UK Private Health Insurance Hidden Costs

The Hidden Costs of Healthcare Waiting: Beyond Bills, to Lost Earnings and Wellbeing

UK Private Health Insurance: The Hidden Costs of Waiting – Beyond Bills to Lost Earnings & Wellbeing

In the complex tapestry of modern life, few things are as universally valued as our health. While the National Health Service (NHS) stands as a cornerstone of British society, providing free healthcare at the point of need, its increasing pressures often lead to a less discussed, yet profoundly impactful, consequence: waiting. For millions across the UK, the wait for diagnosis, consultation, or treatment is not merely an inconvenience; it’s a silent drain on their finances, their careers, and their overall quality of life.

This comprehensive guide delves deep into the often-overlooked "hidden costs" of waiting for healthcare in the UK. Beyond the obvious medical bills, we uncover the far-reaching implications of delayed treatment, from lost earnings and career stagnation to the profound deterioration of mental and physical wellbeing. We'll explore how private medical insurance (PMI) can act as a crucial safeguard, offering a pathway to swifter care and mitigating these unseen burdens.

The UK Healthcare Landscape: NHS vs. Private PMI

The United Kingdom is unique in its commitment to universal healthcare, primarily delivered through the NHS. Funded by general taxation, the NHS provides comprehensive medical services to all residents, from routine GP appointments to complex surgeries, without direct charge at the point of use. This model is lauded globally for its equity and accessibility.

However, the NHS operates under immense and growing pressure. An ageing population, the rising tide of chronic diseases, advancements in medical technology (which often come with higher costs), and staffing shortages all contribute to a system under strain. This pressure is most acutely felt in the form of waiting lists.

Private Medical Insurance (PMI), also known as private health insurance, exists as a complementary, not replacement, service to the NHS. It allows individuals to access private healthcare facilities and services, often with shorter waiting times, choice of consultant, and enhanced comfort.

It is absolutely crucial to understand a fundamental principle of UK private medical insurance: Standard PMI policies are designed to cover acute conditions that arise after your policy begins.

This means:

• Acute Conditions: These are illnesses, injuries, or diseases that respond quickly to treatment and from which you are expected to recover fully. Examples include a broken bone, appendicitis, or a cataract.
• Conditions Arising After Policy Inception: For a condition to be covered, it must develop or be diagnosed after you have taken out and started your policy.

Conversely, standard UK PMI does not cover pre-existing or chronic conditions.

• Pre-existing Conditions: Any illness, injury, or symptom you had, were aware of, or received advice or treatment for before you took out your policy. These are typically excluded, though some specialist policies might offer limited cover after a long, continuous period with no symptoms or treatment, usually under "Moratorium" underwriting.
• Chronic Conditions: These are long-term illnesses that cannot be cured, require ongoing management, or recur frequently. Examples include diabetes, asthma, arthritis, or heart disease. While PMI might cover the acute flare-ups or initial diagnosis of a chronic condition, it generally will not cover the ongoing management, medication, or recurrent treatment for that condition. The ongoing care for chronic conditions remains primarily the responsibility of the NHS.

This distinction is vital for anyone considering PMI, as it shapes what you can realistically expect from your cover. PMI acts as a safety net for unexpected acute health events, providing peace of mind and faster access to care when you need it most.

Understanding Waiting Lists in the NHS: The Root Cause of Hidden Costs

The most visible manifestation of the NHS's pressures is its waiting lists. These lists aren't just numbers; they represent individuals in pain, families under stress, and lives put on hold.

According to NHS England data, as of May 2024, the total number of people waiting for routine hospital treatment stood at 7.6 million, with 6.33 million unique patients. Of these, 3.19 million people had been waiting for more than 18 weeks, and 309,300 had been waiting for more than a year. While the longest waits have seen some reduction, the overall backlog remains stubbornly high. These figures do not even account for waiting times for initial GP appointments, diagnostic tests, or mental health services, which also present significant delays.

Waiting lists manifest in several critical stages:

• GP Referral Waits: While typically swift to see a GP, getting a referral to a specialist can involve internal waits for administrative processing or appointment slots.
• Diagnostic Waiting Lists: Delays for crucial tests such as MRI scans, CT scans, ultrasounds, or endoscopy procedures can mean weeks or months before a diagnosis is even reached.
• Specialist Consultation Waits: After a referral or diagnosis, there are often significant waits to see a specialist consultant.
• Treatment Waiting Lists: Once a treatment plan is decided, the longest waits often occur for actual procedures, surgeries, or therapies.

