Good afternoon. Welcome back from lunch. For the next hour, we want to talk about ethics and integrity and data use and management. And may say, well, this seems a little far out there. But I think it's very important to look at a very brief history of ethics in research and in data management, both from research and clinical perspective. Look at the pertinent ethical principles that we try to apply in any use of data. And discuss the idea of data integrity and ethics within our data management practices. And then look at the applications for data management personnel in the ethical use of data. So we'll start with some definitions. Look at those ethical principles. Briefly discuss some guidelines and regulations that you should be aware of. Discuss the idea or concept of data integrity and what it entails. And then look at applications for our work with data. From the Webster's new Riverside Dictionary, integrity is defined as strict adherence to a standard value or conduct. And also refers to personal honesty and independence. And the one that we often think of, completeness, unity, or number four, soundness, certainly applies to data integrity. Ethic or ethics. And ethic is a principle of right or good conduct or a system of moral values. When we use it in plural or ethics, the branch of ethics is a branch of philosophy dealing with the rules of right conduct. And those apply to any branch of work. Every branch of work has certain codes or certain principles of ethics that should be applied. When we talk about data and human subjects in particular, we think of three main ethical principles, the first one being beneficence, which basically means do no harm. But in addition to not doing harm, it also entails trying to get the most benefit for our patients or for our research participants. So we try to minimize harm and maximize benefits whenever possible. So that one's easy to remember. Beneficence think benefits and not having negative benefits. Respective persons, which is also known as autonomy, comes from the idea that each person has the right to choose for themselves. And so this involves the concept of voluntary informed consent, not just informed consent, but voluntary informed consent, so that that person makes a choice about how their data are used or what types of research or activities they're involved in. And this one also looks at vulnerable subjects. People who cannot necessarily make decisions easily for themselves must be protected in some way under this principle. And so this is where we have protections for children, protections for prisoners, protections for the mentally ill. We include pregnant women and fetuses in this group, students, because they sometimes don't feel empowered to say yes or no. And I think I'm forgetting one group. Did I mention pregnant women? Yeah, OK. So I've gotten the majority there. Generally, you'll see this very much with pediatric populations who cannot consent for themselves and are reliant upon a guardian, often to consent for them. And so they must be protected to be sure that their rights are properly represented. Finally, the principle of justice. You could think of basically as fairness, treating people in an equal and fair manner. And equity, which is not exactly the same as equality, but equity, again, means fairness. And that means fairness in treating all patients the same or all research participants the same. Fairness in making sure that one group is not carrying all the risk while another group is getting all the benefits that applies to research. And fairness in dealing with the individual as far as what their rights are, what the benefits are that are coming to them. And then also fairness between institutions so that one institution is not getting a huge benefit while the other institution is doing all the work. So it applies on multiple levels when we talk about clinical practice or research. Clinical data versus research data are the ethics any different? Any opinions? Are the ethics different or are they the same? I hear multiple people saying the same. Yes, ethics are ethics, okay? The principles are the same. How they are applied may be a little bit different. The regulations or guidelines that govern them may be a little bit different, but the ethical principles that we just discussed are really the same whether you're talking about clinical data or research data. And I can't stress that enough. Don't think that ethics apply to research, but in clinical practice we don't have to think about or do those things because in essence, ethical principles are ethical principles and we should use them in all parts of daily life. And this has applications for us in privacy and confidentiality of records, informed consent versus implied consent when using patient or participant data. The idea of data integrity or data quality which may not be dependent on the patient, more dependent on us but still very, very important in both clinical data and research data. And then data security and storage which are also really part of data integrity but we also often talk about them a little bit separately. So for research we have a large number of ethical guidelines that we use but I would like to bring to the group that we should also be thinking of these guidelines and practices when we're using clinical data as well. One of the best known is the Declaration of Helsinki and I did include that in your reading packet. I don't expect that everybody will have read it but it's something that at some point you should read and understand. It's not hard to read and there are quite a number of things in that declaration that do apply to data and use of data. So any data manager that's going to work with clinical data or research data needs to be aware of these principles. And this is an ethical standard that is used by international committee of medical journal editors. So anybody working on a publication needs to have read this at some point to understand what the ethical principles are that govern medical research and are commonly accepted. The Council for International Organizations of Medical Sciences, which we often call KAYOMS or SIOMS has also developed guidelines in collaboration with WHO and many international review organizations or IRBs often use the KAYOMS guidelines as well as the Declaration of Helsinki. I don't believe that's in your instructional packet but be aware that there are different guidelines although most of them are quite similar in content overall. Within the US, we often refer to the Belmont report which also gives guidelines for the review and use of research data. And then Kenya itself has national guidelines put out by the NCST, the National Council for Science and Technology and within Kenya, we need to be aware of what those guidelines are. I don't think I supply that for the reading packet but I will get a copy and supply to ADA because I think it's important for all of you here within Kenya to definitely have a copy of those guidelines and to understand what they are. They do apply specifically to research but again, if you look at them closely, they have a lot of broad applications to clinical practice. Within the United States, we have a number of regulations so they're not just guidelines, these are actual laws that govern how research is done and how under some of them how data can be used and you may say what do US regulations have to do with us in Kenya or what do US regulations have to do with any international research or international clinical data management? Well, the fact is at least in this setting we get a lot of money from the United States government to conduct research. In addition, while it doesn't fall under these code of federal regulations, most of our clinical data here is covered by US government funds through PEPFAR and so we need to be aware and understand when and how US regulations do apply to our work even though we work in Kenya. For people working in other parts of the world, if they're getting US government money, some of these regulations may apply to them. These include what we call 45 CFR 46. This is a specific federal regulation that governs the ethical conduct of human subjects research and we'll discuss that a little bit more. For any trials involving drugs, the FDA has specific guidelines and rules. So if it's research involving drugs or sometimes research involving devices, then the FDA regulations also may apply. And then for projects which are funded by NIH, NIH may have its own guidelines on the use of data and how data are used. And why do we have to pay attention to them? Because whoever's paying for it has the right to make rules about it. And so the funder can often have a say in the principles guiding our work. And finally, there's something called HIPAA which we will discuss again. This is a US law designed more for clinical records but also for research that guards the privacy of records and something that we also need to be aware of depending on our setups but here we need to know about it. So the US federal code of regulations 45, part 46 covers human subjects protections. It also covers the requirements for the operation and review by IRBs, institutional review boards that are supposed to review all research and the protection of vulnerable subjects which we discussed about under the principle of autonomy. A human subject under this law is defined as a living individual about whom an investigator, professional or student who is conducting research obtains data through an intervention or interaction with that subject or identifiable private information. Now while this applies to research, you can see it's also very applicable to our clinical setting because by that definition every patient or research participant that we come in contact with is a human subject. Privacy and confidentiality rules, as I mentioned apply to both clinical and research data. This is a major concern for patients when it comes to electronic records and data. If you look through the readings I provided you when it comes to electronic data patients are very concerned about whether or not their data will be private. And in fact, within one of those articles patients sometimes do not go to places that have electronic medical records because they fear about the privacy and confidentiality of their data. And so knowing how we protect these things and being able to educate participants and patients about this is very important. As we know electronic records are growing and provide a lot of benefits to improving care. And privacy and confidentiality is a process that has to be safeguarded by every member of the team from the person taking down the information from the clinician or the healthcare worker all the way up through the data manager and data management group all the way to the medical records people who are storing and archiving data. At every step, privacy and confidentiality must be maintained. So in the United States, we have a very specific law called the Health Insurance Portability and Accountability Act of 1996, which we know as HIPAA. And it has issued regulations entitled Standards for Privacy of Individually Identifiable Health Information. For most covered entities who are covered by this law, compliance with the regulations has been required in the United States since 2003. Now some of you here will know that are we covered under HIPAA here in Kenya? Do we need to pay attention to HIPAA here in Kenya? I hear a couple of no's. Does everybody agree with that? HIPAA does not apply in Kenya if all the data is collected and analyzed in Kenya. But within our setting, we have a rather unusual situation and within many academic setting internationally, they will come up with the same situation because sometimes data managers in the United States working for another university manipulate or analyze these data, now that means that we are accountable to this regulation.  