Buckinghamshire Clinical Commissioning Group

5. Mr A complains about Buckinghamshire CCG’s service between August 2017 and May 2018, following a GP referral for an assessment and treatment on his right hip. He says the CCG made him go through the Service when his GP tried to refer him straight to secondary care. He says this caused a delay of 11 months in him getting the surgery he needed.

6. He says the Service referred him to hospital A without giving him any choice of hospital or surgeon. He says the Service ignored his GP’s request to refer him to a consultant at hospital B.

7. He says when the Service later offered to change the referral, he had to decline as he did not want to start again in another queue. He says if the CCG had referred him to hospital B first, he would have had the surgery earlier.

8. Mr A says the delays he experienced meant he was in pain for longer than he should have been. The prolonged pain and difficulties with his hip meant he had a reduced ability to work for longer than he would have if he had the surgery earlier. He says the delays caused him stress and anxiety because he did not know when he would have the surgery. He felt depressed and hopeless, and he says he had no other choice but to decide to have the surgery privately.

9. Mr A also says the complaint process took too long. He says he kept having to chase the CCG for updates when its responses were delayed. He says this caused him more frustration and stress.

10. Mr A would like the CCG to acknowledge it got things wrong and apologise for the impact this had on him. He wants the CCG to implement service improvements. He would like the CCG to recognise how its failings left him with no other choice but to seek private treatment. He is seeking a reimbursement of his treatment costs and a financial remedy to recognise the injustice the CCG caused him.

11. Buckinghamshire CCG commissions the Service. We refer to the Service’s actions throughout our report, but the CCG is the responsible body. What follows is a summary of events. We have not included all the details as those involved are already aware of this information. However, we have included this brief background to put this complaint in context.

12. Mr A had ongoing right hip pain for several years which was no longer being managed with prescribed pain relief.

13. On 25 August 2017, Mr A’s GP referred him to the Service. The GP wanted to refer Mr A directly to secondary care with orthopaedics.

14. The Service triaged the referral on 30 August. The Service said Mr A needed to go through conservative management and treatment before it would consider sending him to a consultant.

15. Mr A had his first physiotherapy appointment on 28 September.

16. Between November and April 2018, Mr A had several hydrotherapy sessions, a steroid injection, and attended osteoarthritis classes.

17. Mr A’s GP wrote a letter to a consultant at hospital B on 24 April.

18. On 27 April, a senior physiotherapist from the Service referred Mr A to an orthopaedic consultant and made an individual funding request (IFR) so this could happen.

19. The CCG approved the IFR, and the Service referred Mr A to secondary care at hospital A on 8 May.

20. On 22 June, the Service received a new letter from Mr A’s GP. The service administrator asked Mr A if he wanted to see another consultant at a different hospital. Mr A declined.

21. Mr A had a hip replacement abroad on 10 September. He paid £9,300 which covered his treatment, transport, and accommodation costs, as well as agency and admin fees.

22. On his return to the UK, Mr A applied to the NHS for reimbursement of the costs under the EU directive.

23. The EU directive is a route to get healthcare in Europe, which may be paid for by the NHS. If eligible, it may entitle an individual to buy healthcare in a European Economic Area (EEA) country and apply for reimbursement from the NHS. The scheme will reimburse up to the cost of equivalent treatment on the NHS only, and in some cases, the full amount back may not be reimbursed. A claim is made to have eligible costs reimbursed from the NHS as soon as possible when an individual returns to the UK. Any other costs, transportation or accommodation costs, cannot be reimbursed under the EU directive.

24. Mr A was reimbursed for the treatment he had abroad under the EU directive. He was reimbursed in full for eligible treatment costs of 7,500 Euros (the equivalent of £6683.42) given the currency exchange rate conversion factor at the time.

The CCG’s decision to go through its specialist musculoskeletal Service

28. Mr A’s GP tried to refer him straight to secondary care. Mr A believes his hip was bad enough for him to be accepted straight to secondary care.

29. The GP referral (dated 25 August 2017) says Mr A had history of symptoms for more than six months and he had a constant full ache in the right hip. He had significant pain with walking and was struggling with work. The referral also says he was not responding to the prescribed pain relief. The referral indicates Mr A had seen an orthopaedic surgeon previously and a new joint had been suggested as he was a suitable candidate for joint replacement surgery.

