SAFEGUARDING CHILDREN THROUGH THE COMMISSIONING OF SERVICES POLICY Page 1 of 21 Policy Owner Policy Author Directorate Ratifying Committee Date of Approval Date of Review Deputy Directors of Nursing & Quality Deborah Brice Nursing & Quality Corporate Policy Sub Committee March 2013 07.02.2013 Document History Version 1 2 Final Update/Review for CCG Author Deborah Brice Deborah Brice Deborah Brice Deborah Brice Page 2 of 21 Date 15.06.10 20.07.10 16.08.10 07.02.13 Contents Section No. Section Name Page No. Executive Summary 4 1. Introduction 5 2. Terms / Acronyms Used 5 3. Background 6 4. National Policy 6 5. Key Guidance and Legislation 7 6. The Children Act 2004 8 7. NHS Standards 9 8. Local Arrangements 10 9. Responsibilities of Clinical commissioning Group’s 10 10. Contractual Service Agreement for Safeguarding Children 12 11. Special Requirements for Specific NHS Organisations 16 12. Assurance of Quality of Service Provision for Safeguarding Children 17 13. References 17 14. Related Policies and Documents 17 Appendix 1 Equality Impact Assessment Stage 1 Screening 19 Appendix 2 Privacy Impact Assessment Stage 1 Screening 21 Page 3 of 21 Executive Summary All NHS bodies have a statutory duty to make arrangements to Safeguard and promote the welfare of children under Section 11 Children Act 2004. Following the passage of the Health and Social Care Bill statutory responsibility transferred from Primary Care Trust’s and Strategic Health Authorities to Clinical Commissioning Groups and the NHS commissioning Board. The Statutory responsibilities for NHS providers Safeguarding Children remains unchanged1. This policy sets out a framework for the statutory responsibilities of safeguarding children requirements under Section 11 of the Children Act 2004 for East North and Hertfordshire Valleys Clinical Commissioning Groups. It describes the Contractual Service Agreement for Safeguarding Children including specialist requirements for specific NHS organisations and independent Contractors. It outlines the process for Assurance of Quality of Service Provision for Safeguarding Children in all provider and commissioned services. The policy sets safeguarding children in the context of National Guidance and multi-agency partnership working within Hertfordshire 1 A Child –centred system: responding to the Munro Review of Child Protection (relates to recommendation 8) DFE & DoH July 2011 Page 4 of 21 1. Introduction 1.1 East & North Herts CCG is committed to being an organisation within which diversity, equality and human rights are valued. We will not discriminate either directly or indirectly and will not tolerate harassment or victimisation in relation to gender, marital status (including civil partnership), gender reassignment, disability, race, age, sexual orientation, religion or belief, trade union membership, status as a fixed-term or part-time worker, socio - economic status and pregnancy or maternity. 1.2 East & North Herts CCG works to a framework for handling personal information in a confidential and secure manner to meet ethical and quality standards. This enables National Health Service organisations in England and individuals working within them to ensure personal information is dealt with legally, securely, effectively and efficiently to deliver the best possible care to patients and clients. 1.3 East & North Herts CCG via the Information Governance Toolkit, provides the means by which the NHS and CCG can assess our compliance with current legislation, Government and National guidance. 1.4 Information Governance covers: Data Protection & IT Security (including smart cards), Human Rights Act, Caldecott Principles, Common Law Duty of Confidentiality, Freedom of Information Regulations and Information Quality Assurance 2. Terms / Acronyms Used CAF = Common Assessment Framework Children’s NSF = National Service Framework for Children, Young People and Maternity Services DFE = Department for Education HSCB = Hertfordshire Safeguarding Children’s Board IMR = Individual Management Reviews ISA = Independent Safeguarding Authority LSCB = Local Safeguarding Children’s Board NHS = National Health Service CQC=Care Quality Commission PCT = Primary Care Trust Page 5 of 21 CCG=Clinical Commissioning Group RCPCH = Royal College of Paediatrics and Child Health SCR = Serious Case Review SI = Serious Incident 3. Background 3.1 Clinical Commissioning Groups should ensure that all providers from whom they commission services have comprehensive and effective policies and procedures to safeguard children.’ 3.2 Clinical commissioning Group’s are expected to ensure that safeguarding children are integral to clinical governance and audit arrangements. Service specifications should include clear service standards for safeguarding children and assurance should be sought for compliance. 