This statement is made by Jane Hanna, former
non-executive director of South-West Oxfordshire Primary Care
Trust (PCT). The Health Select Committee received evidence on
Thursday 10 November 2005 regarding the potential democratic deficit
arising as a result of a significant reduction in the number of
Non-Executive Directors in the planned changes to primary care.
This evidence concerns the issue of an existing democratic deficit
in Primary Care Trust Boards particularly in the context of the
contracting out of services to the private sector.
My interest in this matter is as a former non-executive
Director of South-West Oxfordshire Primary Care Trust (2001-04)
and non-executive Director of the Oxford Radcliffe Infirmary NHS
Trust (1993-97); as a tutor in constitutional and administrative
law at Keble College, Oxford and as a district councillor for
the Vale of the White Horse, Oxfordshire. I became committed to
public and patient involvement in the NHS following the sudden
unexpected death of my partner in 1990, which also led to my founding
a health charity, Epilepsy Bereaved and working as a member of
the Joint Epilepsy Council. This statement includes a summary
of the Netcare Contract and the decision-making of the PCT and
a more detailed statement of evidence supporting this summary.
The Statement below is has been produced using evidence
from a file of written papers and on a written and contemporaneous
record kept of events as they developed.
The experience of South-West Oxfordshire PCT in relation
to the contract with Netcare represents a test case of the effectiveness
of Non-Executive Directors in ensuring proper stewardship of public
funds, proper governance; accountability, openness and locally
responsive decision-making. I believe that South-West Oxfordshire
PCT was the only PCT board in England to vote against the contracting
out of cataract operations to Netcare. The decision of South-West
Oxfordshire PCT was necessary to authorize the signing of the
contract with Netcare. This was because there was no national
legislation or national directive from the Secretary of State
for Health overriding the devolved decision to the PCT. The decision
was an important test case of Shifting the Balance of Power and
the roles and responsibilities of a Primary Care Trust Board.
The SW PCT Board voted not to approve the private
cataracts unit because it was against the local public interest.
Board members, including non-executives were subjected to bullying
tactics in the months leading up to the decision and subsequent
to this decision. Non-Executives also experienced serious delays
and barriers to accessing available information relating to the
decision and had to correct minutes of the public board meetings
on key aspects of the PCT Board's position on at least four separate
public board meetings between January 2003 and January 2004. Exceptional
pressures were placed on the non-executive directors of the Board
and we observed the effects of greater pressure on the executive
members of the Board. In the immediate aftermath the PCT was prevented
from sending out a press release giving the reasons for the decision
and instead the Thames Valley Strategic Health Authority (TVSHA)
issued a press release which was critical of the decision of the
Board. The non-executives were pressured into meeting in emergency
session over the weekend immediately following the decision of
the Board and following our decision not to change our decision,
the Chair was pressured into calling an emergency meeting of the
PCT. The TVSHA agreed to underwrite the financial risks to the
PCT. The PCT Board approved the contract with Netcare at this
meeting, although all the original non-executives (apart from
the Chair) voted against this reversal because of continued concerns
of financial impact on the Oxfordshire system as a whole and the
impact on clinical services.
In January 2005 the PCT Board Chair was not
renewed and the Chair of the Thames Valley Strategic Health Authority
(TVSHA) resigned. In an emergency meeting of non-executives in
January 2005 we discussed how fundamental relationships of trust
within the Board; between the Board and the TVSHA and the NHS
Appointments Commission had been seriously damaged and the need
for an inquiry into events. I resigned in June 2005 after experiencing
other decisions where the PCT was required to rubberstamp national
policy but required to present decisions as local decisions. I
also resigned in the end because despite a request by the non-executives
of South-West Oxfordshire PCT in January 2005 for an investigation
into events there was no internal or public inquiry.
Subsequent to the decision, the TVSHA commissioned
an independent report into eye services in Thames Valley. The
Finnemore report was published in September 2005 and concluded
that local NHS services were on target to meet government waiting
lists for cataracts some as early as the summer of 2004 and that
there was excess capacity in Oxfordshire and highlights the need
for urgency in addressing risks to local eye services.