30. Mr A had psoriatic arthritis (an inflammatory joint condition), which can affect the large joints of the lower limbs (hips). In 2017, he also had shoulder replacement surgery. The GP therefore requested an opinion from secondary care with Mr A expecting to see a consultant.

31. The CCG says the Service followed NICE guidance and its local guidance on the musculoskeletal pathway for hip pain (Thames Valley Priorities Committee Commissioning Policy Statement – TVPC 49).

32. The Service triaged the referral on 30 August. The CCG told Mr A’s GP to undergo conservative management treatment before referring him to an orthopaedic consultant.

33. Mr A had his first physiotherapy appointment on 28 September. The notes from this appointment state Mr A had an orthopaedic surgery consultation five to six years ago where he almost decided to have a total hip replacement at the time. He had an ultrasound guided injection in November 2017 which helped him temporarily. It is noted that Mr A’s GP had referred him for physiotherapy.

34. The notes go onto say Mr A was a professional riding coach and his pain had become progressively worse over the previous three months, to such an extent that it was disturbing his sleep. The physiotherapist noted Mr A was expecting to see a consultant.

35. We have found that the Service should have referred Mr A straight to secondary care given his symptoms.

36. Sections 1.2 and 2.2 of the HCPC ‘Standards of Conduct, Performance and Ethics’, 2016 say: · ‘1.2 - You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.’

· ‘2.2 - You must listen to service users and carers and take account of their needs and wishes.’

37. NICE guidance 138, on ‘Patient experience in adult NHS services: improving the experience of care for people using adult NHS services’, says services should:

· have an individualised approach to services · consider patient views and preferences · have shared decision-making.

38. NICE guidance 177: ‘Osteoarthritis: care and management’ says:

· Section 1.6.3- the clinician should ‘Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment’.

· Section 1.6.4- the clinician should ‘Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain’.

39. We have seen no evidence the Service followed HCPC or NICE guidance.

40. The CCG local guidance on the musculoskeletal pathway for hip pain states: ‘The physiotherapist should consider a referral for specialist assessment if the patient meets all six criteria’.

41. The CCG criteria are as follows: Criterion 1 - ‘patient experiences joint symptoms (pain, stiffness, and reduced function) that have a substantial impact on their quality of life defined as interfering with their activities of daily living or their ability to sleep’.

42. Pain was already having a substantial effect on Mr A’s quality of life, ability to work and sleep: Criteria 2 and 3 - ‘joint symptoms are refractory to non-surgical treatment listed in criterion 2 including where appropriate and no contra-indicated, analgesia, steroid injections, local heat, and cold therapy. Patient has been offered at least the core (non-surgical) treatment options recommended by NICE 177’.

43. Previously, Mr A had had at least the core (non-surgical) treatments recommended by NICE 177. He had already tried physiotherapy, prescribed painkillers, and a local steroid injection, with no success.

· Criterion 4 – ‘patients have a right to be fully informed about this procedure. Clinicians should engage with patients in shared decision making about alternative management, and the risks and benefits of surgery’.

· Criterion 5 – ‘patient has confirmed they wish to have surgery’.

44. We do not know if the service fully informed Mr A about the procedure because we cannot see this documented in the records. We know Mr A nearly had surgery a few years before, so on the balance of probabilities, he understood the options, risks, and benefits of surgery.

45. We have seen no evidence of Mr A confirming he wanted to have surgery at this point. The evidence shows the physiotherapist discussed this with him in April 2018. The records say Mr A has ‘reached the point where he would like to consider surgery’.

46. Mr A was not given the option of surgery in August 2017, so he could not have confirmed he wanted it. But we know he wanted to be referred to secondary care from the GP referral letter. And we know he nearly decided on hip replacement surgery five to six years before.

47. So again, on the balance of probabilities, we think it is more likely than not he would have confirmed he wanted surgery if the CCG had referred him to secondary care in August 2017.

· Criterion 6 - ‘any underlying medical conditions have been investigated and the patient’s condition has been optimised’.

48. The GP referral does not list any conditions which made Mr A medically unfit for surgery. Mr A had a high body mass index (BMI) at the time but NICE recommendations for surgery referral (NICE 177), say:

· ‘patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery.