3.3 In relation to primary care providers Clinical Commissioning groups should work in consultation with the Local Area Teams who will be responsible from April 2013 for ensuring that all independent contactors including GP practices and staff have robust systems and practices in place to ensure they fulfil their role in safeguarding children. Working Together to Safeguard Children 2010 All NHS Trusts are required to register with the Care Quality Commission for the services they provide. As part of this registration each Trust must declare its position with regard to compliance with the Health and Social Care Act (Regulated Activities) regulation 2008, and the Care Quality Commission (registration) regulations 2009. Safeguarding is covered by regulation 11 and by outcome 7 in the associated guidance. The Care Quality Commission may seek evidence and assurance that regulations and guidance have been complied with. All GP practices and other primary medical services are required to be registered with the Care Quality Commission by April 2013. 4. National Policy 4.1 Following the death of Victoria Climbie in February 2000 and the subsequent Laming Review 2009 there has been extensive national published guidance and legislation to assist practitioners in working together to safeguard and promote the welfare of children. The inquiry report into Victoria’s death informed the Green Paper (Every Child Matters) which sets out a vision of the outcomes to be achieved for all children to; Page 6 of 21 • Be Healthy • Stay Safe • Enjoy & Achieve • Make a Positive Contribution • Achieve Economic Wellbeing 4.2 These outcomes were encompassed within legislation; the Children Act 2004 and the Health and Social Care Act 2012 which included the plans for integrated delivery of services around the needs of children through the creation of the Health and Wellbeing Boards, the requirement for Local Authorities to set up Local Safeguarding Children’s Boards (LSCBs) and a new duty on agencies to make arrangements to safeguard and promote the welfare of children. 4.3 To comply with National Safeguarding Children requirements, East & North Herts Clinical Commissioning Group has a duty to ensure that safeguarding is reflected within all partnership agreements and that NHS standard contracts require providers to comply with local Commissioners Policies. 4.4 East & North Herts Clinical Commissioning Group fully recognise their responsibilities in protecting and safeguarding the welfare of children. We acknowledge responsibility for taking reasonable steps to promote safe practice, protect children from harm, abuse or exploitation and to work with providers to continually improve service quality. 5. Key Guidance and Legislation 5.1 The key guidance and legislation for the Clinical Commissioning Group’s regarding the discharge of safeguarding children responsibilities is contained within; • The Children Act 1989 • Letter from Jacqui Smith MP to PCT’s ; Child protection responsibilities of Primary Care Trusts; January 2002 • The Victoria Climbié Inquiry Report by Lord Laming; 2003 • Lord Laming Progress Report 2009 • Munro review DFE 2011 • Every Child Matters Green Paper 2003 • Every Child Matters ‘Change for Children’ 2004 Page 7 of 21 • National Service Framework for Children, Young People and Maternity Services 2004 • The Children Act 2004 • Health and Social Care Act 2012 • Care Quality Commission (CQC) Essential standards of Quality and Safety 2010 • Statutory guidance on making arrangements to safeguard and promote the welfare of children under s11 of the Children Act 2004 • Arrangements to secure children’s and adult safeguarding in future NHS The New Accountability and Assurance Framework - interim advice 2012 • Working Together to Safeguard Children 2010 6. Children Act 2004 6.1 Section 11 of the Children Act 2004 places a duty on key persons and bodies to make arrangements to ensure that in discharging their functions they have regard to the need to safeguard and promote the welfare of children. The NHS bodies covered by Section 11 are Strategic Health Authorities, Designated Special Health Authorities, Primary Care Trusts, NHS Trusts and NHS Foundation Trusts. 6.2 The Department for Children, Schools and Families (DCSF) have published statutory guidance on making arrangements to safeguard and promote the welfare of children under s11 of the Children Act 2004. This has been updated in 2010 to reflect Working Together to Safeguard Children 2010. 6.3 Part 1 covers the general arrangements to safeguard and promote the welfare of children and these are common to most of the agencies to which the duty applies. 6.4 The key features at an organisational or strategic level are having: • senior management commitment to the importance of safeguarding and promoting children’s welfare • a clear statement of the agency’s responsibilities towards children available for all staff • a clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children Page 8 of 21 • service development that takes account of the need to safeguard and promote welfare and is informed where appropriate by the views of children and families • staff training on safeguarding of children for all staff working with or (depending on the agency’s primary function) in contact with children and families • safe recruitment procedures in place • effective inter-agency working to safeguard and promote the welfare of children • effective information sharing 6.5 Part 2 of the guidance gives the arrangements to safeguard and promote children’s welfare in different agencies. Chapter 5 relates to the NHS. 6.6 Section 11 of the Children Act sets out clearly that Clinical Commissioning Group’s and any services provided by them or by others on their behalf should be undertaken with due regard to their new legal obligations. All services, therefore, that are contracted by the CCG, whether or not they form part of the NHS, must abide by the legislation. 