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
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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
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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.
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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. We recommend that the Department of Health include citizen engagement and patient ownership of cross-border services in negotiations with the Welsh Assembly Government to ensure that English residents’ rights to contribute to Welsh services are protected by the Welsh patient engagement process, just as the rights of Welsh patients are protected in the structure of Foundation Trusts.
Transparent and accountable co-operation between localities, regions and governments
The decision-making process on each side of the border needs to be more coordinated, more coherent and more transparent. There needs to be a better and more public interface between the Department of Health and the Welsh Assembly Government. Patients, if they want or need to, should be able to understand the framework in which they will receive care.
The Department of Health did not provide a response to our interim report until 26 January 2009, some 6 months after the publication of our Report. We consider that the delay in providing a response to our interim Report was unacceptable and we expect the
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Government to provide a more timely response to this Report. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems. In its response to this Report, we expect the Government either to announce the publication of its draft protocol, or to give a reasoned explanation for the delay.
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1 Introduction
1. In November 2007, we began a substantial and wide-ranging inquiry into the provision of public services across the border between Wales and England.1 The Committee issued a further call for evidence on 7 February 2008, in which we announced our intention to explore the provision of health services in the first instance, followed by consideration of cross-border issues as they affect further and higher education and transport.2 The terms of reference for our cross-border inquiry were:
• The extent to which cross-border public services are currently provided for and readily available to the Welsh population;
• The arrangements currently in place to co-ordinate cross-border public service provision; and
• The funding and quality of cross-border public services.
2. Our inquiry was widely welcomed and the Committee received over 60 written submissions relating to cross-border health services from a range of individuals and organisations. We held seven oral evidence sessions on the subject between 18 March and 12 June 2008. Our oral evidence sessions considered the situation throughout Wales, although a particular focus was cross-border flows in North and Mid-Wales. The relative geographical isolation and population sparsity of those areas makes access to services across the border vital for residents. We visited the Walton Centre for Neurology and Neurosurgery NHS Trust at Fazakerley, Liverpool and the Royal Liverpool Children’s NHS Trust, Alder Hey. We were impressed by the quality of the facilities and are grateful to the staff at both hospitals for providing us with this opportunity to learn first hand how cross- border health services are provided and how patients, clinicians and administrators perceive the current arrangements.3
3. In 2007, approximately 20,000 people resident in England were registered with a GP in Wales and 15,000 people resident in Wales were registered with a GP in England.4 The memorandum submitted by the Welsh Assembly Government stated that 6.3% of all admissions of Welsh residents go across the border, and concluded, therefore, that cross- border commissioning does not impact on very large numbers of patients.5 However, we note that the consequences for those involved are significant and that those affected are often the most sick or vulnerable and least able to deal with problems if they occur. We therefore consider that cross-border healthcare provision and co-ordination is a serious
1 Welsh Affairs Committee Press Notice: Announcement of Committee Inquiry — Provision of cross-border public services for Wales 6 November 2007. 2 Welsh Affairs Committee Press Notice: Announcement of Committee Inquiry — Provision of cross-border public services for Wales — Call for evidence 7 February 2008. Our Report on Further and Higher Education was published in January, and our inquiry into cross-border transport issues is ongoing. 3 The Committee also records its thanks to Professor Marcus Longley, Professor of Applied Health Policy and Director of the Welsh Institute for Health and Social Care, who acted as specialist adviser for this inquiry. His assistance was invaluable in the compilation of this Report. 4 Government Response to the Welsh Affairs Committee interim report on the provision of cross-border health services for Wales, Cm. 7531, January 2009. 5 Ev 224
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matter which can and should be resolved swiftly, sustainably, and, as the Welsh Assembly Government said, “in ways invisible to the public”.6
Interim Report 4. On 10 July 2008, the Committee published The provision of cross-border health services for Wales: interim report. We felt an interim report was necessary at that time 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 announcement on the establishment of a permanent formal protocol on cross-border health services between the Department of Health and the Welsh Assembly Government. We wanted to contribute constructively to the ongoing discussions in these areas by highlighting key issues which had come to our attention and making recommendations where possible.
5. Our interim report noted the long history of cross-border flows between England and Wales in the provision of health services as well as the need for these to continue in the interests of providing quality health care as close to home as possible. We 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
• Transparent and accountable co-operation between localities, regions and governments.
In the interim report, we also promised that our final report would:
• set out the concerns raised in written and oral evidence received;
• review the current consultations and draft protocols in the field of cross-border health care;
• measure the results of recent developments against our recommended “key criteria”;
• return to the issue of waiting times in more detail; and
• comment on the implications of the Steers Review for cross-border health services.
As stated in the interim report, we had expected to receive the following shortly after publication of the interim report:
• clarification from the UK Government on how super-rare conditions are funded;
6 Ev 260
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• publication of a draft permanent protocol between the Department of Health and the Welsh Assembly Government for consultation; and
• further evidence from the two Governments on the role of patient representative bodies.
Recent developments 6. Since the publication of our interim report, the following developments have occurred:
7. The Steers Review into neuroscience services in Wales has come to an end. Three reports were published: one on North Wales, one on South and Mid Wales, and an All Wales report drawing the conclusions and recommendations together.7 The Review recommended that patients in North Wales should continue to have ready access to services across the border in England (at the Walton Centre) and that two centres in South Wales, at Swansea and Cardiff, should also continue to provide complex care. The Welsh Assembly Government has welcomed the findings and announced plans for implementation groups to take the recommendations forward.8
8. The Welsh Assembly Government continues to consult on the restructuring of the NHS in Wales. The Welsh Health Minister, Edwina Hart AM, has made several announcements regarding the direction in which the NHS will move in Wales, including the proposal for a simplified structure for the NHS in Wales by the dissolution of twenty-one Local Health Boards (LHBs) and seven NHS Trusts in Wales, to be replaced by seven LHBs in total. A further consultation paper on some specific areas of the restructuring was issued and the consultation period concluded in late February 2009.9 On 30 January 2009, proposals on the future of Community Health Councils (independent bodies responsible for monitoring the health service and assisting patients experiencing difficulties) in Wales were also published for consultation.10
9. The European Commission published a draft Directive on the application of patients’ rights in cross-border healthcare.11 This is intended to improve quality and access in cross- border care; establish information requirements for patients, health professionals and policy-makers; and extend the scope for co-operation on health matters. Although the Directive would apply to international borders, rather than internal borders within a state, and it will be some time before a European Community Directive is finalised, European level developments in inter-governmental healthcare delivery should be monitored for lessons that the UK and Wales can take from those negotiations.
10. Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health acknowledged our interim report by way of a letter dated 26 September 2008 saying
7 Report of the Welsh Neuroscience External Expert Review Group, July and September 2008. 8 Written Statement by the Welsh Assembly Government, ‘Independent Adult Neurosciences Expert Review’, 30 September 2008 , Edwina Hart, Minister for Health and Social Services. 9 Delivering the new NHS for Wales, Consultation Paper II, December 2008 10 Proposals on the future of Community Health Councils, January 2009 11 Proposal for a Directive of the European Parliament and of the Council on the application of patients' rights in cross- border healthcare, 2 July 2009.
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that our recommended key criteria were “entirely consistent with the Department’s objectives”. The letter continued “…we expect to provide a full response later in the autumn”. Despite this assurance, the Department of Health did not provide a response to our interim report until 26 January 2009, some 6 months after the publication of our Report. We consider that the delay in providing a response to our interim Report was unacceptable and we expect the Government to provide a more timely response to this Report.
11. As the Government’s response noted, there has been no publication of a permanent protocol on cross-border health services, either in draft or in its final form. This is despite the Minister’s statement in evidence to us last June that he hoped to have secured agreement on a long-term protocol with the Welsh administration by the end of the following month12 and “would be very reluctant to renew the interim protocol for another year”.13 We are very disappointed that a permanent protocol on cross-border health services has not yet been agreed between the Department of Health and the Welsh Assembly Government, or even published in draft for consultation. Our interim Report concluded that this was a critical issue in need of urgent consideration. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems. In its response to this Report, we expect the Government either to announce the publication of its draft protocol, or to give a reasoned explanation for the delay. The Committee also expects a prompt response to its Report.
12. In the interim Report and in a subsequent call for evidence,14 the Committee stated that it would welcome further evidence on the conclusion of the Steers Review, the Welsh Assembly Government consultation on the restructuring of the NHS in Wales and the anticipated announcement regarding the formal protocol. We received some further submissions, which have been considered in this full Report. In connection with the other strands of our cross-border inquiry, we also visited Dublin, where we were able to speak to officials from both the Republic of Ireland and Northern Ireland and benefit from their perspective on the cross-border co-ordination of services. 2 Cross-border health services
Cross-border flows 13. Health care pathways for patients have always crossed the Welsh-English border and continue to do so following devolution in 1999. There is a significant flow of patients from Wales to England in all areas of healthcare and also from England to Wales in primary healthcare. This cross-border movement is attributable to a number of interrelated factors, including geographic convenience for patients, specialties of certain departments and clinicians and the need for a critical mass in some areas of health care, which has led to a UK-wide as opposed to an all-Wales service. Health care is divided into primary, secondary
12 Q 510 13 Q 514 14 Welsh Affairs Committee Press Notice: Cross-border health services for Wales — call for evidence 22 July 2008.
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and tertiary services and cross-border issues are present in all three categories to some degree.
Primary care 14. Primary health care is the term used for the activity of a health care provider who acts as a first point of consultation for all patients. Examples include GP services, dentistry services, ophthalmic services and pharmacy services. About 90% of all patient contacts with the NHS occur in primary care. There are more English patients registered with Welsh GPs than vice versa. Around 20,000 English patients are registered with a Welsh GP, while approximately 15,000 Welsh patients are registered with an English GP. In 2007 there was a net flow of 5,354 patients into Welsh primary care services from England.15 Geographic convenience is the main reason behind cross-border travel for primary healthcare. Patients receiving treatment from primary care services on the other side of the border generally live in immediate border areas along the Wales-England border and choose a GP as close to home as possible, which may not be in their country of residence.16
Secondary care 15. Secondary health care is the service that is generally provided in or by general hospitals. It is usually provided by a specialist following a referral from a GP or other primary care practitioner. Travelling distances increase for patients receiving secondary care as the more specialised the services, the further people usually need and are prepared to travel for treatment.17 The cross-border flow is generally from Wales to England and occurs more often in Mid and North Wales rather than the more urban and densely populated South. This is in part due to geographic convenience, but also because of the lack of secondary care provision in the immediate locality (for example Powys has no District General Hospital within its boundaries).18 The Welsh Assembly Government told us there were around 43,000 admissions of Welsh residents to hospitals in England in 2006-07, including both emergency and elective patients, but only 12,000 English patients treated in Welsh Trusts.19 The Department of Health reported that there were almost 227,000 Welsh out- patients treated at English hospitals in 2006-07.20 The main providers of cross-border secondary care services for Wales are hospitals in Liverpool, Chester, Gobowen (Oswestry), Shrewsbury and Hereford; and to a lesser extent in St Helen’s, Knowsley, Gloucester and Bristol.
Tertiary care 16. Tertiary services are provided by specialist hospitals or regional centres equipped with diagnostic and treatment facilities not generally available at local hospitals. Referral is
15 Memorandum submitted by the Department of Health, Ev 125. 16 Q 190 17 Ev 113; Q 407 18 Ev 260 19 Ev 261. 17,413 admissions of Welsh patients to English hospitals in 2006/07 were emergency admissions while there were 25,196 non-emergency admissions of Welsh patients to English trusts. 20 Ev 125
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generally from a secondary care specialist. Examples include plastic surgery and burns treatment centres, advanced neonatology services, genetic services, organ transplantation and some aspects of neurology/neurosurgery. Tertiary care centres are mainly located in areas of higher population density and the relatively small population size of North and Mid-Wales means that there is simply not the critical mass of people needed to support more local specialist centres (an issue which affects more remote regions of England as well as Wales).21 Cross-border flows of patients for such care are therefore mostly from Wales into England, although in some cases, outpatient care is provided in Welsh hospitals by visiting specialists from England. Examples of tertiary services in England used by Welsh patients include:
• Neurosurgery (usually provided to patients from North Wales at the Walton Centre, Liverpool).
• Spinal injuries and specialist orthopaedic (usually provided to patients from North and Mid Wales at Gobowen Hospital, Oswestry).
• Cardiac surgery (usually provided at Manchester Heart Centre, Manchester Royal Infirmary and Cardiothoracic Centre, Liverpool).
• Children’s services (usually provided to children from North Wales at Liverpool’s Alder Hey Hospital and, on occasion, to children from South Wales at London’s Great Ormond Street Hospital).
Devolution and policy divergence 17. Since devolution, the NHS in Wales has been a responsibility of the Welsh Assembly Government. The UK Department of Health in Westminster retains responsibility for the following health-related matters:
• International and EU business, including the negotiation of legal agreements;
• The oversight of the medical professions;
• The licensing and safety of medicines and medical devices;
• The co-ordination and planning for pandemic influenza; and
• Ethical issues such as abortion, organ transplantation, embryology, surrogacy and human genetics.
18. In the decade since 1999, the identification and pursuit of different health policy priorities by the four nations of the UK has led to the adoption of different models for the provision and organisation of healthcare services. In evidence given to our inquiry, both UK and Welsh Assembly Government Ministers saw this as an inevitable consequence of devolution. Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health said that with devolution “you allow for some flexibility in the different
21 Ev 102 and Q 528. The British Medical Association quotes the Royal College of Surgeons, Delivering high quality surgical services for the future, noting that, for example, a District General Hospital with full services needs a population base of between 450,000-500,000 residents: Ev 114.
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countries to reflect the different characteristics, the different needs and therefore, the different priorities, so you inevitably get a level of divergence”.22 First Minister, Rt Hon Rhodri Morgan AM agreed that “Divergence is inherent in devolution… [Wales] will suit the agenda to Welsh needs and then in England they will suit the agenda to England’s needs”.23 Not all differences in health care provision between England and Wales date from devolution.24 Nevertheless, since 1999, there are several ways in which the health policies of the two nations have diverged over the past ten years.
The internal market 19. A major policy divergence since devolution relates to the differences in the way services are commissioned and funded. Since 2003-04, England has incrementally introduced a national tariff system called Payment by Results (PbR) where each individual treatment is billed to the NHS at a standard rate. Payment by Results is intended to encourage Primary Care Trusts to commission only those services they need, and to establish an incentive for providers to attract more patients and complete a higher number of procedures at a lower unit cost. Along with the extension of patient choice, a declared intention of this system is to foster competition between providers, which it is hoped will lead to improved services and greater efficiency. Welsh commissioners do not operate a tariff system and largely rely on block contracts based on historical data, which provide for any over-performance by providers at a marginal rate.
Foundation trusts 20. In England, hospitals have been given the ability to apply for foundation trust status. Foundation trusts are run by a board drawn from local organisations and communities. The declared intention behind this policy is to make hospitals more responsive to the needs and wishes of their local people. In order to become a foundation trust, hospitals must satisfy certain criteria, including robust financial management structures. Foundation trust status is not available in Wales.
“Patient voice” and “patient choice” 21. As part of the commitment to the use of an internal market and competition as a means of improving quality and efficiency, England has implemented “patient choice” in booking elective treatment. In contrast, the Welsh Assembly Government has stated that it will give patients a greater say in their services, with a focus on “patient voice”. Our evidence examined the contrasting experience of patient groups in these two systems as well as the possibility of cross-border engagement.
22 Q 472 23 Q 526 24 Before 1999, the NHS in Wales was slightly different in structure to that in England, and there were differences in the way health services were provided as well as disparities in the health of the Welsh population compared to that of the other home nations.
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Waiting time targets 22. Waiting time targets in the two nations differ, although the gap between them has recently closed, as shown in the table below. In part, the divergence can be ascribed to the decision of the Welsh Assembly Government to prioritise spending on preventative care. The Welsh Assembly Government has committed itself to reducing waiting times to maximum of 26 weeks from referral to treatment, including all or any waits for therapies and diagnostic tests, by December 2009.25 The maximum wait in England is 18 weeks from the time of referral to a hospital consultant to the beginning of treatment. The targets are also measured differently, depending on the nature of the referral to another provider. In evidence, our witnesses emphasised that waiting time targets represent the maximum wait a patient should experience and noted that actual waiting times for Welsh and English patients were in practice more similar.26 NHS Trust representatives told us that they prioritise on the basis of clinical need and urgency and treat all patients against criteria of clinical need. On the other hand they acknowledged that they have to respond to a difference in the targets they are set by commissioners on either side of the border. We were left with the impression that both clinicians and administrators try to reconcile these inconsistencies as honestly and fairly as they can with the best interests of patients in mind. We were also left with the impression that it is a thankless task—or at least that there is little thanks from either the Welsh Assembly Government or the Department of Health for the way in which they reconcile these inconsistencies on a daily basis. We are not convinced that either the Department of Health or the Welsh Assembly Government are fully aware of the problems created on the ground by such divergence.
Table: Announced waiting times targets (Source: Ev 128)
2005 2006 2007 2008 2009 Max Outpatient wait from referral to first outpatient appointment England 13 weeks Wales 12 months 8 months 22 weeks 10 weeks Inpatient and daycase wait from decision to treat to admission England 6 months Wales 12 months 8 months 22 weeks 14 weeks Whole patient journey from GP referral to start of treatment England 18 weeks Wales 26 weeks
Free prescriptions 23. As of 1 April 2007, prescription charges were abolished for Welsh patients in Wales, including all patients registered with a Welsh GP who fill their prescriptions from Welsh
25 Letter from the First Minister to the Chairman, dated 10 July 2008, Ev 260. 26 Q 591
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pharmacists and those patients with an English GP as long as they fill their prescription from a Welsh pharmacist and present their entitlement card. In addition, charges for wigs and other appliances were also abolished. Welsh patients who receive these services from an English NHS Trust should have their costs met by their Local Health Board.27 Fears around “health tourism” putting a strain on the medicines budgets of affected Welsh Local Health Boards have been expressed.28 However, we found little evidence of any problems in this area. In its evidence, the Department of Heath noted that 88% of prescriptions in England are provided free of charge, due to various entitlements, so the financial impact of the difference between the two systems in respect of this flagship policy is more apparent than real.29
Free car parking 24. By the end of 2011, patients will be able to park for free at almost all NHS hospitals in Wales. Four sites will still have parking charges until the private contracts expire. By mid- 2008, 120 of 130 NHS hospitals and units had free car parking.30 The free parking policy has provoked some controversy. Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health, has said that English health spending has prioritised treating people faster and better, rather than on subsidising parking: “In Wales, you have to wait much longer for your operation, you have to wait much longer in A&E”.31
Performance regime 25. There are some performance regime differences between the NHS in England and Wales, for example:
• Standards regimes: significant aspects of care are increasingly shaped by national standards, such as the various national service frameworks (NSFs). NSFs are long term strategies for improving specific areas of care. They set national standards, identify key interventions and put in place agreed time scales for implementation. Almost all NSFs have different England and Wales versions; in some cases there is no equivalent in Wales to a framework in England and vice versa. Part of their rationale is to ensure that complete and coherent packages of care are available to all patients; this coherence can be challenged if patients move between regimes, and thus between NSFs.
• Inspection and regulation regimes: Health and social care organisations on either side of the border are subject to different inspection and regulatory bodies (e.g. the Healthcare Commission and Monitor in England, Regional Officers and the Wales Audit Office in Wales). As a consequence, aspects of their service respond to different Wales and England imperatives.
27 NHS Wales website – NHS prescription charges http://www.wales.ngs.uk/page.cfm?pid=9586 28 Ev 99 29 Q 502 30 1 April 2008 “Free hospital parking under way” http://news.bbc.co.uk/1/hi/wales/7323027.stm 31 Ibid.
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• ICT programmes: Information technology is increasingly the key medium which links elements of the care system. However, very few systems cross the England- Wales boundary. One example is the system designed to facilitate referral to secondary care: while a “choose and book” service is offered to patients in England to book appointments from a choice of hospitals, no close equivalent exists in Wales.
• Professional initiatives: Each healthcare system regularly generates professional initiatives to improve particular aspects of service provision.
Cross-border problems 26. Given the divergence in 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.
27. Our inquiry was not concerned with the structure of the NHS in Wales or its general operation, which are matters devolved to the Welsh Assembly Government and scrutinised by the National Assembly for Wales. This Committee was interested in ascertaining the problems associated with the border, the diverging policies and the ‘unintended consequences’ of devolution. In its memorandum to the Committee, the Department of Health states: “The border between England and Wales does not represent a barrier to the provision of health care”. It further states: “Patients will not be disadvantaged as a result of any of the differences in the two systems”.32 The memorandum from the Welsh Assembly Government Minister for Health and Social Services agreed that: “the basic position on both sides is that patients should not suffer detriment as a result of these. Any issues should be resolved in ways invisible to the public”.33 Given the likelihood of further health policy divergence in future, we believe that it is essential for robust and detailed systems of liaison to be in place to guarantee that these objectives are being achieved and that structures are in place to guarantee consistent cross-border co-ordination in years to come.
Access to hospital and specialist services 28. As we noted in our Interim Report,34 the main area in which our inquiry found problems with access to services across the border was in hospital and specialist treatment. Although we set out to examine primary, secondary and tertiary services, we found
32 Ev 130 33 Ev 260 34 Welsh Affairs Committee, Session 2007-08, The provision of cross-border health services for Wales: Interim Report, HC 840, paragraph 14 and chapter 3.
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relatively few problems with access to primary health care itself.35 Patients in England and Wales are free to register with a GP on either side of the border and there is an arrangement between the Welsh Assembly Government and the Department of Health to transfer funds between the two to cover the cost of patients registered with GPs on the opposite side of the border to which they are resident.36 However, primary health care providers do play a part in referring patients on to specialist consultants and the procedure for commissioning their care, as well as the applicable waiting time targets are dependent on the location of the GP in England or Wales (see table below). It is not clear to us that patients are fully aware of the potential implications of their decision to register with a GP in either England or Wales, should they need a referral to a secondary provider.
Table 2: Applicable waiting times targets (Source: Ev 126) 1 2 3 4 5 6 7 8 Patients England Wales England Wales England Wales England Wales resident in:
Patient England England England England Wales Wales Wales Wales registered with a GP in: Treated in a England England Wales Wales England England Wales Wales provider in:
Are subject England England Wales Wales Wales Wales Wales Wales to the waiting times standards set by the DH/govt. in:
29. The Committee received evidence that gave rise to greater concern about difficulties and delays accessing secondary and specialist services on a cross-border basis. This was not necessarily connected with policy changes since devolution. As many of the submissions noted, rural communities, such as those in parts of Mid and North Wales, have always faced difficulties accessing health care, especially specialist services.37 The difficult terrain, the relative remoteness of some of the population, and the relatively small population size all present problems. Mr Robin Morrison, Provincial Church and Society Officer, Church of Wales said in this regard: “in one sense the economic and social causation of those facts
35 It should be noted that some concerns were raised regarding primary care commissioning, but that these were relatively minor, for example in dental care. Mr Colin Jenn, Director of Finance for Flintshire Local Health Board specifically submitted supplementary evidence to make the Committee aware that the interim report focused on hospital care, while there were also “admittedly minor” concerns “raised on certain primary care services as well, dental for example” (Ev 139). Bishop Anthony Priddis wrote: “I know of people in Presteigne who wanted to sign up with an NHS dentist in Leominster but were told they were not eligible to do so because they live in Wales” (Ev 105). 36 The Department of Health explained that it “makes an annual financial transfer to the NHS in Wales - £5.6 million in 2007-08 – to cover the extra net costs of providing hospital services for English residents registered with GPs in Wales (Ev 127). 37 Q 100
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in Wales [rural living, poverty, lengthy travel for treatment and worse outcomes for those who travel furthest (‘distance decay’)] has nothing to do with devolved systems” .38
30. The main areas where more obviously avoidable difficulties were reported were: funding disputes between Welsh commissioners and English providers; commissioning and funding systems for rare medical conditions; longer waiting times for Welsh patients in English hospitals; and issues surrounding patient engagement. The problems affecting patients were echoed in submissions from clinicians, hospital administrators and others in the health industry. We received evidence of confusion about the different systems leading to disputes and delays in payment. Many clinicians objected to the difference in waiting targets applicable to patients being seen by the same consultant. Although we were told that any patient needing to be treated as an emergency would receive care without question, we are concerned that there are ongoing problems in the provision of elective treatments for cross-border patients. We explore these areas in detail in this Report and make recommendations for action. We take this opportunity to record our appreciation to all those patients, families and carers who provided evidence and gave us the perspective most central to this inquiry—the impact on patients.
“All-Wales Commissioning” 31. A number of those who contributed submissions to our inquiry were concerned by a perceived move towards “in-country” commissioning on the part of the Welsh Assembly Government, with the ultimate aim of treating all Welsh patients within the nation. In 2005, the then Welsh Minister for Health and Social Services, Dr Brian Gibbons, confirmed the Welsh Assembly Government’s objective that Welsh patients needing tertiary and specialist services should wherever possible and clinically appropriate be seen and treated in Wales. The Welsh Assembly Government confirmed in its memorandum to this Committee that Health Commission Wales has been pursuing this approach.39
32. On 4 July 2007, the Welsh Assembly Government Minister for Health and Social Services, Edwina Hart AM, stated that her “overriding aim is to secure as many services as can be safely provided within Wales’s boundaries” whilst acknowledging that “there will always be rare conditions and highly specialist services that can only be supported by populations greater than the population of Wales. This means that there will always be some patients who must travel outside Wales for the services that they require”.40 The Minister went on to comment in particular on the arrangements for adult neurosurgery:
However, where the population base is sufficient to support an in-country service, that is the way in which I wish to proceed. Therefore in the case of adult neurosurgery, the approach that I now intend to adopt is one in which we will look as actively as possible at redirecting additional elective work generated inside Wales to the two centres at Swansea and Cardiff.41
38 Q 6 39 Ev 262 40 National Assembly for Wales, Official Record, 4 July 2007 41 Ibid.
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33. This statement became the subject of significant concern for clinicians, patients and administrators. Some of those who gave evidence interpreted it to mean that the Welsh Assembly Government was planning to require patients to travel within Wales to receive specialist treatment, rather than crossing the border. For the population of North and mid- Wales, this would mean a long journey to Cardiff or Swansea rather than a shorter distance to a centre in England. In its evidence, the BMA noted the widespread concern generated by this suggestion that well established networks between North Wales and the North West of England would be disrupted, and argued that that sending patients from North Wales any further than the English services already accessed would be “clinically unsafe”.42
The Steers review of neurosciences 34. On 25 September 2007, the Welsh Assembly Government Minister for Health and Social Services, Edwina Hart AM, announced the decision to establish an Independent Neurosurgery Task and Finish Group to conduct a review of adult neurosciences services in Wales.43 The Group was chaired by Mr James Steers, a consultant neurosurgeon. The Group’s work followed a previous review of neuroscience in 2006, conducted by Health Commission Wales, which had recommended the consolidation of neurosurgery services from two centres in Swansea and Cardiff to one site in South Wales, based in Cardiff. This recommendation was based on the principle that a critical mass of patients is required to maintain the viability of specialist services.
35. The Steers Group recommended that many services currently supplied to North Wales residents in England could be provided within North Wales itself and therefore much closer to home for Welsh patients. The report focused on ensuring a coherent pathway of care for neurosciences patients including hospital and community based care and recommended ways in which services for acute hospital care can be tied with specialist long-term care.44 However, the group recommended that the very complex and highly specialised area of neurosurgery would need to remain at the Walton Centre in Liverpool and that links with the Walton Centre would remain for professional development. In fact, it said the critical care capacity must be expanded to cope with the needs of all acute neurology and neurosurgery in North Wales and that clear links should be established between enhanced Stroke Units in North Wales and the Walton Centre for the onward referral of patients to Liverpool when required. In its Report on Mid and South Wales, the Group recommended a managed clinical network for neurosciences, four medical neurology services with in-patient capability in Cardiff, Swansea, Newport and Carmarthen, and that complex care should take place in Cardiff and Swansea.45
36. Following the report’s publication, Welsh Health Minister Edwina Hart accepted the recommendations and announced that a new base in Ysbyty Glan Clwyd will offer medical neurology, stroke management neurophysiology services, and that an inpatient neuro- rehabilitation centre will be established. Additionally, two other district general hospitals in
42 Ev 115 43 http://wales.gov.uk/publications/accessinfo/drnewhomepage/healthdrs2007/1931940/?lang=en 44 Report of the Welsh Neuroscience External Expert Review Group Recommendations for North Wales, 16 July 2008 45 Report of the Welsh Neuroscience External Expert Review Group Recommendations for Mid and South Wales, 18 September 2008
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the North will provide “enhanced” services.46 The Minister also said that neurosurgery for North Wales will remain with the Walton Centre, remarking: “I have been disappointed that over the last year there have been many inaccurate stories about the review and the potential outcome. Many said that people would be compelled to travel to South Wales…My aim was always to improve services for patients in North Wales”.47
Proximity to care 37. Proximity to care is clearly of vital importance to clinical outcomes and we received a substantial amount of evidence on this issue.48 Many Welsh patients and patient representatives told us how hard the travel to specialist centres for treatment already is and several told us that it is not uncommon for patients to refuse treatment or cease treatment part way through because of lengthy travel requirements.49 Bishop Anthony Priddis, Bishop of Hereford, told us in oral evidence:
It would be a nightmare for people just across a Welsh border not to be able to go to Shrewsbury Hospital which was five miles away, or to Hereford Hospital…if patient care really is the end, then geography is going to be key…We know that health and wholeness…is also to do with not worrying about your wife or your husband or your children having to get to visit you or how they are being supported elsewhere…It does not figure in the statistics; it does not figure in the budgets, but it does figure in how people recover…50
38. Despite this, in the course of the inquiry, we received significant anecdotal evidence that patients were being directed towards Welsh providers rather than English hospitals.51 Neurosciences were a particular focus of the inquiry, due to the prominence of the Steers Report at the time we took evidence, but many of those who contacted us expressed the feeling that a more general policy to refer and treat within Wales was emerging, and that on some occasions this was not in patients’ interests.52 In evidence before the Committee, the First Minister, Rt Hon Rhodri Morgan AM, said that in determining the priorities in providing health services, “clinical safety and clinical quality will be the main drivers” and that:
…the issue is always whether what you want is excellent services provided as close as possible to your home or services which are as close as possible to your home which
46 17 July 2008, Western Mail, ‘Health Minister does sharp U-turn over brain surgery plans for North Wales’. 47 Welsh Assembly Government Press Notice,’ More Neuroscience Services to be Based in North Wales, North Wales neurosurgery patients will continue to go to England’, 16 July 2008 48 Qq 24-25, Ev 100-106: Bishop Priddis discussed the phenomenon of ‘distance decay’ and quoted a study from the Emergency Medicine Journal 2007 (24, 665-668), Nicholl et al showing a 1% increase in mortality for each 10km travelled (Ev 104). 49 Ev 118, Ev 179, Ev 210. 50 Q 17 51 For example, Ev 100, Ev 281. 52 For example, Bishop Walker said “The WAG policy to provide all services from within Wales can run counter to its policy of putting patients first” (Ev 101) and the BMA said “Political dogma should not interfere with delivering specialist services to patients. The location where a patient receives their treatment should be based on what is in the best clinical interest of the patient” (Ev 116). See also evidence from Brecon and Radnor CHC (Ev 108).
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are provided as excellently as possible. I think it has to be the first of those: excellent services provided as close as possible.53
39. Our concerns were fully addressed when we welcomed the attendance of the First Minister who came for an extended evidence session, during which he expressed his full commitment and that of his Cabinet to a focus on patient needs and to treatment being provided as close to home as possible. His confirmation that the Welsh Assembly Government is determined not to allow the border to become a barrier was refreshingly direct and specific and we congratulate him on his commitment and clarity.
40. The border between Wales and England is long and porous. Cross-border movements have been a fact of life for many years, as people resident in one country are naturally drawn to centres of population in the other. This is no less the case for health services. For those residing in immediate border areas, the nearest health provider may not be in their country of residence. Equally, whilst advances in technology mean that it is possible to provide more services in local hospitals, some complex conditions will always require treatment in a specialist centre, which may be across the border. All those who gave evidence to our inquiry agreed that there is no practical or realistic prospect of diverting these well established cross-border flows, nor would it be desirable to do so.
41. 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, particularly given the policy divergence that has begun to emerge as a result of devolution. Each Government will choose to fund what it considers to be the most important aspects of health care for its constituents, with finite resources. Indeed, the Committee believes that devolution provides an opportunity for the nations of the UK to learn from each other’s approaches. However, divergent policies must be implemented in a way which accommodates the continuing flow of patients across the Wales-England border. In this context, we support the solutions proposed in relation to the provision of neurosurgery services in North Wales by the Steers Review, and accepted by the Welsh Assembly Government, which would also provide an appropriate model for other specialist and tertiary services. 3 Funding and commissioning
42. As described above, health services in England and Wales are now subject to different funding and commissioning arrangements. Evidence given to this inquiry cited the co- existence of two different systems as a difficulty, particularly for hospitals close to the border, which serve both English and Welsh patients. We heard that this placed an additional administrative burden on providers, as well as suggestions that hospitals were paid more generously for treating English patients and were effectively subsidising Welsh
53 Q 546
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patients from this income.54 In this section of our Report, we examine current commissioning and funding arrangements and their effect on cross-border health services.
Commissioning arrangements 43. In England, Primary Care Trusts (PCTs) are legally responsible for commissioning health services for their resident population.55 In Wales, Local Health Boards (LHBs) are currently responsible for commissioning all non-specialist medical services for patients usually resident in their area. In general, this means that LHBs are largely responsible for commissioning all primary and secondary care. Tertiary and highly specialist services are currently commissioned in Wales by Health Commission Wales (HCW) an executive agency of the Welsh Assembly Government. Current legislation does not define exactly which local NHS body is responsible for commissioning care for people who live on one side of the border but are registered with a GP on the other. As a result, an interim protocol between the Department of Health and the Welsh Assembly Government has been put in place, relating to patients living along the border in Flintshire, Wrexham, Powys, Monmouthshire, Denbighshire, Cheshire West, Shropshire County, Herefordshire, Wirral, and Gloucestershire.56
44. The interim protocol provides that the operational responsibility for commissioning services for a patient is determined by GP registration, rather than residence. The temporary protocol has been renewed annually since 2005 and is in place until April 2009. It is accompanied by an annual funding transfer between the Department of Health and the Welsh Assembly Government for the cost of commissioning services for patients resident on the other side of the border. The Government has stated its intention to replace the interim protocol with a permanent protocol on many occasions.57 However, in its response to our Interim Report, the Department of Health has said that negotiations on a permanent protocol are still ongoing, and are unlikely to be finalised until the restructuring of the Welsh NHS is more clearly developed. The Department said: “it is proposed that it will be more appropriate to build on and extend the scope of the current interim protocol, until the impact of these changes is clearer, rather than to completely overhaul the current arrangements”.58
Funding arrangements 45. Funding arrangements now differ between the NHS in England and in Wales. Since 2003-04, England has incrementally introduced a national tariff system called Payment by Results (PbR) where each individual treatment is billed to the NHS at a standard rate. Providers are paid according to each individual piece of clinical activity performed; hospitals code and count their clinical activity and are then paid according to tariff prices
54 Qq 53 and 74 55 There is also a move in England towards GPs commissioning specialist services direct for their patients. 56 Ev 126. The default legal position would be that residency determines a patient’s entitlement to treatment. 57 Qq 476, 482 and 510. 58 Government Response to the Welsh Affairs Committee interim report on the provision of cross-border health services for Wales, Cm. 7531, January 2009, page 6.
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by Primary Care Trusts.59 Individual activities, known as Healthcare Resource Groups (HRGs), each have tariff prices set by the Department of Health. There are hundreds of HRGs ranging from “Liver-complex procedures” (£5,956) to “Primary Hip Replacement” (£5,220) to a General Surgery outpatients appointment (£163). By 2006-07, Payment by Results had been extended to include not only elective, but also non-elective, accident and emergency, out-patient and emergency admissions for all trusts. The Department of Health is seeking to further extend the scope of Payment by Results.60
46. Payment by Results replaced a system of ‘block contracts’ in which hospitals were paid based on historical activity levels. Under the block contract system, providers charged different amounts for similar treatments. The Payment by Results system pays a single average cost for treatment activities. This means that some providers are ‘gainers’ and some are ‘losers’ under the new system. Where a provider previously offered an activity for a higher cost, it will suffer a loss under Payment by Results; where a provider has previously provided a treatment more cheaply, it will receive funding above the actual cost of providing the service. In theory, Payment by Results therefore means that hospitals are rewarded for quality services (which might attract more patients to choose to be treated there), for efficiency and for performing over and above prior levels of activity (by being paid the full tariff price for each extra procedure rather than a marginal rate).61
47. In Wales, health care funding is still based on block contracts between Welsh commissioners and the relevant providers. Funding to hospitals (both in England and Wales) from Welsh commissioners is therefore based on historical activity and funding levels as a guide for the expected number of treatments over the coming year. Clinical activities are not funded on the basis of actual activities provided. Instead, an overall figure of anticipated activity is agreed in advance between the commissioner and the provider. Unlike Payment by Results, funding for providers who deliver over the envisaged amount of activity is only at marginal rates, although it appears that some contract negotiations are beginning to include contingencies for over-performance.62
Interaction between the two regimes 48. As the direction of cross-border flow in secondary and tertiary care is largely, though not exclusively, from Wales to England, the majority of our evidence concerned the effects of working with two different funding regimes on English providers and on Welsh commissioners and patients. Our inquiry was prompted, in part, by reports of growing tensions and cross-border funding disputes between Welsh commissioners and English providers and we received a significant quantity of evidence on this subject.63
59 The amount received is adjusted for local factors such as labour costs by a ‘market forces factor’. 60 Ev 127 61 An Audit Commission Report, The right result? Payment by Results 2003-07, 14 February 2008, supplies discussion of the performance of the Payment by Results system. 62 The Walton Centre said that it has a contingency amount within its contract with the Welsh commissioner for over- performance. It notes that it has been insufficient to cover the level of over-performance and there is still therefore an under-payment by Welsh commissioners for the services provided (Letter from Ken Hoskisson, Chairman, The Walton Centre for Neurology and Neurosurgery NHS Trust to Edwina Hart AM, 13 January 2009 [not printed]). 63 For example, Breakdown of Cross-border Agreements is Costing the English Trusts Millions, Health Service Journal, 14 February 2007.
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English providers 49. In the course of this inquiry, some witnesses argued that English provider hospitals were ‘losing out’ from the current situation, because they would be funded at a higher rate for the treatments they provided for Welsh commissioners, if they were commissioned under the English tariff system. Two factors were cited in support of this argument: firstly, in some instances the Payment by Results system has increased the price paid for services, where a provider previously charged less than the national average on which the tariff system is now based. Secondly, the block contracts negotiated with Welsh Commissioners do not accommodate additional payment for the provision of extra services (‘over- performance’ against the contract), so the English provider hospitals are left unfunded when they provide those extra services to Welsh commissioners whereas they would be rewarded under Payment by Results.
50. This situation means that some English providers have an apparent deficit in their budgets where funding from Welsh commissioners falls short of the amount they would charge in England to cover the costs of the treatments provided. The amount of this ‘deficit’ varies between providers. Shrewsbury and Telford Hospital NHS Trust told us that “the Trust receives £16 million from the Welsh Commissioners for the activity purchased. If this same activity had been purchased by English Commissioners under PbR tariff the Trust would have received £18 million”.64 Hereford Hospitals NHS Trust stated that its “contract with Powys LHB is £1 million lower than would be the case if the national tariff were applied”,65 and the Countess of Chester Hospital reported that “The Trust income relating to Welsh patients in 2007-08 comprised £18.2 million representing 15% of total income from health service commissioners, although Welsh patients represent 20% of the total patient workload of the Trust”.66 The Walton Centre for Neurology and Neurosurgery and the United Bristol Healthcare also reported shortfalls.67 Hospitals also argued that the existence of two different commissioning and funding streams led to a greater administrative burden, which imposed its own additional costs.68
51. A related issue, raised in evidence by the Countess of Chester Hospital was the historical nature of contracts with Welsh commissioners, which it argued did not reflect current, higher costs. Its evidence stated that:
…the funding for services is subject to negotiation between the provider and the commissioner based on a historic funding position established we believe in 1991. Flintshire Local Health Board insist that they are only prepared to meet the marginal costs of additional activity over and above the historic baseline and that this reflects the national cross-border policy.69
64 Ev 221 65 Ev 147 66 Ev 122 67 Since the oral evidence session The Walton Centre has copied the Committee into a letter addressed to the Welsh Health Minister, dated 13 January, which identifies a much larger deficit due to unexpected increased activity. 68 Q 53 69 Ev 122
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Hereford Hospital NHS Trust also suggested that block contracts did not include provision for costs which were historically funded separately, but now are only funded through the Payment by Results tariffs: “The tariff includes an element for service development, replacement of capital and cover for contingencies. As the tariff system has been expanded, NHS England Trusts increasingly have no access to other sources of income”.70
52. In contrast, the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust at Gobowen, near Oswestry, told us that the operation of two separate funding regimes was not resulting in a deficit for the Trust because the Trust was a ‘loser’ from the English tariff system. In that case, the Trust appeared to receive a greater proportion of income comparative to the proportion of patient activity from Wales: 31% of patient activity was related to Welsh patients, while Welsh patients represented 40% of the Trust’s income.71 In addition, given the relatively high proportion of Welsh patients treated at the Trust, it did not regard the existence of two different commissioning and funding streams as problematic, stating that the hospital is used to the “different currencies and arrangements”.72 Equally, although his hospital receives less money overall from the Welsh commissioners than it would for similar activity commissioned by an English PCT, the Chief Executive of the Shrewsbury and Telford NHS Hospital Trust acknowledged that, for some specialist services, Welsh commissioners may actually be paying above the tariff price in their negotiated contract, saying “it is always going to be swings and roundabouts but…it should be the same across [the board]”.73
53. As might be expected, the balance of the evidence we received was from Trusts who feel they are being disadvantaged under the present system. Both the Countess of Chester Hospital and Hereford Hospitals expressed the view that the ‘deficit’ should be interpreted as a case of the English NHS “subsidising” the Welsh Health Service.74 The Countess of Chester Hospital’s evidence argued:
It is not unreasonable for a provider of services to expect the commissioner to pay a fair price for the services provided—it is clear that as our basic costs are not even being covered, the Trust is effectively subsidising the Welsh Health Service and thereby compromising its full potential to provide services to both English and Welsh residents alike.75
54. Other providers were less concerned about the funding differential. For example, at the time of giving evidence, the Walton Centre reported that, as a specialist centre supplying a narrow range of treatments, the difference in the two funding regimes was more manageable than for a provider delivering a broader range of lines. The Centre stated that its “deficit” was not a matter for concern:
70 Ev 146 71 Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust Annual Report 2006-07, p.21. 72 Q 346 73 Q 71 74 Ev 121; Ev 146 75 Ev 122
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Obviously you have heard that there is half a million pound level of over performance that we are not currently being reimbursed for. I think you can form your own view about whether or not that constitutes subsidisation for the English commissioners. Whatever your view, it is not that significant for the Walton Centre.76
55. Since then, however, levels of over-performance at the Walton Centre have increased significantly and its Chairman has written to the Welsh Assembly Government Minister for Health and Social Services requesting that she “make funds available to bridge the gap” between the funding provided under their contract with Health Commission Wales and that which would be provided if the treatments were commissioned by English PCTs.77 One factor in the escalation of this issue may be the Centre’s application for Foundation Trust status. Several provider trusts told us that their deficits were more significant due to pending Foundation Trust applications. For example, the annual audit for Hereford Hospital Trust remarks that the outstanding payment from the Welsh commissioners is, in part, responsible for an overall debt of the Trust.78 The letter written by the Chairman of the Walton Centre to the Welsh Assembly Government Minister for Health and Social Services goes on to state that: “As a candidate for Foundation Trust status we will find it difficult to convince the Regulator that the current situation is in the best interests of the Trust and our patients”.
56. In his evidence, First Minister Rt Hon Rhodri Morgan AM agreed that the nature of Foundation Trusts as more independent entities having to prove themselves financially responsible, meant that concerns regarding gaps in funding were pursued more vigorously. He argued that this contradicted guidance from the Department of Health, which instructed NHS Trusts to continue existing commissioning arrangements with Welsh LHBs:
I think probably when the Foundation Trusts, through their nature, were on the point of being formed, they wanted to try to maximise income and, therefore, they were under some pressure to ignore the Department of Health guidance about allowing Welsh LHBs just across the border to continue to purchase health care from them on the old basis.79
Welsh commissioners 57. Much of the evidence we received from Welsh commissioners acknowledged that their contracts with English providers would be more expensive if they were calculated under the English Payment by Results tariff rates as opposed to the Welsh block contract method.80 Mr Andrew Gunnion, Chief Executive of Flintshire LHB admitted that his Board was “currently getting a good deal” in its contract with the Countess of Chester Hospital,81
76 Q 161 77 Letter from Ken Hoskisson, Chairman, The Walton Centre for Neurology and Neurosurgery NHS Trust to Edwina Hart AM, 13 January 2009 [not printed]. 78 Audit Commission, Hereford Hospitals NHS Trust, Annual Audit letter, October 2007. 79 Q 577 80 For example, Q 436 (Powys LHB) 81 Q 207
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but other commissioners thought that the fact that English providers would receive more for their services if paid at tariff price rather than block contract price was irrelevant. They noted that contracts between English providers and Welsh commissioners were negotiated and agreed upon and argued that there could be no question of underpayment where Welsh commissioners were paying the price agreed in the contract.82
58. Welsh commissioners also argued that providers were receiving a “fair deal” in terms of the price for their services.83 Mr Gunnion argued that the Payment by Results tariff system could result in over-charging for some services. He gave the example of an antenatal appointment including a blood pressure check. If the patient was found to have slightly high blood pressure, she might be monitored for an hour. Under Payment by Results, the commissioner would be charged twice for this patient: one price, or code, for the outpatient attendance and then another for a day unit attendance whilst her blood pressure was monitored. Under the block contract system, there would be no such additional charge for the blood pressure monitoring. Mr Gunnion concluded that “[under the] payment by results process…everything is counted separately and costed separately [and] that was how we can ratchet up the costs”.84 He added that the result of this example would lead to an potential £300,000 a year in extra costs for Flintshire LHB, but “[w]hether there is an £300,000 additional cost in the system, I think we would argue probably there is not”.85
59. Overall, the view of the Welsh commissioners concerning the ‘deficit’ for English providers was that any perceived shortfall should be the responsibility of the UK Government whose NHS funding change in England had brought about the situation. Under the terms of a Concordat agreed between the UK Department of Health, the Cabinet of the National Assembly for Wales and the Department of Health, Social Services and Public Safety in 2001,86 where one party imposes costs on the other, the party whose decision leads to higher or extra costs is to make any necessary financial transfers. First Minister Rhodri Morgan said in evidence:
The changes that have caused the divergence have been mostly English changes rather than Welsh changes…2005-06 and 2006-07 were a bad couple of years for that reason, in getting the English system to settle down without disadvantaging Welsh patients and to abide by the 2001 concordat on due compensation if one country made a change that disadvantaged another country.87
Welsh commissioners shared the view of their First Minister. Ms Rebecca Richards, Director of Finance for Powys LHB said, “if we were funded to pay for contracts on the basis of payment by results, then of course we would pay it […] The current advice from the Assembly is that we do not because we have not been funded to be able to pay to that level”.88 Indeed, some English providers had a similar understanding. Mr Tom Taylor,
82 Q 211 83 Q 220 84 Q 219 85 Q 219 86 Devolution concordat on health and social care: UK Department of Health, Cabinet of the National Assembly for Wales Department of Health, Social Services and Public Safety, 1 May 2001. 87 Q 579 88 Q 436-437
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Chief Executive of Shrewsbury and Telford NHS Hospital Trust, commented that: “It does need the English Government, the Department of Health, to fund the Welsh system to pay that money back”.89
60. Equally, it was recognised in evidence that in the present situation there is a strong mutual dependence between English providers and Welsh commissioners. Whilst Welsh patients need the English providers for the highest quality care as close to their homes as possible, many of the English providers in border areas rely on the incomes from treating Welsh patients to remain viable.90 Mr Tom Taylor, Chief Executive of Shrewsbury and Telford NHS Hospital Trust said:
…if I pull out of this contract completely and I cannot replace it with a matching income from England then £10.5 million worth of doctors and nurses have got to go… Yes, you can say £2 million worth of subsidy, but look at the other side, if it was not there what would I do if I had that total loss of income?91
Bishop Anthony Priddis, Bishop of Hereford, also emphasised the benefits of English Trusts providing services to Welsh commissioners in terms of the increased capacity of the Trusts to provide specialised services to all patients, English and Welsh:
If you withdraw that funding [from Welsh commissioners] and you get below the critical mass level, then some of the specialisms cannot be supplied because the budget does not stack up for a 24/7 provision in this particular department; and everybody suffers.92
61. There is clearly a lack of effective communication between the Welsh Assembly Government and the Department of Health on these issues despite the practical nature of the problems faced by NHS providers on both sides of the border. The issue appears to be firmly lodged in the ‘too difficult’ tray by officials and Ministers and that is not acceptable. If Ministers cannot agree on a fair approach at a strategic level they should agree a form of arbitration which is neutral and independent and make a commitment to accepting its adjudications. There is an urgent need for enforceable protocols between the UK and Welsh Assembly governments to address the current unsatisfactory state of affairs.
Strategic influence 62. In nearly all cases, Welsh patients are a small minority of an English hospital’s workload. Some Welsh commissioners reported that, as a result, they had little influence on the strategic decisions made by English providers. This is not wholly a product of devolution, however, Mr Geoff Lang, Chief Executive of Wrexham Local Health Board said that the situation had been exacerbated by the creation of foundation trusts in England:
89 Q 71 90 For example, Ev 145 from Hereford Hospitals NHS Trust and Q 126 (NHS Confederation) 91 Q 74 92 Q 18
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There were always difficulties in terms of ensuring that Welsh residents had an important influence on strategic development of services over the border which would be their provider. That has always been a challenge, but we have managed to do that. I think as systems change and become increasingly different, that introduces more tension into that relationship. For example, if you have a foundation trust that has a particular agenda and a particular means of transacting its business and a strategic approach on which trusts have been established with a very clear focus, that may not sit quite so comfortably with the relationship and planning structures in Wales.93
Nevertheless, some English providers told us that Welsh interests were represented at strategic level, for example the Robert Jones and Agnes Hunt NHS Trust, told us that 25% of its board were Welsh residents.94
Commissioning for specialist services 63. The way in which Wales commissions specialist health services from English providers was also raised as an issue in evidence. Specialist services are commissioned on a national basis by Health Commission Wales, rather than individual local health boards. In relation to Child and Adolescent Mental Health Services (CAMHS), the Children’s Commissioner for Wales told us:
There is…a severe lack of specialist provision within Wales for those children and young people whose challenging or violent behaviour requires medium and high secure CAMHS placements, which result in placements being made in England. There is currently no provision for inpatient treatment of eating disorders within Wales. Children and young people are required to travel to England for treatment. There are often problems with the long term funding of these placements by Health Commission Wales. In some cases funding ends before therapy is complete.95
64. The Muscular Dystrophy Campaign reported similar difficulties. Its report Building on the Foundations: The Need for a Specialist Neuromuscular Service across Wales highlights inequalities and inconsistencies in commissioning of specialist services across the border in England.96 The Campaign stated in evidence that LHBs and Health Commission Wales could not always agree on whether treatment of a particular condition counted as a specialist service or not and who was therefore responsible for commissioning care.97 It argued for UK-wide commissioning for neuromuscular conditions as a solution to the lack of consistency in this area. Similarly, the Association of the British Pharmaceutical Industry (ABPI) Cymru Wales suggested to us that it would be in the interests of patients to ensure consistent funding of orphan medicines (i.e. medicines intended for the diagnosis, prevention or treatment of a life-threatening or serious condition affecting not more than 5
93 Q 194 94 Q 339 95 Ev 117 96 Muscular Dystrophy Campaign & Genetic Interest Group Building on the Foundations: The Need for a Specialist Neuromuscular Service across Wales February 2008, p.5. 97 Q 283
30 The Provision of cross-border health services for Wales
in 10,000 people in the European Union) by introducing a UK-wide commissioning process.98
65. In response to this evidence, Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health, wrote to the Committee noting that:
The National Commissioning Group (NCG) commissions 40 highly specialised services from a small number of English hospitals for English patients with rare conditions or who need rare interventions. The NCG also commissions some or most services for the residents of Scotland, Wales and Northern Ireland under specific contractual arrangements with the Devolved Administrations. There is no mechanism for services to be commissioned on a UK basis…For a service to be nationally commissioned by the NCG it will usually involve fewer than 400 patients.99
The Minister did not agree that the National Commissioning Group was the appropriate commissioner for services for muscle wasting neuromuscular conditions in the UK, given the higher numbers of patients in this group (over 1,000 children and adults for every 1 million of the population).
66. Our evidence has demonstrated that there are problems with the cross-border commissioning of specialist care for the conditions such as Muscular Dystrophy and mental health care. The difficulties patients have experienced must be recognised and addressed in a holistic way and we are not convinced that the Minister is right to dismiss UK-wide commissioning out of hand. Given that this problem faces regions of England, even though they generally have far larger populations than Wales, it may be that some other form of high-level commissioning that goes across the boundaries of English regions and across the Welsh border would be appropriate for such specialised services. The solution should be driven by the need of patients rather than existing practice.
Local agreements 67. Our evidence clearly demonstrates the existence of tensions between the Welsh and English commissioning and funding structures in dealing with cross-border treatments. The provider hospitals and commissioners have so far been left to deal with these disputes on a local basis. First Minister, Rt Hon Rhodri Morgan AM said in evidence:
Where there are arguments over money, we like to think that they will be solved between the commissioning LHB…and their provider Trust…If they cannot agree, as they could not in 2006-07, then it tends to come up for arbitration between Ann [Ms Ann Lloyd, Head of the Department of Health and Social Services] and her division, and the Director of Finance who works to Ann, and the Strategic Health Authority in the West Midlands or the north-west of England. That is when you get
98 Ev 99 99 1 July 2008, Letter from Ben Bradshaw to Chairman (Ev 134).
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involved, that is when we get involved, that is when Cabinet Ministers get involved and so on.100
Witnesses told us that the UK Government was also reluctant to become involved. The Countess of Chester’s memorandum stated that the Department of Health had resisted involvement in its negotiations:
Flintshire Local health Board have insisted that they are complying with cross-border policy and that resolution of any underlying deficit in funding will only be resolved by the Department of Health in England transferring funds to Wales. The Department of Health, however, resist this and believe it should be resolved through local agreement.101
If the Department of Health is determined to maintain that approach it should nevertheless provide for, and agree with the Welsh Assembly Government, an arbitration system to deal with unresolved difficulties with the outcome binding on all parties.
68. The Committee was told that the Welsh Assembly Government Minister for Health and Social Services had made a request for additional funds from the Department of Health in order to cover the monies English providers have claimed are outstanding. The amount requested was in the region of £16 million.102 Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health, did not confirm whether this request had been rejected, but stated that his Department was not yet convinced that the figure suggested was based on robust data.103 In oral evidence given in June 2008 he acknowledged that “this is something that needs to be resolved [...] in the form of a properly worked out protocol”.104 However, as the Government’s response to our interim Report makes clear, no permanent protocol covering these issues has yet been agreed.
69. Contracts for the treatment of Welsh patients in English hospitals therefore remain a matter for negotiation between the English providers and the Welsh commissioners. It is clear from our evidence that a significant amount of time and effort has been expended on these negotiations and attempts to develop workable local arrangements by providers and commissioners. Localised solutions have appeared in some areas and some have been relatively successful. For example, we were told of the Central Wales–West Midlands Memorandum of Understanding on Cross Border Collaboration between the Welsh Assembly Government and the West Midlands Regional Assembly, established in March 2007. This is not a legally binding agreement, but signifies a commitment from its parties to be aware of cross-border issues and share information when developing policy. Bishop Anthony Priddis, Bishop of Hereford welcomed the Memorandum of Understanding, but argued that it was not a substitute for national recognition of the issues involved:
…the memorandum of understanding perhaps has achieved two things that are significant and important, but it is only in some ways a beginning. One is that it has
100 Q 595 101 Ev 123 102 Qq 491 and 498 103 Q 499 104 Q 491
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been a clear acknowledgment that these issues are around and that they are difficulties that need addressing. The second is that it has therefore been a means to conversation taking place and the dialogue happening for people to have some channels and routes by which they can talk more about shared difficulties and shared issues. However, that is nowhere near enough. The discussion needs to take place but it is a starting point. It has got to lead, as we have been saying, to some further actions. It is not just a matter of local people across the border being able to resolve the problems themselves; hence your own agenda and your own roles, because these are not just local issues or not just regional, but also national issues.105
70. Several providers gave evidence of a achieving a degree of accommodation within existing negotiated contracts for funding of activity in addition to that predicted, or of negotiating Welsh contracts on the basis of “tariff” calculations. However, these contracts can come under strain if predictions are inaccurate. As noted earlier in this Report, the Walton Centre has recently requested compensation from the Welsh Assembly Government for unexpectedly high levels of activity during the last contract period. Its initial contract with Health Commission Wales had a value of £7.8 million, and an over performance reserve of £200,000. In its evidence to the inquiry, the Centre told us that it approached the Welsh block contract payment as Payment by Results “in shadow form” meaning that it negotiates the contract on a cost per treatment basis, with the aim of achieving a contract value not dissimilar to what it would be receiving under the tariff system.106 However the over-performance contingency in this contract proved insufficient. The Walton Centre’s letter to the Welsh Assembly Government Minister for Health and Social Services states “GP referrals have increased by 12% year on year to the end of November 2008…there was no way that anyone would have anticipated the level of over- performance that we are currently experiencing”. Whilst additional funding has been provided to meet similar over-performance in contracted activity with English Commissioners, this has not been the case in Wales. In its letter, The Walton Centre concludes that the Welsh Assembly Government must be involved in a solution to this problem:
In our discussion with the Welsh Commissioners, there has been a recognition that our negotiations for the 2009-2010 contract will need to take account of lessons learnt from this year but, in respect of the current contract, they have nowhere else to go to seek additional revenue to bridge the gap.107
71. Other evidence reported fundamental and ongoing difficulties with contractual negotiations. The memorandum from the Countess of Chester Hospital states:
The Local Health Board have refused to enter into a formal contract arrangement with appropriate dispute resolution arrangements arguing that they are forbidden to do so by the Welsh Assembly. In the event of a dispute of this nature as an individual
105 Q 33 106 Q 160 107 Letter from Ken Hoskisson, Chairman, The Walton Centre to Welsh Minister for Health and Social Services, 13 January 2009 (not printed).
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provider of NHS services the Trust has very little ability to reach agreement with a local commissioner supported by its government and national policy.108
It would be a matter of concern if it were true that the Welsh Assembly Government is paying lip-service to local settlements being struck while unreasonably restricting the discretion of LHBs to negotiate contracts. We recommend that the Audit Commission and the Welsh Audit Office undertake a joint inquiry into this situation and recommend ways of resolving the issue.
Effects on patient care 72. In the course of our inquiry, we were concerned to determine whether the challenge of managing different funding regimes resulted in any differential treatment between English and Welsh patients and whether it affected the choice of provider to which a patient was referred. One of the key points raised by the Welsh Local Government Association was the potential for diverging policies to lead to undesirable decision-making, particularly where funding was concerned:
…it is important that ‘perverse incentives’ leading to less sustainable options/choices are avoided, and these include differential charges or restrictions on access/availability which encourage longer than necessary journeys to be undertaken—a particular issue in relation to health and social care services.109
73. The representatives of all the NHS Trusts who gave evidence to the Committee assured us that their difficulties in managing different funding and commissioning arrangements had not impacted on service provision.110 It was nonetheless acknowledged that for some Trusts, under the present arrangements it is potentially more “profitable” to treat an English patient than it is to treat a Welsh patient.111 Mr Tom Taylor, Chief Executive of the Shrewsbury and Telford NHS Hospital Trust told the Committee that this had created a temptation to “align…services towards English patients rather than Welsh” in order to secure higher levels of income and that this had affected the strategies put in place in his hospital under a previous, failing management.112
74. Conversely, one way for Welsh commissioners to manage the problem of over performance of English providers and subsequent requests for payment which they cannot meet would be by not commissioning English services. This would, of course, only ever be reasonable if the cost of Welsh provision were equal to or lower than that of English sources. The evidence we received on this subject was mixed and is connected with the perceived move towards “all Wales commissioning” discussed in the previous section of this Report. Some witnesses told us that Welsh commissioners were increasingly requiring pre-approval for funding of English services. They reported that the Welsh Assembly Government has instructed local health boards in Wales not to pay for elective treatment
108 Ev 123 109 Ev 271 110 Qq 74 and 342 111 Qq 63, 71-72 and 158 112 Q 73. The board of the hospital was replaced at the time Mr Taylor took up his post.
