WORKFORCE RISKS AND OPPORTUNITIES ARTS THERAPISTS EDUCATION COMMISSIONING RISKS SUMMARY FROM 2012

Transcription

1 WORKFORCE RISKS AND OPPORTUNITIES ARTS THERAPISTS EDUCATION COMMISSIONING RISKS SUMMARY FROM 2012 AUGUST 2012

2 Welcome to the 2012 CfWI workforce risks and opportunities: education commissioning risks summary (WRO ECRS 2012) for arts therapists. The WRO ECRS 2012 reports cover all professions across health and social care, except the medical profession, which was covered in a report in 2011 ( /medical-shape-2011). The reports will be submitted to the Department of Health in several tranches between November 2011 and the end of August This is a time of great change in the NHS. Employers are considering how best they can transform their services to maximise the quality of patient care, improve productivity and release the 20 billion savings to be reinvested in front line clinical care. This work could have a major impact on the future shape of the workforce and so needs to be considered alongside education and training commissioning decisions that are being made now. Financial allocations are a pivotal component of the overall education and training annual process across England. Presently the Department of Health secures funding to invest in the workforce through the Multi-Professional Education and Training (MPET) levy which is around 4.9 billion for 2011/12. This funding is currently allocated to Strategic Health Authorities (SHAs) largely based on historic patterns of training. The Department sets out key priorities and holds SHAs to account through a Service Level Agreement (SLA). SHAs develop plans for education commissions based on local workforce plans and then commission and fund training from education and clinical placement providers. Looking towards 2012/13, a flat cash settlement for MPET is likely. This allocation will have to accommodate a range of cost pressures which will include new costs, price increases and volume changes. In setting local investment priorities for the MPET allocation, SHAs are encouraged to consider the evidence presented within the WRO ECRS 2012 and the medical specialty training numbers reports. While funding for training for arts therapies courses is not provided through MPET, the arts therapies workforce needs to be considered in the context of skill mix. We hope you find the reports useful, and as always, appreciate your constructive feedback. Professor Moira Livingston Commissioning Director CfWI 2

3 Purpose This information has been collated to inform decisions on education commissioning over the next three to five years. It considers the key factors influencing the estimation of future need for arts therapists and gives an assessment of the current workforce supply. It includes regional perspectives, a summary analysis of risks in education commissioning, and examples of practice. Arts therapies courses are not funded by the NHS. The term arts therapists includes art therapists, dramatherapists and music therapists. Arts therapists work with different groups in a variety of ways across health, social care and public health. work with a range of care groups including people with severe mental health problems, eating problems, dementia and learning disabilities, as well as during rehabilitation and reablement programmes. The Department of Health (DH) definitions are: Art therapists Art therapists provide a psychotherapeutic intervention that enables clients to effect change and growth by the use of art materials to gain insight and promote the resolution of difficulties. Dramatherapists Dramatherapists encourage clients to experience their physicality, to develop an ability to express the whole range of their emotions and to increase their insight and knowledge of themselves and others. Music therapists Music therapists facilitate interaction and development of insight into clients behaviour and emotional difficulties through music. KEY FINDINGS There may be an increase in demand for arts therapists in future, as recent policies call for improved support for people with a variety of conditions where arts therapies could help. NHS data does not differentiate between art, drama and music therapists, limiting detailed analysis. There is insufficient data on the non-nhs workforce. A large proportion of registered arts therapists work outside the NHS, including in the private, voluntary and independent sectors. While there has been a reduction in NHS arts therapists, overall registrations have increased. This may suggest a shift from NHS to non-nhs services. 3

4 Next steps The Health and Social Care Information Centre (HSCIC) to separate NHS workforce data into art, drama and music therapists. The CfWI to work with professional bodies to develop and utilise workforce data for non-nhs staff, as the majority work outside the NHS. Professional bodies to produce and publish evidence of arts therapies improving outcomes for people, in addition to existing evidence from Cochrane reviews and other systematic reviews collated elsewhere (see Anglia Ruskin University, 2012; Nordoff Robbins Presenting the Evidence, 2012). If changes to student funding reduce the supply of students able to fund themselves, the Higher Education Funding Council for England (HEFCE) to consider inclusion of arts therapists on the Equivalent Level Qualification (ELQ) exemption list, or the DH to consider funding the courses just as other Allied Health Professionals (AHP) courses are funded. Employers to improve utilisation of the arts therapist workforce, in accordance with the outcomes frameworks for the NHS, public health and social care. Service providers to recognise and realise the benefits of preceptorship. 4