And so some of you will recall, we had a huge discussion about creating datasets for our research on whether or not we had to pay attention to this law. And the answer according to our IRAC and our IRB was yes you do because Indiana University is a covered entity. And if any data manager at IU is going to look at, personally identifiable information, we have to pay attention to HIPAA. So unfortunately the answer is yes, we have to pay attention to it, except in some cases where all data is only collected here and only analyzed here. In which case HIPAA does not apply. So this privacy rule in the CFR 45 establishes this category of health information which we call protected health information. And a covered entity may only use or disclose to others in certain situations these PHI. It usually requires that an individual should provide consent or an authorization before any of these types of information can be disclosed or used. And that need for authorization though can be waived by an IRB when they say that it's very minimal risk for loss of confidentiality or privacy. The types of PHI, and this is a subset, there are some states which will list up to 16 of these. But the most important subset includes things that could possibly lead to the identification of an individual if they were included in a data set. So name, that's pretty obvious, okay? That if you release somebody's name into a data set that could identify that individual that could be a loss of privacy or confidentiality. All elements of any date except for the year are considered PHI. A social security number and I would, for Kenya's purposes, that would be the national ID number, okay? Driver's license number. Any subdivision smaller than a state. That's a pretty tough one because most of our patients come from villages, okay? But that village or location, sublocation is considered PHI because it's smaller than 5,000 people or smaller than a state, okay? URLs or IP addresses for any individual. Vehicle numbers or license numbers can be traced back to an individual and phone numbers. These are some of the more commonly used PHI. So please take a look at that list because you might see it again. Just a hint. Although I hear all of your quizzes are open books so you know exactly where to go for that. So PHI only become personally PHI when it is received, created or received by a covered entity, okay? So when it's sitting in our database, it's not PHI. When you put it in a data set and send it to a data manager in the US to help create a data set who is working for a university or a health plan in the United States, now it's PHI because a covered entity is anyone working in a US health plan, US healthcare clearinghouse or US health providers that transmit electronic information. And so in some instances for us in Kenya, this now will apply if we are transmitting any data to one of these groups in the United States. So while I certainly don't expect people to understand everything about HIPAA, you should understand where to learn about it and when it does apply in the international setting because it is an important regulation. A researcher themselves is not a covered entity unless they're a provider within a covered entity.  So my research comes under this law even though I'm working in Kenya, okay? And because we collaborate with many different international schools, we're often going to be in this situation when we're using data in research. Research is governed by HIPAA if it is obtained from a covered entity that does not apply to us. And as I mentioned, the IRB may on occasion wave the HIPAA restrictions on use of PHI. Now we have gotten a waiver here at Moore University for the use of specific items within our data sets. That includes birth dates. That includes patient locations. That includes GPS data because we were able to argue successfully to the IRB in the US that it would be virtually impossible for any data manager in the US to identify a Kenyan patient based on those small pieces of information, okay? And so they were able to give us a waiver which makes our job here much easier but not all IRBs are going to make those waivers and so sometimes you may be in the situation where you're going to have to really manipulate data to make sure you're not using any of that personal health information. So how does this all translate into practice? We've talked about some guidelines. We've talked about some regulations. Why does that all matter? We've talked about some ethical principles. Well, electronic health information, whether it's used clinically or whether it's used for research has a lot of important applications that are applicable to ethics and also has some misuses which are very applicable to ethics, okay? So we know that electronic health information can improve quality and safety of medical care. That is beneficence, maximizing benefits, okay? That is beneficence. We know that electronic medical records can be key to sometimes showing accurate outcomes in research on health or health practices. That again is beneficence, okay? But that benefit is now extended to all of society and not just to the individual, right? If we analyze data from a lot of people and use that in public health practices or evidence-based medicine, that again is beneficence. We are maximizing the benefits of that information for use to improve care for many. Confidentiality though and privacy can be lost if we do not properly safeguard the security of our data. And so that would be a breach of autonomy, personal choice about the use of information. And that could be a breach of beneficence if it causes harm to an individual, okay? Information sometimes is or can be used without a patient's knowledge or consent. That certainly applies to a breach of autonomy or a breach of the idea of respect for persons, okay? We'll talk about that a little bit later on because there's often questions about who the data belongs to. Does it belong to the patient, the institution, to the research project? That is a question. So when can it or can it not be used without the patient's knowledge or consent or is that always required? But this definitely applies to the principle of respect of persons. And finally, depending on how we choose to design our databases or collect our data, we could end up excluding some very important populations. And in so doing, we may change the analysis we may change the way that outcomes are reported. And if we do that improperly, now we have breached justice. We have not paid attention, okay, to the correct design in a way that treats all populations fairly. Data integrity. Now I'm sure everybody working in data has heard a lot in all of your studies about data integrity. And if you go online and start looking for definitions of data integrity, you will find a lot of different definitions. And these are just four of about 10 that I found, okay? The assurance that data is accurate, correct, and valid. Accuracy and consistency of stored data indicated by an absence of any alteration in data between two updates of a data record and that it's imposed within a database at the design stage through standardized rules and procedures, okay? Also involves error checking and validation. Another definition states that it's the exact duplication of sent data at the receiving end. Doesn't say much about the collection end, okay? And then a final one, assurance that data are unchanged from creation to reception, okay? I actually like this one, this last one, because it covers all points from the person marking things down on a data collection form all the way through to the person storing that file or backing up that file or archiving that file. This one includes every step of the process. But you'll see the common thread throughout all of these is talking about accuracy and completeness of data, okay? And the idea that this is a process which starts with the first point of collecting data to the very final point of data storage. So think of data integrity as a process and it's a process that depends on collection, just accurate representation of the data. If a patient tells me something in the clinic, but I think, well, that's not right and I mark down something else, I have now compromised data integrity. I have not recorded accurately what the patient told me, okay? Data transfer, okay? Any time that data is transferred from one point to another, it should be done in a way that ensures that that record is complete and is transferred in its entirety and is received in its entirety without change. Also storage and security, preventing loss of data is just as important in data integrity as making sure the data are accurate at the time that they are received because losing data also compromises the data record. And so storage and security are very important. This involves sharing of data. How much do we share? Do we share? Who can see it, okay? And then the analysis of data, the proper representation of those data when we start discussing what they mean. These are all important in data integrity. So this fabrication and falsification is a very serious breach of data integrity. And this is an important challenge to data integrity in research. There have been very highly publicized places where data have been fabricated or falsified in some way in order to make a certain research project or a certain analysis look better. And that is a serious breach of ethical integrity. However, that is only one of the points as I showed you earlier in data integrity, the one that we hear much about. Human error also contributes to loss of data integrity. If I mark down that somebody's liver function test is a 40 and when the person entering the data marks down a 4.0 into the database, data integrity has been compromised. Is that a breach of ethics? I see one person shaking their head. How many people think that's a breach of ethics? How many people think that's just human error and should be expected? Good. It's human error, okay? We cannot, while this is a breach of data integrity, we would not consider that unethical behavior because human error is an accepted part of human practice, okay? We try to minimize those errors as much as possible to protect the integrity of our data. But we also recognize that human, unintentional human error will, that is not a breach of ethics. Whereas purposefully fabricating data or falsifying data is a terrible breach of ethics. And I hope nobody disagrees with that statement, okay? So sometimes there are things that can compromise data integrity that are not unethical, while there are other things that compromise data integrity that are terribly unethical. And so try to learn to balance those ideas in your mind that there is unethical behavior and is human error, okay? Which is an acceptable part of human practice, although we try to minimize it. There has been quite a bit of concern about research misconduct because as I mentioned, there have been some highly publicized cases where people have fabricated or falsified data to make the results look better, whether that's from clinical data or analysis from research data. And so the U.S. Department of Health and Human Services actually sponsored a conference in 1990 on data management specifically to summarize the ways in which conduct of research depends upon the responsible use of data and responsible data management. And out of that conference, they came out with a number of very important principles and guidelines. And one of the important thing is that responsible research begins with experimental design and protocol approval. Does that have anything to do with data? How many people here have been involved in writing a research protocol? No one's holding up their hand, but I know three people in here at least who have been. So yes, design of a protocol has a lot to do with data because every protocol should have a data management plan, a data sampling plan, a data analysis plan. Much of research design is about data. And so understanding that means that the ethics of data integrity begin with the design of the study, not just the conduct of study, but the whole design of a study. Studies should be designed that involve record keeping in a way that will ensure the accuracy and integrity of the data and an attempt to avoid or minimize bias whenever possible. The design guides the criteria for including or excluding data from the statistical analysis. And it should entail responsibility for collection, use, and sharing. Who is going to see that data? Who is going to analyze the data? And how is that data going to be used? I cannot stress this one enough, okay? And you will probably see that a couple more times. All right? Everybody in research, and I should