49. Mr A, therefore met NICE and the CCG’s local guidance to be considered for a referral for a specialist assessment and hip replacement surgery.

50. The rationale for the CCG deciding not to refer Mr A straight to secondary care is a failing. This is because the decision is not supported by the evidence of Mr A’s presentation at the time, or the national or the CCG’s local guidance.

51. When Mr A was referred, the physiotherapist, who assessed Mr A, should have asked for and considered more information from his GP about the previous orthopaedic surgery consultation Mr A had. This is because if a patient has correspondence from earlier consultations that are relevant to their present condition, the treating/receiving clinician has a duty of care to ask for that information if it is missing from a referral. Had the physiotherapist done this, we consider that on the balance of probabilities, this would have given the Service enough information to refer Mr A to secondary care.

No choice of hospital or surgeon

52. Mr A says if the CCG had given him the choice and referred him to a hospital and consultant of his choice, he would have had his surgery earlier. The CCG instead put Mr A in the queue for secondary care in May 2018 by referring him to hospital A.

53. In the GP’s referral, dated 25 August 2017, there is space to specify which hospital a patient wants to attend. Mr A’s GP did not fill this in so at this point, the CCG would not have known which hospital Mr A wanted to go to. However, on 24 April 2018, the GP wrote to the consultant at hospital B, Mr A wanted to see.

54. On 27 April, the Service referred Mr A to an orthopaedic consultant and made an IFR so this could happen. The CCG approved the IFR, and the Service referred Mr A to secondary care at hospital A on 8 May.

55. The Service contacted Mr A around 22 June to see if he wanted to change to his preferred Trust and consultant. Mr A says he was already waiting to see a consultant at hospital A, so he did not want to leave the queue to begin another one.

56. Mr A saw the consultant at hospital A in July. He says the consultant told him he would have his operation in around six to eight weeks, but Mr A later found out that the wait was 40 weeks from the point of referral.

57. The CCG told us Mr A did not tell the physiotherapist his hospital preference. We can see this is the case but there is no evidence that the service started a discussion about hospital choice with Mr A before it decided to refer him to hospital A.

58. We know the GP wrote to the consultant at hospital B, that Mr A wanted to see, on 24 April. The CCG said the Service would not have been able to send this referral directly to secondary care without funding being in place. We understand the CCG’s position, but we can see the Service had a copy of the GP’s letter before it sent its referral to secondary care on 8 May. Therefore, it would have been able to see the GP was trying to refer Mr A to hospital B before it referred him to hospital A.

59. The NHS Choice Framework says a patient has the choice of where they want to go for their first outpatient appointment.

60. The Service should have considered the GP letter dated 24 April and asked Mr A which hospital he wanted to attend before sending the referral to hospital A on 8 May. It did not do this. This is a failing.

61. The Service did not refer Mr A to secondary care in September 2017, and when it did refer him, it did not consult with him about which hospital he wanted to go to for secondary care in May 2018.

62. If the Service had done the right thing, it would have referred Mr A to the hospital of his choice in September 2017. We go on to consider the impact these failings had on Mr A.

Impact of the failings

63. Mr A waited at least five months longer than he would have for his surgery if the Service had:

· accepted him for immediate referral to an orthopaedic consultant in August 2017, and · established he would prefer to attend hospital B before it referred him to a consultant.

64. The failings by the Service meant he was left with no realistic option but to arrange surgery himself. There are several reasons for this.

65. Hospital B has told us its waiting time from referral to hip replacement surgery, at the time the Service triaged the GP referral (30 August 2017), was 30 weeks. Had the clock started for Mr A at this point, it is more likely than not he would have had the operation in late March or early April 2018.

66. When the Service referred him to an orthopaedic surgeon at hospital A on 8 May 2018, hospital A had a 40-week waiting time from referral to hip replacement surgery. If Mr A had waited for surgery here, he would not have had it until mid-February 2019.

67. Hospital B has told us its waiting time from referral to hip replacement surgery in May 2018 was 22 weeks. If the Service had referred Mr A to hospital B, which was his preferred choice, on 8 May 2018, it is more likely than not he would have had surgery around 9 October 2018.