5 CONSIDERATIONS FOR FUTURE REQUIREMENTS Policy drivers Table 1 summarises the key policy drivers and their references. Table 1: Policy drivers affecting the workforce arts therapists Key driver 1. Changes to career framework These changes aim to build a flexible and responsive allied health professions (AHP) workforce with relevant nationally transferable competencies, in order to improve quality and productivity. Better utilisation of the contribution of arts therapists in terms of skill mix could be an affordable way to deliver highquality care. This may have implications on future workforce planning. Relevant policy Modernising allied health professions (AHP) careers: a competence-based career framework (DH, 2008a) Report to the national allied health professional advisory board on the outcomes of the modernising allied health professional careers programme (DH, 2011a) Nationally transferable roles (SfH, 2010) Preceptorship framework for newly qualified nurses, midwives and allied health professionals (DH, 2010) The QIPP agenda (DH, 2009a) Liberating the NHS: Developing the healthcare workforce (DH, 2012) Developing and embedding the leadership framework progress report October 2011 (NHS Leadership Academy, 2011) Clinical leadership competency framework project (NHS Institute for Innovation and Improvement, 2010) 2. Change in commissioning of services, Any Qualified Provider (AQP) This policy is relevant to arts therapists as they support people with mental health needs. The policy aims to enable people who use services to choose between qualified providers of service, where this can improve care. This policy is being phased in over time, with some services switching to AQP from April Any qualified provider (AQP) (DH, 2011b) Transformation within health, through creativity, culture and art (Arts for Health, 2011) Health and wellbeing boards (DH, 2011c) Organisations such as Arts for Health are forming strategic partnerships with other organisations such as the 5

6 Department of Health (DH) to improve research and establish links between service providers. Commissioning of arts therapists in future will depend on decisions made by the new health and wellbeing boards. 3. New approach to special educational needs The Department for Education (DfE) consulted on potential changes to the delivery of services for children with special educational needs, such as streamlining assessments, and earlier identification of need. Support and aspiration: A new approach to special educational needs and disability green paper (DfE, 2011) This may impact on demand for arts therapists in education. 4. Mental health and learning disability policy There is growing recognition of mental health needs in people of all ages, which may increase demand for arts therapists in the future. There is also increasing emphasis on improving the quality of life of people with learning disabilities. New policies focus on early and effective intervention and improved access to therapies. 5. Cancer and end-of-life strategy Government policy aims to improve end-of-life care, and services for people with cancer. provide service to people with cancer and progressive illness, to work through emotional needs. It is possible that these policies may result in a greater demand for arts therapists. Improved mental health therapies for children (DH, 2011d) No health without mental health (DH, 2011e) Valuing people now: a new three-year strategy for people with learning disabilities (DH, 2009b) End of life care strategy - promoting high quality care for all adults at the end of life (DH, 2008b) Improving outcomes: A strategy for cancer (DH, 2011f) Strategic health authority (SHA) perspective SHAs work in partnership with employers (service providers), service commissioners, education providers and each other to assess workforce requirements. SHAs work with local employers to inform their decision making. The CfWI has therefore engaged primarily with SHAs as the agreed route to ensuring that the views of employers are considered, as part of this work. Following NHS reform, it is likely that the CfWI will engage with employer-led Local Education and Training Boards to gain this perspective. The overall numbers of art, drama and music therapists are small, and not all local employers in the regions commission posts. Demand is driven by employers and many of this profession are independently employed. Some regions have described a move towards a more session-based commissioning approach for this workforce rather than full-time employment. Identifying this workforce, and its size, can be a challenge due to independent employment. In the view of some SHAs, arts therapists are not a key area of focus in the NHS and, as such, there is a risk that this group will experience reduced demand for their services from providers. 6