7. NHS Standards 7.1 The Care Quality Commission essential Standards of Quality and safety sets out the guidance requirements about compliance These essential standards of quality and safety consist of 28 regulations (and associated outcomes) that are set out in two pieces of legislation; The Health and Social Care Act 2008 (Regulated activity) regulations 2010 and the Care Quality Commission (registration) regulations 2009.For each regulation, there is an associated outcome 7.2 Regulation 11 Outcome 7: Safeguarding people who use services from abuse with the requiring that ‘people are safeguarded from abuse or risk of abuse and in their human rights are respected and upheld. 7.3 All the relevant NHS organisations are required to discharge their duty under the Children Act 2004 and meet the above standards. 7.4 Section 11 makes clear that the services provided by, and those contracted by Clinical Commissioning Group’s are required to abide by the same legal obligations. 7.5 These standards therefore apply to all services commissioned by East & North Herts CCG. Page 9 of 21 8. Local Arrangements 8.1 Hertfordshire Safeguarding Children’s Board: 8.2 The Hertfordshire Safeguarding Children’s Board (HSCB) established in 2006 in accordance with s11 of the Children Act has a membership drawn from public, private and voluntary organisations across Hertfordshire who have responsibilities for children and their families. There is an independent chair for the HSCB as required. 8.3 “The Local Safeguarding Children’s Board is the key statutory mechanism for agreeing how the relevant organisations in each local area will cooperate to safeguard and promote the welfare of children in that locality and for ensuring the effectiveness of what they do.” Working Together to Safeguard Children 20102 8.4 The HSCB have a number of sub-groups which report to the HSCB main board. These include: • Serious Case Review subgroup • Learning and Development • Policies and Procedures • Improving Outcomes Group • Child Death Overview Panel • Safer Staffing • Audit and Performance analysis • Local Child Protection Forums 8.5 The web address for the LSCB in Hertfordshire is: www.hertssafeguarding.org.uk 9. Responsibilities of Clinical Commissioning Groups 9.1 East & North Herts CCG should: • work with Local Authorities to commission and provide co-ordinated and, where possible, integrated services • identify a senior lead for children and young people to ensure their needs are at the forefront of local planning and service delivery 2 Working Together 2012 is currently awaiting launch. This new document will separate statutory requirements and guidance .The purpose of which is to promote localism. The expectation is that guidance and policy is set locally. Page 10 of 21 9.2 • ensure that health services and healthcare workers contribute to multiagency working • ensure they have in place a designated nurse and doctor who have an over arching responsibility across the CCG area, which includes all providers • ensure co-relate to Local Area Team with regard to Primary Care Services under their commission • ensure that funding is available to enable the Named and Designated professionals to fulfil their roles and responsibilities effectively • ensure funding is available to contribute to the HSCB’s budget, as agreed in the business plan • include clear service standards for safeguarding and promoting children’s welfare in all commissioning arrangements • be accountable for their own safeguarding children’s processes and those undertaken by agencies with whom they have commissioning arrangements • ensure that clinical governance arrangements are in place to assure quality of services provided and contracted by the CCG • co-ordinate the health component of serious case reviews and complete the Health overview report • ensure that all health agencies with whom they have commissioning arrangements are linked into the HSCB and that there is representation from the agency and at an appropriate level of seniority • ensure the East & North Herts CCG is represented on HSCB subgroups • provide the strategic health lead in interagency planning within the CCG area Clinical Commissioning Groups should also ensure that: • all Primary Care Teams have appropriate access to paediatricians trained in assessing young people who may be experiencing abuse or neglect • local arrangements, including having the necessary premises, equipment and appropriately trained staff are in place for undertaking forensic medical examinations Page 11 of 21 9.3 The Accountable Officer of East & North Herts CCG has the responsibility of ensuring that the health contribution to safeguarding and promoting the welfare of children is discharged effectively. 