumours were not just rumours. Before the very eyes of staff, patients were being stabilised in Inverclyde and moved to Glasgow.
In response to reports of those substantive changes, the Greenock Telegraph launched an online petition, which has received more than 11,000 signatures. Protecting the ICU in Inverclyde has united Inverclyde. It has brought together residents, staff and politicians of all political colours. Local businesses have got on board, too—McGill’s Buses printed the campaign message on the back of its bus tickets.
Political parties also condemned the move. One local Scottish National Party councillor said:
“It is a disgraceful decision in the midst of a global pandemic.”
I do not disagree. Another councillor said:
“Local people need to speak loudly by sending a clear message to our political leaders in Holyrood.”
Normally, those local people would be in the gallery behind us, but I know that they are watching online, so I will address them directly: you have spoken loudly, and I hope that your message is crystal clear to our political leaders today.
Of course, the national health service board responded quickly, saying that the ICU is not closing. However, it admitted that level 3 patients are indeed being transferred to the Queen Elizabeth hospital in Glasgow. That mantra was repeated by the Cabinet Secretary for Health and Sport, and we might hear it again today. A change has been made under the proviso of Covid, with no guarantee of reversion to pre-pandemic pathways. That is the guarantee that we seek today.
We know that the NHS is operating in unusual times. Until March 2021, at least, it will be operating under a state of emergency. However, presumably, that means that, post-Covid, we can expect pre-Covid conditions of care.
Inverclyde ICU has proven its value. It currently admits around 1,450 patients a year, but this new pathway will move at least 100 of those patients to Glasgow. That is not just a number; it represents 100 people and 100 families who are already in despair and are in their darkest moments but who will have the added stress of worrying about how to make that journey from Greenock to Glasgow, often twice daily. As I know far too well, that is a long distance when things go wrong in the middle of the night.
It is simply disingenuous to claim that there is nothing to see here, that nothing has changed and that this situation is just a case of poor communication. It is not. The fact remains that, historically, level 3 care patients were not just stabilised in Greenock, but were treated there, too. It remains a fact that patients who required intrusive ventilation were given that there and that people received multidisciplinary support there. I know that because, like thousands of others, I have seen it with my own eyes.
We have been offered a jargon-filled briefing in defence of the change. The beds are there and the staff are there, so the ICU must still be there. That is fine but, if that is so, why are patients being put into ambulances and transferred to Glasgow when, this time last year, they were not? If that does not constitute a major change, what does? It cannot be an ICU by name alone.
If the issue is resource, that is a legacy for which this Government must take responsibility. There are gaps in consultancy, anaesthetics and middle-grade nurses, and the use of locums is rocketing. The unit has been chronically underresourced for years, and services have been chipped away: the ear, nose and throat unit, the out-of-hours general practitioner service, the orthopaedic unit, the physical disability rehabilitation unit, the maternity unit—the list goes on and on. Those are not “perceived” threats—they are actual threats.
In closing, here are some questions for the Government and the health board, on behalf of the people back in Inverclyde. In the middle of the pandemic, why on earth are we reducing, rather than beefing up, ICU care in our local hospital? Why has Inverclyde been put into restrictions because of fears about ICU bed capacity in Glasgow, when we have a hospital right on our doorstep? Why are there no guarantees that the temporary changes are indeed temporary? What is the long-term plan and vision for the hospital over the next five or 10 years? How can we have confidence that the hospital will lie at the heart of providing cradle-to-grave healthcare for the people whom it serves?
It is time to end the obfuscation. We should give the hospital what it needs, give the staff the reassurances that they deserve and give the people of Inverclyde some respect by providing some much-needed honesty in the debate, because they all deserve nothing less.18:11
I congratulate Jamie Greene for bringing this important debate to the chamber. As he indicated yesterday in his comments to the Greenock Telegraph, the situation has evolved since the motion was lodged.
First, I want to highlight my frustration with the health board. As I have said publicly on previous occasions, and to health board staff directly, the communication of the process and the change has been nothing short of a disgrace. Telling staff of a change with 24 hours’ notice is no way to run any service, and it certainly shows a disregard for local staff and for Inverclyde, so I fully understand and support the comments from my constituents expressing their anger.