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unless it is authorised in advance. The North Bristol NHS Trust told us that “in practice, this has meant that a referral from a Welsh GP cannot be accepted without approval from the Local Health Board (LHB) or Health Commission Wales (HCW) for specialist treatments”, adding to the administrative burden of clinicians and administrators in the hospital.113 It also states: “Welsh Commissioners have rigorously applied that guidance and have refused to pay in cases where the Trust has not obtained prior approval”.114
75. We have heard several personal accounts of delays and distress from patients in Wales receiving treatment in England, which were attributed to problems in navigating the different systems.115 Dr Rosaline Quinlivan, consultant in Neuromuscular Disorders, wrote to the Committee to tell us that that she is “often asked to complete pre-referral forms for patients from Wales…The questions asked are on the whole irrelevant and not applicable to my service…these forms simply add delay to the patient pathway”.116 Witnesses from the NHS agreed that the situation was beginning to affect patients’ experiences. Mrs Wendy Farrington Chad, Chief Executive of the Robert Jones and Agnes Hunt NHS Trust said that the prior approval process causes confusion amongst patients by “building in a delay which may not result in treatment” and frustration for staff who “sometimes find themselves justifying the different systems and the processes”.117 We have heard some complaints that treatment has not been authorised, even when it is clinically justified,118or that Welsh patients have had a lower level of service than their English counterparts.119 For example, the Muscular Dystrophy Campaign told us that Welsh commissioners do not consistently fund diagnostic tests for Welsh patients at recognised specialist centres in England.120
76. It is unacceptable that the Welsh NHS should erect bureaucratic barriers which stand in the way of patient needs being met swiftly and efficiently. To erect such obstacles for a very marginal impact on costs is evidence of a process-driven approach to patient care. We urge the Welsh Assembly Government to review its approach as a matter of urgency.
Developing a sustainable funding solution
The need for governmental involvement 77. To some degree, local re-negotiation of contracts may provide solutions to the funding and commissioning disputes outlined in this Report. However, these are unlikely to be resolved successfully in every case. For a genuinely sustainable solution to
113 Ev 184 114 Ibid. 115 For example, Ev 140, Ev 193 and Ev 281 116 Ev 215 117 Q 354 118 Several individual cases including delays and refused clinician referrals are documented by the Conwy Federation of Community Health Councils (Ev 118); see also Ev 215. 119 Q 370 120 Muscular Dystrophy Campaign & Genetic Interest Group Building on the Foundations: The Need for a Specialist Neuromuscular Service across Wales, February 2008.
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be developed, a holistic approach to cross-border issues must be adopted. The problems we have described will recur if not resolved in a sustainable way.
78. However, Ministers from both the Welsh Assembly Government and the UK Department of Health did not appear to consider the problems in this area to be severe. Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health said that the sums involved were “really quite small” relative to the overall budget and that the issues were “perfectly resolvable”.121 Equally, First Minister Rhodri Morgan claimed several times in evidence that the disputes were historical and dated from 2005-06 and 2006-07, but had now been resolved.122 Nevertheless, both Ministers made reference to an imminent new permanent protocol which they claimed would resolve the funding issues.123 As noted earlier in this Report, a permanent protocol has yet to be agreed.
79. In addition, both Ministers pointed to local causes for funding and commissioning disputes, rather than the actions of national governments. Rt Hon Rhodri Morgan AM said that providers had not abided by Department of Health guidance in asking for additional income from Welsh commissioners, and added: “Maybe quite wrongly some of the patients were brought into that process and they should have been left out of it completely by the clinicians or by any of the admin managers as well”.124Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health, stated “there is always going to be an element of tension between commissioners and providers”.125
80. Even if the Ministers are right to say that the figures are small and the financial implications marginal, any failure to resolve these issues will appear neither small nor marginal to the individuals affected, nor to their families. Tension between commissioners and providers may be inevitable, but they must be resolved without damaging patient care.
81. 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 a problem caused by government-level decisions, apparently taken without regard for their impact on cross- border commissioning. A solution must involve a sustainable and enforceable long- term agreement between the two governments so that future disputes will be avoided and that the patient experiences a seamless National Health Service which meets their needs and not those of accountants. We are therefore deeply disappointed that no permanent protocol has been agreed between the Department for Health and the Welsh Assembly Government, or even published in draft for consultation, almost a year after we were assured that a protocol was imminent.
121 Q 498 122 Qq 577 and Q600 123 Qq 490, 520 and 577 124 Q 599 125 Q 488
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82. At present, both English providers treating Welsh patients and Welsh commissioners are left in an unacceptable position. Department of Health guidance states that English providers should continue existing arrangements with Welsh Commissioners, yet it also encourages them to devise management strategies orientated towards a market–led system in England. Conversely, Welsh commissioners see no reason to diverge from a long-standing system due to policy changes across the border over which they have no influence. Neither position is sustainable in the long term.
83. While we were assured that those currently supplying cross-border health services were not influenced by the present perverse arrangements, the potential for detriment to patients is clear. It is to the credit of clinicians and administrators that high quality health care continues to be provided to patients despite ongoing disputes over funding. Nevertheless, we have heard some evidence that patients are beginning to suffer, at a time when they are least able to cope with bureaucracy, administrative confusion and delays in medical treatment. This evidence is necessarily anecdotal, but it is persuasive. We note that there is a deficit of robust research concerning cross-border healthcare and we therefore urge the Department of Health, as the UK-wide body, to undertake a study of the impact of cross-border movements on health services. It would be helpful to be able to compare cross-border issues between English regions to the issues across the border between England and Wales in order to distinguish between issues that are a consequence of devolution and those that are simply the result of ‘normal business’.
Transparency 84. One of the issues raised during this inquiry, as well as in other strands of our work on the provision of cross-border public services for Wales, is the serious deficit in transparency concerning inter-governmental negotiations and discussions between UK- wide Departments of State and the Welsh Assembly Government. Whilst we were assured that negotiations on a permanent protocol were ongoing, we were given no evidence of this. We reiterate the recommendations of our earlier Report on cross-border further and higher education, that meetings between Ministers and officials of UK Government departments and the Welsh Assembly Government must be made more transparent. This is in the interests of a healthy democracy and the effective operation of devolution. 4 Waiting times
Different targets 85. As we noted earlier in this Report, one of the areas in which health policy in England and Wales has diverged is in the targets set for waiting times.126 Over the last few years, there has been a substantial reduction in maximum waiting time targets in England.127 Since devolution the Welsh Assembly Government has also cut waiting times, but has
126 For a table of waiting time targets for the two administrations, see para 23. 127 Qq 224 and 501-504
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prioritised differently and has not reduced targets as significantly as in England. The present situation is that English Trusts work to a maximum waiting time target of 18 weeks from referral to start of treatment. Their Welsh counterparts and the Wales commissioners, work to a longer maximum waiting time target of 26 weeks from referral to start of treatment.128
86. In addition, different arrangements apply to the treatment of patients from across the border in England and Wales. Welsh providers are required to work to the standards and targets set out by the Welsh Assembly Government for all patients whom they see and treat, whether they are patients registered in Wales or patients treated in Wales from any other part of the UK. English providers are required to work to the standards and targets set out by the Department of Health for patients who are the responsibility of English commissioners. Services accessed in England by patients registered in Wales are commissioned by Welsh commissioners to meet Welsh Assembly Government performance standards. English PCTs must ensure that all patients within their area being treated by Welsh providers are given the option of being treated by a provider to English standards.
87. The ways in which waiting time targets are measured are different in England and Wales, making comparison difficult. In evidence, each government told us that its system of measurement was preferable. The Department of Health told us that Welsh rules for measurement for ‘referral to treatment’ times meant that a patient requiring onward referral from a secondary care provider to a tertiary provider would potentially have a second maximum wait of 26 weeks, while English waiting times only relate to referrals from a GP to treatment.129 In contrast, First Minister Rt Hon Rhodri Morgan AM said that Welsh lists were more comprehensive: “In England, it is only GP referrals that are collected. We have a bigger waiting list because we collect everybody on our waiting list; that is, not just GP referrals, but consultant to consultant referrals, physiotherapist to consultant referrals”.130 This was held to be the main reason why Welsh waiting lists were around 30% larger than those in England.131
Actual waiting times 88. Several of our witnesses brought to our attention the difference between waiting time targets and actual waiting times. Some told us that, in common with the targets, actual waiting times in England have fallen most, while Wales is following a few years behind.132 As one clinician stated, “waiting times have tumbled in England, they have come down a fair amount in Wales but tumbled in England”.133 We received evidence suggesting that in some cases the differences in waiting times between England and Wales were substantial,
128 Ev 128: both figures refer to the time between GP referral and the start of treatment. 129 Government Response to the Welsh Affairs Committee interim report on the provision of cross-border health services for Wales, Cm. 7531, January 2009, p.11. 130 Q 591 131 Ibid. 132 Q 592 133 Q 169
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as much as fifteen to twenty weeks134 and “maybe months”.135 Others stated there were only small differences in the waiting times of patients registered on either side of the border. The Welsh Assembly Government told us that waiting times in Wales have fallen at a similar rate to England and that the median wait for all Welsh residents admitted to any trusts was 45 days.136
89. What makes these assertions difficult to assess in actual terms is that the data collected on either side of the border is not easily comparable.137 In addition, there can be significant local divergence. Waiting times have never been uniform throughout the UK and may be linked to local circumstances, for example, if a hospital has a shortage of clinicians in a particular specialty.138 As Mr Mike Ponton, Director of the Welsh NHS Confederation said, “there will be people in England waiting longer for some things than people wait in Wales. [...] You cannot draw a standard conclusion for this”.139
Dealing with different targets 90. Our interim Report noted that the existence of different waiting time targets in the Welsh and English NHS has caused significant problems for clinicians, administrators and ultimately patients. This was one of the main issues highlighted in evidence during our inquiry.140 The issues identified included the administrative burden on hospitals of meeting two different waiting time targets, and the possibility of Welsh patients waiting longer than English patients for treatment in English hospitals, despite there being no clinical difference in their conditions.
Managing two waiting lists 91. Whilst English providers will be commissioned by England commissioners to deliver waiting times within the English 18 week target for their England-registered patients, contracts with Welsh commissioners for Wales-registered patients may specify the 26 week target. We were told that health care commissioners and providers, including GPs, are often finding differential waiting time targets problematic to manage and sometimes confusing.141 A number of English providers referred to the additional administrative burden of differentiating between waiting times as an area of difficulty.142 Mr Tom Taylor, Chief Executive, Shrewsbury and Telford NHS Hospital Trust, said:
The key challenges for an acute provider trust down the border are in having two funding streams and having different sets of targets for different groups of patients.
134 Ev 227 135 Q 236 136 Q 590 137 Q 503 138 Q 67 139 Q 112 140 Welsh Affairs Committee, Session 2007-08, The provision of cross-border health services for Wales: Interim Report, HC 840, para 31. 141 Q 457 142 Qq 53, 167, 176, 221 and 355
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My catchment area is 440,000 people in England and 60,000 people in Powys, and effectively we have to operate with different funding systems and different waiting times, and that obviously causes an administrative burden on the trust into making sure we meet the different targets for the different commissioners.143
Ms Rebecca Richards, Director of Finance for Powys LHB reported that Hereford Hospital had refused to manage the Wales waiting time targets and had left the responsibility for that task to the local health boards with which it contracted.144 Ms Richards said that this arrangement was very difficult to manage,145 but that “[w]e just place [patients] on the waiting list at the point that they would need to be to meet Welsh waiting times”.146
92. Other English providers manage both Welsh and English patients on a single list. In evidence, we were told that clinicians were uncomfortable with and in some cases refused to operate separate waiting lists. The Walton Centre stated “In general, doctors are uneasy that there are two standards for waiting times, which are much longer for patients resident in Wales compared with those in England. They would prefer equity between patients”.147 Mrs Wendy Farrington Chad, Chief Executive of the Robert Jones and Agnes Hunt NHS Trust, told us:
… [patients] are drawn from the waiting list based on the consultant’s assessment of their priority … [The clinicians] do not like to be bothered by waiting times and contracts; they prefer to treat patients on clinical priority and that is what we allow to happen within the Trust and quite rightly so.148
The practical implication of this decision is that waiting times for Wales-registered patients would be no different from those experienced by England-registered patients.149 Mr Ben Bradshaw MP, Minister of State for Health Services in the Department for Health, appeared to acknowledge this practice in his oral evidence, commenting, “in theory, people registered with a GP in Wales who access an English hospital can only expect Welsh waiting times, in practice, they are getting English waiting times”.150
93. The operation of different waiting lists for patients from opposite sides of the border was related by some witnesses to issues of funding.151 The longer Welsh waiting time targets might be achieved more cheaply than the shorter English targets. In addition, the English Payment by Results system now incentivises over performance against targets, but no such encouragement exists in Wales. However, it is far from clear exactly how shorter waiting times are costed and therefore what value might be placed on the use of a single waiting list for both English and Welsh-commissioned patients. We also received evidence
143 Q 53 144 Qq 443-445 145 Q 450 146 Q 447 147 Ev 253 148 Q 348 149 Q 184; See also Ev 245 from the Walton Centre. Due to the nature of the treatments the centre provides, the waiting times would be expected to be shorter than in many other cases. 150 Q 504 151 Ev 227, Q 66
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that Welsh commissioners ‘drip-feed’ Welsh patients into the English system to moderate funding demands. Bishop Anthony Priddis, Bishop of Hereford reported in written evidence claims that cross-border movements were less common “at the end of the financial year when budgets are running out”,152 and an in-Wales solution was preferred. If it is true that care is being influenced by the progress of the financial year, this would be further evidence that the treatment of Welsh patients is being driven by financial imperatives unconnected to patient need.
The patient’s experience 94. The evidence we received showed that it is possible for a Welsh patient to wait longer for treatment at an English hospital than an English patient with the same complaint, due to the difference in waiting times targets between the two administrations.153 We also heard some suggestions that the lack of any incentive for over-performance (or any sanction for under-performance) in Welsh contracts was partly responsible for Welsh patients waiting longer. The Walton Centre stated that “Doctors are frustrated that policy in Wales appears to be that it is satisfactory as long as Welsh minimum standards are achieved, and activity is geared to meet these and not to do any more in that financial year”.154
95. It is important to note that this differential affects only elective treatments. There was no suggestion that Wales-registered patients would ever wait longer than England- registered patients for clinically urgent treatments, either now or in the future.155 However, in the course of the inquiry the Committee received representations that the differential in waiting times was unfair and that Welsh patients were effectively receiving a second-class service from the NHS.156 Patients argued that they were paying the same taxes, irrespective of which side of the border they lived, and should therefore be treated equally.157 We were also told that staff of the English providers did not feel that they should be required to deal with frustrated cross-border patients who were upset and angry when they realised they might have to wait longer than an English-registered patient.158 There was a feeling amongst the providers that they should not be expected to justify disparities between the two systems which were the result of policy-maker, and not their own, decisions.159
96. A number of our witnesses agreed that patients were generally unaware of the existence of different waiting time targets between England and Wales, until they were undergoing treatment. Equally, those patients who lived close to the border and chose to register with a GP outside their home country usually did so for reasons of convenience. They were unlikely to consider any implications in terms of increased or decreased waiting times should they require hospital treatment at a later stage. Witnesses agreed that much more
152 Ev 104 153 Q 66. 154 Ev 253 155 Qq 66, 167, 169, 177 and 221 156 Qq 236 and 378 157 Ev 152, Qq 228, 370 and 401 158 Q 167 159 Qq 221 and 355
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information about the differences in health services should be made available to patients at the time of registration with a GP.160
Looking forward 97. Differential waiting times are likely to persist within the NHS, not only because of divergent policy in England and Wales since devolution, but also for reasons of local variation unconnected with the side of the border on which a service provider lies. At present there is an eight week difference in the stated target waiting times for the Welsh and English NHS. It is not clear to the Committee that Welsh patients are aware of this fact, or of the more general 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.
98. In practice, our evidence suggests that Welsh-registered patients accessing elective treatment in England are not, as a rule, waiting eight weeks longer than England- registered patients. Actual waiting times are generally below English target waiting times both for England-registered and Wales-registered patients treated in English hospitals. Of course, this is little consolation for those individuals who do experience longer or much longer waits.
99. The fact that the waiting time targets in England and Wales are measured differently severely hinders transparency and accountability. Equally, there is no publicly available costing of the shorter waiting times targets set in England compared to Wales. Even if there were a clear cost associated with shorter waiting times, hospital providers are currently left in a difficult ethical position. Many have told us that they will not operate two separate waiting lists which differentiate between patients solely on residence. It is the Committee’s view that providers should not be in this position; the procedure that English hospitals need to operate in this situation is a matter for the Welsh Assembly Government and Department of Health to resolve at a national level. We recommend that, as a matter of urgency, the Welsh Audit Office and the Audit Commission undertake a joint inquiry into the facts of the matter in order to provide a clear evidence base to inform discussions between Ministers to agree how best to resolve these issues. 5 Patient engagement
100. In our interim Report, we concluded that one of the key criteria for cross-border health policy should be to ensure that patients and the public are able and encouraged to engage effectively in health policy development. It is vital to establish a degree of citizen ownership of healthcare provision, in order to maintain the focus of services on the patient. However, we found that where patients receive care on the other side of the border, or where their care traverses the border, patient and public engagement appears problematic.
160 Qq 191and 578
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Patient information and engagement services 101. Since devolution, the arrangements for patient complaints and representation have diverged. In Wales Community Health Councils (CHCs) serve patients needing information, or wishing to make a complaint. CHCs were abolished in England in December 2003. They have been replaced in part with Patient Advice and Liaison Service (PALS) providing information, advice and support to help patients, families and carers on a trust by trust basis. English patient representation is also supplemented by Local Involvement Networks (LINks) and foundation trust representation. LINks are established under the Local Government and Public Involvement in Health Act 2007, which gives the Secretary of State a power to make regulations imposing duties on commissioners and certain providers of health and social care services to respond to LINks and allow entry to LINks under certain conditions. English local government scrutiny committees also take an interest in the performance of local health services. In Wales, new arrangements ment are proposed from October 2009, including Stakeholder Reference Groups for each of the new Local Health Boards, which will represent those organisations and groups with an interest in the health service.
Foundation trusts 102. We received some evidence that patients accessing health services on a cross-border basis feel that they are unable to contribute to the development of the services which they and their families use. As we noted earlier in this Report, Welsh Local Health Boards told us that Welsh patients being treated by English providers represent a minority group and there is a perception that they have little say in the strategic direction of English hospitals, particularly under the new foundation trust system.161 Nevertheless, one of the intended benefits from an NHS trust hospital gaining foundation trust status is greater ownership by the public. In this context, the Committee received evidence that the Shrewsbury and Telford Hospital NHS Trust included Welsh representation in the form of Welsh unitary and district councils on the Trust’s stakeholder engagement board.162 Similarly the Robert Jones and Agnes Hunt NHS Trust told us that 25% of its board were Welsh residents.163 It is therefore evident that some hospitals have been able to include a cross-border dimension in their strategic management structures.
103. The Committee is encouraged by the positive evidence it has heard regarding hospitals which have included 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 urge the Department of Health to promote cross-border engagement at strategic level in English hospitals, and to consider the extent to which this has been achieved when making decisions about foundation trust status.
161 Q 194 162 Q 57 163 Q 339
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Patient representation 104. Whilst the cross-border flow is largely from Wales to England for secondary and specialist care, the flow is reversed for primary care services. We have also heard of problems experienced by English residents who wish to participate in patients’ representative groups in Wales. For example, Mrs Susan Davies, a Welsh woman living in England, wrote to the Committee, telling us us that she had nursed her Welsh mother through dementia for a period of ten years and had significant contact with Welsh health authorities during this time.164 She was later appointed by a Welsh charity, Dignified Revolution, to represent them on a Welsh Assembly Dignity in Care National Co- ordinating Sub-group on Social Care. However, Mrs Davies was told that she could not represent the charity on the sub-group because she was resident in England.
105. We are 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. We recommend that the Department of Health include citizen engagement and patient ownership of cross-border services in negotiations with the Welsh Assembly Government to ensure that English residents’ rights to contribute to Welsh services are protected by the Welsh patient engagement process, just as the rights of Welsh patients are protected in the structure of Foundation Trusts. 6 ‘Border-proofing’ policy
106. In our interim report we recommended that health policy in England and Wales should be ‘border-proofed’ to ensure diverging policies in a post-devolution UK do not have unintended consequences for patients. We said that the west-east direction of travel which characterises life in North and mid-Wales must be factored into policy development. We also concluded that collection of comparable data was essential to producing informed policy development. These recommendations were prompted by the examples given to us in the evidence we collected during the inquiry, which demonstrated that several areas of health and social care policy lack coordination, with consequences for patients and their families.
The border as a barrier 107. In a number of instances, we were told that the border is currently acting as a barrier to effective care. The Institute of Rural Health told us that border GPs working with two systems face growing challenges in identifying appropriate destinations for specialist care.165 In its evidence, the Welsh Occupational Therapy Service Leads Group (WOTSLG) said that there was no clear and consistent policy or guidance on the respective responsibilities for discharging trusts and local services in terms of therapeutic services for Welsh patients and concluded that there was a “lack of joined-up thinking” for the discharge of patients across Welsh borders.166
164 Letter to the Chairman from Susan Davies, 24 November 2008 (Ev 124). 165 Ev 151 166 Ev 271
44 The Provision of cross-border health services for Wales
108. Patient transport is also a significant cross-border issue. We received evidence of problems with the coordination of ambulance services and other modes of patient transport. Bishop Dominic Walker, Bishop of Monmouth, reported occasions when: “it has been arranged for patients resident from one side of the border to be taken to a hospital on the other side [and] ambulances have only been able to take them one way”.167 Bishop Anthony Priddis, Bishop of Hereford, noted in his evidence: “Most funding streams for transport operate either in England or Wales, but not in both”.168
109. To some extent, healthcare professionals have been able to address cross-border problems locally, but these efforts represent an additional burden and a distraction from patient care. The Muscular Dystrophy Campaign concluded in its memorandum that:
There is little accountability when failures relating to cross border issues occur and greater transparency in the system is urgently required. An improved protocol between the Welsh Assembly Government and the Department of Health must be arranged to deal with any discrepancies on cross-border issues.169
The need for a permanent protocol 110. The temporary protocol between the Department of Health and the Welsh Assembly has been renewed annually since 2005 and is presently in place until April 2009. At the time of giving evidence, both parties told the Committee that negotiations were underway on an improved, permanent protocol. The memorandum from the Department for Health stated:
A group of officials from the Department of Health and Welsh Assembly Government has been formed, with support from the NHS and the Wales Office, to address these matters [differences in entitlement for patients in England and Wales]. Consideration is being given specifically to issues such as the funding arrangements for Welsh patients who use English hospitals…Arrangements for resolving disagreements between providers and commissioners are also being reviewed. Discussion also takes place at Ministerial level.170
In oral evidence, the Minister said that he would like to see agreement with the Welsh administration (regarding a draft protocol for consultation) by July 2008 and that he would be disappointed to have to renew the interim arrangement for a further year.171
111. No permanent protocol has yet been published. Most recently, in its response to our interim Report, the Department of Health stated that a protocol cannot be finalised until the Welsh Assembly Government’s NHS restructuring has been completed:172
167 Ev 101 168 Ev 103 169 Ev 175 170 Ev 130 171 Qq 510 and 514 172 Government Response to the Welsh Affairs Committee interim report on the provision of cross-border health services for Wales, Cm. 7531, January 2009, p.6.
The Provision of cross-border health services for Wales 45
The NHS in Wales is—subject to consultation—currently undergoing a period of significant organisation and system change, including a reduction in the number of NHS organisations and a change in their function from commissioning to planning bodies. In view of this, it is proposed that it will be more appropriate to build on and extend the scope of the current interim protocol, until the impact of these changes is clearer, rather than to completely overhaul the current arrangements. We propose to end the short-term focus of the interim protocol by extending it to a longer-term agreement. This will end the annual uncertainty for local NHS organisations and allow for the impact of proposed system changes to be better understood.173
112. Despite this delay, the Department for Health acknowledges that a permanent protocol is of great importance to patients and health care professionals. The Government’s response to our interim Report states:
The intention has always been to replace the interim protocol with a longer-term agreement on commissioning responsibilities. As health policy continues to develop within the two administrations it will become increasingly important for patients, clinicians and managers to understand the implications of the choices they make about using cross-border services. It will also be important to ensure that funding appropriately reflects patient flows.174
113. It is clear that there is a lack of co-ordination at a national level for cross-border health services between England and Wales. Localised solutions have appeared in some areas, but even where these 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. The Committee considers that an improved government-level protocol is essential to standardise and clarify funding arrangements and accountability mechanisms. The result should be seamless care for patients based on clinical need. We are therefore very disappointed at the lack of progress regarding the development of a permanent protocol since we took evidence last year. 7 Conclusion
114. In our interim Report, we put forward four key criteria for cross-border health policy, which we said should be taken into consideration by the Department for Health and the Welsh Assembly Government. We now return to these in the light of developments since we took evidence.
Clinical excellence as close to home as possible 115. 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. All those who gave evidence to our inquiry agreed that there is no practical or realistic prospect of diverting these well established cross-border flows, nor would it be
173 Ibid., paras 22 to 23. 174 Ibid., para 8.
46 The Provision of cross-border health services for Wales
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.
Border proofing of policy and practice 116. It is clear that there is a lack of co-ordination between the UK and Welsh Assembly Governments for cross-border health services between England and Wales. 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.
117. 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. Our interim Report concluded that this was a critical issue in need of urgent consideration. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems.
Cross-border citizen engagement 118. It is not clear to the Committee that patients on either side of the border are generally aware 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. We recommend that the Department of Health include citizen engagement
The Provision of cross-border health services for Wales 47
and patient ownership of cross-border services in negotiations with the Welsh Assembly Government to ensure that English residents’ rights to contribute to Welsh services are protected by the Welsh patient engagement process, just as the rights of Welsh patients are protected in the structure of Foundation Trusts.
Transparent and accountable co-operation between localities, regions and governments 119. Throughout all strands of our inquiry into the cross-border provision of public services for Wales, we have found that the decision-making process on each side of the border needs to be more coordinated, more coherent and more transparent. There needs to be a better and more public interface between the Department of Health and the Welsh Assembly Government. Patients, if they want or need to, should be able to understand the framework in which they will receive care.
48 The Provision of cross-border health services for Wales
Conclusions and recommendations
Introduction 1. We consider that the delay in providing a response to our interim Report was unacceptable and we expect the Government to provide a more timely response to this Report. (Paragraph 10)
2. We are very disappointed that a permanent protocol on cross-border health services has not yet been agreed between the Department of Health and the Welsh Assembly Government, or even published in draft for consultation. Our interim Report concluded that this was a critical issue in need of urgent consideration. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems. In its response to this Report, we expect the Government either to announce the publication of its draft protocol, or to give a reasoned explanation for the delay. The Committee also expects a prompt response to its Report. (Paragraph 11)
Cross-border health services 3. Our concerns were fully addressed when we welcomed the attendance of the First Minister who came for an extended evidence session, during which he expressed his full commitment and that of his Cabinet to a focus on patient needs and to treatment being provided as close to home as possible. His confirmation that the Welsh Assembly Government is determined not to allow the border to become a barrier was refreshingly direct and specific and we congratulate him on his commitment and clarity. (Paragraph 39)
4. The border between Wales and England is long and porous. Cross-border movements have been a fact of life for many years, as people resident in one country are naturally drawn to centres of population in the other. This is no less the case for health services. For those residing in immediate border areas, the nearest health provider may not be in their country of residence. Equally, whilst advances in technology mean that it is possible to provide more services in local hospitals, some complex conditions will always require treatment in a specialist centre, which may be across the border. All those who gave evidence to our inquiry agreed that there is no practical or realistic prospect of diverting these well established cross-border flows, nor would it be desirable to do so. (Paragraph 40)
5. 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, particularly given the policy divergence that has begun to emerge as a result of devolution. Each Government will choose to fund what it considers to be the most important aspects of health care for its constituents, with finite resources. Indeed, the Committee believes that devolution provides an opportunity for the nations of the
The Provision of cross-border health services for Wales 49
UK to learn from each other’s approaches. However, divergent policies must be implemented in a way which accommodates the continuing flow of patients across the Wales-England border. In this context, we support the solutions proposed in relation to the provision of neurosurgery services in North Wales by the Steers Review, and accepted by the Welsh Assembly Government, which would also provide an appropriate model for other specialist and tertiary services. (Paragraph 41)
Funding and Commissioning 6. There is clearly a lack of effective communication between the Welsh Assembly Government and the Department of Health on these issues despite the practical nature of the problems faced by NHS providers on both sides of the border. The issue appears to be firmly lodged in the ‘too difficult’ tray by officials and Ministers and that is not acceptable. If Ministers cannot agree on a fair approach at a strategic level they should agree a form of arbitration which is neutral and independent and make a commitment to accepting its adjudications. There is an urgent need for enforceable protocols between the UK and Welsh Assembly governments to address the current unsatisfactory state of affairs. (Paragraph 61)
7. Our evidence has demonstrated that there are problems with the cross-border commissioning of specialist care for the conditions such as Muscular Dystrophy and mental health care. The difficulties patients have experienced must be recognised and addressed in a holistic way and we are not convinced that the Minister is right to dismiss UK-wide commissioning out of hand. Given that this problem faces regions of England, even though they generally have far larger populations than Wales, it may be that some other form of high-level commissioning that goes across the boundaries of English regions and across the Welsh border would be appropriate for such specialised services. The solution should be driven by the need of patients rather than existing practice. (Paragraph 66)
8. It would be a matter of concern if it were true that the Welsh Assembly Government is paying lip-service to local settlements being struck while unreasonably restricting the discretion of LHBs to negotiate contracts We recommend that the Audit Commission and the Welsh Audit Office undertake a joint inquiry into this situation and recommend ways of resolving the issue. (Paragraph 71)
9. It is unacceptable that the Welsh NHS should erect bureaucratic barriers which stand in the way of patient needs being met swiftly and efficiently. To erect such obstacles for a very marginal impact on costs is evidence of a process-driven approach to patient care. We urge the Welsh Assembly Government to review its approach as a matter of urgency. (Paragraph 76)
10. To some degree, local re-negotiation of contracts may provide solutions to the funding and commissioning disputes outlined in this Report. However, these are unlikely to be resolved successfully in every case. For a genuinely sustainable solution to be developed, a holistic approach to cross-border issues must be adopted. The problems we have described will recur if not resolved in a sustainable way. (Paragraph 77)
50 The Provision of cross-border health services for Wales
11. Even if the Ministers are right to say that the figures are small and the financial implications marginal, any failure to resolve these issues will appear neither small nor marginal to the individuals affected, nor to their families. Tension between commissioners and providers may be inevitable, but they must be resolved without damaging patient care. (Paragraph 80)
12. 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 a problem caused by government-level decisions, apparently taken without regard for their impact on cross-border commissioning. A solution must involve a sustainable and enforceable long-term agreement between the two governments so that future disputes will be avoided and that the patient experiences a seamless National Health Service which meets their needs and not those of accountants. We are therefore deeply disappointed that no permanent protocol has been agreed between the Department for Health and the Welsh Assembly Government, or even published in draft for consultation, almost a year after we were assured that a protocol was imminent. (Paragraph 81)
13. At present, both English providers treating Welsh patients and Welsh commissioners are left in an unacceptable position. Department of Health guidance states that English providers should continue existing arrangements with Welsh Commissioners, yet it also encourages them to devise management strategies orientated towards a market–led system in England. Conversely, Welsh commissioners see no reason to diverge from a long-standing system due to policy changes across the border over which they have no influence. Neither position is sustainable in the long term. (Paragraph 82)
14. While we were assured that those currently supplying cross-border health services were not influenced by the present perverse arrangements, the potential for detriment to patients is clear. It is to the credit of clinicians and administrators that high quality health care continues to be provided to patients despite ongoing disputes over funding. Nevertheless, we have heard some evidence that patients are beginning to suffer, at a time when they are least able to cope with bureaucracy, administrative confusion and delays in medical treatment. This evidence is necessarily anecdotal, but it is persuasive. We note that there is a deficit of robust research concerning cross-border healthcare and we therefore urge the Department of Health, as the UK-wide body, to undertake a study of the impact of cross-border movements on health services. It would be helpful to be able to compare cross- border issues between English regions to the issues across the border between England and Wales in order to distinguish between issues that are a consequence of devolution and those that are simply the result of ‘normal business’. (Paragraph 83)
15. We reiterate the recommendations of our earlier Report on cross-border further and higher education, that meetings between Ministers and officials of UK Government departments and the Welsh Assembly Government must be made more transparent.
The Provision of cross-border health services for Wales 51
This is in the interests of a healthy democracy and the effective operation of devolution. (Paragraph 84)
Waiting times 16. If it is true that care is being influenced by the progress of the financial year, this would be further evidence that the treatment of Welsh patients is being driven by financial imperatives unconnected to patient need. (Paragraph 93)
17. Differential waiting times are likely to persist within the NHS, not only because of divergent policy in England and Wales since devolution, but also for reasons of local variation unconnected with the side of the border on which a service provider lies. At present there is an eight week difference in the stated target waiting times for the Welsh and English NHS. It is not clear to the Committee that Welsh patients are aware of this fact, or of the more general 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. (Paragraph 97)
18. In practice, our evidence suggests that Welsh-registered patients accessing elective treatment in England are not, as a rule, waiting eight weeks longer than England- registered patients. Actual waiting times are generally below English target waiting times both for England-registered and Wales-registered patients treated in English hospitals. Of course, this is little consolation for those individuals who do experience longer or much longer waits. (Paragraph 98)
19. The fact that the waiting time targets in England and Wales are measured differently severely hinders transparency and accountability. Equally, there is no publicly available costing of the shorter waiting times targets set in England compared to Wales. Even if there were a clear cost associated with shorter waiting times, hospital providers are currently left in a difficult ethical position. Many have told us that they will not operate two separate waiting lists which differentiate between patients solely on residence. It is the Committee’s view that providers should not be in this position; the procedure that English hospitals need to operate in this situation is a matter for the Welsh Assembly Government and Department of Health to resolve at a national level. We recommend that, as a matter of urgency, the Welsh Audit Office and the Audit Commission undertake a joint inquiry into the facts of the matter in order to provide a clear evidence base to inform discussions between Ministers to agree how best to resolve these issues. (Paragraph 99)
Patient engagement 20. The Committee is encouraged by the positive evidence it has heard regarding hospitals which have included 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 urge the Department of Health to promote cross-border engagement at strategic level in English hospitals, and to consider the extent to which this has been achieved when making decisions about foundation trust status. (Paragraph 103)
52 The Provision of cross-border health services for Wales
21. We are 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. We recommend that the Department of Health include citizen engagement and patient ownership of cross-border services in negotiations with the Welsh Assembly Government to ensure that English residents’ rights to contribute to Welsh services are protected by the Welsh patient engagement process, just as the rights of Welsh patients are protected in the structure of Foundation Trusts. (Paragraph 105)
‘Border-proofing’ policy 22. It is clear that there is a lack of co-ordination at a national level for cross-border health services between England and Wales. Localised solutions have appeared in some areas, but even where these 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. The Committee considers that an improved government-level protocol is essential to standardise and clarify funding arrangements and accountability mechanisms. The result should be seamless care for patients based on clinical need. We are therefore very disappointed at the lack of progress regarding the development of a permanent protocol since we took evidence last year. (Paragraph 113)
Conclusion 23. 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. All those who gave evidence to our inquiry agreed that 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. (Paragraph 115)
24. It is clear that there is a lack of co-ordination between the UK and Welsh Assembly Governments for cross-border health services between England and Wales. 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
The Provision of cross-border health services for Wales 53
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. (Paragraph 116)
25. 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. Our interim Report concluded that this was a critical issue in need of urgent consideration. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems. (Paragraph 117)
26. It is not clear to the Committee that patients on either side of the border are generally aware 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. We recommend that the Department of Health include citizen engagement and patient ownership of cross-border services in negotiations with the Welsh Assembly Government to ensure that English residents’ rights to contribute to Welsh services are protected by the Welsh patient engagement process, just as the rights of Welsh patients are protected in the structure of Foundation Trusts. (Paragraph 118)
27. Throughout all strands of our inquiry into the cross-border provision of public services for Wales, we have found that the decision-making process on each side of the border needs to be more coordinated, more coherent and more transparent. There needs to be a better and more public interface between the Department of Health and the Welsh Assembly Government. Patients, if they want or need to, should be able to understand the framework in which they will receive care. (Paragraph 119)
54 The Provision of cross-border health services for Wales
Formal Minutes
Tuesday 17 March 2009
Members present:
Dr Hywel Francis, in the Chair
Mrs Siân James Albert Owen
Mr David Jones Mark Pritchard
Mr Martyn Jones Hywel Williams
Alun Michael Mark Williams
Draft Report (The provision of cross-border health services for Wales) proposed by the Chairman, brought up and read.
Ordered, That the draft Report be read a second time, paragraph by paragraph
Paragraphs 1 to 119 read and agreed to
Summary agreed to.
Resolved, That the Report be the Fifth Report of the Committee to the House.
Ordered, That the Chairman make the Report to the House.
Written evidence was ordered to be reported to the House for printing with the Report, together with written evidence reported and ordered to be published on 4, 18 and 31 March, 29 April, 13 and 20 May, 3, 12 and 24 June, 1, 8 and 15 July, and 7 October 2008 in the last Session of Parliament.
Ordered, That embargoed copies of the Report be made available, in accordance with the provisions of Standing Order No. 134.
[Adjourned until Monday 23 March at 4 p.m
The Provision of cross-border health services for Wales 55
Witnesses
Tuesday 4 March 2008 Page
Bishop Anthony Priddis, Bishop of Hereford, and Mr Nick Read, OBE, Ev 1 Chaplain for Agriculture and Rural Life, Diocese of Hereford, and Bishop Dominic Walker, OGS, Bishop of Monmouth, and Mr Robin Morrison, Provincial Church and Society Officer, Church in Wales
Tuesday 18 March 2008
Mr Tom Taylor, Chief Executive, Shrewsbury and Telford NHS Hospital Trust Ev 12
Ms Jo Webber, Deputy Director of Policy, NHS Confederation, and Mr Mike Ev 18 Ponton, Director, Welsh NHS Confederation
Monday 31 March 2008
Dr Peter Enevoldson, Medical Director, Mr Christopher Harrop, Director of Finance, Mr Ken Hoskisson, Chairman, and Ms Mel Pickup, Chief Executive, Ev 26 Walton Centre for Neurology and Neurosurgery NHS Trust
Mr Geoff Lang, Chief Executive, Wrexham Local Health Board, and Mr Ev 33 Andrew Gunnion, Chief Executive, Flintshire Local Health Board
Mr Jeff Lansdell, Patient Complaints Advocate, Clwyd Community Health Council, Councillor John MacLennan, Chairman, Conwy East Community Ev 40 Health Council, and Ms Gail Roberts, Chief Officer, Clwyd Community Health Council
Tuesday 29 April 2008
Mr Robert Meadowcroft, Director of Policy, Dr Mark Rogers, Consultant Ev 47 Clinical Geneticist, University Hospital of Wales and Mrs Lynne Taylor, Contact Family Officer, Wales Duchenne Family Support Group, Muscular Dystrophy Campaign
Mrs Wendy Farrington Chad, Chief Executive, The Robert Jones and Agnes Ev 53 Hunt NHS Orthopaedic and District Hospital NHS Trust, Gobowen
56 The Provision of cross-border health services for Wales
Tuesday 13 May 2008
Mr John Howard, Chief Officer, Montgomery Community Health Council, Ev 59 and Mr Bryn Williams, Chief Officer, Brecknock & Radnor Community Health Council
Ms Judith Paget, Chief Executive, and Ms Rebecca Richards, Director of Ev 66 Finance, Powys Local Health Board
Tuesday 3 June 2008
Mr Ben Bradshaw MP, Minister of State for Health Services, and Mr David Ev 71 Flory, Director General, NHS Finance, Performance and Operations, Department of Health
Thursday 12 June 2008
Rt Hon Rhodri Morgan AM, First Minister, Ms Ann Lloyd, Head of Ev 81 Department of Health and Social Services, Mr Tony Parker, Director of Rail and New Roads, Mr Mark Drakeford, Special Adviser to the First Minister, Welsh Assembly Government
List of written evidence
1 Memorandum submitted by the Association of The British Pharmaceutical Industry (ABPI) Cymru Wales Ev 98 2 Anonymised memorandum Ev 100 3 Memorandum submitted by Bishop Dominic Walker, Bishop of Monmouth Ev 100 4 Memorandum submitted by Bishop Anthony Priddis, Bishop of Hereford Ev 102 5 Supplementary Memorandum submitted by Bishop Anthony Priddis, Bishop of Hereford Ev 106 6 Memorandum submitted by Brecon and Radnor Community Health Council Ev 108 7 Supplementary memorandum submitted by Brecknock and Radnor Community Health Council Ev 109 8 Memorandum submitted by The British and Irish Orthoptic Society Ev 111 9 Memorandum submitted by British Dental Association (BDA) Ev 112 10 Memorandum submitted by the British Medical Association (Wales) Ev 113 11 Memorandum submitted by Carmarthenshire Community Health Council Ev 116 12 Memorandum submitted by Children’s Commissioner for Wales Ev 116 13 Memorandum submitted by Conwy Federation of Community Health Councils Ev 118 14 Memorandum submitted by Countess of Chester Hospital Ev 121 15 Letter from Susan Davies to the Chairman Ev 124 16 Memorandum submitted by the Department of Health Ev 125 17 Supplementary Memorandum submitted by the Department of Health Ev 133
The Provision of cross-border health services for Wales 57
18 Letter from the Minister of State for Health Services to the Chairman Ev 133 19 Letter from the Minister of State for Health Services to the Chairman Ev 134 20 Letter from the Minister of State for Health Services to the Chairman Ev 134 21 Memorandum submitted by Flintshire and Wrexham Local Health Boards Ev 135 22 Supplementary memorandum submitted by Flintshire and Wrexham Local Health Boards Ev 138 23 Supplementary memorandum submitted by Flintshire Local Health Board Ev 139 24 Memorandum submitted by Gloucestershire Partnership NHS Foundation TrustEv 140 25 Memorandum submitted by Gloucestershire Primary Care Trust Ev 141 26 Memorandum submitted by Hafal Ev 143 27 Memorandum submitted by Mark Harper MP Ev 144 28 Memorandum submitted by Hereford Hospitals NHS Trust Ev 145 29 Supplementary memorandum submitted by Hereford Hospitals NHS Trust Ev 148 30 Memorandum submitted by the Institute of Rural Health Ev 149 31 Memorandum submitted by Dr D Alun Jones MD BSc DPM FRCPsych, Consultant Psychiatrist Ev 152 32 Memorandum submitted by Llandrindod Wells & District Volunteer Bureau/Community Support Ev 157 33 Letter from Lord Livesey of Talgarth to the Chairman Ev 158 34 Memorandum submitted by Meirionnydd and Gogledd Gwynedd Community Health Councils (CHC) Ev 158 35 Memorandum submitted by David Fearnley, Medical Director & Deputy Chief Executive, Mersey Care NHS Trust Ev 159 36 Memorandum submitted by Ministry of Defence Ev 160 37 Memorandum submitted by John Howard, Chief Officer, Montgomery Community Health Council Ev 166 38 Supplementary memorandum submitted by Montgomeryshire Community Health Council Ev 168 39 Memorandum submitted by the Muscular Dystrophy Campaign Ev 172 40 Supplementary memorandum submitted by the Muscular Dystrophy CampaignEv 179 41 Memorandum submitted by Elizabeth Newman Ev 179 42 Memorandum submitted by the NHS Confederation Ev 180 43 Memorandum submitted by North Bristol NHS Trust Ev 183 44 Supplementary memorandum submitted by North Bristol NHS Trust Ev 184 45 Memorandum submitted by North Cheshire Hospitals NHS Trust Ev 185 46 Memorandum submitted by North East Wales Institute of Higher Education (NEWI) Ev 185 47 Memorandum submitted by the North East Wales Trust Ev 189 48 Memorandum submitted by North Somerset PCT Ev 191 49 Memorandum submitted by Nottinghamshire Healthcare NHS Trust Ev 191 50 Memorandum submitted by Kate Spall, Founder of The Pamela Northcott FundEv 193 51 Memorandum submitted by Lembit Öpik MP, received from a Consultant At the Royal Shrewsbury Hospital Ev 205 52 Memorandum submitted by the Parkinson’s Disease Society Ev 205 53 Memorandum submitted by Powys Local Health Board Ev 205
58 The Provision of cross-border health services for Wales
54 Memorandum submitted by Professor Charlie Jeffery, University of Edinburgh Ev 207 55 Memorandum submitted by Radiotheraphy Campaign Hereford Ev 210 56 Memorandum submitted by the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust Ev 214 57 Memorandum submitted by Dr Quinlivan, consultant in Neuromuscular Disorders, Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust Ev 215 58 Memorandum submitted by Mr and Mrs M and J Robinson of Hay-on-Wye Ev 215 59 Memorandum submitted by the Royal College of Midwives UK Board for WalesEv 216 60 Memorandum submitted by the Royal College of Physicians Ev 217 61 Memorandum submitted by the Royal National Institute of Blind People (RNIB) Ev 217 62 Memorandum submitted by Shrewsbury and Telford Hospital NHS Trust Ev 219 63 Supplementary Memorandum submitted by Shrewsbury and Telford Hospital NHS Trust Ev 220 64 Memorandum submitted by Shropshire County Council Ev 221 65 Memorandum submitted the Statistical Directorate, Welsh Assembly Government Ev 223 66 Memorandum submitted by John Tyler Ev 226 67 Memorandum submitted by Huw Thomas and colleagues Ev 226 68 Supplementary memorandum submitted by Huw Thomas and colleagues Ev 239 69 Memorandum submitted by the United Bristol Healthcare Trust Ev 242 70 Memorandum submitted by the Vale of Glamorgan Community Health CouncilEv 244 71 Letter from Rt Hon Paul Murphy MP, Secretary of State, Wales Office to Hywel Williams MP Ev 244 72 Memoranda submitted by the Walton Centre for Neurology and Neurosurgery NHS Trust Ev 245 73 Memorandum submitted by the Welsh Ambulance Services NHS Trust Ev 255 74 Letter from the First Minister for Wales, Welsh Assembly Government to the Chairman Ev 260 75 Letter from the First Minister for Wales, Welsh Assembly Government, to the Chairman Ev 260 76 Memorandum submitted by the Minister for Health and Social Services, Welsh Assembly Government Ev 260 77 Letter from the Minister for Health and Social Services, Welsh Assembly Government, to the Chairman Ev 263 78 Letter from the First Minister for Wales, Welsh Assembly Government, to the Chairman Ev 263 79 Memorandum submitted by the Welsh Consumer Council Ev 264 80 Memorandum submitted by the Welsh Language Board Ev 264 81 Memorandum submitted by the Welsh Local Government Association Ev 268 82 Memorandum submitted by the Welsh Occupational Therapy Service Leads Group (WOTSLGs) Ev 271 83 Memorandum submitted by West Midlands Regional Assembly Ev 276 84 Memorandum submitted on behalf of a constituent, by Kirsty Williams AM, National Assembly for Wales Ev 281 85 Letter from the Minister of State for Health Services to the Chairman Ev 282
The Provision of cross-border health services for Wales 59
List of unprinted evidence
The following memoranda have been reported to the House, but to save printing costs they have not been printed and copies have been placed in the House of Commons Library, where they may be inspected by Members. Other copies are in the Parliamentary Archives, and are available to the public for inspection. Requests for inspection should be addressed to The Parliamentary Archives, Houses of Parliament, London SW1A 0PW (tel. 020 7219 3074). Opening hours are from 9.30 am to 5.00 pm on Mondays to Fridays.
Memorandum received from the Welsh Language Board, 14 February 2008
60 The Provision of cross-border health services for Wales
List of Reports from the Committee during the current Parliament
Session 2008-09
First Report Cross-border provision of public services for HC 57 Wales: Further and higher education Second Report Globalisation and its impact on Wales HC 184 –I, II Third Report Proposed National Assembly for Wales HC 5 (Legislative Competence) (Agriculture and Rural Development) Order 2008 Fourth Report Work of the Committee 2007-08 HC 252 Fifth Report The provision of cross-border health services for HC 56 Wales First Special Report The proposed draft National Assembly for Wales HC 200 (Legislative Competence) (Housing) Order 2008: Government Response to the Committee's Seventh Report of Session 2007–08
Session 2007-08 First Report Energy in Wales: follow up inquiry HC 177 Second Report The proposed Legislative Competence Order in HC 44 Council on additional learning needs Third Report Work of the Committee in 2007 HC 325 Fourth Report The proposed National Assembly for Wales HC 257 (Legislative Competence) Order in the field of social welfare 2008
Fifth Report The proposed draft National Assembly for Wales HC 576 (Legislative Competence) (social welfare and other fields) Order 2008 Sixth Report The provision of cross-border health services for HC 870 Wales: Interim Report Seventh Report The proposed draft National Assembly for Wales HC 812 (Legislative Competence) (Housing) Order 2008 First Special Report The proposed Legislative Competence Order in HC 377 Council on additional learning needs: Government response to the Committee’s Second Report of Session 2007-08 Second Special Energy in Wales – follow-up inquiry: Government HC 435 Report Response to the Committee’s First Report of Session 2007-08 Third Special The proposed National Assembly for Wales HC 715 Report (Legislative Competence) Order in the field of social welfare 2008: Government Response to the Committee’s Fourth Report of Session 2007-08
The Provision of cross-border health services for Wales 61
Session 2006-07 First Report Work of the Committee in 2005-06 HC 291 Second Report Legislative Competence Orders in Council HC 175 Third Report Welsh Prisoners in the Prison Estate HC 74 First Special Report Government Response to the Committee’s Second HC 986 Report of Session 2006-07, Legislative Competence Orders in Council
Session 2005-06 First Report Government White Paper: Better Governance for HC 551 Wales Second Report Proposed Restructuring of the Police Forces in HC 751 Wales Third Report Energy in Wales HC 876-I Oral and written Energy in Wales HC 876-II Evidence Fourth Report Future of RAF St Athan HC 1129 Fifth Report Current Restructuring of the Police Forces in HC 1418 Wales Oral and written NHS Dentistry in Wales HC 771-i Evidence First Special Report Government Response to the Committee’s HC 433 Second and Third Reports of Session 2004–05, Manufacturing and Trade in Wales and Public Services Ombudsman (Wales) Bill Second Special Government Response to the Committee's Fourth HC 514 Report Report of Session 2004-05, Police Service, Crime and Anti-Social Behaviour in Wales Third Special Government Response to the Committee's First HC 839 Report Report of Session 2005-06, Government White Paper: Better Governance for Wales Fourth Special Government Response to the Committee's HC 1431 Report Second Report of Session 2005-06, Proposed Restructuring of the Police Forces in Wales Fifth Special Report Government Response to the Committee's Third HC 1656 Report of Session 2005-06, Energy in Wales Sixth Special Report Government Response to the Committee's Fourth HC 1657 Report of Session 2005-06, Future of RAF St Athan Seventh Special Government Response to the Committee's Fifth HC 1695 Report Report of Session 2005-06, Current Restructuring of the Police Forces in Wales
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Welsh Affairs Committee: Evidence Ev 1 Oral evidence
Taken before the Welsh Affairs Committee
on Tuesday 4 March 2008
Members present:
Dr Hywel Francis, in the Chair
Mrs Siaˆn C. James Mark Pritchard Mr David Jones Hywel Williams Mr Martyn Jones Mark Williams Alun Michael
Witnesses: Bishop Anthony Priddis, Bishop of Hereford, and Mr Nick Read, OBE, Chaplain for Agriculture and Rural Life, Diocese of Hereford, and Bishop Dominic Walker, OGS, Bishop of Monmouth, and Mr Robin Morrison, Provincial Church and Society OYcer, Church in Wales, gave evidence.