9.4 The Area Team of the NHS Commissioning Board is responsible for performance managing Primary Care and Dental Services 9.5 The NHS Commissioning Board is responsible for performance managing CCGs. 10. Contractual Service Agreement for Safeguarding Children 10.1 Responsibility for Safeguarding Children 10.2 The Commissioning Framework for Health and Wellbeing 2006, places the focus on reorientation towards promoting health and wellbeing, ‘investing now to reduce future ill health costs’. 10.3 Abuse of a child can have a serious impact on all aspects of the child’s health, development and well being which can last through adulthood. The high cost of abuse and neglect both to individuals and to society underpins the duty on all agencies to be proactive in safeguarding children. 10.4 The Heath and Wellbeing Boards, statutorily established from 2013, replace the former Children’s Trusts. 10.5 Service Standards 10.6 In line with the Commissioning Framework for Health and Wellbeing and in accordance CQC requirements, commissioners should include clear service standards for safeguarding and promoting children’s welfare in all commissioning arrangements. These are set out below. 10.7 The following standards should be included within contractual agreements and be adhered to by all organisations providing services that have been commissioned by the East & North Herts CCG. This includes services solely or primarily for adults as they may be parents or carers, cared for by children or young people or represent a danger to children. 10.8 Professional organisations should create and maintain a culture and ethos that reflects the importance of safeguarding and promoting the welfare of children. Children and young people should be cared for within child friendly environments by staff who have specific expertise. 10.9 Accountability 10.10 There should be; Page 12 of 21 • a lead senior manager who is informed about, and who takes responsibility for the actions of their staff in safeguarding and promoting the welfare of children • a clear line of accountability through the organisation which includes all staff 10.11 Policy 10.12 Each organisation should have a comprehensive safeguarding policy which is in line with national and HSCB guidance and which takes account of guidance from any relevant professional body. Inherent within any policy should be that children without exception have the right to protection from abuse regardless of gender, ethnicity, disability, sexuality or beliefs. This policy should be easily accessible by staff at all levels and subject to periodic review and updating. 10.13 Staff Training and Continued Professional Development 10.14 Staff should be trained and competent to be alert to potential indicators of abuse and neglect in children, know how to act on their concerns and fulfil their responsibilities in line with LSCB procedures. To achieve this standard all organisations should; • have a training policy covering all staff detailing, required skills and competencies commensurate with their role and responsibilities • a training strategy should be in place for this policy to be achieved see appendix 1. 10.15 This should be in accordance with; • the Common Core of Skills and Knowledge for the Children’s Workforce 2005 • suggested Learning Outcomes for Target Groups in Training and Development ; interagency work to safeguard and promote the welfare of children DCSF April 2006 • the intercollegiate document, Child Protection Roles and Competencies for Health Staff 2010 • hold a database detailing the uptake of all staff training so employers can be alerted to unmet training needs and training provision can be planned. • have in place a training programme that is appropriate to the role of staff and ensure that staff are released to attend the relevant training • ensure training needs analysis is linked to appraisal Page 13 of 21 • enable and ensure provision of staff to have update training every 3 years as a minimum • ensure staff are aware of any new guidance or legislation and any recommendations from Local and National Serious Case Reviews and Internal Management Reviews and Partnership case reviews 10.16 Safe Recruitment and Vetting Procedures 10.17 There should be a policy in place for safe recruitment practices for staff. Where a criminal record review is mandatory this must be undertaken routinely and updated as required. 10.18 Employers must comply with new Disclosure and barring service2012. It merges the criminal record bureau and the Independent safeguarding authority. The Independent Safety Authority (ISA) decides who is unsuitable to work or volunteer with vulnerable groups including children, drawing information from various agencies, government departments and the Criminal Records Bureau. 