Thread by @alexander_minh

Whilst all eyes on the NHS, there is a storm brewing in social care

Many vulnerable potential #coronavirus victims, stuck in settings which may facilitate transmission if there is staffing crisis or insufficient supplies, incl PPE

#CoronaUK #Covid19

theguardian.com/world/2020/mar…

Cases at HCOne's 80 bed Highgate care home in Lanarkshire jump - 6 to 11

At Oaklands, Hove where most residents tested positive, manager "expressed her concern that none of her staff had been tested for the virus."

hc-one.co.uk/Carehomes/High…

#Covid19UK

carehomeprofessional.com/more-care-home…

Staff and residents test positive for #coronavirus at Bradwell Hall 187 bed nursing home in Staffordshire

"A large number of staff are also unable to go in to work after showing signs of the illness."

#Covid19 #Covid19UK

stokesentinel.co.uk/news/stoke-on-…

Staff member tests positive for #coronavirus at 12 bed Heather Holmes residential home, for people with learning disabilities, in Northamptonshire

#Covid19UK #Covid19 #CoronaUK

cqc.org.uk/sites/default/…

itv.com/news/anglia/up…

Oakridge care home (91 beds, Basingstoke) resident hospitalised after testing positive for #coronavirus

Staff reportedly not tested

#Covid19UK #Covid19 #CoronaUK

dailyecho.co.uk/news/18300339.…

A resident developed severe #coronavirus disease at Salford care home, The Broughtons (42 beds)

Staff reported to be "running out of masks"

#Covid19 #Covid19UK #CoronaUK

bbc.co.uk/news/uk-englan…

Resident of Ackroyd House Care Home, 51 beds, Rotherham dies after contracting #coronavirus

#Covid19 #Covid19UK #CoronaUK

examinerlive.co.uk/news/local-new…

Staff member tests positive at The Meadowside and St Francis Care Centre, 69 beds, Plymouth

#Covid19 #Covid19UK #CoronaUK

bbc.co.uk/news/uk-englan…

Two people confirmed to have #coronavirus at Chestnut Court care home in Dagenham (62 beds)

#Covid19 #Covid19UK #CoronaUK

barkinganddagenhampost.co.uk/news/health/tw…

Resident of resident of Ritson Lodge Care Home, 60 beds, Norfolk, tests for #coronavirus

#Covid19 #Covid19UK #CoronaUK

edp24.co.uk/news/health/ri…

Care home manager struggles to buy enough food for 20 residents

Forced to go from supermarket to supermarket, gleaning sufficient provisions - but that increases risk of #coronavirus

Can't a better way be devised, to protect vulnerable?

@MattHancock

itv.com/news/meridian/…

Resident tests for #coronavirus at Scarborough Hall care home, 85 beds, Scarborough

#CoronaUK #Covid19 #Covid19UK

thescarboroughnews.co.uk/health/coronav…

Coronavirus outbreak in France: Several care homes report deaths in double digits

france24.com/en/video/20200…

'Delivering coffins non-stop': coronavirus stalks a Paris nursing home

93 residents infected with #coronavirus, 13 died

#Covid19 #Covid19UK

uk.reuters.com/article/us-hea…

Most residents at 74 bedded Oak Springs care home, Liverpool now exhibiting symptoms. 1 confirmed #coronavirus infection. 2 suspected cases dead.

What cost will be borne by elderly of slow UK government reaction & half measures?

#Covid19UK #Covid19

liverpoolecho.co.uk/news/liverpool…

"grim crisis in Europe's care homes"

"More than third of care homes in Paris region alone are thought to have been affected by coronavirus...hospital deaths are recorded in the daily toll of coronavirus, deaths in care homes are not"

#Covid19 #Covid19UK

bbc.co.uk/news/world-eur…

#Coronavirus deaths started at Oaklands nursing home, Hove

"If Covid-19 makes its way into a care home, it's going to kill people...How it's getting into care homes is by staff."