68. The Service contacted Mr A on 22 June 2018 to ask if he wanted to change to hospital B because it knew this had been his choice.

69. This put him in a very difficult situation. He had no details at this point about the waiting time at either hospital. He had been in the ‘queue’ with hospital A for over six weeks. He did not want to run the risk of going to the back of the ‘queue’ at hospital B and waiting even longer for surgery. We can understand why he chose to remain with hospital A.

70. After his appointment with the hospital A consultant in July 2018, Mr A learned the waiting time there was 40 weeks from referral to surgery.

71. With no prospect of surgery soon, he felt he could no longer continue. The pain was manageable for a limited period, but he could not cope with the prospect of several more months of it. So he arranged surgery abroad, which he had on 10 September 2018.

72. Mr A should have had surgery by the beginning of April 2018. That did not happen because the Service made a mistake in August 2017. But it had another chance to do the right thing.

73. If the Service had referred Mr A to his choice of hospital B in May 2018, he would only have waited a few more weeks than he did - until early October - for surgery on the NHS. Mr A has told us he would have waited for hip replacement surgery on the NHS had this been the case.

74. In summary, if the Service had not made mistakes, Mr A would not have been put into a difficult situation and felt he needed to arrange surgery abroad. This surgery meant he incurred costs, some of which could not be reimbursed under the EU directive. The CCG is, therefore, responsible for the outstanding costs.

75. Mr A considered all the available treatment options for him and sought a reasonable approach by seeking treatment abroad. Hip replacement surgery would most likely have been considerably more expensive had he paid for this privately within the UK.

76. Mr A discovered the EU directive scheme before he left the UK. At this point, he became aware that he may be able to have some of his treatment costs reimbursed on his return to the UK. He was reimbursed the eligible treatment costs via the EU directive. This was £6683.42.

77. He paid £9,300 for a package via an agency, including treatment, accommodation, and travel costs as well as agency and admin fees. Sensibly, Mr A also took out and paid £207.06 for travel insurance (for between 8 and 22 September), specifically for his circumstance of having medical treatment abroad. It included cover if he needed to stay longer than expected or required a further consultation post operatively. Fortunately for Mr A, this was not necessary.

78. However, Mr A is still out of pocket by £2,823.64, as the additional costs he incurred could not be reimbursed under the EU directive.

79. Mr A was left in pain and distress, unable to properly exercise, maintain his wellbeing and work as he would have hoped for over five months.

80. If the CCG had not made mistakes, he would have had surgery by early April 2018. He arranged his surgery for 10 September 2018.

81. Mr A says that the pain he experienced affected his ability to teach horse riding. Mr A says he did carry on teaching but had to do shorter lessons.

82. He says he could not add any new customers because it would have been too much to cope with. He says it is not possible to quantify how much business he lost but he says he had missed opportunities which were a potential financial loss.

83. We recognise that on the face of it, Mr A experienced an impact on his work for five months or so. But we cannot quantify the financial loss of this. He would have been waiting for surgery for some time, even if the CCG had not made mistakes. And he was able to continue with work, albeit at a slower pace. There is no evidence to quantify a specific financial loss, but we acknowledge this was a difficult time for Mr A.

84. Mr A says the delays caused him stress and anxiety because he did not know when he would have the surgery. He felt depressed and hopeless, and he says he had no other choice but to decide to have the surgery privately.

85. Mr A says the delay to his surgery meant he could not exercise, and he put on weight. He says his general health and wellbeing declined. Mr A says not being able to take part in his day-to-day activities caused him mental anguish and distress.

86. The Service’s failings would have made it harder for Mr A to exercise and maintain good general health and wellbeing. We must also consider the impact the hip problems would have had on Mr A’s ability to exercise and stay fit and healthy. The delays we have found added over five months to Mr A not being able to exercise and maintain good general health and wellbeing properly.

87. We can understand how the prolonged pain, which caused the difficulties in his daily and work life, would have made Mr A feel depressed and hopeless. Mr A experienced mental anguish and distress at not being able to do what was normal for him.

88. The CCG is, therefore, responsible for the distress Mr A experienced. The unnecessary delays we have identified would have caused him stress and anxiety alongside his pain, while he was waiting for a referral to secondary care. We have made recommendations to remedy the injustices to Mr A.