The National Audit Office also investigated
the netcare contract from a remit of best value, but this did
not include investigating allegations of political interference
with the PCT.
A public board paper for the meeting of South-West
PCT on 24 November 2005 includes a six month review of the NETCARE
contract. Netcare are currently contracted to provide 800 cataracts
a year in North and South Oxfordshire from April 2005 for four
years. South Oxfordshire is contracted to take on average 456
cataracts and 593 pre-operative assessments per year. The Board
Paper shows that in the first six months of the contract £255,000
has been paid to Netcare to carry out assessments and operations
although only £40,000 of work has been carried out.
A six month review in November 2005 found that only
50 of 323 available pre-operative assessments have been booked
and only 43 operations have been done out of 249 theatre slots
available. The tariff cost is £72 for preoperative assessments
and £824.34 for a cataract operation, but the cost is six
times the national tariff as the NHS has to pay for all contracted
procedures, regardless of whether they are performed. The set
up costs of the mobile units and project management are not mentioned
in the review but have to be paid for by the NHS.
The review concludes that "the uptake of slots
for Netcare has been slow. The population commonly requiring cataract
surgery is elderly, and the Oxford Radcliffe Hospitals have a
strong reputation and short waiting lists". The review notes
that in relation to the general surgery chain run by CAPIO referrals
have also been slow and concludes "The concept of Independent
Treatment Centres has been show to catch on".
Board members of South-West Oxfordshire PCT were
first made aware of initiatives on treatment centres in January
2003 but the Board had concerns even at this stage about the lack
of information and transparency about the initiatives. The minutes
of the Board meeting on 27 February 2003 (after correcting at
the Public Board meeting on the 24 April 2003 state:
"The Board accepted the next steps. It was
noted that the PCT needed clarity on the timescale and additionally
at what point the PCT would need to make a decision to commit
or pull out".
It was always the understanding of the PCT Board
that the board was required to take a decision to approve each
Treatment Centre after reviewing the outline and full business
case, and that legally the signature of the PCT Board was needed.
We also understood that the Secretary of State has power to make
a formal direction to the PCT.
Board members considered an initial proposal for
an ophthalmic treatment centre at a private meeting in July 2003
and a decision was made unanimously at this stage not to proceed
because it was not in the interests of Oxfordshire's population.
This was because the NHS ophthalmic service was on target to meet
waiting lists and had Beacon status as a centre of excellence
and that funding a private unit would not be cost-effective and
would expose the existing system to serious risk. Two other Primary
Care Trusts locally did the same and a letter was sent by the
Board to the Thames Valley Strategic Health Authority requesting
withdrawal from the scheme.
The Chief Executive of the PCT received a letter
on 21 August from Celia Cohen at TVSHA stating that after detailed
discussions with the operations directorate of the Department
of Health at the highest level the request of the PCT had been
refused and that "we must remain a committed participant
within the procurement process". The PCT Board, however,
had never made any decision to commit to the ophthalmic Treatment
Centre (Ophthalmic ISDTC).
Leaked papers from an anonymous source on 21 August
2003 included an update from the national team to PCTs (Richard
Audley) stating that a meeting will be arranged with the bidder
and that:
"this is a pro-active meeting and not to
question if anybody agrees of disagrees with the ISDTC".
Under the section of the paper "Programme Forward",
the update continues:
"we only have until 19 September to resolve
all outstanding issues . . . The buy in and signature on the contract
of the PCTs is your responsibility. If you need any support with
engaging them or keeping them on board do not hesitate to ask
the NIT OC Team. We will provide assistance in any way we can,
and if required will call on that provided by Sir Nigel Crisp
and John Bacon to remind PCTs of their commitments and responsibilities
to this programme".
A leaked email on 27 August from Tony Hickson at
TVSHA stated:
"The OC chain has based their figures on
the Cataracts, PLUS other ophthalmic procedures, which I know
is flawed, however these figures have been out in the tender document
by the NIT (National Implementation Team) and cannot be changed".
Leaked anonymised emails on 28 August 2003 between
managers in Oxfordshire state the view of one manager:
"I think we must keep any local noise to
zero".