expand that, say everyone who deals with data from a patient or research participant. So let's expand that to both clinical and research, okay? Everyone with a role in a project or a clinical care system has a responsibility to ensure the integrity of data, okay? That comes from the person collecting the data to the person picking up the paper forms and carrying them to the data entry operator, to the data entry person and the data manager, to the person filing those forms, to the person archiving those forms and storing those forms. Everyone has a role and a responsibility to make sure those data are maintained and those data are kept confidential. The ultimate responsibility within research does sit with the principal investigator, but the fact is that anybody who helps plan the study, helps collect data, helps analyze or interpret the data or publishes is part of the publishing of the data or maintains records, is responsible for helping to maintain data integrity. It is a team effort, it is not something the data manager alone has to grapple with, but something that we often rely on the data manager to educate the rest of the team about. And so you need to be as a data manager an expert in data integrity and know how everyone's behavior affects it and how you can help educate them to protect data integrity whenever possible. Data collection can be very repetitious, very time consuming and quite boring, okay? And there's often a temptation to underestimate how important it is. We've seen this on our own forums. If people consistently miss fields or they don't understand what a field means and are often marking down the wrong types of information or incorrect information, this severely compromises data quality and data integrity. So it is a very important part of the process. So those who are responsible for collecting data, in our case that is the clinicians, all of the care workers within the other programs within our clinical setting, everybody must be adequately trained and motivated to collect data in the most conscientious way possible and the most obsessive compulsive way possible, okay? And we are planning to do here quite a number of trainings throughout the care system to try and improve data quality, to educate our clinicians and our workers within the different clinical settings about the importance of data quality and how data collection plays a role in that. We should always employ methods that limit or eliminate the effect of bias whenever possible and we should always keep records of what was done by whom and when. So this is very important in the design of a database. For those of you who work with the AMRS, we want to know who entered the data, who collected the data, who viewed or changed data from a data management perspective because keeping records of what was done by whom and when is very important when we start looking at data quality and ensuring data integrity. And finally, analysis and selection of data. Oh, good. We'll have a bit of time for questions. Finally, analysis and selection of data. Data does not stop. Data management and ethics of data management do not stop with the creation of a data set but it also goes as far as reporting, okay? How data is used in analysis is also governed by ethical principles. We do not change analyses to give the outcome we want. We report all the data, we analyze all the data and we report what we find in an honest fashion. However, because we often can't report everything that's done, we often have to choose which ones we think are more important and that's where judgments come in but we need to try and make decisions which are not just favorable to the outcomes we were hoping for but decisions that make sense with regard to representing the data accurately. So we have to critically evaluate the reasons that we included or excluded data from a data set. We have to talk about those. We have to tell people what we did or did not include and why, okay? And we have to have a lot of regard for how that might bias the outcomes when we're doing analysis. And we have to clearly document at each step of the process what we did, why were these things done so that if somebody wants to come and do that analysis again they could replicate it. And if we used an analysis technique which was a little bit controversial we chose a test that maybe some other statisticians wouldn't use we should explain why we used it and justify that and open ourselves up to comment by others on whether that was the correct analysis to do. Retention of data, what should we retain? It might be impractical to store large amounts of data particularly if they're on paper, okay? And so what do we choose to retain? At minimum enough data should always be retained to be able to reconstruct anything that was done for an analysis. Now in a patient record from a clinical standpoint we should retain everything and we should retain everything for as long as is required by law by the country we're working in, okay? This will differ from country to country and from institution to institution, okay? I honestly don't know what the law is in Kenya or if there is one. As to how long more university or more teaching and referral hospital has to maintain patient records. For research data it may be determined by the funder, maybe determined by the country you're in, maybe determined by the country that funded this study. So for many of our studies here we must retain data for five to seven years depending on the state, okay? The state law that applies to that project in the United States if they were funding the project, okay? But for clinical records that is gonna depend on the institution and the country's law. Sharing of data. Who gets to see data? This is important for responsible research and also for responsible clinical practice. De-identified data should be shared and this is a conclusion again from that same conference we discussed earlier. De-identified data should be shared so that others can verify your conclusions or analysis.  That is not considered to be ethical. It should be verifiable by others but we do not share personal information on participants or patients. We only share de-identified information, aggregate data so that people can do that. Personal information should never be shared because of confidentiality and privacy concerns. Data security involves two processes and I hope this is second nature to most of you by now but this is a good review. It means both limiting access to data and also backing up data. Data backups we don't just do because we worry about it, we do it because it's part of data integrity and data security, okay? Loss of data compromises data integrity and so we do not want to lose it and because we know that computer systems fail, data can easily be lost. We do regular backups to prevent that so we can rebuild data sets or databases when necessary. As far as limiting access, that can be locking up all paper records, password protecting, all computerized information, limiting access to any records to people who have the defined privileges to see that data, defining privileges of access for different levels of users with an electronic system and then preventing outside access so that people can't hack into private information. Ownership of data, I'm not gonna give you an answer on this one but I'm gonna make you aware that this is an important ethical concern within data whether you're talking about clinical data or research data but often comes up with research. Who owns it? Does the patient own it? In a clinical system, does the patient own the data or does the hospital own the data? You will hear, you say patient, I agree with you. I think the patient owns the data. I should not do anything without that patient's consent unless it's part of a hospital policy that these data are going to be used in that way and they've accepted care within that facility as is the case here but I personally as a physician feel that that data belongs to the patient, not to me but to them. However, you will find administrators at MTRH or any hospital in the world who tell you that data belongs to the institution. That's part of their record. That's part of their mandate. And so there's disagreement sometimes on who owns patient level data when it comes to clinical care. When it comes to research, there's that same thing. Does the research own the data? Does the funder own the data? And when you publish, who owns the copyright? Does the public, we sign away our right, our copyright to that published information, okay? There are a lot of ethical concerns when it comes to ownership of data and there are no right or wrong answers. These are things that are hotly debated all across the globe but something you should be aware of. This is an ethical question when it comes to use of data, who owns it and who has the final say on how it should be used. And finally, ethics in publication. We've covered many of these but because many of you will be involved in creating data sets or analyzing data or publishing data in journals, you should understand ethics in publication have a lot of guidelines that are very pertinent to data and data management. Research should always try to answer a specific question. We don't just go out and collect masses of information and then start doing willy-nilly analysis to hope we find some question in there we can answer. Research should always have a specific question in mind and we should try to answer that question through proper collection and use of the data that we get. Statistical issues such as sample size and what statistical tests we use are very important part of design to ensure that the data is very likely to answer the question that we want. I may design a study with great research question but if I choose the wrong strategy to collect and analyze data with no hope of answering that question that research is now unethical because I am not creating a plan that will maintain any kind of data integrity. IRB approval is always required when using human subjects, human tissues or medical records. And so there must be oversight by an ethics review board for the use of human subjects data in whatever form for research to be considered ethical. We don't just go out and start doing collecting data and reporting data from human subjects without some type of ethical oversight. Data must be appropriately analyzed. I shouldn't say should be, it must be. Now there may be questions about what the appropriate analysis is. Biostatisticians don't always agree on the same test but inappropriate analysis are not necessarily ethical misconduct. Again, this comes with the idea of human error or human judgment. If somebody is doing a master's project and they do an analysis and they do an analysis with every intention of doing a good one and they analyze to the best of their ability, they may report things that were not necessarily as well reported as they could have been. They might even be wrong because perhaps they didn't know to use the right statistical tests. Is that ethical misconduct? No, that's human error again, okay? It would have been better if they had the advice of a biostatistician or a statistician who could help them analyze the data but that is not ethical misconduct, that's human error. Sometimes biostatisticians at the very top of their game disagree on which test is the best. And so the analysis, there may be disagreements about the ethical misconduct. No, there is sometimes disagreement on how to analyze the data in the best possible way. So that is not ethical misconduct. However, as I said before, fabrication or falsification of data is always considered ethical misconduct. Finally, sources and methods of obtaining and processing data must be disclosed. Exclusions should be explained in full. If I decide to remove something from the data set, I need to say so. And methods used to analyze the data should be explained in detail. It's okay, it's considered fine to go ahead and do other analyses from the data once your initial question, you've made an attempt to answer that. But again, we don't just go collecting data and then start saying, okay, now what in here is there to analyze? Okay. And finally, bias, which always exists, should be discussed in detail in all publications or in all data analysis.