#Covid19 #Covid19UK

bbc.co.uk/news/uk-englan…

Treating social care as the poor relation in this #coronavirus crisis will have dire consequences

"We have thermometers, that's it"

"staff looking after a resident with Covid-19 were also looking after another resident"

#Covid19 #Covid19UK #CoronaUK

theguardian.com/uk-news/2020/m…

US: "The #coronavirus outbreak raced through four nursing homes over the weekend, infecting hundreds of residents at senior living facilities and killing at least five people"

#Covid19 #CoronaUK #Covid19UK

abcnews.go.com/US/health-offi…

Oak Springs care home Liverpool has third #coronavirus death

52 of remaining 66 residents have symptoms

Four placed on end of life care plans

80% of staff off sick with symptoms

No testing

#Covid19 #Covid19UK #CoronaUK

thetimes.co.uk/edition/news/o…

Estimated that about half of UK care homes have cases of #coronavirus, despite some locking down voluntarily before Gov lock down

Social care sector feels treated like second class citizens

#Covid19 #Covid19UK

thetimes.co.uk/article/corona…

Thousands of vulnerable elderly in care homes across Europe are dying of #coronavirus, without even the dignity of deaths being properly counted & acknowledged

Yet it poses a public health risk to all

#TakeItOnTheChin #HerdImmunity #Covid19 #Covid19UK

ft.com/content/58ece0…

Further to the large #coronavirus outbreak at Oaklands care home in Hove, 4 care homes in the city are now affected

Hove MP has written letter to No 10 about “widespread and needless loss of life across our care network”.

#Covid19 #Covid19UK #CoronaUK

theargus.co.uk/news/18354268.…

#Coronavirus death toll rising at Oak Springs 74 bedded care home, Liverpool via @JamesHopeThomp1

6 residents have died, at least 3 more deaths anticipated

Such a vulnerable group & no promised Gov shield has materialised

#CoronaUK #Covid19 #Covid19UK

liverpoolecho.co.uk/news/liverpool…

63 of 150 residents of single Italian care home, Borromea Residence, died in 1 month, starting from 3 March 2020

Only 36 residents tested, some still living, all positive for #coronavirus

How many uncounted #Covid19 dead?

#Covid19 #CoronaUK #Covid19UK

edition.cnn.com/2020/04/01/eur…

A "'tsunami' of #coronavirus deaths go unnumbered" in French care homes

#Covid19 #CoronaUK #Covid19UK

france24.com/en/20200403-as…

Care home staff contact local press about "multiple" #coronavirus deaths at 71 bedded Summerhill care home, Kendal, owned by tight lipped care giant HCOne

30 staff self isolating

Face masks running low

#Covid19 #Covid19UK #CoronaUK #StateOfCare

thewestmorlandgazette.co.uk/news/18351150.…

Taiwan & others took measures against #coronavirus profiteering from face masks & other PPE

What is UK Gov doing?

@MattHancock

#Covid19 #Covid19UK #LordsQs

Care homes, still having to buy their own, struggling because of astronomic PPE price hikes:

surreycomet.co.uk/news/national/…

Eight days after it was reported that staff had tested positive for #coronavirus at 187 bedded Bradwell Hall nursing home, Staffs, a resident has died of #Covid19

#Covid19UK #CoronaUK

stokesentinel.co.uk/news/stoke-on-…

#Coronavirus: Leaked document from Brighton & Hove CCG includes script to give to care homes on blanket DNR (Do Not Resuscitate) orders on "industrial scale"

#Covid19 #Covid19UK #CoronaUK #WeCommissioners

theargus.co.uk/news/18357706.…

bbc.co.uk/news/uk-politi…

https://t.co/gE0G8QDPv8

Dark times & panic have normalised the normally unthinkable

Leeds district nurses as well as Hove CCG & Wales GP now implicated in mass DNR

Wonder what messages were given by the centre?

@CNOEngland

#Covid19 #Covid19UK #HerdImmunity #CoronaUK

theguardian.com/world/2020/apr…

RCGP Hon Sec's approach to care home residents who contract #coronavirus:

- No admission to hospital
- As required medication in place to make people comfortable

argued on grounds of high mortality.

theguardian.com/commentisfree/…

Chinese CDC data: many older people survive

#Covid19

"A crisis on a scale that defies imagination is sweeping Britain’s care homes. Unseen, unreported and too often alone, our elderly are dying from the #coronavirus epidemic – killed by the system that is meant to keep them safe."