The impact of these delays on patient health can be profound. What might start as a manageable condition can deteriorate, leading to increased pain, more complex treatment requirements, or even irreversible damage.

Consider the following statistics, which paint a sobering picture of the NHS’s operational environment:

(Sources: NHS England statistics, various reports by Nuffield Trust, King's Fund. Statistics are approximate and vary by region and specific reporting period.)

These delays aren't just medical problems; they are economic and social problems, creating a cascade of hidden costs that ripple through individuals, families, and the wider economy.

The Tangible Financial Costs of Waiting

While the immediate draw of PMI is avoiding medical bills, the financial burden of waiting for NHS care extends far beyond potential private treatment costs. These are the tangible financial impacts that often go unnoticed.

Direct Medical Costs (if forced to pay privately without insurance)

If an individual decides they cannot wait for NHS treatment and does not have PMI, they must bear the full cost of private care. These costs can be astronomical and are a significant barrier for most.

These costs quickly escalate. A simple diagnostic pathway – GP visit, specialist consultation, an MRI, and perhaps physiotherapy – could easily set someone back £1,000-£2,000. For surgery, the figures can be equivalent to a deposit on a house or a significant chunk of annual income.

Lost Earnings (Income Impact)

This is arguably the most pervasive and insidious financial cost of waiting. When health deteriorates, the ability to work, perform effectively, or even attend necessary appointments is compromised.

• Time Off for Appointments and Treatment: Even if you eventually receive NHS treatment, the accumulation of GP visits, hospital appointments, diagnostic tests, and follow-ups can mean significant time away from work. For those on hourly wages or without generous sick pay, this translates directly into lost income. Self-employed individuals are particularly vulnerable, as every hour not working is an hour not earning.
• Reduced Productivity While Awaiting Care: Living with pain, discomfort, anxiety, or a debilitating condition makes it incredibly difficult to concentrate or perform at full capacity. This "presenteeism"—being at work but not fully functional—leads to lower output, missed opportunities, and potentially impacts career progression.
• Inability to Work Due to Worsening Condition: As a condition progresses, it may render an individual temporarily or even permanently unable to work. This can lead to a complete loss of income, reliance on statutory sick pay (SSP) which is often insufficient, or navigating the complexities of long-term disability benefits. For many, SSP offers a paltry £116.75 per week (as of 2024/25), a fraction of most people's regular earnings.
• Long-Term Career Stagnation or Loss: Extended periods of ill health can derail careers. Promotions may be missed, skill sets may become outdated, and a prolonged absence can make returning to the workforce challenging. For businesses, this means losing valuable employees and having to invest in recruitment and training for replacements.
• Impact on Self-Employed and Small Business Owners: For those who are their own boss, their health is directly tied to their livelihood. A waiting list for a hip replacement or a diagnosis for chronic fatigue can mean business operations grind to a halt, contracts are lost, and financial stability crumbles. There's no corporate sick pay; every hour of illness is a direct hit to the bottom line.

Productivity Losses for Businesses

The hidden costs aren't just borne by the individual. Businesses, particularly small and medium-sized enterprises (SMEs), suffer significant productivity losses when employees are off sick or working at reduced capacity due to health issues. A 2023 report by Vitality found that ill health costs the UK economy £150 billion a year, with presenteeism (working whilst ill) being a major contributor. The CBI also regularly highlights the economic impact of ill health and NHS waiting lists on business.

Travel and Accommodation Costs

If specialist treatment or diagnostic facilities are not available locally (a common occurrence for specific, rare conditions or highly specialised procedures), individuals may incur significant travel and accommodation costs, adding to the financial strain, particularly for those on a tight budget.

Care Costs

Should a condition deteriorate due to waiting, it might lead to a temporary or permanent need for professional home care, or even institutional care, before or after eventual NHS treatment. These costs are substantial and generally fall to the individual or their family unless very specific and limited NHS continuing healthcare criteria are met. This often means family members, particularly spouses or adult children, have to reduce their working hours or give up work entirely to provide care, incurring further indirect financial losses.