Both Jamie Greene and I have raised the issue of the ICU in the chamber, and I did so directly with the First Minister, as the minister will be aware. I will put on the record a couple of undeniable facts. First, the campaign that was run was adamant that the ICU was closing, but it is not. The beds are still there and are being used, the staff are there and patients are still going to the ICU. Level 1 and level 2 intensive care services remain at the Inverclyde royal hospital.
The issue concerns level 3 intensive care, which Jamie Greene touched on. I want level 3 fully returned to the IRH. In fact, I would like more services at the hospital—I will come to that point in a moment. I have spoken formally and informally to various members of health staff at the hospital, and it is clear that there are a variety of opinions as to the decision that was taken and the care that patients will get. Ultimately, however, the patient should be uppermost in the minds of everyone who cares about this issue and other issues in respect of the IRH.
I would like level 3 care to be fully delivered at the IRH once again, and I would like that to happen as quickly as possible. Jamie Greene touched on the state of emergency that is in place until spring 2021. The health board will provide many reasons for why there are challenges to local provision. Those need to be fully understood, and solutions need to be put in place to try to deal with them. However, staffing is always raised as an issue, and—to be frank—the public of Inverclyde do not always accept that as a reason.
The health board regularly states that the IRH has a long-term future, and I agree with it on that point. However, the one action that would put that beyond any doubt would be for the health board to build a replacement for the Inverclyde royal hospital. That would remove any accusations that the hospital is going to close or is going to be downgraded.
Locally, I have yet to meet anyone who thinks that the building of the hospital in its current location—at the top of a hill with no shelter, totally exposed to all the elements—was a good idea. It is no wonder that the building has had so many problems with water ingress over the years. I welcome the investment that has gone into the hospital. The new facilities, including the new theatre, will be put to good use. However, unless a new-build hospital is progressed, debates in the chamber such as this one and debates across Inverclyde will continue for many years to come.
In some quarters, there is a belief that the health board does not consider Inverclyde to be a priority, but I do not share that view. We now have Orchard View hospital, which was the replacement for Ravenscraig hospital, and the new Greenock health centre is currently under construction. Those two projects alone will provide better health outcomes for patients and better working conditions for staff. I know that from my own family’s experience—one of my aunts was a patient at Orchard View and previously at Ravenscraig hospital.
The continual claims that services are going and that the hospital is shutting will do nothing to entice people to work at the IRH. Who would want to work in a hospital if they thought that it was going to shut? That is yet another reason why a new-build hospital is important: it could help to deal with some of the recruitment issues that the health board continually highlights.
The public perception in Inverclyde is that we need to travel elsewhere for some services. Not one person has raised travel as a concern when it comes to specialist services. However, having to travel for services that are considered to be more routine frustrates many of my constituents. My constituency has one of the oldest population shares in Scotland and, under the Scottish index of multiple deprivation, we now have some of the most deprived data zones in the country, including the zone with the highest level of deprivation.
Many people in my community have underlying health conditions, many of which are a result of their previous working conditions. The health board understands most of that but, along with the investment in the two new facilities that I mentioned, it can show that it fully understands by committing to a new build. That will result in improved recruitment and make it easier for services to be delivered locally, rather than asking my constituents to travel elsewhere for routine services.18:16
I, too, am pleased to speak in the debate, and I thank my colleague Jamie Greene for taking this very important issue forward on behalf of his constituents in the Inverclyde area, which is part of the West Scotland region that we both represent.
Inverclyde, which was previously the region of Scotland that was hardest hit by Covid, has undoubtedly been heavily impacted by the pandemic. The first wave resulted in a high death toll, which left it unenviably dubbed Scotland’s Covid capital. The area currently sits at level 3, having made a marked improvement, with cases currently stabilised.
In response to those challenges, continued local clinical provision has been vital for the community. The Inverclyde royal hospital has served local people well through the years, covering an expansive area across Greenock, Dunoon, Cowal, Largs, Gourock and Port Glasgow. Altogether, it serves a population of 125,000 people.
The intensive care unit, which is staffed by a dedicated team, provides the highest quality of critical care, and I am aware that many families—Stuart McMillan spoke about his own family’s experience—have a deep appreciation for the treatment that their loved ones have received. Any changes to how that critical care is to be provided must therefore be communicated clearly and sensitively, especially as Covid cases continue.
Every health board holds a responsibility to communicate clearly, transparently and openly any changes to the delivery of services. In failing to do so in this case, Greater Glasgow and Clyde health board’s previously unclear messaging regarding critical care at the IRH has caused distress, frustration and tangible concern across Inverclyde, which is certainly regrettable.