The next line of business is a debate on motion 1, 2, 3, 1, 7, in the name of Jackie Baillie, on referral back to lead committee at stage 1, National Care Service Scotland Bill. I would invite those members who wish to speak to please press the question speak buttons and I call on Jackie Baillie to speak to and to move the motion up to six minutes, please. Thank you, Presiding Officer. I come to this chamber more in sorrow than in anger and I come to move a motion to ask the Parliament to send the National Care Service Scotland Bill back to the Health, Social Care and Sport Committee for further evidence-taking and consideration before stage 1. This is only the second time that such a motion has been brought before the chamber. Such is the seriousness with which this action is taken. Members will know that I first proposed a national care service more than a decade ago. That was in response to Clostridium difficile that ripped through our hospitals and care homes, causing deaths as a result. People were transferred from hospitals to care homes without testing, care staff were without adequate PPE, standards were variable and there was little oversight at the time. Sounds all too familiar. Whilst Nicola Sturgeon said no 10 years ago, the SNP changed their minds and I welcome all converts no matter how late in the day. I have long believed in a national care service and therefore do not take this next step lightly. Let me set out why I think the Parliament needs to send the report back to committee. Let me at this point record my thanks to the health committee, the finance committee, the education committee, many other committees besides and all the clerks for their diligent work on this piece of legislation. It has not been easy but my beef is not with them, it is with the Scottish Government. Members should read the report from the committee. Page after page of criticism requests for clarity, areas identified requiring substantial improvement. The finance committee looked at this twice and was still highly dubious about the budget. The real problem arises with a backroom deal that was done with COSLA, a deal that changes the fundamental governance structures of the national care service. Some might agree that the deal is a welcome change. There are many in the independent sector, the voluntary sector and those with lived experience of care who do not think that it is right. However, whether you agree or disagree, that is not the point. The point is that the committee has been unable to scrutinise this as the Scottish Government has been unwilling to share its amendments before stage 2. That was despite polite requests from the committee. The minister kept saying no. Despite an SNP member of the committee asking to see the target operating model, which would have given us a clue about the direction of travel, the minister still said no. This Parliament's history has too many examples of legislation that lie on the statute books simply incapable of being enacted because it is such a mess. Like the hate crime act passed in 2021 but not yet enacted, or legislation that is sadly challenged in the courts because there was insufficient scrutiny of evidence. The national care service, frankly, is too important to get wrong. The Government has already indicated that the national care service will not be up and running until 2028-29, so there is time to take an extra few weeks to scrutinise the Government's amendments, which fundamentally change the Government's arrangements. That should properly be considered at stage 1. There is precedent. Let me cite a recent example of the Rural Affairs and Islands Committee, who successfully argued that it should see that during the wildlife management bill and got sight of amendments before stage 1 was completed. Many members in this chamber have noted in the past that stage 2 is in any event too short a process. Amendments are dealt with and dispatched at pace, and where those changes have not been considered by committee at stage 1, it does make for poor scrutiny and ultimately for bad legislation. The second issue for me is the lack of an expert bill advisory group. Every bill that I have ever worked on in the past has had an expert advisory group because it helped Government to shape the bill, but it also helped in the context of making sure that the bill was capable of implementation too. I am entirely in agreement with what Jackie Baillie is saying, but it is not a surprise because we both have exactly the same views about the importance of scrutiny in this Parliament. What is going to ask Jackie Baillie if she agrees with me that we seem to have a tradition in this Parliament now about too many framework bills, which mean that we do not have enough time to scrutinise because we do not have the necessary detail. Does she agree with that? I absolutely do. In fact, the Delegated Powers Committee made that point that it is not good legislative practice to stick substantive decisions in spending into secondary legislation. An expert advisory group simply does not exist for the national care service bill, so there is a genuine lack of confidence that the proposed changes will work and promises of co-production after the bill is passed is not enough. Witness after witness described the bill as vague, lacking in vision and failing to articulate a set of general principles. Rachel Cackett from CCPS encapsulates the problem and I quote, I do not know what the bill will look like. For me there is a question about what principles are being agreed at stage 1 and what exactly those amendments will look like. We also have Dr Jim Elder Woodward from Inclusion Scotland rightly complaining that the Scottish Governments deal with COSLA did not take any cognisance of the co-design process and that it was made without reference to any stakeholder. This Parliament is a relatively young institution. We do not have a second revising chamber. It is therefore important that we take the time to get things right. I want to support this bill, but it is currently a mess. We are in danger of making bad legislation because the Government has not allowed appropriate scrutiny. This is about the integrity of the Parliament and the integrity of us as members. Every party in this chamber, aside from the SNP and Greens, have expressed disquiet. Parliament matters, and I ask backbench members of the Government parties not to just railroad this through. I move the motion in my name. I refer members to my register of interests as a practising NHS GP. I am also a member of the Parliament's Health, Social Care and Sport Committee. The lead committee charged with scrutinising the national care service bill had four sessions with COSLA. We now know that every single one was a waste of time. This is not COSLA's fault, and it is not the MSP's fault. It is because the Scottish Government eventually came to the conclusion that Whomza Yousaf's original version of the NCS bill simply would not work. They pulled it, and they changed much of what had been focused upon and scrutinised for the past 18 months. We were unable and still are unable to ask appropriate questions due to unseen changes that the Government are making. Why not just let us see the bill in full, the full detail? Is it not ready? Do they even know what they want? This is a secret group creating secret changes in a secretive SNP Government at the helm. When it comes to the latest SNP rebrand of the NCS bill, health committee members are well aware that there is a dearth of detail and so many unanswered questions, many questions including over money, and it is not just Opposition Members shaking their heads. Parliament's Finance and Public Administration Committee has repeatedly raised concerns about how this would all be funded, that costings did not and could not reflect the actual costs on the provisions of the bill. The SNP Green Government are already spending over £800,000 every month on civil servants for the national care service. To get the NCS up and running, we are told by Social Care Minister Marie Todd to expect a total spend of £2.2 billion, but that is all very unclear given the many iterations of the memorandum of financial understanding that has gone through. This bill is far from ready for a stage 1 debate and vote, and the lead committee has simply not been able to properly examine what is now on the table, because we do not know what is on the table. Despite warnings from the SNP Green Government, it says that it is unable to articulate and communicate how their national care service would actually work in practice. Parliament is being asked to support a bill on the basis that, come the second reading, all will be revealed. Really? That is not how scrutiny of legislation is supposed to work. We are not just here to give the Government the benefit of doubt. All of us here are here to scrutinise the Government's plan and decisions made to make sure that the people of Scotland get a good deal, not the best guess. The fact is that the only reason this bill is going on the agenda tomorrow is because the health committee voted along party lines. To be clear, MSPs on the health committee are united in our thinking that the bill must be sent back for proper scrutiny if we are not in Government. The four committee members who are not SNP or Green dissented from up to 46 of the report's 110 points of recommendations, including support for the Bill's general principles. SNP Green Ministers may well respond by saying that this is a framework bill, and that at this stage we only need to agree the principles. This is not good enough. It is not right to push through a bill that the Government itself cannot even articulate if the current bill were a car. We do not know what make, what model or even what colour this car is, and the Government are suggesting that we put down hundreds of millions of pounds in a deposit anyway. Yes, I will give way. I thank Dr Gohani for giving way. There has been much talk from the Opposition around a framework bill. I remind the chamber that the national health service was established in the UK using a framework bill. Thank goodness that those folk back in the day had the radical view of doing it that way, to create what is an institution that works for all. It is a pity that Dr Gohani and others do not have that radical age that 9-11 and others do. Well, no question. If you wanted to speak, just put your name forward and do a speech. I ask members across this chamber to vote not along party lines, but on the principle that committees and scrutiny of legislation are important. Thank you, and I move the amendment in my name. Thank you, Dr Gohani. I now call on Minister Marisod up to five minutes, please. The National Care Service Scotland Bill is our opportunity to reform the social care system in Scotland. I welcome the Parliament's consideration of such an important issue, but the fact that I am here to prevent what is essentially a delay in delivering this much-needed change is disappointing. I have five minutes. I will not be taking interventions. People across the country deserve better, and that is what the bill will bring. Most importantly, it will put the people who access social care services right at the heart of our system. We are already working hard to make the changes needed in the social care system in Scotland, but the reality is that we need longer-term, widespread reform to fix some of the issues that are ingrained within the system. I do not intend to set out fully today the Government's approach to the National Care Service and the bill. The stage 1 debate, which is already scheduled for tomorrow, will provide the right opportunity for that. That debate has been a long time coming. I have welcomed the scrutiny that the Scottish Parliament has brought to the bill. Seven committees have reviewed the bill in the 20 months since it was introduced, and my officials and I have met thousands of people to discuss the National Care Service. That is surely one of the most extensively scrutinised bills ever to go through the Scottish Parliament. We have worked hard to ensure that all of the committees have been provided with everything that they have asked for to help their considerations often at short notice. I will continue to do everything that I can to ensure that the important business of parliamentary scrutiny continues to be respected. I am grateful to the Health and Social Care and Sport Committee for the substantial stage 1 report that it published last week. That report makes more than 100 recommendations, and my officials and I are currently considering those. Although it is important to take due time to consider all of those recommendations fully, I have already written to the convener of the committee welcoming the report and signalling my agreement to provide further information to the committee. I had previously committed to providing a summary target operating model for the National Care Service to the committee. I have shared that today. I have also this week shared a fact sheet with all members that provides an overview of our plans for the National Care Service. That summarises the material that was previously provided to the Health and Social Care and Sport Committee and the Finance and Public Administration Committee. In brief, it describes our intention to create a national care service board to oversee social work, social care support and community health services and to drive transparency and consistency and to reform local integration joint boards. Officials have already arranged to discuss stage 2 arrangements with the clerks to the committee to ensure that sufficient time is built into the timetable to allow for thorough scrutiny and, if necessary, more evidence. That is a key priority should the