Executive members of the Board met with TVSHA
and national team in September and reported that they had negotiated
a reduction in the numbers of the cataracts. Non-executives express
concern in private and public sessions of the PCT of the lack
of information on the initiative including financial risk and
impact on clinical services.
The South-West Oxfordshire PCT Board decides in a
public board meeting on 25 September to proceed to consider the
full business case for the ophthalmic ISTDC but only on condition
that the business case ensures that the treatment centre meets
the needs of the local population; is affordable; that workforce
issues are sustainable and integration with local services is
achievable. The PCT also agreed to consult the public on the Treatment
Centre at the September meeting (minuted as a correction to the
September Board meeting minutes at the PCT Board meeting of 27
November). A letter is sent to TVSHA from the PCT to inform them
of the PCT Board's position.
The Oxford Radcliffe Hospitals NHS Trust produced
an impact assessment on the eye hospital concluding that the:
"the current plan is drastic on the Oxford
eye Hospital".
On the 13 October the Chair of the Local Optometric
Committee wrote to ask the Chief Executives to put their views
before any Board was made. The Committee:
"We feel strongly that the DTC locally is
unnecessary to meet the NHS targets for Cataract Surgery in Oxfordshire,
but risks seriously undermining the quality of training, and therefore
in the long term the standard of Clinical expertise"
Neither the full impact statement from the ORH or
the letter from the Chair of the Local Optometric Committee were
circulated to non-executive board members at this time or indeed
at any time before the decision of the PCT Board on 27 November.
Executive directors were under intense pressure from
August onwards and on 5 November the Finance Director sought the
support from Martin Avis, the Chair of PCT and Jane Hanna, non-executive
in a emergency meeting with Cherwell Vale PCT representatives;
members of the national team and the TVSHA. A written note of
the pre-meeting between South-West Oxfordshire representatives
and Cherwell Vale representatives states the understanding between
South-West Oxfordshire PCT and Cherwell Vale PCT:
"SHA is pushing for early approval to the
OTC ahead of the December Public Board meeting. All present agreed
serious reservations regarding the process and merits of the OTC
which needed to be progressed with the TVSHA."
At the meeting with TVSHA and the national team,
the PCT representatives from both boards stated that there was
a serious risk that PCT boards might not approve the full business
case given the speed of decision-making; the gaps in information
and full evidence and the of lack of patient and public involvement
or consultation. A TVSHA representative said
"that the PCT did not have an option. The
Boards would be surcharged".
When the basis of a surcharge was challenged,
the representative stated
" . . . this was new territory".
When the TVSHA were asked to put the liability to
surcharge in writing another TVSHA representative present said
the
"the TVSHA would never put a threat in
writing".
It was agreed that the PCTs would consider the full
business case at a meeting in November, but would not guarantee
approval.
At a private meeting of South-West and South-East
Primary Care Trusts the Board, Martin Avis explained that he and
other Chairs had been verbally threatened since August. Martin
told the meeting that another local PCT Chair had been told she
would lose her job if the contract was not approved. Subsequently
I have learnt from the person involved that it was the Chair of
Cherwell Vale PCT.
At an emergency private session on Tuesday 25 November
between senior managers of South-West Oxfordshire PCT and Martin
Avis, Jane Hanna and Catherine Kirby (Non-Executive), the Finance
Director, Caroline Kenny became distressed after realising non-executives
might vote against the treatment centre and made a statement "but
what about my career". It was understood by everyone present
that all that senior managers has been under extreme pressure
regarding their personal futures.
The Non-Executives had made it clear to the Chair
on many occasions and he had told the non-executives that he had
communicated to TVSHA that we were happy for the Secretary of
State to override our decision in the national interest as he
has powers to do, but that we were not prepared to agree to a
contract except on the objective merits of the scheme.
THE VOTE
ON 27 NOVEMBER
The Non-Executives were very worried by the intense
pressure and the lack of full information needed to make the decision.
On the night before the meeting we were emailed at 5.40 pm with
a 40 page document on the clinical practice of Netcare and we
only received the actual completed Full Business Case one hour
before our meeting on 27th. Prior to this we had received very
scrappy papers with key information missing on local affordability
and about local risk. The full business case was very much a national
document and did not put the local case. A summary paper by our
executive putting a local case was lacking in evidence regarding
the impact of the decision and on key financial risks.