A 2018 Audit Scotland report highlighted the need for greater engagement and collaborative decision making in how health and social care services are delivered. It makes the point that any changes must be implemented in a way that involves local communities from the start, which I am sure would help to allay understandable concerns and encourage discussion.
I recognise and appreciate the steps that the health minister has taken to seek assurances from the health board that the ICU in Inverclyde would not, in fact, be closing. Clarity from the health board on that point was sorely needed from the outset. Furthermore, I am relieved to hear that local patients who require critical care will, in most cases, continue to receive treatment at the unit. Only those who require the most specialist care will be transferred to the Queen Elizabeth hospital and, post the Covid pandemic, they should return to Inverclyde for continued specialist care and to be near their families, which is important.
Research has shown that almost a third of Covid-19 patients who require ventilation are also in need of renal support, which regrettably has not been available at the IRH for some time. That raises concerns that services at the IRH will continue to be reduced or downgraded, which I sincerely hope will not be the case.
Of course, these are unprecedented times. The strain on health and social care provision has been enormous, especially as we head into winter. I therefore recognise that, in response to that burden, changes to clinical pathways might have to be made. However, although the health board has advised that this particular change might affect only a small minority of patients, its decision suggests that the Inverclyde royal hospital is undergoing a further reduction in services for local people. The debate raises the bigger question of the need for greater investment in the Inverclyde area.
The latest change contributes to the concerns that Inverclyde is not receiving the investment that it needs, especially in these difficult times. Local people deserve greater provision, and that includes a renewed emphasis on not only securing but expanding health and care services at Inverclyde royal hospital.18:20
This is an important debate. I welcome the opportunity to speak in it and to make the case for local services at Inverclyde royal hospital, which has served the communities of Greenock, Gourock, Port Glasgow, Inverkip, Kilmacolm and many others well through the years.
As has been said, Inverclyde has, sadly, the highest Covid death rate in Scotland. It is also home to the most deprived community in Scotland. We should be investing in services in Inverclyde, not removing them from it.
For many residents of Inverclyde and beyond, it seems that NHS Greater Glasgow and Clyde is particularly wedded to a policy of centralisation. That is despite profound community concern that the hospital will be left behind; concern that the views of patients, families and local residents will be ignored; concern that previous moves to centralised services, such as in out-of-hours primary care and birthing suites, indicate a pattern of behaviour; concern that staff are treated as an afterthought; and concern about the geography of Inverclyde and the reliance on coastal transport links that can be subject to flooding, weather-related disruption and congestion.
According to Transport Scotland, the M8 between Renfrewshire and Glasgow is the most congested section of motorway in the country. People who travel from elsewhere in the city have access to a number of alternative routes, but those who travel from Inverclyde are limited.
For all those reasons, there is deep anxiety in the community about the extraction of any services from the IRH, let alone the extraction of intensive care beds.
The Scottish Government’s failure to understand that anxiety or to intervene and set the health board on a different path is increasingly met with frustration and distrust. The specific decisions to relocate ICU beds have been taken without any meaningful consultation at all with the local community. A worker at the hospital told me that staff are not even clear about what the deciding factor was in deciding to reduce ICU services. They also want to know what the contingency plans are for the emergency department, given the increased pressures from the lack of ICU services.
As has been said, the public have made their feelings known. More than 11,000 people have signed a petition that calls for the ICU in Inverclyde to be safeguarded.
The health board’s communications—even with senior councillors and the integration joint board in Inverclyde—have been appalling. The leader of Inverclyde Council, Stephen McCabe, could not have been clearer when he said:
“The board say they are committed to the IRH, but the bottom line is people no longer believe them.”
There is a real sense of betrayal in Inverclyde. It was not all that long ago that the Scottish Government promised to keep health local. It said that there would be a presumption against centralisation. Prior to the previous election, the First Minister came to the west and took to the front page of the Greenock Telegraph to promise that there were
“no plans to centralise services out of Inverclyde”.
Only a few weeks ago, the Cabinet Secretary for Health and Sport gave an assurance that the Scottish Government was totally committed to the IRH. However, services are under continued threat and, under freedom of information provisions, I have obtained information that shows that the total repairs backlog cost at the IRH now stands at an eye-watering £100 million and counting. I say to the Scottish Government that that is a strange way of showing that it is totally committed to a hospital.