general principles of the bill be agreed to tomorrow at stage 1. We need to listen to the different views that I have heard from so many stakeholders to the perspectives that seven committees of this Parliament have already heard in evidence, to the voices of thousands of people who rely on social care provision, who have taken part in our co-design work and to carers who provide such essential support. People need change and they are telling us that they need it now. Of the many thousands of people that we have spoken to who are trying to access social care in Scotland now, none are telling me to slow down. Everyone is telling me to speed up. We will ensure that the parliamentary process is robust, but we are letting people down if we spend our time in Parliament getting tangled up in procedural delay instead of talking about the substantive issues that impact on people's lives. Focusing on the parliamentary process is not helping those people who really need it. Delaying this vital work means hugely significant policies, like our rights to break for carers and Anne's law, which will be delayed in their introduction. There is an important debate to be had about how we demonstrate the value of social care in Scotland, about how we ensure that people who require social care get access to the help that they need wherever they live, about how we embed human rights in social care provision and I look forward to that debate tomorrow. I now call on Claire Focke to speak on behalf of the Health, Social Care and Sport Committee up to four minutes. The Health, Social Care and Sport Committee has undertaken extensive scrutiny of the National Care Service Scotland Bill since its introduction in June 2022. That has included two calls for written evidence, 18 panels of witnesses, as well as three oral evidence sessions and multiple exchanges of correspondence with the responsible minister. The committee held a number of informal engagement sessions with a range of people with lived experience and different experiences. To inform its scrutiny further, the committee commissioned a literature review of international models of social care, including a combination of different models in UK countries, EU countries, Nordic countries, Switzerland, Alaska, the USA, Canada, Japan, Australia and New Zealand. The committee also visited Aberdeen, where members met representatives of Granite Care Consortium and visited Camp Hill community to engage with staff and service users. It visited Dumfries, where members had informal discussions with care and other organisations representing registered care homes, registered care at home and wider community and third sector organisations. On a visit to Glasgow, committee members met representatives from the Coalition of Care and Support Providers in Scotland and service users and front-line staff from the key before holding a formal meeting at the William Quarriers conference centre. Meanwhile, six other committees have undertaken their own scrutiny of those aspects of the bill that were relevant to their remit. On 12 July, the Scottish Government wrote to inform the committee that it had reached an initial consensus agreement with COSLA on a partnership approach that will provide for shared legal accountability with respect to the proposed national care service. On 20 September, the Scottish Government confirmed its intention to bring forward amendments to the bill to reflect the changes required as a result of the consensus agreement with COSLA. My committee subsequently wrote to the Scottish Government on 7 November requesting additional information regarding the precise implications of the consensus agreement for the bill and received a detailed response from the minister on 6 December. The committee's stage 1 report, which was published last week, sets out in detail the conclusions and recommendations that we have reached as a consequence of our exhaustive scrutiny. The consensus agreement with COSLA on the shared legal accountability means that a number of key aspects of the bill will need to change. Accountability for social care will no longer be transferred from local authorities to Scottish ministers. Integration joint boards will no longer be replaced by local care boards. Instead, a national care service board is proposed and local government will now retain social care functions, staff and assets. The Scottish Government has made clear its intention to bring about these changes to the bill through amendments at stage 2. On that basis, a majority of the committee has recommended that the general principles of the bill be agreed to. However, we have done so on the understanding that further scrutiny of the changes that the Scottish Government now proposes to make to the bill should take place as part of an elongated stage 2 process. That would include a further written call for evidence, the gathering of additional oral evidence before we progressed to the formal part of stage 2. That is the consideration and the disposal of amendments to the bill. I regret that it was not possible for the committee to reach a consensus position on the general principles of the bill at stage 1. However, I want to underline my commitment to ensuring that substantial further scrutiny takes place at stage 2, as I have outlined. I rise to support the motion in the name of Jackie Baillie. I think that there is an element of ministerial cosplay at work here. If you listen to the remarks of the minister and her predecessor, Kevin Bevan or Kevin Stewart, who evoked the name of Nye Bevan, you would be forgiven for thinking that they imagined themselves in the rubble and poverty of 1940s Britain, in which the NHS, our much-loved national institution, was first forged. However, we are not in 1946. Apart from the nomenclature and the reality of the national care service, the similarities end. That will not give care free at the point of delivery. It is in fact a ministerial power grab. What lies before Parliament that will debate on Thursday if this motion to defer it is not successful is merely a framework, but a framework that will still cost in the order of £2 billion. For what? A vast and unnecessary ministerial bureaucracy that strips power from our communities and gives it to the centre. Let me be clear from the outset. My preference would not just be to defer this bill but to scrap it in its entirety. We are clear—the Liberal Democrats are clear—that it represents little more than a mammoth bureaucratic exercise that would waste time and money that would be far better spent elsewhere. However, I support it also being referred back to the committee today, because the call for stakeholder evidence went out and came back over a year ago. That evidence was geared towards the first iteration of the legislation, but what is being put before Parliament this week is a different version of the bill altogether. Indeed, there are a lot of this is no longer happening in the convener's remarks. Surely that should all give us pause to the thought and say that this parliamentary process has been derailed and must be started again if it has to continue at all. The landscape around it has fundamentally changed and so too have the proposals in the bill. During its consideration of the bill, the committee did not have the full detail of what has been proposed. We just heard that in the convener's remarks. The so-called national care service would look like, and stakeholders have not seen that detail either. Let me quote directly, Presiding Officer, if I may, from the pages of the committee report, which says that one of the challenges that the committee has faced with the bill has been the lack of available detail at the start of our scrutiny. That is a fundamental problem with any piece of legislation going through a democratically elected Parliament. Members of the Finance Committee, who very publicly last year said that their numbers did not stack up, still say today that they still harbour grave concerns. Presiding Officer, this is just not the way that we should be doing business in this place. It is absurd that we should begin the legislative process in this context. The minister was very clear that she said that people are telling her that we need change. Well, they are right, we do need change in our social care but it is not the kind that she has in mind. When people talk about reform and change of the care sector, they might want to be sure that, when your gran needs help, she will get it when she needs it and it will be cheaper than it has been, with reliable staff that we can all access in every part of this country. They are not imagining a ministerial paragraph that will asset strip our communities, put power in the hands of ministers rather than social care partnerships to direct their care entirely. That is a bureaucracy. It will cost a lot of money and Liberals believe fundamentally why we oppose this in its entirety is that power always works best when it is closest to the people it serves. Nothing about this bill will deliver it and nothing about this bill resembles in any way the national health service of which we should all be rightly proud. We now move to closing speeches. The minister said that focusing on parliamentary process was not needed. This is not obtuse process, this is scrutiny. It is clear that this secretive S&P government do not want scrutiny. The convener of the health committee is right in saying that the extensive scrutiny was performed but when secret fundamental changes happen we are unable to perform proper scrutiny. For example, we took no evidence from COSLA regarding the agreement. Do you not think that that might be important? What are the facts? The national care service was introduced in 20 June 2022. We started taking public evidence and health committee in October 2022 and the user realised that this bill was not going to work and pulled it. We had four delays instigated by the government. With all this dither and delay, why are we rushing through stage one when we have no idea what the government is doing? Simply put, are the amendments ready? If they are, then why the secrecy? If not, then this government simply needs to stop making it up as they go along. The lead committee could not take appropriate evidence or ask appropriate questions because we have not seen the actual bill due to the massive changes being made and the fundamental changes being made. Members, our job is to scrutinise bills and we cannot allow this precedent to be set. Otherwise, it undermines the role of committees. The establishment of a national care service gives this Parliament the chance to be bold, ambitious and innovative. It is not us who are delaying this. I fear that it is the Government that could have been brought forward 10 years ago. The Scottish Government has chosen to force through a bill through stage two when it falls seriously short of the mark. The convener is correct to say that we took hours of scrutiny. The report page after page of criticism and a major change with a deal with COSLA. Last minute, the minister has chosen to send a letter to the members in this Parliament rather than to engage with the committee. We have three minutes to respond to that. The committee will be able to take proper scrutiny if the minister would come in front of the committee. Time and again, trade unions, the third sector, carers and those who receive care came to the committee and to members individually to express serious concerns about the way that bill was progressing. However, the conclusion is to ignore this and push on anyway. Minister, if you have spoken to hundreds and hundreds of people, then you have not listened to hundreds and hundreds of people and hundreds and hundreds of people through their stakeholders are still very confused. A national care service is something that Labour has called on for years because if delivered properly it will deliver that much-needed parity between health and social care. Presiding Officer, it is challenging to fully understand the SNP's motives when it comes to their stubborn position on the national care service. It is widely acknowledged that this bill has changed directions significantly, is unclear and needs further scrutiny at stage 1. The Government itself agrees. I know that members on the Health and Social Care Committee agree, and other committees have expressed extensive concerns about the bill. Stakeholders are continuing to express extensive concerns. I want to address the notion that the minister put forward is that we have to delay things. There was extensive evidence on the committee to tell us about the things that we can take forward at this point in time—fair work principles through the trade unions and the work on anzolot. Those things do not require to be delayed. That is what the Government chose to tell people about the national care service. As you have heard from my colleague Jackie Baillie, Labour wants a national care service. My colleague and I tried hard on committee to fight for an expert advisory group. It was rejected. We asked for amendments to come at stage 1. It was rejected. We eventually had to ask for the general principles of the bill, which are completely unclear to be rejected, but the committee chose not to do that, although there was division and that was significant. I know that I have to close now, but I hope that other members, particularly the backbenches, will choose to send that back for proper scrutiny at the Health and Social Care and Sports Committee. Thank you, Ms Mocken. That concludes the debate on referral back to lead committee at stage 1, National Care Service Scotland Bill. It is now time to move on to the next item of business, and we have a very short pause to allow front-bench teams to change positions.