After a very robust debate of some two hours a vote
was taken at the Public Board meeting. The vote was four (Execs
and Chair): four (Non-Execs). Jean Bradlow, the Public Health
Director abstained in the vote. All the non-Executives (apart
from the Chair) stated that they were unconvinced by the evidence.
The impasse in the vote was resolved by the Chair.
He asked the non-executives to repeat their reasons for voting
against. Jane Hanna summarized the concerns which were minuted.
Martin Avis, Chair then voted with the non-executive members.
In the aftermath of the decision. The executive members
of the PCT were very distressed. Jean Bradlow told Jane Hanna
that the decision would effect her job and Mary Wicks, the Chief
Executive was visably upset.
The non-executive directors were congratulated by
representatives from Cherwell Vale PCT that were present in the
audience and by some of the managers in South-West.
The Chief Executive, Communications manager, the
two Chairs of the PCTs and Jane Hanna and Catherine Kirby agreed
key messages for a press statement.
IMMEDIATE EVENTS
FOLLOWING THE
BOARD DECISION
ON 27 NOVEMBER
A press release was produced that afternoon from
the PCT explaining the reasons for the decision, but we were told
that TVSHA had forbidden the issuing of the press release. Jane
Perry, Communications manager of the TVSHA issued a press statement
"We know that treatment centers are very
beneficial for patients so we are surprised and disappointed by
the decision by the South-West Oxfordshire PCT Board not to progress
their plans for a local treatment centre"
The non-executives were then exposed to negative
publicity in the local press on the Friday. Senior executives
from the PCT and the Chair of the PCT were summoned to TVSHA.
All the non-executives were rung on Friday 28th by the Chair of
Trust and told that he had been instructed that the Secretary
of State for Health wanted a letter on his desk reversing the
decision by Monday at 12 noon. Martin also told us that he had
been told by Jane Betts at the TVSHA that she was on her way to
the Appointments Commission and that the "tumbrels were turning"—we
understood this to mean a phrase used during the french revolution
and the guillotine !
Martin Avis called an emergency meeting on Sunday
29 with non-executives, the Chair of the Professional Executive
Committee and the Chair of the Patient and Public Involvement
Group of the PCT. It was explained that everyone's positions on
the Board were under threat from our decision. Non-executives
told the Chair of Trust and the Chair of PEC that they would need
to meet alone to decide what to do. The meeting lasted from 11am
until 7pm. We carefully wrote a letter saying that they we were
always prepared to consider new evidence that a national scheme
was in the local interest but that we could only do this at a
properly constituted Board meeting as required under our standing
orders. The letter was proposed to Martin Avis by email that evening
and he agreed he would send the letter the next day.
On Monday 1 December the Chair rang me to say TVSHA
would not allow us to send a letter to the Minister unless it
was sent by Mary Wicks, the Chief Executive as well as the Chair
on behalf of the non-executives. The Chair indicated he was very
concerned about Mary Wicks. We agreed to write instead to Jane
Betts, Chair of Strategic Health Authority.
Nigel Crisp said on the Today programme in December
that the PCT could decide not to approve the treatment centre,
but we would need to give our reasons. John Reid stated in Parliament
that it was our decision so long as we gave reasons. We produced
two pages of reasons after the meeting of the 27th but we also
clearly understood from our Chair and from the executive team
that we had been told that these reasons were not sufficient and
that the PCT had to reverse the decision.
On 4 December the TVSHA agreed that the financial
risk to the PCT would be underwritten. Nick Relph, Chief Executive
of Thames Valley Strategic Health Authority wrote:
"The SHA commits that should this number
(400 cataracts) be shown to be too high either by the ophthalmology
review or from experience once the programme has commenced we
shall ensure that the PCTs financial position is not adversely
effected. This will be achieved by reducing the numbers in the
contract and brokering this activity elsewhere . . . I understand
that the precise level of establishment costs is still subject
to agreement but would expect either the NIT and/or the SHA to
ensure that your financial position is not prejudiced . . . regarding
project management costs we are working with the NUT to ensure
that adequate funding is made available for project management
costs"
Martin Avis emailed all non-executives on 5 December
to state that
"There is now no financial risk in the
brokerage, set-up costs . . . The excessive amount of precious
executive (and non-executive) time this agreement, for some 450
cataract operations per annum, has and is consuming should cease
. . . it is unfortunate that the Board has become split by this
incident"
We also received emails from Tony Williams, Chair
of South-East PCT (which shared the same executive directors as
the South-West) expressing his serious concern about the pressures
on Mary Wicks, the Chief executive.