The people of Inverclyde are faced with constant threats of cuts and closures, the removal of ICU beds without consultation and a repairs backlog that keeps getting worse. Surely even Government ministers in Edinburgh can understand why they feel forgotten and left behind.
I pay tribute to the NHS staff, who have gone above and beyond throughout the Covid crisis. It is important that people whom we depend on to care for us have a safe modern working environment and certainty about the future of the services that they provide. It does not matter whether they work in a big city hospital or in a hospital such as the IRH, in the west: every part of the country should be getting a fair deal, and a fair deal for West Scotland means investment in our hospitals and a complete rethink of the centralisation agenda. If the Scottish Government and health boards really are committed to hospitals such as the IRH, they should prove it by investing in the IRH and keeping health services local.
I call Clare Haughey to respond to the debate. Minister, you have around seven minutes.
Minister, we cannot hear you. Please hold on until broadcasting sorts you out.
Mr Greene seemed to be desperate to say something a moment ago. Mr Greene, you can have a minute while we sort this out.
You are very kind, Presiding Officer. It is an unusual precedent to set, and I hope that nobody follows it. Given the nature of the new virtual proceedings, it is difficult to intervene on a Government minister during their formal response, and we do not have the opportunity to sum up.
I want to stress to the minister that I will be listening carefully, with respectful intent, to what she says. We have posed specific questions and raised specific concerns, and I hope that they are addressed. If our questions are not answered during the debate today, members will be writing to her for more information.
I should say that I am not setting a precedent and that it really is for the minister to respond to such points.
Minister, we still cannot hear you. Would anyone like to jump in for a wee minute?
We will try again. Will it be third time lucky? No—but you have a very nice living room, minister.
Emma Harper would like to make a little contribution. This is not setting a precedent.18:26
I have listened to the debate with great interest because, in Dumfries and Galloway, we also have issues with care being moved to other centres. I have a question to ask the health secretary tomorrow about cancer patients going to Edinburgh and bypassing the Beatson, in Glasgow, which adds two hours to their journey. That is not really optimal. I am concerned about how we are going to look at issues such as staffing, which is a concern, and about the fact that we do not have enough ICU spaces for the level 3 care that is required. I will be happy to hear the minister’s responses to those points.
I would also be happy to hear the minister. We will go to Maurice Corry.
I have been very involved with the Vale of Leven hospital in Alexandria. One of the lessons that we have learned is to keep up the pressure in any campaign. It is therefore important for the residents of Inverclyde to keep this thing going and eventually we will see progress. It is important that services are delivered in our localities in the best interests of the residents, and that care is delivered to people near their families.
In addition to the £100 million repairs backlog at the IRH, there is a £76 million backlog at the Royal Alexandra hospital in Paisley, a £15 million repairs backlog at the Vale of Leven hospital in Dumbarton and a £30 million backlog at Crosshouse hospital in Ayrshire. All those hospitals serve West Scotland and it is only right that we have a fair deal for them. We need significant investment, not just in new big-city hospitals but in the hospitals that serve the communities in the west of Scotland.
I want to say two things. First, if I had known this was going to happen, I would have been armed with all the figures for Hairmyres hospital in East Kilbride.
Secondly, it is of course impossible—and it could not be expected—for the minister to respond to all those additional points.
We have still not managed to get Clare Haughey back online so I suggest that we suspend for a couple of minutes to see whether information technology colleagues can get her.18:29 Meeting suspended.
18:31 On resuming—
I invite Clare Haughey to respond to the members’ business debate on the ICU at Inverclyde royal hospital.18:32
Thank you, and I apologise for the technical difficulties.
I welcome the opportunity to respond on behalf of the Government to this members’ business debate. I start by making completely clear that, contrary to what is stated in Mr Greene’s motion, the two ICU beds at Inverclyde royal hospital remain open, and there are no plans to close them. The chief executive of NHS Greater Glasgow and Clyde has given the Cabinet Secretary for Health and Sport an absolute assurance about that.