Alright guys, we are Kyle here with Layton Sports Cars. We are doing 2022 prism football, hobby four box number 12, random teams. Here are the list of names. Also shared a link in the chat there if anybody needs to check it out. And good luck everybody, four box number 12. See if we can find a color blast, manga, 101. I haven't got one of those yet. We're due. Brilliance Rogers. Got Green and Yellow Hyper, Javon Holland. Hamilton and Dean. Yeah Steve, that was great man. Congrats on that one, that was sweet. Those color blasts are awesome. Ha ha, we got more skin. Snake skin. Yeah, that's Julie Kase. Come on now, let's get another rookie. Good luck guys. Is Julian Love for the Giants? On the red and black snake skin, case hit. Although that's two for this case. Nice one Giants, short print. Very sweet card too, love those. Got Green and Yellow Hyper, Trent McDuffie. Rookie for the Chiefs. Rucker and Cook. Yeah those snake skins are sweet man. Yeah we saw that on Monday Jacob, that was a tough game. We have Prism Break, Jamar Chase. And Rogers. Discount double check on the Green Scope to 75. Green for his new team. Got Benoto and Washington. Appreciate that Timmy. Gomez-Adams mustache. What do we even see him do? Who's that? It's just you, that's weird. Me and Ashmi. Hype Waddle, got Daryl Green, Purple, 125. Got Snoop and a Malik Willis rookie base. It's like an auto coming. He's not wrong man, you got nothing bro. He does have a left hand. Silver Richie Grant. That's not the argument here. Here we go, Lyons. Got Lyons rookie silver auto Aiden Hutchinson. There you go Lyons, Matthew B. Sweet Hutch there. Gonna be a menace to quarterbacks for a long time. Nice one there. We got Sauce rookie base. Sauce. Rogers is going to the jet smack. He certainly is. That's like 99%. Unless he retires I guess. Darius, Slay, Silver. Yeah, yeah. I don't really feel like it. And rookie auto this time, Tyquan Thornton. Patriots rookie receiver. Not a bad one there. We've got the Patriots. Slay's officially a creation. How is he? Unfortunately. Pearson Booth. recent Bradbury, but we let Slay walk, I really agree with that. I mean Ali was an NLB rookie last year, so he can't win rookie of the year, but in cards he'll be a rookie. Prism, Breeze Hall. And T. Higgins orange, nice color match there, 249. He's like wonder. Got Ritter rookie, Dolchich. Can he win rookie card of the year? That's an award then, yeah I guess that's it. See, here's what it says. She may go award for it. It's possible. Silver lockdown buyered. Oh, there we go, Lions again. Beautiful card here. Blue Wave rookie Hutchinson. Nice. Doubling up on the eight and this to 199. Congrats to the Lions. Doubling up on the Hutch. That's Matthew B. I'm gonna say I'm biased. I'm gonna say Masataka Yoshida. That's the best rookie right there. If I've seen that written in front of me, I would, but you're so bad. That's how it spelled though. Ooh, nice silver here. We got silver rookie Desmond Ritter. That's pretty nice. There you go, Falcons, beautiful silver. Nice rookie QB there. It's Donnie's boy Higley. Nick M with the Falcons. Nice Des. Got purple cracked ice, Miles Sanders. Did Desmond Ritter catch it? Oh wait. Hickins rookie. Let me get it. I don't have any more cards with him as an eagle. Let me get this top one. He needs it. I got you. Silver Regi Wayne. Blue cracked ice, Andre Johnson. Beast. All right. It's 99. Dramatic, just let me have a moment. Nietzsche and Walker. Higley, I personally liked this prism there in the last two years. I'd say last three years. I didn't clock the 19th, I don't know. Travis Kelsey, Brilliance. Have Justin Fields, Blue Wave, 2199. Nice Fields there for the Bears. I'm DJ Moore now. Yeah. Got some weapons. Now only Claypill could actually play like he was supposed to. All right, that one did not wanna cooperate. Means there's a 101 in here. Nope. I'm not bad though. Got blue cracked ice and Sir Malik Willis. That's cool. Well, that one's really nice. Number to 99. That one's a barrier. There you go, Titans. Boo and Steelers. Purple Power Rookie, this is George Pickens. There you go, Steelers. Sean P, what a case for the Steelers, man. Crazy. Crazy 12 boxes for the Steelers. That's the 49. Well, we're gonna be knowing when the repair. We'll mag that one for you. Really nice hit there, Sean. Oh. Nice Pickens. Yeah, it was like 49. And you just looked at me weird. I thought you said it was that four net. No. I was like... All right, guys, box two. Good luck, good luck. This is random teams number 12. That's not four net. If that was four net, I would be three out. Oh, my God. I'm like Jake. I'm Barty. What are we doing? Yo, like wow. Ah! It's a five-bit screen. All right. Let's go. I just want to make sure that he doesn't pick him up. Prison break, Garrett Wilson. Got Orange Wave to 60, Stalback. Cowboys. We got a sauce. Rookie. Make sure I didn't put any autos in there. I know I didn't, because there's two, but... Silver fireworks, Chubb. Orange, Lombardi, Lenny. There he is. There he goes. I'm always about to jump out of here. It's a 249 on Lenny. I can jump higher than him. Hutchinson, Rookie. There's no chance that I jump higher. Three Hutchins already. And an FL player on the screen. What if they're in three? I can maybe jump higher than current Dave Vince Willfork. Even though I'm not... Pretty athletic, bro. No, I'm not. No, I don't know why. I'm just saying I'm not 100%, but I probably do it now. Antonio Gibson, 249. Well, Barbecue Willfork. Who likes Barbecue? He, like, does a combination of stuff. It was an interesting set. You know, it's like Barbecue, Chet. Oh, yeah, he does. Which is the nagging cheese. They made me know that. What do they say about Antonio Gibson? We got a nice auto coming. Looks like, color-wise. Good luck, guys. They should talk about football in the back of these cards. The price of about six likes. Got Silver, Ed Reid. And it's a 49. We got Purple Power, Rookie Auto, George Carlotis. There you go, Chiefs. Sheldon with the Carlotis, Rookie Auto. Absolute beast. 41 of 49. Alave, Rookie. Haskins. Who's everybody thinks winning this March Madness bracket? I think I filled one out. Probably not gonna be very good. Got Brilliance, Hertz. Got Purple Cracked Ice, Jair. For the Packers, to 225. Desmond Ritter, Rookie Base. Fireworks, Rookie Picket, or Pickins. Got PS2, Purple Cracked Ice, to 225. Base, Kenny. Really correct? I think I have Houston winning, but I know they just had an injury. So, like Sasser, so that's not good. Maybe he'll figure it out though. Got Silver, Devante Parker, and looks like an auto coming. It is Franchise Legends Auto. Isaac Bruce, to 149. Ooh, nice. Nice Brucey. He was so good. Oh yeah. Give it a pull. Brucey's time to shine. Brucey's time. Should we eat that now? Got George Pickins. Yeah, I like Yukon. They're a, that Rookie, or not Rookie. Freshman Center, their backup's good. And the Sonogo, the main center, he's really good. Got Lockdown, can't even read it. Fred Warner Silver, Lockdown the word. Got DeForest Buckner, Blue Wave, that is to 199. Rashad White, Yukon Josh, nice. I like it. Been a while since Yukon, probably Shabazz here. Did they win then? Xavian Howard, we got Aaron Jones, Green and Yellow Hyper, to 175. What's up Travis? How you been man? The Rockets are crushing the Lakers right now too. The Rockets are gonna play themselves out of like a, that I'm born over over. Jeez. They probably are. No, yeah. You said no, yeah, I don't know. No, yeah, yeah. I mean, yeah, no. Silver Rookie, Kyla Gordon for the Bears. Yeah, no, what I meant. Zah Bears. It was, no. Or Red Wave, Max Crosby, to 149. No, yeah, that's why I meant it. Jay Dave and Ty Quan Thornton. You have a title, cause I'm getting a headache. Forrest is getting in Tony's head. Oh, we have Excedrin here. Got prison breakout bits. We're in Excedrin family. This is Kyla Gordon, Blue Cracked Ice, Rookie to 99, there you go Bears. Goodbye, bye, I like the jug. Christian Watson, Rookie. Holmes and Watson. Come on, where's the black? Is there something? Oh, we got a cracked ice hype. That's sweet. That's hype. That is Javonte Williams, Blue Cracked Ice to 99. Nice one there for the Broncos. Beautiful card. That looks pretty cool. Looks like a Sapphire card. Sapphire tie dye.  