10.19 Managing Allegations Against Staff 10.20 Organisations should; • have in place procedures for responding when allegations are made against people who work with children and comply with LSCB policies and procedures, and guidance contained within appendix 5 of Working Together to Safeguard Children 2010 • have a named senior officer who has overall responsibility for; - ensuring the organisation operates procedures for dealing with allegations - resolves any inter-agency issues - liaises with the LSCB - seek advice from the Local Authority Designated Officer (LADO) who; - provides advice and liaison - ensures cases are dealt with as quickly as possible 10.21 Inter-agency Working 10.22 Staff should be aware of and where appropriate trained to use the Common Assessment Framework (CAF), 2006. Staff should work together with other agencies in accordance with the HSCB policies and Page 14 of 21 procedures for the area within that service is provided. All services should have in place, policies and procedures that are in accordance with national legislation and guidance including Working Together to Safeguard Children 2010 and the Common Assessment Framework. 10.23 If staff have concerns that a child is or may be suffering significant harm, staff should follow published guidance; What to do if you’re worried a child is being abused; 2006. 10.24 Information Sharing 10.25 Organisations should have in place or have adopted local policies and procedures for sharing of information where there are concerns for the welfare of a child. Senior Managers should promote good practice in information sharing according to the published national guidance: Information Sharing; Guidance for Practitioners and Managers. DCSF 2008 10.26 Supervision 10.27 Organisations providing services should have a policy and arrangements in place to provide staff with supervision and support to; • enable them to manage stresses within their work • promote good practice and quality assure the services they provide • ensure that staff use effective systems to record their work • follow local multi-agency policy and procedures 10.28 The level of supervision provided should be in accordance with the degree and nature of contact that staff have with children, young people and families. 10.29 A confidential service should be provided for staff for emotional support when dealing with cases of child abuse. 10.30 Staff should be aware how to contact their own NHS Trusts, Named Professional(s) for safeguarding or, if working outside an NHS Trust, the CCG’s Named and Designated Safeguarding Professionals. 10.31 Vulnerable Children 10.32 Staff should be alert to the increased likelihood of harm being suffered by disabled children and those living in special circumstances, whose needs may not be recognised by staff employed in providing services. 10.33 Responses to Incidents and Complaints 10.34 There should be a policy with regard to incidents and complaints relating to any aspect of safeguarding children. This should include the Page 15 of 21 need to inform the Senior Management Lead for Safeguarding within the organisation. 10.35 Thresholds for raising a Serious Incident (SI) should be clear and if required advice should be sought from Named Professionals for Safeguarding. 10.36 Within the NHS Trust the Director responsible for safeguarding children, Named Nurse, Doctor or Professional for that Trust should be informed about any incident or complaint relating to child protection. In all cases the Designated Nurse should be informed. 10.37 Serious Case Reviews (SCRs) 10.38 SCRs are conducted in accordance with Chapter 8 of Working Together to Safeguard Children 2010 • when a child dies, including by suicide, or is seriously injured and abuse or neglect are known or suspected to be a factor in the death/injury • where the case raises concern about inter-agency working when a child has suffered significant harm 10.39 Named Safeguarding Professionals within NHS Trusts should be provided with additional time in which to conduct Individual Management Reviews (IMR), which form part of Multi-Agency Serious Case Reviews (SCRs). They will be supported by the Designated Health Professionals. IMRs should be conducted according to the HSCB and NHS Hertfordshire SCR Guidance 10.40 Child Death Reviews 10.41 LSCBs have a statutory duty to review all child deaths in accordance with Working Together to Safeguard Children 2010. 10.42 Organisations involved with the management of child deaths, must be familiar with the relevant policies and procedures for that local area and respond accordingly. 11. Special Requirements for Specific NHS Organisations 11.1 All NHS Trusts, excluding Ambulance Trusts, NHS Direct sites and NHS walk-in centres should designate a Named Doctor, Named Nurse and Named Midwife (where relevant, e.g. maternity services provided) for Safeguarding Children who provide advice and expertise for colleagues and other agencies and promotes good professional practice within the Trust. 