I am sure that all members agree that the quality of care and patient safety must be of paramount importance, and those principles underpin what is happening in Inverclyde. The health board is formalising the clinical pathway that ensures that the most seriously unwell local patients can access the specialist services and support that they need. That is referred to as level 3 critical care, such as the provision of support for multiple organ failure, and involves the transfer of a small number of such patients to Glasgow. During the Covid-19 pandemic, that has already been happening on an ad hoc basis, with a small number of local patients having been transferred to the Queen Elizabeth university hospital under the pathway from March this year. Nonetheless, the board has been clear that the two ICU beds at the IRH will remain open. Patients will continue to be assessed locally, and will not bypass the hospital. Those patients who require level 3 care will be stabilised and will, if necessary, receive invasive ventilation before being transferred. As such, critical care services at the IRH—comprising the ICU, high dependency and coronary care units—will continue to stabilise or treat local patients with a range of complications, such as diabetes, sepsis, pneumonia, exacerbations of asthma, heart attacks, and other cardiac conditions.
The changes in the clinical pathway reflect the best evidence about the quality of care and outcomes. For example, we have learned that around 30 per cent of Covid-19 patients who require ventilation also require renal support. That support has not been available to ICU patients at the IRH for a number of years; therefore, patients who require such highly specialised care will be transferred to Glasgow, following admission and stabilisation at the IRH. Contrary to the terms of the motion, the change is about ensuring that local patients who are most acutely ill, including as a result of Covid-19, can receive the best treatment and care.
However, that does not mean that all critically ill Covid-19 patients from Inverclyde are being transferred. We have learned from the initial wave of Covid-19 that many patients benefit from non-invasive ventilation in a high dependency unit setting. As such, NHS Greater Glasgow and Clyde has increased capacity to offer that on the IRH site, and has made new appointments in respiratory medicine to support its delivery. The board anticipates that that should reduce the number of patients who ultimately require transfer for specialist support.
The health board has been clear that the IRH critical care team will continue to provide treatment for local patients, including those who are admitted to the two ICU beds. That includes those who do not require to be transferred and those for whom transfer would not be clinically appropriate. For patients who are transferred to Glasgow for specialist treatment, once they improve and no longer need the level 3 support, they will be assessed for transfer back to the IRH for their continued recovery and rehabilitation.
It is important to appreciate the change in context. The IRH critical care service currently admits approximately 1,450 patients per year. The health board estimates that the number of most unwell local patients that it will need to stabilise and transfer under the pathway is approximately 100, which equates to less than 7 per cent of total critical care admissions each year. Therefore, the overwhelming majority of local people who require critical care will continue to be treated at the IRH, while the most unwell people will receive the specialist care that they need in Glasgow.
NHS Greater Glasgow and Clyde has further assured the Cabinet Secretary for Health and Sport that local staffing and all other IRH services, including surgery and the accident and emergency department, will be unaffected. It should be noted and respected that this change, predicated as it is on maintaining the quality and safety of patient care, has the full backing of local clinicians.
That said, I agree that this small but important change to the patient pathway should have been better communicated by the NHS board. That would clearly have helped to allay the level of local concern that was expressed in early October. Members can be assured that the issue has been raised with the board and that it accepts the criticism. I know that local elected representatives were fully briefed on the issue by NHS Greater Glasgow and Clyde on 8 October, and that the board issued a media release the same day to further clarify the position.
None of that should be news to Mr Greene, as the health secretary wrote to him on 30 October setting out the same detail that I have provided today.
I reiterate the Government’s commitment to ensuring that, wherever possible and appropriate, health boards and their planning partners fulfil their obligations to meaningfully engage with local communities about any proposed changes to their services. I am clear that the change that we are discussing is being informed by the emerging clinical evidence about how best to treat the most critically ill patients, not least those with Covid-19.
As a result of the pandemic, NHS boards are currently operating under a state of emergency that will run until at least the end of next March. This is not business as usual. For obvious reasons, operational changes that are required to ensure that patients are safely and effectively treated during this time cannot be subject to the levels of public engagement and formal consultation that are ordinarily required. That said, members can be assured that, when the current state of emergency ends, any proposals for permanent changes of services would have to be considered in the normal way, which includes the process surrounding major service change and ministerial approval.
I assure local people that the IRH will continue to play a key role in the delivery of their healthcare services. For the avoidance of any doubt, both the Scottish Government and NHS Greater Glasgow and Clyde have been consistently clear about our commitment to the continued provision of comprehensive hospital, community and primary care services across Inverclyde, including those provided at the IRH.Meeting closed at 18:39.