The Intangible Human Costs of Waiting: Beyond the Balance Sheet

While financial costs are quantifiable, the human toll of waiting for healthcare is often more devastating, yet harder to measure. These are the burdens that weigh heavily on an individual's wellbeing, relationships, and overall quality of life.

Deterioration of Physical Health

The most direct intangible cost is the progression of the illness itself. What might have been a minor issue can become major, or even irreversible, due to delays:

• Increased Pain and Discomfort: Living with chronic or escalating pain day-in, day-out is debilitating. It affects sleep, mood, concentration, and the ability to perform basic daily tasks.
• Progression of Illness: Many conditions are time-sensitive. A small, treatable tumour could grow; joint degeneration could worsen to the point where more invasive surgery is required, or a full recovery is no longer possible.
• Risk of Irreversible Damage: For conditions affecting vision (e.g., glaucoma), hearing, or neurological function, prolonged waiting can lead to permanent impairment.
• Need for More Invasive Treatment Later: Delay often means that a condition that could have been managed with minor intervention now requires major surgery, more aggressive medication, or longer rehabilitation. This not only puts a greater strain on the body but also increases recovery time and potential complications.

Mental and Emotional Wellbeing

The psychological impact of waiting for healthcare is profound and often underestimated:

• Anxiety and Stress: The uncertainty of diagnosis, the fear of what a delay might mean, and the constant worry about future health can lead to high levels of anxiety. This is compounded by the stress of navigating the healthcare system and dealing with the pain or symptoms.
• Depression: Prolonged pain, loss of independence, financial strain, and the feeling of helplessness can easily lead to depression. The inability to participate in life as before, coupled with the lack of immediate solutions, can be incredibly demoralising.
• Impact on Sleep: Pain and anxiety are notorious sleep disruptors, leading to a vicious cycle of fatigue, reduced resilience, and worsening mood.
• Feeling of Helplessness and Loss of Control: When one's health is in decline and access to swift treatment is elusive, individuals can feel a profound loss of control over their own lives, which is deeply disempowering.
• Impact on Relationships and Family Life: The stress of illness and waiting lists can strain family relationships. Partners may become carers, children may see their parents less able to engage, and the entire family unit can suffer from the emotional and practical burden.

Reduced Quality of Life

Beyond the immediate symptoms, waiting for treatment erodes an individual's overall quality of life:

• Inability to Participate in Hobbies and Social Activities: Pain, fatigue, or the need to conserve energy can force individuals to withdraw from sports, hobbies, social gatherings, and other activities that bring joy and fulfilment.
• Loss of Independence: As a condition worsens, individuals may become reliant on others for tasks they once performed independently, leading to feelings of frustration and inadequacy.
• Impact on Family Dynamics: Spouses may take on additional burdens, and children may have to mature faster to assist with family responsibilities or care for a sick parent. This can create resentment or feelings of guilt.
• Missed Opportunities: Personal milestones (e.g., attending a wedding, going on a dream holiday) or career opportunities (e.g., taking on a challenging project, applying for a promotion) can be missed due to ill health or the inability to plan around unpredictable healthcare waits.

These intangible costs are the silent destroyers of wellbeing, often accumulating long before any direct medical bill arrives. They underscore why the proactive decision to consider private medical insurance is not just a financial calculation, but an investment in preserving one's life quality.

Case Studies/Real-Life Scenarios: Illustrating the Impact

To truly grasp the hidden costs, let's consider a few illustrative, albeit fictional, scenarios that highlight the distinct paths taken with and without PMI.

Scenario 1: The Active Professional with Knee Pain

Meet Sarah, 48, a marketing manager. Sarah loves hiking and has an active social life. She develops persistent knee pain that starts to impact her ability to walk long distances and even climb stairs comfortably.