7 Profession s view 1 The British Association for Art Therapists (BAAT) reports that, while art therapy has been shown to be cost and clinically effective, the number of specialist art therapy posts in the NHS has decreased, although many art therapists are now employed under other generic titles such as mental health workers (BAAT, 2011a). This has been attributed to various factors, including the economic downturn, lack of awareness of the role, and regional differences in opportunity. Although there are National Institute for Health and Clinical Excellence (NICE) guidelines that support the use of arts therapies to treat people living with conditions such as schizophrenia and personality disorders, the full range of conditions supported by the service is not explicitly acknowledged. The professions consider that more robust research needs to be carried out to add weight to the array of anecdotal and some scientific evidence as to the benefits of arts therapies. Several Cochrane Reviews have highlighted positive outcomes for music therapy, including for schizophrenia (Cochrane, 2011).The Boorman Review highlights the significance of mental health problems on sickness absence in the workforce (Boorman, 2009). Demographics provide service to people of all ages. In particular, the service is used by people with communication difficulties, mental health needs and learning disabilities. People with complex needs are living longer and into later life. The general population is also growing and ageing; according to Office for National Statistics (ONS) forecasts, the total population of England is projected to grow from 52.7 million to 60.4 million in 2031 (ONS, 2010). Additional drivers Economic downturn Art, drama and music therapy courses are not funded by the NHS therefore students must identify funding themselves to gain qualifications. Art, drama and music therapy courses are not exempt from the Equivalent Level Occupation (ELQ) rule, which means that students who already have a masters level qualification must pay higher fees than those who do not.. With the rise in the cost of university fees from 2012, both of these factors may deter future applicants. Also, as the professions are market driven, the economic downturn may have a detrimental impact on service provision. If the cost of university fees results in an undersupply of students becoming art, drama or music therapists and there is still a market demand for arts therapists, inclusion on the ELQ 1 The CfWI engaged with representatives from each profession to inform this report. Although in some cases the source is not explicitly named, this information may be available on a case-by-case basis. Please contact the CfWI if more information is required. 7

8 exemption list could enable more students to take arts therapies courses. Alternatively, the DH could consider funding these courses just as other AHP courses are. CURRENT AND FORECAST SUPPLY Existing workforce Supply Much of the service within the NHS is provided in mental health and learning disability settings. However, most arts therapists are employed outside the NHS, in local authorities and the private, independent and voluntary sectors. Table 2 shows the NHS arts therapist workforce in 2010, which consists of art, drama and music therapists. This shows a mainly part-time workforce, with the majority of NHS staff working at the therapist level. Table 2: Current qualified NHS workforce arts therapists Staff type Headcount (HC) Full-time equivalent (FTE) FTE/HC Consultant therapist Manager Therapist Instructor/teacher Total *Headcount totals may not equal the sum of components. Source: HSCIC Non-Medical Census 2011a Table 3 shows the Health Professions Council (HPC) registered arts therapist headcount (HC) in England (HPC, 2010). This shows that many more arts therapists were registered than were employed in the NHS alone, with 30.6 per cent of registered arts therapists working in the NHS. Art therapists make up more than half of the arts therapists group, which is predominantly female. Some arts therapists on the HPC register may have retired but remain on the register until their current membership requires renewal; at that point they will leave the register. 8

9 Under and over Total Education commissioning risks summary Table 3: Current qualified registered arts therapists Staff type Female HC Male HC Unknown Total Art therapists Music therapists Drama therapists Total Source: HPC registration data as at September 2010 Age profile Figure 1 shows the age profile for the arts therapist NHS workforce in England. Figure 1: HC and FTE age profile by 5-year age band, 2010 arts therapists 140 Age profile (HC and contracted FTE) - arts therapists Contracted FTE Headcount Age bracket (years) Source: HSCIC Monthly Workforce Extract, April 2011 Note that the Under 25 age bracket only contains those between the ages of 21 and 24, whereas the other groups are in 5-year bands, therefore the relative numbers for that age band in figure 1 will be smaller. Figure 1 indicates that there is no impending retirement bulge in the NHS workforce, as there is a good supply of younger arts therapists. It is unknown whether the NHS age profile is representative of all arts therapists, as there is no available data for art, drama and music therapists separately. Current vacancies and employment The HSCIC (2010) three-month vacancy rates showed that the London SHA had one arts therapist vacancy as at March 2010, while the remaining SHAs record no vacancies. However, these rates could be misleading as not all local providers employ arts therapists, and qualified arts therapists are often employed under generic job titles. Non-NHS vacancy rates are unknown. 9