Q1 Chairman: Good morning; a very warm welcome concerned about a whole range of English/Welsh to you all to the Welsh AVairs Committee. The issues where the borders interfered. As a result of acoustics in this room are very poor and there is a lot that, the memorandum of understanding, which you of background noise, so our Members will be very have been sent, was drawn up by that group and keen to raise their voices, and I hope that you will be signed last year, and we established a core oYcers’ very happy to do so as well so that we can hear one group. It is about forty people from organisations another clearly. For the record, would you please from both sides of the border, including the Welsh introduce yourselves? Assembly Government and the Regional Assembly. Mr Morrison : Robin Morrison: I am Church and I currently chair the Core OYcers’ Group. Under Society OYcer for the Church in Wales. that group, thematic groups have been set up, and Bishop Walker: Dominic Walker, Bishop of Health and Social Care will meet for the first time Monmouth in the Church in Wales. later this month, so there will now be an established Bishop Priddis: I am Anthony Priddis: I am Bishop group looking at health and social care issues. I also of Hereford. chair the Borders Institute of Rural Health, which Mr Read : Nick Read, the Agricultural Chaplain for has made a separate submission to this Committee— Hereford, and I chair the Cross-Border OYcers’ but it is concerned again with health issues across the Group. UK though again looking at border issues. Bishop Walker: Similarly, my diocese borders the English border, and the River Wye forms its natural Q2 Chairman: Can I, as Chair, ask you to very boundary, although in some of our parishes in the simply outline your work? Originally we thought of north some of the farms go over into England, but asking both of you, Bishop Anthony and Bishop people inevitably worship one side of the border or Dominic, but all four of you perhaps could say a worship on the other side, and we are in constant little bit about the work you undertake in relation to contact with people who encounter diYculties, cross-border issues. particularly in terms of health and where it comes to Bishop Priddis: I think we made clear in the written health provision, where they have perhaps a GP one statements to you—speaking for myself and also for side of the border or they are referred to a hospital Dominic as a Bishop—the nature of our dioceses. In on the other side. They encounter the diYculties we my case that encompasses the whole of have outlined. Herefordshire plus south Shropshire, with about Mr Morrison : My perspective and context is that I twenty parishes that are in Wales that are also part am responsible for the specialist work of the Church of our diocese. By virtue of being a Bishop and by in Wales—for example, social responsibility oYcers virtue of having presence, as we do as Church of throughout Wales and rural life advisors throughout England in most of the communities, I travel around Wales, and working with the social, economic, a great deal in the diocese talking a great deal and environmental policy of the Welsh Assembly listening, and I am therefore acutely conscious of a Government. I used to chair a health trust and I used lot of areas where they speak about the cross-border to be on a health authority, but that was in England, issues. We have referred to those in terms of health, so I do not have current experience in Wales on but also, as we have intimated, there are other issues those issues. in other areas. Nick has done a lot, as our rural oYcer, to highlight these issues, and also his work in the West Midlands. Q3 Chairman: Can I place on record our Mr Read : I chair the West Midlands Rural AVairs appreciation of the written evidence you have given Forum, which is the rural stakeholders group for the to us; it was most helpful in preparing for this session West Midlands. That forum established a cross- and indeed for this inquiry. It occurs to me that I border working party in 2003 because we were need to ask a further question: even though you may Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 2 Welsh Affairs Committee: Evidence
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison not have been doing your present work perhaps ten In that factual information you referred to the years ago pre democratic devolution, it occurs to me divergence of statistics between England and Wales that many of the issues you are raising have become in terms of Welsh health being worse than in more challenging since devolution. That is not to England, which is something that is generally known make a judgment of devolution, but would that be and understood. I was not quite clear, though, the case? whether you were suggesting that that divergence Bishop Priddis: I think that would be our perception. applies not just to the generality of England and the Bishop Walker: And it continually develops because generality of Wales but to the communities in your as changes are made one side of the border they do two respective dioceses. not necessarily change the other side of the border. Bishop Walker: It certainly applies to the valley For instance, if GPs in England are required to have communities within my own diocese and also people extended opening hours, it will not apply to GPs in in Newport itself, where I live, where some of our Wales; therefore someone living in England with a estates have children—80% of the children are below GP in Wales will not have the same access to their the poverty level, and at least a third of those are GP. On the other hand, free parking is going to be because of poor diets. Of course, we have a very high introduced in Wales, so those visiting patients in suicide rate—not as high as other parts of Wales, but Wales will be able to park free of charge but might one of my priests told me recently he had taken the have to pay in England. seventh funeral for a teenage suicide in the last year, Bishop Priddis: What would bother me about it is and that was in a small valley community. We do that when you have two systems that begin at source have particular problems caused by poverty and with the same rules and same regulations, then the deprivation. I can understand why the Welsh longer the time is of slight divergence here and slight Assembly Government therefore says these are divergence there, the more it spreads and the more, Welsh problems and we need to have Welsh therefore, the systems become complicated for solutions. The problems arise with border issues everybody. They then have to think, “Which bit, when sometimes the ideology seems to get in the way which used to be the same, is now diVerent?” of the practicalities. That not only aVects patients, Increasingly, that is more and more and more of it. but also aVects clinicians. They sometimes find it Some changes may be slight. For prescription very diYcult to know what the rules are. I was charges, at one level you may say that is slight, but speaking to a doctor the other day who said: “I can it changes the culture, it changes the attitude and the see one patient with a particular problem and put mentality. It has been said that committees will them on one waiting list, and the next patient has spend a long time deciding how to spend £10 and it exactly the same problem, but I have to look where will go through on the nod if you spend £100,000! It they live and then I put them on a diVerent waiting is the small detail that aVects people more. list; so one patient would be treated weeks ahead of the other.” Somehow there seems to be a problem in Q4 Chairman: Of all the issues, I take it from what which people perceive there being a lack of justice, you have said and from what you have written for us and there needs to be some sort of pragmatic that of all the issues that we are facing, health is by solution. far the most challenging. Is that accurate to say? Bishop Priddis: I would endorse that entirely. From Mr Read : I think the finding of the Cross-Border where we are it is entirely unreasonable that there V Group—we commissioned some research—was that should be that di erence of treatment according to there is a whole range of issues. Health is certainly where people live and waiting lists. We would want challenging, but transport is another area. In almost to see much greater quality and treatment for people, every field environmental, social and economic whichever side of the border they live. The issue of development is aVected by the border, usually to the rural poverty is dear to your heart, I know, and as I detriment of those living on both sides. Although have referred to earlier, South Shropshire district is, health is an issue, it is not by any means the only on Defra’s figures, the most deprived rural district in issue that needs to be addressed. England. Part of the consequence always for rural Mr Morrison : It has got related issues around it, but poverty is that so much of it is hidden. In sparsely as a focus for this concern it is probably, in my view populated areas, even if the proportion is significant, V the most diYcult one to address. One can look at it is still di use. As Dr Stuart Burgess was saying just many other issues and see borders disappearing and the other day, as rural advocate: if you have 2 million becoming invisible—for instance in the private people in England who are deprived in rural areas, sector the Institute of Directors which I chair in put them together and that is the size of South Wales: one is conscious that their view of Birmingham; but in fact they are spread around and V administrative borders is very diVerent from the it does not show up. It is those people also who su er public sector’s view. I think the point for the reasons most with these cross-border issues. you hinted at Mr Chairman, is the dilemma of the unintended consequences of devolution. Q6 Alun Michael: That is why it is so important that we get to the facts in order to make the diVerence. Q5 Alun Michael: Can I commend the papers that Mr Read : It is diYcult to distinguish as a you have both submitted, particularly the paper consequence of rurality and being a peripheral area from the Bishop of Monmouth, which we ought to and what is the consequence of being on the border; use as a model for future requests for evidence, but our approach is that the diYculties of living in a partly because it starts oV by referring to the facts. rural area are compounded by the cross-border Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 3
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison issues, understanding that distance decay and that greatly if decisions can be made without that being people often give up on treatment rather than connected and joined up, and without a structure travelling for miles for treatment happens in rural that ensures that the implications are thought areas anyway; but when you have a transport through and ensures that there is not the potential to scheme that goes across the border to get access to cause, frankly, financial chaos and therefore health healthcare is even more diYcult. You can easily chaos—and the same would be true in other areas— distinguish between the two, but it makes rural with a decision one side, taken in good faith, serving issues far more diYcult. those people, which has undiscussed and un- Mr Morrison : It is important to point out that those thought-out consequences. facts were the same more or less in the 1930s, and in Bishop Walker: Often people perceive that they are one sense the economic and social causation of those caught between two systems and they tend to facts in Wales has nothing to do with devolved compare the two systems of course and feel, “If I systems and so on. It is quite evident that certain lived the other side of the border I would be better ministers of health in Wales post 1999, post oV because ...”Itisusually, “If I lived in Scotland devolution, have gone for collectivist values that I would be even better oV”! put, for example, public health policy at the centre of the solution to those facts; but I am not sure that the Q8 Alun Michael: Presumably without noticing the way of tackling those and reducing those per se is reverse! through internal health systems alone. Bishop Walker: That is right—the grass is always greener on the other side, I suppose. Vulnerable Q7 Alun Michael: That takes us quite nicely from the people seem to be given lots of information but seem facts, which may diverge, to the practicalities and to know less the more bits of paper they are given. then to the divergence of philosophies, values and My mother has macular degeneration and she is political approaches, as you said in your paper. given an amount of paper to read as her eyesight Divergence is obviously something to celebrate. I becomes worse and worse. Her doctor is saying, “If notice in the paper you refer, for instance, to the you lived in Scotland, I could treat you. I will write impact of the policy in providing your services to CardiV and see if they can treat you”—and you within your paragraph 8 and then to the example of discover they have the same policy as England, so St Luke’s Hospital in paragraph 9. I wonder whether she is not being treated at all! We are getting the each of you could comment on the impact of feeling, as Bishops, that people feel they have divergence of policy on both sides of the border? nowhere else to turn so they turn to the Church to see Bishop Priddis: The divergence, we have both whether we can bring justice for them. referred to in quite a lot of examples, but part of the problem about divergence is divergence of some of Q9 Alun Michael: MPs more or less feel the same! the philosophy. I think it is spreading further rather Mr Morrison : The pieces of paper thing is pertinent, than closer. That is the feeling in terms of the is it not? One of the things we have said in Wales is diVerence and the implications of that. Part of it, that if you have got divergent philosophies leading therefore, is what we have just been saying about to divergent provision of care, systems and so on, targets, waiting lists and diVerent treatments, and then one way to solve that problem is to give more those implications; and part of it as well is that both information so that GPs, primary care and local Shrewsbury and Telford Hospitals and Hereford health boards and so on will ensure individuals Hospital are looking for foundation trust status, and understand their choices and the alternatives where is the funding to be for that? Is it going to be oVered. I think that is slightly naive because I do not reliable and secure for people across the Welsh think information solves the problem. I think there border, and what will be the implications of that for are many vulnerable people who cannot manage future planning? If there are decisions made in Wales that information in the way that one would assume. over which a foundation trust has no control, will It is interesting that, obviously, in looking at they be devastating for the finances of that divergence, you have got to say it is entirely foundation trust? Where is the dialogue? Who asks appropriate within devolution for the people of the questions? Who accepts the implications of the Wales to have elected members and to come up with decision-making in one area that is totally their own systems, and there will be systems that do legitimately within their philosophy and structure not impact at all on this cross-border issue. I think but which actually has un-thought-out one must be careful not to put all this together in one consequences, because nobody is speaking up for single focal point. If we go back to Bevan, one of them? These are real, real issues, and they could be Bevan’s points was to erode diVerences, so there is a extremely damaging. As I have said, if you withdraw huge irony in this in Wales where the direction of 10% of the funding because a philosophy goes more travel chosen is increasing diVerences. I remember and more to look in Wales towards Swansea and Brian Gibbons, when he was in the role, saying, “We CardiV—if the implication of that is that a want voice, not choice in Wales”. That clever little foundation trust hospital serves a whole county, it is turn of the words symbolised a whole divergent financially no longer viable and that would carry philosophy of values. Values in Wales are conflicting vast implications for another 170,000 people. It may about this; it is not that there is one simple system; not be the responsibility of the Welsh governing but our starting point is pragmatic and we would say body, but nevertheless that is part of the implication. you start with the patient on the hospital ward, not There is all that raft of questions that concerns us the civil servants writing the policies and not even Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 4 Welsh Affairs Committee: Evidence
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison the boards of the acute sector trusts and so on. You Bishop Walker: I think I understand the means lead start with the patients and what matters to them. It to the end; therefore, if you have diVerent means that ought not to be beyond us to re-jig the system to you will in the end achieve diVerent ends. Sometimes follow patient needs, but clearly that is not the I think the philosophy is not thought through far approach. enough to see what the end product is going to be. I Mr Read : It is important to determine where policy used the St Luke’s Hospital example, not because I is being made in the sense that we now have a want to lobby for St Luke’s, although I have regional health board. We used to have three in the benefited after heart surgery from their care, but I West Midlands, but we have a single regional health think it shows how, if you have a rigid philosophy board developing regional health strategy. We rural- that says “Wales will meet all Welsh needs within proofed that. We also rural-proofed—forgive the Wales”—and in fact it cannot of course—but if you jargon—the health promotion strategy in the West say that that is the ideology, even though a patient Midlands. The health promotion strategy took could be treated free of charge in London and that account of cross-border issues and dealt very much frees up a bed and saves Wales £300,000 a year, with people. The regional health strategy dealt with somehow it seems that they are putting the ideology provision of acute NHS services. That was the before the practicality. I can understand why they do strategy that was quite a surprise, to understand that not want private healthcare, but then I could argue Hereford Hospital, for example, wanted an that St Luke’s is not providing private healthcare oncology unit. It did not feel that we were justified because no-one is paying for it; it is all being given in having specialist cancer treatment because of the free. number of people that hospital served, but had not Mr Morrison : Could I add to that, Mr Chairman? cottoned on to the fact that people travel from This is a quote from the NuYeld Trust Report, Powys to access healthcare there. So policy is also which you may know. In the same report the being made at a regional level, not just in Richmond Director of the European Region of the World House and the Welsh Assembly Government; and Health Organisation who had written a substantial how that policy is interpreted and applied across the piece of work on the value of values, says: “In border needs to be carefully thought through. practice the diVerence between policy statements and policy outcomes aVects the diVerence between Q10 Mr David Jones: Bishop Dominic, there is one the means and ends.” But if you look at policy paragraph in your submission which startled me, outcomes as well as studying policy statements frankly, and I would like to ask you about it, on this about direction of travel and values, et cetera, you can see that ends can be warped very easily where a issue of divergence. In paragraph 4 of section C you V quote the author of a work Developing Policy- gap develops between that di erence. Divergent Values: Examining the NHS in the UK: “DiVerent systems make diVerent choices because Q12 Hywel Williams: Bishop Dominic, I am slightly policy-makers diVer in their meaning and the troubled by the statement in your submission—and priorities they attach to diVerent values.” Then there the comment that you have just made—at (a) on is this astonishing sentence, in my view: “Devolution page 3 where you say: “A patient in North Wales is not just about diVerent means but diVerent ends.” requiring neurological treatment is likely to be sent I can fully understand how devolution can be about to Swansea.” It is the “likely” that worries me diVerent means, but I would have thought that in the because I am not aware that large numbers of people case of healthcare the ends must surely be uniform— from North Wales have been sent to Swansea at keeping people as healthy as possible and, if they are present. It might be the case later on, but that is an ill, treating them as eVectively and speedily as open policy debate at the moment. I am concerned possible. I am just wondering why you quoted that that we are jumping the gun here slightly. extract in your submission to the Committee. Bishop Walker: The Bishop of St Asaph tells me that Bishop Walker: I think it was to try and emphasise that is already the case, but being in south-east Wales that there are diVerent philosophies—and I quite I am not sure what happens in north-east Wales. understand why there are. We fully support the idea that Wales has particular health needs that need to Q13 Hywel Williams: That is your source; that is be addressed in a particular way but yet it seems that what the Bishop of St Asaph says. while they are saying, “we put the welfare of the Bishop Walker: Yes. patient first”, in practical reality often the patient Mr Morrison : He was unable to be here today, but does not feel that or that does not appear to be the has sent us his own comments, which we have not case. For instance, quoting the case of someone passed on directly to you. That issue reflects the living in the north-east of Wales who has a previous dilemma as well because it is an open-ended neurological problem; they get sent to Swansea when question to some degree, but we know that in policy they could go to Liverpool. That appears to be terms the intention is to make Wales self-suYcient in putting the philosophy and ideology before the care terms of critical mass, and therefore have specialist of the patient, when presumably the care of the centres that will enable that critical mass of volume patient is what matters. of patients to be achieved as much as possible in order to attract the doctors to those specialist Q11 Mr David Jones: It is not a question of means, centres, so it is a bit of a loop. That is the direction which I quite understand; it is diVerent “ends”: what of travel and one could describe it as an end, but it do you understand by that expression? would have consequences if implemented. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 5
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison
Q14 Hywel Williams: I refer to point 10 on page 4 That, therefore, puts people more at risk. Those are where you state that Wales seeks independence and part of the implications for us over these kinds of to be self-suYcient in all clinical areas. I have to say I issues. do not recognise that as a stated aim of the Assembly Government at present. I am not here to defend them as such, but I thought they were more pragmatic in their view of provision of health services and that they would provide them wherever Q17 Mark Pritchard: Would you see the cross- they were available rather than saying they are border arrangements that Shrewsbury and Telford seeking independent answers in all clinical areas. I NHS Hospital Trust has, one where Welsh people are wondered if you could source that contention of needing access to English healthcare and the English yours on page 4. hospital trust whether Hereford or Shrewsbury or Bishop Walker: “All” may be wrong; it may be most even in Cheshire is requiring access to funding from clinical areas. Certainly there are areas in which they Welsh patients, whether that funding is 100% cannot be, as I highlighted earlier, with things like funding of the actual healthcare or not? heart transplantation. Bishop Priddis: They mutually need one another. It would be a nightmare for people just across a Welsh Q15 Mr Martyn Jones: Can we see the papers from border not to be able to go to Shrewsbury Hospital the Bishop of St Asaph? If you have not got them which was five miles away, or to Hereford Hospital today,would you be kind enough to send us his views which was twelve miles away, and certainly on the situation—or should we write to him directly? Shrewsbury because there is nothing else anywhere Bishop Walker: We had an e-mail from him. We near in terms of a Welsh hospital. The same would could ask him.1 be true of Wrexham, the opposite direction; that people on the English side can be a mile or two miles from Wrexham Hospital. If there was a clear Q16 Mark Pritchard: Gentlemen, welcome. Thank demarcation, clearly that would be absurd because you for your work and remarks to the Committee, we would be back to the issue about what is best for which have been very helpful. Bishop Anthony, your the patient. Presumably, what is best for the patient memorandum notes: “The needs of patients on the is partly geography and closeness, shortness of eastern border of Wales to be able to continue to travelling time, optimum speed of care therefore; access hospital care in England are vital not only for and if the end really is patient care rather than trying them but also for English hospitals.” On the issue of to build on the best department down in Swansea so mutual dependence, could you flesh out some detail that that can get stronger, for example, or possibly of your understanding? the best department in Liverpool and take Bishop Priddis: It was partly the point that I was everybody in that direction—if patient care really is mentioning a few minutes ago about the funding for the end, then geography is going to be key to that the elective medicine at the hospitals, and partly the because closeness of provision of the best care that is fact that in Hereford Hospital 10% of the funding nearest is clearly in the patient’s interest. It is not just comes from Powys at the moment. Shrewsbury and in the patient’s interest in terms of best and speediest Telford—I do not know the proportion, but they medical care; it is also in the patient’s interest in serve a rather bigger catchment area in total, and I terms of the support networks. This is an issue that imagine that probably a similar proportion, maybe I suspect we, as clergy, see rather more acutely than even higher given the geography there, may well come from cross-border funding. Part of the issue is hospitals themselves see because we see a great deal about that. I think that the issues I referred to in, for through our congregations and through our villages example, Shrewsbury Hospital with the proportion and towns the relationships and networks of the of people who use accident and emergency being family and friends visiting. We know that health and lower in rural areas anyway—what then happens is wholeness is not just to do in a restricted narrow way that you need the critical mass, and it goes back to with immediate physical treatment at a hospital; it is the question you were asking just now, Mr Williams. also to do with not worrying about your wife or your Certainly in terms of accident and emergency, if you husband or your children having to get to visit you are going to have an accident and emergency or how they are being supported elsewhere, and all department in a hospital, it needs that hospital to be the pressures on them. Equally, it is about the wider big enough and serving enough people to have family and friends support for people to have the enough other departments. There are four critical health and wholeness of their whole relationships other departments, preferably ten, that a hospital and all the other dimensions of their life. This does needs if it is going to be able to provide the best not figure on the statistics; it does not figure in possible provision for A&E. Therefore, if the budgets, but it does figure in how people recover and numbers are withdrawn because a specialism has in how the communities respond. The geography V developed in Swansea that the Welsh Assembly then a ects that, if people have to go five hours down to wants doctors to refer people to—and if the Swansea rather a half-hour journey. The consequence of that is that some of the departments implications are not just there for the medical get weaker, then the provision of A&E gets weaker. treatment in the restricted more physical way; it is also there for the wider support and the wider sense 1 Note by witness: the Bishop of Asaph had nothing further of good, the recovery rates and the support that to add people are given afterwards. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 6 Welsh Affairs Committee: Evidence
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison
Q18 Mark Pritchard: If you look at a very large Bishop Priddis: I see. county like Herefordshire, do you think the drive for foundation status in Hereford Hospital and Shrewsbury Hospital Trust as well is likely to tempt Q20 Mark Pritchard: Clearly, that disenfranchises both trusts to continually look towards Wales and constituents of both mine and centrally in Shropshire. The point is not about English versus perhaps to look to Wales more so in the future seeing Welsh or not helping the Welsh patients or the Welsh Wales as a helpful revenue stream—payment by not prepared to go—it is not about that. As a results, et cetera? If that is the case and if you agree Member of this Committee it is about Welsh with that, do you share my concerns that there are taxpayers being able to access the Welsh health patient needs in the other parts of those counties, for services that they have paid for. It is not a party example in Shropshire, the eastern side, and Ross on political point. If the direction of travel of the Welsh Wye in Herefordshire and that those patient needs Assembly as a whole is to provide as many health may well be forgotten or downgraded as a result of services as they possibly can in the coming years, the foundation trust hospitals looking towards then clearly there is a divergence of policy in relation Wales and focusing their attention mostly on their to foundation trusts in England because they will be western side rather than thinking of the county as a pulling against one another. whole? The primary function, surely, of an English Mr Read : I am not clear from your question. There hospital trust, however helpful you want to be to seems to be an assumption that all hospitals oVer the Wales, is to service the needs of the English patients? same degree of service. A lot of the cross-border Bishop Priddis: The first bit of your question I think traYc is to a degree of specialism that does not exist I can say “yes” to; that the foundation trust status is in very many hospitals: Liverpool for neuro-surgery; going to strengthen, if anything, what already exists Liverpool and Birmingham for paediatrics; Stoke- anyway—I think the primary care trusts. I think it on-Trent for cardiac surgery, and Oswestry for will make people who run those hospitals more orthopaedics. They would not be part of a normal concerned to make sure the funding stream is there district general hospital set-up. In order to maintain for people across the Welsh border if it is an English that degree of specialism in a sense you have to cast hospital—so I think you are right about that. I am the net as widely as possible, and pragmatically the not sure I would necessarily go with you quite so east-west transport routes across much of the border much about the other issues for two reasons. One is are just so much more straightforward than north- that whether or not, in terms of Shrewsbury and south. In terms of patient care it must make sense. Telford or Hereford Hospitals, including people from Wales would then mean there has to be greater attention given to Wales, I do not see that that is the Q21 Mr David Jones: If I may come back on that case. I would have hoped that if a hospital is serving point, you may be aware of the controversy at the people on a western region, it will have no greater moment over Walton. You say it is clearly much more convenient for north-east Welsh patients to go need to give them a higher priority than the people to Walton, but we have now a Welsh Health Minister on the south or the east of their region. I do not see who has said on the floor of the Welsh Assembly that that if it operates properly, once they are aboard as she intends to aim at what she called an “in-country” it were in terms of system and decision-making and solution, which would require North Wales patients policy so that they can come and funding will follow to travel to South Wales. Clearly, your point about it, they need to be given a higher priority or higher convenience is absolutely right, but that is not treatment from any other people. I do not actually apparently what is happening in the Assembly. see that the consequence need be that any people in V Mr Read : It is not a policy that we would support England would su er; rather it seems to me that the for that reason. reverse is true, for the reason I was saying earlier: if Bishop Priddis: It is precisely what concerns us and you withdraw funding and you get below the critical precisely what we are referring to in terms of mass level, then some of the specialisms cannot be divergence of philosophy; and it is precisely what is supplied because the budget does not stack up for a behind the point you picked up on earlier about 24/7 provision in this particular department; and ends. What you have just articulated surely is an end V then everybody su ers. The English patients would that is intended, and it has a consequence that we suVer with withdrawal of specialism if the funding would say is not for the patients’ best interests. I were not there to provide the doctor care seven days think you have put very clearly why that reference a week. Actually, not looking after the Welsh part, in was there in paragraph 4 that Bishop Dominic terms of your question, would actually make the wrote. English suVer. Q22 Mrs James: Forgive me gentlemen because Q19 Mark Pritchard: If I may, I will give you the some of what I was going to ask you about you have example of Shrewsbury and Telford NHS Hospital covered already and I want to tease out a bit more on Trust, who have one trust on two hospital sites. One the particular issue of the experience of people living is a hospital in my constituency and one is in on the border. Bishop Dominic, in your written Shrewsbury. If the focus is going to be revenue from evidence you state: “Although cross-border issues Wales, then it makes sense for the trust to pour more are regularly faced by those living near the Welsh/ investment into the site that is nearest to the Welsh English border, they are not confined to them border. That was my point. alone.” Can you illustrate how those cross-border Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison issues, particularly health issues, diVer from those diYculty if it is longer routes; if you only have one living on the border as opposed to in other parts of paramedic, then they cannot necessarily provide the Wales? treatment that is needed to sustain a patient in a Bishop Walker: What I meant was someone in critical condition because you might need two Aberystwyth, for instance might need a heart people. In paragraph 9 I have referred to some of transplant and would have to travel to England for those areas. Longer travelling time ought, I think, in it. It is not just something that aVects twenty miles the best interests of the patient to mean that at times outside the English/Welsh border; it is a bigger issue you can have two paramedics present rather than than that. Bishop Anthony said that there is not the one; but clearly that has cost implications, and that critical mass in Wales in order to provide specialist is part of the diYculty. services and therefore inevitably people from Wales have to travel to England for some treatment. That is particularly so for some paediatric problems as Q27 Mrs James: It is not just faced by people well as heart transplantation, because by-pass cross-border. surgery and everything else can be done in CardiV. Bishop Priddis: No.
Q23 Mrs James: Those are the specialisms that Q28 Mrs James: Far West Wales faces similar Bishop Anthony referred to; because of critical mass problems. you need larger centres of population. Bishop Bishop Priddis: I am sure Scotland would say the Anthony, this is related to the question: you say in same to us. your memorandum that there is a reduction in the Mr Read : There is a paper by Iredale et al in 2005, rate of service use as the distance from the source of Health and Place. I will reference this to you. healthcare increases. Can you tell us a little more on that? Q29 Hywel Williams: Bishop Dominic, you say in Bishop Priddis: Are you meaning the academic V sources for that? your paper that there are two di erent funding approaches for patients with the same problems being adopted between Wales and England Q24 Mrs James: Yes. You stated it in your (paragraph 6, section C). Can you give us some submission. examples of diVerent funding arrangements that you Bishop Priddis: I referred in one of my paragraphs to have identified? I am slightly worried at the the College for Emergency Medicine Journals about conversation we are having in regard to the uptake. That was more about mortality, a 1% diVerence between England and Wales, and I am increase per 10 kilometre of travel. I think it was interested to see examples. more of an issue you were referring to, Nick. I do not Bishop Walker: Robin may know more clearly. know whether you have got the more detailed Mr Morrison : Again, I cannot quote an individual factual papers that that came from. case in, say, a hospital ward; but I think what we are Mr Read : I do not have them on me but I can hearing about—and it is anecdotal, clearly—is that certainly send you details. because the commissioning arrangements are diVerent—the block and tariV systems, for Q25 Mrs James: It related to the time. For example, example—there is a fault line there which some if you were in an accident would you need to get to clinicians struggle with. We are hearing that in some hospital within a window of opportunity? hospitals clinicians are doing their best to get round Mr Read : There is that, and also the distance decay. this so that on a ward the care package or the A number of studies have shown that people in a funding package of the commissioning route will not way do not access health services in the first place, make any diVerence at all. We are also hearing that unless there is an acute situation where there has that fault line is an irritant, and people are reacting been a road traYc accident or something, but of diVerently to it. I suppose that that is a hugely course they go and see a GP, and the GP refers them complicated area because it would depend upon the to the specialist hospital, which is X miles away, and individual ward staV, teams, boards and oV you go. they decide that they are not going to take it any There may of course be very legitimate reasons why further because of the sheer hassle involved in two diVerent systems are needed and can work well. getting there and the eVect on the family. There have If there is a fault line, for example in the same been a number of studies done in Wales. I can get you hospital, it does seem, as we said earlier, not only to the details. disadvantage the patient, which is the main concern here, but some processes within the hospital. We Q26 Mrs James: That relates to cross-border mentioned foundation hospitals earlier, and one of transport services that you mentioned earlier on. Are the things around that status is to give more there particular problems with the ambulance flexibility in systems and in governance and services? autonomies and so on, which presumably might aid Bishop Priddis: There are. I think the A&E the case of cross-border issues because there might departments reckon that people need to be there be local autonomies that can address the specifics. I within 45 minutes for more acute treatment— guess we are talking throughout the health economy cardiac arrest problems; and if they are not, then the but primarily in the acute sector here, and I suppose mortality rates change quite significantly. Part of if there is no fault line there is no problem; but you what I have already said is that there is then a are quite right that we must get from generalities to Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 8 Welsh Affairs Committee: Evidence
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison the specifics. I would urge you, as a Committee, to insuYcient critical mass to make it possible. Can you find people who would give you that evidence. We expand on those sorts of conditions? You have certainly only have it anecdotally. talked about heart conditions and there have been certain discussions about— Q30 Hywel Williams: I would say anecdotal Bishop Walker: I think some rare illnesses, like evidence is entirely valid. It is interesting what Niemann-Pick disease, that kind of thing, where people think. I am just worried that popular debate there may only be a small number of people who has been coloured by anecdote and not suYciently suVer from that particular illness in Wales and where by statistics. specialists in that reside in particular English Bishop Priddis: If I might say, I am pleased to hear hospitals; and therefore it may be necessary to you say that. “Anecdotal” means people without provide for a child with Niemann-Pick disease to go any voice. That is literally what “anecdote” is; and to Cambridge or Oxford or somewhere where there therefore it is not to be dismissed. It is rather giving is a specialist in that particular illness. voice, which is part of what we seek to do. Q33 Mark Williams: Bishop Anthony, in your paper Q31 Hywel Williams: Are the current cross-border you talked at length on cross-border traYc in people. funding arrangements impacting on the quality of In part, I guess, a solution to this has been service provided to patients, the quality within a development of a memorandum of understanding hospital? Are there quality issues? between central Wales and the West Midlands. Is Mr Morrison : That is an important question, is it that addressing some of the concerns you have not, because as Bishop Anthony earlier said, if you addressed? Mr Read , at the start, talked about the put geography and distance decay and all these other work of core oYcers and the thematic approach to factors alongside quality of provision, which is your hospitals’ more general problems. As a matter of question—it is such an important question because, process, what is being done through that again it might well be that whatever the systems, memorandum to address some concerns you are good local provision and response achieves hearing and that we agree with you on? enormous quality of patient care and outcomes for Bishop Priddis: Nick and I have observed before that individuals. The relationship between systems that we feel that the memorandum of understanding have glitches in them and local delivery is an perhaps has achieved two things that are significant interesting debate. Presumably, we are interested in and important, but it is only in some ways a removing the glitches to give the quality as much beginning. One is that it has been a clear chance as possible. That is, I know, a controversial acknowledgment that these issues are around and way of looking at it because it does start with the that they are diYculties that need addressing. The patient end. I know how diYcult that is, particularly second is that it has therefore been a means to in large-scale organisations and large-scale public conversation taking place and the dialogue service delivery.The interesting thing in Wales for me happening for people to have some channels and was the public reaction to Design for Life, which routes by which they can talk more about shared clearly tries to address many of the crucial issues diYculties and shared issues. However, that is about quality and excellence, centres of excellence, nowhere near enough. The discussion needs to take quality of provision and how you link these and focus these in certain places. The implications of that place but it is a starting point. It has got to lead, as of course is the local reaction against the perceived we have been saying, to some further actions. It is removal of local access to services, and that was so not just a matter of local people across the border widespread in Wales that I would have thought that being able to resolve the problems themselves; hence is quite good evidence that the case we have been your own agenda and your own roles, because these arguing for in terms of access and geography, and are not just local issues or not just regional, but also carers as well as patients, is already made for us. It national issues. Nick would be the best one to take then gets very diYcult because you cannot spread that further. the resource too thinly, so there is a tough policy debate to be had alongside the public reaction to that Q34 Mark Williams: Can I reiterate that point and issue. I think you are absolutely right to go for follow up from Mrs James’s question on people quality. That raises all sorts of other issues about living further away from the border. Would you training, standards and values in hospitals and the agree there is a need for people further afield to have poor outcomes in hospitals, which I guess is a much an input into those cross-border issues? larger conversation than the remit of this group. I am Bishop Priddis: Absolutely. totally with you: if we want to raise the bar on quality, let us remove the stupidities in the system that make it more diYcult for clinicians to do an Q35 Mark Williams: Perhaps not on the scale of excellent job. people from Powys and the West Midlands, but certainly— Q32 Hywel Williams: Bishop Dominic, you Bishop Priddis: I would agree, and also north, mentioned the apparent policy of the Assembly to because this is a West Midlands-driven agenda and provide more services from within Wales: but be that therefore that may touch on the middle and south of as it may you also say that there are bound to be the border issues, but does not touch Cheshire in the certain medical conditions where there is an same way. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison
Mr Read : In practice, the MOU was a corrective at that level gets translated into political policy- mechanism to ensure cross-border was taken into making. I think for future policy development this is account. The way it works is that the organisations a very useful first-stage tool, and who would argue that have signed up to the MOU have signed up to a against it? As has already been said, more is needed. commitment to share non-confidential information and to discuss with their partners on the other side Q37 Mark Williams: Would you welcome that? You of the border when it comes to policy development. talk about three strategic bodies. We are going to The other tool that is being developed is a cross- hear from the Minister from the National Assembly, border toolkit, so the way that we rural-proof I am sure, and the Minister for Health here about the policies to see how they impact on rural areas. We dialogue between the UK Government and the want to be able to subject policy development to an Assembly Government on that matter. In terms of analysis that says, “How will this impact on those practitioners on the ground, would you welcome communities on both sides of the border?” In that? practice we are looking at policies that are already in Mr Morrison : Subsidiarity is an important principle existence—the Wales Spatial Strategy, the West in this in terms of giving access to local people and Midlands Regional Strategy, and so on. It is asking local organisations. The issue then is: how do you get the question: “How is this going to aVect people who the best of perhaps three diVerent approaches to live on either side of the Welsh border and how will cross-border issues and push them into the present policy development on the English side impact on structures rather than just bolt them on? It is really policy development on the Welsh side? It is not diYcult anyway and we have economic forums in creating a separate policy, but it is subjecting the Wales. The spatial planning in Wales, which is existing policies to that mechanism. The toolkits are second to none in Europe in many ways, still has the the cross-border toolkit and the people who apply problem of diVerent zones and areas of Wales that, and the thematic working groups that I have feeding back in ways that actually influence political mentioned, which are in a sense trying to roll out the policy-making. It is that little bit of the loop that is issues for each of those specific areas. We identified tricky. six areas initially, of which health and social care is Chairman: I think we are at the heart of the issue that one. I am slightly envious of the situation along the Mr Williams alluded to there in regard to the Mersey lines where they have a sub-national ministerial meetings that take place, but the public is strategic document. That was economically driven, not aware of what is being discussed. It may well be but each of the partners are buying into that at that this Committee and your evidence would help in £5,000 a time each year, so they have a budget to this respect. In the policy process we need to know monitor and carry out research. We do not; we are what they are discussing and what informs those entirely reliant on the volunteers, those who attend discussions. the meetings. There is significant buy-in from the Welsh Assembly Government and from the Q38 Mr David Jones: I do not know whether Regional Assembly and the West Midlands, so the someone can assist me with this, but the copy of the major stakeholders are there and we need to progress memorandum of understanding I have got is it. It is early days but it is generating dialogue now labelled “draft”: has this been adopted or is it still that did not happen before—of that we are quite a draft? convinced. Mr Read : It was signed twelve months ago tomorrow by Carwyn Jones of the Welsh Assembly and David Smith of the Regional Assembly; but Q36 Mark Williams: Bishop Dominic, your since then another forty or so organisations have memorandum talks about the need for that signed it. They were the photo opportunity, but, yes, dialogue. Are you satisfied this is beginning to work there is a rolling programme of signatures. and that the people who should be engaged in dialogue are participating? Is there anybody else you Q39 Mr David Jones: This document before the would like to add to the list of participants! Committee now represents the memorandum of Bishop Walker: I do not have any knowledge of the understanding as it now is and it has not been memorandum of understanding and how that is changed or amended in any way, has it? working because that does not cover my area, but I Mr Read : I honestly cannot say, but I have a copy am sure that having clinicians and patient user of the final document with me. groups and other community people in dialogue, with, hopefully, Members of Parliament as well as Q40 Mr David Jones: It might be helpful if a final Members of the Welsh Assembly, would lead to a copy of the document were put before the way forward. Committee. Mr Morrison : This is complicated, though, is it not? Bishop Priddis: I think it is the same but we will If you look at cross-border geography you might check. well end up with three strategic forums, all quite rightly focusing on their own specific areas. As Q41 Mr David Jones: On the assumption that the partnerships and strategic bodies become more final document has not changed from the draft we mature, not just the cross-border ones but, say, have in front of us, my concern is clause 5 which across Wales, one of the issues is how dialogue, co- states: “This memorandum of understanding is a operation, sharing of information and collaboration voluntary arrangement rather than a binding Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 10 Welsh Affairs Committee: Evidence
4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison agreement or contract, and so does not create any BishopPriddis: I do not think that is something I legally enforceable rights, obligations or would hold a strong view about one way or the other restrictions.” My concern therefore is that if any because my presence here is because I am able to aggrieved patient who at the end of the day is the speak from the presence of our 400 and more person supposed to benefit from this process, decides churches in the diocese, from our congregations, that he wishes to take the issue to court on, for from the people about their needs and, as we have example, judicial review, he has not got any legally been saying, their desire to be treated in the best enforceable rights he can point to for taking that possible way, equally, fairly, with fair access, and step. Is there not a deficit at the end of the process for where geography needs matter. If you, as politicians, the aggrieved patient in that he has no recourse if he think that devolution can achieve that better with is dissatisfied with whatever treatment he or she has more funding or less funding, in a sense that is your received? question, not my question. We can say what the Mr Read : That clause was inserted at the request of needs feel like and what needs addressing, but how the Welsh Assembly Government lawyers. practically and politically it is addressed I do not think is within my brief. Q42 Mr David Jones: It looked legally drafted! Mr Read : They changed very little to the text itself. Q47 Alun Michael: I just want to ask about this It was originally a cross-border agreement, which business of how binding an agreement is. I accept they vetoed; and then it became a concordat, which entirely that an agreement to which people and they vetoed; they accepted MOU and the insertion V of that clause because, obviously, they did not want organisations are committed can be more e ective to be contractually bound. than a legally binding document that means people giving more money to lawyers; but that requires not only those who are signatories but those who Q43 Mr David Jones: To paraphrase Sam Goldwyn, provide the funding to be committed as well. At the it might be fair to remark that a non legally- level of regional government and central enforceable document is not worth the paper it is government departments, do you think there is written on! suYcient recognition to the binding but not legally Mr Read : I do not think that is true because binding nature of the agreement to which you have dialogue is happening in a way that it did not referred? happen before. Mr Read : I think there is in a sense, that this document has also been signed by the Government Y Q44 Mr David Jones: But unenforceable dialogue! O ce for West Midlands and Advantage West Mr Read : Except it is a public document that Midlands; but I am concerned, following the sub- organisations have signed. The job of the Core national review at the end of the Regional Assembly, OYcers’ Group that I chair is to monitor and to be as to who in the West Midlands might take the lead able to flag up those who are not honouring the in making sure this happens. At the moment it sits agreement. If they have taken the trouble to sign the very squarely with the Regional Assembly. When agreements, we may not be able to take them to there is no longer an assembly I would hope that they court, but at least we can point up that they are not would be able to take it on board, but I think that is fulfilling the expectations. an open debate.
Q45 Mr David Jones: Perhaps that should be said Q48 Mr Martyn Jones: As a Committee, we have to very publicly and very vocally. find some answers to problems that we have Mr Read : Yes, it is on the Web; who signed it is on instituted the inquiry for in the first place, and with the Web, and we have an annual conference at which your spiritual connections we are hoping you might we will monitor progress. People bought into it, have some answers! Are there suYcient mechanisms although they are not legally bound to it. in existence within the public services to identify and Bishop Priddis: It is a moral force at least and it is a resolve cross-border issues? move in the right direction. We sympathise with Mr Read : No. What concerns me is that the you entirely. thematic group that is being established for health Mark Pritchard: I was thinking that if we had and social care will identify local solutions. The treaties rather than understandings, paradoxically issues are reasonably well known, but they will not we might have had fewer wars! Chairman: Order! Is this a supplementary or not? necessarily be able to feed that back into policy developments within the Welsh Assembly Government at regional level or national level. I Q46 Mark Pritchard: It is a supplementary. Given think we will come up with some answers, but I do everything that has been said thus far this worry about our ability to see those answers morning—and it is not a political question or even a delivered. philosophical question but it is pragmatic in terms of delivering more healthcare for the people in Wales— do you think that more devolved power in healthcare Q49 Mr Martyn Jones: Is there a suYcient level of to Wales would be a good thing, or perhaps a bad research currently being undertaken on the impact thing? of cross-border issues? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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4 March 2008 Bishop Anthony Priddis, Mr Nick Read OBE, Bishop Dominic Walker and Mr Robin Morrison
Mr Read : No. that drives the policy-making, the systems can be BishopPriddis: No. found. What is needed is a language and clarity Mr Morrison : There is an awareness of the issues, about the need. If we do not keep insisting on it, it clearly, and diVerent bodies from the NHS may be that you need local solutions. Maybe one Federation, the two diVerent professional bodies, hospital trust, if it were given the freedom to find its are aware of this and will all have their spin on it. As own solution of how it treats English and Welsh to independent research, I am not aware of any at all, patients equitably, could come up with some but I could well be wrong—not that research solves interesting suggestions. Whether or not that would all the problems, of course. be acceptable within the hierarchy of what happens to governance boards in hospital trusts is another Q50 Mr Martyn Jones: It would be good if it did! issue. That is a systemic issue and it needs sorting. Even if we do not know what the problems are, if you Mark Pritchard: On a point of information, I am not do not know of research, that is worrying. sure whether, gentlemen, you are aware of the new Mr Morrison : There is a question mark about the sub-regional working arrangements, with the kind of research in relationship to patients and dialogues going on at the moment between hospital functioning and so on, because there are Shropshire and Herefordshire, to work at sub- various interests at stake here, and I would be quite regional level on a range of issues, health being one careful about the way research is set up. of them. I encourage you to find out a little more about that; it is breaking news at the moment. Q51 Mr Martyn Jones: The $64,000 question: how Chairman: We have almost come to an end. We have could cross-border issues best be identified and started this inquiry with health, and you have largely resolved; and, as part of that, do you know of any spoken about health, but at the beginning you examples around the world where this is happening? alluded to a number of other policy areas where Mr Read : I do not know around the world. There is there seems to be a policy divergence. Would you a very useful local thing: the Shropshire Pathfinder write to us and tell us your experiences of those Project, which is about delivering services. situations where there is a practical impact of that Shropshire was the West Midlands pilot project and policy divergence, rather than opening up a there was one in each of the English regions. That discussion with you now? In thanking you for giving certainly identified cross-border issues as important evidence and also for your written evidence, could I and came up with some solutions involving IT for place on record my personal appreciation and also of example and access to services, which could equally this whole Committee for the way in which you have apply on both sides of the border if funding were not only represented the views of the people on both there. There are local solutions and people on the sides of the border but also engaged in a very serious whole are quite pragmatic locally about how you and deep way with the policy developments. It was make things work; it is whether the structures allow asked of me by a member of the press yesterday: why those things to work. did we begin with you! It was very clear today that Mr Morrison : I totally agree with that, and Bishop you have very strongly given the answer to that. I Dominic’s statement in terms of recommendations was very strongly reminded of the Church’s role in for action contains a key sentence about the systems recent decades, in my lifetime, and the way the needed which makes equality of care possible in Church has engaged in the big issues of our time. I whatever provider or care situation—wherever it is, am reminded of the late Glyn Simon in the late 1960s cross-border, immediate geography or elsewhere. We involved in large issues, global issues like South are not saying this is how you do that system; we are Africa, and Aberfan, and then the Church initiative saying it is not beyond health authorities and during the miners’ strike in 1984/1985, and of course individual hospitals and their governance boards to the Bishop of Monmouth in the 1990s and his do that, so long as politically, behind the scenes, engagement with steel closures. If I could say, you there is that recognition that it needs to happen. If are in that great tradition, and I thank you for that. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 12 Welsh Affairs Committee: Evidence
Tuesday 18 March 2008
Members present:
Dr Hywel Francis, in the Chair
Mr David Jones Alun Michael Mr Martyn Jones Hywel Williams
Witness: Mr Tom Taylor, Chief Executive, Shrewsbury and Telford NHS Hospital Trust, gave evidence.
Q52 Chairman: Good morning and welcome to the applying to be a foundation trust now we have got Welsh AVairs Committee and our inquiry into cross- back into balance and we are very keen to make sure border provision of public services for Wales. For that the whole catchment population is treated the record could you introduce yourself. equally. I have said in the written evidence we have Mr Taylor: I am Tom Taylor, Chief Executive of the worked proportionately on that total 500,000 Shrewsbury and Telford NHS Hospital Trust. population in terms of members for our council and therefore there will be two Welsh members for our council, there will be 14 English, because Q53 Chairman: Could I begin by asking you a very proportionately that is how it works out and we have general question about the impact of devolution on oVered a place on our council of governors to health services in your region, have you found it to Montgomery Council; we have oVered a place to have been positive or negative? What kind of Powys Local Health Board, so we are completely challenges are before you as a consequence of it? open in everything we do cross-border, but it does Mr Taylor: The key challenges for an acute provider put in a level of complexity. trust down the border are in having two funding streams and having diVerent sets of targets for diVerent groups of patients. My catchment area is Q54 Alun Michael: In the first place could you say a 440,000 people in England and 60,000 people in bit more about the health service that your trust Powys, and eVectively we have to operate with provides for Welsh patients, the shape of the services diVerent funding systems and diVerent waiting that are actually provided and the proportions. You times, and that obviously causes an administrative referred to proportions a moment ago. I take it that burden on the trust making sure we meet the is in terms of population; what about proportions in diVerent targets for the diVerent commissioners. I terms of the care that you provide being consumed, think it is diYcult for clinicians who go into medicine if I can put it that way, by patients on either side of to treat patients who are ill to say, “If you live this the border? side of the border, I will treat you in 18 weeks, If you Mr Taylor: In terms of the financial volume of the live that side of the border I can only treat you in 38 contract, which is one way of putting it, Powys is the weeks,” so I think there are real issues there. We third largest of my commissioners. My two English work hard as a trust. I have been Chief Executive for primary care trusts, Shropshire County Primary 32 months and we had a £34 million historic deficit Care Trust and Telford and Wrekin, are by far the when I went there, which is the reason why I went, biggest, so the total Powys contract is just under £15 and I have worked very hard over that period to million out of a total turnover of £215 million, but I work with all commissioners—English and Welsh— am very clear that although 15 out of 215 is a small to ensure that whatever the diVerent policies are, the proportion, it is still the third largest and in any patient gets the best service the patient can. That is business—and I have worked in both the private and what we are in business for in running NHS trusts so public sector—and why would you want to fall out we are very keen to work as an acute trust on the with your third largest customer, is my view on life. original founding principles of patients being treated We do not treat them any diVerently because the on the basis of need, not the ability to pay, and that value is smaller. There is a key issue for that is the ethos we put through the organisation. Subject population: within the Powys contract there are two to the limitations of the contract, we try very hard to main elements, there is a general contract for general make sure that you do not see a specific diVerence hospital services which is about £13.5 million and either side of the border, but it is within certain there is an orthopaedic contract which is just over parameters because there are targets set on me as a £1.2 million, a slightly separate one. The key issue in chief executive and accountable oYcer and there are the main general contract is that half of that contract targets to get the organisation back into financial is for accident and emergency services, and that balance—and we will have a £4.1 million surplus this population really cannot go anywhere else other year—and at the same time achieve all the targets, so than the Royal Shrewsbury Hospital. You could not it is diYcult. I have run a large acute trust in go to CardiV or Swansea and it is not easy to get to Birmingham where therefore you are in the centre of Wrexham or Aberystwyth so we are a key provider. England and you are only dealing with an English Also for the Welsh Assembly specialised purchaser, catchment population and none of those constraints we have a £1 million contract with Health or diYculties apply, so it adds a layer of complexity Commission Wales which is mainly for renal dialysis to the situation. I am going through the process of services in Shrewsbury and also for fertility services Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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18 March 2008 Mr Tom Taylor and there are some smaller contracts as well, £40,000 between people in Telford in the furthest east part of or £50,000 but those are the main contracts that we my English border and people in Powys. That is not have. my way of life. My way of life is those 500,000 will be treated exactly the same, and I am very clear Q55 Alun Michael: Is there any imbalance between about that. In terms of engagement, as we are going contract and demand? through (and we are still waiting for the application Mr Taylor: No, there is not an imbalance between process to be a foundation trust) I have established contract and demand. The imbalance across the very early on in this process what I have called a border is the value that I receive for providing those stakeholder engagement board, and I have oVered services into Wales. If I could just expand on that a places to all the unitary and district councils in little bit for you: under the English system, which is England and in Powys. Montgomery Community called payment by results, there is a national tariV Health Council are on that as an equal member; and if there is a hip operation it has got a price Powys Local Health Board have one place; whether it is at my hospital or anywhere else. The Shropshire County PCT have one place; and Telford Welsh commissioning is still done on historic what and Wrekin have one place. To go back to what I said were called block contracts and are not subject to to your earlier question, these provide me with about payment by results. The gap, as it is referred to, in £180 million and about £15 million and they equally other words the diVerence between what I would have one place, so I am very clear about that. In that receive if that Welsh contract were under payment by engagement council I have also got all the voluntary results in England, used to be £3 million. By workers, what is called the Shropshire Partners in negotiation and hard work between Powys and Care which are all the care homes, I have got the ourselves, we have reduced it to about £2 million but, strategic health authority, so we have got all the key quite frankly, if I provided that activity in England people, and because I think there is a huge issue for exactly the same number of out-patients and in- about where business could help, I have got the patients and emergencies and not one more case, I chamber of commerce in there as well. We are would receive £2 million more. That is not Powys’ working through developing the proposals for the fault because the Welsh system only receives its foundation trust with that group so I am not saying, funding from the English system and the English “Here we are, we are a foundation trust now, we will Department of Health does not pay Wales to pay by talk to you,” I am organising it 12 months before we Y payment by results. Therefore we are in a di cult will be a foundation trust. I chair it personally as position and it is the same right up and down the chief executive of the organisation, my chairman is border. on it, one of my non-executive directors is on it; and Alun Michael: It sounds to me as if we could have my director of strategy is on it. We cannot give it perhaps more detailed information on that to look at much more weight. We are trying to develop with exactly how it works otherwise we might get bogged those people. We did 78 public presentations on the down in it. foundation trust application and I do not think there is many that have done that. We went to some public Q56 Chairman: Could you provide that for us? meetings and there were zero members of the public Mr Taylor: I can provide a further briefing on that if 1 who turned up; we went to others and there were 50 that would help. or 60. That is democracy.
Q57 Alun Michael: Could I turn to the question of the foundation trust element because you have Q58 Alun Michael: Most of us know the feeling, yes! referred already to the fact that the membership of Mr Taylor: We knew that but we set it up and we the trust will be balanced in population terms across went and we agreed as part of the strategy that I the border. Community engagement and would do a public meeting in every town on my accountability is right at the heart of the foundation patch which had a population of more than 5,000. trust approach, and some foundation trusts have That is pretty low for public meetings. We did a been very good at engaging their local community; mixture of going into people’s existing meetings, so others have been, frankly, quite disappointing. Can parish council meetings because we knew at least the you tell us a bit about your arrangements for council would be there, if nobody else was, and we achieving that community engagement and whether went into patient group meetings had public the approach will be the same in relation to the Welsh meetings, and we did councils, cabinets, staV part of your catchment as to the English? meetings and everything else. All of those were done Mr Taylor: I will answer the second part first; it will proportionately in Wales as they were in England. Is be exactly the same. I am very clear, in the building that helpful? we are in, MPs often have constituencies of 60,000, Alun Michael: Yes, that is very helpful, thank you. 80,000 or 100,000 and I have six English MPs and one Welsh Assembly Member, and it is one Labour, two Lib Dem and four Tories so it is evenly split Q59 Mr David Jones: Just a brief question, Mr across the seven, and I understand the need for those Taylor, on the question of renal dialysis. You people to look after their constituencies, but my mentioned that you had a contract of £1 million constituency is 500,000 so I do not diVerentiate per annum. Mr Taylor: The total contract is £1 million and the 1 Ev 220 dialysis part of that is about 750K. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 14 Welsh Affairs Committee: Evidence
18 March 2008 Mr Tom Taylor
Q60 Mr David Jones: From Health Commission week by Powys Health Board on community Wales? hospitals, and because they are eight and ten-bedded Mr Taylor: Yes. and there is a real clinical governance issue which was in a public report last week, that report is saying Q61 Mr David Jones: Are HCW paying you at that those services need to be provided in district precisely the same rate as English commissioners or general hospitals. It is not saying whether that is in atadiVerent rate? Welsh district general hospitals or in English district Mr Taylor: No, it is a slightly diVerent rate and that general hospitals. is for the purchase of a number of renal dialysis slots for patients that are treated in the Royal Shrewsbury Q66 Hywel Williams: Can I move on to asking about Hospital. One of the things we have been trying to waiting times. Does the divergence in waiting times work with Health Commission Wales is on the in Wales and England create pressure to prioritise development of an additional six station units at patients depending on where their GPs are and if Welshpool and we have been very keen to push that Y they are in England? forward. I understand, although I have not o cially Mr Taylor: In the contract, there are diVerent been told, that that will go ahead but it will only be maximum waiting times in the English contracts provided by a Welsh provider not by me. than there are in the Welsh contracts. The arrangement I have with my clinicians is that they Q62 Mr David Jones: You will not be providing it? will treat people on clinical priority and we will work Y Mr Taylor: I have uno cially been told that. I have round the waiting list, but clinical priority for me has Y had no o cial communication but I have been told to be the more key issue. We are very clear with our that it will go ahead and that it will be provided by doctors; treat people on clinical priority and we will a Welsh provider. If that happens then that is still manage how we work the contracts and the waiting good for the population and actually it could free up times with the commissioners, and that overlay of some of my capacity at Shrewsbury because some of clinical priority seems to me is how we get around that capacity that I am currently using at making sure that all the population gets treated for Shrewsbury would be people who would go into the clinical reasons. If there are reasons why a patient Y Welshpool unit. The di culty that comes with does not need to be seen urgently clinically then, yes, dialysis is that it is a growing population. There are it will take longer for them to be seen if they are a not enough donor organs and as people live longer Welsh patient because that is what the Welsh because of dialysis therefore the pool is growing and contract says, but on clinical safety grounds they will growing and growing. When I came to the trust 32 always be seen. months ago, the capacity in my trust was 24 stations, it is now 48 in that short space of time, and we would like six more in Wales. I would very happily run them Q67 Hywel Williams: It is just that the impression but I am not sure I will be allowed to. sometimes is that the maximum waiting times are the standard usual waiting times. Q63 Mr David Jones: Do HCW pay you less or more Mr Taylor: I am well aware of that. If you look at the than English patients? average waiting times, that is not the case. If you Mr Taylor: Less than English patients. look at the mean and work it all through, that is not the case. It very clearly is not and we can look at that. V Q64 Hywel Williams: Are there other services that It is di erent by speciality because sometimes you have problems getting clinicians. There are certain you think that might in the future be provided on a Y Wales-only basis? You mentioned a moment ago specialties where it is di cult to employ clinicians in accident and emergency being provided in that specialty and therefore inevitably at that end of V demand and capacity there is more demand out there Aberystwyth or, dare I say it, even Cardi . Are there V realistic prospects of those sorts of large-scale but it is unmet because I have not got the sta . Right changes? now, today, I have a vacancy for a dermatologist. I Mr Taylor: I do not think it is clinically safe. If there have advertised that job and I have failed at the was a complete repatriation and all Welsh patients moment to attract anybody for that. The waiting list must be treated in Wales, I think there would be can only go up because I have not got a consultant serious clinical issues around that, particularly dermatologist to see someone unless I can move because of some of the travel distances that are them to somewhere else, so there are operational involved in that, so I do not think it is. issues that sometimes mean it is not as black as white as it looks on waiting lists. Q65 Hywel Williams: Can I just interrupt you. Is anybody seriously suggesting complete repatriation Q68 Hywel Williams: That is very helpful indeed. of all services to Wales? There are ways therefore of addressing divergence in Mr Taylor: There have been statements attributed to terms of clinical priorities. Do you think in general ministers in the Welsh Assembly reported in the that waiting times should be uniform across the UK, press that say that will happen. In the discussions or at least comparable? Should we have one NHS that we have had with Powys over this year and next rather than four? year’s contract there is not a reduction in the Mr Taylor: This is a personal view, yes, I am very contract and actually they are looking to provide me clear. Devolution is not of my making but my with services. There has been a report only issued last personal view is, and I do come from the old school Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 15
18 March 2008 Mr Tom Taylor of going back to what Nye Bevan said about people Mr Taylor: The honest answer— being treated on need and not ability to pay, I do not V V see why that is di erent in di erent countries. Q73 Mr Martyn Jones: —Or is there a temptation and you do not succumb to it? Q69 Hywel Williams: I know you have only been Mr Taylor: I will be very, very honest with you in with the trust for a comparatively short period of terms of that. For the predecessor management of time— my organisation to the day I went, yes, that was true. Mr Taylor: —I have been in the NHS for a long time. That is what they tried to do, but they are all gone. Very clearly all gone. And it is absolutely not an intention of the current board at all to do that. I was Q70 Hywel Williams: In your experience, was there the fourth chief executive in 12 months and my ever any uniformity across the NHS? Were residents chairman was the third chairman in seven months in the north west of Wales able to get treatment as and there was no finance director for six months so quickly as the residents of the south east of England leadership was not strong, you could say. in the past, in your opinion, devolution or not? Mr Taylor: Devolution or not, it is always based on Q74 Mr Martyn Jones: It is very good to hear that what capacity is in which part of your country, so in because Christine Russell, one of our colleagues, the that sense devolution is irrelevant, but I do not think Labour MP for Chester, has said recently that there it has helped. is some truth in the argument that English patients are subsidising Welsh patients. Would you agree Q71 Mr Martyn Jones: You have answered most of with that? Mr Taylor: For me you could argue to the tune of £2 the questions about the relative cost and charging million, yes you could, and that is why I am saying between the two countries. In a sense you have it is within tens of millions to solve this, but there is answered most of the questions but if you use the always a flip side, because I do have this discussion term “profitability”, which is probably not the way with my English and Welsh MPs, who all come in on to do it, you implied really it is more profitable to a quarterly basis and we have a very open briefing so treat English patients than Welsh patients. we do have this discussion. If 70% of my costs, just Mr Taylor: Financial contribution is a much nicer to flip it the other way, are manpower and if this term. You can tell I am an accountant really who has contract (which it is) is worth £15 million, if I pull worked in the private and public sector! Yes, out of this contract completely and I cannot replace V inevitably, because 70% of my costs are sta costs it with a matching income from England then £10.5 and I have a fixed amount of buildings costs and million worth of doctors and nurses have got to go, V everything else, therefore if I can get a tari in and I am not sure that any of my MPs are going to England which is higher I am bound to make a agree with that, funnily enough, so we have stopped bigger financial contribution, and right now that having that argument now on that basis because value would be circa £2 million. It does need the there is a flip side to it. Yes, you can say £2 million English Government, the Department of Health, to worth of subsidy, but look at the other side, if it was fund the Welsh system to pay that money back, and not there what would I do if I had that total loss of I would think there are all sorts of issues around, income? I say regularly, and I have said this since the “Ah, but would the money come back?” et cetera, et day I went with a £34 million deficit, that I have to cetera, but I am sure they are not beyond the wit of run this place like a commercial business but it is a man. My honest view, having looked at this up and people business. I employ 5,000 people to look after down the border, is that the amount of money the health care needs of 500,000 so it is a people needed to resolve that is in the tens of millions out of business, but it was losing £10 and £12 million a year. hundreds of millions of an NHS budget. If you look Nobody in this building is going to leave any from Bristol, Gloucester, Cheltenham, Hereford, hospital open that keeps losing £10 or £12 million me, Chester, if you go up the border, the diVerence every year. I have been very public on the radio and in what we are currently getting—and there are some the television and everywhere about that and said to instances, there were bound to be for some specialist the population, “We will have to do this a diVerent services where the Welsh will actually pay slightly way,” and that is what we have done. We have now more than tariV, it is always going to be swings and got shorter waiting lists. I get 14 times more letters roundabouts but, to go back to Mr Williams’s of thanks and gifts and donations than I get problem, it should be the same across. If the English complaints. In an external survey last year, 90% of system paid the Welsh system to pay it back and the patients said the services they got from me were there was a guarantee that it came back, we would excellent or good. In terms of one and three-year not be having this discussion. It is £2 million for me mortality, mine is the best survival rates of any trust out of a £215 million budget. anywhere in the West Midlands. Even in all the big teaching trusts in Birmingham nobody comes anywhere near me for survival rates, just nobody. Q72 Mr Martyn Jones: You used the term “financial There are two rates; there is one year and three year. contribution” and you said you get a better financial If you are 100 you are average; if you are above 100 contribution from the English patients. Does that you are poor and if you are below 100 you are good. mean there is any temptation at all to align your There was only one trust in the whole of the West services towards English patients rather than Welsh? Midlands which had two scores below 100 for both Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 16 Welsh Affairs Committee: Evidence
18 March 2008 Mr Tom Taylor one year and three; that is mine. Our maternity I have £215 million and I have 5,000 staV and we services are the best. There are only 17 trusts in provide clinics and operating services and it actually England that provide what is called a level three can be that they are cross-subsidised both ways in an maternity service and we are one of them. In a recent odd sense. It would be much, much easier if the Health Care Commission review only five of those English Parliament simply paid the Welsh got top marks out of 17 so the maternity services we Parliament at English tariV rates. We all know the provide are the best five in the whole of the country. activity. I can tell you exactly how many spells and We are proud of the services we provide. The staV are cases were emergencies and everything else. That is proud of the services. They have worked their socks why I know the gap is £2 million because I apply this oV with me to turn this round in the last 32 months activity to the English tariV and then look at the for the whole population, for all 500,000. I could not contract and say what is the gap, so it is very simple; runitontwodiVerent levels (subject to the contract if the English Department of Health would pay negotiations obviously) and we run it as “this is how Wales that money and it was guaranteed to come we will treat all the people.” back to me, the cross-subsidy or not being treated fairly would go away. Q75 Mr David Jones: Just before we leave that last point, would you agree with me that Miss Russell’s Q79 Mr David Jones: Are you saying therefore in comment is rather odd, that English patients are your view that the Welsh health budget should be subsidising Welsh patients, in that English patients ring-fenced? and Welsh patients pay their taxes at precisely the same rate, is it not actually the case that you are not Mr Taylor: What I am saying is the element of the Welsh budget that is purchased in English hospitals getting a fair deal from the Welsh Assembly V Government? should be paid at the payment by results tari and Mr Taylor: You could argue that it is not Welsh ring-fenced accordingly. patients that are subsidising, it is Welsh commissioners, that is the fairest statement, but the Q80 Mr David Jones: And could not be used for any English are subsidising Welsh commissioners other purposes? because of the way the financial system operates Mr Taylor: That would be my view. between England and Wales.
Q76 Mr David Jones: Getting back to my Q81 Mr David Jones: In your professional opinion, substantive question, though, would you agree that would it be viable for Wales to provide all health care you are not getting a fair deal from the Welsh services from within its borders? In your opinion, is Assembly Government? there suYcient critical mass? Mr Taylor: I am not getting a fair deal to the tune of Mr Taylor: No and I think there are two things: there £2 million. is not a suYcient critical mass and the geography. If you look at the Powys population particularly and Q77 Mr David Jones: You have referred in your the scarcity of the population I think the distances annual report to the extent to which you are travelled would make it clinically unsafe. dependent on the continued referral of patients from local health care commissioners included in whom Q82 Mr David Jones: Clinically unsafe? are Powys Local Health Board. How would your Mr Taylor: Clinically unsafe, certainly for our A&E V trust be a ected financially if services for Welsh services it would, absolutely. patients were provided within the borders of Wales and not at your hospital? Mr Taylor: It is very simple, it is coming back to the Q83 Mr David Jones: And half the contract is earlier answer, if I were to lose £15 million, which is A&E services? what I get from Wales, just from Powys (it is £16 Mr Taylor: Judith Padgett, who is the new Chief million if you add the Welsh Assembly), and I still Executive of Powys Health Board, was very clear have to make sure I am in financial balance, if I four weeks ago. She attended a meeting called by the cannot recover that £16 million from English West Midlands Strategic Health Authority who were providers—and I make it very clear, I would not be reviewing our foundation trust application and able to recover all 16 of that from England—all I can Shropshire County and Telford and Wrekin and do is what any business would do then, I have to cut Powys were all called in with me and sat in the room my costs accordingly, and as 70% of my costs are with me to tell the health authority exactly what they manpower, the impact will be job losses, very clearly. thought of us, and Judith was very clear, she said that whenever she talks to Welsh Assembly Q78 Mr David Jones: And a reduction in services? members, whenever she talks to her council Mr Taylor: There is bound to be. This actually cross- members, whenever she talks to the community subsidises both ways because enabling that £15 or health council and more importantly whenever she £16 million enables me to provide staV which in talks to the patients, the Royal Shrewsbury is their some specialties might provide more services to hospital of choice. That is the issue. It should be England than they do to Wales because I do not allowed to be their hospital of choice. pocket the money into separate pockets and say, Mr David Jones: I am pleased to hear that, my wife “You are a Welsh nurse, you are an English nurse.” was trained at the Royal Shrewsbury Hospital. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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18 March 2008 Mr Tom Taylor
Q84 Alun Michael: The partnership between your Mr Taylor: I could not possibly say that. The reason trust, the Welsh commissioners and the Welsh it has changed and, if I am honest, the reason I chose Assembly Government, we have heard in previous to leave the SHA and come and do this job was evidence from the bishops about the importance of because the SHAs were going down from 28 to ten, developing that sort of partnership. Can you tell us they were going to be much more hands-oV and how that partnership works in practice and whether much more strategic, and that is not what I wanted those arrangements are suYciently --- I am not sure to do for a living, frankly, so I volunteered to go to if robust is the right word, but do they work in the this what was known as a basket case. Well, it was, way that you feel is needed or is it still a work in let us be honest! When Pat Hewitt was Secretary of progress? State for Health and had 18 category 1 turnaround Mr Taylor: If you just separate Powys Local Health trusts, the worst 18 in the country, we were fourth Board for now. When I came 30 months ago I went worst with a £34 million debt. That is why I went to down there and the previous relationships were so do this turnaround. But inevitably because there are poor that the then chief executive said, “That is a now only ten strategic health authorities and they first, that somebody from your organisation has cover the whole of the West Midlands (and it used to walked through the door,” and that is only 30 be one, then it went to three, and it has gone back to months ago. There had been an arbitration the one). When there were three in the West Midlands previous year when there had been a diVerence of you could be much more hands-on and you could opinion on the contract to the tune of £2 million resolve problems much easier. What has happened which had gone to Department of Health and the of course is—and it is well-documented—they have Welsh Assembly, and they decided that it should be gone from three to one and reduced staV £1 million to England and £1 million to Wales. I said significantly so inevitably they are more hands-oV. to Andy who was the then Chief Executive, “If you There are fewer people to do more of the and I ever get to arbitration we have failed and we performance management. Because a number of the Y should not be accountable o cers. If we get to this trusts are moving towards and have become again we have failed.” so we have had that foundation trusts and are therefore under Monitor, understanding and it has carried on with Judith, and so the regulator is Bill Moyes, then the SHA’s view Chris Mann, the chairman, meets my chairman on a has been, “We need to manage the primary care separate basis so we have worked really hard and I trusts, not the acute trusts and the mental health have no absolutely no problems whatsoever with the trusts.” The problem at the moment is we are in arrangements with Powys Health Board. Jill Todd, transition because places like mine have not got to be who has just retired as clinical health, and I worked a foundation trust yet so we still do report to the together in Birmingham so we worked hard together. SHA but the SHA has already had to lose all the staV It is inevitably more distant, and not just in a to be hands-on with us so we are in this transitional geographical sense, with Health Commission Wales phase where we have not yet got to be where the because in terms of Health Commission Wales, at £1 SHA will only manage ten PCTs because there will million, I am very, very small beer so inevitably the not be any acute trusts because we will all be relationship is not as strong. Peter Shanahan, who is foundation trusts and we will all be under Bill the West Midlands SHA finance director, and GeoV Buggles who is the Welsh finance director, I went Moyes. with both of them down to CardiV a few weeks ago and one or two other purchasers and providers to try Q87 Alun Michael: That implies that you would see to cement a stronger relationship, so that is starting the SHA as having a more hands-oV and less of a to come, but it is nowhere near as strong as the direct direct role in the future than at present? one-to-one relationship with Powys. Mr Taylor: Yes.