89. We have considered if there is any further impact of the CCG’s failure to refer Mr A to his hospital of choice in May 2018.

90. As we have set out, if Mr A had surgery at hospital B, he would only have had to wait until early October 2018, rather than face the prospect of waiting until February 2019 for surgery at hospital A.

91. Mr A would still have been left in pain for months longer than he should have. But if the CCG had done the right thing in May 2018, he would have avoided having to make the difficult decision to arrange his own treatment, and the effort, inconvenience, and cost of this. We have already set out that we find the CCG’s actions led to this. We have not found any further impact of this specific failing.

Complaint handling

92. Mr A says the complaint process took too long. He says he kept having to chase the commissioning support unit (CSU), working for the CCG, for updates when its responses were delayed.

93. The Ombudsman’s Principles for Good Complaint Handling (our Principles) say public bodies should do the following.

· deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.

· acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply. Public bodies should keep the complainant regularly informed about progress and the reasons for any delays and provide a point of contact throughout the course of the complaint.

94. The complaints team received Mr A’s first complaint letter on 26 September 2018. The CSU acknowledged the complaint on 28 September and said it would respond in 40 working days (by 23 November).

95. On 19 November, the CSU wrote to Mr A with an update. It explained its reasons for the delay and told Mr A it expected to respond in 15 working days (by 10 December).

96. The CSU sent the CCG’s first response to Mr A on 6 December.

97. The CSU told Mr A how long he could expect to wait to receive a reply and told him about the delay and its reasons before the first target date has passed. This is in line with our Principles and there do not appear to be any failings in how the CCG handled Mr A’s first complaint.

98. The complaints team received Mr A’s second complaint on 24 December. On 27 December, the CCG acknowledged receipt and said it would respond in 40 working days (by 22 February 2019).

99. On 18 February, the CSU wrote to Mr A with an update. It did not give a reason for the delay but told Mr A it expected to respond in 25 working days (by 25 March).

100. On 27 March, two working days after the CCG should have given Mr A an update, the CSU wrote to Mr A with an update. It said the CCG needed to meet with Mr A’s GP before the CSU would prepare its response for the CCG’s clinical chief officer to approve. The CSU did not give an expected time for a response or update.

101. Mr A emailed the CCG on 28 March as no deadline for a response or update had been given. He emailed the CCG again on 5 April as he had not received a response to the email he sent on 28 March.

102. On 8 April, the CCG emailed Mr A. It said it was unable to respond until a meeting had taken place with the organisations involved in the complaint, as explained in its letter dated 27 March. It said that the meeting had now taken place and it would respond ‘this week’, which should have been by 12 April.

103. Mr A emailed the CCG on 15 April, as he had not heard from the CCG. He told the CCG of his intention to escalate his complaint if he had not heard from it by 16 April.

104. The CSU sent the CCG’s second response to Mr A on 1 May.

105. In line with our Principles, the CSU should have explained the reason for its delay in responding to Mr A’s complaint when it updated him on 18 February 2019.

106. The CSU should also have given Mr A a new target date to expect the response when it wrote to him on 27 March. The CSU explained the reason for the delay, and we note it was waiting for the CCG to meet with Mr A’s GP. However, this did not prevent it from giving an estimated date for a further response. In line with our Principles, it should have done this.

107. The CSU should also have given Mr A a further update before 12 April. It should not have left him to chase up the response after update deadlines had passed.

108. Had the CSU sent Mr A updates when it said it would, this would have prevented Mr A to chase the CSU unnecessarily.

109. The complaints team received Mr A’s third complaint on 27 August. On 29 August, the CSU acknowledged it. It said it needed to speak to the CCG to understand how it wanted to proceed with responding to Mr A’s letter.

110. The CSU said it would respond in ten working days to tell Mr A of the agreed action plan to address this complaint.

111. On 12 September (within ten working days) the CSU emailed Mr A and said he would receive a full and final response by week beginning 23 September.

112. On 20 September, the CCG emailed Mr A. It said it had not concluded its review. The CSU had been informed by the CCG that it would receive an update on Mr A’s complaint, ‘during the course of the coming week’, which would have been by 27 September.