• Without PMI (NHS Pathway):

  • Week 1: Visits GP. Referred to orthopaedics.
  • Week 6: Receives letter for specialist consultation. Current waiting time estimated at 16 weeks.
  • Week 22: Sees orthopaedic specialist. Recommended MRI.
  • Week 26: MRI scan finally conducted.
  • Week 30: Follow-up consultation reveals a torn meniscus requiring arthroscopy. Put on waiting list for surgery.
  • Week 40: Surgery performed.
  • Week 42-60: Physiotherapy begins, but wait times for NHS physio are long. Sarah takes two sessions of private physio for £80 each, because she can't wait.
  • Total Time: Over a year from initial pain to partial recovery.
  • Hidden Costs:
    • Lost Earnings: 5 days sick leave for consultations/scan/surgery. 1 week post-surgery recovery. Reduced productivity for months due to pain. Missed a key project at work because she couldn't stand for long presentations, delaying a potential promotion. Estimated lost income/opportunity cost: £3,000+.
    • Wellbeing: Frustration, anxiety, unable to hike or enjoy hobbies for a year. Deterioration in fitness. Strain on relationship with partner due to her mood and limitations.
    • Direct Costs: £160 for private physio.

• With PMI (Private Pathway):

  • Week 1: Sarah experiences knee pain. Calls private GP service (often included with PMI) or sees NHS GP. Gets referral.
  • Week 2: Consults a private orthopaedic specialist. MRI scan arranged for within days.
  • Week 3: MRI scan results reviewed with specialist. Diagnosis of torn meniscus. Surgery scheduled for the following week.
  • Week 4: Arthroscopy performed in a private hospital. Private physio sessions booked immediately post-op.
  • Week 6: Sarah is already back to light walking, actively rehabilitating.
  • Total Time: Approximately 6 weeks from initial pain to significant recovery.
  • Benefits:
    • Minimal Lost Earnings: 2 days off work. Back to full productivity swiftly.
    • Enhanced Wellbeing: Less pain, faster resolution, back to hobbies quickly. Minimal anxiety.
    • Financial Peace of Mind: All covered by PMI (minus policy excess).

Scenario 2: The Small Business Owner with Debilitating Fatigue

Meet David, 55, owner of a thriving graphic design studio. He starts experiencing extreme fatigue, brain fog, and muscle aches, significantly impacting his ability to work and manage his team.

• Without PMI (NHS Pathway):

  • Month 1-3: Numerous GP visits, initial blood tests (all normal), told it's "stress." Fatigue worsens. Client deadlines are missed, new projects are turned down.
  • Month 4: Finally referred to a specialist (e.g., rheumatologist or neurologist) for further investigation. Waiting list: 6-9 months.
  • Month 10: Sees specialist. More tests ordered, leading to a slow, incremental diagnostic process.
  • Month 12+: Still no clear diagnosis, but symptoms persist, forcing David to reduce his working hours significantly. He considers selling his business or letting staff go.
  • Hidden Costs:
    • Business Impact: Revenue dropped by 50%. Lost several key clients. Staff morale affected due to uncertainty. Business nearly folds. Estimated business loss: £50,000+ in revenue.
    • Financial Impact: David took no salary for months. Drained personal savings.
    • Wellbeing: Severe depression, isolation, feeling of failure. Strain on family due to financial worry and David's inability to engage.

• With PMI (Private Pathway):

  • Week 1: David uses his PMI virtual GP service. Symptoms are taken seriously. Immediate referral to a private specialist network.
  • Week 2: Sees a top private rheumatologist/neurologist. Comprehensive blood tests and diagnostic imaging ordered for the same week.
  • Week 3: Initial diagnosis (e.g., early-stage autoimmune condition or chronic fatigue syndrome). Treatment plan starts immediately with specialist and allied health professionals.
  • Month 2: With proper diagnosis and management, David starts to feel better, gradually increasing his work hours.
  • Benefits:
    • Business Continuity: Minimal disruption. David can manage symptoms and work.
    • Rapid Diagnosis: Crucial for managing conditions and preventing long-term damage.
    • Mental Health: Less anxiety due to proactive management and clear pathway.
    • Financial Stability: Business protected, personal finances secure.

These examples vividly demonstrate that the 'cost' of waiting extends far beyond a simple medical bill; it can encompass entire livelihoods, personal aspirations, and mental fortitude.

How Private Medical Insurance Mitigates These Hidden Costs

PMI doesn't eliminate all health challenges, nor does it replace the NHS. Instead, it offers a powerful mechanism to mitigate the hidden costs of waiting by providing timely access to care for acute conditions.