Q85 Alun Michael: What about the role of the Q88 Alun Michael: Right, and one of the pieces of English strategic health authorities in resolving any evidence we had was the importance of having, as I cross-border issues—you referred to them in passing say, the partnership developed through a health there—should they have a bigger role or do you protocol across the border. Have you been engaged think the role is about right? in that process? Mr Taylor: As the former deputy chief executive of Y Mr Taylor: We have with Powys. We have a strategic the strategic health authority I have some di culty board that meets every couple of months. I do not do answering that question but, nevertheless, I will. that. I have tried to say we should put that a bit lower David Nicholson, who is currently Chief Exec of the down but we do have bi-monthly meetings with NHS, and I used to run West Midlands SHA (or Powys which largely monitor the contract and what Birmingham and Black Country) so I have worked are the strategic directions, so that does work very with David, and in Shropshire and StaVordshire well with Powys, and in England there are strategic before that with Bernard Crump. I think it is partnership boards which are local authority, fire, diVerent to what it was 32 months ago when I was police, health, everything, I sit on two for my sins, I there and that is because there used to be 28— sit on Shropshire County and I sit on Telford and Wrekin, so we have got the experience of working Q86 Alun Michael: —You mean it is not quite such and we can take a lot of that experience in England an important body any more! and try and mirror what we do in Wales. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 18 Welsh Affairs Committee: Evidence
18 March 2008 Mr Tom Taylor
Q89 Alun Michael: That would be looking to the on me but that is one. The second is the waiting links between diVerent organisations that have a times, and in England we are working to a maximum need to work together in relation to separate local from first GP referral into the hospital, through out- authority areas. You will understand the evidence we patients and into diagnostic phase, so X-rays and had last time was coming from the bishops and tests, and operation, of 18 weeks by December of therefore looking much more at the community’s this year, which is challenging, but we have worked view of things and they spoke quite optimistically on that, and in Wales that is coming down from 34 about the nature of the developing understanding of weeks for in-patient and out-patient to 22 weeks, protocols? and the final one for 2009 is 13 weeks for each Mr Taylor: Let us be honest, this only ever works element, so the diVerent waiting times is the key around people, does it not? I can talk all the numbers policy one. The other one is simply the way it is I want about half a million patient contacts and £200 funded. I go back to payment by results versus block million turnovers and all this but none of it works on contracts. The funding stream is the key single issue its own; it only works around people. If you have got for me. the wrong people in the wrong jobs they will never work together. If you get the right people in the right Q91 Chairman: Do you think that those divergences jobs you will get a chance of this working. We have could be or should be addressed by this health taken that view. We have had that very open protocol that has been discussed between the English discussion with the Welsh and said, “Look, we have and the Welsh health ministers? The Secretary of got to work this together.” and that is where we are. State for Wales was before us last week and he was Yes, it is developing but it is a lot better than it was. saying this is making some progress and is likely to The Shropshire one is interesting because that is be published soon. Are you part of that process? actually chaired by the Bishop of Shrewsbury so we Mr Taylor: No, I am not part of that process. From all behave! what I have seen of it, it is too high level to have a real impact on the funding stream. Unless it actually addresses the funding stream then it will not address Q90 Chairman: Mr Taylor, we began this session by issues. That is my very clear professional view. asking you about the impact of devolution. If we can be a little more precise at the end of this session and Q92 Chairman: On that realistic point, I will thank ask you where are the major policy divergences you for your frankness this morning and also thank between England and Wales and how does this you for your written evidence as well. I look forward impact on yourself and on services to the to receiving the other evidence which you community? mentioned earlier. Mr Taylor: The first major policy divergence is one Mr Taylor: I will provide you a briefing on payment 2 that does not have a major impact on me but is free by results. prescriptions in Wales, and £6.85 or whatever it is for an item in England. It does not have a major impact 2 Ev 220
Witnesses: Ms Jo Webber, Deputy Director of Policy, NHS Confederation, and Mr Mike Ponton, Director, Welsh NHS Confederation, gave evidence.
Q93 Chairman: Good morning. Could you England where partnerships between state and introduce yourselves for the record, please. private providers work together whereas now, even Ms Webber: My name is Jo Webber and I am Deputy more than ever in Wales, the statement has been that Policy Director at the NHS Confederation. it will not be that way and the market-place will be Mr Ponton: I am Mike Ponton, the Director of the put to one side and a diVerent approach will be Welsh NHS Confederation. made. There is also famously compared the policy of “Voice” versus “Choice”, so in England there is Q94 Chairman: Thank you very much for that and choice but in Wales it is rather more about working thank you for coming along today to this session. with the citizens and the community about shaping Could I begin by asking you about the impact of health services around them, so those are the two devolution. Could you describe to us briefly what clear ones, and then of course payment by results impact devolution has had on the development of and particular policies like that you have heard policy and the delivery of services in Wales? about. Mr Ponton: Clearly devolution has had an impact because in Wales we are adopting diVerent policies. As I was listening you were already talking about Q95 Alun Michael: Could I just follow up your last things like waiting times, but basically I think one of statement there before going on to another question. the principal reasons about health and devolution You say it is more about working with the citizen in was that, in Wales at least, you could shape health the community, but of course the creation of NHS services around the needs of Welsh people and Welsh foundation trusts is very much about the communities. There are some stark diVerences accountability of the hospital trusts in and their beginning to materialise, particularly in terms of the engagement with the local community and that is market-place and the pluralistic-like approach in not a part of the approach in Wales, is it? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 19
18 March 2008 Ms Jo Webber and Mr Mike Ponton
Mr Ponton: The approach in Wales, certainly Mr Ponton: On patients? In terms of specialist following Beacham, is that with all public services it services, patients have always had to travel. The has to go much closer to the people it serves, and I impact here is whether it would be possible to build think the reaction to foundation trusts in Wales is services in Wales to avoid so much travel, and I think that the concept of mutuality is very interesting and that what should be the spirit (and I have read that the establishment of members and members voting it is) behind this all-Wales policy is an intention to for governors and so on is interesting, but part of the make things as easy as possible for patients against one-Wales approach, as far as I understand, is to getting the highest quality and safest care. look at the governance of the NHS as part of strengthening engagement with the citizen. Q101 Alun Michael: That ease of access must include the cross-border elements as part of this so that Q96 Alun Michael: So you will be looking with would be, as you see it, very much a part of what has interest at the impact of the developments that we developed in terms of patient choice? heard in the previous set of evidence? Mr Ponton: Very much. Mr Ponton: I cannot see that Wales could be completely self-contained. There are always going to be specialist services that need to be provided Q97 Alun Michael: To what extent are health services elsewhere, but the other side of that is that specialist currently provided for and accessed by Welsh services become less specialist in a sense as patients in England and vice versa? Perhaps you technology and science improves and then you can could tell us at the same time has the proportion of bring services much closer to people. services provided on a cross-border basis changed over the last ten years during the period that we have had devolution? Q102 Alun Michael: Could we ask about the data. Is Ms Webber: I am not sure I have information about there suYcient data currently available on the extent the proportion of services that have changed, the to which cross-border health services are provided flow, but obviously there are the issues that you were and the choices that are made by patients cross- hearing in the last set of evidence around the funding border? Do you collect such data and is it adequate? streams and the Choice agenda which has meant that Ms Webber: Individual organisations will obviously there is a diVerence between the diVerential access, if collect that data because of the funding issues and you like, in terms of the waiting times and also in particularly the English hospitals and the way in terms of the funding streams. which they get their funding, so I think the data is probably there but whether it is aggregated and Q98 Alun Michael: What is that diVerence? collated together, I would say probably it is available Ms Webber: As you heard before, there is a but it will take some work. diVerence between the Welsh experience in Welsh hospitals of a 26-week maximum waiting time and in English hospitals working towards the 18-week Q103 Alun Michael: The data is not much use unless maximum waiting time. it comes in a form that helps to inform decisions, and one of the dangers is that you have got very good information on both sides of the border but not Q99 Alun Michael: Yes but forgive me, that is about about the community that straddles the border. esoteric things being done in the management within Mr Ponton: Perhaps I could explain that we do not the service rather than what happens to patients. It collect data; we of course represent health is those diVerences I think I am trying to get to. organisations that would, and I have seen data Mr Ponton: We cannot separate this discussion from recently in preparing for this that shows that the way that medicine is changing and the NHS is certainly in Wales we have figures of the number of changing, so your question about the proportion of Welsh residents that are treated in England, and I am care and the movement of patients is changing, and sure that Health Commission Wales will have I think that traditionally in Wales for some things, information about the patients that they refer to particularly specialist care, there has been a west to English hospitals. I am sure also that English east patient flow and that applies to north Wales and systems will be able to show that and I am sure that south Wales and mid Wales, as we have been hearing. in some ways there will a tie back to certain That is changing because of the issue of critical mass communities. Both countries of course are which we have heard about and also the ability to developing new information systems which will be sustain very specialist services. I think that the diVerence now is that the current Minister of Wales much better and much more flexible in interpreting is challenging the assumption of critical mass and and providing information. patient flow and so that is now part of what you might call the hot debate in Wales about how our Q104 Alun Michael: It does sound as if there is work relationship with England and patient flows might that needs to be done on making sure that the change. available data is collected and expressed in a way that allows us to understand what is happening Q100 Alun Michael: What is the impact of that on across the border. patients? Mr Ponton: That has to be right, yes. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 20 Welsh Affairs Committee: Evidence
18 March 2008 Ms Jo Webber and Mr Mike Ponton
Q105 Mr David Jones: You mentioned at the Ms Webber: Certainly from the English point of beginning of the overview of your submission to the view, yes, they are the same issues. As we said in our Committee that devolution has created four evidence, there are some key issues. From what we diVerent health systems in the UK. That seems to be heard—and we came part way through the a theme that the NHS Confederation is developing evidence—the issues that were being pointed out will this year because I think that was a statement first be ones that I think will be generalisable on the made by Dame Jill Morgan in an interview on 4 English side of the border. I do not know what you January and you appear to be repeating it, and when think, Mike, about the Welsh side of the border. people repeat things I usually think they are doing so Mr Ponton: The issues are the same and we know for a reason. Do you think that this is a good thing from a Welsh commissioning point of view that the or a bad thing? issue of block contract against tariV is a real one in Ms Webber: I do not think you can say whether it is negotiating services, but also there is the other issue good or bad at all. It takes years for the systems to about the diVerence between in Wales of Local V embed and therefore it is going to look di erent in Health Boards looking after resident population V di erent places for quite a while. In terms of some whereas PCTs look after registered population, but comparators though, it is very interesting that places the fact is in a lot of places along the border there is V have focused in on di erent areas as their main either choice or there is not choice. In some places V priorities. As Mike was saying before, the di erence there is a choice to either register with an English GP between the Choice and Voice agenda is a Y V or a Welsh GP but in some places it is very di cult fundamental di erence between the English system to exercise that choice because they do not exist, so as it is at the moment and the Welsh system. I think it is quite a mixed picture. it will take time to really see how the health systems develop and what the strengths and weaknesses are of each system, but the one thing that you can say is Q109 Mr David Jones: In your experience, how is that this means that they are more responsive to the that choice being exercised? Are Welsh patients local needs as they have been gauged. living close to the border more likely to register with an English GP? Y Q106 Mr David Jones: That is the point because, Mr Ponton: I think it is di cult for me to say. I do frankly,Choice and Voice does not mean anything at not think there would be any evidence there. I would all to a patient, does it, it is an irrelevant have thought that it is access and reputation as philosophical concept. What matters to the patient everywhere else that dictates where people will surely is the service that that patient is receiving, and register. in terms of impact on, let us say, patients in the border areas, would you say that the divergence of Q110 Mr David Jones: You say in your policy has been good or bad for the patient? memorandum that health services across the UK Y Ms Webber: I think again it is very di cult to say will continue to diverge in the future. Do you think whether it has been good or bad but what we can say such divergence will eventually lead to a divergence is there is something about two people living next V to an unacceptable degree in the service provided to door to each other with access to di erent kinds of patients of the NHS? health services, which is something that needs very Mr Ponton: I do not see it that way. I think that the clear thinking through because of the confusion for interesting thing of course is that health issues are the individual receiving those services as to what generic and, wherever you go, the same set of health they are entitled to or not. issues exists. They are maybe diVerent proportions and have diVerent importance to the population, Q107 Mr David Jones: That is absolutely right. For and I think what you find in devolution is a diverse example someone who lives in Saltney can actually range now of responses to those health issues. walk to Chester Cross in about 20 minutes but would be subject to a wholly diVerent health regime and that must cause confusion surely? Q111 Mr David Jones: Forgive me for interrupting Ms Webber: There is a lot dependent on where of but if you put it at its most basic, if you are a Welsh course you are registered with your GP. That is one patient and you are waiting significantly longer for a of the issues around the English/Welsh border. The hip replacement than an English patient, is that not jury is still out as to whether you could say one going to give rise to some resentment? system is good or bad. What you can say is they are Mr Ponton: With respect, I think that is one of the locally determined. transitional issues about devolution. If you look at waiting times now the gap is closing rapidly.
Q108 Mr David Jones: In terms of patients the jury may well be out. In terms of health providers we Q112 Mr David Jones: But there are people suVering have heard just now from the Chief Executive of the as we speak now as a consequence of waiting much Shrewsbury and Telford Hospital Trust as to the longer in Wales than in England. impact it is having on him as a provider. Would you Mr Ponton: But there will be people in England say that his experience is general and that other waiting longer for some things than people wait in health providers in the cross-border area are Wales. That is one of the things. You cannot draw a experiencing similar problems? standard conclusion for this. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 21
18 March 2008 Ms Jo Webber and Mr Mike Ponton
Q113 Mr David Jones: Forgive me, target waiting there are a lot of things that have been happening times in England are significantly shorter than in over the last ten years, and devolution is one of them, Wales; is that not correct? but not the only one of them. Mr Ponton: They are shorter but if you look at the performance in Wales over the last year or so, Q117 Hywel Williams: With respect, in your particularly now, the gap is becoming much submission you say that it was essentially the same narrower very quickly. I think in answer to your across the UK before 1999. question, the issue is do we regard waiting times as Ms Webber: Essentially. important across the UK, and the answer is yes, and the way one responds to waiting times is going to be Q118 Hywel Williams: I just want to clarify whether V di erent depending on your resources and the it is devolution that is causing the alleged problems services available. or not. Mr Ponton: I think that one of the diYculties in Q114 Hywel Williams: You referred in your answering that question is that across the United memorandum to the lack of clarity that has been Kingdom and across Europe health services have associated with cross-border commissioning become very, very high profile political public issues arrangements. Has this problem always existed and and of course in my case, in Wales, it is very much in what impact does it have on the quality of the care our face all the time. It is the huge talking point provided to patients? across Wales and therefore people’s knowledge and expectations have changed significantly and I think Mr Ponton: Obviously devolution has sharpened that is having an impact now on the way that we these issues because we are talking about two consider the future of the NHS and how it operates. diVerent administrations and two diVerent health systems, and you have already identified the issues that have been in the public and political mind. The Q119 Hywel Williams: One of the things that problem concerns waiting times principally, concerns the Committee I am sure, and myself in although I believe that is now starting to change, but particular, is specialist services. Is there a lack of then there is this question about what sort of services clarity in respect of the commissioning of specialist are on oVer. I think that devolution has made it very services by Health Commission Wales? Is there a clear that there will be diVerent approaches and to problem there? some they will look better over the border and to Mr Ponton: Health Commission Wales is being others they will not. I think at the end of the day, reviewed and I think the answer is yes. It was set up though, areas such as access, quality and safety are to support Local Health Boards and to undertake being treated very similarly everywhere, and so if the bits of commissioning that Local Health Boards you want to be optimistic then you would say that could not undertake individually or collectively, and although the NHS in its various parts in devolved they were always grey areas in what was countries would look diVerent, its outcomes and its commissioned by who, but now of course the very standards will be very similar. That is what we nature of Health Commission Wales, its governance should be aiming for. and its reporting lines, are all subject to review and the question in Wales is not only is Health Commission Wales the right way of commissioning Q115 Hywel Williams: I did ask you as to whether services but also is commissioning itself the right these problems and this lack of clarity had existed in term in Wales? Because we do not have an internal the past because I am concerned that some people market as such, should we be talking about better seem to think that devolution has caused a great planning and service arrangement rather than this number of problems, to the extent that the Health rather puzzling term “commissioning”? Minister from England said in an article about three weeks ago that these problems started with Q120 Mr David Jones: On that last point, I am devolution. My understanding is that that is not the interested in the funding of treatment for super rare case. You do say in your memorandum from the conditions. I was speaking yesterday to NHS Confederation that the history of the NHS was representatives from a medical charity who were essentially the same across the UK before 1999, telling me that some patients suVering from certain whereas I would think that the standard of service in conditions can receive treatment but only at an terms of patient experience was diVerent in Wales enormous cost, probably way beyond the budget, I historically for a very long time before that. would guess, of Health Commission Wales, and the Mr Ponton: Sorry, could you say that again. suggestion was that there should be a national UK- wide fund to provide funding for the treatment of such super rare conditions. Do you have any views Q116 Hywel Williams: You say in your on that, in other words, rather than it being devolved memorandum that the history of the NHS was to Health Commission Wales who may not have the essentially the same across the UK before 1999. I resources? think it was diVerent, was it not, before 1999? Is it Mr Ponton: I think devolution has set the scene down to devolution? which is that the Welsh Assembly decides how much Ms Webber: I think that is very diYcult to say. I am of its money is given to health, and one has to make afraid that my knowledge of the Welsh health system very diYcult decisions about what one does with it. before 1999 is extremely limited, but I would suggest There are always going to be very emotive and very Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 22 Welsh Affairs Committee: Evidence
18 March 2008 Ms Jo Webber and Mr Mike Ponton diYcult and often individual decisions about that. I acceptable service to patients, and other times it will do not see how making it a UK-wide fund would not, and I think the issue in your part of the world is make that any diVerent. It would just mean that what are the advantages of patients having to travel similar pressures were dealt with at a higher level. I to south Wales against travelling east to England, do not think you can have a devolved health service and I do not think anybody can produce any new and avoid making those very diYcult decisions, so, policy which does not take full account of that and no, I do not see the advantage of that, I have to say. convenience to patients and their families.
Q121 Mr Martyn Jones: You will be aware of the Q123 Mr Martyn Jones: There is another aspect of statement by Edwina Hart, the Health Minister in this of course that there might be knock-ons for the Assembly, that elective neurosurgery was going English providers. to be directed to Swansea and CardiV, and that Mr Ponton: Sure. created some concern in north east Wales, as you might imagine. It has since been backtracked on Q124 Mr Martyn Jones: Can you give me any considerably but would you consider in general instances of where that might happen, of unintended terms that the idea of Wales providing services on an consequences of this policy for English providers? all-Wales basis would be a viable proposition? Ms Webber: Of? Ms Webber: I think there has to be a certain amount of pragmatism about this, and certainly in terms of Q125 Mr Martyn Jones: Of repatriating all the patient care the main thing is to get, particularly with services within Wales. You have already said it is not those conditions where the treatment is time actually going to happen but if there was any move sensitive and some emergency situations, the right towards that, there might be knock-on consequences treatment to the patient at the right time, and I think for English providers and what would they be? a system needs to be able to enable that to happen, Ms Webber: Absolutely. As your last evidence so if there is an issue about getting to a certain place session was pointing out, there are some people who in a fast enough time to allow treatment to be most have reasonable-sized contracts with Welsh health eVective, then I think that needs to be allowed within boards to treat patients in English hospitals and they the system. Echoing what the last witness said, in obviously would then be looking at what their terms of knowing whether there is a safety issue, funding would be if those patients were removed there is an issue here and there is a feeling, from their funding stream, and that is an issue there particularly by some senior clinicians on the English because there is a knock-on impact on critical mass side of the border, that what they do not want to do in some of the English hospitals. I am not saying that is put patients’ lives or recoveries in jeopardy the system would fall apart but it is going to be an because of moving them from one part of Wales to issue for English providers if they do not have those another. contracts as part of their work. Mr Ponton: I have been reading some of the press Mr Ponton: I think we should be clear about this, statements and the sort of things you find on too, that health services are changing dramatically in websites about what has been said about this, and it that now the question is: are hospitals the right place seems to me that there is an appreciation that Wales to care for people? Every hospital up and down the cannot be self-suYcient in all aspects of clinical care, land now has to think about what the future is and we all know that. I think what has been because specialist care is starting to look not happening is that some of the assumptions about specialist in many cases, it can be provided locally this west-east patient flow needed to be challenged and it can be provided in the community. Every because, as I have already said, as each week, month, hospital has to think about what is its niche in the year goes by medical care changes, and makes it future and like any other organisation it has no right possible to do more locally. The issue that I think we to expect that to be given unless it has a place and a have to deal with here is what can we safely and well value for money and a role that is its specialist role. deliver close to patients in Wales, and where we Things are changing and we must not get those cannot because it is so specialist that it needs things confused. What we would not want, I think, diVerent skills and a critical mass, then it will be done is to have massive destabilisation of hospitals, which somewhere else, and that is the way of the world. quite clearly we will be dependent on for quite some time to come. Q122 Mr Martyn Jones: I can see that as a pragmatic position but there are situations for elective Q126 Hywel Williams: You say in your submission treatments where within Wales there is the ability to that the Welsh position not to adopt payment by do those procedures, for example neurosurgery in results has meant that hospitals are paid less for Swansea and CardiV, so you could have patients treating Welsh patients. Is this sustainable? If it is going there for perfectly good treatment but it would not, what do you think the consequences will be? Is be massively inconvenient for them. Is that covered the system likely to break down and when would by your statement? that likely to be, if you could look into the crystal Mr Ponton: I think our view would be this: access is ball for us? a huge issue around health care and so one has to Ms Webber: I think again it is one of those situations consider the needs of individuals in access to the where you are weighing up taking the whole of the right sort of care. Sometimes it is going to be possible Welsh patient group out of the equation or keeping to provide that in Wales and it will provide an what you have got at the moment, so I think at the Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 23
18 March 2008 Ms Jo Webber and Mr Mike Ponton moment hospitals will continue with the contracts as has been involved with, which you will have seen they have to date. I think the interesting issue is from our evidence, is how you can make that much around as waiting lists normalise, so as the Welsh clearer, because that is one of the areas of confusion waiting lists get less, whether then some of the about what packages you are oVering patients patient flow becomes less across the borders, but I depending where their GP is. think there will always be, particularly whilst the English system is one of registration with GPs and Q129 Hywel Williams: Do you have your own the Welsh system is one of residency, a flow across. figures on that particular point? We heard in earlier The hospitals see their catchment area not in terms evidence that there were 14,000 Welsh patients of political boundaries but actually in terms of registered with GPs in England and 17,000 English communities that they serve, so I think that will patients registered with GPs in Wales. I am not sure continue. Whether that becomes unsustainable in where that figure came from. Do you have your V the long term obviously depends on the di erent own figures? funding levels. If the block contract continues to be Mr Ponton: We do not have figures because, as I say, an acceptable level of funding then it will obviously our function is to support health organisations and V continue to be used, but if the tari and the block we have to use the information that comes from contract continue to diverge there will obviously be them and what government provides, but I think we some point at which hospitals need to consider this. need to know, that is the issue. Those figures are not Mr Ponton: Block contracts are not entirely enjoyed familiar to me but I cannot say that they are wrong, in Wales either. It is a very crude way of so-called and we have to know because there is obviously a V commissioning. We have talked about tari sin pressure right at the primary care level about the cost Wales for some time. What you are about to see, I of caring for people on either side of the border. That believe, in Wales is this discussion about is there a is one of the issues that has to be resolved because I better way of doing things in terms of planning and know that local health boards in Wales for example arranging for services to be provided? In that debate, feel that they are not getting compensated in the way V tari s are featuring because they also ask the that they should, and I am sure that PCTs and, as we question about value for money. It is not that Wales have heard, English providers feel the same thing. is blind to the advantages of such an approach; it is This is an unavoidable issue that we have to face up that Wales was and is still not ready for it, and a lot to. One of the options dealing with primary care on is happening to make it ready, like IT and the the border is to give patients a choice and that is to development of information for example. say if you live in Wales but you register with an English GP,you get the English package of care, and Q127 Hywel Williams: You have answered my vice versa for those in England who register with question therefore in some ways. If you are looking Welsh GPs, but then you have to make sure that at the divergent payment arrangements between people understand the choices they are making, and England and Wales, those are now being addressed I think that is one of the issues we have to face up to. gradually, you would say? Mr Ponton: Yes. Q130 Hywel Williams: Can I take that a little bit further. We have been talking this morning about Q128 Hywel Williams: Can I refer you then to people who were going over the border daily perhaps something that Mr Taylor said in the earlier to see their GPs. Do you have any information about evidence—and I do not know if you heard this but people who migrate from Wales to England and it intrigued me at the time—he said the problems of England to Wales, there are certain paths for paying for treatment over on his side of the border example, to explain the question, there are large could be addressed if the Welsh Assembly numbers of people who move into Wales and they Government was funded to the same extent as the tend to be older and they tend to have higher levels English patients were funded and it was ring-fenced. of health need, as we know. Has anyone ever Is that how you see it? assessed what that impact is on Welsh health Mr Ponton: I think he misunderstood the way that budgets? the two systems are funded because obviously how Mr Ponton: I think the demographic information is much money is spent on the NHS in Wales is entirely available. Whether that has been translated into up to the Welsh Assembly Government whereas in health budgets I could not say. I have not seen it. England it is about the Department of Health and the Government here. There is some transfer of Q131 Hywel Williams: Just lastly, you note again in money between the two, so the issue for example your memorandum that oYcials from the about local health boards in Wales having English Department of Health and the Welsh Assembly patients in their practices, and it is somewhere Government continue to work together to explore between £2.2 and £2.5 million from the Department issues arising from the interim protocol on of Health that comes to Wales to pay for the care of commissioning. What outcomes do you wish to see English patients, but one of the issues that is still on- from that on-going work? going is whether that is enough and how these Mr Ponton: The Confederation’s involvement in this experiences are changing. The call behind that is has been to help to get English and Welsh NHS how many English patients are registered in Wales organisations together to talk about the issues, and against how many Welsh patients are registered in there has been a lot of discussion about what can be England. One of the issues that the Confederation done, so they majored on this issue about whether Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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18 March 2008 Ms Jo Webber and Mr Mike Ponton patients were registered in Wales or England or not people we are serving along the border what they are and the diVerence there, and we came to what deciding on. That is not diYcult actually, it is pretty seemed to be the most practical option, being “make explicit, you have just got to make sure that people a choice, which system are you in?” That is now with know it. both the Department of Health and the Welsh Assembly Government because we are observers in Q134 Alun Michael: If it is explicit enough. that process but not active in it. They have to make Mr Ponton: I agree entirely, I think it is about how a decision about what is the appropriate option to explicit it is for the public and it is around what V o er people living along the border and what is the matters to patients, and I think there is an issue appropriate compensation financially to both sides around ensuring that they do know the full package from that. because it is about weighing up things like waiting times versus free prescriptions, it is the whole range Q132 Alun Michael: I would just like to ask a of things on which they need to make their choice. question about this whole organisation because you said that people have to understand the decisions Q135 Mr David Jones: Could I revert to the ring- that they are asked to take and the choices that they fencing point that intrigues both Mr Hywel Williams are asked to make, but behind the choices that are and me. I was a bit surprised, Mr Ponton, when you oVered to them is the whole opaque system of suggested that the chief executive of a major NHS organising the NHS and financing it, which has trust did not fully understand the Welsh funding always been opaque, apart from the small number of regime. It seems to me that he is on the receiving end people who spend all their lives working in it and of problems which arise as a result of the disparity of may or may not understand it. I would not want to funding regimes between England and Wales, and he make that presumption, the times that I have had to explained quite graphically that he is losing £2 deal with the finances of the NHS and have million a year, eVectively, as a result of this. Surely, understood more than I ever wanted to but still felt this is something that has got to be addressed and if that it was diYcult to get a grip on it. Essentially, if in fact the Welsh funding regime does not you look for instance at the Welsh health circular accommodate that at the moment, then ways must that was issued at the end of March with the status be pursued to amend the Welsh financing regime so and the direction, what does it mean in terms of as to ensure that hospitals like Mr Taylor’s receive people on both sides of the border, because it relates adequate recompense for the services that they specifically to that and appears to be an interim provide. attempt to clear up the obscure while the work Mr Ponton: I think I said that I have a diVerent continues that you have just referred to between understanding of the way that the NHS is funded in people. How are members of the public meant to Wales and I think my understanding is the right one, understand this and how are we all expected to but I am not minimising his problems in running an follow the decision-making process? organisation where he is dealing with two types of Mr Ponton: I think that is a very good question payment. That is a real problem and I think our view because it is complicated and it is complicated from is that that has to be resolved in a certain way, but a very, one might say, simple diVerence in the way ring-fencing is not the answer. The answer is making that we approach the responsibilities and funding of sure that fair, true, cost, value for money is the issue the service, and that is “registered” against at negotiations. What we are dealing with now are “resident”. It is simple but it has caused a lot of historic situations where in Wales, not just with complications in funding. Frankly, I often hear in English providers but with all providers, we have discussions about the complexities of the way that block contracts and in England they have we have organised and manage the NHS that people implemented payment by results because they see do not really care a jot about that; they want to know that as giving more control and more information on what they are going to get. value for money. I do not think in Wales that that argument has been lost. What I am saying is that it Q133 Alun Michael: Yes, exactly. is still being thought through in terms of not only Mr Ponton: That is part of our view, we need to make what we know but some of the future reforms that absolutely explicit along the border that if you are we might hear about in the months to come. registered with an English GP and you live in Wales then this is the range of services you will get, the Q136 Hywel Williams: Can I just ask you about a choice for example, that is the important thing I suggestion from the Institute of Rural Health would guess—if it is important and I think again we suggesting that there should be a Border make assumptions about a lot of these things— Commission on Health. Do you think that is against if an English person is registered in Wales, necessary and, if so, what would such a then they know they are going to get a certain commission do? package. At the moment would they know? I do not Ms Webber: I am not absolutely sure that that is think so. They will know about waiting times necessary, in my personal opinion, and I think that because that is a big deal but will they know about is because I do not see that there are any issues here the other things? No. Our advice to both the that could not actually be sorted out through cross- Department of Health and the Welsh Assembly governmental action and through using the Government is if you want a simple solution, that is protocols and being very clear about the orders at the one, but you have to make it very clear to the local level. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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18 March 2008 Ms Jo Webber and Mr Mike Ponton
Mr Ponton: We do not want another organisation; border between England and Wales have the we have got enough of those and we are thinking emphasis rather than these, what you might call, about changing that already. What we want is clarity bureaucratic issues. and equity and that should be within our grasp. As Chairman: Could I thank you both for your evidence we have heard, a lot of talk is currently going on today and also your written memorandum. If it about trying to deal with that and I think perhaps occurs to you as we progress in this inquiry there are some urgency needs to be put into that now to clarify issues that you would like to draw attention to then the situation and make sure that all the good things we would be pleased to receive a further that are happening across the border and along the memorandum. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 26 Welsh Affairs Commitee: Evidence
Monday 31 March 2008
Members present:
Dr Hywel Francis, in the Chair
Mr David Jones Mark Pritchard Mr Martyn Jones Hywel Williams Albert Owen
Witnesses: Dr Peter Enevoldson, Medical Director, Mr Christopher Harrop, Director of Finance, Mr Ken Hoskisson, Chairman, and Ms Mel Pickup, Chief Executive, Walton Centre for Neurology and Neurosurgery NHS Trust, gave evidence.
Q137 Chairman: Good morning. Welcome to the services for the whole of Wales which accesses our Welsh AVairs Committee. I could not say, “Welcome services at Walton and the North West specialised to Liverpool”, because we are visiting! For the commissioning team. record could you introduce yourselves, please? Mr Hoskisson: I am Ken Hoskisson and I am the Q140 Hywel Williams: It is just that I noticed in the Chairman of the Walton Centre. submission from Health Commission Wales they say Ms Pickup: I am Mel Pickup and I am the Chief here that “each specialised commissioning group Executive of the Walton Centre. have their own commissioning strategy for a certain Mr Harrop: I am Chris Harrop, Director of Finance procedure”. Might there be some divergence within at the Walton Centre. England for the emphasis placed on treating one Dr Enevoldson: I am Peter Enevoldson, consultant particular condition as compared with another? neurologist and Medical Director at the Walton Mr Harrop: It is possible, but that is not our Centre. experience because we only really deal with one commissioning body. Q138 Chairman: I am not sure whether you can hear us very clearly but do not be afraid to raise your Q141 Hywel Williams: It is diYcult to generalise that voices, we will not be oVended. Could I begin by there is a Welsh system and an English system which asking you the question, what impact has devolution diverge, there might be divergences within the had on medical services and do you consider them to English system as well? be opportunities or challenges or problems? Mr Harrop: I think probably the comment that Peter Ms Pickup: From a medical perspective Peter can was trying to make was about the waiting times in answer that. particular, because obviously with regards to a Dr Enevoldson: I think that it has not altered the way commissioning body we are working to consistent medicine is practised at all. It has obviously altered waiting times for the whole of England and they the system within which medicine has to be practised diVer from those in Wales. I think that is the issue. and most of that, I think, is from the clinical point of Dr Enevoldson: Those waiting times are common view around the diVerential waiting times that have within all regions of England. grown up with the system not parting company but diverging. The commissioning priorities in Wales are Q142 Mark Pritchard: You mentioned the gap has obviously diVerent from those in England and, as grown. How have you identified that gap, in what English waiting times have come down more than way, and, geographically, where precisely? Welsh waiting times, the gap has grown between Dr Enevoldson: As I understand it, if it is a Welsh them. patient registered with an English GP, then it is English waiting time targets that apply; if it is an Q139 Hywel Williams: Could I ask a supplementary. English patient registered with a Welsh GP, it is You said there was a divergence between England Welsh targets and obviously it goes with wherever and Wales. Is England uniform in its the patient is registered. commissioning? We have specialised commissioning from Wales and is there a similar body in England? Q143 Mark Pritchard: As a provider, have you Mr Harrop: There are very specialised identified particular areas in Wales that are worse commissioning teams across England, all with a than other areas? consistent commissioning agenda, so in terms of the Dr Enevoldson: I do not think we would say that, standards of performance within each contract they within our patch of North Wales they are fairly would be uniform across England. We only deal with uniform. I think I am right in saying that. one specialised commissioning body which acts on Mr Harrop: That is right. Again, we only deal with behalf of the North West of England so, in a sense, one commissioner for the whole of Wales. Although we only have two main commissions. We have the the majority of patients who are accessing our Health Commission in Wales which commissions the services are from North Wales, we provide a service Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup to the whole of Wales and our contract is for the Q147 Albert Owen: For our constituents in North whole of Wales, so there is no diVerentiation between West Wales you go to Bangor, how frequently would diVerent parts of Wales as far as that is concerned. your staV be at Bangor? Dr Enevoldson: I think in Bangor it is three days a week, in Wrexham it is three days a week and in Glan Q144 Albert Owen: Which actual services does your Clwyd it is four days a week, so there is very good Trust provide for Welsh patients and what provision there. In our English hospitals it is three or proportion of your care is given to Welsh patients? four days a week. Dr Enevoldson: The services we provide are neurosurgery, both elective and non-elective emergency; neurology, elective and non-elective, and Q148 Albert Owen: Do you see the viability of some of the neurology is provided within the centre having an all-Wales service for the treatment of and some out in the district general hospitals of Welsh patients? North Wales. We provide some neuroradiology and Dr Enevoldson: For what, neurosurgery? the diagnostic backup services to those two core services. We provide a very, very small amount of neurorehabilitation, but the neurorehabilitation that Q149 Albert Owen: Yes. we provide is just a very small amount commissioned Dr Enevoldson: For neurosurgery it is absolutely by Health Commission Wales whereas most impossible unless you are going to employ a huge neurorehabilitation in North Wales is commissioned number of neurosurgeons, such is the by the Local Health Boards so commissioned subspecialisation within neurosurgery now. Gone separately and we do not provide that. In percentage are the days anywhere in this country where anyone terms I think about 20% of our patient activity would ever contemplate having a centre, I would derives from Wales and about 16% of our patient- have thought, starting up with four or five related income comes from North Wales. neurosurgeons. You need a critical mass for neurosurgery. For neurology it is possible to provide some basic neurological care in the neurology centre Q145 Albert Owen: You have got a very large area covering a smaller population, but they always need that you cover. I notice in your submission you have to be able to plug into a much bigger centre because the Isle of Man and other large areas, so it is 20% of there are certain things which one cannot provide. the total area that you cover? You just do not have the critical mass in terms of the Dr Enevoldson: It is about 20%, yes, and we do some diagnostics or other skills to provide those facilities pain services, chronic pain relief services as well for for some patients who still need to plug into a North Wales. bigger centre.
Q146 Albert Owen: Does anybody else want to Q150 Albert Owen: The critical mass is obviously comment on that point? No. The other one is you important. What about the number that would be in mentioned that you organise satellites across North your team? Wales. Could you explain how the whole mechanism Dr Enevoldson: I think for a population like North works and co-ordinates? Importantly, you Wales you would need, I would guess, to cover for mentioned a figure of 16% of the income, how is that leave and everything else, according to the ABN organised? guidelines, probably about six or seven full-time Dr Enevoldson: I will leave the finances up to Chris, neurologists and at the present time there are ten if I may, but from the point of view of the services, days a week going into North Wales. We do not the services are organised in the same way as for our think it is suYcient, but that is what we are neurology patients throughout all our area, namely commissioned to provide. There are also the the neurologists are employed by the Walton Centre facilities available at the Walton Centre and some and they spend two or three days each out in a patients come to the Walton Centre for their care district general hospital. They go there, they do their and the other thing which one has to realise is there clinic, they do their administration and then they is—for want of a better term—a large leakage across spend a session doing ward referral work, namely if the border from, in particular, Flintshire and a patient with a neurological problem has been Denbighshire to the Countess of Chester Hospital. admitted to that hospital and the local physician We have five neurologists who go to the Countess of wishes a further opinion, a specialist neurology Chester and a lot of their clinic, probably 20%, are opinion, then the neurologist will see the patient. dealing with the Welsh population. Sometimes just the provision of the opinion is suYcient; sometimes the patient will need to be transferred to the Walton Centre. That is if the Q151 Albert Owen: My final point is when you said it severity of the condition is such or that the patient is absolutely impossible to have an all-Wales service, needs the extra expertise that is available at Walton would you say at the risk of being controversial that in terms of the other personnel there, whether it be is it impossible for the people of North West Wales medical, nursing, diagnostic or if there are certain to travel down to South Wales? treatments which are only available at the Walton Dr Enevoldson: My clinical view is that it would be Centre and those are a number of medical treatments detrimental to their clinical care for elective care. but in particular the neurosurgery which can only be For non-elective care it is just a no-brainer, practised safely in a centre like the Walton Centre. absolutely impossible. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 28 Welsh Affairs Commitee: Evidence
31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup
Q152 Hywel Williams: I am wondering about an all- Dr Enevoldson: I do not want to be shroud waving Wales what. The Minister in her statement was fairly here or anything like that, but to me I know the value precise. I think she said in the case of the adults and of that integration of care, as a neurologist, knowing neurosurgery the approach that she intends to take my neurosurgeon and the neurosurgeons I deal with. is an all-Wales one. I am a complete layman in these If I was referring a patient who had presented to me, matters. What proportion of your work is as a neurologist, to a neurosurgeon that was 150, 200 neurosurgery and what about the other work that miles away who I only ever speak to occasionally on you do? We did hear by explanation a very the telephone, I do not bump into in the corridor, I interesting presentation from Herefordshire last do not think that I could send that patient to the week or the week before, where they said that right neurosurgeon at the right time, so from the services which were commonly hospital-based at one point of view of the referral I think it is more diYcult. time were now being provided out in the community The patients themselves obviously have to do the and increasingly so. travelling down to South Wales which, I think Dr Enevoldson: I think one has to realise that everybody would agree, is quite a journey. I think it neurosurgery can never be done in the community, is quite a journey also if you are 75 and you already can never be done in district general hospitals, it can have a bit of a disability and you need to be driven only be done in big centres. The outcomes are so down there by the neighbour because your spouse much better. Neurosurgery has to be centre-based. does not drive or they themselves have a disability or In terms of neurology, we are keen to keep those bits you have to somehow try to get public transport. of neurology that can be done close to home and that These are real practical diYculties. To subject is why we run what we call “the satellite model” of patients and their carers, neighbours and extended providing neurological care to DGHs. That care is family, it is not just the patient, it is everybody not only outpatients but inpatients, ward referral having to make that trek to Swansea, have your work. We are keen to keep that as close to home as outpatient appointment, come all the way back, go possible. We are keen to provide as much as we are down then for your operation, the people who are commissioned to provide and with that it is not just your nearest and dearest to visit you and then to the consultant time but also we have been trying to come back and go back again for your follow-up get some specialist nurses, MS nurses, epilepsy appointment, to me it seems almost inhumane. I nurses to help back up the local services. think there would be a huge impact on the patients themselves. Lastly, one would have to say what Q153 Hywel Williams: I am interested in whether would happen if, for example, there was a post- you can disentangle the stuV that you must provide operative complication a week or two weeks after in hospital from the stuV you must provide in the the surgery took place in South Wales and the community. Must there be a link between the two? It patient is in North Wales? Sometimes they can be is common sense, I guess, I suppose there must be. dealt with at leisure but at other times they may be Dr Enevoldson: I think there should be a link and I more acute. Where would that patient go? Would should also say that one of the points about they travel back down to South Wales again as an neurosciences is that to get the best care one needs emergency or would they go to Walton, in which case integrated care. Neurosurgery cannot survive you then have a neurosurgeon having to deal with without neurology; some of neurology can do that patient when he did not do that original operation. That is diYcult, more diYcult anyhow, without neurosurgery,but you get the best care when Y everything is integrated. That integration comes not impossible but more di cult. about because you both need the same diagnostics, the same nursing care and the same physios and Q155 Mr David Jones: A question, I guess, for Mr things like that, but also there is that integration Harrop. Could you explain how payments for between the neurologist and the neurosurgeon. If I treatment of Welsh patients is calculated? need a neurosurgical opinion I can wander down the Mr Harrop: Yes, it is very similar to the English corridor with the scan in my hand and say, “Paul, system. We agreed with Health Commission Wales what do you think of that? How should we manage quite a long time ago that we would try and mirror this?” It is at a human level that you can integrate the payment by results process, even though Health your care and you can pick your neurosurgeon for Commission Wales do not formally recognise the right patient. It is the sort of thing that if you are payment by results. The mechanism by which we working together, you can provide proper integrated contract with Health Commission Wales is exactly V care; if you are working in di erent hospitals, then the same as it is for the English counterpart with one that breaks down. That is why neuroscience in this exception and that is, unfortunately, the contract we country, and I think in every other country, is have with Health Commission Wales does not becoming increasingly centre-based. reimburse us for overperformance. We negotiated a certain level for the current financial year, I Q154 Mr David Jones: Just to pursue that point appreciate we are in the last day of that financial further, please, Dr Enevoldson. You referred to the year, but for the current year we negotiated a question of integration of care. What in your settlement of £7.2 million and we do not receive a opinion could be the potential impact upon a patient penny more for overperformance. That is not typical having that integration, if you like, fractured as a of the system in England because obviously payment result of requiring that patient to go to Swansea or by results by definition means we get paid for every CardiV for elective neurosurgery? additional patient we see and that is on an agreed Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Commitee: Evidence Ev 29
31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup tariV basis. We have been negotiating very keenly that basis. If within their envelope they can only with colleagues in Health Commission Wales for the aVord a certain level of rehabilitation input, for coming financial year to make sure that level of example, or outpatient follow-up activity, then they performance is recognised in the future. are able to make those choices based on the information we give them. You are right in saying it Q156 Mr David Jones: For the financial year is a block contract and that makes it very diVerent in commencing tomorrow? terms of how we manage the service each year, but it Mr Harrop: Absolutely. is done on the same currency basis.
Q157 Mr David Jones: Is it as profitable to treat a Q161 Mr Martyn Jones: It is interesting to hear that, Welsh patient as it is to treat an English patient? because we have heard from other trusts that they Mr Harrop: At the moment it is exactly the same believe they are subsidising Welsh patients by pricing structure both for English and Welsh English patients. In fact, Christine Russell, one of patients. Obviously the big diVerence is when we our colleagues, said publicly, and I quote: “[There is] reach that level by which there are not any additional some truth in the argument that English patients payments for Welsh patients, we are in eVect [are] actually subsidising Welsh patients”, and reducing the unit price for everybody who we see another of our witnesses said that English patients within that total contract. are subsidising Welsh commissioners. Do you agree with either of those statements to any great extent? Q158 Mr David Jones: On a per capita basis, it is Mr Harrop: This is a personal view, I suppose, and, potentially more profitable to treat an English based on what I just said, I do not believe that to be patient? true to any great extent for the Walton Centre. Mr Harrop: Potentially, but I would not put too Obviously you have heard there is a half a million much emphasis on that because the level of pound level of overperformance that we are not significance is fairly low. currently being reimbursed for. I think you can form your own view about whether or not that constitutes Q159 Hywel Williams: How much is the overall subsidisation for the English commissioners. performance worth? Just to explain, when we had Whatever your view, it is not that significant for the the Herefordshire people over they said the dispute Walton Centre. was about two million which within a global spend of however many billions that is, it is Q162 Mr Martyn Jones: That is interesting because I inconsequential? How much is it worth to you? How think probably other trusts would like to talk to you much of a loss are you making do you reckon? about how you are dealing with it. Mr Harrop: For us it is about half a million for the Dr Enevoldson: One of the points is if we are dealing current financial year which is about 1% of our total with Health Commission Wales in a very specialised turnover. subject we can provide across a relatively restricted number of service lines whereas I think if you are Q160 Mark Pritchard: Perhaps I misunderstood the dealing with a Local Health Board providing care over a huge number of lines, then that would be commissioning and the financing process, but I Y thought that for English patients there would be per more di cult. We have only basically got three patient as an agreed tariV whereas for Welsh patients services and two of them are divided into elective and V non-elective. I think that might explain some of the it is an agreement for a block tari , so I am intrigued V by your earlier reply that basically they bring in the di erences, I am not sure but, having read that same amount of money. evidence which was given to you and knowing our Mr Harrop: The decision we took about 18 months situation, I think that might explain something. It ago was to try and mirror the English payment by might do, I do not know. results system so although the contract, as you say, is a block contract, we said, “Well, if we look to Q163 Mr Martyn Jones: It probably does, it going to payment by results by shadow form, what certainly seems to. The next question I was going to would that look like?” The value of the contract was ask you was how do you get out of it, but I think you not that dissimilar to what we had been working have got out of the impasse because you have the with previously, so we thought this is an ideal time to specialised service provision. implement the same kind of tariV system, the same Dr Enevoldson: I think so and perhaps there have pricing system, for our Welsh patients as well as our been quite good relationships with Health English patients and it was within the financial Commission Wales and both realise that we are in envelope that Health Commission Wales had at the it together. time. Although, on the one hand, you can say, “This is a block contract and thereby it is a diVerent system Q164 Hywel Williams: I did read out the quote from to the English system”, we are actually using the the Minister earlier on. I wondered has the apparent same currencies and the same contract mechanism, uncertainty had any eVect on your forward so in other words we identify it by speciality level and planning, financially or whatever? by point of delivery so we classify it as outpatient, Ms Pickup: Yes, it has. Whilst clearly the Welsh inpatient, critical care and rehabilitation. We are Assembly does not recognise as a policy the concept able to provide a very high level of detail to our of foundation trusts, we are pursuing an application commissioners and they can then make choices on to become one of those and, as a requirement of that, Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 30 Welsh Affairs Commitee: Evidence
31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup we have to outline our forward plans for the next five been waiting considerably longer than that”. We years. Inevitably, the announcement from the have to be cognisant of that, be very aware not to Minister last July essentially gave us a financial risk. inflame or exaggerate that situation and when To be able to forward-plan on the basis of that and people do come armed with a full and certain mitigate against it is a particular challenge. That knowledge that there are two diVerent waiting times level of uncertainty exists until the outcome of the we have to deal with their frustrations around that. independent review about that. Q168 Hywel Williams: This is a question of a matter Q165 Hywel Williams: Could I ask you, have you of opinion I suppose, but do you think that there heard anything directly from CardiV or the Minister should be uniform or perhaps comparable waiting herself about this or is it something you have read in times throughout the UK? the press? Ms Pickup: Purely on a personal level and this is my Ms Pickup: We were informed about it through a opinion, if I were Welsh I would prefer to wait the press inquiry and that is how it was brought to our same amount of time as an English patient. attention and I went on the website and read the transcripts of the Minister’s speech. Aside from that, Q169 Hywel Williams: There is an interesting we did not have any communication and it was just question here and that is the Health Minister in at a point at which we were finalising for a July London has said that the divergence is because of submission our integrated business plan so that devolution, and devolution in its current form has threw up a particular challenge. We had been invited been in since 1999. I do not know if historically you to give evidence to Mr James Steer, who is chairing can tell me whether there was divergence in waiting the review panel. Dr Enevoldson went down to times previous to the establishment of the Assembly V Cardi to do that and subsequently Mr Steer visited or is it subsequent to the Assembly being the unit quite recently to see it for himself and established? Perhaps you are not in a position to understand the issues. say that. Ms Pickup: I could not answer that. Q166 Hywel Williams: The subsequent Dr Enevoldson: I think there was always a longer communication has been through Mr Steer rather waiting time in Wales because traditionally there has than directly? been more diYculty in getting commissioners to sign Ms Pickup: Yes, but the Chairman and myself did up to more resources being put into the neurology write a joint letter to the Minister, once we became clinics in particular in North Wales. There did not aware of the announcement and the subsequent used to be a diVerence between the waiting times for process, oVering our support for the independent surgery once a decision to operate had been made. review and oVering to give any assistance that we Everything was absolutely one waiting list until could. We got a reply back saying, “No decisions recently, but certainly in terms of the waiting times have been made”, and we will await the outcome of for an outpatient appointment for neurology it has the review. always been longer in Wales. Those waiting times have tumbled in England, they have come down a Q167 Hywel Williams: Could I turn to some broader fair amount in Wales but tumbled in England, issues about waiting times. Clearly, there is a because extra resources and extra neurologists have divergence between Wales and England. How does been put in. If we had the same sort of resources put that impact on your Trust? in in North Wales, in fact I am sure we could have Ms Pickup: I think it is something that has existed reduced those waiting times far more, but I would for some considerable time. Dr Enevoldson has like to put on record the fact that if a Welsh patient alluded to some of the clinical considerations that requires treatment urgently or semi-urgently, they are brought about as a consequence of that. I think are treated under the same waiting lists as an English from a managerial and operational perspective we patient. There is no question that any clinician have to be very cognisant of managing in would allow where somebody lives or which GP they administrative terms these patients quite diVerently are registered with, whether they be English or because we have to diVerentiate between the waiting Welsh, to influence their clinical decision about an times for English and Welsh patients, so at an urgent or semi-urgent patient. operational level it does carry with it some additional administrative burdens to do that. Aside Q170 Hywel Williams: One more question, from all those things, Dr Enevoldson would always Chairman. Are you a public body in respect of the make the point, and indeed it is the case, that if it is Welsh Language Act 1993? Do you have a Welsh a clinically urgent case, then they will be treated as a language scheme and do you have any contact with clinical urgency and that is irrespective of whether the Welsh Language Board? Do you have any they are English, Welsh, from the Isle of Man or statistics on the numbers of patients who speak wherever. At a level beyond clinical urgency where Welsh and the number of staV who are able to patients are just waiting in a queue for treatment, provide nursing services, for example, through the then inevitably patients are frustrated and what we medium of Welsh? Do you have any of that which have to deal with at a face-to-face level with a patient you might be able to let the Committee have? is “Why can’t I come in sooner because I have been Ms Pickup: We do have some. We are always very sat in the waiting room next to an English patient cognisant of the provision of services that we give to and they have only been waiting six weeks and I’ve North Wales and certainly in our major publications Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Commitee: Evidence Ev 31
31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup like our consultation document for foundation trust the Walton Centre and that there should be one status, we had two versions, one was a Welsh version centre to provide for the population of South Wales. and one was an English version. We are in the I think it also found that centre should most properly process of having signage proofread by one of the be in CardiV. Welsh Assembly departments because we are having dual signage, English and Welsh, at the centre. As far Q174 Mr David Jones: Which would of necessity as I am aware, we did elicit recently that we do not have led to the closure of the Swansea centre? employ any Welsh-speaking staV, but we do avail Dr Enevoldson: Yes. ourselves of translation services for Welsh patients and very often we use Language Live, not just for Q175 Mr David Jones: Did you take the Welsh patients but for any patients who do not recommendations of that review into account when speak English. making your own forward planning for the Walton Centre? Q171 Hywel Williams: One of the considerations we Dr Enevoldson: I think one would say that we felt have is quality issues and I did notice that one of the assured that we would continue to be the provider of things that Mr Steer is looking at as well is quality. I neuroscience services for North Wales and when the am less concerned about the sign outside and more news came through the press that it was being concerned about the recovering patient who has had considered otherwise I think it would be fair to say brain surgery perhaps and, because of the surgery, we were rather surprised. has lost the ability in English, for example, which I know from personal experience does happen. It is Q176 Albert Owen: Dr Enevoldson, you partly the quality of the nursing service and any answered when you mentioned that if there was any psychotherapeutic services that you might provide serious or semi-serious treatment needed by a Welsh following, say, the removal of a tumour or whatever. patient that clinical need would override everything, Dr Enevoldson: I think there are some nurses who are but is that clear right the way along from GPs to bilingual within the centre, not many but I think people in the general hospital services to your there are one or two. What I would say is for the administrators at the centre because the anecdotal outpatient services in North Wales the clinic nurse evidence we get from constituents is that they are with the neurologist is always bilingual and that, I phoning up a unit and being told, “No, you’re from understand, is very helpful on occasions. It is very Wales. You will be treated diVerently”. It is clear all helpful particularly with the more elderly patient. the way through? Dr Enevoldson: It is clear for the Walton Centre. It is Q172 Hywel Williams: Do you have any plans for clear for everybody employed by the Walton Centre, the inpatient nursing care to see if it is possible to do they know what their position is. I think the people something about this question? who work out in Wales would always through their Ms Pickup: I cannot say that we have got any local contacts be saying, “If something needs doing, documentary plans around this. We have policies it will be done whatever”. Of course, how that then around diversity and equal access, et cetera, and we is played back within the media and to the patients have, as I say, patients who do not speak English can be distorted. because they are from any number of diVerent places. We are able to identify that fairly quickly and Q177 Albert Owen: It is not just the evidence we are get the right kind of translation services. I am sure if getting, which again is anecdotal, it is somebody V a member of sta came to a job interview who had phoning up the Walton Centre and being told, “Oh, those skills, then that would be considered to be yes, you’re from Wales. You’ll have to wait longer”, advantageous. these are the things we are being told. There are things I want to take the opportunity to clear up and Q173 Mr David Jones: Of course, there was a review put on record the excellent service that you do, but prior to Mr Steer’s current review, as I understand it, this is the feedback we get from constituents and conducted by Health Commission Wales. To what patients, that they are led to believe they are second extent, if at all, do the recommendations of that class in treatment. You said you have to manage this review impact upon the Walton Centre? when people come into your waiting room so it is Ms Pickup: That predates my time in my current role obviously an issue and an issue I want to ask about. but I think—and I will hand over to my colleagues— Ms Pickup: From a patient perspective, what they my understanding is that the report was published in would deem to be of themselves if they are suVering December 2005. an illness would be they are an urgency or an Mr Harrop: Around that time. You referred to emergency or it is important they are seen quickly. Design for Life. The clinical definition of that might be diVerent. I Ms Pickup: Yes, and, as far as I am aware, I do not think if it were the case, and it is the case, that the think any of those recommendations were clinical view is that is urgent, then that patient’s implemented so as to aVect the Walton Centre before appointment and treatment will be expedited in line the subsequent announcement around this with every other member of our catchment repatriation of elective work. population. If it is the case that they believe Dr Enevoldson: I think that review found that the themselves to be urgent but the clinical view is that provision of neuroscience services for the North they are not necessarily that urgent, then if they are Wales population should continue to be provided by phoning up the centre and they are pressing the staV Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Dr Peter Enevoldson, Mr Christopher Harrop, Mr Ken Hoskisson and Ms Mel Pickup and saying, “Why can’t I have my appointment? I Review we have been asked to participate, comment know that I am waiting longer than English patients. on, be consulted on the North West’s response to Why am I waiting?”, then there is only one answer that about defining the clinical model for the future. and the answer is the Welsh waiting times, as we are Those discussions do not take place around Welsh, commissioned to provide, are diVerent and they are we do not have any dialogue. longer. This is the diYculty I alluded to in answer to a previous question about how our staV feel. Q181 Mark Pritchard: You have had no input at all Sometimes they are in a very diYcult situation with regard to the protocol between England and playing out the decisions of the Assembly to people Wales on the delivery of health services? who are clearly frustrated and anxious about their Ms Pickup: No. treatment. The fact of the matter is that there are diVerential waiting times. Q182 Mark Pritchard: Would you like to have input Mr Harrop: To add to what Mel said, we are slightly into the decisions that are being made at strategic diVerent to some of the hospitals you have spoken to level? and obviously the type of treatment that we provide Ms Pickup: I think it would be very beneficial and, means we are able to see inpatients much more in part, that was the reason that we wrote to the quickly than perhaps some of the other district Minister, to oVer up our services in assistance. generals you have spoken to. At the moment we have Clearly, that was not appropriate at the time, but I very few inpatients who are waiting longer than their think going forward then certainly, given that it is English counterparts, purely by definition because 20% of the population we serve and would want to the type of service we provide is a very urgent service, continue to serve, I think that would be helpful, yes. so from an inpatient point of view you are not likely to find many patients waiting that long. I think the Q183 Mark Pritchard: Am I going too far in saying issue we are talking about really relates to the non- perhaps, as a senior management team, you might urgent—if you can call it non-urgent—neurology feel a little bit frustrated that you do not have input outpatients we see who obviously do wait longer into an organisation that is expecting you to deliver than their English counterparts, but we need to the outputs from a strategy they agreed? make the point that from an inpatient perspective we Ms Pickup: I think it is safe to say that the level at do provide a very quick service. which we have dialogue we are very happy with. We have a good relationship with Health Commission Wales, but ultimately in terms of the chain of events Q178 Mark Pritchard: Dr Enevoldson, you said that that lead to decisions, that dialogue with the ten days is not enough for Wales. How many days commissioner at that point is quite a long way down would be enough? the track. It is not about determining the decisions, Dr Enevoldson: I would have thought—this is just oV it is about how we engage with them to deliver the the top of my head, I would have to sit down with the decisions, not really influencing their commissioning figures—probably 50% more, 15 days. You might decisions. We can do it at a fairly local level on the need a bit more than that to bring the times down basis of our experiences and what we did last year initially but then after that you could hold it. I would and certainly the dialogue going forward will all be guess something like that. That would be for about clearly whatever the contract was last year in neurology. I do not think there is any additional terms of the block payment, we have overperformed neurosurgery required. on that, so what are we going to do about this coming year. In terms of overarching health strategy, Q179 Mark Pritchard: On the English/Welsh health there is not the opportunity to do that and that protocol, what sort of input have you had to that? would probably be helpful. Have you been involved in any consultations and also do you think it would be helpful, perhaps for the Q184 Chairman: Thank you very much for your Chief Executive, to have an English/Welsh health evidence this morning. Could I also place on record protocol? our thanks for the written memorandum that you Ms Pickup: I am not clear what the protocol is. provided for us, it was very helpful to us in preparing for today’s session. We look forward also to visiting Q180 Mark Pritchard: Let me ask you another you at your centre this afternoon. Thank you very question. English strategic health authorities, what much. sort of input do you have with them with regard to Dr Enevoldson: Can I say in answer to your question commissioning Welsh health services? about the waiting times and how long people do Ms Pickup: Clearly, as a centre, we sit in the North wait, we do have some statistics which you might West NHS region and by definition, therefore, we are find helpful, illustrating how few patients are waiting answerable to the executive of that body and we more than the English waiting times, in practice have dialogue. I have dialogue with the Chief there are very few. Executive, there are other groups, the Director of Chairman: We would be very grateful to have that. Finance, et cetera, and more recently in terms of the Could you send those on to us. Thank you very strategic health authority’s response to the Darzi much. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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Witnesses: Mr GeoV Lang, Chief Executive, Wrexham Local Health Board, and Mr Andrew Gunnion, Chief Executive, Flintshire Local Health Board, gave evidence.