#Covid19 #Covid19UK

mirror.co.uk/news/uk-news/c…

13 now died in one week at 90 bedded Burlington Court care home, Lanarkshire

Two staff positive for #coronavirus receiving hospital treatment

#Covid19 #Covid19UK

mirror.co.uk/news/uk-news/c…

Ireland:

£££ help for care homes with #coronavirus
Cut down agency workers - the most obvious vectors
Daily staff temp checks
Infection control coordination - regional & national

What about UK?

@MattHancock

#Covid19UK #Covid19 #CoronaUK #StateOfCare

irishtimes.com/news/health/co…

While Irish Gov implements #coronavirus support package for care homes, for obvious public health reasons:

irishtimes.com/news/health/co…

"Almost 400 care companies which provide home support across UK have told BBC" they have not got enough PPE

#Covid19UK

bbc.co.uk/news/health-52…

1) Quickening #coronavirus disaster in care homes, deaths rising, and huge fears about gov policy, described as "importing death":

news.sky.com/story/coronavi…

The orgs which signed up to gov's policy:

assets.publishing.service.gov.uk/government/upl…

#Covid19UK #Covid19

2) In addition to being given v troubling messages about blanket DNR orders, care homes are told they should be able to cope with isolating possibly confused residents, based on policy assumptions about PPE they haven't got

#Covid19UK #Covid19

assets.publishing.service.gov.uk/government/upl…

15 residents dead of #coronavirus at 69 bedded Castletroy care home Luton

#Covid19 #Covid19UK #CoronaUK #StateOfCare

itv.com/news/anglia/20…

7 residents dead of #coronavirus at 60 bedded Hawthorn Green care home, London

21 residents symptomatic

#Covid19 #Covid19UK #CoronaUK #StateOfCare

news.sky.com/story/coronavi…

David-Revolving-Door-Behan, former CQC CEO, is Chair of care giant HCOne

Staff at Castleview care home Dunbarton, with 8 suspected #coronavirus deaths "belittled" about infection concerns & managers allegedly witheld PPE

#Covid19UK #OurNHSPeople #FTSU

eveningexpress.co.uk/news/scotland/…

3 care home companies say they are denied #coronavirus tests & that it's impossible to follow UK Gov advice on isolation

Carer: 'We are like cannon fodder. We are being made to risk our lives & lives of our loved-ones for £8.37 an hour.'

dailymail.co.uk/news/article-8… #Covid19UK

#Coronavirus outbreak at 126 bedded Newton House care home, Grantham

Barchester, the large private provider who runs a chain of care homes, has given little information

#Covid19 #Covid19UK #CoronaUK

lincolnshirelive.co.uk/news/local-new…

4 residents die of suspected #coronavirus at 124 bedded Vida Grange care home, Harrogate

Three others in hospital, one tested positive

The home is using ozone sanitising technology

#Covid19 #Covid19UK #CoronaUK

yorkpress.co.uk/news/18364576.…

#Coronavirus detected in 20 care homes across Northern Ireland

There are 484 N Ireland care homes, with a total of 16,000 beds

Social care workers & district nurses shortchanged on PPE

#Covid19 #Covid19UK #CoronaUK #StateOfCare

bbc.co.uk/news/uk-northe…

"Care workers & service users have been placed in terrible danger by belated & inadequate response to pandemic" by UK Gov & devolved assemblies

381 out of 482 UK care providers surveyed by BBC did not have adequate PPE #Covid19 #Covid19UK #StateOfCare

wsws.org/en/articles/20…

"Care home residents with suspected #coronavirus are being denied hospital beds, shadow minister [Barbara Keeley] has warned....concerns of ‘blanket policy’ across the system."

"entire sector is being denied protection equipment & testing"

#Covid19UK

manchestereveningnews.co.uk/news/greater-m…

Four residents have died after #coronavirus symptoms at 71 bedded Stanley Park care home, County Durham

One resident in hospital

Several other people symptomatic

#Covid19 #Covid19UK #CoronaUK

thenorthernecho.co.uk/news/18370949.…

"Industry body estimates up to 1,000 people may have died in care homes so far"

"Hundreds of UK care home deaths not added to official coronavirus toll"

#Covid19 #Covid19UK #CoronaUK #StateOfCare #LearningFromDeaths #Safeguarding #LeDeR

theguardian.com/world/2020/apr…

Sheffield: "Half of the residents in a care home we visited have #coronavirus."

"Newfield Nursing Home, where a whole floor has been devoted to caring for patients suffering from #COVID19."

