House of Commons Welsh Affairs Committee The Provision of cross– border health services for Wales Fifth Report of Session 2008–09 Report, together with formal minutes, oral and written evidence Ordered by the House of Commons to be printed 17 March 2009 HC 56 Incorporating HC 401 i-vii, Session 207-08 Published on 27 March 2009 by authority of the House of Commons London: The Stationery Office Limited £0.00 The Welsh Affairs Committee The Welsh Affairs Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Office of the Secretary of State for Wales (including relations with the National Assembly for Wales). Current membership Dr Hywel Francis MP (Labour, Aberavon) (Chairman) Mr David T.C. Davies MP (Conservative, Monmouth) Ms Nia Griffith MP (Labour, Llanelli) Mrs Siân C. James MP (Labour, Swansea East) Mr David Jones MP (Conservative, Clwyd West) Mr Martyn Jones MP (Labour, Clwyd South) Rt Hon Alun Michael MP (Labour and Co-operative, Cardiff South and Penarth) Mr Albert Owen MP (Labour, Ynys Môn) Mr Mark Pritchard MP (Conservative, The Wrekin) Mr Mark Williams MP (Liberal Democrat, Ceredigion) Mr Hywel Williams MP (Plaid Cymru, Caernarfon) Powers The committee is one of the Departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk. Publications The reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the internet at www.parliament.uk/parliamentary_committees/welsh_affairs_committee.cfm. Committee staff The current staff of the Committee is Dr Sue Griffiths (Clerk), Judy Goodall (Inquiry Manager), Georgina Holmes-Skelton (Second Clerk), Carys Jones (Committee Specialist), Christine Randall (Senior Committee Assistant), Annabel Goddard (Committee Assistant), Tes Stranger (Committee Support Assistant) and Rebecca Jones (Media Officer). Contacts All correspondence should be addressed to the Clerk of the Welsh Affairs Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 6189 and the Committee’s email address is [email protected]. The Provision of cross-border health services for Wales 1 Contents Report Page Summary 3 1 Introduction 7 Interim Report 8 Recent developments 9 2 Cross-border health services 10 Cross-border flows 10 Primary care 11 Secondary care 11 Tertiary care 11 Devolution and policy divergence 12 The internal market 13 Foundation trusts 13 “Patient voice” and “patient choice” 13 Waiting time targets 14 Free prescriptions 14 Free car parking 15 Performance regime 15 Cross-border problems 16 Access to hospital and specialist services 16 “All-Wales Commissioning” 18 3 Funding and commissioning 21 Commissioning arrangements 22 Funding arrangements 22 Interaction between the two regimes 23 English providers 24 Welsh commissioners 26 Local agreements 30 Effects on patient care 33 Developing a sustainable funding solution 34 The need for governmental involvement 34 Transparency 36 4 Waiting times 36 Different targets 36 Actual waiting times 37 Dealing with different targets 38 Managing two waiting lists 38 The patient’s experience 40 Looking forward 41 5 Patient engagement 41 2 The Provision of cross-border health services for Wales Patient information and engagement services 42 Foundation trusts 42 Patient representation 43 6 ‘Border-proofing’ policy 43 The border as a barrier 43 The need for a permanent protocol 44 7 Conclusion 45 Clinical excellence as close to home as possible 45 Border proofing of policy and practice 46 Cross-border citizen engagement 46 Transparent and accountable co-operation between localities, regions and governments 47 Conclusions and recommendations 48 Introduction 48 Cross-border health services 48 Funding and Commissioning 49 Waiting times 51 Patient engagement 51 ‘Border-proofing’ policy 52 Conclusion 52 List of Reports from the Committee during the current Parliament 60 Formal Minutes 54 Witnesses 55 List of written evidence 56 List of unprinted evidence 59 The Provision of cross-border health services for Wales 3 Summary The border between England and Wales is long and porous and as a result cross-border movements have been a fact of life for many years, including for health services. Given the divergence in health policy between England and Wales, and the significant number of patients who cross the border for treatment, our inquiry examined the interface between the two systems and the effectiveness of co-ordination between the Department for Health and the Welsh Assembly Government. We wanted to discover whether cross-border patients are treated fairly and whether the Welsh Assembly Government and the Department of Health consider the border in the development of the diverging policy environment. We chose to undertake this inquiry because we had heard of significant confusion amongst patients, for example in knowing what they are entitled to receive from their health service. We also heard that cross-border providers were being disadvantaged by the need to cope with two separate funding and commissioning schemes. In July 2008, the Committee published an interim report on the provision of cross-border health services. We felt this was necessary because developments were anticipated in several key areas, including the conclusion of the Steers Review into neuroscience services in Wales; the Welsh Assembly Government’s consultation on the restructuring of the NHS in Wales; and an expected announcement on the establishment of a permanent formal protocol on cross-border health services between the Department of Health and the Welsh Assembly Government, to which we wanted to contribute. Our interim report concluded by recommending that four “key criteria” should be established in cross-border health policy: • Clinical excellence as close to home as possible; • Border-proofing of policy and practice; • Cross-border citizen engagement; and • Transparent and accountable co-operation between localities, regions and governments. This Report returns to these key criteria in the light of developments since we took evidence. Clinical excellence as close to home as possible Cross-border movements between England and Wales have been a fact of life for many years. There is no practical or realistic prospect of diverting these well established cross- border flows, nor would it be desirable to do so. For these reasons, healthcare providers in England and Wales need to maintain close links to ensure that patients receive the treatment they need regardless of their country of residence. This will require commitment and good will from those concerned with policy and delivery by the NHS on either side of the border and a readiness to adapt funding and other arrangements to meet the reality of different bureaucratic processes. Divergent policies must be implemented in a way which accommodates the continuing flow of patients across the Wales-England border. 4 The Provision of cross-border health services for Wales Border proofing of policy and practice There is a clear lack of co-ordination between the UK and the Welsh Assembly Governments. There are potentially serious consequences of leaving individual organisations to cope with the tensions raised by different funding and commissioning arrangements for Welsh and English patients. The opportunity for financial pressure to impact on health service provision must be removed. It is unacceptable that individual providers and commissioners have been left to negotiate ad hoc solutions to problems caused by government-level decisions, apparently taken without regard for their impact on cross-border commissioning. Even where local arrangements work well, patients should not have to rely on the good will of those involved to ensure that their health care pathways are coherent. A solution must involve a sustainable and enforceable long-term agreement between the relevant Ministers and Departments so that future disputes will be avoided. The key test must be whether all parties demonstrably have as their highest priority the need to secure the best possible service for patients. The Committee therefore considers that an improved government-level protocol is essential to standardise and clarify arrangements and accountability mechanisms. We are very disappointed that a permanent protocol on cross-border health services has not been agreed between the Department of Health and the Welsh Assembly Government. We are disturbed by the fact that this has not even been published in draft for consultation. Cross-border citizen engagement Patients on both sides of the border are generally unaware of the potential for divergence between the Welsh and English health services. Better information for patients must be made available, particularly in immediate border areas where the choice of a Welsh or English GP may have implications for later care. The Committee is encouraged by the examples we were given of English hospitals including a cross-border dimension in their management structures. We believe that this model could and should be replicated in all hospitals near the border which serve both English and Welsh patients. We are nevertheless concerned by the anecdotal evidence we have received suggesting that English residents with an interest in Welsh health services may find their engagement in those services limited.