11.2 Ambulance Trusts, NHS Direct sites and NHS walk-in centres should designate a Named Professional for Safeguarding Children. Page 16 of 21 12. Assurance of Quality of Service Provision for Safeguarding Children 12.1 Organisations should; 13. • be able to provide assurance that their safeguarding practice meets the Health and Social Care Act ‘essential standards of quality and safety’ CQC 2010 • be able to demonstrate that they are working towards meeting standard 5 of the Children’s NSF with full compliance being achieved by 2014 • be able to demonstrate that they have in place arrangements as described in paragraph 3.2 • undertake regular case audits with reference to the standard of record keeping, sharing information and multi-agency liaison • be able to demonstrate that they have acted on recommendations from local SCRs and National Inquiries. References See section 5: Key Guidance and Legislation, plus: Health and Social Care Act 2008 CQC essential standards of quality and safety 2010 The Commissioning Framework for Health and Wellbeing, 2006 The Common Core of Skills and Knowledge for the Children’s Workforce, 2005 Child Protection Roles and Competencies for Health Staff, 2010 Safeguarding Vulnerable Group Act, 2006 Common Assessment Framework (CAF), 2006 What to do if you’re worried a child is being abused, 2006 Information Sharing; Guidance for Practitioners and Managers. DCSF 2008 14. Related Polices and Documents HSCB Safeguarding Children Policy and Procedures 2010 East & North Herts CCG Allegations and Suspicions of Child Abuse against Staff Page 17 of 21 East & North Herts CCG Serious Incident Policy East & North Herts CCG SCR process Page 18 of 21 Appendix 1 – Equality Impact Assessment Stage 1 Screening 1. Policy Title: Safeguarding Children through the Commissioning of Services Policy Proposed Date of Completion: Existing March 2013 EIA Completion Details Names & Titles of staff involved in completing the EIA: Deborah Brice. Designated Nurse Safeguarding Children, Looked after Children and Care Leavers. Review Date: March 2014 2. Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public 3. Impact on Groups with Protected Characteristics Probable impact on group? Positive Adverse None High, Medium or Low Please explain your answers Age Being married or in a civil partnership Disability, inc. learning difficulties, physical disability, sensory impairment etc. Having just had a baby or being pregnant Race, ethnicity, nationality, language etc. Religion or belief Sex (inc. being a transsexual person) Sexual Orientation Other: No impact on any of the groups above. Please explain and provide evidence The NHS of the 21st century must be responsive to the needs of different patients and individuals within society, and challenge discrimination on the grounds of age, gender, ethnicity, religion, disability and sexuality. The NHS will treat patients as individuals, with respect for their dignity. Patients and citizens will have a greater say in the NHS, and the provision of services will be centred on patients' needs. ENHCCG does not discriminate on grounds of sex, age, sexual orientation, ethnicity, educational level, employment, disability, marital status or religion. 4. Which equality legislative Act applies to the policy? Page 19 of 21 Human Rights Act 1998 Equality Act 2010 Health & Safety Regulations Mental Health Act 1983 Mental Capacity Act 2005 5. How could the identified adverse effects be minimised or eradicated? 6. How is the effect of the policy on different Impact Groups going to be monitored? Page 20 of 21 Appendix 2 – Privacy Impact Assessment Stage 1 Screening 1. Policy Title: Safeguarding Children through the Commissioning of Services Policy Proposed Date of Completion: March 2013 Existing PIA Completion Details Names & Titles of staff involved in completing the PIA: Deborah Brice. Designated Nurse Safeguarding Children, Looked after Children and Care Leavers. Review Date: March 2014 2. Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public Yes Technology Does the policy apply new or additional information technologies that have the potential for privacy intrusion? (Example: use of smartcards) Identity By adhering to the policy content does it involve the use or re-use of existing identifiers, intrusive identification or authentication? (Example: digital signatures, presentation of identity documents, biometrics etc.) By adhering to the policy content is there a risk of denying anonymity and de-identification or converting previously anonymous or de-identified data into identifiable formats? Multiple Organisations Does the policy affect multiple organisations? (Example: joint working initiatives with other government departments or private sector organisations) Data By adhering to the policy is there likelihood that the data handling processes are changed? (Example: this would include a more intensive processing of data than that which was originally expected) If Yes to any of the above have the risks been assessed, can they be evidenced, has the policy content and its implications been understood and approved by the department? No Please explain your answers Safeguarding children requires a multi-agency response with all statutory partner agencies. This policy will impact positively on the safeguarding children agenda and partner agencies. It has been endorsed by the Hertfordshire Safeguarding Children Board Policy and procedure sub-group. Page 21 of 21