Q185 Chairman: Good morning and welcome to the Mr Lang: Could I add also to that in terms of Welsh AVairs Committee. For the record could you challenges. I think there is also the increasing introduce yourselves, please? divergence in philosophy regarding the market Mr Gunnion: Andrew Gunnion, Chief Executive, system for England and a Welsh system which is far Flintshire Local Health Board. more built upon partnerships and strategic links Mr Lang: GeoV Lang, Chief Executive of Wrexham between commissioners and providers. That does Local Health Board. manifest itself in some of the system changes that Andrew referred to, but clearly in terms of issues Q186 Chairman: Could I begin by asking you what such as patient choice, the use of the private sector proportion of the care you commission is carried out as a provider for NHS care, the government policy V in England and how has this changed in recent in Wales is di erent from England and, therefore, times? there is a divergence. That does not, in my Mr Gunnion: The majority of the care that we experience, present particular problems because we commission is within Wales, a significant proportion have not been great users of the private sector and in for Flintshire residents is within England and a terms of patient choices Andrew said the referral significant provider of secondary care services is patterns which have existed over many years still commissioned through Countess of Chester exist. In practical terms that is not impacting at this Hospital in particular. I think we account for around point but potentially, as we move forward, that 18% of their total activity. It is about a third of our could have a greater impact. district general hospital activity for the county of Flintshire. As with all other Local Health Boards, we Q189 Chairman: Do you get a sense that a Welsh commission secondary care services, we do not patient or an English patient has a better deal commission specialist services. We do have a number whether they are registered in England or Wales with of other contracts across North Wales, GeoV will a GP? probably talk for Wrexham in a second. We have Mr Gunnion: I think that would be diYcult for us to given information to the Committee which gives a answer. What we can say is the fact that we work figure in terms of the quantum of the activity we with the local trusts to ensure that the patients get commission from a range of providers, mainly their care based on their clinical need. I think there historically-based, for services which are not is clearly at the margin a small number of patients provided within North Wales itself. There are some who get treated within the maximum waiting time specialist services in hospitals such as Aintree where there is a diVerential between England and Hospital, Royal Liverpool Children’s Hospital, Wales in terms of the clinical need, the clinical care. Alder Hey, et cetera, which are still classed as our It is consistent and there should be no diVerence responsibility to commission and we have contracts between English and Welsh residents apart from, as with those as set out in the evidence given to the GeoV said, some system changes which give patient Committee. choice which creates a degree of flexibility for English residents in Wales. Q187 Chairman: In general terms what impact has devolution had on the services you provide? Q190 Mr David Jones: You have noted in your Mr Gunnion: I would not say a significant impact to memorandum that a significant number of Welsh be honest, because what has happened is that the patients from your catchment area are registered clinical and cultural links between the North West of with English GPs and vice versa. Do you know why England and North Wales are strong and, therefore, this should be? have been maintained through devolution. Those Mr Gunnion: It is partly due to geography, links are clear I think and are well respected and well particularly in certain areas because there is used. The main, significant part of our local movement around the boundary, patients will often population sees, for example, in Deeside the retain their GP when they move house. It is through Countess of Chester as their natural, local hospital patient choice, geography, a whole range of issues so, therefore, what we try to do is to ensure that we why a patient will wish to retain the link with their commission services as best we can to meet those GP. local needs as locally as we can and to work with Mr Lang: Certainly from a Wrexham perspective, those local hospitals wherever possible. many of those areas are rural areas and it is about the location of GP practices and they are quite far apart Q188 Chairman: How would you describe the and, therefore, the border between England and opportunities and challenges that are before you Wales from a patient perspective does not exist. They now as a consequence of devolution? use their local GP, whether that be a Welsh resident Mr Gunnion: I think the challenges are the fact we moving to a GP in England or an English resident are moving to diVerent systems, in particular in registering with a Welsh GP, that is their local terms of waiting times and also in terms of the practice. financial allocation of resources and diVerent systems of paying for hospital care. That is causing Q191 Mr David Jones: Have you done any studies, challenges which I would class as more for example, into the extent to which free administrative and bureaucratic rather than actual prescriptions in Wales or shorter waiting times in clinical services. England impact upon a patient’s choice of GP? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion
Mr Gunnion: There is nothing to suggest in terms of Q195 Mark Pritchard: Being precise then, if you the information we have that has had any impact at have an English trust on one of the border counties, all in terms of patients moving. We have not noticed it goes for foundation status, payments by results anything. and says, “Actually the tariV we are currently getting from the Welsh patients”—because the tariV is being Q192 Mr David Jones: Have you conducted any bought en masse as a block rather than following per research? patient—“has got to end. We are going to phase it Mr Gunnion: We have not specifically looked at it, out over 12 months”. Is that what you are talking no, but in terms of the historical numbers and the about having a real impact? distribution of numbers, it has not changed. Mr Gunnion: That is not currently the policy in Wales. Obviously it could have an impact if that were to happen. I think GeoV is right, what we have Q193 Mr David Jones: Does this phenomenon tended to do is have quite good links at a local and impact at all on your planning and commissioning strategic planning level. I think they are getting arrangements? potentially increasingly diYcult to maintain as the Mr Lang: The cross-border registration? From our systems begin to diVerentiate. The challenge for us is perspective, no. In terms of what we plan to deliver to continue to ensure that when we are strategically for our residents, no. Wherever people who are planning services, such as cancer, cardiac services, registered with our GPs are resident, they have those links that exist are maintained. I think the access to the same services and in terms of the issues around how services are paid for evolve and standards that we oVer in terms of waiting times and constantly change. Wales is looking at a similar other things, those are common, whether those be version, a limited version of the PBR-type approach. patients who access the services in England or access It is constantly changing and that is something we them in Wales. In terms of our commissioning, we have to manage and make sure that does not get in provide for access to the traditional referral route so, the way of patient care. for example, if you are registered with a GP in Mr Lang: I think the issue for me in terms of whether Wrexham but may be on the border with England or not it is increasingly a problematic relationship is and traditionally you have been referred into partly the way the two parties see the relationship England perhaps to Shrewsbury, perhaps to and certainly to date we have had a very positive Oswestry, that will still carry on and our relationship with providers over the border, we are commissioning reflects that. We do take into account seen as key partners in their development. At the those patterns in natural clinical links and also links moment I think that is okay.What I would be unsure in terms of access for patients. If it is a more local of is if the systems increasingly become more hospital in England then we do commission for diVerent whether we would still be viewed as key those hospitals to secure that access. partners and, therefore, have influence for the benefit of people in North Wales. If we lose that Q194 Mark Pritchard: English NHS reforms, are influence because we are not seen as key partners for there any particular reforms past, present or looking the future, I think that is a concern. forward that you think will aVect your ability to commission services? Mr Lang: I do not think there are particular ones Q196 Mark Pritchard: I am glad you have that aVect our ability at this point and I do not feel mentioned patients. I wonder what research you that hitherto there have been problems. I think what have undertaken which identifies the impact of that we do not know is the degree to which the reforms diverging health policy either side of the border, that respective governments bring in will what impact it has on patients? increasingly be divergent and, therefore, cause Mr Lang: Certainly in Wrexham I have not greater problems. There have always been diYculties undertaken any specific research on that. There has even before devolution in terms of things like been a significant amount of work that the NHS strategic planning and the relationship perhaps Confederation, which I understand has given between North Wales and the former health evidence to the Committee, has undertaken on the authority in North Wales which related to providers impact of cross-border policies and we fed into that in England. There were always diYculties in terms of work and had the opportunity to influence things ensuring that Welsh residents had an important like the cross-border protocol in terms of finance and influence on strategic development of services over resourcing. We were part of those discussions and a the border which would be their provider. That has part of the discussions about the emerging potential always been a challenge, but we have managed to do impact of the policy positions, but then the that. I think as the systems change and become discussions have been taken forward between the increasingly diVerent, that introduces more tension Welsh Assembly Government and the Department into that relationship. For example, if you have a of Health. foundation trust that has a particular agenda and a particular means of transacting its business and a Q197 Hywel Williams: Going on that influence issue, strategic approach on which trusts have been we did hear from the Walton Centre that 600,000 of established with a very clear focus, that may not sit their catchment is in Wales out of three and a half quite so comfortably with the relationship and million-odd. Last time we heard from Herefordshire planning structures in Wales. They are potential I think it was £15 million of their £215million areas of greater tension. funding comes from Wales. In that respect of Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion fundamentals, surely the needs of Welsh patients and on them are working together to try and ensure they the ability of Wales to pay ensure that there is going connect up. Certainly from a North Wales to be influence, do you not think? perspective we have long established links, for Mr Gunnion: Yes. I think depending on where we example, with the Walton Neurosurgery and are, obviously Welsh payments, Welsh residents and Neuroscience Centre in terms of things like commissioners have a significant role to play; in transferring scanning images electronically and so certain other areas it would be less. I think what on and having the infrastructure there to do that to GeoV was saying was that where it would become allow the best clinical care for patients so those more marginalised it might well be more diYcult to problems are tackled as we move along and are there maintain that communication and that influence if to support patient care. we start to consume less capacity of a particular provider where there is a clear link between us such Q200 Hywel Williams: What I am concerned about as Walton, Countess of Chester, Robert Jones and here is getting a sense of proportion about this, we Agnes Hunt. I think that is going to be given as a fact heard earlier on this morning that it is about half a of life because we will need to ensure that we have million pounds. We heard a couple of weeks ago it eVective planning and commissioning links with was £2 million’s worth diVerence. However, the those providers because it is in their interest, our NHS Confederation did tell us that commissioning interest and the local patients’ interest most of services across the border lacked clarity. Would importantly. you agree with that and how can you address that lack of clarity without impacting on patient care if Q198 Hywel Williams: What I am concerned about it exists? here is the impression which has been given to my Mr Lang: I would say there is a lack of consistency constituents across North Wales, that there is some in terms of methodologies, systems and approaches. sort of threat that, to put it at its most crude, It depends on what one means by “clarity”. Clarity somebody from Saltney will have to go down to of responsibility, I think there is clarity of Swansea to have their ingrown toenail cured. We are responsibility, it may not be ideal but there is clarity not talking about that sort of thing at all, are we, there. I think there is clarity of relationships in terms gentlemen? of who is commissioning services from whom and Mr Lang: Absolutely not. As Andrew has there is clarity at the moment around the principles mentioned, the relationships that exist are built upon and rules that surround that engagement. There is the natural clinical relationships between GPs and inconsistency in that some of those rules and their local hospitals and between consultants in our principles in England are diVerent to ones being district general hospitals in North Wales and the applied across the border and diVerences that we specialist centres. Certainly we are not engaged in would apply with a Welsh provider. My experience discussions to try and change those clinical patterns of relationships with providers in England is there is and links and I am not aware that those discussions clarity about our role, there is clarity about the are ongoing, so from that perspective those strategic services we commission and by and large those links are still maintained. I think even if there were a relationships are very positive in delivering for view that certain services could potentially be patients. transferred to other centres that needs to be reflective of the fact that the clinical relationship between the Q201 Mr Martyn Jones: Do current funding secondary care hospital and the tertiary care is often allocations take account of cross-border payments an ongoing one. Individual patients rarely have one- for Welsh patients being treated in England? oV encounters for very specialised services, they Mr Gunnion: In the main, yes, but there have been have an ongoing relationship and that needs to be some technical adjustments, if you like, over periods maintained and kept. From that perspective I think which have not been made so it is not totally in sync, we will have an ongoing relationship and I do not but in the main, yes. sense that there is anything particularly undermining that at the moment. Q202 Mr Martyn Jones: Are there arrangements for the reciprocal of that, English patients being treated Q199 Hywel Williams: That is very reassuring to in Wales? hear. The more interesting questions, I suppose, are Mr Gunnion: Yes. around the diVerent uses of IT, the diVerent systems Mr Lang: Yes. of commissioning, but those are matters that people like yourselves sort out and I am just concerned that Q203 Mr Martyn Jones: What are they? the impact on the actual care that the patient gets is Mr Lang: The Assembly Government and the minimised or even does not occur at all. Department of Health periodically undertake Mr Lang: There are challenges in terms of financial assessments to gather the data relating to the flow of systems that we talked about, but those are patients across the border and then there is at an all- manageable and they are manageable through Wales and England level a calculation of the cost of agreements at a local level and a national level. There English patients being treated in Wales and Welsh are challenges with things like information strategy patients being treated in England. There is a resource and information systems where some of the national adjustment between the Department of Health and policy is common in principle but diVerent in its Wales, England can pay for services in Wales and deployment and both of the strategy teams working Wales can pay for services in England. That is Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion periodic so, as Andrew said, over time it does drift a Mr Gunnion: I would say that we are currently little bit as activity changes but, for example, within getting a good deal in terms of that particular Wrexham Local Health Board’s allocation there is a contract, yes. specific sum to relate to the services provided over the border in England. That is not ring fenced in that it cannot be topped up and it cannot be reduced, but Q208 Mark Pritchard: There are some people in the it is identifiable and we are able to track that in terms Assembly who want to see NHS Wales expand of relationships with hospitals over the border. within Wales. Do you think that is a good idea or not and how would that impact on you? Mr Lang: I think there are some services that one Q204 Mr Martyn Jones: You say that is an intra- could expand in Wales. If we look at services national thing in the sense that it is between the two provided over the border they range from very, very countries on a global scale. How does that aVect specialist services down to what we might call fairly your Local Health Board funding? Is it allocated in routine district general hospitals services and, headcount? indeed, over time some of the services which we Mr Lang: Essentially it is built up from a provider by consider to be highly specialised now in a number of provider and Local Health Board and PCT by PCT years may well be considered appropriate to deliver analysis, so it is aggregated to the national level to in a district general hospital. That is part of the allow the departmental settlement and then through natural change of healthcare. For example, cardiac the allocation process the element that it relates to, catheterisation, which five or six years ago would for example, English patients being treated in a local only ever have taken place in regional centres such as hospital in North East Wales or North East Wales the cardiac thoracic centre in Liverpool, now takes Trust is removed from what would have been a place in Glan Clwyd Hospital in North Wales and settlement in that area which is transferred to that is an entirely appropriate clinical change. England. Likewise, money is removed from England and is given to us so that we can commission our services over the border. Q209 Mark Pritchard: If I may briefly interject, forgive me. Whilst that might be right clinically that Q205 Mr Martyn Jones: English providers, more and more can be delivered locally in the including the Countess of Chester Foundation context of Darzi and scarce resources, is it not the Trust, have stated they receive less funding from case that, whilst that might or could happen in Welsh commissioners than English commissioners principle, the reality is that there will not be the for the same work. What is your perspective? resources there and it is counter to national Mr Gunnion: They receive less than they would get government policy? if we were funded and commissioned on the basis of Mr Lang: I do not think the picture is black or white payment by results. I suppose it is a historical on that. I think there are examples where, given that diVerece between price and cost. We would argue we know—and cardiac intervention is a good that when the allocations, as GeoV has just outlined, example—because of the need of the population and have been undertaken and the funding identified, we the need to expand capacity throughout the country have funded the Countess on that basis as is agreed that there is a need to ensure we have more spots between England and Wales and, therefore, we are available and more places and you then have options paying them a fair price for the work they are about where you place those. From my perspective, undertaking for local residents. I accept that if we provided that—and this is an important proviso— were funded and worked under a diVerent system when you weigh up value for money, clinical that would lead to a diVerent cost or price to us, but outcomes and the issues of access for patients, there I think it is about the system as against what is the is a credible position to provide within North Wales actual cost. We would argue we are covering the I think that is appropriate to do so. I think there are costs to them of providing the services to us. very diYcult issues if you start saying that it is a disproportionate burden on scarce resources to have Q206 Mr Martyn Jones: They are not getting an a unit in North Wales just because we want one. That element of profit. There is some diVerence here. would be a very diVerent proposition. Mr Gunnion: Yes, the contracts that we have, a change in activity would be funded at a marginal rate Q210 Mark Pritchard: Finally, do you welcome the rather than a full cost basis and that can lead to the statement by the Health Secretary yesterday about sort of figures that are bandied around, “We would the possibility of a health voucher scheme being get £X more if we were funded on that basis”. We introduced in certain circumstances? have not within NHS Wales been funded, nor is there Mr Lang: I am afraid I am not familiar enough with any agreement for NHS Wales to contract with the detail of that to be able to comment. England on that basis. It becomes almost for me an Mark Pritchard: A very good response. academic exercise which we are not allowing to get in the way of the delivery of services between England and Wales in terms of the Countess of Q211 Mr David Jones: Mr Gunnion, if I could please Chester in terms of delivering services on that basis. go back to the point you made about the disparity in funding arrangements being eVectively an academic Q207 Mr Martyn Jones: Would you say on that basis exercise. From the perspective of the English NHS that we are getting a good deal then? trust, it is not an academic exercise, is it, because Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion from that perspective they are actually receiving a Q216 Albert Owen: It is likely to happen, is it not? shortfall in terms of the income they are receiving You are facing that now. It would not be your from your health board? Is that not correct? decision, it would be the Welsh Assembly Mr Gunnion: No, because under the system for Government’s decision? which we are commissioning we are paying a price Mr Gunnion: It is to do with national policy. that we should be paying. If we were commissioning under a diVerent system they would get more. We are Q217 Albert Owen: On the reviews that are going on not giving them less than we should be giving them, within the neurology unit and the review of the we are giving them what they need to provide the Welsh Assembly Government, what kind of input work on the basis of the agreement between England have you put into that? and Wales to provide services. Mr Gunnion: In terms of the general policy around cross-border issues, certainly I have had oYcers in my organisation heavily involved in that both, as Q212 Mr David Jones: I understand that, but if you V look at it from their perspective and the disparity in Geo said, with the national confederation work funding arrangements between England and Wales, and my director of finance has also been working were you funding them on an English basis they with the Welsh Assembly Government and had would be receiving more revenue, would they not? meetings with the Department of Health to talk Mr Gunnion: Yes. about the technical aspects of the revenue transfers and allocation issues. There is quite a significant input in terms of oYcers tying into the technical Q213 Mr David Jones: On that basis, of course, they process of resource allocation between England would be able to provide superior facilities for and Wales. patient care, is that not correct? Mr Lang: In terms of the neurosurgery issue Mr Gunnion: Possibly, yes, but I would argue that specifically, certainly that has been a subject of much potentially we have only got the power of local discussion, as one would expect. The views that commissioning that once so if we spend it have been expressed are particularly in relation to somewhere else we cannot spend it elsewhere, there the clinical continuity of care and the need to will always be choices. I think the issue for us would maintain that and the need to maintain the be to understand how the system will flow through relationships between secondary care clinicians and the healthcare system. clinicians in the specialist centre, which are very good in North Wales, and to keep continuity of care over time because often, as I mentioned earlier, Q214 Mr David Jones: Certainly just to reiterate the episodes are not single and one-oV, they are part of point, from the perspective of the English provider an ongoing package of care. Those are important V they are su ering a revenue loss as a result of the issues and I think there are great diYculties in trying disparity between the two funding systems. If in fact to do that on a North-South Wales basis for issues of you were funding on the same basis as an English geography and access and also the other major issue commissioner they would have a better income was one in relation to patient access, particularly stream? visitors and family support in relation to patients Mr Gunnion: Yes. who may be having planned procedures. Whilst it is fair to say that patients will often travel for a Q215 Albert Owen: Mine is along the same lines planned procedure if they believe that to be of the really.You say it is an academic exercise, but we have highest quality and the right place to be, the issue is just heard evidence that there is a shortfall in the really we have that service on our doorstep almost in Walton Centre of half a million pounds and they are terms of the Walton Neurosciences Centre and, therefore, it is a very diYcult issue to consider looking for five-year planning for foundation status. V Obviously the pressure on the Welsh commissioner patients travelling perhaps to Swansea or Cardi . for the underfunding is going to become more and more as the progress of the foundation status in Q218 Albert Owen: On the Steer Review, are you various hospitals continues. What is the response speaking with one voice for local health policy in there? There is underfunding, they will want to North Wales? maximise their profits and their incomes that they Mr Lang: Yes. get in so the current situation is not sustainable, is it? Mr Gunnion: Yes. Mr Gunnion: We are merely commissioning within the rules that were set for us by the Welsh Assembly Q219 Hywel Williams: I am concerned about the Government and if those rules change then clearly whole question of profit and loss and that coarse we will have to look at it. My understanding is that understanding of the relationship. In the Countess where there is a policy initiative which impacts on of Chester or Walton Hospital they are not forced in one nation there will be a revenue transfer to cover any way to come to an agreement on their cost with that. If we were to move into that scenario we would the Welsh Assembly Government. I take it it is an be funded to commission on that basis, so the money agreement voluntarily gone into as far as you know? would revolve around the system in that sense Mr Gunnion: We basically have regular meetings because we would get additional funding from the with, for example, the Countess of Chester where we Welsh Assembly Government to pay for that identify changes in activity and changes in clinical additional price. care and agree with them how we should be in Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion essence paying for the service they provide. What is matter of great concern but the routine waiters, clear on the payment by results is that a lot of the those patients are then eVectively seen in turn and in work we undertook was that some of the requests for accordance with the amount of capacity that is additional funding were technical coding issues, so commissioned. If I give an example of our the patients would go for an antenatal appointment, relationship with the Robert Jones and Agnes Hunt be checked, have slightly high blood pressure. On the Hospital where we commission a lot of orthopaedic payment by results they would then be coded, not surgery there, we commission enough capacity to just for an outpatient attendance but then be coded deliver the Welsh national maximum waiting time for a day unit attendance while the blood pressure is guarantee. What that means is that we do not buy monitored for an hour and therefore potentially we enough capacity for all Welsh residents to be treated would end up paying two sets of payments if we paid in turn chronologically because that would mean we through the payment by results system. In terms of would have to buy even more and they would be Flintshire Health Board that would lead to a treated then in line with the English standard. All of potential £300,000 a year. Whether there is a the patients categorised as urgent get treated as they £300,000 additional cost in the system, I think we need to be. The routine waiters do have a longer would argue probably there is not, but in terms of the period. That period has narrowed over recent years pure payment by results process where everything is and is less of a contentious issue than it used to be, I counted separately and costed separately that was would not say it is not contentious but it is less of a how we can ratchet up the costs. What we do in contentious issue. In practical terms, what that terms of our negotiations is have discussions around means is it is very diYcult for clinicians at the sharp the services and in relation to that to identify what end having discussions with patients to explain why we believe are the fair, reasonable and true costs of one patient would have to wait 26 weeks and another that, not what is the given cost or given price. may have to wait 32 weeks for no other reason than area of residence. I think that is where the Q220 Hywel Williams: Which is why you are saying practicalities hit in terms of the patient-clinician relationship and also the diYculties for the hospital we are getting a very good deal. V Mr Gunnion: If you compare it in stark terms, yes, in managing e ectively two sets of waiting and booking systems that have to be brought together to but we think it is a fair deal in terms of the price for V the services that are being provided. use their capacity to best e ect. Mr Lang: And one the Countess have agreed to with us. Within that there are certain elements of financial Q222 Hywel Williams: That is interesting, the way allocations which are outstanding at a national level you have unpacked that, and that for people with and there is a transfer of issues of superannuation acute problems, therefore, there is equality of service funding between England and Wales and that throughout the UK in fact. equates in terms of the Countess, and they Mr Lang: Yes. understand that it is done at a national level but they are down half a million pounds. These figures can be Q223 Hywel Williams: Should there be a uniform looked at and are not quite as stark as sometimes waiting list targets throughout the UK for acute and presented in the press. more routine treatment? Is that practical? Mr Lang: Is it practical? Yes, it is practical to have Q221 Hywel Williams: Could I turn to waiting lists. either exactly the same waiting time or as wide apart What are the practical implications of the diVering as practically you can manage it. Ultimately the waiting list targets for patients, commissioners and decision is one for the Government in terms of what providers? What does that mean in real terms? they wish to commission. In practical terms we can Mr Lang: From our perspective in Wrexham, and I commission, provided we have the resource, think it is the same for all Local Health Boards, from whatever waiting time standard we are given, the commissioning perspective we commission the whether that be the same as England or it be V same maximum waiting list and waiting times for all di erent. I think the desirability or otherwise is a our residents wherever they are, so whether they are matter for the Government to determine. We have to treated in North Wales, England or elsewhere. I was implement that policy. listening to the end of the evidence session with colleagues from the Walton Centre and there are Q224 Hywel Williams: Could I ask you therefore the very practical issues about those patients who do same question that I asked colleagues earlier. I do wait up to the maximum period of time. As was said not know if you are able to tell us about the situation earlier, because of clinical urgency if a patient is prior to the establishment of the Assembly, but do urgent, whichever hospital you are in and wherever you know whether there were diVerent waiting times you are from, you are treated in accordance with for people from Wales as compared with England your clinical need, though if you are a Wrexham than before the Assembly? patient attending Shrewsbury you may well get Mr Lang: Yes, there were and at times they had treated quicker than a Shrewsbury resident because greater divergence than they currently do. Through your clinical need determines that to be the case and the greater impetus that the Welsh Assembly all hospitals are working that way. What we have Government put on reducing waiting times back in then is those patients who in terms of a classification 2005 when its major health strategy, Design for Life, will be seen as routine, although it is never routine to and a pathway towards a 26-week waiting time the individual involved and is very important and a referral to treatment by 2009 were announced, Wales Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion has increased rapidly its reduction in waiting lists good links with cross-border as opposed to Gwent compared with where it was in previous years. having problems down in the south as well. It is not Having worked in a former North Wales health as straightforward as England versus Wales and authority which commissioned services in England, never has been and probably never will be. Is that we often had greater disparity at that point than we correct? currently do now. That is not to say our current Mr Gunnion: I would concur with that. disparity is not a diYculty, but it is less than it was. Mr Gunnion: To add a bit of context, certainly this issue was raised within the Flintshire local scrutiny Q230 Chairman: The whole of this session has been committee two years ago in terms of access and an exploration of the relationships between England Flintshire waiting times. We did a piece of work and Wales across the border. How would you which highlighted that 95% of Flintshire residents characterise the co-ordination across the border were treated within English waiting times. As GeoV now? Is it ad hoc or is there some degree of says, there is a significant number of patients who coherence? have to wait longer but it is probably not as big as we Mr Gunnion: I suppose if I was being honest it is all think it is, but that does lead to problems on an probably ad hoc. There are some good examples, individual basis. there are some areas where we could certainly do Hywel Williams: We will be questioning the Health better. This is not just about foreign devolution, it Minister, Ben Bradshaw, later on and I hope we will has always been the way that strategic health be able to ask him about his statement that waiting authorities have tended to plan within their strategic lists’ divergence has been caused by devolution. It health authority area. NHS Wales or North Wales would be interesting to hear what he has to say. have tended to plan in its area and what happens then is about how good the links or the boundaries Q225 Mr David Jones: But the earlier divergence in are. They are often maintained through personal waiting times was not a consequence of deliberate relationships rather than central diktats. government policy which the current divergence in waiting times is? That is right, is it not? Q231 Chairman: It may be a little late to be opening Mr Lang: Given that we only had one government, up this debate and maybe it would be better to ask yes, it is a matter of implementation. you to write us. Very briefly, how would you suggest to us that the situation could be improved? Q226 Mr David Jones: The divergence we are Mr Lang: From my perspective, I think we have got experiencing is a matter of deliberate government some examples of where things have worked very policy, is that not correct? well and that is as a result of good relationships Mr Lang: I think— between the Department of Health and Welsh Chairman: You do not have to answer that question. Assembly Government oYcials in looking at It may sound as if it is a leading question. Would you emerging policy and understanding the practicalities V like to put it di erently? and how it would work. That is the level at which the connection needs to be eVective. When it gets to our Q227 Mr David Jones: Is it not correct that current level then we are eVectively implementing the policy divergence in waiting times is a product of deliberate as set. Often we are asked to contribute to some of government policy? That is a straightforward that development and when we are asked we question. willingly do that, as we did with the cross-border Mr Lang: It is correct to say that, as employers and flows work, but essentially the issue is understanding a commission in the health service in Wales, we if we are to be given a direction in Wales what are the commission to a standard set by the Welsh Assembly implications of that across the border, thinking Government. through how that will be managed and is that manageable or not. That has to happen early in the Q228 Mr David Jones: Correct. You explained the policy process. diYculties that clinicians have in explaining to patients this divergence in waiting times and what a problem it is for them. It is a problem also, is it not, Q232 Chairman: We understand that there are for the patient who, I guess, is wondering why he or discussions currently taking place about developing she is paying taxes at exactly the same rate as an a health protocol. Are you part of that process and, English patient but is having to wait for longer? Is if not, would you wish to be consulted about it? that not correct? Mr Gunnion: We have been involved in the past, as Mr Lang: It is a problem for the patient, yes. GeoV has said, in terms of the development of the current guidance, both in terms of the work of the Q229 Albert Owen: On the waiting lists again, we are Confederation and working with Welsh Assembly comparing England and Wales and Mr Williams Government colleagues linking into strategic health asked about historic ones before devolution came in authorities in the North West and West Midlands in because within Wales there was a huge diVerential terms of how we manage patient flows and resource between North West Wales and South. The Gwent allocations across. I think that can be improved and area had one of the highest waiting lists in Northern we would certainly welcome an opportunity to Europe, so it is not just across the border. One of the continue to ensure we can participate and contribute reasons North Wales had less was because there were to that process. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Geoff Lang and Mr Andrew Gunnion
Q233 Chairman: Thank you very much for your Mr Lang: We will certainly try to. I am not sure how evidence today and also for the memorandum that long back the records are but, yes, we will certainly you supplied which was helpful in preparing for this try to do that for you. session. You mentioned about waiting lists pre- Chairman: Also if you could give some thought to devolution, post-devolution. Could you provide us the last question I posed in terms of how cross- with some statistics about that or try to? border relationships could be improved and provide some more coherent approaches, that too could be helpful to us. Thank you very much.
Witnesses: Mr JeV Lansdell, Patient Complaints Advocate, Clwyd Community Health Council, Councillor John MacLennan, Chairman, Conwy East Community Health Council, and Ms Gail Roberts, Chief OYcer, Clwyd Community Health Council, gave evidence.
Q234 Chairman: Welcome to the Welsh AVairs not as if it is an operation of wish, it is an operation Committee. For the record, could you please of need and those are the sorts of cases that come to introduce yourselves? our notice. Councillor MacLennan: I am Councillor John MacLennan, Chairman of Conwy East Community Q236 Chairman: That is helpful. You have given one Health Council. example which may or may not illustrate a more Ms Roberts: Gail Roberts, Chief OYcer of Clwyd general situation. Could you in more general Community Health Council. terms—any of you—explain to us how patients Mr Lansdell: IamJeV Lansdell, Patient Advocate perceive what now seems to be a policy divergence for Clwyd Community Health Council. between England and Wales in certain areas? Mr Lansdell: I deal with an average of 200 clients a year and the perception I see from talking to patients Q235 Chairman: Please do not be afraid to raise your and their relatives is that they get a raw deal on voices so that everyone in the room can hear you. waiting times. They are sitting in a waiting room, waiting to see the consultant, chatting to somebody Could I begin by asking you, what impact has and saying, “Well, how long have you waited?” “Oh, devolution had on medical services in your area? I have only waited so many weeks.” “Why is that?” Councillor MacLennan: It is hard for us to quantify “I live in StaVord”, or, “I live in Chester”, or that, Chairman, really, as CHCs. We measure the whatever. Or they will be sitting in hospital beds next services that are provided by the complaints and the to each other with a condition that maybe has incidents that are reported to us. They seem to be at deteriorated quite considerably and reduces the the moment quite low, but from the papers benefit of treatment maybe and they are chatting to submitted to you, you can see that there are issues each other and found that they waited six, eight V surrounding the di erences. weeks, maybe months longer. That tends to be the Mr Lansdell: I think one of the problems is when general feeling and I think it is a case of people then members of the public approach us they are usually start to talk, but there is some evidence to support at the end of their wits trying to get resolution to this what is happening when people are faced with and it is usually crisis time for them. It is usually a waiting times which are longer than they would case whereby they have been told by a clinician that normally have to wait if they were receiving the if they lived over the border they would receive this treatment that was being funded by an English PCT. treatment without any delay whatsoever. In one case Ms Roberts: There is a very strong perception that where a lady was told she needed the surgery—this there is an inequality in accessing services and, as surgery was planned—but after discussion with the was rightly said before, people see themselves paying family it was decided to delay the surgery until she the same taxes, making the same contributions and recovered a little bit of strength and the surgery they fail to see why the diVerent governments are could be carried on nearer to her home, so she could allowing this discrepancy to still continue. We have have her friends and family around her and reduce all heard the term “postcode lottery”, I do not know travelling times, et cetera. When she visited the local how many times we have heard it, that rings true centre, which in this case was the Walton Centre, she with people. They see it as an inequality in the system found that they were perfectly willing to go ahead when they are paying their taxes at the same rates. with the procedure and definitely stating she needed it. When they applied for the funding they were told Q237 Mr David Jones: The diVerence in approach to no way would the Welsh Assembly Government the provision of health services between England fund this treatment. I got involved with the family and Wales is resolved to the rather irritating jargon and I applied to Health Commission Wales and they of “patient choice” in England and “patient voice” point-blank refused to fund that situation. The lady in Wales. Cutting through the jargon, what does this is now in the position whereby she is trying to sell her mean in practicality for Welsh patients? house in order that she can move a few hundred Mr Lansdell: I think I can give a case. I like to speak yards over the border to Cheshire, register with a GP on fact. I can give two cases. One was a gentleman there and she will get the operation she needs. It is who was receiving treatment in a Manchester Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts hospital for a cancer condition and he was Q241 Mr David Jones: Yes. prescribed a medication for that condition. He then Ms Roberts: My personal view would be that, whilst was discharged from hospital and approached his it is extremely laudable, I see little actual patient GP for follow-up prescriptions and was told he voice changing the services. could not have it because it was not an approved medication issued in Wales. What this gentleman did Q242 Mr David Jones: Does “patient choice” mean in the end was he rented a flat not far from the anything? hospital where he needed to keep going back for Ms Roberts: I am aware that “patient choice” is the treatment and got the prescription by registering terminology used in England. Apart from that, I do with a GP locally. In another case a gentleman has not know, sorry. been receiving, again, essential treatment. He has to have an infusion in his medication every four weeks. Q243 Mr David Jones: Thank you. Is there any If he misses, his muscles start to degenerate. He was evidence as to how patient choice versus patient having this treatment in Hope Hospital. For quality voice—if these terms do mean anything—have of life issues, he moved from where he was living in aVected the flow of patients across the border? For Manchester to live in the Wirral area. Then he saw a example, have you seen Welsh resident patients consultant from the Walton Centre—it was registering in England in order to access English interesting to hear what the Walton Centre was services and English standards of services? You have saying earlier—and a consultant from there told mentioned some individual examples, but is this a him, “Well, the probability is you are going to have widespread phenomenon? to travel to CardiV for this treatment if Wales are Ms Roberts: I would not say it is widespread, but we going to fund it”. He said, “This is a bit of nonsense. are aware that it does occur and although there is a At the moment I can still go to Hope Hospital. I had degree of stability in the cross-border flow of this course of treatment over a number of years, I patients, we have anecdotal evidence where we think can go there in a day and receive my treatment and there are decreased numbers being referred to places go home. If I have to go to CardiV, it means I have to such as Robert Jones and Agnes Hunt, particularly travel the day before, I have to stay overnight, take a from the North West where there was quite a strong day having the infusion and because it is quite a flow of patients at one time. That is not to say that traumatic occurrence, it will mean another night’s is necessarily bad because the patients in theory stay and a day to travel back”. You are talking three should be treated in Ysbyty Gwynedd rather than days every month whereas if he continues to have it being referred over to Oswestry. Generally speaking, in Manchester, it is a case of one day a month and a we think it is pretty stable in terms of the flow. lot less hassle and strain on him. Mr Lansdell: Part of the problem that comes from the flow is particularly I have noticed people Q238 Mr David Jones: Those are interesting mentioning when they have an English GP and the examples, but what does “patient voice” mean then? expectation of the GP is, say, district nursing services Does it mean anything? will do X, Y, Z, the reality of it in North Wales is Councillor MacLennan: You cannot quantify it, I do district services will produce A, B, C. It is not within not think, in a sentence like that, Mr Jones. I think the same timeframe and that sometimes causes false it may be patient choice and clinician’s voice in some hope for people that they will receive a service. When ways. The patient has to go where the clinician the reality comes down to it and they get back home directs them. Is that what you are getting at? and the service is agreed it is not quite what they were expecting. It is those sorts of issues that sometimes Q239 Mr David Jones: I understand that the Welsh deflate people, particularly those who are very approach to the provision of healthcare is patient poorly and are looking for any light at the end of the voice. I have said previously in these Committee tunnel and when they get an expectation which lifts sessions I do not wholly understand what “patient them and then when the reality comes that it does voice” means. I am just wondering if any of you not then develop or the service is not delivered as witnesses understand what “patient voice” means. they expected, it can be quite a deflating blow to Ms Roberts: From our perspective there is a very, somebody who is very poorly or particularly very strong notion in the Welsh Assembly somebody who is looking after somebody who is Government about engaging with the citizens and very poorly. that has been reflected in all sorts of documents, the Beecham Report, which Mike Ponton from the NHS Q244 Hywel Williams: Could I pursue an answer Confederation referred to, and the One Wales with Mr Lansdell. I have asked a number of times Report. There is a very strong message that there about the famous patient who is going to be should be engagement with the public and, transferred from the Walton to CardiV and been therefore, the public voice be there to shape the assured a number of times that has not happened or services which are going to be provided or are being would not happen in the future, that is the headline provided. case and you have just mentioned one. On what basis was that person transferred? Would it be any Q240 Mr David Jones: That sounds very touchy- diVerent from, say, someone being transferred from feely. What does it mean in practice? Liverpool to Manchester or from Ysbyty Gwynedd Ms Roberts: If you are asking from a personal point to London depending on what treatment was of view? available? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts
Mr Lansdell: He was told that by the consultant Q249 Albert Owen: I appreciate that. neurologist on the basis that there was a change in Mr Lansdell: That is what I am doing at the moment. procedure taking place. There was a possibility that Once I get that sorted, I will then look at historically the Walton Centre would not be providing that what happened because it is more important from service and it would be then provided by CardiV. my perspective. That was a consultant’s perception at a consultation. Q250 Albert Owen: I fully appreciate that. We have Q245 Hywel Williams: I am concerned that there are lots of constituents with similar concerns and a great number of perceptions about any potential obviously I liaise with the CHC in my area, but if this change and there is the actuality. Are you saying that was brought to my attention, I would certainly take actually occurred or was it a perception of the it up with the Walton Centre to confirm that was the consultant? case before I made that public. I would obviously Mr Lansdell: The patient was told that. find out both sides of it and I think this is an important issue that you have raised and certainly,as Q246 Hywel Williams: It was the consultant’s part of this inquiry, we need to gather that perception, telling the patient who was then information which is why we have had all the elaborating to think he might have to spend three witnesses. It has not been taken up with the Walton days in CardiV. Centre for them to confirm or deny this was an Mr Lansdell: What they were saying about the only option? accessibility of Walton, I have dealt with clients who Mr Lansdell: No. were not complaining about that aspect of it, but when you are taking the history of the story you get Q251 Hywel Williams: We had the Bishop of somebody who maybe has a major brain Hereford and the Bishop of Monmouth before us haemorrhage and they need brain surgery quite recently saying that the divergence in health service quickly. The consultation and the transfer have provision between England and Wales is leading to taken place within two hours and they are in theatre. patient confusion. Would you agree with that? I know of one chap who was taken and actually was Ms Roberts: Yes, very much so. It is leading to in the door and in theatre that quick and he survived, patient confusion. Going back to the previous point went back to work and made a full recovery. I would I made, it is an inequity in accessing. North Wales ask the question, how would he have survived if he patients are historically very good travellers, they are had had to travel to CardiV for that surgery? happy to go where the best services can be provided.
Q247 Hywel Williams: Could I ask you, Mr Q252 Hywel Williams: Surely they have no option? Lansdell, a direct question. Has anyone been Ms Roberts: They do not want all the services in V transferred to Cardi ? Have they died in an Wales necessarily,they want the best services as close ambulance? Is that happening? Because I am to home as possible. worried, Mr Lansdell, that people reading the evidence from this session will then be encouraged to think they might be transferred to CardiV, where Q253 Hywel Williams: I take issue with that. People that, as far as I can see, has not happened and does in the far end of my constituency have no option but not seem to be a likely possibility. Perceptions are to travel to CardiV, Swansea, London, Manchester dangerous sometimes. or Liverpool for that matter. They have no innate Mr Lansdell: I think it is the way that whole matter extra ability to travel. I find that rather diminishes was dealt with when it was put forward as a the problems that they face in travelling to places like proposal, suggestion, whatever it was, it gathered a Liverpool, Manchester, CardiV or London. momentum of its own. When you deal with these Ms Roberts: Given the numbers doing that, there is people who are very vulnerable and quite poorly a very small number indeed that have to travel for they are desperate for treatment which is close to specialised treatment. We are talking about really home and which provides comfort. If something specialised treatment. The move within the health goes wrong they are only an hour or two hours down service is to provide as locally as possible as much as the road. possible to try and alleviate all the hardship involved Hywel Williams: My concern is that they might be with having to travel. We are talking about a tiny worried by this and unnecessarily so. number of people in the main. There is a general acceptance, though people do not like it, I agree, but people would rather go somewhere that is a centre of Q248 Albert Owen: Could I come in on that point. I excellence if they really have to because they have a think it is important what Mr Williams has said specific condition. there. Are you suggesting that this person was told that and then the complaint was taken up by yourself to the Walton Centre and it was confirmed Q254 Hywel Williams: Chairman, I am speculating that was one option or was the advice given? here, but if I was living in London, and the only Mr Lansdell: That is the chap who was told that. treatment available was in Yorkshire I would be an What has happened is that the more important part extremely good traveller as well. Can you see the of that complaint for me is to get his treatment point here? There is a danger of clinicians and sorted out. perhaps administrators being comforted by the Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts delusion that Welsh people in the West are very good Q257 Albert Owen: Is there a trend? You may not travellers when, in fact, they have no choice, that is have the statistics, but were the complaints similar in the only point I am making. nature before devolution? There are other Ms Roberts: I fully agree with you and I am sure this diVerentials now. Are people more empowered? Are is the argument that we have all been supporting they coming forward a bit stronger now? when it has come to the Minister’s recent Ms Roberts: They are coming forward in terms of announcement about neurology. We have all been making complaints. Going back to the waiting singing from the same hymn sheet in North Wales. times, I think there always has been a diVerence in the waiting times. I think Welsh waiting times have, generally speaking, been longer and it depends on where you are as to how long the waiting times are. In Gwent I know that there was a huge orthopaedic Q255 Hywel Williams: Going back to the Bishop’s waiting list at one point in time and that was creating assertion about confusion, what can be done to an awful lot of problems. I suppose part of the minimise patient confusion about accessing services reason, perhaps again a personal opinion, we have on the cross-border basis? What can we practically had longer waiting times in Wales may be the do so people are not unnecessarily concerned and demography but also the chronic disease within worried, or perhaps necessarily, depending on what Wales which has caused some problems. Yes, I think your opinion is? Surely confusion cannot be good? there always has been a diVerential. However, I must What can you do about it? agree that it has not been improved post-devolution Councillor MacLennan: Misconceptions come from and it is a policy of the Welsh Assembly Government a variety of sources, they come from the patients that the waiting lists are the length they are. themselves who perhaps do not understand what is happening to them, it comes from the doctors who perhaps do not really know where the consultants Q258 Albert Owen: Of course, you make a very are going to send the patients, it might come from the important point that you deal with the complaints hospital which cannot treat that patient for that and, as the example you gave these are real issues particular illness and has to refer them somewhere and they are very serious, but people who get good else. There are a number of ways in which patients treatment do not often register the fact that they can become confused about where they go for their have good treatment. That is very diYcult. You said treatment. We have put some cases before you. about quantifying problems. We do get letters as Y Regarding the one in She eld where a patient had MPs, I am sure Assembly Members do, for good Y to go for treatment in She eld and no contract was service, but they are rarer than the ones that are got made with the hospital prior to him going there, that for bad service. had to be done afterwards. There is confusion all Mr Lansdell: On that point, quite often you will get over the place, I think, Mr Williams. It comes from patients who are complainants in particular who are a variety of sources, not just from one. If it was from very, very keen to highlight the good service they one it would be so easy to sort it out, but it comes have had within an area. You can have sometimes from so many diVerent places that it is very, very diYcult to quantify and stop. quite a horrendous story told to you, but within that there will be messages of goodwill and I personally will try and include that in any letters that go in, so that you are giving a balanced view either to the trust or the Local Health Board or whatever. It is very Q256 Albert Owen: I want to go back to this equality diYcult for patients who maybe have experienced it of service for English and Welsh patients issue, I from both sides of the border because there is a lot think it is important. Do you think the gulf there is of movement of people over the border as well. It is bigger now with waiting times since devolution or those people who are the ones who give you a clearer was this an historic thing that happened? Again, the indication of how it is diVerent, people like the question I put to the LHB with regard to within gentleman who moved from the Manchester area to Wales, there were huge diVerentials. Again, it is only North Wales and found he was having all sorts of anecdotal, but I know of constituents of mine who hurdles which he did not have to encounter when he moved from the Gwent area—and that was not the was living in Manchester. reason they moved—telling me about the excellent service they got in the North West of Wales compared with the South East of Wales. Is equality Q259 Hywel Williams: Could I check, you are of service now poorer than it was before the concerned, though, with complaints mainly? Assembly came into being? Forgive my lack of knowledge, as CHCs, do you Ms Roberts: It is a slightly diYcult one for us. If we have an overall brief to look at quality of services, put it into the context of the CHCs’ role, we have good bad or indiVerent, or is your work inevitably only had an advocacy service and, therefore, only skewed towards dealing with complaints? been logging complaints, concerns et cetera, since Councillor MacLennan: No, we are statutory 2004. Therefore, we have no data going back to 1999 consultees under the Welsh Health Act, CHC which gives us a little bit of a problem in answering regulations for the Welsh Assembly or any other the question. I would say I agree with what has been NHS trust or LHB to consult us regarding patient said by the LHB. services or change to patient services and we Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 44 Welsh Affairs Commitee: Evidence
31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts comment on those. We also lobby the Welsh Q264 Hywel Williams: A very, very quick one. Apart Assembly Government on matters aVecting from the Minister’s statement which I quoted earlier, patients. which is now subject to the Steer Review, can you identify anybody at all who says that all services Q260 Hywel Williams: You have a specific function should be provided within Wales? to take up complaints? Councillor MacLennan: Within one part of Wales, Councillor MacLennan: It is part of our function, Mr Williams? one of the functions. Q265 Hywel Williams: No, within Wales. The question my colleague asked earlier on, is it feasible Q261 Mr Martyn Jones: Do you think it is viable for to provide all the services within Wales? Can you Wales to provide most or all of its services within the identify anybody who says that should be the case, Welsh border or should we carry on commissioning that we should be moving in that direction, that we across from England? should achieve it? Does anybody say that, can you Ms Roberts: We understand the critical mass tell me? arguments that were well portrayed by the staV from Ms Roberts: Not that I am aware of. Walton and Wrexham. Though we would all like Councillor MacLennan: It might be a political issue everything to be as close to home as possible, we there. A political party might say that, but whether accept the argument that cannot always be. I am the patients will. quoting what the public have said to us in the past rather than my opinion or necessarily my organisation’s opinion. Residents of North Wales Q266 Hywel Williams: We cannot identify anybody see the Children’s Hospital for Wales in CardiV and who is saying that? they do not necessarily see it as a children’s hospital Councillor MacLennan: No. of Wales. For them their children’s hospital of Wales—talking about my catchment area of Q267 Mr David Jones: Further to that point, Ms Denbighshire, Flintshire, Wrexham—is Alder Hey Roberts, you mentioned the issue of Alder Hey so, no, I do not think it is feasible to have all the which, in fact, the Committee will be visiting today, services provided in Wales. We understand the I hope. Why did you mention Alder Hey specifically? critical mass argument. For some specialisms that is Ms Roberts: It was an example in relation to the three million and that is the whole population of Children’s Hospital of Wales. Wales, but having it provided in South Wales or vice versa makes access extremely diYcult. Wales has an Q268 Mr David Jones: Yes, can you expand on that? unusual topography and for that reason I think we Why are you concerned that the establishment of could not provide it all within Wales. Children’s Hospital of Wales will impact on Alder Hey? Q262 Mr Martyn Jones: Could we provide more Ms Roberts: I quoted that as being one of the issues services locally? that is quite regularly raised by members of the Ms Roberts: I think things are changing so rapidly public who we interact with. within the medical profession, new procedures, new Mr Lansdell: I think the issue with Alder Hey is that drugs, so much more day case surgery than was ever many of the children from North Wales who end up provided and if we think back 20, 30 years what was in Alder Hey are critically ill and need one or both of happening then and what people are able to do now, their parents or family support and sometimes it is yes, things are provided much more locally and this not just the parents, sometimes it is grandparents will continue to expand probably far greater than I and uncles and aunts that are needed to support. The can start to imagine at this point in time. issue would be how could they provide that level of Councillor MacLennan: I do take your point support if they had to travel to CardiV as opposed to regarding financing and commissioning, Mr Jones. I travelling to Liverpool which is an hour away. think part of the problem is the resources are allocated to Local Health Boards and to Health Q269 Hywel Williams: I am sorry, Chairman, I am Commission Wales in some parts. It has to depend puzzled at this. Is anybody saying that children who on how Health Commission Wales manages its are currently going to Alder Hey should be going to budget. That sometimes can be quite frustrating and CardiV, or are we dealing with speculation here? interesting, shall we say. Mr Lansdell: No, what I am trying to reinforce is the strength of argument to keep Alder Hey on the Q263 Mr Martyn Jones: Would you say in the areas frame and what I am trying to explain is the you represent patients would not be concerned outcome, if it was moved to CardiV what possibly where their care is located so long as it is convenient could be the outcome for the patients. and high quality? Ms Roberts: I think Mr Martyn Jones asked the Councillor MacLennan: Yes, I think that is question about all services being provided within absolutely right. I also think, as was mentioned here Wales and on that basis I said that the some of the by one of your witnesses regarding patient outcome, public’s perception was that a service provided in if that is measured against money then problems do Wales, such as the Children’s Hospital of Wales, if start there for patients, or clinical outcomes I you live in Flintshire they do not see that as being the should say. children’s hospital in Wales. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Commitee: Evidence Ev 45
31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts
Q270 Mr David Jones: Exactly, it is the title Ombudsman or you can go straight to the Public “Children’s Hospital of Wales” whereas in fact Service Ombudsman for Wales. In England it goes to realistically, would you agree, it can only serve the Healthcare Commission which appoints an conveniently the children of South Wales? investigator who looks at it and then a panel looks Mr Lansdell: Yes. at it. It is very diYcult to try and explain to a patient Ms Roberts: South and West, yes. sometimes why there is such a divergence in the way Councillor MacLennan: That is a perception of the these matters are dealt with and that then does lead public, yes. to people becoming a little bit disillusioned and work being very bureaucratic. Q271 Mr David Jones: To what extent do you liaise with English patient representative bodies over Q275 Mark Pritchard: It makes your job more cross-border issues and how easy do you find it to diYcult, I should imagine. do so? V Y Mr Lansdell: Having di erent systems, certainly, Ms Roberts: We do find di culty in that the yes. Community Health Councils were abolished in England, so it has meant that there is a variety of creations in order to capture the public view. We do, Q276 Mark Pritchard: Moving swiftly on then, the however, liaise quite closely with the Patient Institute of Rural Health has suggested the Advocacy and Liaison Service, PALS, which exists establishment of a Border Commission on Health. in centres such as Walton in order to ensure that Do you think that would be a good idea or just Welsh patients have access to our services and that another body adding to, what I think most witnesses issues such as Welsh language, et cetera, are taken on have suggested explicitly or at least alluded today, board by the hospital and publications are produced the existing confusion within the health market? bilingually, et cetera. We have very, very close Ms Roberts: Without having some further relationships with the Patient Advocacy and information about the remit of a border Liaison Service. commission, I would not be able to comment. Mr Lansdell: Part of the problem is when you go out Q272 Mr David Jones: How satisfied are you with of the remit of something being approved locally and the independence of PALS? then go somewhere like Health Commission Wales Ms Roberts: I think from a Community Health for approval and when a service is readily available Council point of view, we have always had a slight to English patients but they will categorically decline diYculty with the independence. Whilst we embrace it in Wales and give a load of reasons, if this new the fact that it is wonderful somebody has a first line board is just another tier in this, I think it would just of contact to hopefully immediately resolve their complicate matters for patients. Matters need to be complaint or concern, from then on we are very simplified where there is a simple line to obtain. concerned that if a person wishes to make a formal complaint they do not have an independent Q277 Mark Pritchard: National policy is extremely mechanism with which to do so. important and has an impact on, if you like, a wider constitutional settlement with the Union and we Q273 Mr David Jones: Is it fair to say, without being have seen that with regard to the provision of some accused by the Chairman of asking a leading health services in Scotland not being provided in question, you do not regard PALS as being England, Berwick-upon-Tweed or wherever. In the suYciently independent? context of health and on cross-border issues which Ms Roberts: We find that people who have been we are looking at, if you have a county, let us say through the system do not feel that they are Shropshire for example, where you have a single independent, no. health trust, the Shrewsbury and Salford NHS Hospital Trust, Shropshire being the largest county Q274 Mark Pritchard: I want to ask a quick in England, can you see a situation whereby some supplementary. Do you think some patients are patient on the east side of Shropshire begins to get confused sometimes about the complaints perhaps a little bit resentful that the provision of procedures either side of the border, because they are Shropshire’s health is skewed somewhat because diVerent and, in fact, there is confusion around more provision is going into East Shropshire because public information campaigns and oftentimes those there is a revenue stream coming in from Wales? Can information campaigns start at diVerent times in the you see the possibility of some upset? calendar? Is that something you have come across? Mr Lansdell: I think for most of the people I deal Mr Lansdell: It is very confusing, particularly when with all they are after is equality of service and you have a complaint which started in Wales but fairness. If they have to wait six months, then maybe the final treatment has been received in everybody will wait for six months. Most people will England and you are trying to separate out the two accept that is the standard, but when there are all the complaints because if they are not happy with the diVerences, people who are poorly are not interested local resolution then it is up to local resolution. The in the reasons, they only want to know why. They are complaints process is similar, you deal with them not interested in the stuV that is going on in the quite in a similar manner but if local resolutions fail, background or the minutiae of discussions and who the Welsh system means you can either apply for an is responsible for this. All they are interested in is, independent review and then take it to the “When can I have this course of treatment to make Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 46 Welsh Affairs Commitee: Evidence
31 March 2008 Mr Jeff Lansdell, Councillor John MacLennan and Ms Gail Roberts me better?” “If it is delayed too long, will I never get Chairman: Could I thank you on behalf of the better?” Those are the key things that Joe Public is Committee for your evidence today and also for worried about. your earlier written memorandum. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 47
Tuesday 29 April 2008
Members present:
Dr Hywel Francis, in the Chair
Nia GriYth Alun Michael Mr David Jones Albert Owen
Witnesses: Mr Robert Meadowcroft, Director of Policy, Dr Mark Rogers, Consultant Clinical Geneticist, University Hospital of Wales and Mrs Lynne Taylor, Contact Family OYcer, Wales Duchenne Family Support Group, Muscular Dystrophy Campaign, gave evidence.