10 Art therapists A survey of the art therapist workforce found that only 58 per cent of people who qualified in 2007, 2008 and 2009 found employment as art therapists, while a further 37 per cent found employment in a similar role to an art therapist but with generic job titles such as mental health worker, which tend to pay less (BAAT, 2011a). The BAAT has expressed concern that these generic roles are replacing specialist roles in order to reduce costs, which may lead to a loss of skill in the workforce. Dramatherapists and music therapists The BAMT keeps a detailed register of employment details for members but this data is a not yet collected for the CfWI. It lists role type and employment role, together with population. According to representatives from the BAAT and the BAMT, the issue of generic roles replacing specialist roles is likely to be common to dramatherapy and music therapy as well as art therapy. Trainees Places on art, drama and music therapy postgraduate courses are not commissioned under Multi-Professional Education and Training (MPET) funding. Students must therefore identify their own funding for training. To qualify as an art, drama or music therapist, students must have appropriate experience such as a primary degree in art, drama or music, and then complete an MA in art therapy/art psychotherapy, dramatherapy or music therapy. Courses are usually two years (full time) or three years (part time) (BAMT, 2012) (BADTh, 2012). There are 22 courses in total (10 for art therapy, five for dramatherapy and seven for music therapy). These are delivered across the country, with more courses found in the south and midland areas than in the north. The BAAT (2011b) indicates that there have been large numbers of successful art therapy graduates every year up to However, there is the risk that the number of people enrolling in art therapy courses could reduce when university fees are increased. This may also apply to drama and music therapy graduates, although there is no available evidence to support this specifically. Geographical distribution Figure 2 shows the HC of NHS arts therapists in each SHA in September 2010 (HSCIC, 2011a) and the weighted capitation (DH, 2011g). The data is also presented by SHA as percentages of the total for England, thereby allowing for comparison with the weighted capitation for each SHA. The CfWI recognises that it is also important that all training posts are of high quality, and high-quality training placements may not be equally available across England. Figure 2 is intended for use in conjunction with local intelligence. 10

11 Based on weighted capitation alone, Figure 2 indicates that the London, East of England and South West SHAs have a higher arts therapist HC than if provision were to follow weighted capitation, while the remaining SHAs have a lower HC than their weighted capitation. However, Figure 2 does not take into account the non-nhs workforce, which accounts for the majority of arts therapists, so it is unknown to what extent non-nhs arts therapists contribute to overall service provision in each SHA. Figure 2: Map showing NHS staff, planned and actual commissions in relation to weighted capitation by SHA arts therapists Source: HSCIC Census 2011 (headcount); DH 2011 (weighted capitation). 11

12 Total Education commissioning risks summary Regional perspectives Training is not commissioned by the SHAs for these professions. There has been specific feedback from the SHAs on their employment plans. The East Midlands SHA often has challenges identifying the requirements for these professions. These professions often have close links to mental health trusts within the region. Demand for this workforce in the London SHA is reducing and there is a shift to using these professionals on a session-by-session basis rather than in full-time employment. The West Midlands SHA has no significant initiatives or changes proposed for this workforce. Supply projections The models for commissioning the education and training of arts therapists, including students identifying funding for themselves, complicate supply and demand modelling. There is also insufficient training data available, so it is not possible to model future supply at this stage. Figure 3 shows that the full-time equivalent (FTE) NHS arts therapy workforce decreased by 15.7 per cent between 2006 and The participation rate remained relatively static overall, changing from 0.67 in 2006 to 0.68 in 2010, with a dip to 0.63 in However, a large proportion of arts therapists work outside the NHS. Figure 3: Historical NHS workforce HC and FTE since 2006 arts therapists Historical NHS workforce - arts therapists NHS HC NHS FTE Source: Health and Social Care Information Centre (HSCIC) Non-Medical Census 2011a 12

13 Total Education commissioning risks summary Figure 4 shows the NHS HC and HPC registrations for arts therapists since This shows that while the NHS workforce has decreased, the total registrations have increased by 25.6 per cent. Assuming the majority of HPC registered arts therapists are working, this suggests that there has been a continued increase in service provision in the non-nhs sectors alongside a slight decrease in the NHS. However, there is a lack of non-nhs data to confirm this. Figure 4: Historical workforce HC and FTE since 2006 arts therapists 3500 Historical HPC registrations and NHS workforce - arts therapists Total HPC registrations NHS HC Source: Health and Social Care Information Centre (HSCIC) Non-Medical Census 2011a; HPC 2010, 2011a, 2011b Interplay with related groups may work alongside a wide range of professionals, including the following professionals: speech and language therapists (often in schools) dietitians (often in eating disorder services) occupational therapists other mental health professionals. Additionally, arts therapists could provide an element of skill mix, for example, to contribute to the mental health service. This could be an affordable way to deliver high-quality care to meet the increasing demands of the growing population. 13