Ooh, nice Rookie here. Another one for the Lions, Malcolm Rodriguez. That is to 75 on the green power. Lions having a nice break. Dean and Phillips. All right guys, box number three. Good luck, good luck. This is four box break number 12. Anyone think Purdue's gonna win? No, they're probably what the favorite? Maybe not. Josh, you would know. Who's the actual favorite? Purdue. Got Brilliance, Dalvin Cook. Daniel Carlson, kicker for the Raiders. It's a 225. Al Geer and a Desmond Ritter. Nice pack for the Falcons. Desmond the Riddler. I just feel like Purdue's had too many struggles this year with some big 10 teams. I don't know if they can get all the way through. Got Hype Silver Fields. Have Dalton Schultz. That is the 249 on the orange. Snoop Connor. FAU in the finals. FAU was pretty good this year. They were pretty good. I think they lost to like Stetson being here, but after that, that was like first week. Stalbeck Silver, and we got an auto. This one is rookie auto for the Broncos, Montrell Washington. Red wave to 149 on the auto. Nice hit there, Broncos. Got Pickens rookie. Yeah, I feel the same way, Josh. They had so much Hype all year and just, I mean, they stayed up there, but I also don't see Alabama winning it, but Brandon Miller is pretty good. They got a nice squad around them. Traylon Burks, emergent. Quitty pay. And I saw a color match there. Blue wave, 199. Zona's nice, yeah, I like Zona. Zubelis, that dude's a beast. Reminds me of Sabonis. Rebounding everything. Green Scobroger McCreary rookie. There you go, Titans, number 275. Yeah, I don't think they're gonna get even close though, Carl. I think that's Yukon's side of the bracket, too. Prism Break, Breez Hall. Got Purple Cracked Ice, Max Crosby. That is the 225. Michi, I'd say it just depends on your preference. If you have a very certain player you wanna go after, I would recommend buying a specific player, especially if it's in older products maybe. Got Zach Wilson, Silver, we got a redemption. I know one guy who's a redemption. This is not him, they got Debo Samuel. Nice one there, Base Autograph Prism Silver. That's going to the Niners, nice Debo. It's going to Gregory M. Brian Burns, Green and Yellow Hyper, to 175. Kade York. But yeah, I'd say if you're looking for a specific player or team, you could check eBay and stuff and get some people that you really like. Just get started that way collecting. Silver All Out, Cordero. Ooh, nice one here, Blue Cracked Ice for the Titans. This is Traylon Berks. A real solid rookie year as the receiver there. That is Sean P. with the Titans, nice Traylon. We'll mag that one for it to 99. Michi Mannell is a good start, Greg, there you go. Got Silverberry Sanders. Purple Deandre Swift. Two lines running backs there, to 125. Silver Rookie Jordan Davis. Nice one there for the Eagles, big man out of Bama. And we got a red wave, Marlon Humphrey. That's the 149 for the Ravens.  This pack over the next box. Brilliant's Kelsey. Ooh, nice orange here. It's going to go to the Jets Rookie Breeze Hall. Solid hit there for the Jets. Had a really good year before he got injured. You go David. Having a nice break. Matt Corral Rookie. Fireworks Tyreek. Orange Wave Devonte Adams, number to 60. Nice one there, one of 60 on the tee. Malik Willis Rookie. All right guys, time for box number four. And this is four box break number 12. Good luck, good luck. See a big, big color. Taking silver nicest. Yeah, there's a Traylon up in the middle. Doesn't even know. Looks like we got an auto. Silver Warren Sat. Auto is going to be Jalen Waddle. Veteran Silver Auto, not numbered on the Waddle. The best touchdown celebration in the AFL. The Waddle. You got Gino. Blue Cracked Ice in 99. Didn't write back. There's so many bins down there. Nice Gino. Christian Watson Rookie. What's up Rob? It is indeed. It is Kyle. Silver Rookie Tyquan Thornton. Got Chris Jones. Purple Cracked Ice, number to 225. Ego Chiefs. Hutchinson Base Rookie. What's up Rob? How you been man? 25 mil for Sanders, nice. Is that like front loaded or is that 12 a year? I feel like four years on a kind of a older running back. We couldn't give him that. Silver Daryl Henderson, I know. You never shot a penny, easy. Got Bateman a 249 on the orange. Easily taken Sanders over. We got a sauce. I'll look at force in the reflection of the sauce. Wow, I got it. I got him. Is that just black and white, that's why I say it's very easy. That's just a photo. This is just black and white, okay. You didn't have variations. We figured it out. It's like rookie variations. Ooh, nice Kenny here, new recruit insert. And Noah Phant, blue wave for the Seahawks. It's a second blue wave in a couple packs. Silver Fireworks, digs. Antonio Gates, that's the green scope to 75. Got Garrett Wilson, rookie. He's a Bill of Start, Coca's RB1 this upcoming year. I don't know. I think so. Keeps Singletary, height Wilson. Makes sense. We got Arnold Edequite, that is a red wave rookie, two 149 for the Falcons. Greg D and Arnold again. I remember David Montgomery's son, but he's somewhere else though. Lions. Yeah, so I thought, I wasn't sure. Silver DJ Moore, got an auto coming. It is the 75 green scope rookie auto, Snoop Conner. That is gonna go to the Jags on the Snoop rookie auto. McBride rookie, Abner. That was Andrew Madison, back to the Vikings. Interesting. Two years, seven million, very cheap for you. That is very cheap. Prism break, Birx. Madison's good, so not bad. Cuandre digs to 175, green and yellow hyper. I'm really gonna do the Calvin. Kenny Pickett, and a Crystal Lave base. Nice rookie pack there. Orange CJ Mosley to 249. Birx rookie, and Thibodeau, Thibodeau, Thibodeau. Cheerio. Rookie for the Jags, Devin Lloyd. The green and yellow hyper to 175. Gordon and Rashawn White. Ooh, silver throwback rookie. This one's going to the Jets, nice one here. Got Garrett Wilson. Sick looking silver throwback. That's the 2012 Prism throwback. Nice card there. J-E-T-S. Those throwbacks are really cool. They are. Then we've got Rookie Alante Taylor. This is for the Saints. Purple cracked ice to 225. You go Saints. Donnie's saving his questions for when I'm breaking. All right, and last pack. Let's do it in a fight. The Grinchy Sandwich or a Taco? Brilliance, Josh Allen. Underrated movie. And Purple is gonna be Dan Jones for the Giants to 125. Davis and Thornton on the rookies. Back out again with white bands, you ever heard that? All right guys, that will do it for random team, four box number 12. Do a quick recap here. Donnie's got some fire. Had Snoop Conner on the green scope auto to 75. Jalen Waddle, veteran auto. Montrell Washington, red wave auto, rookie auto. Franchise Legends, Bruce. Brucey. Got Carlottis. Purple. That is the 49, nice Carlottis there. Got Tyquan Thornton, Patriots rookie receiver. Hutchinson rookie, a silver auto there. Nice one there for the Lions. And Purple powered a 49. We got George Pickens for the Steelers. Really nice hit there, 45 a 49. All right guys, congrats everybody that hit and thank you guys for filling up the break. We will be right back with more.


to ensure that everyone have the same information. What we have right now is pockets of information going to various individuals. Like I just heard from Mr. Dunbar, said most sitting information is being flowed through LinkedIn. Some companies have LinkedIn and some companies do not. There needs to be conservative effort of communicating what the standards will be, what the cost will be across all industry, especially in filter down to the small business. It may be a regional approach to be able to help and maybe just understanding that CMMC is here to stay, take away the fear, but communicate clearly what it really means to have this certification.


This review provides a comprehensive overview of the literature on non-hermitian flukae topological matter in one and two spatial dimensions, including its exotic properties resulting from the interplay between driving fields and non-hermiticity. The authors introduce useful tools for studying these systems and present typical examples of non-hermitian flukae topological insulators, superconductors, and quasicrystals, highlighting their topological invariance, bulk edge correspondences, non-hermitian skin effects, dynamical properties, and localization transitions. The authors conclude by summarizing their main findings and presenting future directions for research. This article was authored by Longwen Zhou and Dijian Zhang.