Q278 Chairman: Good morning and welcome to the Q282 Alun Michael: We always knew that we had a Welsh AVairs Committee. For the record could you long porous border between England and Wales so introduce yourselves, please? that should never have been a surprise to anybody. Mrs Taylor: I am Lynne Taylor, Contact Family When you say that the current service provision for OYcer, Wales Duchenne Family Support Group. neuromuscular conditions is failing patients in Mr Meadowcroft: I am Robert Meadowcroft, Wales, can you try to help us to understand the cause Director of Policy for the Muscular Dystrophy of that failure? Is it a cross-border issue per se or does Campaign. it derive from a lack of provision in Wales? Or is it Y Dr Rogers: I am Dr Mark Rogers, Consultant insu cient funding? Or is there some other cause? Clinical Geneticist. Mr Meadowcroft: From my point of view I think there are two issues here. There are some cross- border diYculties: patients who have been referred Q279 Chairman: Before we start could I extend our to services in England and who have diYculty in deepest condolences to Helen Jenkins and her accessing those services or the Local Health Board family; could you convey those to her, please. (LHB) has not paid for the service. I think there is a Mr Meadowcroft: We certainly will do, Chairman; more fundamental problem, if I may say, in Wales. thank you. We would like to see a recognition that the neuromuscular conditions are specialist conditions. There are more than 60 of them; they are low Q280 Chairman: Could I begin by asking you very incidence; they can be described as “orphan” or briefly what you consider to be the impact of “ultra-orphan” conditions and they need specialist devolution on health services for Welsh patients? clinical support and intervention. I think that if the What opportunities and challenges have been authority in Wales would recognise first that they are created by devolution in the field of health? specialist conditions and secondly there should be Mr Meadowcroft: I think that the impact of specialist support, I would have thought the next devolution in terms of health services has been step would be to have a review of where we are. Let mixed, to be perfectly frank with you. We are seeing us look in Wales at exactly where we are with services the emergence of separate health systems but also and then see what the gaps are and what needs to be some diYculties, not least with cross-border services addressed. which I know is the focus of your Committee’s work and of our hearing today. I think there is an Q283 Alun Michael: Can I just probe that answer a opportunity to improve services in Wales given that little bit? You said that sometimes there are we now have a devolved service. There are still some diYculties in accessing those services. That sounds threats to be overcome and we are concerned that like a diYculty for the people across the border who people with neuromuscular conditions in Wales ought to be providing that service. Secondly you said should have access to good quality services no that sometimes LHBs are refusing to pay. Then you matter where they live. There is a challenge and an say that we need to recognise a need for specialist opportunity there. treatment which I think implies that you are suggesting that there needs to be an England and Wales or at least a cross-regional strategic approach Q281 Chairman: You used the word “mixed”; is that to providing the appropriate services for these generally recognised by policy makers? particular conditions. Am I understanding you Mr Meadowcroft: I would hope it is becoming correctly? recognised in the sense that our focus is the Mr Meadowcroft: I think it would help if I clarified neuromuscular conditions so our responsibility is to my first point which is that the problems in accessing draw to the attention of policy makers the diYculties services in England, so far as I understand it, are not that people living with neuromuscular conditions problems with the services in England themselves, it have in accessing good quality services. We are is the referral and funding mechanism to go from the working very hard to do that. There are some Welsh side of the border to the English service. We encouraging signs and, if I may say, some are thinking of Oswestry, we are thinking of the disappointing signs in the response so far. Walton Centre, but also with regard to referral to a Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mr Robert Meadowcroft, Dr Mark Rogers and Mrs Lynne Taylor specialist diagnostic centre. Certainly the as other patients become more aware of the existing neuromuscular centre in Newcastle runs an services and where they should access that service, internationally recognised diagnostic service for they are all either coming to CardiV and Swansea many conditions and yet there are delays in people where that service is, and now I am told I am on a being referred or funded to go there. waiting list for a sleep study for my son. A sleep Dr Rogers: If I am permitted to go back to the first study will be able to assess whether my son might question, certainly I see there are potential benefits need nocturnal ventilation to prolong his life. I am set up with devolution in the sense that there is the now told I am on a waiting list and if I want one now option to actually lobby the Welsh Assembly I will have to go to Great Ormond Street to access Government; you can look at a Welsh only solution. that service and I am not sure if the trust will pay for However I do feel that in relation to neuromuscular that if that was possible. I feel that I do not want to services that that option has not been acknowledged go to the service in London—which I know is a very and that option has failed. Primarily from my point good service—I feel I have a good service in CardiV of view what it seems to have produced is an extra but unfortunately there is not the funding or the layer of bureaucracy but not an extra layer of multi-disciplinary team there that I have been used bureaucracy that works, it is an extra layer of to having. That service has been depleted even more. bureaucracy that just creates a barrier and it clouds the issues. More particularly between the LCBs and Q284 Mr David Jones: If I could just revert to Dr Health Commission Wales (HCW) and particularly Rogers’ point about squabbles between Local when it comes to neuromuscular services both Health Boards and Health Commission Wales as to myself and a colleague (who happens to be based at whether or not a particular treatment is a specialist the University Hospital of Wales like myself) were service, I heard what you had to say with absolute looking at it from an all Wales perspective and not dismay. I would imagine that this process can go on from a local CardiV perspective, we put before HCW for quite a long time. a document in 2004 requesting that neuromuscular Dr Rogers: I will not say I am tearing my hair out but services be considered as a specialist service. Under the biggest frustration for me is that as the lead for any definition of specialist services, neuromuscular the genetics part of it—what I would have to services would be regarded as a specialist service and emphasise is that I am a clinical geneticist and yet they said to wait until the end of the neuroscience because I have had an interest in managing patients, review. The neuroscience review came, we had input in fact I manage a significant case load in CardiV but into that and now what has happened is that there is also cover patients from throughout Wales and I go another neuroscience review and it just gets stalled. up to Oswestry and occasionally to North Wales— At present, if the Local Health Boards are asked to the biggest frustration for me is that I would like to fund a patient for certain treatment—it usually put in a bid to actually try to look at how we can comes up with cross-border issues but it is not only improve the eYciency of the service. I am actually a cross-border issues, sometimes it is within trust relatively expensive person; it would make more issues within Wales—they will say, “That patient has sense to actually have more time from somebody a neuromuscular condition, it is specialist, it is not who is a specialist nurse or a combination of our problem” and refer it to HCW. HCW say that it specialist nurses and physiotherapists, but there is is not a specialist service, it is not their problem. The nobody who I can actually put the bid into to try to patient then ends up in a mess in the middle. improve the service because nobody will accept that Fortunately most patients somehow manage to get the neuromuscular service fits in their camp. through the system and somehow manage to get care because there are enough clinicians who are Q285 Mr David Jones: Is there nothing in place to interested and actually it is only when you start to break this log jam? complain that the diVerent trusts turn round and say, Dr Rogers: There does not seem to be. “Right, that patient has a neuromuscular condition; they come from such-and-such; we should not be Q286 Alun Michael: You have described a service paying for them”. If you are quiet things happen and issue and clearly there is a problem. Is this problem you just get away with it, but as soon as you actually unique to Wales or is it a problem that would be start to complain the service seems to stop. experienced across the UK, for instance in specific Mrs Taylor: I have a son who is 13 years old with regions within England (the West Midlands is one Duchenne muscular dystrophy, the most common of that springs to mind)? neuromuscular conditions. It is quite a debilitating Mrs Taylor: I am a contact family for the Duchenne condition where children from a young age have to Family Support Group which is a national charity use wheelchairs and it is life limiting, into late teens, and I hear similar stories across the borders in sometimes early twenties, depending on what care England, depending on where you live how they have. My issue is not so much a cross-border accessible that service is and I find the same sort of issue, my issue is within CardiV where I live. I have frustrations that I have with the care that I have for always felt the service was fairly good and there were my son. clinicians there with the expertise. Recently what I have found is that that service is becoming more Q287 Alun Michael: I suppose the other side of the vulnerable and depleting, particularly from a question is whether there are examples of good physiotherapist point of view. We do not have a practice in other parts of the UK that we could dedicated physiotherapist with the clinicians. Also, learn from. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mr Robert Meadowcroft, Dr Mark Rogers and Mrs Lynne Taylor
Mr Meadowcroft: I think that is absolutely right. hopefully developing well in Wales and, as Dr There are some very good neuromuscular services in Rogers said, building on the CardiV expertise but other parts of the UK. In some ways we could argue looking outside of Wales when necessary. that we have international expertise in the UK both in London and Newcastle and a first-class centre at Q291 Albert Owen: You said in your oral evidence Oswestry. Are other regions in England having today and in your written evidence that you have similar problems? Some are. What is the Muscular given us that the commissioning of the services by Dystrophy Campaign doing about it? We are doing the Local Health Boards and indeed by Health two things. We have argued that there should be a Commission Wales are haphazard to say the least. national standard for services, what they call a Will the recent proposals announced by the Welsh national definition with specialist commissioning for Assembly Government for the centralisation of the the services in England. We have also identified that commissioning and funding to hospitals assist with the southwest region appears to have very poor the provision of cross-border services? services compared to other regions. We have done Dr Rogers: Yes, you would like to think that there is some work with them over the past four months and the potential, but at the end of the day it is whether that is going forward very well. What the southwest or not they are actually going to recognise and has done, which I think is very helpful, is that they address neuromuscular services within that and I have undertaken a review of services that involve suspect that that is not top of their agenda. patients in the review of clinicians and they are establishing what needs to be done to improve the services in the southwest. That is a very good Q292 Albert Owen: You said that one of the response. problems was that the Local Health Boards are not engaging with each other and are looking for excuses Q288 Alun Michael: In other words we could learn not to deal with this. Would a centralised service from those sorts of experiences of the regional view, improve that? for instance. Dr Rogers: Ideally a centralised service should Mr Meadowcroft: Yes, indeed. improve it as long as that centralised service does Dr Rogers: There is absolutely no doubt that there actually take decisions and has some sort of teeth are services, particularly at Newcastle and the and power. The frustration with HCW is that HCW Scottish Muscle Network System that is based should have been an authority that could make around Glasgow; those are very good examples. One decisions and could actually have some sort of of the frustrations is that CardiV was one of those power. I do not want to get into the politics of things, centres; CardiV, to a certain extent, still does have a but basically there did not appear to be enough lot of that expertise. Some of the protocols that I funds to go round for the number of services it was developed in CardiV have been taken over by supposed to be providing specialist care for. That is Newcastle. Newcastle has been able to move the reason why it dragged its feet on recognising forward; we have just stagnated. What has happened neuromuscular services as a specialist service, for a period of time is that CardiV has just marked because there just were not the resources to fund the time. Now, as people who have been working within services that were already labelled as specialist the system are now retiring, there is no succession services. planning and there is no training of people to come up and to replace them so the service, as Lynne has Q293 Albert Owen: You think there should be said, is just declining and diminishing. specialist services also commissioning at the board level for specialist services? Q289 Alun Michael: Do you think it is realistic to Dr Rogers: Yes. think that Wales can sustain its own neuromuscular Mr Meadowcroft: I think the members of the services without having an interchange with other Committee will know that there is a review of regions of England, for example? specialist services taking place led by Professor Dr Rogers: Not with no interchange because the very Aylward and I think he may have reported to the nature of a number of the complications means that minister in the past week or so. The minister, Edwina you are always going to need to be able to go to some Hart, in the Welsh Government has said that in her centres in the UK and if some patients want to access view there should be a managed clinical network for particular specialist services which might be right at neuro-disabilities. We are slightly anxious about that the forefront and where there is research being done, because neuro-disabilities would include, for then you will need to go to that research centre which example, cerebral palsy which is a very diVerent kind might be London or it might be Newcastle. of condition than our conditions, there is diVerent clinical treatment. We very much want to see a recognition that the neuromuscular conditions Q290 Alun Michael: The sort of review of services themselves need a separate approach, a skilled that you are talking about would be a review of specialist approach rather than being subsumed in a requirements in Wales together with how the broader group. interfaces manage with the diVerent regions of England. Mr Meadowcroft: Yes, very much so, with the Q294 Albert Owen: But at a Welsh level. objective of having a service so that patients can Mr Meadowcroft: Yes, across the UK but for this access high quality services wherever they are, discussion today at the Welsh level. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 50 Welsh Affairs Committee: Evidence
29 April 2008 Mr Robert Meadowcroft, Dr Mark Rogers and Mrs Lynne Taylor
Q295 Albert Owen: You also referred in your Q299 Albert Owen: If that centre of excellence is in memorandum to the refusal of certain Local Health Newcastle would you envisage patients having to Boards to pay for services provided in England. On travel from Wales to that point or would you see a what basis is this payment refused? Is the refusal to collaboration with Local Health Boards or trusts so pay justifiable? that they would have the diagnostic and clinical Mr Meadowcroft: The refusal to pay appears to be treatment closer to home. because there is a mistaken belief—mistaken in our Dr Rogers: It depends a little bit on the particular view—that there is an existing physiotherapist issue because sometimes the clinicians will prefer to service within the LHB. It is not a specialist see the patient themselves to know exactly what they neuromuscular physiotherapy service and it is the are dealing with. In other circumstances they will be recognition that patients with the kind of diYculties more than happy to take my word for the clinical that Lynne’s son has need specialist physio. At my description of what I am saying, together with the kindest I think it is a refusal to recognise the sample they have in front of them. Again it would be distinction. What is the impact of that? We are a mixed type of model. Hopefully because it is such funding the specialist physio service and making up a long way for patients to go, most patients would the shortfall at the centre in Cheshire at the not need to go but there are circumstances where Winsford Centre. definitely the nuances that can be achieved by looking at the patient is particular relevant. They have the expertise in that and they should go and Q296 Albert Owen: Are they refusing to pay because see them. the service is provided in England? Is there an England/Wales issue here? Q300 Mr David Jones: There was one answer you Mr Meadowcroft: Yes, I think there is. gave, Dr Rogers, which rather concerned me. You suggested that there was a dragging of feet in terms Q297 Albert Owen: You also state in your of designating certain services and specialist services memorandum that the UK Government should because of financial constraints. Is that what you consider establishing a centralised fund for rare said? conditions. Again you have touched on that. How Dr Rogers: I think that is what I said. would that work in practice? Mr Meadowcroft: The model in our minds is the Q301 Mr David Jones: Could you expand on that National Commissioning Group (NCG) which please, because that sounds really quite alarming? operates in the NHS in England which sets aside a Dr Rogers: That is the impression I got. I may be small sum of money for the kind of specialist wrong about it being the reason, but we have never diagnostic services that Dr Rogers spoke about. One been given any specific reason and the impression of the problems we have in Wales at the moment is that we have been given was that because the that there can be a diYculty getting funding to send resources were so limited financially to Health people and to send samples to Newcastle for the Commission Wales they did not have enough diagnostic service. Without a clear, defined diagnosis resources to actually provide the care to everybody V the services themselves can be problematic. else who e ectively was on their books and therefore if we were applying to be another member then basically we did not stand a chance. I have nothing Q298 Albert Owen: So there are no satellites now in in writing. Nobody ever wrote because nobody ever Wales that deal with this rare condition? As we have actually made a formal response to the document seen from the evidence we have taken from the that we sent to them in 2004. We still have not had a Walton Centre, for example, they have satellites in response. North Wales. Are you saying that does not exist? Dr Rogers: Not realistically, no. It depends on Q302 Mr David Jones: Are you pressing for a whether you are looking at the clinical point of view response? or the diagnostic point of view or the molecular Dr Rogers: We have been pressing for a response and point of view because those are all separate issues. I each time we have pressed for a response we have think one of the problems when it comes to been told that we need to wait for the outcome of the diagnostic and molecular issues is that these are such neuroscience review. When the neuroscience review rare disorders that it does not make sense to have a had been published and we then pressed for a Welsh system when you are talking about a response there was a delay and then of course what condition which is so rare that only one place in has happened is that there is another neuroscience England is able to do it. We need to be able to use the review. The answer is that we will have to wait for the resources that are present in England as well. To start next neuroscience review. The neuroscience reviews oV with, when devolution first started, we were able are not really looking at the issues of neuromuscular to use those resources and there was no problem, but services; they are focussing on other things. over the years what happened is that a decision was made that we were not going to be contributing to Q303 Nia GriYth: I would like to clarify a little of the funds of those centres so those centres then what you have said to us so far. From what I turned round and said that they were not able to understand you are saying that there is very often a provide a service for us if we are not actually going problem with the Local Health Boards either to be contributing to it. because they see the services too specialist, ie it must Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mr Robert Meadowcroft, Dr Mark Rogers and Mrs Lynne Taylor be the Health Commission Wales who deals with it, needs to be done at an expert centre; it is not the sort or they do not see it as specialist enough, in other of thing where there is enough expertise in Wales to words they think their own physiotherapists can do it in Wales. carry out the procedures for which you need a more specialised person. Am I right in thinking that the Q306 Nia GriYth: If we take that first layer that you issue then of funding with the LHBs applies both are talking about, you are saying that Wales is big within Wales and if you go across border, then you enough to sustain that model on its own. also have the problem with Health Commission Dr Rogers: Yes. Wales if it is cross-border? Mr Meadowcroft: Yes. Q307 Nia GriYth: But it would have to be bigger than any LHB, in other words it would have to be at Q304 Nia GriYth: You have also now indicated that an all Wales level and probably the people you are possibly some areas are so specialist that a unit on its sending out you would not have one per LHB. Even own is too small to be looking at it so it has to an with the reorganised LHBs they might be taking two England and Wales initiative. or three of the newly created larger units that we are Mr Meadowcroft: Yes. now creating. Dr Rogers: Yes but I think this is where again cross- V Q305 Nia GriYth: How do you really see the way border issues come in. In Cardi I have in the past forward and what would be the ideal solution in gone up to Glan Clwyd Hospital and Bangor terms of strategic planning in order to ensure proper Hospital and done clinics up there. When I was first care for all patients in Wales? appointed as a consultant six years ago I seriously Dr Rogers: I am very much in favour of what is considered whether it would be realistic to think known as the hub and spoke kind of model in the about trying to set up a clinic in Glan Clwyd, but sense that if you could have a centre of excellence actually there still is not the population in North Wales to really justify a service on its own even as a where you have enough experience, excellence and V knowledge of the particular conditions and enough sort of outreach of Cardi , especially when you have patients coming that you can build up that Oswestry and the Walton Centre so close across the experience, excellence, teaching and succession border. That is not so easy,I admit, for patients in the planning, but that is not good enough for far reaches of Anglesey—they found it much easier somewhere like Wales. The trouble with that is that to come to Bangor—but somewhere along the line patients have to travel such long distances that it is we probably do need to compromise and look at the Y pragmatics of it. We probably cannot give our ideal very di cult to deliver that care in Haverford West V or in Aberystwyth or in Bangor. You need to have solution, I would see maybe a centre in Cardi or some way of actually reaching out to the patients South Wales that could cover two-thirds of Wales, who are at long distances. Some of that comes and maybe North Wales, we just have to accept through education and knowledge so at a realistically that the problem of going to Oswestry physiotherapy level you can have the expert and the Walton Centre are the best options for the physiotherapists based in one centre. They can then patients. go out and lecture and talk and advise physiotherapists locally so that you can eVectively Q308 Nia GriYth: Are you saying that in an ideal get a shared care type of model. Some of the care can world, if you were drawing your hubs and spokes be delivered close to home with local from scratch, you would like to do it without the physiotherapists but some of the care can also be constraint of having a Wales/England border and delivered and the expertise taught by somebody you would like to draw it on the best geographical more centrally. When there is then something which proximity model. is supremely specialist then we need to turn to Dr Rogers: Yes. England or somewhere else. A good example of that would be not in one of the conditions which is life Q309 Nia GriYth: You are also therefore raising the threatening but in facioscapulohumeral muscular whole question of the complications of funding and dystrophy; a lot of the patients there cannot lift their then the complications again in your larger model arms above that height but if you fix the scapula then with more specialists where you would be going to they can do that. That is a relatively simple England; do you see any particular way out of that operation to do but it needs a specialist who has a lot problem? Can you see a way of resolving the delays of knowledge and experience in it and there are only and the problems that currently you are very few centres that can actually do that. The only encountering? centres that I know of, that do it, are in England. Dr Rogers: If you do have a central pot of money There is one case which I can think of, one of my that recognises that there are maybe certain patients had her first operation before anyone procedures that will be accepted as being realised they were not going to be paid for it. There automatically funded, that you do not have to go was a problem getting the second operation. When through certain channels that get delayed, then you people realised she came from Wales they realised could turn round and say, “Right, spinal surgery for they were not going to be paid for the operation. We a child; most of that could probably be done in went to the LHB, it has now been bounced to HCW Wales” but if you have a child from mid-Wales who and we are not quite sure where we are sitting in it. would normally go to the orthopaedic hospital in She is waiting for the operation on the other side. It England then that should automatically be funded. 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If somebody was able to identify a central fund, you Mr Meadowcroft: Yes. should be able to calculate roughly how many of these procedures would be required a year, so it is not Q317 Mr David Jones: There are regional protocols as if we are talking about a limitless pot; you should in existence at the moment although, as we have be able to estimate roughly how many procedures already heard in this inquiry, they are not actually would be required. enforceable, they are purely memoranda of understanding. You referred to an improved Q310 Mr David Jones: In paragraph 1.5 of your protocol. Is there any government level protocol in memorandum you say that “there is little place at the moment? accountability when failures relating to cross-border Mr Meadowcroft: I am not aware of one. Dr Rogers issues occur and greater transparency in the system may be aware of one. is urgently required”. Could you tell the Committee Dr Rogers: I am not aware of one. how more accountability could be introduced into the system and similarly what could be done to improve transparency? Q318 Mr David Jones: I understand that the Mr Meadowcroft: The problem we are flagging up Secretary of State for health—the Westminster here is that the waiting times for patients referred to Secretary of State—has recently expressed similar services outside England are not recorded in the concerns about the lack of a protocol. Are you aware usual way so the delays are not being publicised in of that? terms of waiting lists and so on. Greater Mr Meadowcroft: I am not aware of that. transparency in publishing those waits would allow people to see where the problems were and for them Q319 Mr David Jones: You are obviously aware of to be addressed. the recent announcement of proposed changes to the NHS in Wales and the merger of Local Health Q311 Mr David Jones: How are they currently Boards. Do you think that will help or hinder cross- recorded? border health provision? Mr Meadowcroft: I am not sure. I think there was a Mr Meadowcroft: I do not have a view on that yet. I decision taken not to publish those waits to the out- think the move to having fewer Local Health Boards of-country services. may well be helpful because there are such small numbers of people with neuromuscular Q312 Mr David Jones: So we have no statistics at all conditions—we are talking about 3000 in Wales— that we can work from. and when they are dispersed across 22 LHBs they are Mr Meadowcroft: I will need to come back on that less visible than they would be across a smaller point if I may, but that is my understanding, that we number of LHBs. That ought to be helpful but there do not collect those statistics at the moment.1 are other things that need to take place as well. That administrative change on its own will not solve the Q313 Mr David Jones: Clearly you would like to see problems of lack of specialist physios, lack of that start to be done. neuromuscular services. However, I think it might be Mr Meadowcroft: Very much so. Our report has a step in the right direction. highlighted the delays that are taking place in referrals to the Oswestry Centre but they are not being flagged up in the ordinary way as LHB delays. Q320 Albert Owen: Do you think the structures of That is my understanding of that. Local Heath Boards should be coterminous with the NHS trusts? Mr Meadowcroft: We do not have a view on that, but Q314 Mr David Jones: That is the issue of it would seem to make sense from the outside. transparency; what about accountability? Clearly we are focused here on the medical model of Mr Meadowcroft: For me it follows on that if we care. There is also a local authority dimension as well have transparency on the delays and the problems and we do wish to see much better liaison and patients are facing, then we can have an cooperation with local authorities on the social accountability to sort that out. care side. Q315 Mr David Jones: Which body should be held to account? Q321 Chairman: In ending this session could I place Mr Meadowcroft: I would have thought it would be on record our appreciation of the report that you the LHB if they are the cause of the delay in the published.2 You impressed us and it was one of the patient being referred to access of a service. main reasons why we invited you to come along and give evidence. Also your memorandum was Q316 Mr David Jones: You go on in the same extremely helpful to us and your evidence today. I paragraph to call for an improved protocol between should declare an interest. One of my friends wrote the Welsh Assembly Government and the to me, Mr Ray Thomas of Neath who is one of your Department of Health to deal with any discrepancies on cross-border issues. Presumably you are talking 2 Building on the Foundations: The Need for Specialist about a government level protocol. Neuromuscular Service across Wales, Muscular Dystrophy Campaign, February 2008 www.muscular-dystrophy.org/ campagns/building—on—foundations/building—on— 1 Ev 179 1.html Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mr Robert Meadowcroft, Dr Mark Rogers and Mrs Lynne Taylor keen supporters, and he urged us very strongly to backup. Sometimes they are told the news by a GP listen carefully to your evidence. It occurs to me that or somebody who is inappropriately trained to give your Campaign is very much a carers’ organisation that news. Then they are left in limbo for years. I and I reflect on the mantra that is currently being have spoken to so many families and they want to used in Wales, namely that one should have a know about what care a child can have, accessibility patient’s voice rather than patient choice. Do you to school. You then go on to grants and trying to have an observation on that beyond the role of access grants. In CardiV that is particularly diYcult. organisations like yourselves? You are clearly a I know a family who had great diYculty trying to get patient’s voice and a carer’s voice, but are there a grant for their son to have a downstairs toilet. In other voices within government and within LHBs my case the transition to adulthood I am very, very that are being raised on your behalf and are people worried about how I will get the service for my son listening to you? when he is older. He is 13 now; he has got a cough Mr Meadowcroft: I understand the point; I am going assist machine but because the service is depleting to ask Lynne to comment too, if I may. From my will I get ventilation for him? I have to have point of view, is government listening to us or are the ventilation for him in the next few years otherwise he LHBs listening to us? I think the Campaign is is not going to be here. It is not just me; there are Y making an impact not because of anything that I am other families in Wales with the same di culties and doing or my colleagues are doing but because of frustrations, particularly when I am told that my son people like Ray Thomas and people like Lynne. I needs physio and but there are not enough physios think the voice of people living with the conditions to give him physio. It is not one or two sessions a quite rightly is powerful and they are living with it week, it is on-going physio to prevent contractures. from day to day. To see people with devastating There is corrective wheelchair service as well; you struggle with wheelchair services trying to get conditions like Duchenne, living their lives as full as appropriate seating for the children to prevent them they can and getting a quality of life as best they can, having corrective surgery. There are all these it can be inspiring. The other side of the coin is that professional groups and health professionals that when the care and support are not there people’s you need to prolong your son’s life. lives are limited and frustrating. We are committed Chairman: Thank you once again, all of you, to engaging with people with the condition to allow particularly Mrs Taylor for your evidence. We will them the opportunity to come and speak to you take very seriously everything that you have said. If today in Lynne’s case or other opportunities too for you feel that there are other matters in the light of the that voice to be heard. We are committed to that. evidence you have given and questions that we have Mrs Taylor: Can I pick up on the quality of life asked, if you would send in a supplementary point? That is the main thing you think about with a memorandum we would be very pleased to receive it. child. I do hear such tragic stories from a diagnostic Also, if any of your members who might want to give point of view of this condition. These families are testimony themselves, it is greatly appreciated as we told news with no support whatsoever; there is no have seen today.
Witness: Mrs Wendy Farrington Chad, Chief Executive, the Robert Jones and Agnes Hunt NHS Orthopaedic and District Hospital NHS Trust, Gobowen, gave evidence.
Q322 Chairman: Welcome to the Welsh AVairs patients. Clearly our close proximity to Wales Committee. For the record could you introduce enables that to be highly beneficial to both sides. We yourself, please? refer to ourselves as an Anglo-Welsh provider. In Mrs Farrington Chad: My name is Wendy terms of devolution, clearly there has been an Farrington Chad. I am the Chief Executive of the opportunity through devolution to improve the Robert Jones and Agnes Hunt Orthopaedic access to services provided through our hospital for Hospital in Gobowen. Welsh patients. We have seen over time the waiting times for treatment from Welsh commissioners Q323 Chairman: I understand that Dr Quinlivan is reduced which is clearly an advantage. We have unable to be with us today. experienced though through devolution an increase Mrs Farrington Chad: Unfortunately Dr Quinlivan in the questioning of patient referrals to our hospital is ill today and is unable to attend. through processes such as the prior approval process, through processes for approval even on Q324 Chairman: Could I begin by asking a general contracts that we have with LHBs and this can put question about what you consider to be the impact some delay and confusion into the process of of devolution on health services for Welsh patients treating patients. Generally that has resulted in the and what opportunities and challenges have been hospital increasingly needing to justify its treatment created by devolution in the field of health? for patients from Wales and our clinicians having to Mrs Farrington Chad: You may be aware that the describe the treatment in detail prior to patients hospital has a long history of serving Welsh patients being referred. Previously they would have come of which we are extremely proud. That goes back through to Gobowen directly and that treatment prior to the formation of the NHS so we have a very would not have been questioned. Some of our long history, over a hundred years of serving Welsh services, as you may be aware, are unique even in Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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England in terms of provision. Some of them are Q330 Alun Michael: Can you just explain that? general but we do provide specialised services. It is Surely once a referral is made surely the delay is with very important, particularly for specialised services, you rather than being cross-border. Why does the that access to those treatments is not delayed delay diVer? unnecessarily. Clearly we all need processes in place Mrs Farrington Chad: The Welsh Local Health but that should not put unnecessary delay in the Boards work to diVerent waiting times than the system. English primary care trusts so we have a diVerent contractual commitment to the LHBs. In England the waiting time for treatment is currently now 18 Q325 Alun Michael: You refer to specialist and weeks; it is longer in Wales. The waiting time in general services; could you give us some of the Wales is generally longer than in England. breakdown, what proportion of the care you provide is specialist and what proportion is general? Q331 Alun Michael: I understand that in terms of Mrs Farrington Chad: It does vary across the wide target and performance, but surely once a referral is geographical catchment that we have, but in terms of made to you it is a matter of your processes rather Welsh patients the split roughly is one third specialist than the referring body. and two thirds general, the general tending to be Mrs Farrington Chad: We can only treat patients based around our geographical catchment being the more quickly if the contract or volume that the north of Wales and mid-Wales. The specialist covers purchaser signs up to is suYcient to meet that those areas but also areas further into Wales and waiting time. indeed in South Wales. Q332 Alun Michael: I do not think I quite Q326 Alun Michael: Perhaps this relates to the understand this. That means that because of the question you raised in your answer to the Chairman. contractual arrangements you have to deliberately You refer to the delays that arise from the delay the treatment that you provide to Welsh patients. questioning of referrals; is that questioning mainly in Mrs Farrington Chad: It is not about delays. The relation to general referrals or to specialist referrals? analogy I would use is that it is eVectively a queuing Mrs Farrington Chad: It can apply to both but for system. The more people queuing, the longer they general referrals some commissioners have put in a wait. The Welsh Commission has asked us to meet process for prior approval for all activity as a way to waiting times that are in excess of the English system manage their contracts. Of course we are obliged to so in eVect their queue is longer. That is not work to that. Where we do not have contracts for something that the trust decides; that is a policy services—non-commissioned activity as we would issue, as I understand it. call it—then we need to obtain prior approval for every referral. That can take some time, depending Q333 Alun Michael: Perhaps I am being slow on this, on the nature of the service in question. but I would have thought that the judgment on where you take people oV your list would depend on Q327 Alun Michael: Is that clinical questioning of the clinical circumstances rather than on a contract. the referral or is it purely administrative? Mrs Farrington Chad: Certainly, and that is one of Mrs Farrington Chad: It is both in eVect, it is the points I would wish to make to the Committee, clinically questioning the need for the patient to that our clinicians would prefer to treat patients on actually come to the hospital in Gobowen rather clinical priority and not on waiting time. However, than be treated perhaps more locally. we do have to adhere to waiting times within the Local Health Boards and some Local Health Boards actually view those waiting times as a minimum, not Q328 Alun Michael: So it is questioning the a maximum. With the prior approval process we are clinician’s judgment who has made the referral. told by some health boards in eVect when we can Mrs Farrington Chad: Yes. treat patients which does cause extreme anxiety for clinicians.
Q329 Alun Michael: What other issues arise when Q334 Alun Michael: The prior approval I you are providing services to Welsh patients? understand, but leaving that on one side for the Mrs Farrington Chad: As a hospital and particularly moment once somebody has been fully referred are V in terms of our location we e ectively operate two you saying to me that the contracts mean that systems providing services to England and to Wales. because there is an expectation of shorter waiting We recognise there are diYculties and that should times from an English body making a referral, to not cause a problem. The prior approval process fulfil your contractual obligation you have to allow does cause some diYculty, particularly also the those patients to go higher up the queue than diVerence in waiting times for treatment between patients from a Welsh LHB because that LHB’s England and Wales which is particularly focused contract will be more tolerant of a longer delay? around the borders because the populations are Mrs Farrington Chad: No, it works on clinical mixed and they do not recognise the barriers and and priority. The waiting time is contractual; the waiting the diVerences between two systems. That can cause list is clinical. The two have to come together in confusion for patients. terms of performance. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mrs Wendy Farrington Chad
Q335 Alun Michael: I do not think I understand Mrs Farrington Chad: Certainly that would be the that. How can it be clinical if the contract then forces case. In fact in 2006 the Trust undertook a a longer wait? consultation on Foundation Trust proposals across Mrs Farrington Chad: Because the waiting time is an its whole catchment and actually developed a average. In terms of the contract it is measured on membership from that of which 25% were Welsh average waiting time. Some patients could wait less residents. There was a lot of interest from Wales. than a week, some patients could wait longer. The Similarly with staV, over a third of our staV live in waiting time is an average system. Wales and a large number of them are Welsh speaking, so again that was representative of our Q336 Alun Michael: Yes, but the whole point, surely, catchment. is that that is holding you to account for your V performance; it is not forcing you to take longer than Q340 Mr David Jones: How do the di ering the times, which are meant to be maximums and not payment regimes for Welsh and English healthcare minimums, of course. impact practically upon your Trust? Mrs Farrington Chad: It is holding the trust to Mrs Farrington Chad: The Trust operates a number account for performance but it is also a performance of payment regimes. For England in the majority it V that is agreed with the Health Board, it is not is related to the tari which is the payment by results something that the Trust solely on its own can system which is in place in England. For specialised manage. It is about working with the Health Board services in England and Wales we operate a cost for and it is what they require and set as their case actual cost basis. For LHBs in Wales we operate commissioning priorities. We respond to those agreed prices which are based on historic contract priorities. service agreements. Alun Michael: I think it would be useful perhaps to have some follow-up to this because we have gone as Q341 Mr David Jones: Does that result in a loss so far as we can here and we do not have a clinician with far as patients referred to you by Welsh LHBs are us. I must say that I am surprised by what you say concerned? and I am afraid it does not make sense to me. Mrs Farrington Chad: No, it does not. It is quite interesting because the Trust costs as a specialist provider are in excess of the tariV system that is Q337 Mr David Jones: Is a consequence of this operated in England. In actual fact we would prefer therefore that a patient from England referred to you an actual cost arrangement because that recovers after a patient from Wales may be treated earlier very openly only the costs you incur and there is no than the Welsh patient? loss or gain on the services. The tariV, as you may be Mrs Farrington Chad: Potentially. It would depend aware, in England is based on an average system and on the clinical circumstances. I really do not think it due to the specialist nature of some of our service is appropriate to put a hard and fast response to that. provision that does not always cover the actual costs involved. The system with the LHBs based on Q338 Mr David Jones: Is that a possible historic cost does cover the cost involved, although consequence? whether that will always be the case in the future we Mrs Farrington Chad: Yes, it is a possible would need to consider. consequence, but the hospital does not function in that way and no hospital would function in that way, Q342 Mr David Jones: Would you prefer to operate which is why we have some issues with the system under one regime or are you happy to operate under because it is the clinicians who are actually trying to the two or three separate regimes you have get their patients through on a clinical basis and were mentioned? being tied by the restrictions of the regulations and Mrs Farrington Chad: As a Trust we are perfectly rules, it is not the other way round. happy to operate a number of regimes. That is about agreement locally and nationally with Q339 Alun Michael: As I say,I think we have reached commissioners. It is perfectly reasonable and V the limit of what we can intelligently pursue here, but acceptable and we are capable of operating di erent I wonder whether we might, in view of the fact that systems. We do not see that as a barrier in any way. because of illness we do not have the clinician here, ask for evidence of what happens in practice from a Q343 Mr David Jones: Therefore it is not more clinical perspective. I still do not understand how the profitable for you to treat patients from mid-Wales outcome ends up. Can I just explore one other thing, rather than patients from England or vice versa. and that is your moving to Foundation Trust status. Mrs Farrington Chad: No, there is no diVerence, and Obviously as a Foundation Trust the membership of certainly that would not be a driver in terms of our the Trust will be drawn from patients, the public and approach. staV and that is very important. Will that system enable people in Wales who are part of your natural Q344 Mr David Jones: As a specialist care provider catchment area or have a specialist interest to be you clearly deal with both Local Health Boards and members of the Trust, bearing in mind obviously Health Commission Wales. Would you prefer cross- that some people getting access to specialist services, border provision to be managed by a single as you said earlier, might come from a very wide authority or are you happy for the current catchment area across the Welsh border. arrangements to prevail? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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Mrs Farrington Chad: As a Trust we see the national they wait no longer than 18 weeks and in Wales no commissioning arrangements in Wales working very longer than 26 weeks. That is built into the system well. The Health Commission Wales agreement and and you are saying it is the LHBs that use that as a the individuals involved work very well. There are yardstick and that is where the problem is. Can I ask some advantages in a single commissioning body, you a practical question? If somebody from my certainly in terms of dealing with one agency. In constituency in Northwest Wales was to phone up eVect that would be an advantage. If that were part and say, “I have been waiting; I have been to see my of a single approach as well then that could have GP” what would the response be of your some advantages, although potentially it could administrators? Would they say, “Yes, you have to remove the local flexibility particularly around the come on the list because of the LHB” or would you LHBs and their local population needs. There could say to them, “You are going to wait a minimum of be a potential that that was not taken into account, 26 weeks”? but as a Trust we would support particularly Mrs Farrington Chad: No, that would not be the specialised commissioning for specialised services. response. They would go on the waiting list as any That would seem to be a sensible route to develop patient goes on the waiting list and they are drawn for Wales. from the waiting list based on the consultant’s assessment of their priority. I would probably speak Q345 Mr David Jones: Do you welcome the for all my consultants and say that that is all they proposed merger of Local Health Boards in Wales? would like to look at. They really do not like to be Would that make your life easier? bothered by waiting times and contracts; they prefer Mrs Farrington Chad: We welcome that. We have to treat patients on clinical priority and that is what very good relationships with the Local Health we allow to happen within the Trust and quite rightly Boards we deal with, particularly in North Wales so. However, we do have to monitor the actual and in mid-Wales, although we welcome further treatment times of patients because we are bound to integration of commissioning. We are happy to work do that and LHBs are bound to do that for their with those developments. patients as well, so we do have to keep a track of patients. If patients are coming up for long periods Q346 Albert Owen: I may not have heard you with of wait then obviously we discuss with clinicians in regard to the deficit for treating Welsh patients. trying to prioritise those cases forward. When we took evidence earlier from the Walton Centre they said that 20% of the patients come from Q349 Albert Owen: You have said that there is a Wales but 16% of the funding, so there was a deficit problem with the two waiting time diVerentials. of some 4%. It could be argued from a Welsh Mrs Farrington Chad: It is the published diVerence perspective that the Welsh Assembly Government in waiting times between England and Wales. get a good deal by the cross-border issues. It is not Whether that is actually the experience is another an issue for you, you have not calculated that. issue. Some patients get treated more quickly; some Mrs Farrington Chad: Our position as a Trust is patients wait a lot longer because they are trying to possibly slightly diVerent in that we do not gain from access specialised services where maybe there is only the tariV system. Some trusts in England are tariV one clinician available. It does vary, but the gainers, as they are called; they actually gain from published waiting times and what goes out into the the average system. We do not gain from the average public agenda are diVerent figures and I think that is system so we are actually looking at reducing our the issue that causes confusion. costs across the board because of that. So we are in a slightly diVerent situation. Q350 Albert Owen: Are they reflecting the reality of Q347 Albert Owen: So you would not be looking to the situation? renegotiate with the Welsh Assembly Government Mrs Farrington Chad: Absolutely. for the current financial period. Mrs Farrington Chad: No, we can operate the two Q351 Albert Owen: That is the point I am trying to systems as we have done for many years and Welsh make. I understand what the consultant would say, is proportionally a larger part of our activities than but the pressure on the Trust from the National maybe the other centres so we are more used to the Health in England is the same: meet this 18 week diVerent currencies and arrangements. target. That is going to cause the diVerential, is it not? As managers you have to manage that Q348 Albert Owen: That explains that, thank you situation. very much. I want to come back to the performance Mrs Farrington Chad: We have seen over the recent targets and waiting times. I understand what my years both England and Wales have attempted to colleague, Mr Michael, says about nobody from the reduce their waiting times, so they have both come clinical side being here, but is it my understanding down at a steady level. As a Trust our activity is not that for the non-emergencies—we are talking about managed on that basis overall, so we have reduced non-emergencies on this, if there was an emergency waiting times for both England and for Wales. there would be no diVerential whatsoever and Indeed, the discussions with Welsh and English somebody would be flown in from a mountain in PCTs is about where we cannot achieve that for all Wales or the Peak District in England and severe patients. As a Trust we have the same issues across injuries would be dealt with regardless—in England the board. Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 57
29 April 2008 Mrs Wendy Farrington Chad
Q352 Albert Owen: But there is less pressure on you disruption and anxiety. If those were perhaps dealt as a Trust from the Welsh side of the border than with through the specialised commissioning route there is from the English side. then maybe it could work better. Mrs Farrington Chad: I think that depends on the individual LHB or PCT discussion. Certainly locally within North Wales we are under some considerable Q357 Nia GriYth: Do you think the patients should pressure from our LHB to treat more patients and have more information immediately available from reduce waiting times, which is obviously what we their GPs at the point of referral rather than waiting want to do and that is what we are there to do. down the line and then finding out that things have not been done that need to do be done? Q353 Albert Owen: You would prefer a universal Mrs Farrington Chad: Certainly, and the feedback waiting time across the whole of the United we get from the patients is that they want to be Kingdom, England and Wales; it is as simple as that. treated in our hospital and they are very unhappy Mrs Farrington Chad: Yes. when it is suggested to them that they have to go elsewhere. Q354 Nia GriYth: The Committee has heard from the Bishops of Hereford and Monmouth about Q358 Alun Michael: Some of the questions I want to patient confusion and obviously we have thoroughly ask perhaps relate to that. In some quarters there explored the issue of waiting times. Do you think seems to be some pressure for health services for there are any other issues which are particularly Welsh patients to be provided within Wales alone. If confusing to patients or indeed to those of you who that were to happen how would it aVect your Trust? are trying to administer the system? Is it practical or is there a need for a critical mass of Mrs Farrington Chad: The prior approval process patients for certain services to be provided at an causes confusion because that is building in a delay which may not result in a treatment. That can often acceptable level? lead to increased frustration. I think generally if Mrs Farrington Chad: In terms of the impact on the patients know what to expect then there is less cause Trust I have described the proportion of activity that for complaint. It is the lack of understanding that comes to the Trust from Wales and that is 30% of our often causes the complaint. Any delay or not income in total which is around £21 million. Quite responding and then potentially being refused simply the Trust would not be viable or could not treatment at the end of that does lead to complaints sustain itself as an organisation without that activity and we have had a number of issues raised with us from Wales. I think the inter-dependence there is from patients and from Assembly Ministers and clear. It is not just income that is extra over and MPs as well in terms of that sort of diYcult situation. above the basic funding level, it is fundamental to support a large group of staV who are all employed Q355 Nia GriYth: Very often presumably for the and live predominantly locally in and around the patient it is the first time or the only time so they are Oswestry and North Wales area. In terms of your not used to the system. Does it put an administrative second point around the critical mass, certainly for burden on your staV to respond and to explain and some services there would be a critical mass issue to operate the system? involved. We provide spinal injuries services and we Mrs Farrington Chad: Yes, it does and it puts them are one of ten centres in the UK. The population in a very diYcult position as well because patients do coverage of those centres is around the five million not often understand the Health Board and the total which, for us, brings our catchment beyond the policy issues; they see all the access and waiting West Midlands, Cheshire and North and mid-Wales issues as being the Trust and the hospital and that is so that there is a critical mass in those services. quite right. My staV are sometimes in the position of Similarly with the paediatric neuromuscular service almost justifying the diVerent systems and the we are one of only four centres so that is an even processes whereas really that is not their position to rarer incidence and there is a need to concentrate do that. We really want to treat the patients and see very scarce and specialist clinical and financial them in the hospital receiving the high quality care resources to provide the high quality services. For we provide. more general services most of the access would be around the geographical location where it is simply Q356 Nia GriYth: Would you see a way then of more convenient for residents from North and mid- eliminating this issue and minimising the diYculties? Wales to be treated in Gobowen. There is a mix of Mrs Farrington Chad: In terms of the prior approval issues there, but critical mass certainly would come system I think it could be made to work better if into play. certain activities were perhaps excluded from that and particularly some of the more specialised treatments that we provide. Maybe that could be Q359 Alun Michael: Looking at one area, which is done through Health Commission Wales almost the Powys LHB which obviously is local to you, the agreeing what those procedures would be. Certainly consultation document on restructuring the Welsh there are some areas of activity—spinal surgery is NHS proposes that Powys LHB will no longer one of them and the paediatric neuromuscular provide secondary care services. How would that service is another—where they are fairly low volume aVect the services that you provide in the Trust in areas but they can cause a lot of confusion, general? Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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29 April 2008 Mrs Wendy Farrington Chad
Mrs Farrington Chad: I am not sure that would aVect Mrs Farrington Chad: Certainly, and as an us directly. We do not have any direct involvement organisation we have suggested through the with Powys’s secondary care services; we act as a Department of Health on some issues we have had separate provider to them. to resolve that there should be such an agreement in place, typically around issues of finance, contracts and settlement of such matters. Q360 Alun Michael: So it should not directly aVect them. Q365 Mr David Jones: Are you aware of any current Mrs Farrington Chad: No. cross-border arrangements to regulate the devolution of health services between England and Q361 Mr David Jones: Have you had any Wales? involvement in eVorts to produce an English/Welsh Mrs Farrington Chad: Not directly, no. protocol on the provision of cross-border services? Mrs Farrington Chad: I have not personally, no, but Q366 Mr David Jones: We have evidence of an I have been in this post for only a year so it may informal arrangement between mid-Wales and the predate my taking up the chief executive role. West Midlands. Are you aware of that? Mrs Farrington Chad: Not that I am aware of but I may understand it as something diVerent. I am not Q362 Mr David Jones: I think you were here at the aware of it from your description. previous evidence session and heard the previous witnesses suggesting that such a protocol would be Q367 Mr David Jones: Are there any practical helpful. Do you think it would be helpful? diYculties caused to you by diVerent clinical Mrs Farrington Chad: I do. I think it would be guidelines and frameworks operating in England helpful in terms of consistency, although I suspect it and Wales respectively? may be diYcult to gain agreement and consensus Mrs Farrington Chad: None that have been brought because the issues would be diVerent across diVerent to the attention of our board in terms of clinical borders in and around Wales. Certainly in terms of guidelines. The main issues have been around intention it would be something from both England administrative and contractual arrangements. The and Wales that should be taken forward. clinical guidelines I think are broadly consistent and we have some very good and strong clinical links with other providers in Wales. Q363 Mr David Jones: What diYculty do you Y perceive? You referred to di culties across Q368 Chairman: Thank you very much for your V di erent borders. evidence. Could you convey our good wishes to Dr Mrs Farrington Chad: One example may be the Quinlivan for a speedy recovery and also ask her if application or otherwise of the tariV system. It may she would address from a clinical perspective the benefit some LHBs and some English providers and questions that have been raised by colleagues here it may dis-benefit others. Gaining a consensus on today in relation to waiting times? such an issue I suspect will be diYcult. Mrs Farrington Chad: I certainly will do that and I am sure she will be very happy to respond.3 Q364 Mr David Jones: If that protocol were to be Chairman: Thank you very much. carried out at a government level then surely that issue would not arise. 3 Ev 215 Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 59
Tuesday 13 May 2008
Members present:
Dr Hywel Francis, in the Chair
Nia GriYth Mark Pritchard Mr David Jones Hywel Williams Alun Michael Mark Williams Albert Owen
Witnesses: Mr John Howard, Chief OYcer, Montgomery Community Health Council, and Mr Bryn Williams, Chief OYcer, Brecknock & Radnor Community Health Council, gave evidence.
Q369 Chairman: Good morning, welcome to the almost stamped on the forehead of Welsh patients, Welsh AVairs Committee. The acoustics in this room who feel, in many respects, from where they are, are not brilliant, so please do not be afraid to raise second-class citizens. your voice so that everyone all around can hear you. For the record, could I invite you to introduce yourselves, please? Mr Howard: My name is John Howard; I am the Q371 Chairman: Mr Howard, you have anticipated Chief OYcer of Montgomery Community Health my second question, which is at the very heart of the Council. question, namely the divergence. How do Welsh Mr Williams: My name is Bryn Williams, I am the patients view that divergence of policy between Chief OYcer of Brecknock & Radnor Community England and Wales? Health Council. Mr Williams: There is certainly a two-edged sword to the whole question. Generally, there is a positive feeling about having health services in Wales. Q370 Chairman: Thank you, also, for your Having said that, from the population perspective, memorandum, which was very helpful in preparing the major problem that we have is one about waiting for this session. Could I begin by asking a very lists, as an example. When we have reports from our straightforward question about the impact of complaints oYcers, whereas the rest of Wales, devolution on the quality of services accessed by perhaps, have got diVerent problems in relation to Welsh patients in your area? where the complaints come from, ours are basically Mr Howard: Certainly. It is a little bit like the V around this concept about waiting lists and how they curate’s egg: it is good in parts. It initially started o can access those waiting lists across the border that with large hopes for having local input, influence are better. From the Welsh perspective of service, we and able to be heard and things, and I think that feel it is a bit of a two-edged sword anyway because started and evolved very well, and there is a basic whilst John said: “At least we have still got CHCs in one, of course, and that is that we would not be here Wales and it is democratic”, it is still very much a if there had not been devolution, inasmuch as the political football. As a result, whilst it is useful to Community Health Councils were disbanded in have the democracy and having the means by which England but have been retained in Wales and, we can get at the levels of power in health services, therefore, are there for the benefit of patients. We think there is—and we would say that, wouldn’t including through the AMs and MPs, etc, it has also we—a considerable benefit because patients are got its downside because often you will engage in represented through the Community Health discussion about future services, whereby you would Councils, either through its strategy or, in fact, think in terms of how can we improve services, how through the complaints process, and so on. So there can we make it a better service, but then, of course, is a benefit in that. Obviously, as things have if something happens, like we discuss perhaps the progressed and as the health services (how shall I say closure of some facilities, then those MPs or AMs it) have diverged with England, there is a degree of are stood on the picket lines, and it is a bit naughty, conflict and there are issues where because (and both if you can put it that way. On the one hand, you are Bryn and I represent Powys) Powys is, participating in the discussion of making the service geographically, a third of Wales with a very small a better service, more economically viable, more population but it has no district general hospital, it eVective and more eYcient, but at the same time you has to access secondary care services from outside of have got this whole situation of running with both Powys. Therefore, especially when the population sides of the fence. I must come back to the point that, that I serve actually is about 12% of the Royal really, if we talk in terms of democracy and health Shrewsbury’s business, both financially and in there is participation of the masses. I find it services, we see the diVerence between the Welsh absolutely a benefit, because it becomes their service, provision and the English provision, and we often in essence, and where things go wrong then they see issues around patients being told: “If you were participate in those discussions. Both John and I English you could be treated a lot better”. These are have also got what we call health focus groups, issues that are often put right at the forefront and which will be of interest to others, that we run in Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Mr John Howard and Mr Bryn Williams communities where we feed information to almost know when you get a complaint from a communities and the communities feed back patient where they come from. We have tried to information to us about perceptions of health. minimise that, and some of the information that has got out into the public domain, in some respects, is, Q372 Mark Pritchard: Mr Howard mentioned 12% for lack of a word, scurrilous. It is basically untrue. feeding into the Royal Shrewsbury Hospital. Did I Arguments that Powys does not pay its bills, for hear you correctly—12%? example, and things like that, we have tried to Mr Howard: Twelve per cent of our business, yes. downplay, but there are still issues and huge issues around the diVerent ways of funding now between Q373 Mark Pritchard: Are any of those paediatric the English system and the Welsh system that causes patients at all? the problems and, therefore, it is this idea of V Mr Howard: Yes, because there is very little commissioning services with di erent lengths of paediatric service in Powys. Part of the problem we waiting times that actually cause the problem. I have is that there are, in some respects (because, I think it is really a result of the consultants not suppose, of the way the funding works) certain knowing how to handle it, from their point of view, services that are what I would class as “fragile” in and how to manage that situation. In some respects Wales. Some of them are paediatric services, some of they often seem more intent on raising the issue than them are, for example, mental health and things like actually getting on and treating the person’s that. They are just very thin on the ground. We do problems. not have a district general hospital so we do have to access them through Shrewsbury. Q378 Hywel Williams: Thank you for that explanation. We have heard in evidence to this Q374 Mark Pritchard: What about any accident and Committee a diVerence between the Welsh and the emergency admissions at all to the Royal English approach, which has been characterised as Shrewsbury Hospital from Powys? being “patient’s choice” in England and “patient’s Mr Howard: A&E? We are dependent upon the A&E voice” in Wales. What does that mean in practice, as services in Shrewsbury. far as you are concerned? If you can make a distinction (and we would be very glad if you could) Q375 Mark Pritchard: Are you aware of a proposal could you tell us if one approach is better than the going to the Telford & Wrekin Primary Care Trust, other? the Shropshire Primary Care Trust, and, indeed, the Mr Williams: Yes, if I can respond to the choice Royal Shrewsbury and Telford NHS Hospital Trust thing. If Welsh patients have a choice, the most this very week that proposes downgrading important thing to Welsh patients is that they are on paediatrics and accident and emergency at the Royal a common waiting list with the English patients and, Shrewsbury Hospital and building a specialist, therefore, they would automatically be going across purpose-built site halfway in the county, therefore the borders. There would be no borders if their removing the accessibility to those services choice was available to Welsh patients because they eastward? Would it cause you problems? would automatically be going over the border and Mr Howard: It would cause us problems. We have getting the service. It is perceived to be a very much been involved with the Shropshire PCT and the first and second-class service to many Welsh people; Telford & Wrekin PCT in looking at the services in that they cannot access those services in the same Shropshire. I was at a meeting last week looking at timescales as they do in England. We can put all sorts the review of their services for the future. There were of issues forward, like: “We have got free issues in there about, specifically, maternity and neo- prescriptions”, or “We have got free parking”, but natal. A&E I was not aware of; I thought that was they are miniscule compared to the need to have safe. I did not think there were proposals to change common waiting lists across a bigger border. that. Obviously, as a stakeholder we would expect to Mr Howard: Choice and voice. Almost by definition have been consulted on that by Tom Taylor and his in Wales there is very little choice because you have board at Shrewsbury before any kind of advances or one supplier, and therefore if you, in some respects, changes were made. fall out with your GP you have very few places to go. As far as a district general hospital is concerned, you Q376 Hywel Williams: Can I ask a very brief have one and you go there and you are used to going supplementary to Mr Howard on your initial reply? there. So you have a choice: you either have it or you If I heard you rightly, you said that Welsh people do not. The voice issue is dependent upon how much who have been treated in hospital were told by staV you are listened to, because many a voice can be that if you were English you would be treated better. spoken but it is not always heard. Therefore it would Mr Howard: Faster. be interesting to actually plot the diVerence about when the public voice is used what changes happen Q377 Hywel Williams: Is that globally or is it or what the outcomes are and what the process is. specifically to do with the waiting lists? Are you There is often a danger and there is a feeling alleging a general attitude while you were at the back sometimes that going through a consultation process of the queue, or is it on the specific issue? is sometimes a tick-the-box exercise; “We have Mr Howard: It is specifically to do with waiting times consulted”. There are issues that have to be for elective surgery, and it is very much geared—and considered in the delivery of health service, like there are a number of consultants—so that you access, that really are only looked at, in some Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Mr John Howard and Mr Bryn Williams respects, from the health service’s perspective, not because at least you know what you are getting and necessarily from the patient’s point of view. The what you get for that money; in Wales there is clinical aspect: it is clinicians who say that, and in nothing like that. many respects there is a debate and a debate could be had as to whether in fact there are outcomes that Q381 Mr David Jones: Mr Howard, I listened very come out of that which are definitely there, and are carefully to the answer that you gave to Mr Hywel prima facie from the patient’s point of view. Finance Williams’s first question just then. Given your view issues, actually, go into that and therefore they as to the priority that the patient has in all this become complex, and then there is the public’s process, would you say that patient voice means perception, or the public voice. In some respects the anything at all or is it simply meaningless public voice is often the last one, if they were sloganising? weighted. I think they are very low-scale because Mr Howard: I think it is important for people who there is a fear sometimes that the way in which, for ostensibly speak with the patient voice to actually be example, the Community Health Councils are asked able to demonstrate where their church is or where to contribute to public consultation is one, we help their constituency is. I think that is important. I am a organise the public consultation sessions, and from little bit fearful of the way that things are developing that we then have to submit a response. If we are whereby people can almost say: “Ah well, we’ll have submitting something that is at variance with the you to speak on behalf of the public” without them proposals we have to put up a full business plan and necessarily having an identified kind of constituency so on, which we do not have the resources to do. So, or church or body where they, kind of, can keep their in some respects, it is actually quite diYcult to views. The danger is always that the person who submit a public perspective. speaks loudest gets heard most. Chairman: You are anticipating lots of the questions on which I want to give an opportunity for the Q382 Mr David Jones: So does it mean anything? Committee to cross-examine you more fully. I am Mr Howard: It depends on who is hearing and what not being disrespectful, but could you shorten your eVect they have. answers a little? Mr Williams: It adds to this whole perception of whether there should be a big change in health Q379 Hywel Williams: Can I ask you: the Local services or whether there should be incremental Involvement Networks has been set up in England— change. One of the good things in the Welsh situation is that incremental change is a necessary the LINks. Do you think that that will have an Y impact on the way that the patient’s voice is heard in part of the process. The di culty is, of course, England comparable to the function that you have suddenly somebody will get a wonderful idea and in Wales as Community Health Councils? there will be a dramatic change throughout Wales, and then we have to live with that for a few years Mr Howard: I hope so. before the incremental changes are coming through. A particular example is all the LHBs that we have Q380 Nia GriYth: Can I just raise this issue about got in Wales at the present moment, and the change the waiting times that we have been discussing. that is perceived in that regard. If there was good Presumably,the reason for the waiting times being as thought about it in advance then certainly there they are in Wales is because certain specialities and would not have been that sort of activity. One thing so forth may be diYcult to obtain within the given that we are finding—John and I—from a Powys- time. Would you see the solution being that we need wide perspective, is that we are able to oVer (and I to switch immediately in Wales to exactly the same am sure Judith and our colleagues behind will waiting times in England, or would you see that comment on this) an influence over the policy, the there could be agreements made about certain types strategy and the implementation direction of health of elective surgery? Which would you see as a services in Powys. I think that is vitally important. possible way forward? We are also able (you asked the question about Mr Williams: Can I just say, Chairman, in answer to whether the patient’s voice is necessary or that, that the system that is operated in England is worthwhile) to oVer quite— one of tariV for whatever service is available, so there is a standard charge for a service. As an example, a Q383 Mr David Jones: Forgive me, I did not ask particular operation, say, would be in X-amount of that. What I asked you was whether the expression days. In Wales they have got a broad contract “people’s voice” actually means anything. system, and it does not matter whether a patient is in Mr Williams: Fine. The people’s voice means a lot two days or 20 days, it does not cost any diVerent. It because we act with the people and through the does not matter if the throughput of those hospital people to the process of policy-making at beds is two or 20, it still does not matter. So you are government level. Your MPs in Wales, I am sure, in a whole situation where it is ineVective, ineYcient would reflect that. So we are able to influence at all and uneconomic. So you get diYculty then in those sorts of levels as well as a voice. actually auditing that sort of situation because it is an ineVective and ineYcient sort of system. So you Q384 Alun Michael: Can we look at the actual flow must alter your systems, otherwise the waiting lists of patients across this long, porous border of ours. are not likely to change very much in the future, Has the patient choice agenda aVected the flow of unless the system is altered. I like the tariV system patients across the border? Have you seen patients Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Mr John Howard and Mr Bryn Williams registering in England in order to access services not of the Welsh people who have been receiving available in Wales, or registering in Wales from the treatment at Hereford if they have to go somewhere other side of the border for particular reasons? else in South Wales, as an example. Mr Howard: There are patients who, because of where they live, can only access the services through their GP. Remember, the GP is the gate-holder, Q390 Alun Michael: Would you explain that basically, so therefore they will go to where they sentence? Who is pulling people, and how? think their closest GP is. There was a—whether it is Mr Williams: The information I get from the apocryphal or not—discussion recently up in Commissioners and from others is that there is a Cheshire of a small village there talking about definitive directive to them to pull people back into aspiring to become Welsh so that it could have free Wales that are getting services outside at the present prescriptions. Whether it is real or not is a diVerent time. I have got some correspondence that, perhaps, thing. I am not sure that there is choice coming back would interest you in that regard as well—of into Wales. There are some things—waiting times individual cases. for, say, cataracts—that you can get done faster in Mr Howard: As far as Shrewsbury is concerned, Wales than you could in England, and therefore there were guidelines for the foundation trust—not there is a choice sometimes but not much of it. in specific numbers—that increased those. They are doing their best to actually get representatives from Wales into their trust and going about safeguarding Q385 Alun Michael: With respect, I think what we the statutory rights that we have as Community are trying, as a Committee, to get to is what is really Health Councils with their foundation trust status. happening rather than what may be apocryphal. Is there any evidence of how patient choice has aVected the flows across the border? Q391 Mark Pritchard: Mr Williams, you mentioned Mr Howard: Not from my perspective. the word “directive”. Of course, if the Hereford and Mr Williams: Certainly from Brecknock & Radnor’s Shrewsbury & Telford NHS Hospital Trusts are perspective, I get all sorts of comments from the going for foundation status (certainly the latter) population to say that they find it very confusing in then, obviously, payment by results and their relation to the whole set-up and why one system financial projections in the future are based on should be diVerent to another when you pay into a existing patient flows and projected patient flows. If national income tax. you are saying there is a directive from somebody (and perhaps you can say who it is from—I am sure with such an important document you, no doubt, Q386 Alun Michael: With respect, my question was will have in your mind who it is from if not about evidence of flows across the border. Is there necessarily the date) then, clearly, there is an impact any evidence? for those English hospital trusts going to foundation Mr Howard: I can only say there are 800 English status and, indeed, if they did not get foundation patients registered with Welsh GPs in status an impact on their, if you like, balance sheet Montgomeryshire. for today and in the interim. Also, it has implications for the Welsh Government and, indeed, the national Q387 Alun Michael: Compared to? Government and the financial settlement for Wales Mr Howard: Compared to 55,000 in and the part that deals with the National Health Montgomeryshire as a whole. Service for the health service in Wales. On the first part, who actually set this directive or this letter that Q388 Alun Michael: Compared to ten years ago? you mentioned? Mr Howard: I have not got a change. I do not know Mr Williams: From what I understand, and I have whether that has altered in the last 12 months. seen nothing on it and other people also make the same comment—they have seen nothing specific in writing—it is from the Welsh Assembly Government Q389 Alun Michael: I think I have to take that as “no and from the Health Commission Wales. Whether evidence”, with respect. You have talked about that is a fact or not I do not know, but certainly that confusion, but there is nothing you can point to. One is the impression that has been given throughout the of the points about the changes on the two sides of service and is an impression that I am getting from the border is that, obviously, there are developments leaders of the service and, indeed, from patients who of foundation trusts on the English side of the actually have been receiving treatment outside of border. Are the interests of Welsh patients being Wales, who are being told by their consultants that dealt with adequately within those new they have to go back into Wales for the service. arrangements? Mr Williams: From a Hereford perspective to South Powys, the catchment area for Hereford also Q392 Mark Pritchard: Mr Williams, I am confused. embraces South Powys. As a consequence, they have A few moments ago you mentioned about taken that into account when they have put their correspondence and a directive. Now you are saying business plan forward. The diYculty is, of course, it is rumour and innuendo, and it is what people are when we get this thing about pulling people back saying. Which is it? I am sorry, I am confused. into Wales, and there is strong evidence that that is Mr Williams: I am sorry if I confused you. I am happening. I think it will be to the detriment of probably confusing myself just as bad. Certainly the Hereford, the provider, and it will be to the detriment reflection that I get, and as I said earlier— Processed: 20-03-2009 10:44:08 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Mr John Howard and Mr Bryn Williams
Q393 Mark Pritchard: I am sorry, Mr Williams. So Q399 Mark Pritchard: Mr Williams, you said that we are absolutely clear, have you received the Commissioner you had a meeting with had had correspondence or not on the issue of patients instructions from the Welsh Assembly Government. returning to Wales from English trusts? Were those instructions in writing or oral Mr Williams: I have not seen any correspondence instructions? from any particular body, but the overall impression Mr Williams: I got it from hearsay from that person, is as I have indicated. I have the minutes of a meeting but I have not seen any correspondence. that I had with the Commissioner who said that that is the directive that they have had. Q400 Mark Pritchard: In the minutes you are kindly going to copy to us, is there a reference to that Q394 Mark Williams: Just to reiterate what you instruction that was made orally in that meeting? have said: are you aware of an increase in appeals to You minuted that yourself. the Health Commission Wales for precisely the Mr Williams: Yes. reason my colleagues have been talking about? I have my own constituency examples of people who Q401 Mark Pritchard: Thank you very much. have been having neurosurgery treatment in Finally, if I may, we met with the Bishops of Frenchay Hospital, Bristol and who have been told Hereford and Monmouth, and they alleged that the that they have got to go to Swansea. Are you aware divergence in health policy between England and of any information on that point? Wales was confusing. I think you have touched on Mr Williams: I am not aware of that particular that. You used the term “second-class citizens”. situation, but at the same time there is some What do you think the Government, nationally or in correspondence that I have that would indicate that Wales, needs to do in order to equalise or bring from Birmingham, as an example, they have been equality in patient treatment between Wales and told to come back into Wales for the service. You can England and vice versa? have that correspondence. Mr Williams: The view that has been expressed by Mark Williams: That would be helpful. It would be the population—and it is a view that I hold—is that very interesting if you could get any figures on the they all pay national income tax into the national increase in appeals from patients. Government and, as such, health services should not be divided by borders; there should be freedom Q395 Mr David Jones: Mr Williams, forgive me, I across borders in health service provision. That is the am still confused, and I think other members of this impression we are getting. What they are saying, at the moment, it seems, is that because of the Committee are confused too. Do you have V correspondence in your possession that indicates di erences in waiting times they are getting a second- that a direction has been given to return Welsh class service compared to their counterparts in patients who were having treatment in England back England. to Wales? Is there correspondence in your possession? Q402 Mark Pritchard: So a National Health Service Mr Williams: I have individual correspondence in means “national” by definition? that direction, yes, about individual patients. Mr Williams: Yes. However, I have not seen any general correspondence from the Welsh Assembly Q403 Mark Pritchard: I am not, hopefully, reading Government or anywhere else, other than the too much into what you are saying, but by definition, minutes I have taken at a meeting with one of the conversely, you are saying that Wales is not part of Commissioners (a Commissioner who is local to us) the National Health Service. who has indicated that that is the instruction she has Mr Williams: No, what I am saying is that it is had from the Welsh Assembly Government. running a diVerent NHS system than they run throughout the rest of Britain. As such, issues like Q396 Mr David Jones: Have those minutes been waiting lists should be common to all; there should agreed with that person? not be the creation of artificial boundaries in health Mr Williams: Certainly the person has agreed those service provision. If we go back to the question you minutes, yes. asked about choice, if there was choice the people of Wales would access the service across the border, because of the waiting lists. Q397 Mr David Jones: Will you provide copies of Mr Howard: Can I come back on that from a those minutes to the Committee? Montgomeryshire CHC point of view and say that Mr Williams: I will indeed.1 our view is that if you are buying a service from a hospital, everybody who gets treated at that hospital Q398 Mr David Jones: Will you also, please, provide should get the same service; there should not be a copies of the individual letters, blanking out if distinction between whether you are Welsh or necessary the names of the individual patients? whether you are English. Mr Williams: Yes.2 Mr David Jones: Thank you. Q404 Albert Owen: Can I come in on this patient choice issue? 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13 May 2008 Mr John Howard and Mr Bryn Williams that some of the patients get diVerent advice from reasonably access within a fair distance. At the same the Local Health Boards, the GP and the hospital, time, what the speciality is will depend upon how far and that that is what is causing the confusion? Are it would seem to be reasonable for them to travel. It they saying diVerent things to the patients? could be seen to be reasonable to travel a long Mr Williams: I think that is absolutely right. I have distance for something that is very serious or a short the impression that neither the managers, the distance for something that is not so serious. directors, the consultants nor the GPs are fully aware of the regulations that bind this whole system Q408 Mark Williams: But, if you look at the some of together. There is absolute confusion; not just the specialisms anecdotally, for someone, say, in amongst the population but amongst the people Newtown, and I am thinking about this question of within the service as well. the all-Wales service model that we seem to be moving down, the choice between perhaps coming to Q405 Nia GriYth: In your evidence you have my constituency to Bronglais Hospital in mentioned the diYculties of travelling a long way to Aberystwyth or a shorter journey over to get certain types of treatment. Do you think there is Shrewsbury, what do people say? any possibility that Wales could provide more of the Mr Howard: In all honesty, they would prefer to go health services within the Welsh borders as opposed to Shrewsbury. The argument in Powys is they say, to funding services across the border? If so, which “Where do the patients go?” and they say, “They go ones do you think might be possible? where the water goes”, so everything from the Mr Howard: The answer to that is yes, it would be Cambrians goes to Bronglais in Aberystwyth and nice to see that you have consultants coming into then everything on this side of the Cambrians, the Wales to certainly do more services and oVer more English side of the Cambrians goes to Shrewsbury, services. The diYculty is that in many respects where so there is a flow in that direction, and there is a there is an operation required then certainly there are history of that. There are of course the diYculties problems and diYculties in Montgomeryshire that there are, and Bronglais serves the needs of the because we have no facilities for that. There are people around Cammaes Road and Machynlleth issues around the changes in the consultant contract and so on also into Merrionnyddshire and they are that actually have put diYculties on consultants’ dependent on that. It is the only district general travelling for out-patient clinics, inasmuch as their hospital between the north and the south of Wales. time is then lost because of the travel time. The If you actually drew a map of Wales and put on it the argument is that patients travel and, therefore, you cities and the hospitals, there is only one dot that is have, say, 10 or 15 patients travelling to prevent one not on the southern corridor or the northern consultant. That is where the equation between corridor and I think, therefore, that Bronglais is travel does not balance out. That is why, on important to the needs of the people of Mid Wales. occasion, it seems that things seen from a health When you look at the size of the services and the service perspective only govern the decisions that are range of services that are oVered, Bronglais does not made. Services that could be done in Wales? have the catchment to be able to provide the full Anything that does not actually need clinical range of services that you can get in Shrewsbury. intervention or a direct operation. Q409 Mark Williams: As you will appreciate, we are Y Q406 Nia Gri th: That you would be seeing as a currently having a debate on the future of our Trust buy-in from consultants who are currently employed and the geographic parameters which are being in England as opposed to sending people to North defined from above to us. Obviously, within Powys or South Wales to consultants who are employed in there are issues as well. I should imagine that in the V Wales. So, e ectively, what you are describing there, south of Breckonshire, there is a gravity to the south, although it would be taking place in Wales, would but more generally we have got this great jigsaw still be a buy-in from an English service. puzzle and I am not convinced, from listening to Mr Howard: Yes. your evidence, that, given this move, this drive towards an all-Wales service model, Powys really can Q407 Mark Williams: Returning to Mr Williams’ fit into that jigsaw puzzle. What is your take on that? point about access—the need to view access from the Mr Howard: There is the usual statement when patient’s perspective, not necessarily one defined by people are asked about the Health Service in Powys the NHS—can you tell me more about what patients and their usual answer is, “Well, Powys is diVerent, are actually saying about where their care is located, isn’t it?” and it is right in that way. It is the most odd- England or Wales, and how much does it matter to shaped piece that you could ever fit into a jigsaw, them? wherever it was, because, if it is a third of Wales Mr Williams: The only occasion it matters to them, geographically, it has got a very small population, as far as my recollections are concerned, is from the 130,000 population, and in fact, when you talk maternity perspective—from having children; they about the distance from the north to the south, it is like to have their children born in Wales for Welsh the equivalent of Bristol to London, there is a huge parents. However, at the same time, generally, they area to cover without a district general hospital, so are quite happy to travel from here to Timbuktu, if you are dependent upon something like five district necessary, to get the best service. What we must hospitals around. 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13 May 2008 Mr John Howard and Mr Bryn Williams was that was providing those services and you patients forums and with us and discussions and we bought into the services from that, but we have got have meetings for that. There is a special group that a very good GP service. It is probably as good as has been established to look at cross-border issues anywhere else you can get in the UK and I think which involves a number of primary care trusts in primary care is important, is imperative, but it is still England, the Powys Local Health Board in Wales, a gatekeeper in that it opens the door into access for representatives from the CHC which represent the secondary care and for tertiary care, it is like being five CHCs— on an escalator, you go wherever the escalator takes you. Q416 Albert Owen: And is that a forum that you see Mark Williams: Hopefully it is a short escalator. will be able to collate evidence of the movement of people across the border? Q410 Albert Owen: You mentioned your Mr Howard: Yes, it is doing that at this moment, it involvement in consultation and you felt that you is collecting that information so that it can actually did not have a positive role in that, or that is the way put it into the public domain. The problem they have I interpreted your answer, so to what extent do you got is that all these bodies, in all honesty,are working currently liaise on other matters with the Welsh as well as they can to try and solve the problems that commissioners and English providers to address the kind of bubble up to the surface, but there are some issues cross-border with regards to Welsh patients? things that bubble up to the surface that are outside Mr Howard: We are involved in discussions with their control that they are unable to address and it is them very regularly. Both of us are on the local those things that they need help with. Powys Local Health Board and I can go and attend any meeting at any of the secondary care Q417 Chairman: Mr Howard, you mentioned this commissioners and providers. cross-border forum. I wonder whether you could provide us with a short memorandum describing the Q411 Albert Owen: So you are on the steering work of this forum. committees and you can feel involved in the policy Mr Howard: Yes, and I will happily send you some development? minutes of the work that they have done and the Mr Howard: Yes, and we are involved in all frame of reference that they have got.3 discussions and debates about changes and so on. We are fortunate inasmuch as we are involved in that Q418 Mr David Jones: Mr Howard, could I refer you almost to the extent that, because we are dealing to one paragraph towards the end of your with so many hospitals from time to time, you are all submission to the Committee. You say, “The CHC is over the place. convinced that specialist services that have relatively low numbers would be better linked covering a safe Q412 Albert Owen: Are those committees speaking clinical network embracing the whole of the UK. with one voice when it comes to cross-border issues? There may be instances where Wales does not have Mr Howard: No, no. Come on! the critical numbers to maintain safe services”. We heard similar evidence from the Muscular Q413 Albert Owen: I expected that answer! Dystrophy Campaign. Could you expand on that Mr Howard: How well do you know Wales! point and could you also maybe, if you are able, give the Committee some examples of the sorts of Q414 Albert Owen: Another issue that you have problems that you have had in that sort of area? raised is that you said that, because of devolution, Mr Howard: I just think that there are issues around you are still in existence, so what sort of relationship catchment areas, that, where there are limited kind do you have with other bodies across the border on of specialist services, so there are few people who representing the interests of patients? need them, therefore, it is best to have all the Mr Williams: The first thing is that across the border specialist resources in one place rather than actually with the advent of foundations trusts, I have got two spreading them thinly. It is the quality of service that CHC members who are actually sitting on the I think is paramount. I cannot give you any specific working group in relation to Hereford, say as an instances, but it works in a small kind of perspective. example, and John has got a similar arrangement For example, in Powys there are issues now around actually up north. In addition to that, we interrelate a minor injury service and, because we do not have closely with the chief execs of Powys LHB, as an any A&E in Powys, there is an issue about the example, not just in a formal manner, but in an quality of minor injury services and, if it works on informal manner as well and with all the operators a clinical basis at that level, then it should work at a within the service, so you build up a relationship in higher level. Therefore, it is looking at the UK as a a sense over the years, informal as much as formal, whole network and actually having a network in that and the informality is a lot better and a lot easier respect. The specialist services you can think about than the formality is. are things like the services you get from Alder Hey and so on. Q415 Albert Owen: So groups across the border have mutual interests for patients? Q419 Mr David Jones: How would you suggest that Mr Howard: We do have links and primarily the link network be funded? is around a provider, so, therefore, the provider, say the Royal Shrewsbury, will have meetings with 3 Ev 168–171 Processed: 20-03-2009 10:44:08 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Mr John Howard and Mr Bryn Williams
Mr Howard: I just think it is a matter of accessing the Mr Howard: If you lost those services, if, as Bryn services, knowing where they are and accepting that, mentioned, the fact that people in CardiV decided for the really good-quality,specialist services that are that it was fortress Wales and ring-fenced, then I available, you have to access them and you have got think that the loss of services from DGHs (District to go wherever that service is, and it might be— General Hospitals) in England by repatriation to Wales would actually put services at those hospitals Q420 Mr David Jones: I understand that, but how in diYculty. If you just go through the equation, if would that network be funded? Would it be funded Shrewsbury has 12% of its business in Wales, centrally, by the UK Government? therefore, it would have to lose 12% of its staV if it Mr Howard: I would have thought it would have to lost those services back to Wales and, therefore, the be top-sliced. business may not be sustainable. There are issues used in the NHS about a DGH needing half a Q421 Mr David Jones: By the UK Government? million population catchment. If you lost 55,000 of Mr Howard: By the UK Government, yes. the half a million that Shrewsbury and Telford has, it would have to reduce its services, so, therefore, Q422 Mark Williams: I think I am returning really services are not sustainable and it would probably be to the point made by Mr Williams, my colleague the smaller services that would be fragile. here, and he quoted from your document Why not Chairman: Thank you very much for your evidence come to England: you’ll be treated better. Are the and for your earlier memoranda and we look current arrangements for cross-border provision of forward to receiving your additional memorandum. services for Welsh patients in England sustainable? Thank you.