113. On 7 October, Mr A emailed the CSU for an update as he had not heard from the CCG since its last email sent on 20 September. The CSU responded the same day. It said it expected to send Mr A the response in the next five working days which it did on 10 October.

114. Mr A would not have felt he needed to chase the CSU on 7 October 2019 if the CCG had given him an update by 27 September. We acknowledge the CSU responded to him the same day and advised when it expected to respond. But it should have given him an update before 27 September if it knew it would not have been able to respond by this date.

115. Delays to complaint responses can happen for different reasons. For us to find a failing, we would expect to see actions that fell far short of what we set out in our Principles.

116. We recognise the complaints process took a long time. This can be frustrating and stressful for a complainant. We understand this caused Mr A anger, frustration, and distress.

117. The CSU did not update Mr A on multiple occasions after his second and third complaints.

118. We have found failings in way the CCG handled Mr A’s complaints.

1. We have found the Buckinghamshire Clinical Commissioning Group’s (the CCG’s) decision was wrong in making Mr A go through its specialist musculoskeletal service (the Service) to have conservative management for his hip. This caused a delay in him getting a hip replacement. The Service did not refer Mr A to the hospital of his choice. This added to the delay Mr A was already experiencing.

2. The delays caused Mr A unnecessary pain for over five months more than he should have experienced. Mr A reached a point where he could no longer cope with the pain. This is because the CCG put him in a position where he felt he had no other choice but to seek alternative treatment.

3. We have found failings in the CCG’s handling of Mr A’s second and third complaint. The CCG did not provide Mr A with updates when it said it would. This led to Mr A chasing the CCG for updates unnecessarily.

4. Our decision is to uphold this complaint. We recommend the CCG acknowledges what it got wrong, to apologise for the unnecessary pain, emotional impact, and inconvenience Mr A experienced, and to pay him a financial remedy to recognise this. We recommend the CCG makes service improvements and ask it to reimburse Mr A for the outstanding costs of his treatment.

119. The failings we have found mean Mr A experienced a delay of over five months to his surgery. The pain and suffering he experienced during this time was unnecessary. The pain had a significant impact on his life, and he eventually felt he could no longer cope with waiting for an NHS operation. The failings we have found in the way the CCG handled Mr A’s complaints caused him additional anger, frustration, and distress.

120. In considering our recommendations, we have referred to our ‘Principles for Remedy’ (our Principles). These say that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

121. Our Principles say public organisations should seek continuous improvement and should use the lessons learned from complaints to ensure they do not repeat maladministration or poor service.

122. Within four weeks of the date of this report, the CCG should write to Mr A and apologise for the impact caused by its failings in his care and treatment and the impact of its complaint handling.

· it should acknowledge how making him go through conservative management meant he experienced unnecessary pain for a prolonged time.

· it should acknowledge that not referring him to the hospital of his choice when it should have done added to the delay he was already experiencing, causing him uncertainty about when he would have his surgery.

· it should acknowledge this contributed to Mr A feeling he could no longer cope with the pain and that he had to find alternative treatment sooner.

123. The CCG should acknowledge that a lack of updates during the latter part of the complaints process caused him frustration and left him to chase the CCG for updates.

124. Within eight weeks of this report, the CCG should develop an action plan to show how it plans to address the failings in its decision not to refer Mr A to secondary care within a timely manner, consider his individual needs, and the failings in how it handled Mr A’s complaints. It should also show how it is going to address its failure to refer Mr A to the hospital of his choice.

125. The action plan should include the reasons for the failings, where possible, and the steps the CCG will take, timeframes for the actions, details of who is responsible for each one, and how the CCG will monitor the actions.

126. Finally, our Principles state that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

127. To decide a level of financial remedy, we review similar cases where a similar injustice has arisen, along with our severity of injustice scale. Following this review, within eight weeks of this report, the CCG should pay Mr A £1,500 in recognition of the unnecessary pain, the significant emotional impact, and the inconvenience he experienced as a result of the delay in his surgery.

128. Within eight weeks of our final report, the CCG should also reimburse the outstanding costs Mr A incurred which he could not claim back under the EU directive. The CCG should reimburse £2,823.64 plus interest for the outstanding fees Mr A incurred and his necessary travel insurance.