Morning everybody, welcome back to another vlog. Today I am doing like a little bit of a reset routine. You know I love doing this, especially coming back from like a trip. I just feel like I need to get my life together, you know? I got a little bit of laundry done this morning. I put away the dishes. I feel like I'm like getting back in the swing of things. I got my nails done. I actually got them done like a week ago, but I kept forgetting to mention it. And I did the Hailey Bieber like chrome thing. To be fair, Hailey Bieber didn't really like invent chrome nails, but I think it's like why it became popular on TikTok. So I did like a neutral color. I think it's called Funny Bunny by OPI. And then like the pearl chrome over it, really fun. And I've just been trying to like get back in the swing of things. Drew and I have been going on like hikes and trying to get outside and walk more on the weekends. And yeah, in combination with like resting and relaxing and like recharging, I definitely am trying to like get out and explore LA more. But anyways, I got a fun, exciting package in the mail. Probably one of my favorite packages that I ever get. And that is from Brooklynin. Brooklynin is sponsoring this blog. I literally love them so much. High quality bed sheets are obviously really expensive. And that's why I love Brooklynin because they offer the quality and the comfort at an affordable price by cutting out the middleman. Brooklynin was founded on the philosophy that people deserve beautiful, simple home essentials without the luxury markup. I love them. And as always, they are going to hook you up with a discount code. So make sure you click the link below and use the code carryD at checkout to get $20 off your order of $100 or more. And we're going to open this up. I cannot wait any longer. Drew literally like will not allow any other sheets on our bed at this point. And I mean, it makes sense.  You would obviously want your sheets to be extremely comfortable. Oh my goodness, I'm so excited. I got the Luxe Hardcore Bundle by the way. And the bundle is like so easy to put together. Instead of buying each item individually, you can save 25% by creating a bundle. And the Luxe Hardcore Bundle includes a core sheet set, a duvet cover and extra pillowcases. So it's got you all covered. The sheets are made with Luxe Satine. That's this sheet set right here. This is such a cute design. It's like the ultimate bedding upgrade. It's an over 480 thread count. And it's just like got this kind of like luminous finish to it. Look how pretty this is. Oh my gosh. And then the duvet cover and the pillowcases I got in just like an ivory color. I just love this because you can shop from the comfort of your own home obviously. You have the ability to mix and match over 20 different colors and patterns for your duvet cover, your sheet set and your extra pillowcases. And I mean, yeah, Brooklyn has over 100,005 star reviews. So that speaks for itself. They're just so fantastic. I love them so much. Okay, so we're gonna throw these in the wash and then put them on our bed later. I'm literally so excited. As you can hear the trash truck just went by. So the trash would be empty. I'm gonna take some of this stuff out to the trash and recycle. And I'm actually gonna do a workout this morning. I have been kind of struggling getting back into a routine with workouts. So we're gonna get that in and then like hopefully feel those endorphins going and just have like a really good productive day. Life together. I've tan and then I just did a bunch of work. Having exciting tonight. And that's something is that we're going to Disneyland. It's been like, I don't know, probably three weeks since we've been and actually our passes expire. We have like annual passes and they expire in October and there's been zero word from Disney on like whether or not you can renew them. And like, I don't know, it's confusing. So we're just gonna enjoy it while we can. I'm wearing like the most adorable outfit. I'm sorry, I'm gonna tomb my own horn here. No, I am. No, I am. Me. I win. You do look pretty cute. He's got his new spirit jersey. Keep in mind, it's 92 degrees in Anaheim. So. I'm from Arizona.   Drew's feeding Lila right now. It's like probably 4.30.  You know what I mean? Like you already paid for it. So kind of, kind of amazing. Okay, so let's get the ear situation figured out this angle. Also this from like the 60s. I think it's kind of cute actually. I mean, I'm pretty sure it's just like particle board or whatever you call it. All right, so we have a variation. These are like always my go-to. These are the ones that I got in Tokyo actually. If you've been watching my vlogs since then, we went to Tokyo in 2018 and we went to Disneyland there. So I got those. Those are like the most comfy. I also got these a few years ago. These are really cute. They would be cute with my outfit. I have this other pair that Drew got. These are like the Fantasia pair. We also got these in Japan. I have pink. These were the ones I got last time. Those are really cute. I have these just solid black velvet. I got these on Etsy. Those are kind of a move. And then the Sherpa ones, which will be for fall time. I think I'm just gonna go with the classic. I know that's boring. I wear these practically every time I'm at Disneyland but they just kind of hit every time. So cute. Yeah, I am in my mid 30s, whatever. All right, so we have my ears. One of them is collapsing. I don't quite know what's happening with that but that's okay. We'll roll with it. And then I have just this red tank top that's from ARC. And then these overalls are like a vintage pair of overalls that I got from a vintage store. Vintage store. Here in LA, I wanna say it was like on Melrose somewhere probably in like 2019. So I've had them for a few years now and they're like the perfect length. I don't chafe in them. And then I have, I would have loved to wear red converse for this but I just have my black platform converse. So cute. This is a rogue ear for a dog toy in the background. But yeah, we're gonna head to Disneyland and see what we can get up to in a few hours. This has kind of been what we've been doing lately. Obviously also having Layla. We can't go for like 12 hour days, you know? So we're gonna go probably for like three, four hours, have a blast and then come home and go to bed by midnight because we're old people. Let's go have fun. You be so good, okay? Did you just get a treat? Okay, we'll be back for you in a little bit. I'm kind of mad at this song but this like movie made us like totally uneducated. Like what actually happened. So his quickly in angered, oh my God. Did me best up for that one. Let's not so, earth was on a roll. Duh. So we think our plan is, cause Drew here has a hankering for some chicken fingers. I don't know why. These specific chicken fingers. That's what he's in the mood for. So we're gonna go on the Disneyland side first and get these chicken fingers, get some food in us and then maybe go to Ogos if they have availability. The Star Wars Cantina. Get ourselves a little cocktail. We'll see. Princess, thank you. Our business is the teacups, obviously. This one right here is a bit of a monster on the teacups. So we gotta keep him in mind. It'll be a blast. Oh, it's so pretty at night. I love it. Don't sleep on the teacups, y'all. It's become like our favorite ride for nighttime, especially if it's just so fun. And it's literally always like a five minute wait or less. Well, depending on when you go, but at nighttime all the kids are in bed. So all the adults get to turn up. You're gonna be nice to me, right? Right? It's already happening. Next up, we're going on Snow White. I've actually never been on this. My mom might correct me. Oh, yes. I'm ready. Basically because it's busy tonight, we're just gonna go on all the kids' rides and have a great fricking time. This is the cottage I would like to live in, please. And thank you. We've watched enough Escape to the Country to envision this and manifest it. Yeah, we're gonna get this one bashful. If any of you also watch Escape to the Country, what is your guess on this mystery house? I'm gonna say 550,000 pounds. How about you? We're now heading over to, okay, first of all, Snow White slapped. That was so good. I happened on it because I remember all the good gyms. But anyways, now we're gonna head over to California Adventure. We have a Fastpass for Midway Mania. I think our Fastpass starts at like 8.40. It's like 8.25 now.  Let's get out of here. Oh my goodness. So good. I'm being fed. Go fighting. Okay. Thank you. It is time for our favorite ride and potentially where our relationship is the most tested, Midway Mania. Yeah, obviously. I try so hard to win every single time and I get so mad because I'm genuinely trying to beat him, and it never happens. Alexa, if you're watching this, can you believe that? Next up, it's time for Drew's favorite ride. Look at the fireworks. Flashback to when we were on Matterhorn. Magical. No, not good. I learned. I'm not enjoying myself. And now we have our last Fastpass of the California Adventure side, which is soaring over the world. Across the world? Around the world. It used to be soaring over California, now it's soaring around the world. And then we're heading back over to the Disneyland side in hopes that all of the kiddie rides will be less busy, so. I don't think they will be. Yeah, it's probably not. Potentially in the night. We're not sure if this is the last ride of the night or not, but there was only like a 25 minute wait for Matterhorn, and we're on the left side, so we're gonna get our ass kicked. If you know, you know.  Much more violent. I got the shampoo out of me too. Oh, so good. I think we're gonna, oh. I think we're gonna end it on that note, because it's getting late. We need to get home, but like so much fun. Oh God, okay, gotta go. We're taking a last minute detour. I've never done this before. I do love Pinocchio, so let's frickin' do it. It's the sky is falling, that's by my side, to live through it for me. Well, that's gonna do it for us. It was such a fun night. We were here for what, five hours? Two daynights in a row. Two daynights in a row. Yeah, we went out last night to the Grove and had a great mom and dad's night out, and Disney was no different. Good morning, it is the next day. I'm so tired, I actually slept in this morning. It was so needed. But I realized I never ended off this vlog, and honestly, I had such a good sleep last night. The sheets are honestly the most comfortable sheets I've ever slept on, and I'm not just saying that. So again, make sure to check out the link in the description box below and use my code CARYD at checkout to get $20 off your order of $100 or more at Brooklyn Inn. I am going to enjoy the rest of my day today. I hope you are doing the same. I'm sending you a lot of love, and I will see you very soon in the next vlog. Bye.