1. Faster Access to Diagnostics and Treatment: This is the primary and most significant benefit. PMI policies typically offer access to private consultations, diagnostic scans (MRI, CT, X-ray), and surgical procedures with significantly shorter waiting times compared to the NHS. This means a quicker diagnosis, less time in pain, and a faster return to health and work.
2. Choice of Specialist and Hospital: With PMI, you often have the freedom to choose your consultant and the hospital where you receive treatment, within your insurer's network. This choice can be invaluable, allowing you to select a specialist known for their expertise in your specific condition, or a hospital facility that offers greater comfort or convenience.
3. Comfort and Privacy: Private hospitals and facilities typically offer private rooms with en-suite bathrooms, better catering, and more flexible visiting hours. While these aren't medical necessities, they significantly contribute to a more comfortable and less stressful recovery environment.
4. Enhanced Recovery Environment: Many PMI policies include or allow for easier access to post-operative physiotherapy, rehabilitation services, and mental health support. This holistic approach to recovery can accelerate healing and ensure a more complete return to normal life.
5. Proactive Health Management Tools: Increasingly, PMI policies offer additional benefits such as virtual GP services (often available 24/7), online physiotherapy platforms, mental health helplines, and even health assessments. These tools can help catch issues earlier, provide immediate advice, and reduce the need for in-person appointments, further saving time and reducing stress.
6. Peace of Mind: Perhaps the most undervalued benefit is the psychological comfort of knowing that if an acute health issue arises, you have a clear pathway to prompt care, bypassing potentially long and anxiety-inducing NHS waiting lists. This peace of mind allows individuals to focus on their lives and work, rather than dwelling on health anxieties.

Again, it's essential to reiterate that PMI covers acute conditions that develop after your policy begins. It’s for new, unexpected health challenges, not ongoing management of chronic illnesses or conditions you already had. This makes it an invaluable proactive measure rather than a reactive solution for existing problems.

Dispelling Myths and Understanding PMI Limitations

Despite its benefits, private medical insurance is often misunderstood. Clarifying these points is crucial for anyone considering a policy.

Myth 1: Private Medical Insurance Replaces the NHS

Reality: This is fundamentally untrue. PMI complements the NHS. The NHS remains the primary provider of emergency care, GP services (though some PMI policies include virtual GP access), and ongoing management for chronic conditions. If you have PMI and experience a life-threatening emergency, you would still go to an NHS A&E. PMI is designed to provide faster access to elective, non-emergency treatment and diagnostics for acute conditions.

Myth 2: It Covers Everything

Reality: As stated repeatedly, standard UK private medical insurance does not cover chronic or pre-existing conditions. This is a critical distinction. It also typically excludes:

• Emergency care (as this is handled by NHS A&E).
• Normal pregnancy and childbirth (though some specialist plans might offer limited maternity cash benefits).
• Cosmetic surgery (unless medically necessary).
• Organ transplants (often limited or excluded).
• Drug or alcohol abuse.
• Self-inflicted injuries.
• Conditions arising from war or civil unrest.
• Overseas treatment (unless specific travel cover is added).

PMI is for acute conditions – illnesses, injuries or diseases that are likely to respond quickly to treatment and enable you to return to the state of health you were in immediately before the condition developed.

Myth 3: It's Only for the Wealthy

Reality: While PMI can be an investment, it's far more accessible than many assume.

• Various Levels of Cover: Insurers offer a spectrum of policies, from basic (e.g., covering only in-patient treatment) to comprehensive (covering out-patient, mental health, dental, optical). You can tailor a policy to your budget and needs.
• Controlling Costs: Options like higher excesses (the amount you pay towards a claim), 6-week options (where you use the NHS if the wait is under 6 weeks), or limiting your hospital choice can significantly reduce premiums.
• Group Policies: Many employers offer PMI as an employee benefit, which can be a highly cost-effective way to gain cover.

Here’s a table summarising key inclusions and exclusions:

This table underscores the focused nature of PMI on acute, unexpected health events.

When to Consider Private Health Insurance: The Proactive Approach

Given the insights into hidden costs and the nature of PMI, when is the right time to consider it? The answer is almost always: before you need it.