Catherine Kirby wrote a detailed email on behalf
of the non-executives on 7 December that in the interests of greater
clarity and the integrity of the Board a large number of questions
that remained unclear or without evidence or information still
needed to be answered—these were listed in detail in the
email. In particular, this concerned the financial risks on the
Oxfordshire system as a whole; clinical risks to our population
as well as the failure to adequately involve or consult local
stakeholders and the public.
Nick Relph, Chief Executive of TVSHA wrote to Martin
Avis on 10 December that the Treatment Centre did not require
formal public consultation.
"It would not normally be necessary to
consult when the change relates to a new, additional, service
for local residents"
In Parliament, David Cameron MP asked the Secretary
of State in a parliamentary question on 9 December
"Will he give me an assurance that, if
a primary care trust votes against a diagnostic and treatment
centre because it believes it is not in the interests of local
people, it will not be subject to improper pressure from the Department
of Health or the Strategic Health Authority to change its mind?
Can he assure me that that has not happened,
and will not happen, in the case of South-West Oxfordshire primary
care trust"
Dr Reid responded
"I will be prepared to accept them and
all reasonable people will accept that local primary care trusts
have to make their own decisions, but the public will want to
be sure that those decisions are based on the interests of local
patients, and are not unduly influenced by the interests of local
providers and producers, especially consultants. It is essential
that, in all these, decisions, the interests of the patients are
put first"
EMERGENCY MEETING
11 DECEMBER
The Chair called an emergency meeting for the 11
December 2003. The Board members present was different from the
original first meeting on the 27th. For example, Mike Russell
was present as a non-executive, but had been away in the immediate
lead up to and the original board decision. The Board approved
the OTC.
The non-executives who voted against at the first
Board meeting did not alter their position. The reasons given
were that the non-executives were concerned that 800,000 pounds
was being transferred from the local eye hospital and that patients
who needed eye care of a more serious kind such as patients with
diabetes and glaecoma would lose vital high quality services for
the sake of a private mobile cataracts unit that was not needed.
We also were very concerned that even if TVSHA took the financial
risk that this was a risk that remained on the Oxfordshire NHS
and that, based on our experience, the PCT would inevitably be
caught up in resolving financial risk to the whole system. We
also considered that it was wrong to proceed with such haste without
public involvement and consultation. There were also some concerns
about price because the local NHS provider was quoting a lower
price than netcare and when we were assured that netcare would
be 12% under National tariff we could never get a clear answer
as to what the national tariff was—the national tariff figure
changed from meeting to meeting or were not given at all. We gave
our reasons in writing again after the meeting of the 11th.
AFTERMATH
Lesley Legge, Chair of the Oxfordshire Health Scrutiny
and Overview Committee wrote to Dr Reid on 18 December seeking
an explanation why decision-making was so rushed and uninformed
and why there had been inadequate involvement of local people
or indeed adequate information to the Health Scrutiny Committee.
She questioned how there could be any meaningful public involvement
and protection of local interests when these interests could be
suspended as a matter of national expediency.
Following the decision, the non-executives were emailed
by the Chair with information about their duties to act in a corporate
manner.
Martin, Chair of Trust was only the Chair in Oxfordshire
not to be renewed in January. The Guardian reported in
June 2004 that he had been verbally threatened since August and
the "The Chairs of other PCTs were, but they wont talk".
He told the non-executives of the PCT that he had been verbally
informed by Bernard Williams, Chair of the Appointments Commission
that he was not renewed because of the Treatment Centre decision.