Witnesses: Ms Judith Paget, Chief Executive, and Ms Rebecca Richards, Director of Finance, Powys Local Health Board, gave evidence.
Q423 Chairman: Welcome to the Welsh AVairs Ms Paget: No, not at all. Committee. Could you, for the record, introduce Chairman: Well, that is pretty straightforward. yourselves please. Ms Paget: Good morning. I am Judith Paget, the Chief Executive of the Powys Local Health Board. Q426 Albert Owen: As we are aware and as we have heard from the evidence session previously, the fact Ms Richards: I am Rebecca Richards and I am the is that Powys does not have its own district general Director of Finance at Powys Local Health Board. hospital and you have to commission services from outside the boundaries of the county, but also in Wales and in England, so what proportion is within Q424 Chairman: Could I begin by asking you what Wales and what proportion is in England? has been the impact of devolution on health services Ms Paget: Rebecca will remind me if I have got the for Welsh patients? figures wrong, but, of our total secondary care Ms Paget: I think it touches on some of the issues commissioning allocation, 23% of it flows to that have been mentioned in the previous evidence England and the rest remains in Wales. really. I think, through the Assembly’s policy described in Making the Connections and the Beecham Review, there is a real focus on the citizen Q427 Albert Owen: So what factors determine this voice to drive service change and improvement in care? Is it specialist services available in close Wales. I think that, as a result of that, we have seen proximity across the border? a diverging policy agenda in relation to the Health Ms Paget: Yes, there are a number of factors. Service and things that have already been mentioned Ms Richards: Obviously the patient flows is the this morning, diVerent waiting times, issues around main, predominant factor, so, if a patient is referred tariV and payment by results being introduced in to an English DGH, then we pick up the costs for England and not Wales, we do not have foundation that patient and at the English DGH, if a patient is trusts in Wales, we do have free prescribing and other referred into Wales, we pick up the costs at that issues which have been addressed by the Assembly, DGH because it is part of our contracting so I think basically it is around the diVerent policy arrangements with those organisations. direction that has been taken now in Wales as V di erent from England. Q428 Albert Owen: You will be aware of the recent report on the providers of the Powys Local Health Board stated that the county’s current network of Q425 Chairman: Those diVerent policy directions or community hospitals is not providing an adequate directives are a particular issue for us. We have heard service. Do you agree with it? in earlier evidence that there may be a suggestion Ms Paget: I think the position of the Powys Local that the Welsh Assembly Government has sent out a Health Board actually is to welcome the Clinical directive requesting you, or directing you, to Governance Report. We are in the process of going repatriate Welsh patients. Has that happened? through the detail of it in terms of a programme of Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Ms Judith Paget and Ms Rebecca Richards action. I think broadly we are very supportive of patients will need to travel. It is about finding the what the Clinical Governance Support & right fit for Powys that is clinically safe. Development Unit have said. Q433 Albert Owen: So satellite services within the county is the priority? Q429 Albert Owen: So the current system is not Ms Paget: Yes, and certainly we want, where we can, meeting modern-day requirements? to arrange for consultants to come into Powys to Ms Paget: I think that would be fair, yes. deliver care where that can be done safely. I think in Powys, as we have heard from the previous evidence, Powys residents are used to travelling outside Powys Q430 Albert Owen: So what is the net eVect on the for a large proportion of their care that is DGH- service provision of implementing the report’s based. We do provide outreach consultant follow-up recommendations? clinics locally, we do provide day surgery locally, and Ms Paget: I think what we really need to do is to be our plan is to continue doing that. very clear about what services we can deliver in Powys safely and how we do that, so that will Q434 Albert Owen: When you said they are used to probably mean us having much stronger links with it, they do not have much choice though, do they, if neighbouring NHS Trusts. I think we need to, in you have admitted that the standard is not very good many respects, focus some of our services in three now and it needs modernising? main centres in Powys, one in the north, one in the Ms Paget: I think that the issue is not so much about middle and one in the south, and we then need to do the standard, but actually Powys residents need to some very close working with our communities and travel to access DGH care because it is not available our local authority colleagues and the voluntary in Powys and never has been. I think what the sector to redesign how health and social care is Clinical Governance Report has said is that we really delivered in the rest of Powys, so I think it is sort of need to relook at the services we are delivering in two main emphases really, focusing and centralising Powys and actually put in place a clinical our services north, middle and south, where we can governance infrastructure that allows us to continue and where that is appropriate to do, and working doing that safely. with our communities around redesigning services in other areas. Q435 Albert Owen: The reason I push you on that is as somebody who has got a constituency on the periphery and it is condescending to say that they are Q431 Albert Owen: So can cross-border used to it in many ways. They do not have the choice collaboration assist in addressing these alleged and, if they are given the choice of services being problems, and you have given a breakdown of how delivered closer to them, then that is the choice they much is currently across the border and how much is would go for. within it, or are we looking at a Welsh solution to Ms Paget: I think so, but the issue is how you this? balance access and safety and I think that is the issue that the Clinical Governance Report has tried to Ms Paget: No, I think there are opportunities for uncover really and to try to put forward some both English and Welsh NHS organisations to proposals about how we actually maintain that support Powys and I think that is the way that the balance and deliver as much care locally as we Powys LHB will move forward. We know we will possibly can, recognising that Powys residents, as need to have, and we already do have, lots of you say, will always need to travel for some services. discussions with the Shrewsbury and Telford Hospital NHS Trust and with Hereford, but also we Q436 Alun Michael: In your written evidence, you talk to Gwent, we talk to the new Hywel Dda Trust, make the statement that you encounter diYculties so we are in active discussions with all those NHS with English NHS Trusts over the diVerent Trusts that sort of circle Powys really because we are healthcare funding regimes in Wales and England. It very sure that, in order to maintain local access to is perhaps an open-ended question, but what is the service in Powys, we will need to develop those very solution to that? strong relationships. Ms Richards: Just by way of background, the way that we fund NHS Trusts in England is based on our historically funded agreements, so in 2003/04 the Q432 Albert Owen: But the reconfiguration that you local health boards were resourced at a level of talked about, does that make travel for certain funding to correspond to those contracts that would Y patients more di cult to English hospitals or within have been held by the former Health Authority with areas of Wales? England. Of course a lot has happened since 2003/ Ms Paget: No, I do not think so. 04, payment by results has come in and the funding Ms Richards: No. As Judith said, we want to try and flows regime in England has totally changed, but the provide as many services locally and as safely as funding for NHS organisations in Wales has not possible, so there may be opportunities, I think as and, therefore, we have historical agreements that somebody previously said, about bringing services we uplift for inflation and we address for diVerences into Powys where it is safe to do so, but clearly where in activity, but we do not recognise payment by it is unsafe to provide those services locally, then results because it is much more expensive for us to Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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13 May 2008 Ms Judith Paget and Ms Rebecca Richards commission on that basis than it is against our England, so there would be a hit financially to Welsh current contracts. So the simple answer is that, if we organisations if they were to commission at the same were funded to pay for contracts on the basis of level as English waiting times. On top of that, the payment by results, then of course we would pay it. English funding regime is diVerent in England from Wales which would mean that we would have to pay Q437 Alun Michael: Well, if we ignore that there is a higher price for those activities as well if we were water into, and water out of, the bath, as it were, do to change to payment by results. you think that really you ought to be paying the V English tari prices for Welsh patients in England? Q442 Alun Michael: Yes, but does it not follow then Ms Richards: The current advice from the Assembly that they cannot be taking patients from the list is that we do not because we have not been funded purely on a clinical basis if it is aVected by the to be able to pay at that level. financial arrangements? Ms Richards: Yes, sorry. To give assurance, the Q438 Alun Michael: So, in other words, your answer patients that are assessed as clinically urgent will be to the question is a reference to what the Welsh treated as clinically urgent. The diVerence between Assembly Government is telling you? England and Wales is only on elective, non-urgent Ms Richards: Yes. We are only funded to pay on the cases. basis of our historic agreements. We have not been funded to reflect the changes in the financial flows as a result of payment by results. Q443 Mr David Jones: To pursue that point further, Hereford Hospitals NHS Trust says that the employment of two diVerent funding systems in Q439 Alun Michael: But we have heard from England and Wales is ultimately unsustainable, and previous evidence that that causes problems for the that is probably right, is it not? Trust which is receiving patients, does it not? Ms Richards: We have discussed with them the Ms Richards: Yes. diVerent waiting times that they operate. A lot of organisations in England that we commission from Q440 Alun Michael: What impact do you expect the do operate diVerential waiting times targets for us. Welsh ‘financial flows’ work, the introduction of a Hereford have expressed a diYculty in managing V Welsh tari , will have on cross-border service diVerential waiting times and, as a result of that, we provision? actually manage the waiting lists for patients within Ms Richards: At the moment it has all been put on Powys to operate to Welsh waiting times targets on hold, is the latest advice from the Assembly simply their behalf and also for Monmouthshire LHB as because of the consultation that has now come out well. about the reconfiguration of the NHS in Wales. For this year we were going to do a pilot where we were going to start trying to commission on an HRG Q444 Mr David Jones: With respect, it is more than (Healthcare Resource Group) basis within Wales simply expressing a diYculty, it is a positive refusal and that would have had impacts on certain to operate diVerential waiting times system, is it not? organisations and certain NHS organisations in That is the truth of the matter. It has actually broken Wales, but, because of the consultation for the down so far as the Hereford Trust is concerned and proposed changes in Wales, that has been put on they refuse to operate it. hold pending a further review of how funding should Ms Richards: They have refused to operate it. We are flow within Wales. having discussions with them at the moment about whether they would be able to reverse that decision V Q441 Alun Michael: Just as a supplementary and manage a di erential waiting times system. question, looking at the situation at the moment and bearing in mind what you have said, we have really Q445 Mr David Jones: But, as we speak, the system had conflicting evidence on whether the way that has broken down? services are paid for makes a direct diVerence as far Ms Richards: Yes. as individual patients are concerned. We have been told, on one hand, that it does make a diVerence and, Q446 Mr David Jones: And you have made it clear on the other hand, that cases are dealt with by the in your memo that the local health board has taken NHS Trust in England purely on the basis of clinical on the management of the waiting list because of priority, irrespective of which side of the border such refusal. patients come from. I think it is diYcult to reconcile Ms Richards: Yes. those two statements. What is your experience? Ms Richards: I will try to explain the diVerences as I understand them. We have diVerential waiting times Q447 Mr David Jones: Well, how do you manage the between England and Wales and, putting payments waiting list because you are commissioners, you are by results to one side, if we were to try and catch up not providers? How can you assess the clinical and fund the same level of waiting times in England priorities? as we would in Wales, then it would be a one-oV hit Ms Richards: We do not assess the clinical priorities, to Welsh commissioning organisations because we but we actually get a consultant to do that for us. We would have to treat the backlog of patients to get just place them on the waiting list at the point that down to the same waiting times as they would be in they would need to be to meet Welsh waiting times. 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13 May 2008 Ms Judith Paget and Ms Rebecca Richards
Q448 Mr David Jones: Where is that consultant Q456 Nia GriYth: You have obviously hinted at this based? diYculty of diVerent systems and it must be very Ms Richards: In Hereford. confusing for patients as well operating in that sort of situation. What do you think are the main Q449 Mr David Jones: So you have got a bizarre implications for patients who are sort of caught system whereby you employ a consultant in between the two systems and have you done any Hereford to decide which of your patients should be research to see what could be done or how you could treated first? minimise the impact on patients? Ms Richards: It is their consultant that does the Ms Paget: I have been in Powys for nine months clinical prioritisation. now and the thing that has struck me since I have been there is, I think, just the level of confusion really amongst patients about the diVerent systems. When Q450 Mr David Jones: Well, looking at that from the IgotodiVerent meetings or meetings in diVerent outside, it appears eccentric, if not to say Byzantine. communities, I often spend some time trying to Would you not agree? explain how the systems work because I think there Ms Richards: I would say it is a system that is quite is a level of confusion and I think the community diYcult to manage. health councils have alluded to that, so yes, I think that is a real issue for patients really. Q451 Mr David Jones: And it is clearly causing you problems. Ms Richards: Yes, it is a managerial issue that we Q457 Nia GriYth: I think one of the things that has would rather not have. been particularly highlighted to us has been this Ms Paget: And that is why we are now looking at prior approval service, and patients obviously get whether or not Hereford would now work with us to very confused about how that works and they may take that back. find that they are waiting and then they do not even get a treatment. Can you see any way of dealing with, or improving, that situation? Q452 Mr David Jones: You would rather just be able to pay them straightforwardly without having to Ms Richards: Yes, certainly. To echo Judith, I have perform this juggling act? been in post now for four months and certainly there Ms Richards: Yes. does appear to be confusion not just by the patients, Ms Paget: We would like to have the same but by some of the GPs as well who refer patients to V relationship with them that we have with other di erent organisations, and the fact that we are providers, yes. managing the waiting lists for two of our organisations means that they need to request our approval before the patient subsequently gets Q453 Mr David Jones: Or, even better, may I treated. As we said earlier, we are trying to work with suggest, you would rather have the same system that those organisations to see how we might improve the applies in England because that would make your system between us so that we do not manage all the life a lot easier? Surely that must follow? waiting times ourselves so that there is a direct Ms Richards: I think we would like a consistent referral in, and also we are doing some work with the system across both England and Wales for all NHS local GPs to give them information on what they can organisations. advise the patients to expect when a referral is made, so there is a whole communication issue that we need Q454 Mr David Jones: Do you think that the to improve as we go forward. commissioning of services by a centralised NHS board, as proposed by the Welsh Assembly Government last month, will help address this Q458 Mark Williams: We have heard a lot of situation or will it not make any diVerence? evidence about the dependence of Trusts on other Ms Paget: I think it will address some of the issues side of the border on Welsh patients. Generally, do that are of concern in Wales about having 22 LHBs you agree with the Hereford Hospitals NHS Trust each with their own commissioning role and that Welsh patients ought to be encouraged, and function, and I am sure that that is why the Minister enabled, to access English hospitals where this is in is now getting comments and consultation on that in line with ease of access and a patient’s clinical need? terms of making an ultimate decision about whether Ms Paget: As I have mentioned before, I think that that will actually improve the system for patients. there is a recognition on the part of Powys Local Health Board that patients always will flow into Q455 Mr David Jones: In your professional opinion, places like Hereford and Shrewsbury and we have do you think that the consequence of that will be not done anything to not support that. I think as I that patients resident in Wales will be treated as just said, when talking to patients and community quickly as patients resident in England? groups, I often get asked, “Will Powys LHB stop us Ms Paget: It would be diYcult for me to comment going to Hereford?” because they feel that there is on that given that the issue that is driving the some threat over this issue, but, from our point of diVerential waiting times at the moment is Assembly view, we are working very collaboratively with both policy and, therefore, it would be for the Assembly Hereford and Shrewsbury around access to services to determine how that might change for the future. for our residents and that will continue, I am sure. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 70 Welsh Affairs Committee: Evidence
13 May 2008 Ms Judith Paget and Ms Rebecca Richards
Q459 Mark Williams: The consultation document cross-border working group that was referred to by published by the Welsh Assembly Government on the previous witnesses and takes an active role in restructuring proposes that the Powys LHB would that. I think that group is becoming much more no longer oVer secondary care services. What is the proactive in terms of looking at the cross-border impact going to be on English and Welsh providers? issues and relationships between England and Ms Paget: Well, I think that that proposal, in my Wales. understanding, relates directly to the proposals in the Clinical Governance Report that said that there Q464 Mr David Jones: The memorandum of were a range of services that Powys LHB was understanding you refer to is not, I think, a legally currently providing that perhaps it should no longer enforceable document. do so for the future and, therefore, we will need to Ms Paget: No, but it sets out the principles of how work— we might work together and the relationship, and I think some of those things are really important when Q460 Mark Williams: Which services? Would you you are working across boundaries in this way. elaborate upon that. Ms Paget: Things like the management of acutely ill Q465 Mr David Jones: But it does not contain any patients in some of our hospitals which we currently element that the patient could rely upon for the undertake, things like maybe mental health services. purpose of— There is a whole range of services in the report that Ms Paget: No, it is more about how the it suggests that Powys should no longer provide for organisations will work together really. the future, so that will require us to work with other NHS organisations to actually make sure that we Q466 Mr David Jones: Do you think that such a can secure those safe services for Powys residents for protocol would be best agreed at a national level or the future. are you content with what is happening at the moment? Q461 Mark Williams: Finally, we have alluded to, Ms Paget: I think there has been some work, and and I am aware of, the history of Powys. It is unlikely Rebecca may know more of this than I do, but there that Powys would ever be in a position to provide all has been some work between the Assembly and the the health services within its borders, but are there Department of Health looking at the border issues, areas of specialism that could be developed within particularly in relation to financial flows and Powys as opposed to across the border in England? responsibilities between organisations both sides of Ms Paget: I think that we in Powys need to be very the border, and I think some of that work is probably clear about what we can deliver and that we should being picked up and pursued and, whether that deliver locally, generalist services. I think there is a includes some sort of memorandum of agreement real need for us to focus very much on intermediate about how we will operate across the border, I think care, care outside of hospital, improving both that might be useful. community health and social care delivery for our communities. I think then, in terms of other services, Q467 Mr David Jones: It seems to me that such a that that is where the discussion with the memorandum agreed at that level would be of more neighbouring NHS Trusts come in because we will assistance to you in dealing with, for example, the need to talk to them about what possibilities there problem that you have got with the Hereford Trust are and what opportunities and options there are for at the moment. more services to be delivered on an outreach basis Ms Paget: Yes, I think there are some things that in Powys. could be set out at that sort of Department of Health/Assembly level that would be helpful to us in Q462 Mark Williams: You mentioned at the start setting the context in which we work together. your three-centre model. How advanced are you in that work? Q468 Mr David Jones: I think you were present at Ms Paget: Very early. The report from the clinical the earlier evidence session, but I put to the earlier governance team came out at the middle of March witnesses the suggestion that specialist services that and we are currently preparing a whole programme had relatively low numbers would be better dealt of work to go before our Board at the end of May with on a UK-wide basis. Do you have any which outlines all the streams of work and there are observations on that? seven or eight streams of work taking the Ms Paget: As you know, the responsibility for recommendations forward, so we are at that quite commissioning very specialist services rests with the early stage in that process. Health Commission (Wales) and it is not the responsibility of local health boards, and I am not Q463 Mr David Jones: Has the Board had any close enough to some of the issues that they have involvement in agreeing an English/Welsh protocol been discussing to properly comment on that. for the delivery of services? Chairman: Well, thank you very much. Could I place Ms Paget: There is a memorandum of on record our thanks to you both and also to the understanding that operates across the borders of earlier witnesses for the helpful, open and England and Wales which we have signed up to, and professional way in which you have answered all our also our Chairman, Chris Mann, is involved in the questions. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 71
Tuesday 3 June 2008
Members present:
Dr Hywel Francis, in the Chair
Mr Martyn Jones Mark Pritchard Alun Michael Hywel Williams Albert Owen
Witnesses: Mr Ben Bradshaw MP, Minister of State for Health Services, and Mr David Flory, Director General, NHS Finance, Performance and Operations, Department of Health, gave evidence.
Q469 Chairman: Good morning, bore da, and are independent studies, not government studies, welcome to the Welsh AVairs Committee. Minister, they certainly support our own assessment as well, could you introduce yourself and your colleague for and I would expect that similar improvements have the record please. occurred in Wales too. Mr Bradshaw: Mr Bradshaw, Minister of State for Health Services and on my left is David Flory, who Q472 Chairman: To what extent can we still call it a is the Department’s Director General of NHS ‘National Health Service’ or is it the case that we Finance, Performance and Operations. now have four separate health services? Mr Bradshaw: Well, there are a number of practical Q470 Chairman: Could I begin with a simple matters that are still dealt with on a UK-wide basis, question: what has been the impact of devolution on and pay is an obvious example, the GP contract, the National Health Service? international matters, public health protection, and Mr Bradshaw: Well, I think the impact has been the planning for pandemic flu, for example. The same as it has in other areas where policy is devolved principle of a healthcare system free at the point of in that the administrations in the devolved countries need for people, not based on the ability to pay, is have set their own priorities within a national still the principle that defines the healthcare systems framework. If you are asking me to analyse what I in all of the United Kingdom and the systems have think the main divergences are, in sort of broad far more in common with each other than, for terms on health, I think we could say that in England example, any of them do with any other healthcare the direction is to more decentralisation, system in any other country,so I think the diVerences commissioning by primary care trusts, by GP can be exaggerated, but I think it is perfectly right, if practices in some cases, patient choice, moving you accept devolution as a principle, which I think towards now individual health budgets for people everybody in this room does, that you allow for and an independent regulator. In Wales, the some flexibility in the diVerent countries to reflect direction of travel has been in the other direction. It the diVerent characteristics, the diVerent needs and, is more of a centralising direction, a reduction in the therefore, the diVerent priorities, so you inevitably number of health boards, and I think those decisions get a level of divergence. are the legitimate decisions of diVerent administrations, reflecting the needs and priorities in Q473 Hywel Williams: Good morning, Minister. On those areas. I think it is very important to emphasise, the two variables, centralisation and accountability, however, that in both Wales and England there has we are not of course comparing like with like. been an immeasurable improvement in both the Centralisation in a country of three million people delivery and outcomes of healthcare over the last with 22 health boards is no diVerent from, say,a large 11 years. conurbation in England having 22 health boards commissioning in that particular context, and of Q471 Chairman: You referred to the divergence. Is it course Wales has retained the Community Health too early to tell yet, with democratic devolution only Councils which some people might see as being being in place for barely a decade, whether or not independent and retaining a level of accountability, there has been a change in the quality of service so you would agree that we are not comparing like between England and Wales? with like here on those two variables when you Mr Bradshaw: Well, I can only really speak for compare England and Wales? England, but certainly as far as England is Mr Bradshaw: I entirely accept that, yes. concerned, I do not think there is any doubt, if you look at the reports of the independent regulator, the Q474 Mark Pritchard: Minister, it is nice to speak Healthcare Commission, that are now showing about something apart from the environment when significant improvements both in capacity and we last met, but on the point just raised on the quality of healthcare and all of the independent Community Health Councils, we had some international surveys, one of which most recently witnesses before us some weeks ago and I just showed that the UK healthcare system was wondered whether you could help us here. Are you improving more rapidly than any healthcare system aware of any meetings between Welsh Assembly in any countries of the developed world, and these Ministers and commissioners in Wales where the Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 72 Welsh Affairs Committee: Evidence
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory commissioners have been told to try and reduce the from income, and what the regulator looks for is a number of patients crossing the border from Wales financial projection from the Trust that shows its and visiting English acute trusts? income and expenditure over a number of years Mr Bradshaw: Well, I do not think it is within my ahead and it assesses how that Trust plans to deal remit to comment on what meetings have taken with fluctuations in either income or expenditure place in Wales and we would not be informed of that. and how they formulate their assumptions about it and manage the risks around it, so, in that sense, Q475 Mark Pritchard: Perhaps I can put it simpler. there is no fundamental reason at all in the scenario Are you aware of any meetings that have taken place for Shropshire and Telford why a successful that have had that content in those meetings? application could not be progressed if the Trust Mr Bradshaw: I am not aware and I would not meets all the financial criteria and other factors expect to be aware or to be made aware. These are which are taken into account. matters for the Welsh Assembly. Q477 Mark Pritchard: Is there not a perverse Q476 Mark Pritchard: On the issue then of incentive? The Minister says he is responsible for Foundation Trusts, I am a Shropshire MP, as you England, but of course it is the Westminster know, and we have the Telford and Shrewsbury NHS Government that is responsible for the financial Hospital Trust, an acute Trust, which is very reliant settlement for Wales and that includes health, but if, on Welsh patients crossing the border into for example, Welsh Ministers were inclined to lobby Shropshire and particularly reliant for the future of for greater funding for Wales which, in turn, would mean a greater health provision within Wales, then the Trust in relation to its possible Foundation Trust Y application. Given the diVerent financial regimes that would cause a di culty,would it not, given your and indeed diVerent health targets between Wales comments, Director, for an English hospital trust, and England, how do you think that will impact whether foundation or not, because of course, as we upon the Foundation Trust process? see the Welsh health services improve, increase and Mr Bradshaw: It should not have any impact at all. expand within Wales, that will have a direct financial I may ask David Flory to comment on this in some impact on those hospitals in Hereford and Shrewsbury, Telford and Chester, into cross-border detail because this is one of his areas of deep V expertise, but, if you look at what has happened in areas, which may very much a ect their financial Chester, for example, a very successful FT hospital, output? there have been issues, which you will be aware of, I Mr Flory: The system that operates in England now am sure, from the evidence you have taken, about is one in which, structured around payment by tariV payments, but these have been resolved quite results, income comes into Trusts as patients are successfully.One of the reasons I think we would like referred there or choose to go there and for hospital to see a permanent protocol is to make sure that that service providers there is a volatility in that now. is put on a sustainable footing. You will also see from They cannot be secured or guaranteed patient flows the memorandum that it is fairly clear, the system at for a period ahead. They have to, by demonstrating the moment, in that you can expect a healthcare the necessary quality standards and by the way in system, depending on where you are registered with which they deliver their service, attract the patient. your GP, so for argument’s sake, with your hospital Therefore, in any forward-looking scenario, there is in your constituency, a patient registered with a GP an element of risk that the existing patient flows in Wales would generally expect the provision of care might change, they might increase or they might to be provided by the Welsh Assembly, and the same decrease, and all of that needs to be modelled, built would be the case for England. In practice, what into and thought about in the risk assessment that happens in Chester is that Welsh residents registered the Trust produces for consideration by the with GPs in Wales who are referred to Chester do not regulator. enjoy, do not get a second-tier service, they do not Mr Bradshaw: If I may add to that, free choice of operate separate lists and they get treated just as course in England means that hospitals are in quickly as an English patient would, so I think in all practice competing for patients anyway within of these areas it is perfectly possible, and indeed England, and the implication of your question happens in practice, for the two healthcare systems would seem to be that either Welsh Health Boards to manage these. Do you want to comment a bit are going to stop commissioning or stop sending more on the details of the FT application, David? patients to these hospitals. I think that would be Mr Flory: Yes, Minister. The process for Trusts to highly unlikely. There are long traditions and there become NHS Foundation Trusts is one of are very strong geographical reasons for residents in assessment and then authorisation by an these border areas of Wales to want to be treated in independent regulator, a Foundation Trust monitor. Chester or at your hospital and, given the advantages in terms of waiting times, I think it There are now 96 Foundation Trusts in England and Y what we have learnt from the process is that on the would be politically very di cult for suddenly a financial side it is a very risk-based assessment that decision to be made that would stop that flow. is undertaken and this plays out in many diVerent ways in many diVerent Trusts. The sources of income Q478 Mark Pritchard: Director, you used the word are varied, not only for the resident-based “volatility” and, to me, that would concern my population, but there are separate flows of income constituents. They look to their acute hospital Trust beyond the tariV payments that the Trust receives and indeed Primary Care Trust and they want to see, Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
Welsh Affairs Committee: Evidence Ev 73
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory as the Minister started oV his introductory remarks, terms of our feeling that it would be helpful to have free healthcare at the point of need, but when you a formal ministerial group, I think they could be start talking about volatility and risk, to me, that improved by doing that. I think that would be very does suggest that in the medium to long term, if the helpful and I think that would help us develop a models are wrong, if the calculations are wrong, and permanent protocol which is where I think we need if the financial director of a particular Trust or the to be sooner rather than later. chief executive happens to have got it wrong, and we have had a few across both England and Wales that have got it wrong, then, to me, that sends out a very Q483 Hywel Williams: I just want to ask a worrying message that basically the future of supplementary, Chairman, to Mark Pritchard’s healthcare of my constituents and indeed over the previous question. Just on your role as Minister for border in Wales is based on financial models which, Health in England, were a group of patients from, as you imply, are volatile. say, the south-west of England to be referred Mr Bradshaw: I would argue that, if anything, the consistently to a hospital, say, in the South East, that opposite would be the case because, if the Welsh would be a matter for those patients and those keep their form of commissioning which is by Health medical practitioners, so you would not feel it Boards and they purchase the services, in a way, that necessary to intervene even if that might endanger a flow of patients across the border to England is more hospital somewhere in the South West. Is that the secure than the flows of patients from within case, Minister? Essentially it is tough, but, if that is England who have free choice and who can go the way the market operates, that is the way the anywhere, so I think the opposite of the argument market operates. you are making is actually the case. Mr Bradshaw: Well, we have only had free choice in England since the beginning of April, so it is early Q479 Mark Pritchard: Does that not indicate that days and, whilst we think it is an important the future of Wales having been part of a national mechanism to drive up the quality of care and to give health service and having all the things that England people a choice which I think they are entitled to, I has is actually not a bright one? The future is not think the jury is still out as to how much people will bright because, as I said earlier, there is a perverse incentive for the Government here in Westminster to use their new choice. If you look at opinion polling, ensure that those new Foundation Trusts are flying for example, most people still put proximity as one financially and they never will be if Wales begins to of the most, if not the most, important issues when stand up on its own two feet and have its own it comes to choosing where they have their national health service? healthcare, but it is perfectly possible, for example, Mr Bradshaw: No, I do not accept the premise of the now that people can compare infection rates at question or the analysis. hospitals, mortality rates at hospitals and all those sorts of things, that they might decide, “Well, I’d Y Q480 Mr Martyn Jones: How often does the Welsh rather not go to my local hospital”. It is very di cult Health Minister meet UK Health Ministers? to imagine the flows of patients being so strong that Mr Bradshaw: There is no set frequency to such that would threaten the existence of a whole hospital meetings. They will happen as and when it is felt that and I think that is probably inconceivable, and they are necessary. David is nodding here. However, it is not inconceivable, for example, that, if hospitals begin Q481 Mr Martyn Jones: Do you agree with the to lose patients because they are providing a sub- Secretary of State for Wales, who agreed with us, standard service, yes, they either have to improve that it would be helpful if those meetings with the that service or they may have to face the possibility Welsh Health Minister were announced and it was of that service no longer being viable. That is a broadly outlined what was going on in the meetings? natural consequence of patient choice and I think it Would that not help with transparency? is a positive thing because the experience in England Mr Bradshaw: I certainly agree that I think it would shows that it helps drive up quality and standards. be useful to have more formal, regular meetings at ministerial level, and we have suggested, for our part, setting up a ministerial group to oversee the Q484 Albert Owen: Can I just pick up on your point whole issue of cross-border matters and, within the in response, Minister, to Mr Martyn Jones with normal constraints of the need for free and frank regards to ministers from diVerent parts of the exchange inside government, I am always in favour United Kingdom meeting. Are they with Scotland of transparency and openness as to what is being and Northern Ireland as well and do you discuss best discussed and when those meetings are being held. practice in the four nations? Mr Bradshaw: David may be able to comment on Q482 Mr Martyn Jones: It would be nice to have a this. There do not seem to be so many cross-border free and frank exchange with the Welsh Health issues with Scotland, I think, because of the Minister. Are you satisfied that the joint ministerial geography,because of the population, because of the meetings are satisfactory or could they be improved? fact that traditionally a significant number of people Mr Bradshaw: I think the discussions that we have in England have been registered with GPs in Wales are satisfactory and they are had when we need to and a significant number of people in Wales have had have them, but I think, by implication, what I say in their hospital treatment in England— Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 74 Welsh Affairs Committee: Evidence
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory
Q485 Albert Owen: I understand that, but there are Q487 Albert Owen: The point I am making is: with diVerences between the four nations in the many two separate commissioning and funding regimes, ways in which they provide healthcare, and the are the Welsh providers under-funded? reason I asked that is that they all pay the same level Mr Bradshaw: I would not say so, no, because the of National Insurance and taxes and people in the implication of your question is that the procedures component parts expect the same level of service in England are more expensive and I do not accept from the National Health Service. If there are issues that and, as I think I have just indicated from the across the border, are you aware of them at the overall spending figures, in Wales slightly more is central level and is there then a sharing out of best spent, but I am not aware that more volume is practice? delivered. If anything, I suspect the contrary is the Mr Bradshaw: If you are asking as to whether we case because payment by results has increased the exchange views and whether we exchange volume of activity in English hospitals and made Y information about what we intend to do in terms of English hospitals more e cient. There is a separate policy, yes, I think that is generally good practice. I issue about the money that is actually paid by Welsh health boards to English hospitals for procedures, think on the need for discussions with Scottish V counterparts, for example, I am not aware I have which has been an area in some cases of di erence had a discussion with my Scottish counterpart which we have managed to resolve. The reason that that figure is lower in general terms, I think I am because I am not aware that that has been necessary right in saying, is because it is based on an historic on a particular cross-border issue in contrast with figure, so it is somewhat out of date. You should not Wales where, for example, I have spoken to Mrs take the inference from that that it means that Hart about the Chester issue and the Secretary of current costs of providing procedures in Wales is State has spoken to her about other issues as well, so lower. I think we will have those discussions on a case-by- case basis. I think it is basic commonsense and courtesy to inform colleagues in the devolved Q488 Albert Owen: You are aware of the tensions administrations if we are intending in England, for and you mentioned them in your memorandum. Just example, to take a particular policy decision which to move on, and again you have touched on it, with they might not be taking or thinking of taking and regards to the health boards in Wales vice versa. I think that is general good governance commissioning, there is talk, you may know, and and we would expect, and hope, to be informed proposals that there may be a National Health about decisions that they are taking. Service Board in Wales. Do you think things would improve or would that cancel out then this historic Mr Flory: If I could add, Minister, certainly those arrangement and things would be fairer, in your discussions take place very regularly at permanent- opinion? secretary level between the diVerent administrations. Mr Bradshaw: I would not expect that to have any material impact. In a way, there is always going to be an element of tension between commissioners and Q486 Albert Owen: Minister, I think it would be very providers and that is why you have commissioning good if we had courtesy and we heard things on an and provision. Obviously in Wales, they think it agreed level rather than having ministers in one part would be helpful otherwise they would not be of the United Kingdom saying one thing and moving in that direction. David, do you want to say another, but that is for another day perhaps. Moving whether you think it would have any impact one way on to some of the issues that you mentioned to Mr or another on that? Pritchard regarding the two separate commissioning Mr Flory: I think we have seen through and funding levels in England and Wales, and also commissioner-provider interaction in terms of Mr Flory talked about the mechanism by results, do negotiating contracts for health delivery both pre- English providers become more expensive than and during PBR— Welsh providers and is this an issue? Mr Bradshaw: Payment by results. Mr Bradshaw: Again David may want to comment Mr Flory:—that eYciency improves, productivity on some of the detail of this, but the tariV that is improves and the cost per procedure in many, many charged in English hospitals is set at an average level, examples across the countries come down. There is so it may be that for some procedures it is more that tension that the Minister refers to between the expensive and for some procedures it is less in an commissioner and the provider. Where the patients’ individual case, but the implication of your interests are put absolutely first and foremost in that, question, “Does payment by results make we see fantastic examples of how services for those operations and procedures in hospitals more patients, which better meet patients’ needs, have expensive?”, no, I would argue that the opposite is been developed as a result of that commissioner- the case. The whole point of payment by results is to provider interchange. increase and improve eYciency and, if you look at the overall spend on health in England compared Q489 Albert Owen: The reason I raised the local with Wales, spending per head in England per year health board issue is that between Local Health is £1,547 and in Wales it is £1,639, so it is less than a Boards there is friction. We have had evidence £100 diVerence, but a little bit more in Wales. I am anecdotally from constituents, but also evidence not aware of any evidence to suggest that that results during this inquiry that they are getting diVerent in higher volumes of activity in the Welsh hospitals. answers from hospitals in England across the border, Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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3 June 2008 Mr Ben Bradshaw MP and Mr David Flory so I would suggest that, if Wales had a Board, that something which you yourself have said is very would be eliminated. Would you see that as a benefit important, and that is improving cross-border to Welsh patients? relationships? Mr Bradshaw: Well, I have resisted assiduously Mr Bradshaw: No, the point I was trying to make is commenting on the merits or otherwise of internal that, as far as the English providers are concerned, I Welsh policy and, if you will forgive me, I do not am not aware of their having made any intend to do so. I suggest that you direct those representations to us one way or another. Clearly, if questions to the Welsh Minister when she appears the Welsh Assembly Government thinks for the before you. reasons that have just been outlined by Mr Owen that it would help create a better coherence in Wales Q490 Albert Owen: The First Minister has recently about commissioning policy, for example, from stated that the Welsh Assembly Government English providers, then I am sure that they would requested funds from the Department of Health, and have their own good reasons for pursuing that, but this is the Department of Health, not the Welsh we are not aware that English providers have internally, but they wanted extra money for the complained to us that the existence at the moment of providers’ tariV prices for the treatment of Welsh the large number of health boards in Wales is causing patients and that request was made. Was that request problems to them. Are we? rejected by your Department? Mr Flory: I am not aware of that at all. Mr Bradshaw: Not as such. First of all, there is not currently a requirement, and we are not making it a V Q494 Mark Pritchard: Given the Community requirement, that Welsh Boards pay the tari rate Health Councils, and one of the things we have for procedures carried out in English hospitals. I heard in this inquiry repeatedly from many witnesses think this is an issue that needs to be resolved. I think is of patient confusion, given that you did state that it is best resolved in the form of a proper formal and it would make no material diVerence to have a sustainable protocol. National Health Service Board in Wales, do you think it would just unnecessarily create another layer Q491 Albert Owen: But can you confirm that a of bureaucracy and indeed add to that confusion? request was made and one was rejected as it stands Mr Bradshaw: No, I think again you are slightly now and may change in the future? misquoting what I said. I was answering the question Mr Bradshaw: Not exactly. I was going on to explain in response to what the impact on English providers exactly what did happen. I think I am right in saying, would be and I made it quite clear that it was not my and David will correct me if I am wrong, that the job, and it is not my intention, to comment on the suggestion was made that, if we were to require advantages or otherwise of decisions that are quite Welsh Boards to pay the full tariV cost, the up-to- rightly made by the Welsh Assembly Government in date tariV cost of operations carried out by English terms of the configuration of health services providers, a figure was suggested by the Minister in commissioning their own— Wales as to how much she thought that would cost in terms of extra revenue. We were not confident that that figure was robust, but we certainly were not Q495 Mark Pritchard: But it is obviously seen as rejecting either the principle or the idea that this is part of Westminster government with the financial something that needs to be resolved, but I think it is settlement in Wales giving you day-to-day something that needs to be resolved properly and responsibilities dealing with cross-border issues seriously in the form of a properly worked-out across Wales and more so in Scotland and other protocol to end the uncertainty. I certainly think the devolved areas. Do you have a view that this is going principle is right and we need to have discussions to impact on you and your oYce? about the costs. We did not think the figures that Mr Bradshaw: We do not have any reason to suppose were provided were necessarily robust. that there would be any negative impacts on those Mr Flory: That is right. areas for which I am responsible of this development at all and, as I have said a number of times, it is Q492 Albert Owen: So this is work in progress then? entirely up to the Welsh Assembly Government what Mr Bradshaw: Exactly. structure they would like to see in their country. Albert Owen: Developing as we speak. Q496 Albert Owen: There is just one interesting Q493 Mark Pritchard: Minister, coming back to the point you raised there. You said that you have had National Health Service Board, earlier you no complaints from English providers. I would put mentioned the importance of a cross-border it to you that during our evidence one of the English relationship in health provision. Given the providers said that they received 20% of their importance of that, if there is no material diVerence patients from Wales and they were unhappy that in establishing Boards, which is what you have just they only got 16% funding, so there is disquiet mentioned, which is stating an opinion rather than amongst some of the English providers, I put it to not having an opinion on the National Health you. Service Board, why should it go ahead if it is going Mr Bradshaw: This is an issue that I have already to have no material diVerence on something which touched on. I imagine you are talking about the Wales hopes will have a material diVerence on Chester Hospital. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 76 Welsh Affairs Committee: Evidence
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory
Q497 Albert Owen: No. conscious decision to make driving down waiting Mr Bradshaw: Well, anyway the Chester Hospital is times our number one priority. In Scotland and in a similar situation, and that is why I think we need Wales they have also been very successful at bringing to resolve the issue about the payment of tariV. That waiting times down, but they have also had other is quite a separate issue, I would argue, and that does slightly diVerent priorities that they have put not depend on the structure of healthcare emphasis on, so it is a consequence of devolution, commissioning from Wales. It is an issue that we but I do not think we should lose sight of the fact need to resolve, however many health boards there that waits in both Scotland, Wales and in England are in Wales, and it is not really relevant— have come down substantially. Albert Owen: It was the Walton Centre, for the record, which is very controversial in north Wales. Q502 Hywel Williams: I suspect your answer to this next question will be similar maybe, which is about Q498 Hywel Williams: You will be aware, Minister, free prescriptions and free hospital parking in Wales. that these questions about cross-border treatments I am not asking you to comment on decisions that have been hugely controversial in Wales for various the Assembly have made in this respect, but is it reasons. You did say that the Health Minister for sensible for Wales to be able to provide that sort of Wales has suggested a figure as to the cost of tariV service, whilst patients in England complain that prices which would then equalise matters. Can you they cannot, or at least not the ones that are not tell us and the people of Wales actually who might be registered in Wales of course? listening how much are we talking about in real Mr Bradshaw: You will forgive me, but you said you money, if you can reveal your cards, as it were? would not ask me to comment on the decisions Mr Bradshaw: I think the figure that she used was which have been taken by Wales and then you invite £16 million. me to say whether I think it is sensible. As I have Mr Flory: Yes. already said, I think these are matters entirely for the Mr Bradshaw: So, if we look at the overall spend in Welsh Assembly Government. What I have said, and health terms, we are talking about really quite small I will say again, is that, as far as England is figures in a £110 billion budget, so I think that is a concerned, given that 88% of all prescription items good indication of how I think these issues are in England are free anyway, given that there are perfectly resolvable and why it should not be too concessions in place for the people who need to use diYcult or too challenging for us to resolve them hospital car parks regularly, they may have a long- through the process which I have already described. term condition or something like that, we have made adiVerent decision and that is that the funding Q499 Hywel Williams: If she is asking for £16 million should be prioritised to minimise waiting, and that is and you are prepared to concede a certain amount a decision I am very happy to stand by and defend. between nought and £16 million, the actual V di erence between you might be even smaller than Q503 Hywel Williams: In your written evidence you £16 million. say that “it is diYcult to make direct comparisons on Mr Bradshaw: Well, until we have had a chance to sit hospital waiting times between Wales and England down and really thrash out the figures, I think it due to the diVerences in recording information, and would be wrong to speculate on what the figure diVerent targets and timings”. Now, is that might be, but I think the fact that she put a figure of acceptable for patients accessing a national health £16 million on it, and we are not quite sure if that was V V service, that there should be di erent ways of based on robust data, indicates that the di erences counting? that we are talking about are really fairly small here, Mr Bradshaw: Well, it is diYcult to make and the impact is also pretty minor. comparisons, but it is not impossible. If you start, for example, with targets, and these are publicly Q500 Hywel Williams: There has been a great deal of published targets, they are diVerent. In England, we heat around this and that actually throws some light have a target of a maximum wait from GP referral to on it as well. Thank you. treatment of 18 weeks by the end of this year, which Mr Bradshaw: Well, I do not see why there should we are on target to meet. In Wales, I believe the target have been any heat around it. My impression is that is 26 weeks by the end of next year. With accident the public heat is around other issues which you may and emergency, there is also a diVerence in targets, want to come on to ask me about or discuss later. and in Wales you do not have the 24/48-hour standard in terms of GP access and you are not Q501 Hywel Williams: If I can just continue with a getting extended GP opening hours, so there are further line of questioning around waiting times, can diVerent targets and I think it is inevitable that, limits in waiting times or in fact in any other where you have diVerent targets, you do in some significant variation in performance between cases have diVerent outcomes. You are right to say England and Wales be justified? Should they not be that some of these are measured in diVerent ways. the same, which carries on from the question that the For example, I believe I am right in saying that the Chair asked you initially, I think? Can you justify waiting times in Wales include referrals from those sorts of variations? consultant to consultant, whereas in England we are Mr Bradshaw: Well, as I think I have indicated in my only talking about GP referrals, but the vast answers to previous questions, this is a consequence majority of referrals are from GPs. In terms of of devolution and in England we have taken a outcomes, I think where we can be quite clear, and Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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3 June 2008 Mr Ben Bradshaw MP and Mr David Flory these are published data, in England in terms of patients have to wait longer than patients in actual waits for outpatients, for example, the latest England, but that is as a result of devolution. Would figures we have available are that 109 outpatients you agree with me that actually devolution has been waited for more than 13 weeks for their first the answer to some of those health inequalities by appointment compared with 25,042 in Wales. providing for more localised planning, better Inpatient maximum waits are broadly similar, we delivery, et cetera? think, at the moment. Diagnostic waits in England, Mr Bradshaw: Yes, I think you are absolutely right, the latest figures are six weeks and in Wales 14 weeks. and one of the great strengths of devolution is that it A&E, we have the 98% target for all A&E, whereas enables the sort of flexibility that we have discussed Wales has the 95% target only for the major A&E. earlier to deal with the particular problems that you We are meeting that at just 0.5% below our target, outline in diVerent parts of the United Kingdom. from the latest figures, 97.5%, and I believe the latest One example I would say is that Wales has been Y figures for Wales are 93.8. It is di cult always to quicker and more focused on the whole issue of make accurate comparisons, but I think there are public health than we have in England for the comparisons that can be made. In terms of your reasons that you suggest, that lifestyle diseases and supplementary question, I would very much life expectancy in parts of Wales were more serious welcome a more formal agreement on data and issues than they have been, so Wales has set a priority comparability of data and I would welcome, for on public health. I think it is probably too early to example, the involvement of an independent see, but my Welsh colleague, when she comes before organisation like the King’s Fund in helping us get you, may be able to help you with this, whether that through some of these because I think the has had a quantifiable impact, whereas in England implication of your question is absolutely right, that people, the public, in a democracy have a right to the big public issue for us in 1997 was long waits. know, they have a right to accurate and comparable You could argue that our current big priority, information, that is their basic democratic right and because this is what the public tell us matters to them I think we need to do more work in order to deliver most, is being able to see their GP at a time that is that to people. more convenient for them and being able to get to see a GP quickly and make an appointment ahead, so we have been very much in England responding Q504 Hywel Williams: I would say that there is a V to the concerns of the English public, whereas I am di erence between targets and outcomes of course, sure my colleagues in Wales have been responding to and we did have some evidence from the health the concerns of the Welsh public. service in north-east Wales, that in eVect these Chairman: I am sure the Health Minister in Wales targets might be 26 weeks in practice and most will be very pleased to hear the praise that you have people had their service on the same basis almost as just attributed to her concerning the virtues of the people over in England, so I think you would agree that it is important that we bear that in mind. health service in Wales. Mr Bradshaw: You are absolutely right and I think it is also very, very important, when we talk about waiting time targets in terms of maximum waits, to Q506 Alun Michael: Indeed, the same as we look emphasise that, although our maximum wait target forward to discussing it with her. You talked about is 18 weeks, the vast majority of people will get their how the service is seen by the public. Have you treatment much more quickly than that and I think undertaken any research to establish how patients that, as far as England is concerned, at the moment on the two sides of the border perceive the diVerence the current average is down to eight weeks. Of course in health service provision between England and what you say about north-east Wales is quite right Wales and how it aVects them? because, as I said earlier, although, in theory, people Mr Bradshaw: I am not aware of any research that registered with a GP in Wales who access an English we have done specifically on the perception of cross- hospital can only expect Welsh waiting times, in border issues. We do measure in England, and again practice, they are getting English waiting times, so I cannot comment on Wales, but we do measure you are absolutely right and they are not having to patient satisfaction rates through the GP Survey and wait any longer, in practice, because English the Healthcare Commission also measures patient hospitals are not operating separate lists. satisfaction, and patient satisfaction is a very important part of the Healthcare Commission’s Q505 Hywel Williams: If I can just ask you one very annual health check, the league tables that it broad question, therefore, about health inequalities, publishes, for example. There is the British Social historically health inequalities have been marked in Attitude Survey, I think, which is British-wide and Wales as compared to England by people dying surveys people’s attitudes to the quality of younger, life expectancy being shorter, and also the healthcare and their latest figures show that sorts of diseases that people die of in that they are satisfaction in both England and Wales is increasing nastier in some ways with some of them being related strongly in general terms. In England, between 1996 to heavy industry. However, there is a perception and 1997 general satisfaction rose from 36% to 49% that devolution in some way has accentuated the and in Wales it rose from 41% to 47% in the same health inequalities, particularly in respect of, as we period, so a slightly faster rise in England, but I were discussing, waiting times. You did in fact say in would not say that that was statistically of an interview in the Health Service Journal that significance there. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 78 Welsh Affairs Committee: Evidence
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory
Q507 Alun Michael: Would that actually distinguish think this is something that you have referred to two between attitudes within the cross-border catchment or three times in your evidence. I wonder if you could area, in other words, those in places like Shropshire tell us a little bit about the arrangements to establish or the North West or on the Welsh side of the border a new protocol. What is the timescale for its as distinct from broad English and broad Welsh publication, what is its remit and with whom will the reactions? Department of Health and the Assembly Mr Bradshaw: No, not that I am aware of. There Government be consulting when drafting it? may have been some more local surveys done, and I Mr Bradshaw: Well, oYcials have been meeting am not sure about the Welsh side of the border, but regularly since the interim protocol was first agreed by Primary Care Trusts or individual hospitals in in 2005 and those meetings have been continuing those areas. I am not aware that they have shown pretty much monthly, I think. We would like to see any diversion from the more general trends of rising an agreement with the Welsh administration by July satisfaction in both England and Wales. on a way forward and we believe also that it would be very important to consult fully and publicly on Q508 Alun Michael: Perhaps I could ask you then: any proper, sustainable, long-term protocol. would it not be a good idea for her to have some work which was objective and perhaps joint across Q511 Alun Michael: I think that may point towards the border to look at the impact of the cross-border the answer to my next question which was: should flows on the perception of patients and that protocol not be owned more widely than by communities? oYcials in Whitehall and Cathays Park, both Mr Bradshaw: I think that would be something that involving their elected representatives in the could very helpfully inform the development of a Assembly and in the House of Commons and by the formal protocol, which we would very much like to wider public? You seem to agree with that. see, and help inform the work of the Ministers’ Mr Bradshaw: Absolutely, and it is not for me to group to discuss cross-border issues, which again we make this comment, it is something that your are very keen to establish. Committee may wish to comment on, but I certainly sense a level of frustration among parliamentary Q509 Alun Michael: That was a question about colleagues on both sides of the border that these perception. The other element, I suppose, is about issues have not been resolved, and I can understand patient confusion which sometimes arises because of that frustration. the diVerent policies which we have already discussed. What is your Department doing, in Q512 Alun Michael: That is helpful. In the conjunction with the Assembly, to try to minimise memorandum, you state that a group of oYcials that confusion? Does this take us back to the from relevant departments in Whitehall and Cathays protocol that you have referred to? Park have been formed to address cross-border Mr Bradshaw: Yes, and, as you will know from the issues. Is this the group that has been meeting for the memorandum, the protocol is based on the principle last three years? that your healthcare is dependent on where you are Mr Bradshaw: Yes. registered with your GP,by and large, and we believe that most patients both sides of the border are aware Q513 Alun Michael: You are envisaging this going to of this and certainly it is the responsibility of the GPs a public consultation phase before their work is to make them aware of it, but I think you are right completed? in the implication of your question and I think it Mr Bradshaw: I would expect oYcials, or I would would be helpful to have a more formal and settled hope that oYcials, could work up a proposal that protocol. I think it would be easier for people to Ministers could then agree that would then be understand and it would end any uncertainty that consulted on. I think it is very important that there something might change drastically one way or be a proper and full public consultation. another in the future. I think it would give people the certainty and the stability that they seek, and of Q514 Alun Michael: And you would see that being course in cross-border areas you can choose, within in the remaining part of this year? certain parameters, where you register with your GP, Mr Bradshaw: I would be very reluctant to renew the so one could make the argument that people living interim protocol for another year and I have made in cross-border areas enjoy even more choice that clear. because they can choose, in a way,from two diVerent health systems. Q515 Alun Michael: Just two specific points, firstly, that we heard evidence from the Muscular Q510 Alun Michael: I think what we are trying to Dystrophy Campaign that there are concerns about tease out is two things. One is what the perception of the capacity to provide funding and treatment for people on both sides of the border is and the second the super-rare conditions, and we heard about things is whether there are any confusions or whether in like very specialised physiotherapy services. In fact people are as clear as we would like them to be. fairness, I think it is worth saying that they saw this You have referred to the development of a protocol as not just being a cross-border issue between and we heard from the Secretary of State for Wales England and Wales, but an issue of rare services indeed that he believed that there is a need for an being required in diVerent regions of England as improved protocol on cross-border issues, and I well. Do you think that there is a need for a UK-wide Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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3 June 2008 Mr Ben Bradshaw MP and Mr David Flory fund and system to deal with those sorts of Lord Darzi, is going to publish in July. There are treatments, which is basically what the Muscular diVerent models, as has already been acknowledged Dystrophy Campaign suggested to us? in questioning earlier, of patient involvement in Mr Bradshaw: Well, David may like to comment on Wales from England, and FT membership is one of this in a bit more detail in a moment because I think the models we have in England, but we also have he actually sits on the group, but there is already an Links now and there is a debate about the English national commissioning group which democratic accountability of Primary Care Trusts, involves, and includes, representatives from the so there are diVerent models again going back to the devolved administrations specifically to look at diVerent traditions and priorities in the diVerent these issues of very high specialisms that are best areas, but I join with you in welcoming the fact that provided on a UK basis. There are even some patients resident in Wales who use English FT procedures, I think, where patients are sent overseas hospitals are engaging in that process and I think it for treatment, and one could, for example, think of would be odd, given that they are receiving care from the Great Ormond Street Children’s Hospital in those hospitals, if they did not. London where certain procedures and specialties are provided, but are not provided anywhere else in the Q518 Chairman: Could I come back to this issue of UK, and there is probably a range of others which I the improved protocol. Can this Committee take it cannot think of oV the top of my head, but these are as read that the oYcials drafting this protocol are dealt with fairly sensibly in this commissioning taking note of the evidence that we are receiving in group. this Committee? Mr Flory: I think that what the Minister says reflects Mr Bradshaw: Well, I would very much hope that that there is a system that deals with this in terms of they would, yes, Mr Chairman. If I may say so, I very the national commissioning infrastructure in much welcome your inquiry, I very much welcome England which is joined in by colleagues from Wales, the fact that you are focusing on health, I think this Scotland and Northern Ireland. I do not believe it is is a very important issue, and I am sure that the necessary for that to extend to a single fund, evidence that you have gathered and any however; I think that diVerent parties and interests recommendations that you make will be taken very can make their own contribution to that system. carefully into account, indeed I hope they will be, by oYcials both in my Department and by Welsh Q516 Alun Michael: Could I ask that perhaps you Assembly Government oYcials in drawing up the look at the evidence that we were given by the recommendations that will be made to Ministers. Muscular Dystrophy Campaign which incidentally was reinforced by an event they held for Members, Q519 Chairman: I am sure my colleagues would be a reception at Journalists’ House, which did seem to very reassured by that. In that spirit then and also in suggest that it is not seen to be operating as perfectly the spirit of transparency which you endorsed as you suggest, but I would not like to put you on the earlier, would you be able to write us a note spot for any further detail. Could we perhaps have a informing us of the names of these oYcials so that we note in respect of that? could actually consider inviting them to appear Mr Bradshaw: Yes, I will happily look into that and before us before we complete our work?2 write to you about it in more detail.1 Mr Bradshaw: I would be very happy to do that; I think that is an excellent idea. Q517 Alun Michael: That would be very helpful. Just on one final point, the Foundation Trusts based on Q520 Mr Martyn Jones: Your written evidence the English side of the border are quite rightly states that there is a review underway into recruiting members in Wales. Indeed, if I may say so, arrangements for resolving disagreements between I welcome the fact that they are engaging people providers and commissioners. Who is conducting throughout their catchment area. Have you the review, who is being consulted and when is it discussed with the Welsh Health Minister how to likely to report? look objectively at the lessons to be learned from Mr Bradshaw: I cannot quite remember the wording that engagement of the wider community? that was used in the oYcial memorandum, but, if I Obviously it is early days for those Trusts, but gave the impression that there is some kind of formal perhaps in a year or two’s time, the lessons to be review going on, that is not the case. These are learned from that would be looked at both in matters that are reviewed constantly, if you like, as Whitehall and Cathays Park? part of the ongoing work of the group of oYcials Mr Bradshaw: Well, I have not discussed specifically that we have discussed earlier, and I would expect the lessons to be learned with my Welsh counterpart again this to be something that should be resolved by from the experience of FT membership in cross- the development of a formal, sustainable protocol. border areas, but we certainly, as the Department of Health, monitor the performance of FT membership Q521 Mr Martyn Jones: The NHS Constitution very closely and we think that, where it works well, proposed in the Government’s draft legislative it is really a very good model which you may see programme, do you know if that oVers anything for extended across the Health Service in England when the provision of cross-border services? it comes to the next stage review which my colleague, 2 Note by witness: The oYcials best placed would be Bob 1 Ev 133–134 Alexander and Jim Lusby Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 80 Welsh Affairs Committee: Evidence
3 June 2008 Mr Ben Bradshaw MP and Mr David Flory
Mr Bradshaw: These are issues that are still under answer to a previous question, given the historic discussion between Westminster and the Welsh patient flows, given the proximity, this is really a Assembly Government and I believe they were the political issue for the Welsh Assembly Government subject of discussions between my Secretary of State to decide on its policy, but I suspect that when they and the Welsh Secretary quite recently, but no firm look into it, as I am sure they will, they will find, as decisions have been made at this stage. you have, that patients are generally going to hospitals in England because they want to and they are their nearest hospitals and the most convenient Q522 Chairman: Could I end, Minister, by referring ones for them. I am not sure if the question as to to a letter I have received from one of our colleagues, what the intention of the Welsh Assembly Ian Lucas, the MP for Wrexham. He is very much, Government is in this regard is much better put to as you know, a border constituency MP and he my Welsh colleague. quotes a letter, and I hope you do not mind my doing this, from you to him in which you say, “I Q523 Chairman: Well, could I thank you both for the understand that the Assembly is looking into how evidence that you have given today and also for the Welsh patients can increasingly be treated in Wales”. written memorandum you have provided for us Now, when we visited Liverpool, particularly the which was extremely helpful in preparing for this Walton Centre and Alder Hey Hospital, both session. Finally, could I, on behalf of this clinicians and also patients from north Wales were Committee, thank you for the frank way in which very disturbed by that kind of statement. In the you have answered the questions and your guidance course of your meetings with the Welsh Health for the way in which we should address our Minister, would it be the case that you actually questions to the First Minister and the Welsh Health discussed this? Minister, thank you. Mr Bradshaw: I am sure we would discuss it. Again Mr Bradshaw: Well, it is not really for me to suggest you are slightly inviting me to comment on policy how you address your questions, but I hope I have made in Wales, but, as I think I indicated in an not been too frank! Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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Thursday 12 June 2008
Members present:
Dr Hywel Francis, in the Chair
Mrs Siaˆn C James Albert Owen Mr David Jones Mark Pritchard Mr Martyn Jones Hywel Williams Alun Michael Mark Williams
Witnesses: Rt Hon Rhodri Morgan AM, First Minister, Ms Ann Lloyd, Head of Department of Health and Social Services, Mr Tony Parker, Director of Rail and New Roads, Mr Mark Drakeford, Special Adviser to the First Minister, Welsh Assembly Government, gave evidence.