14 CONCLUSION provide service across healthcare, social care and public health. They support colleagues in services such as mental health, education, rehabilitation and social care. Robust evidence is needed on the contribution of arts therapists in improving outcomes for people using their services. Such evidence could drive improvements in the utilisation of the arts therapist workforce. Government policies and strategy emphasises the role of arts therapies in meeting the needs of different care groups. In the challenging economic climate, the new health and wellbeing boards may choose to commission more posts for arts therapists to support improved skill mix in the healthcare and social care sectors. There is also a growing population, which may increase demand for the service. However, as prospective students must identify their own funding to train, the economic climate may threaten the future supply of newly qualified arts therapists due to the rising cost of tuition. Furthermore, unlike other healthcare qualifications, courses in the arts therapies are not exempt from the ELQ list. If this proves to be an issue in future, Inclusion on the ELQ exemption list or funding of arts therapies degrees by DH could alleviate this. Workforce data for the arts therapies is limited by, for example, the lack of differentiation between the three arts therapies professions, and by the numbers working outside the NHS. Improvements in data collection, together with provision of further evidence of improvements in outcomes for people, is therefore key to the success of workforce planning for arts therapists. 14

15 REFERENCES Anglia Ruskin University: Music for Health Research Centre (2012) mhrc_research.html. Arts for Health (2011) Transformation within health, through creativity, culture and art... [online] Available at: [Accessed March 2012]. Boorman, S. (2009) NHS health and wellbeing. [online] %20Report%20VFinal% pdf [Accessed March 2012]. Cochrane (2012) Music therapy for schizophrenia or schizophrenia-like disorders. [online] Available at: summaries.cochrane.org/cd004025/music-therapy-for-schizophrenia-orschizophrenia-like-disorders Department for Education (2011) Support and aspiration: A new approach to special educational needs and disability A consultation. [online] Available at: 27 [Accessed March 2012]. Department of Health (2008a) Modernising allied health professions (AHP) careers: a competence-based career framework. [online] Available at: dance/dh_086264#dhcontent [Accessed March 2012]. Department of Health (2008b) End of life care strategy - promoting high quality care for all adults at the end of life. [online] Available at: dance/dh_ [Accessed March 2012]. Department of Health (2008c) Framing the contribution of allied health professionals: Delivering high-quality healthcare. [online] Available at: dance/dh_ [Accessed March 2012]. Department of Health (2009a) Implementing the Next Stage Review visions: the quality and productivity challenge. Letter- David Nicholson. 10 August. [online] Available at: /dh_ pdf [Accessed March 2012]. Department of Health (2009b) Valuing people now: a new three-year strategy for people with learning disabilities. [online] Available at: dance/dh_ [Accessed March 2012]. 15

16 Department of Health (2010) Preceptorship framework for newly registered nurses, midwives and allied health professionals. [online] Available at: dance/dh_114073#dhcontent [Accessed March 2012]. Department of Health (2011a) Report to the National Allied Health Professional Advisory Board on the outcomes of the Modernising Allied Health Professional Careers Programme. [online] Available at: dance/dh_124801#dhcontent [Accessed March 2012]. Department of Health (2011b) Any qualified provider. [online] Available at: [Accessed March 2012]. Department of Health (2011c) Health and wellbeing boards. [online] Available at: [Accessed March 2012]. Department of Health (2011d) Improved mental health therapies for children. [online] Available at: [Accessed March 2012]. Department of Health (2011e) No health without mental health. [online] Available at: [Accessed March 2012]. Department of Health (2011f) Improving outcomes: A strategy for cancer. [online] Available at: dance/dh_ [Accessed March 2012]. Department of Health (2011g) Weighted capitation formula. [online] Available at: _ [Accessed March 2012]. Department of Health (2012) Liberating the NHS: Developing the healthcare workforce. [online] Available at: /dh_ pdf [Accessed March 2012]. Higher Education Funding Council for England (2011). Withdrawal of funding for equivalent or lower qualifications (ELQs). [online] Available at: [Accessed March 2012]. 16