Non-executives met in January in emergency session
to review what had occurred. It was agreed that there had been
a serious breakdown of trust as a result of what had occurred
in relation to the treatment centre decision. The relationships
of trust which were discussed included within the PCT, between
the PCT and the NHS system as a whole including the NHS Appointment
Commission.
During February Martin Avis and executive board members
told non-executives in private board sessions that it had been
made very clear that we had no choice but to agree to all the
other treatment centres, but that the board was also instructed
to present these national initiatives as local decisions of the
PCTs.
Jane Betts Chair of TVSHA resigned at the end of
March concluding that the SHA was quoted in the Guardian as saying
the TVSHA was
"local office of the NHS"
She was quoted as admitting the bullying tactics
from TVSHA and that TVSHA was:
"the jam in the sandwich" because
it was under heavy pressure from the Department of Health to deliver
a deal that the prime minister had set his heart on. The contract
was "on the top 10 list of things the prime minister wanted
to see done . . . someone was playing political hardball with
the people of south-west oxfordshire"
A New Chair, Fred Hucker was appointed to South-West
Oxfordshire PCT in April 2004. He was formerly a non-executive
at the TVSHA. There were only two applicants interviewed for the
job—Paul Wesson, non-executive Director of South-West Oxfordshire
PCT, was the other candidate. Bernard Williams was a member of
the appointments panel.
After Fred Hucker was appointed all the Non-Executives
were sent a letter from Sir William Wells, Chair of the Appointments
Commission informing us that our new Chair would be making recommendations
about our performance at the end of 12 months and that our appointment
might be terminated before the end of our office term. It stated
that this letter was sent to all non-executives of PCTs with new
Chairs. The non-executives interpreted this letter as a threatening
letter given the situation we were in and given we had not been
placed on probation in the first twelve months after our original
appointment.
Jane Hanna resigned on Thursday 27 May some six months
later because no attempt had been made to learn lessons and instead
the Board has continued to make other decisions under centralised
pressure and without openness or consultation with local patients
and the public.
File on 4 on 2 June reported on a detailed investigation
into the events surrounding the cataracts decision and other examples
from across the country. Nigel Crisp was interviewed about the
allegations of bullying and why he had said on the Today programme
in December 2003 that local Boards could make decisions on Treatment
Centres. He said that it was in fact that the treatment centre
decisions were in fact many people's decision including the private
provider before cutting short the interview.
In December 2003 TVSHA had commissioned an independent
review of eye services in Thames Valley. In June 2004 a draft
final report was leaked and reported in the local press. The report
was extremely critical about the financial and clinical risks
that threatened eye services in Thames valley as a result of the
Netcare contract.
The Finnemore report was finally made public in September
2004. The final Report differs not in terms of facts but in the
interpretation of the facts. The detail of the final report still
concludes that local NHS services have a high reputation and are
on target to meet government waiting lists for cataracts some
as early as summer 2004 and that there is excess capacity in Oxfordshire;
it includes reports from hospitals of clinical priorities being
distorted by focus on cataracts at expense of patients with more
serious eye conditions; and highlights the need for urgency in
addressing risks Whilst the draft report concluded that the eye
unit was being put in the wrong place and that there was a significant
risk of destabilising the Oxford eye hospital, the final report
now says that the excess capacity will be helpful in managing
need from elsewhere in Thames Valley and perhaps as far a field
as Scotland and Wales. In terms of risk the detail of the report
continues to highlight that the risks are urgent in terms of longterm
viability and quality of patient services.
A public board paper on a review of the treatment
centre, 24 November 2005 finds that only 50 of 323 available pre-operative
assessments have been booked and only 43 operations have been
done out of 249 theatre slots available. The tariff cost is £72
for preoperative assessments and £824.34 for a cataract operation,
but the cost is six times the national tariff as the NHS has to
pay for all contracted procedures, regardless of whether they
are performed. The set up costs of the mobile units and project
management are not mentioned in the review but have to be paid
for by the NHS. Finally, the paper mentioned negotiations by TVSHA
regarding the underwriting of the financial risk, but does not
mention the written agreement from TVSHA to the South-West PCT
Board that all financial risks will be underwritten by TVSHA.
Jane Hanna
23 November 2005