• Before Symptoms Appear: This is perhaps the most important time. PMI will not cover conditions you already have. By securing a policy when you are healthy, you ensure that any future acute conditions will be covered. If you wait until you have a health issue, it will likely be classed as pre-existing and excluded from your policy.
• If You Are Self-Employed or Run a Business: Your income and your business's viability are directly tied to your health. PMI provides a vital safety net, ensuring rapid return to work and minimising financial disruption.
• If You're Concerned About NHS Waiting Times: If you value prompt diagnosis and treatment and want to avoid the anxiety and hidden costs of long waits, PMI offers a clear alternative for acute conditions.
• If You Value Choice and Comfort: For those who desire the ability to choose their consultant, a private room, and a more tailored healthcare experience, PMI provides these options.
• If You Have Dependents: Your health directly impacts your family. Having PMI can ensure you're able to continue supporting them without long periods of illness or financial strain.
• If You're Approaching an Age Where Health Issues Become More Common: While no one can predict the future, the likelihood of developing an acute health condition generally increases with age.

Taking out PMI is a proactive step, much like car insurance or home insurance. You don't wait for an accident or a flood; you get covered beforehand for peace of mind and protection against future unforeseen events.

Navigating the UK Private Health Insurance Market: Finding the Right Fit

The UK private health insurance market can appear daunting. With multiple providers (such as Bupa, Aviva, AXA Health, Vitality, WPA, National Friendly, and Freedom Health), a myriad of policy options, and complex terms and conditions, it's easy to feel overwhelmed.

Key factors to consider when choosing a policy include:

• Budget: What can you realistically afford in monthly or annual premiums? Remember that cheaper policies often come with higher excesses or more limited cover.
• Level of Cover:
  • In-patient Only: Covers treatment requiring an overnight stay. This is the most basic and cheapest option.
  • Full Cover (In-patient & Out-patient): Covers both overnight stays and day-patient/out-patient consultations, tests, and therapies. More comprehensive and more expensive.
• Excess: This is the amount you agree to pay towards a claim. A higher excess will reduce your premium.
• Network of Hospitals: Some policies restrict you to a specific list of hospitals, while others offer a wider choice. Limiting your choice can reduce costs.
• Underwriting Method:
  • Full Medical Underwriting: You provide detailed medical history upfront. This gives clarity on what's covered/excluded from the start.
  • Moratorium Underwriting: No detailed medical history upfront. Pre-existing conditions are automatically excluded for an initial period (typically 2 years). If you have no symptoms or treatment for that condition during this period, it may then be covered.
• Optional Add-ons: Consider if you need extras like:
  • Mental Health Cover: For access to private counselling, psychotherapy, or psychiatric care.
  • Dental and Optical Cover: For routine check-ups, treatments, glasses, or contact lenses.
  • Physiotherapy/Complementary Therapies: Access to a wider range of physical therapies.
  • Virtual GP: For convenient remote consultations.

This is where an independent, expert broker like WeCovr becomes invaluable. We understand the nuances of each provider's offerings, helping you navigate the complexities of policy terms, exclusions, and pricing models. WeCovr works with all major UK health insurers, allowing us to compare plans comprehensively and find the right coverage that aligns with your specific needs and budget. We provide clear, impartial advice, ensuring you understand exactly what you're buying, so there are no unwelcome surprises when you need to make a claim. Our expertise means we can simplify the process, helping you make an informed decision that safeguards your health and finances.

Conclusion

The decision to secure private medical insurance in the UK is a significant one, and it's far more nuanced than simply avoiding NHS waiting lists. The true cost of waiting for healthcare extends into every facet of life – silently eroding financial stability through lost earnings, diminishing physical capabilities, and taking a heavy toll on mental and emotional wellbeing.

While the NHS remains a cherished institution providing essential services, its inherent pressures mean that for non-emergency acute conditions, the burden of delay often falls squarely on the individual. This burden manifests not just in potential medical bills if one opts for private care without insurance, but in the insidious accumulation of lost income, reduced productivity, spiralling anxiety, and a profound deterioration in overall quality of life.

Private medical insurance acts as a critical strategic investment, offering a pathway to swift diagnosis and treatment for acute conditions that arise after your policy begins. By facilitating quicker access to specialists and procedures, PMI helps mitigate these pervasive hidden costs, allowing individuals to return to health, work, and a full life with minimal disruption.

It's about proactive protection – safeguarding your future health and financial resilience against the unexpected. If you're considering private health insurance, engaging with an expert broker like WeCovr can demystify the options, ensuring you choose a policy that truly serves as a robust shield against the unseen, yet very real, costs of waiting. Investing in your health today is investing in your future peace of mind, your financial security, and your overall wellbeing.