A Scottish Review investigation

The land deal,
the end of life,
and the public interest

Early next week – as early as Sunday if the parties are disposed to interrupt their weekend – Europe's largest health board and a private developer will finalise the most controversial land deal in the history of the NHS in Scotland. It will make end-of-life care a business to be conducted for profit – while the hospice which provides the care at present, and has done so with distinction for more than half a century, has its funding for this work withdrawn. After years of delay, the will of Greater Glasgow and Clyde Health Board appears finally to have prevailed. On 31 January, it will only remain to sign the missives.
     Yet, even in the final minutes of the 11th hour, serious questions need to be faced about this commercial transaction in the name of the National Health Service. They are, of course, broadly related to the ethics of the proposition. But our questions are more practical. They are based on an independent trawl of official papers to which the Scottish Review has obtained access. What we have discovered from our research raises potential issues of governance and accountability which ought to concern, not only the members of Greater Glasgow and Clyde Health Board, but the Scottish Government.

I
The proposal in 2000

The original template for the land deal – although these vulgar words are avoided in favour of the cuddlier 'partnership arrangement' – is more than nine years old. It is set down in board paper 00/154 dated Tuesday 19 December 2000. How many non-executive members of the current board have seen this document? It would repay careful study.
     The paper, headed 'Elderly Services: Proposed Changes to Continuing Care', seeks board approval for the redevelopment of Blawarthill Hospital, Glasgow. This represented an abrupt change in policy. Earlier that year the board had decided not to redevelop the hospital but to close it, giving as its main reason 'the reducing clinical need for NHS continuing care'. In defiance of demographic trends showing a dramatic increase in the number of elderly people, the board has consistently adhered to its perverse assessment of need. It has, however, been consistent about little else. Determined to close the hospital in April 2000, it was equally determined to keep it open in December of the same year. It said it had been influenced by 'responses received' during a consultative period.
     The main thrust of the revised plan provided 60 beds for the 'frail elderly', along with a mix of other services, in what was described as 'a new purpose-built facility financed by private capital'. The paper maintained that the money for the project 'can be sourced immediately' and that the 'revenue implications are competitive'. The first claim proved to be over-ambitious: nine years later, the cheque is still not in the bank. The second, with its brisk whiff of the marketplace, remains open to interpretation – and some suspicion.
     The board approved the plan.
     Did it know what it was approving? Was it fully informed?
     In one vital respect, clearly not. For nowhere in this document is there any mention of the St Margaret of Scotland Hospice in Clydebank. Nowhere is it stated that the beds for the 'frail elderly', built by private capital and subject to a 'facilities management arrangement with a nursing home provider', would replace the high-quality continuing care provided by the hospice to elderly patients nearing the end of their lives.
     Was the withdrawal of support from the hospice always part of the plan – reflecting the board's bizarre devotion to the theory that there is a reducing demand for continuing care of the elderly? If it was, it should have been plainly stated in board paper 00/154 before the board committed itself to the Blawarthill development. If it wasn't, we are entitled to know why. Had the board forgotten that a single hospice already provided half these beds and that the NHS supported them financially? The lack of coherence from a major public body is disturbing.
     We repeat: did the board know what it was approving? Was it fully informed?
     More specifically:
     Had it known that the hospice beds would be sacrificed, would it have approved the deal?

II
The proposal in 2009

Nine years on, in an un-numbered board paper dated 3 November 2009 and headed 'Disposal of Blawarthill Hospital, Glasgow', the board's 'Performance Review Group' is asked to approve the 'land transaction' – a spade is at last being called a spade. And soon, it seems, it will be used to turn the first sod.
     A building firm called James Walker (Leith) Ltd has been selected as the developer.
     Let us try to be clear about the procedures; they tell us a great deal about the values of Scottish public life. James Walker (Leith) Ltd will buy the land from the health board for an undisclosed price (this information having been removed from the paper in the interests of 'commercial confidence'). It will then 'rent the beds' – we quote from official terminology – on a five-year 'bed contract'.
     How much is this contract worth?
     What is the cost to the NHS of each 'rented' bed at Blawarthill compared with the cost to the NHS of each hospice bed at Clydebank?
     Why is the contract only for five years?
     What will happen after five years?
     Is the developer, as owner of the land, theoretically then entitled to redevelop the site for some other purpose?
     The answer to all these questions is: We don't know. Who does know? Do the members of Greater Glasgow and Clyde Health Board know? They should.
     Most important, who will look after the elderly patients, all requiring end-of-life care, occupying these rented beds? The board paper mentions as possible 'nominees' a large nursing home provider, Southern Cross Healthcare, or – mysteriously – 'other member of James Walker (Leith) Group'. Glasgow City Council, meanwhile, has emerged as a major player in the development and will be responsible for an adjoining build of 60 care home beds. It may already have entered into an agreement with Southern Cross Healthcare for this project.
     'The revenue costs of reproviding the NHS beds,' the paper states, 'can be met from within the board's existing expenditure on NHS continuing care for the frail elderly.' There is, however, an un-named victim of this 'reprovision': the St Margaret of Scotland Hospice has had a £1.2 million annual grant for its continuing care beds withdrawn. Unless it is able to bridge the enormous funding gap, the hospice will no longer be able to provide its highly skilled end-of-life care to old people with complex medical needs.
     What level of clinical care will be provided by the alternative at Blawarthill? Do the 'competitive revenue implications' allow for any?

III
The private houses

When the health board, in late 2000 or early 2001, approved this scheme, the definitive board paper 00/154 gave no indication that the board was also approving a private housing development. Yet in the un-numbered board paper dated 3 November 2009, the 'main stream residential site' [sic] is an integral part of the deal. So much so that the board is anxious to have the core facilities established before James Walker (Leith) Ltd proceeds with its 'private residential development'.
     Since this does not appear to have been part of the original package, members of the board should be aware when it was added to the plan; and, more to the point, why.
     We have a further question. In the board paper of 3 November 2009, why was it not made clear that the nominee for the private residential development, Dundas Estates and Development Company, is a subsidiary of the main developer, James Walker (Leith) Ltd? It is relatively simple to establish a link between these companies. The parent company's own website is transparent on the subject: it set up Dundas Estates in 1982.
     Were the board members aware of the association?

IV
The case for ministerial intervention

We have said next to nothing about the hospice itself, which is graded 'excellent' by the Care Commission and raises £30,000 a week – every week – to sustain its admirable work for the terminally ill; we have said nothing about the dilemma it faces in the light of the health board's funding decision and the insulting suggestion that it should become a nursing home, an 'option' which would destroy the unique ethos of the hospice at a stroke. At this stage, we have confined ourselves to questions of governance and accountability.
     But there is a larger question still. Why, with scarce resources and the ability to make a rational choice, would any responsible public body commit to such a building project when the service is already being provided to the highest standards of clinical and nursing excellence by a top-rated hospice?
     Greater Glasgow and Clyde Health Board has a duty to account satisfactorily for its actions in this matter in the last nine years. It it fails to do so in the very short time left, there is in our view a compelling case for ministerial intervention to halt the land deal pending an inquiry by Audit Scotland.

First published in SR on 26 January 2010