PPE is "plastic aprons, masks and gloves"

#Covid19UK

news.sky.com/story/coronavi…

Labour, via @leicesterliz new shadow social care minister, has quite rightly called on UK Gov to include care home #Covid19 deaths in daily Gov deaths stats

#StateOfCare #LearningFromDeaths #Covid19UK #CoronaUK #Coronavirus #LeDeR #OurNHSPeople

theguardian.com/world/2020/apr…

Unsurprisingly, funeral directors allege UK care home #coronavirus deaths are not all reported

Fits with the pressure on primary care not to refer to hospital & to implement blanket DNR orders

@leicesterliz

#Covid19 #Covid19UK #CoronaUK #StateOfCare

dailymail.co.uk/news/article-8…

13 residents at 72 bedded Stanley care home, Durham, a Care UK facility, have now died of suspected #coronavirus

BBC report management say staff have PPE

bbc.co.uk/news/uk-englan…

Mixed employee reviews, eg:

indeed.co.uk/cmp/Care-Uk-He…

#StateOfCare #Covid19UK #Covid19

UK Gov is resisting transparency about care home deaths, but European data suggests that care homes may account for about HALF of #coronavirus deaths

ltccovid.org/2020/04/12/mor…

theguardian.com/world/2020/apr…

#StateOfCare #Covid19 #Covid19UK #LearningFromDeaths #OurNHSPeople #LeDeR

Joint statement 7 April 2020 by Age UK and other organisations which support older people, on the pressure on older people to accept DNR orders

ageuk.org.uk/latest-press/a…

#StateOfCare #Covid19 #Covid19UK #CoronaUK

Manchester Evening News reports a care home manager's concern about UK gov lack of support for social care sector, and policies which will import #coronavirus into care homes full of highly vulnerable, potential victims

#HerdImmunity #Covid19UK #AktionT4

manchestereveningnews.co.uk/news/greater-m…

A whistleblower who works in deaths registration in South England has informed @Channel4News that some #Covid19 deaths are not being recorded or counted

"dozens and dozens"

#Coronavirus #Covid19UK #CoronaUK #StateOfCare #OurNHSPeople #FTSU #LeDeR

channel4.com/news/can-we-re…

The deaths registration whistleblower reported by @Channel4News believes number of community deaths in their area is equivalent to number who died in hospital

This fits with other European data:

#Covid19 #Covid19UK #StateOfCare @C4Ciaran @leicesterliz

https://twitter.com/alexander_minh/status/1249813588392529921

More evidence supporting other European data which suggests that care home deaths account for roughly half of all #Covid19 deaths

ltccovid.org/2020/04/12/mor…

#Covid19UK #StateOfCare #CoronaUK #LearningFromDeaths

https://twitter.com/Davewwest/status/1249993952931074050

Why is #PatrickVallance saying this?

There is official data on care home deaths from Belgium, Ireland, France & Italy cited in this paper:

ltccovid.org/2020/04/12/mor…

Belgium has reported coronavirus cases in 90% of its care homes

#StateOfCare #Covid19UK

https://twitter.com/drjawalsh/status/1249732738841817088

Care giant HCOne (Chair David-Revolving-Door-Behan former CQC CEO) & MHA another provider report 311 & 210 #coronavirus deaths respectively

HCOne says two thirds of its 350 homes affected

CMO said only 13.5% UK care homes affected

theguardian.com/world/2020/apr… #Covid19 #Covid19UK

Even the Daily Mail....

UK "Tory Health Minister Helen Whately sniggers" when asked about 4,000 UK care home deaths

#Covid19 #Covid19UK #CoronaUK #Coronavirus

dailymail.co.uk/news/article-8…

Daily Mail says "Industry figures say the true count [of UK care home deaths] is much higher – potentially 4,000 dead"

But no source given as far as I can see

dailymail.co.uk/news/article-8…

#Covid19 #Covid19UK #CoronaUK

Scotland records & publishes number of care home #coronavirus deaths

So should Westminster

So far, a quarter of Scottish deaths have taken place in care homes (data as of 15 April 2020)

nrscotland.gov.uk/files//statist…

#Covid19 #Covid19UK #CoronaUK

NHS England's been forced to drop policy which helped keep older people out of hospital, which had effect of massaging UK Gov's daily #coronavirus death figures (which only include hospital deaths)