17 Health and Social Care Information Centre (2010) Vacancies survey March [online] Available at: [Accessed March 2012]. Health and Social Care Information Centre (2011a) Non-medical staff census as of 30 September [online] Available at: [Accessed March 2012]. Health and Social Care Information Centre (2011b) Monthly Workforce Extract, April [ ] (Personal communication, July 2011). Health Professions Council (2010) FR00955d England statistics September [online] Available at: [Accessed March 2012]. Health Professions Council (2011a) Statistics - historic. [online] Available at: [Accessed March 2012]. Health Professions Council (2011b) Statistics - current. [online] Available at: [Accessed March 2012]. NHS Institute for Innovation and Improvement (2010) Clinical leadership competency framework project. [online] Available at: [Accessed March 2012]. NHS Leadership Academy (2011) Developing and embedding the leadership framework progress report October [online] Available at: ng_and_embedding_the_leadership_framework_- _Progress_Report_%28Oct_2011%29.pdf [Accessed March 2012]. Nordoff Robbins Centre (2012) Presenting the evidence. [online] Available at: [Accessed March 2012]. Office for National Statistics (2010) 2008-based subnational population projections by sex and quinary age; England and Government Office Regions. [online] Available at: [Accessed March 2012]. The British Association of Art Therapists (2011a) BAAT surveys. [online] Available at: [Accessed March 2012]. 17

18 The British Association of Art Therapists (2011b) Frequently asked questions with regard to training as an art therapist. [online] Available at: [Accessed March 2012]. The British Association of Dramatherapists (2012) guidance document final.pdf [Accessed March 2012]. The British Association for Music Therapy (2012) [Accessed March 2012]. Skills for Health (2010) Introduction to Nationally Transferable Roles. [online] Available at: [Accessed March 2012]. 18

19 DISCLAIMER The Centre for Workforce Intelligence (CfWI) is an independent agency working on specific projects for the Department of Health and is an operating unit within Mouchel Management Consulting Limited. This report is prepared solely for the Department of Health by Mouchel Management Consulting Ltd, in its role as operator of the CfWI, for the purpose identified in the report. It may not be used or relied on by any other person, or by the Department of Health in relation to any other matters not covered specifically by the scope of this report. Mouchel Management Consulting Ltd has exercised reasonable skill, care and diligence in the compilation of the report and Mouchel Management Consulting Ltd's only liability shall be to the Department of Health and only to the extent that it has failed to exercise reasonable skill, care and diligence. Any publication or public dissemination of this report, including the publication of the report on the CfWI website or otherwise, is for information purposes only and cannot be relied upon by any other person. In producing the report, Mouchel Management Consulting Ltd obtains and uses information and data from third party sources and cannot guarantee the accuracy of such data. The report also contains projections, which are subjective in nature and constitute Mouchel Management Consulting Ltd's opinion as to likely future trends or events based on i) the information known to Mouchel Management Consulting Ltd at the time the report was prepared; and ii) the data that it has collected from third parties. Other than exercising reasonable skill, care and diligence in the preparation of this report, Mouchel Management Consulting Ltd does not provide any other warranty whatsoever in relation to the report, whether express or implied, including in relation to the accuracy of any third party data used by Mouchel Management Consulting Ltd in the report and in relation to the accuracy, completeness or fitness for any particular purposes of any projections contained within the report. Mouchel Management Consulting Ltd shall not be liable to any person in contract, tort (including negligence), or otherwise for any damage or loss whatsoever which may arise either directly or indirectly, including in relation to any errors in forecasts, speculations or analyses, or in relation to the use of third party information or data in this report. For the avoidance of doubt, nothing in this disclaimer shall be construed so as to exclude Mouchel Management Consulting Ltd's liability for fraud or fraudulent misrepresentation. 19

20 The Centre for Workforce Intelligence produces quality intelligence to inform better workforce planning that improves people s lives CONTACT E enquiries@cfwi.org.uk T +44(0) Mouchel Management Consulting Ltd Registered in England No at Export House, Cawsey Way, Woking, Surrey GU21 6QX