#LeDeR #LearningFromDeaths #Covid19 #Covid19UK #AktionT4

hsj.co.uk/patient-safety…

NHS England board in frame for rolling over on gov inaction on Exercise Cygnus & has faced calls to resign en masse

There's a horrible whiff of self interest in helping limit political damage to UK Gov by hiding harm

#LeDeR #Covid19UK #LearningFromDeaths

https://twitter.com/alexander_minh/status/1250687083968159744

Lack of UK #coronavirus testing generally & especially in care homes conveniently hides deaths numbers & also distorts data on whether the curve is really flattening, paving the way for political abuses on public safety

#Covid19 #StateOfCare #Covid19UK

expressandstar.com/news/health/co…

In Parklands Court care home's example below, over 20 suspected #Covid19 deaths were not registered as such, because they weren't tested despite two previous confirmed #coronavirus deaths in the home

#StateOfCare #Covid19UK #LearningFromDeaths #LeDeR

https://twitter.com/alexander_minh/status/1250696941350117376

Latest ONS #Covid19UK round up as of 16 April 2020

What's the real figure?

In particular, how many of the deaths registered under 'Dementia & Alzheimer's Disease' were actually #Covid19 deaths?

ons.gov.uk/peoplepopulati…

expressandstar.com/news/health/co…

#StateOfCare #ThinningTheHerd

LSE article on under-counting of UK care home #Covid19 deaths

Those who are not moved by deaths of older people should know that it affects us all when infections hubs are allowed to develop, through poor infection control

#Covid19UK #LearningFromDeaths

blogs.lse.ac.uk/politicsandpol…

Some UK care home staff are voluntarily becoming residential to protect residents

Pity UK Gov didn't lead

Similarly, UK Gov should have ensured healthcare workers treating #Covid19 are sequestered away from gen pop, as in China

#Covid19UK #StateOfCare

bbc.co.uk/news/uk-scotla…

Belgium reported 90% of its care homes have #coronavirus

Daily Mail now suggests up to 75% of UK care homes affected & reports survey which says 1.4% of residents died of #Covid19 - scaled up that's 5,300 nationally

dailymail.co.uk/news/article-8…

#Covid19UK

https://twitter.com/alexander_minh/status/1250012389652783107

Laing Buisson conducted the UK care home sector survey which produced result of 1.4% residents dead of proven or suspected #COVID19

The survey covered 13.5% of 385,100 total care home beds

6.8% residents believed infected with #Coronavirus

#Covid19UK

laingbuissonnews.com/care-markets-c…

1) New Candesic paper estimate that if 80% UK care home residents are infected, up to 100,000 could die

minhalexander.files.wordpress.com/2020/04/candes…

Attack rate in care homes likely to be high. An eg:

infectioncontroltoday.com/covid-19/covid…

#Covid19 #Covid_19 #Covid19UK #StateOfCare

2) Candesic partner Leonid Shapiro has estimated that there may have been 6,000 UK #Covid19 care home deaths so far

#HerdImmunity #ToryBritain #AktionT4 #Covid19UK #StateOfCare #LearningFromDeaths #LeDeR #CoronaUK #Covid_19 #OurNHSPeople

fr24news.com/a/2020/04/coro…

3) FT also reports Candesic estimate of 6,000 UK care home #Covid19 deaths & asks if true number of UK #coronavirus deaths so far is nearer 30,000

#HerdImmunity #Covid_19 #Covid19UK #OurNHSPeople #StateOfCare #LearningFromDeaths

ft.com/content/9d6b46…

reddit.com/r/worldnews/co…

4) In last few day, non-government estimates of UK care home #coronavirus deaths have climbed from 5,000, to 6,000 and now 7,500:

itv.com/news/2020-04-1…

Utterly corrosive when UK Gov stats can't be trusted

#Covid19 #StateOfCare #Covid19UK #Covid_19UK

https://twitter.com/alexander_minh/status/1251376310917779456

Some pushback on whether doctors should record #Covid19 on deaths certs

* @gmcuk guidance says you MUST *

In any case, it's just medical common sense during pandemic to help track reportable disease for public health purposes

gmc-uk.org/ethical-guidan… #Covid19UK #OurNHSPeople

Belgium reported 90% of its care homes had been infected with #coronavirus

1 in 4 (350) London care homes have declared outbreaks

news.sky.com/story/coronavi…

#Covid19 #Covid19UK #StateOfCare #CoronaUK

https://twitter.com/alexander_minh/status/1250012389652783107

20 suspected #Covid19 deaths at 69 bedded Berelands Care Home in Prestwick, Ayrshire:

bbc.co.uk/news/uk-scotla…

What will be overall #coronavirus attack rate in UK care homes, which have not been properly supported by UK Gov?

#Covid19UK #StateOfCare

https://twitter.com/alexander_minh/status/1246548115840212992

"Residential homes have emerged as key breeding ground for [#coronavirus] infections from Madrid to New York

theguardian.com/world/2020/apr…

Too late, ageist policy makers are realising poor infection control in care homes not only betrays the vulnerable, but affects everybody #Covid19

Care home deaths account for half of Irish & Scottish #Covid19 deaths, as in other European countries

Real UK #coronavirus death toll is likely to be at least twice the official daily statistic despite Gov dissembling

#Covid19UK

ft.com/content/aaf10e…

bbc.co.uk/news/world-eur…

Overall UK care home deaths likely account for approx half of UK #Covid19 deaths, as found in Ireland, Scotland & other European countries

-> Gives minimum estimate of 40,000 UK deaths so far

Current total world #coronavirus deaths reported to be approx 200,000

#HerdImmunity

1) #Coronavirus outbreaks 50 Northamptonshire care homes - comprises one fifth of homes in county

But counting process will underestimate number of affected homes

Local Authority & @PHE_uk refuse to release total number of cases

#Covid19 #Covid19UK

northamptonchron.co.uk/health/coronav…

2) Local Auth & @PHE_uk claim release of Northamptonshire care home #covid19 case numbers might breach privacy

But anonymised statistical data on total numbers would not!

Surely proactive transparency needed on global picture?

@ICOnews

#Covid19UK

https://twitter.com/alexander_minh/status/1255063070071820288

3) As ever, @ICOnews encourages public bodies to proactively publish data they know will be important to communities, including specifically during #coronavirus emergency

Esp as capacity for processing individual FOIs is much reduced

@PHE_EoEngland

ico.org.uk/media/about-th…

UK care home deaths predicted by Cambridge statistician to overtake hospital deaths:

thetimes.co.uk/edition/news/c…

There are many more care home beds than hospital beds

#Covid19 #Covid19UK #Coronavirus #StateOfCare #LearningFromDeaths

https://twitter.com/alexander_minh/status/1240875316534484994

Does manufacturing consent to ending UK #coronavirus lockdown early, at expense of our most vulnerable, including data throttling to simulate a false peak?

Certainly been a good deal of activity that massages stats

thetimes.co.uk/edition/news/c…

#Covid19 #Covid19UK #CoronaUK #LeDeR

Public Health England has published number and distribution of #Covid19 outbreaks in English care homes

Highest number in South East which has most care homes

At least 29% of English care homes now have #coronavirus

gov.uk/government/sta…

#StateOfCare #Covid19UK #LeDeR

Breakdown of #Covid19 outbreaks in Northamptonshire care homes, by local council, from today's Public Health England stats on care home outbreak numbers and distribution

gov.uk/government/sta…

#Covid19UK #StateOfCare #CoronaUK #LeDeR #Coronavirus

After Cheltenham Festival, 50% of care homes in Cheltenham Borouhg Council now have #Covid19 outbreaks according to today's Public Health England data

Total proportion of care homes affected across Glos LAs is 29%

gov.uk/government/sta… #Covid19UK #StateOfCare #CoronaUK

Yvonne Doyle Med Director of Public Health England claimed some care home #Covid19 patients died too quickly for tests to be done

thetimes.co.uk/edition/news/c…

Wonder how many post mortem #coronavirus tests have been done in UK?

rcpath.org/uploads/assets…

@Smyth_Chris #Covid19UK

Mark Lucraft Chief Coroner gives UK Gov a pass on key worker deaths due to shameful lack of #coronavirus PPE

judiciary.uk/wp-content/upl…

Labour objects:

theguardian.com/society/2020/a…

#Covid19 #Covid19UK #OurNHSPeople #StateOfCare #LearningFromDeaths #CoronaUK #Covid_19 #NHSWorkforce