Q524 Chairman: Welcome to the Welsh AVairs for hips and knees and Bridgend Hospital for Committee, First Minster. Could you, for the record, hernias and other general surgery, and then Bangor introduce yourself and your colleagues, please. for cataracts involving journeys from North to Mr Morgan: I am Rhodri Morgan. I am First South Wales both ways), and, again there was not Minister. On my left is Ann Lloyd, the Head of the much of a hullabaloo about it: it was a decision that Department of Health and Social Services. On my the Health Minister at the old Welsh OYce made and right is Mark Drakeford, Special Adviser, and that was it, there were a few questions in the House further to Ann’s left is Tony Parker, Director of Rail and it died a death. It did not come oV as a scheme, and New Roads in the Department of Economy and but there was no political controversy about it. Transport. Because you have the Assembly as an additional scrutiny body,if these decisions were taken now, they would be subjected to much greater degree of Q525 Chairman: Thank you very much. Perhaps I scrutiny. could begin by placing on record our appreciation of you coming here today and also the fact that there has been great interest on both sides of the border for this inquiry. We have received a great deal of written evidence already, and I thank you and your colleagues for providing some of that written Q526 Chairman: In the last five years, where would evidence. Minister, perhaps I could begin, first of all, you say the major points of divergence have been? by asking a question which I pose to everyone when Clearly there are beginning to be significant they come before us on this particular inquiry: What divergences, seemingly in health and certainly in impact has devolution had on the provision of cross- education. Could you outline for us where the border services for Wales? divergences are? Do these provide opportunities, Mr Morgan: Transparency, I suppose, because you challenges or real threats? have a very transparent process in the Assembly in Mr Morgan: Divergence is inherent in devolution, is CardiV. It has encouraged people to question openly it not? It is not that it was impossible to have and to scrutinise decisions, and anything which divergence pre-devolution—an individual Secretary excites any amount of controversy will probably get of State like John Redwood or Peter Walker, 50 times as much attention in the media and from the famously, could decide to be to the right or to the left political cross-party cut-and-thrust compared to the of the existing government and could run Wales in previous days of the old Welsh OYce. Looking back, the way that they chose—but since devolution the for instance, to decisions before devolution and agenda is simply now determined by the perception trying to compare them with what happened after of Welsh needs by who ever happens to be in charge devolution—which I suppose is at the heart of your of Wales at the time, and they will suit the agenda to question—and looking to my time as a Member of Welsh needs and then in England they will suit the Parliament, when the North Wales Cancer Centre agenda to England’s needs. In relation to a kind of was opened in Glan Clwyd Hospital there was a big choice-oriented agenda, I suppose we would say that row about whether that was going to make the we have not chosen to go down that route, but in Clatterbridge Hospital, on which two-thirds of England the Department of Health has, and the North Wales previously depended, non viable, but it Department of Education to a limited extent has, was a row which really was confined to a couple of through Academy Schools, but then we do not have MPs in the House of Commons and that was it: it the big metropolitan areas where you can be died a death there and the North Wales Cancer choosing where to go to school. Normally in Wales, Centre simply proceeded. I think if that were to for geographical reasons, you will simply have a happen now, there would be a much bigger local school and that will be it. To some extent it is hullabaloo about it. Likewise, a bit earlier than that, the geography; to some extent it is where is the centre in the very early 1990s, a decision was made to have of gravity of political opinion in relation to an treatment centres to try to shorten the waiting lists in agenda such as choice in the provision of public Wales (two were in South Wales: Rhydlafar Hospital services. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
Ev 82 Welsh Affairs Committee: Evidence
12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Q527 Chairman: It has been suggested to us that a patient arrived in Cheltenham after about a six- with the advent of democratic devolution in Wales hour taxi journey only to find the battery had run and the ability to formulate and shape our own down—I know it sounds incredible—in the PET policies, there has been a drift potentially towards scanner, and they were sent back in the taxi. But the introspection—a kind of “Fortress Wales” attitude. PET scanner in CardiV will be open fairly soon. That Could you make an observation on that in the is a major £16 million initiative for academic context of what is seemingly happening specifically research, plus repatriation of a specialist diagnostic in health and the apparent shift towards an in-Wales facility costing a huge sum of money. solution? Mr Morgan: The two examples I gave you in answer to your first question I think will give the lie to that. Q529 Albert Owen: What is a PET scanner? From time to time an initiative will be taken, such as Mr Morgan: I think it stands for positron emission was done in Peter Walker’s time as regards the tomography. treatment centres, which involved forming a Fortress Wales (that is, patients from South Wales Q530 Chairman: Just in case I missed the thread of would go to Bangor for cataracts; patients from your argument: I did pick up at the beginning that North Wales would go to Bridgend Hospital and you were asserting the fact and acknowledging that Rhydlafar Hospital for knees or piles and hernias for the foreseeable future the East-West link or and varicose veins, and so forth) whereas, connection is to be reasserted, and there is no such geographically, it might be said that that is a long thing as an in-Wales solution to all problems in the journey for relatively simple routine treatments. The Health Service. Glan Clwyd Cancer Centre, which I will mention a Mr Morgan: I am not sure about the use of the word V little bit later, cutting o two-thirds of North Wales’ “reasserted”—but no change, except that from time patients from Clatterbridge; the one-third in the to time specialist services become mainstream Wrexham area continue to go to the Christie. I do services and then can be repatriated; the PET not think we have done anything that you could scanner being one example. Deep brain stimulation describe as introspective, “Fortress Wales” oriented is now being commissioned from English providers, policy comparable to those two initiatives which but Edwina Hart has said that she thinks it may be took place before democratic devolution. I think possible within a year or so for deep brain they give the lie to that allegation, wherever it has stimulation to be available in Wales. Provision for come from. eating disorders (anorexia, bulimia) is currently by private providers, at the Priory Clinic in Bristol. We Q528 Chairman: You would be happy for me to say are investing in an eating disorders clinic in that one of our greatest assets in Wales is the fact that Bridgend, because there has been such a hue and cry we are next to England and we should about why everyone has to go to Bristol. Again, that acknowledge that. will not cover North Wales, because this 1:13 Mr Morgan: I have always said that. Very closely relationship of population means that a dependency integrated. It will be diVerent in North Wales. on Manchester, Liverpool, maybe Chester and Obviously the population of North Wales is one Shrewsbury, et cetera, is much more likely to last for thirteenth of the population of the north-west of a much wider range of services, but occasionally you England, therefore the relationship with even the get examples like Glan Clwyd and the North Wales Cancer Centre. I cannot foresee one—I do not know small/medium centres, like Chester, but certainly V with Merseyside and Greater Manchester in the of one which is on o er at the moment—but you are provision of health services is totally diVerent from not saying there will never be a further investment in the relationship between South Wales, which has health services similar to what was done in the mid- two million people, and the greater Bristol area, 1990s in Glan Clwyd. which would have about one to two million people. Therefore, where Bristol will have some services Q531 Chairman: I get the drift of what you are which are supra-regional, South Wales will have one saying, that you will judge each case on its merits and or two services, where people travel in from Bristol, there is a pragmatic approach or from Devon and Cornwall sometimes—to Mr Morgan: Yes. Morriston for burns surgery, but it is pretty rare that way—and there is a little bit of a flow to Bristol. From mid Wales, of course, there is some flow to Q532 Mark Pritchard: Given the repatriation Birmingham, as well as flows to Hereford and comment you have just made First Minister, would Shrewsbury. But, yes, the availability of services you say it is either an aspiration or a policy? which are reasonably close by is a great advantage, Mr Morgan: It is so pragmatic, I find it diYcult to because it means we do not have to invest, but from categorise. If something became suYciently time to time specialist services become capable of mainstream that you could and should provide it being repatriated. The big one that is going on now locally—and sometimes that will mean locally in is the PET scanner. At this moment, everyone in North Wales and sometimes it will mean locally in Wales has to go to Cheltenham for PET scanner South Wales—then you make a decision, as with treatment. I am not sure about whether North Wales deep brain stimulation. We think we can do that. people go to Cheltenham as well. Certainly there With the PET scanner that was partially driven by have been some very high profile cases. For example, academic research and the availability of money Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford from the Government in London towards it, as well Q538 Alun Michael: I was looking rather more at as the fact that it is a clinical facility—it is both. Each how you carry forward a policy of coherence on both decision is almost sui generis. sides of the border. For instance, there has been a lot of discussion about the role of improved protocols Q533 Mark Pritchard: Are you saying to us that between the two governments. overall you do not have an aspiration for Wales to Mr Morgan: Yes. have more in-Wales health solutions? Mr Morgan: I would anticipate that certain specialist treatments become mainstream. When Q539 Alun Michael: And also improved protocols, they become mainstream, you have to give serious for instance, between the health services in Wales consideration as to whether you can provide them and the West Midlands, to take one example. We eVectively and safely clinically; that they would be heard evidence from bishops as well as from health absolutely at the cutting edge, the best, et cetera; and experts, some very good evidence. That takes you to then you need shorter travelling journeys. a policy level, but it also takes you to the practicalities. Q534 Mr Martyn Jones: What input do you Mr Morgan: Yes, it does. These are very practical personally have in policy decisions regarding where issues. We have a concordat going back to 2001 a particular service is delivered on what side of the which specified that not any one of the four border? administrations running health in the UK— Mr Morgan: It depends what you mean by policy practically it applies more to England and Wales decisions. On policy decisions which become than it does to Scotland and Northern Ireland, so financial decisions and/or have resource not one of the four, but really it is not one of the implications, and the usual budget to and fro two—should do anything which has an adverse between the Finance Minister, the Health Minister, consequence, either financially or in terms of patient the Education Minister, and so on, there will be care, on another administration, and that, if they do, times when I am drawn in and there will be times financial compensation should be provided if there is when I am not drawn in. a financial adverse consequence. The row which we are all aware of and which you are all aware of—it Q535 Mark Pritchard: But not all the time. has produced a lot of newsprint and a lot of Mr Morgan: Not all the time, no. coverage—over the new payment by results system which came in in England about two or two-and-a- Q536 Alun Michael: Earlier in your evidence, you half years ago now—and the row was in the build-up referred to the greater divergence and the greater period to that—was in our minds not in keeping with transparency that comes with the advent of the concordat. Although we have made it so now— devolution. It also means, therefore, that more is we have made it to be so now, after a lot of patient known, does it not? It also exposes anomalies where negotiation—initially certain English Trusts were they exist and unintended consequences sometimes not abiding by the guidance given by the when there is a decision on the two sides of the Department of Health and were trying to charge border. We have heard evidence from both sides their Welsh LHBs extra, contrary to the DoH about the absolutely crucial importance of the need guidance which was in line with the concordat. We for simplicity and clarity from the point of view of were asking the DoH, “You enforce your guidance,” the individual families, the people who are seeking to and of course they had no motivation to enforce the access services. Against that background, clearly guidance because if they had enforced the guidance you have a pivotal role in developing and then that would have accelerated the compensation maintaining the relationship between the Welsh based on the 2001 concordat. That is a practical issue Assembly Government and the Government of then about the negotiations over sums of money. It is Westminster. £2 million here, it is £10 million there, but everybody Mr Morgan: It is in my job description. tries to say, “But there is a concordat. You have to abide by the concordat,” but making sure it sticks Q537 Alun Michael: How do you work at trying to was very diYcult. But it is okay now. There are no achieve coherence and a minimum of those problems at this moment in 2008-09. anomalies to which I have referred? Mr Morgan: Decisions are partially technical, partially financially driven, and partially politically Q540 Albert Owen: This may sound naı¨ve, but I was driven. It is in my job description to lead on matters not here in the House at the time the first which relate to the relationship between Westminster Government of Wales Bill went through. They were and Wales. But that does not mean that individual heady days and there was excitement about Ministers do not also have their opposite numbers, devolution, but were these cross-border issues given and sometimes quite small issues can have a political suYcient attention during the passage of that Bill, or salience which means that I have to get involved. I was it the case that these belonged to the old Wales think PhD’s will be written on this subject in the OYce, so that is what the Assembly will run, this is future, but I cannot analyse it today to say that there what the rest is, and then there is this grey area and is a level of radar and above that radar the First it is not just increased transparency now, but it is that Minister will be involved. It is not like that. It is too many of these problems that were not dealt with at unpredictable. that time are coming home to roost. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Mr Morgan: I do not recognize that description at Q543 Mr David Jones: First Minister, you have all. As Mr Michael put it, more is known now but mentioned the issue of improved scrutiny and more is challenged now. That is the issue: the transparency. scrutiny mechanism is so much stronger. People Mr Morgan: I did not say improved; I just said more. have interpreted that scrutiny mechanism as being the age of challenging either the Minister or the man Q544 Mr David Jones: I see, so you do not regard it or woman in the white coat, who is either running necessarily as an improvement? the Health Service, as Ann would testify, or Mr Morgan: Sometimes, yes. providing the clinical side of the Health Service. People now do not accept a decision by a Minister. Q545 Mr David Jones: You have quoted previous When Ian Grist in the 1990s said, “Okay, patients instances of patients from South Wales being sent to from North Wales will travel to South Wales to have Bangor for cataract surgery, and nobody raised a their hips and knees done, or their piles and hernias peep about it at the time. But of course that is not and varicose veins done, and patients from South really the issue we are concerned with. We are Wales will go to Bangor to have their cataracts concerned with sending patients from North Wales done,” people said, “Well, he’s the Minister, he to South Wales for elective neurosurgery. That is makes the decisions. Okay, we may not like the five- what has caused the kerfuZe over the last 12 hour journey in an ambulance, but if that’s what he months. Would you accept that if it had been says, that’s what we’re going to do.” That would suggested under the old Welsh OYce that patients never happen now because they would challenge it. from North Wales should have to travel to South They would say, “We don’t like that.” It is just the Wales for a brain operation, there would have been mood music. It is not just devolution; there is a much just as much an outcry then as there has been over more challenging mood among the public now recent months? about all decisions by all Ministers. I am sure the Mr Morgan: I do not think you can prove it either setting up of the North Wales Cancer Centre at Glan way, but I think the level of challenge is much, much Clwyd would have produced a much bigger row greater now. I am not approving of it; I am not now, testing whether you can guarantee that you are disapproving of it; I think it is a statement of fact really going to be able to recruit cancer specialists that the level of challenge is much greater. In relation into North Wales when you have never done it to patients from North Wales being told in 1990, before, when we have a very good service in “You will go to South Wales for hips and knees and Clatterbridge and an even better one in Christie for general surgery”—and the numbers, of course, are outpatients from the Wrexham area. quite large, much larger than in elective brain surgery—the operation is probably seen as less tricky or threatening, but the numbers involved are Q541 Albert Owen: I accept that within Wales there probably at least 10 times greater—the diVerence is greater scrutiny—I accept that and I very much between relatively no kerfuZe back in 1990 and an welcome it. It is far more democratic. But I was awful lot of kerfuZe about a proposal floating in the asking whether the protocols and concordat of 2001 air in 2007 is mostly related to the change in the should have been done during the passage of the public mood, created partially by devolution and Government of Wales Act. partly by the fact that the public now challenge Mr Morgan: I think the Government of Wales Act— things much more, whether it is ministerial, whether and Alun will correct me about this—was to set up it is to do with the Assembly, whether it is to do with the machinery for establishing concordats. I do not Westminster, or even clinical decisions as well. They think it was envisaged that you would write the demand their rights. concordats before the Assembly was set up. The Chairman: I think we have to move on now. concordat coming along in 2001 appeared to solve the problem—and it did solve the problem until Q546 Mr Martyn Jones: What principles should 2005–06, when the impending change in the system govern the access Welsh patients have to the English came along in England. We carried on with the old NHS? For example, should they use whichever system of the cost and volume, and England made service is best for them regardless of where the their change to payment by results. Foundation service is? Trusts were being brought in at the same time, I Mr Morgan: Obviously, clinical safety and clinical think, so, that was a bit of a driver as well, because quality will be the main drivers, and the issue is Chester wanted to be a pilot, an early first phase always whether what you want is excellent services Trust, and probably quite a large part of their provided as close as possible to your home or catchment area was in the Deeside strip in Wales. We services which are as close as possible to your home did not make changes, but England did make which are provided as excellently as possible. I think changes. We said, “Okay, we insist on our rights it has to be the first of those: excellent services under the concordat,” and that was very diYcult to provided as close as possible. There is one warning enforce. about cross-border services which I do want to refer to now—although I do not think it could happen again now—when the worst disaster to hit the Q542 Albert Owen: So it is post-devolution changes National Health Service struck, that is the Bristol that are the big issue. children’s heart hospital scandal about 15 years ago, Mr Morgan: Yes, I think so. one notable characteristic was that children Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford requiring heart surgery in the Bristol area stopped Q551 Mr Martyn Jones: As First Minister, will you going to the Bristol children’s hospital because GPs ensure that she comes before us? in the Bristol area knew there was something wrong. Mr Morgan: Let me finish. I have agreed with your Patients from South Wales and from Devon and Chairman that I will come today to deal with three Cornwall continued going there, because their GPs topics: health, transport, education, in whatever way were out of the loop and they did not pick up that you choose. I hope that at the end of that session you there was something seriously wrong at that will not require a further session. If you decide you hospital, and many of them died as a result. It was a do need a further session, that is a matter to be horrible thing. That is the only example I can think looked at then. of that cuts against the principle that you should be willing to travel further to get greater excellence Q552 Mr Martyn Jones: You know that only rather than travel shorter and make a compromise Members of this House and her Majesty the Queen on the excellence. are exempt from coming before select committees, First Minister. Even Members of this House come by Q547 Mr Martyn Jones: Given that you have stated convention. When a health Minister did not want to we should have excellent services as close as possible come before a select committee in 1989—and she to our homes, why did your Health Minister was also called Edwina, strangely enough—she was announce that elective neurosurgery would only be persuaded to come by her Prime Minister, Margaret performed within Wales, given that that would Thatcher. Do you have the ability to persuade aVect patients? Edwina Hart to come before this Committee? Mr Morgan: I am not aware that she went beyond Mr Morgan: You are asking me now to speculate on floating the possibility that this was a possible an issue in which you are saying, before we have solution. Our broad policy is that diagnostics should finished the session, that you are not happy with the be brought closer and rehab should be brought outcome of the session and you want a further closer, but the operations themselves will quite session with another Minister. That is up to you to frequently move further away. We have taken a hell do and you can cross that bridge when you come to of a beating (to use the famous Norwegian football it, but I do not think you should do that before we commentator’s expression after Norway beat finish the session, otherwise you are implying that England that time) for suggesting that people should my evidence is not up to muster for you. If you do have their operations done further away from home, make that decision, we will cross that bridge when while at the same time saying that they should have we come to it. their rehab and their diagnostics done closer to Chairman: Thank you, Minister. On behalf of the home, but you cannot compromise on the Committee, I can accept the answer you have given, excellence. and we can move on
Q553 Albert Owen: I am going to take the evidence Q548 Mr Martyn Jones: If you are having an and the responses you have just given. You said operation done by a particular surgeon and that “floated an idea”—so it has been kicked around or surgeon is three-and-a-half or four hours away, that whatever terminology you use—but it was actually a is not a good thing, surely, if anything goes wrong statement by your Minister on 4 July 2007 that said post-operatively. they wanted an all-Wales neurosurgery in the future. Mr Morgan: I do not think that is rehab, is it? To qualify that and defend her, she did say not emergencies, but just elective work. This type of Q549 Mr Martyn Jones: There is this idea that there elective work, as you know, is planned and we have is some kind of collective delusion in North Wales excellent services. The two centres she referred to that this was just floated. Surely that should have were Swansea and CardiV. I am not strategically been seen. Why is the Health Minister not prepared placed between a CardiV and Swansea MP here, but to come before our Committee and defend this I do get upset when my constituents get caught up in decision or clarify the statement for the people in a spat between CardiV and Swansea, and that is North Wales? what I think this was, trying to resolve a problem Mr Morgan: Your definition of rehab is very between two neurosurgery services in South Wales diVerent from mine. I have to say that. and then thinking, as a consequence, that to make those viable we will just have in-Wales for the rest of Wales, when there is a perfectly adequate high- Q550 Mr Martyn Jones: Forget about the definition, quality service across the border, which has satellites First Minister. That was perhaps a throwaway within North Wales, which provides the rehab that comment. Why is your Health Minister not prepared Mr Jones was referring to. It is an excellent service. to come before this Committee and clarify her That is what has caused this problem. It is not position? It was her statement of her position. You anything else that Ministers in the previous have come here, and we are very grateful for that, Conservative administration did; it was a statement but where is she? by your Welsh Health Minister with regard to the Mr Morgan: It is up to this Committee to decide, services within the borders of Wales. after you have heard today’s session, whether you Mr Morgan: I am saying that the diVerence between want to look again. Obviously I come here in the then and now is that people are much more willing hope— to challenge an idea being floated. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Q554 Albert Owen: I respect that. I am challenging Mr Morgan: The version I heard was that it could you now: is it the policy of the Welsh Assembly involve surgeons from CardiV and Swansea going to Government for people from North Wales to travel Ysbyty Gwynedd, for instance, and providing a to either Swansea or CardiV for neurosurgery, or is service there. We do not know. Anyway, that is all the present situation to the Walton Centre a policy open and up for grabs now after the completion of that you defend and feel should move forward in the the Steers Review. There is no proposal to change the near future? present— Mr Morgan: I have heard all sorts of possibilities. We are about to come to the end of the Steers Review Q561 Albert Owen: So that statement was incorrect into the future of adult neurosurgery. Is that or taken out of context? covering emergency or just elective? Mr Morgan: There is no definitive decision— Ms Lloyd: All neurosciences. Mr Morgan: That will be coming to an end very shortly. In advance of the completion and Q562 Albert Owen: It is the record. publication of that, I am not going to make any Mr Morgan: -- on removing services from Walton or definitive statements. I am sorry about that. I just removing North Wales’ patient flows to Walton. think the timing is wrong. We will supply you with a copy of the Steers Review, but I am not aware of any Q563 Albert Owen: Sure, but I am quoting from the proposal to change the present pattern. The Steers Assembly record here. It is what has caused this Review is looking at where the surgeons and the argument. You kept making reference to one- neurologists provide their services. What is the pool thirteenth of the population of North Wales of skills and talent that is available, so that, along the compared to Merseyside and the north-west of broad principle that I have mentioned—that you England. When we took evidence from the Walton cannot compromise on excellence—you will provide Centre with regard to referrals, 20 per cent of their services which are as excellent as you can get. work was generated from Welsh patients, so it is a huge amount of people that we are talking about. Q555 Albert Owen: As close to home as possible. Mr Morgan: Indeed. But not as big as the percentage Mr Morgan: You will make a compromise on the of Clatterbridge’s work that was removed from travel, not on the excellence. That is the key thing for Clatterbridge when the North Wales Cancer Centre me. Although we as an administration took a hell of was opened. a beating over the issue of saying that people should be willing to compromise on the distance they travel and not expect to have every single specialist service Q564 Albert Owen: People were still going to provided in their local hospital— Clatterbridge a long time after. Mr Morgan: They may have been, but that was Q556 Albert Owen: Do you think you are wrong? probably 40 per cent of their work. Mr Morgan: Pardon? Albert Owen: I am not going to argue figures— Chairman: We must progress now. Thank you very much for that. Q557 Albert Owen: Do you think those who wanted to give you a beating, the media and Members of the Parliament like myself, were wrong, or was the Q565 Mark Pritchard: First Minster, who sets the statement wrong initially to suggest that people from health policy in Wales? Is it yourself or the Health North West Wales— Minister? Mr Morgan: There was no definitive statement Mr Morgan: The Health Minister would take the about where operations should be carried out. lead and then the Cabinet either agrees or does not agree with what she is proposing, and sometimes I Q558 Albert Owen: I could quote it back to you. It am deeply involved myself as well. It will depend on says, “within Wales”. the nature of the decision. Mr Morgan: No, it did not. Q566 Mark Pritchard: Given the Health Minister’s Q559 Chairman: I think we have to make some comments on the record which Mr Owen has just progress. read out, is it not clear, and given your response, that Mr Morgan: I am sorry, you are not letting me finish there is a divergence of policy between the First what I am saying. I was saying that the possibilities Minister and the Health Minister? that were being floated that I heard of included Mr Morgan: I do not think it works like that. I have surgeons from the neurosurgery departments in been trying to say this morning that, given the much CardiV and Swansea providing a service in North higher degree of scrutiny there is now, an idea will be Wales. floated and then there will be a strong reaction to it, and then a specialist is brought in from outside with Q560 Albert Owen: Sure. It says, “Therefore, in the absolutely no previous track record of involvement case of adult neurosurgery, the approach that I now in Wales, although a strong track record of intend to adopt is one in which we will look as involvement in the subject—as with James Steers— actively as possible at redirecting additional elective and will be asked to make a report on what is the best work generated inside Wales to the two centres at way to deal with the adult neurosurgery service issue Swansea and CardiV.” That is pretty clear. in the future. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Q567 Mark Pritchard: Forgive me, but do you not Q574 Mr David Jones: I understand that, First feel some sense of embarrassment that you are here Minister. When this policy was announced—and I before the Welsh AVairs Select Committee, having to am bound to say that I agree with Mr Owen: it looks give an account of clear contradictions between very much to me like a statement of policy—on 4 what the Health Minister has previously said on the July last year in the Assembly, had she had any record and what you have said previously on the discussions with you about a potential conflict of record and, indeed, reiterated today? interest? Mr Morgan: I think that is a misunderstanding of Mr Morgan: I do not think there is a potential the nature of decision-making. Sometimes an idea is conflict of interest. floated, and then, following a reaction to it—and those reactions, as I have said several times this Q575 Mr David Jones: Forgive me, I asked: Did she V morning, are very di erent from what they would have any discussions with you about a potential have been 15 years ago –it is given to somebody to conflict of interest? come back with a recommendation, as we expect to Mr Morgan: I certainly do not recall one, because I have from James Steers, who is Edinburgh-based, do not think there would have been one to have. fairly soon, over the next couple of weeks. Ms Lloyd: Yes, in the next month. Q576 Mark Pritchard: Earlier on I asked you about Mr Morgan: It is imminent. whether you have an aspiration to see more in-Wales health solutions. You did not say yes or no to that Q568 Mark Pritchard: do you accept there is question, yet a few moments ago you mentioned confusion and this confusion, if it is not dealt with, wanting to see more health services delivered locally, could turn into chaos. Whilst the people of Wales closer to people in Wales. By definition, is that not want the Welsh Government to get on and deliver either a policy or an aspiration? health services as close to home as possible and the Mr Morgan: There is a danger of getting into a highest quality of care possible, that delivery semantic and meaningless discussion about what is perhaps is going to be stalled while this confusion is the diVerence between a policy and an aspiration. I going on. cannot get into my head what diVerence it would Mr Morgan: I did not catch that last bit. I am sorry. make if it was a policy or an aspiration. Decisions come up for funding, like the PET scanner: Are we Q569 Mark Pritchard: This confusion is not helping going to go for a PET scanner? Who is going to fund the delivery of health services on the ground. Whilst it? Can we get a grant? Yes we did, so we go for the there is this confusion at senior level within the PET scanner. That means that people do not have to Welsh Government it is not helping Welsh patients. travel to Cheltenham and so on, and it means that Mr Morgan: I am not aware of any evidence that it academic researchers in the medical school can use has aVected the quality of patient care. the PET scanner, which is great. Now, is that a policy or an aspiration? It is a very good thing to have, and Q570 Mr David Jones: First Minister, I apologise in it was an aspiration to have a PET scanner, so, you advance for the questions I am just about to ask you, know, I am not sure. but I believe they are important. You have referred Mark Pritchard: I am trying to build to a case here. to Professor Steers’ inquiry. It is the case, is it not, There is a practical (to use a word we have used that Health Commission Wales, prior to the last many times this morning) point to why, if there is an Assembly election, issued a report in which it aspiration or a policy or both to see more healthcare recommended that one or other of the two delivered locally,that has major implications for two neurosurgery units in South Wales should be closed?. major health policies of the Westminster Mr Morgan: I cannot remember. Do you remember? Government and the Welsh Government. First of Ms Lloyd: That is true. Yes. all, on polyclinics, because that will not deliver your aspiration for practical delivery of services more closely to Welsh patients, and, secondly, on the Q571 Mr David Jones: It is the case. And it is the foundation status of payment by results to which case, is it not, that Mrs Edwina Hart was active in you referred earlier. There is a perverse incentive for campaigning for the retention of the neurosurgery the Westminster Government to ensure that unit in Swansea? Foundation Trusts in England in the border counties Mr Morgan: Yes, in her constituency capacity, I am do extremely well, and that means clearly drawing sure she was. from Welsh patients as well. Chairman: Please pose your question. Q572 Mr David Jones: Indeed. Mr Morgan: Probably every candidate standing for Q577 Mark Pritchard: I am getting to the question, every party in the Swansea area would have been Mr Chairman. Thank you for your guidance. doing exactly the same. Therefore, if we are having more Welsh patients coming into Foundation Trusts in order for those Q573 Mr David Jones: I accept that. She has a Foundation Trusts to be successful with payment by constituency interest, does she not? results, that means that there is no incentive for the Mr Morgan: When you say constituency interest, in Westminster Government to ensure that in-Wales an election, yes, constituency interests are probably health solutions grow. Would you accept that is the slightly wider than your own constituency. logical consequence and thought process? Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Mr Morgan: I am afraid I am in danger of having got Mr Morgan: I think we have changed considerably lost in the question build-up there. We have no less than in England. The changes that have caused aspiration to set up Foundation Hospitals. We have the divergence have been mostly English changes no ambitions or aspirations or policy to set up rather than Welsh changes, let me put it that way, polyclinics. On the issue of the impact on the and handling those produces tensions from time to formation of Foundation Trusts in England, to be time. 2005–06 and 2006–07 were a bad couple of honest I think probably when the Foundation years for that reason, in getting the English system Trusts, through their nature, were on the point of to settle down without disadvantaging Welsh being formed, they wanted to try to maximise patients and to abide by the 2001 concordat on due income and, therefore, they were under some compensation if one country made a change that pressure to ignore the Department of Health disadvantaged another country. On the general issue guidance about allowing Welsh LHBs just across the of where should services be and not compromising border to continue to purchase health care from on excellence, it does mean occasionally that we in them on the old basis; that is on the cost and volume Wales have to accept that a service will go outside basis. Although the guidance said you must allow Wales that previously has been provided in Wales. the Welsh Trust to continue to use the cost and Paediatric cardiac surgery left CardiV—strangely volume basis, they were seeking to ignore that. We enough, after the Bristol children’s hearts disaster. do not have that problem now, but we did have that The worst disaster ever to aZict the NHS anywhere problem in 2005-06, as they were getting ready for in Britain occurred in Bristol, in the children’s payment by results, and in 2006-07 in the first year. hospital, but, as a consequence of it, we lost I think those have now been solved and the paediatric cardiac surgery in Wales to Bristol to help Foundation Trusts and the would-be Foundation them rebuild. That is one of those ironies that Trusts along the English border are now abiding by happens. You would have thought they would have the DoH guidance—on which, in any case, we are sent all the patients to CardiV as the next nearest now attempting to reach a new protocol, to prevent paediatric cardiac service—and we had an any underlying tensions. amazingly good paediatric cardiac surgery service— but it did not happen that way because the Department of Health flooded money into Bristol to Q578 Mark Pritchard: Does it mean, finally, that rebuild. We lost paediatric cardiac surgery as a result Welsh patients do not have choice—which is and we do not have it now. We have to accept that apparently the watchword of the National Health from time to time. You will send patients to Great Service. They do not have choice. Those living on the Ormond Street Hospital—we have always sent border have to go into England to receive treatment, patients to Great Ormond Street Hospital and so has and choice frankly does not apply to the National everybody else—and occasionally you have to Health Service when it comes to Welsh patients. accept that a service is so super specialised that it will Mr Morgan: Welsh geography is such that along the be closed in Wales and will migrate into a big centre English/Welsh border the substantial market towns, in England. That does not just apply in North Wales, like Chester, Shrewsbury, and Hereford, are all in it applies in South Wales as well from time to time. England. The small border little towns tend to be in Now and again, as with burns surgery in Morriston, Wales. Therefore, you will tend to get Welsh GPs I think it is due to be designated now as a supra- who have English patients because they are in regional centre, in which it has a status for dealing Knighton or Presteigne or wherever, and you will with burns surgery. For burns, serious industrial tend to have Shrewsbury, Hereford, and Chester, incidents in the docks or the oil refineries or having a lot of their patients coming over the border whatever, if there are a lot of burns, they will be from Wales. It is not a matter of choice; that is a brought from the west of England, from Swindon, matter of plain and simple geography, where the from Bristol, from Devon and Cornwall I think, to towns are, and where the substantial towns are. Morriston. Occasionally, you will get a designation of a Welsh centre as a supra-regional, but it tends to be more the other way.You must not compromise on Q579 Mrs James: Before we go to the question, First excellence. You always try to drive towards Minister, I would like to say that we are aware that excellence and provide it as locally as possible. we are awaiting the Steers Review, and as the MP Sometimes, you will lose Parliamentary seats and where Morriston Hospital is situated I would like to you will lose Assembly seats because of not make the point that it is of the highest quality. There compromising on that principle, as we have done. is no doubt across the country that the neurosurgery services at the Morriston are of the highest. That is why it has been such a burning debate. It is not Q580 Mark Williams: I am not wishing to open a simply an argument between CardiV and Swansea; it whole can of worms, but I just thought I would go is about where the best services are situated. We back to Mrs Hart’s statement, but more the practical believe in Swansea that they are in Morriston manifestation of that. It may be a question for Ms Hospital. I would like to go now to the question Lloyd. What practical directive, if any, was given to proper: how would you characterise the situation Local Health Boards following Mrs Hart’s with regard to cross-border health services? Do you statement? I have talked to two LHBs and they seem think it is working. Do you think it is of marginal a little unclear, to put it mildly, as to what the follow- significance? Do you think it is just a bit of a on from that statement was, specifically with regard nuisance. to neurosurgery, though I have to say the generality Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford as well. The Committee has had a copy of a letter that serve communities across England and Wales from the South Birmingham NHS trust concerning are treating their widest range of customers in the the provision of artificial limbs, asserting that same way, so that people become members of them. funding is no longer available from the local area— I assume this is something you would welcome, that presumably it has been directed to or repatriated to they are being treated in the same way. the all-Wales solution—stating that “the matter is Mr Morgan: Not necessarily as part of a Foundation entirely beyond and outside our control.” Is that an Trust model or as something you cannot have unless LHB response to the ministerial directive or—as the you have a Foundation Trust model, but a wide level Minister has talked about the pursuit of excellence of patient engagement and community engagement and we all agree with that—the specifics of is an essential part of an eVective health service and individual cases. What have you said to the LHBs is a fundamental part now of the awarding of following Mrs Hart’s statement? research contracts. You must show that you have Ms Lloyd: The practical implication of that consulted with the patient group involved or statement was that we had to start building the case families, et cetera. Likewise, our proposal for to present to Mr Speers in terms of exactly what were keeping Community Health Councils and the flows going through the borders in order to expanding the role of Community Health Councils inform the work that he would have to do. We asked essentially is part of the same mood music of trying the LHBs, therefore, to be quite specific about the to engage the public to the maximum degree, nature of cases/the case mix that went out through whether you are talking about the intelligent patient Wales and where those patients came from, because or the families and communities generally. nobody like Mr Steers could start to undertake a comprehensive review without that sort of information. There was a very considerable amount Q585 Alun Michael: You are making a much of work done, as well, in terms of not just narrower point. I have strongly supported the neurosurgery but the whole complex field of retention of Community Health Councils. In this neurosciences that has to be looked at. The case, the point I am making is that there is a cross- questions are: Is the neurology service suYcient in border anomaly. The fact that everybody is being Wales at the moment or does everybody have to go treated in the same way across the patient cohort somewhere else—and that might be either within or surely is something as well. without of Wales—to get a general neurological Mr Morgan: Could I ask Ann to answer this. Let me service? The views of LHBs on that, on the pass your question on, in a sort of rugby player consequences of starting to move more closely to sense, to Ann and put it this way: Where there is a patients and excellent service—because we cannot pending Foundation Trust application, such as with compromise on safety and we will not compromise Gobowen, where probably 40 per cent of the on quality—were the sorts of pieces of evidence that turnover or patients or whatever come from Wales, were required of the LHBs together, on behalf of the is the Trust itself then involving the communities Government, in order to present to Mr Steers so he and/or patient groups in Wales, and CHCs in Wales could start to undertake his comprehensive review. for that matter, into this discussion?
Q581 Alun Michael: You referred to Foundation Q586 Alun Michael: Yes, we have heard that. I just Hospitals, primarily in relation to financial wanted to be sure, because you were talking about arrangements across the border. One of the main the financial cross-border issues, that those issues of characteristics of Foundation Trusts is to seek to engagement with the public are also understood. involve large numbers of the community. Mr Morgan: Okay. Ms Lloyd: That is right. Ms Lloyd: Yes.
Q582 Alun Michael: Members of the relevant Q587 Mr David Jones: First Minister, would you say communities who feed the hospitals in Wales and the health service in Wales follows diVerent guiding England, so that members on both sides of the principles from those that apply in England? border are treated in the same way. I would like to Mr Morgan: Not guiding principles, no. confirm that that is something you welcome. Mr Morgan: Do you mean on the governance side, in terms of directors? Q588 Mr David Jones: Essentially, Welsh patients should be able to expect to enjoy the same level of Q583 Alun Michael: No, the whole point of an NHS service as a patient from England? Trust is that it engages the widest possible Mr Morgan: That is not an issue of principle. The engagement from people in the wider community. guiding principles are the same; that it should, with Therefore, members of the public are admitted— very few exceptions (dentistry and so forth) be free Ms Lloyd: To board meetings and monthly meetings at the point of need. Those are the guiding and stakeholder meetings. principles. They are the same in Wales and in England. Q584 Alun Michael: In the wider engagement. It is the most exciting thing about Foundation Trusts, Q589 Mr David Jones: A lot of my constituents from which, personally, I would like lessons learned wonder why they pay their taxes and national within Wales, as a matter of interest. Those hospitals insurance contributions at precisely the same rates as Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford patients who live in England and yet have to wait do not follow, three out of the four principles that considerably longer for their hip operation in were recently pronounced in England are very much Gobowen. Welsh-oriented ones. Helping people stay healthy Mr Morgan: That is a matter for Gobowen to and independent is very much a principle that we answer, why they would give a lower priority to have stated from well before 2002 when they were patients from Wales than in England. My published. Giving people choice in their care services understanding is that the median wait for elective is one we do not follow. Delivering services closer to surgery in Wales is one day longer than in England. home is one we very strongly do follow, and tackling inequalities. Three out of the four are the English Q590 Mr David Jones: The target waiting time, as health service not copying exactly, but moving closer you know, is considerably lower if you come from to the Welsh definition, and, therefore, that is going England than if you come from Wales. to shrink the divergence of what we are seeking. Mr Morgan: You will be aware of the recent analysis Cracking the waiting lists, which was the big English by an independent, very highly respected body, drive back in 1997 and which we followed about CKHS, the UK’s leading independent healthcare three or four years later, is one example where we information and improvement services provider. It have learned from England. We were concentrating reveals that waiting times in England and Wales have on these other three: helping people to stay healthy fallen at a similar rate. The analysis that has been (trying to promote health and well-being as distinct done recently of the median waiting time is 44 days from treating people when they are ill and, especially, in England and 45 days in Wales. I do not think looking at the elective surgery waiting lists); anybody is going to lose a lot of sleep over a 24-hour delivering services closer to home; and tackling diVerence in the median waiting time.1 inequalities. That means the divergence is now getting less because England are saying, “Well, yes, Q591 Mr David Jones: Ben Bradshaw, the English Wales has followed us on waiting lists, but now we Junior Health Minister, came before the Committee are going to follow Wales on three out of four of recently, pointing out the massive disparity in these principles.” waiting lists between England and Wales. I think you would concede that many more people, thousands Q593 Mr David Jones: Delivering services closer to more people, are on waiting lists in Wales than they home, therefore, does not mean that a patient from are in England. Queensferry should have to go to Swansea for his Mr Morgan: It is the length of time you wait and not brain operation, does it? the number of people on the waiting list that is Mr Morgan: No, or to Cheltenham for a PET scan. significant. I am assuming that the median waiting Whatever it is, you do not compromise on the time is probably the most significant one. Nobody excellence. Sometimes that does mean having to go wants a long tail of the people on the second half of further, in order not to compromise on the the median; that is longer than the median. If the excellence, but you do not travel further in order to median waiting time is 44 in England and 45 in Wales have a service that is not as good. that would not bespeak of the massive diVerence you are referring to. Waiting lists are collected diVerently. NHS statistics started to diverge long before Q594 Hywel Williams: You would also agree that devolution in how records were kept of treatment health inequalities predate democratic devolution, and outcomes. That is not a consequence of not only diVerences in waiting lists but also expected devolution; it is a consequence of administrative lifespan and the sorts of diseases that Welsh people devolution as much as anything. It started well are subject to as compared to those in England. before democratic devolution. We collect on to our There is a broad picture here, quite apart from any waiting lists all referrals; in England it is only GP waiting list questions. referrals that are collected. We have a bigger waiting Mr Morgan: Well, strangely enough, less than you list because we collect everybody on our waiting list; would think. If you look at the demographic that is, not just GP referrals, but consultant to statistics for the four constituent parts of the United consultant referrals, physiotherapist to consultant Kingdom, you would have expected Wales, given its referrals. I cannot tell you how much diVerence socio-economic mix or much smaller middle-class as that makes. a proportion of the population, to have an adverse Ms Lloyd: It is 30%. There is a 30% diVerence. life expectancy. Actually, it is tiny. It is Scotland which has the adverse life expectancy, not Wales, Q592 Mr David Jones: In your opinion, are these whereas Scotland is a middle-class country very cross-border disparities likely to continue, get worse, similar to England in socio-economic status. or get better in the future? England has the best life expectancy. We are about Mr Morgan: I would like to think that we could one year shorter. Scotland is about three years make up that one day diVerence in the median shorter than us, but you would expect Scotland to be waiting time and possibly overtake England but, to up there with England because its socio-economic be honest, in the recent statement of principles that status is very similar. Within Wales, yes, we do get have come out in England it was very much a shift. disparities. The famous Blaenau Gwent/Monmouth Other than for that one principle of choice, which we disparity, which is about five years, and Ceredigion and Powys have very long life expectancies—and 1 Ev 260 memories as well! Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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Q595 Hywel Williams: Let me get on to some more Robert Jones & Angus Hunt Trust, they get fewer practical issues, speaking about cross-border issues. patients as a percentage than funding. Are Welsh If there are issues to be resolved on cross-border patients getting a bad deal from Gobowen? problems, at which level should they be resolved? Mr Morgan: If Gobowen seeks to bring pressure to Should they be between the Department of Health bear on the LHBs from Wales who have and the Welsh Assembly Government, or between commissioned services to it, by making it clear to the Primary Care Trusts and the Local Health patients from Wales, “Your LHB is not paying us Boards, or is it horses for courses? enough money compared with what we get from Mr Morgan: That is the key issue. Where there are England,” we would say that is clinically a very arguments over money,we like to think that they will improper thing to do. Some people say that did be solved between the commissioning LHB, usually happen; some people say it did not. I do not know, in Wales, and their provider Trust (or Foundation but it was part of that diYcult period in 2005-06 Trust these days) in England. If they cannot agree, as when the new payment by results was coming in, and they could not in 2006-07, then it tends to come up the Department of Health issued guidance to for arbitration between Ann and her division, and Gobowen, Chester, Shrewsbury, and Hereford that the Director of Finance who works to Ann, and the you have got to allow the Welsh to continue to pay Strategic Health Authority in the West Midlands or not on payment by results but on cost and volume the north-west of England. That is the arbitration (the old system). They were not abiding by that procedure. Sometimes, of course, it bubbles away guidance from the Department of Health, because politically and then that is where politicians have to they kept moaning and saying, “Yes, you should be get involved. That is when you get involved, that is giving us this extra money” or “It’s going to mess up when we get involved, that is when Cabinet our application for Foundation Trust status” or Ministers get involved and so on. But, basically, we whatever. Maybe some of the patients, quite hope it will be solved at the level of the LHB and the wrongly, were brought into that process and they individual Trust. should have been left out of it completely by the clinicians or by any of the admin managers as well. Q596 Hywel Williams: Given the traYc across the border in health terms, should the governance Q600 Albert Owen: I think it was more arrangements for NHS bodies on either side include administrators who were saying this rather than provision for patients and citizens from across the clinicians. They said they were seen regardless of border? I know you have answered the question, to where they were situated. Do you think that is some extent, in response to Alun Michael earlier. resolved now? Mr Morgan: I did ask Alun whether he was referring Mr Morgan: 2008–09, we have no current disputes, to governance, and I think he said no, he was not. He but because of the underlying tensions there is this was referring to a kind of stakeholder involvement in very rapid fire series of meetings and exchanges of policy and so on. letters going on right now—and we hope we will be able to report back to you on, we hope, a successful Q597 Hywel Williams: Not formal governance. outcome—of trying to get a much firmer Mr Morgan: Not formal governance, not in the memorandum of understanding, so that any further terms of a non-executive directors, et cetera. Ann I changes that happen in England are not going to do not know if you have any observations on that. cause any rumbles and tensions or any of the kind of We are not involving governance, so far as I am rows you are talking about now in the future. In aware. 2008–09: so far, so good, no problems. Ms Lloyd: No, we have not, but we do use their Chairman: Perhaps we could move on to higher quality standards and outcome data to assure the education issues. Local Health Boards undertaking their governance by their boards that there is no major divergence. We Q601 Albert Owen: Higher education issues are use the data rather than putting people on their probably less contentious, but some of the questions boards. I have here might not be so. How does the Welsh Assembly Government ensure, when talking about Q598 Alun Michael: First Minister, in response to cross-border impacts with the Department of Mr David Jones you made a remark regarding the Innovation, Universities and Skills, that at an early waiting times at Gobowen, in particular. You said stage your policy is reflected on Wales with regards that is an administrative issue for the Trust itself. Are to part-time students, for instance, or the changes to you suggesting there—and we have had some student finance regimes? evidence in our inquiry from Trusts within Mr Morgan: Student finance has been quite a vexed England—that they do have two lists: one for Welsh political issue in the last five years and may become patients and one for English patients? so again with this review, which is going to start Mr Morgan: Yes. before the end of 2009, into whether the cap is going to be lifted above the present £3,000 in England. If it Q599 Albert Owen: That is purely down to them and happens, if that cap is lifted or got rid of altogether, the way they administer it. For example, the that would create a lot of disturbance in the student Boughton Centre serve 20% of the patients but get finance regime. England made its decision to go for 60% of their funding from Wales—and I would say a more market-based model. It is not a matter for us, Wales get a good deal there—but with regards to the but it was not a model that we wanted to follow in Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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Wales. Some of our universities are very dependent understand why they want to reduce the number of on inflows of students from England: Aberystwyth quangos, and it is quite right that they should reduce in particular, other universities less so, but all the number of quangos, but it is very hard when you universities are involved in this cross-border flow merge a UK and an English quango. and the international flow. They all want international students most of all, and trying to get Q604 Albert Owen: When you were developing your the international students in is a very, very big issue strategy for science, on what formula were you financially. The issue, then, of the England-Wales basing it? How much research and development flow is critical to some universities, Aberystwyth in money, for example, were you getting and have you particular. put the case for more? Mr Morgan: Indeed. That is how we got the PET Q602 Albert Owen: I did not want top-up fees either scanner. That was funded through the OYce of but they are there now. Some of the Vice-Chancellors Science and Technology. That was UK funding, are suggesting that it could hamper them in the topped up by HEFCW funding within Wales.3 A lot future with regard to funding. How would you of these things will be jointly funded in that way. resolve that? Would you work with the English Department of Innovation, Universities and Skills Q605 Albert Owen: Do you see it improving in the at an early stage to try to resolve these issues? 2009 future? is fast approaching. Mr Morgan: Yes, but the merging of a UK and an Mr Morgan: We have asked quite recently when this English quango is always going to mean a lot of very review is going to start. If it starts on 1 January 2009, careful negotiation. You are right, science policy is, that is only seven months away; if it starts on 31 in principle, not devolved, but that does not mean, December we have a bit more time because that is 18 because of its importance for climate change or for months away. We do not know, but we have asked higher education or for economic development, that recently for a very early sight of and a very early we do not have to have a pretty strong input into discussion on what you are thinking of doing in making our own science policy and devising how to England, because it could have a very, very make sure that is properly done. significant eVect on the viability of the Universities’ cross-border flows of students; extra payments for Q606 Albert Owen: Are there bilateral talks on this staV which would mean staV flowing from Welsh now between your Ministers and Ministers in universities to English universities if the cap was London? used or if lifting the cap was used in order to increase Mr Morgan: On science? academic salaries in England at a level we could not aVord to do in Wales. You can see the problem. Q607 Albert Owen: On the science funding. Mr Morgan: Yes, but usually it is done by lobbying Q603 Albert Owen: The Assembly Government has the research councils or the MRC or the new a science policy for Wales, which was published in Technology Strategy Board for the near market- 2006. With the very fact that science money is not research and our science advisers group.4 We have devolved, how do you get engaged in that at a very had a meeting with Iain Gray, the new Head of the early stage to ensure that science departments and Technology Strategy Board already, and we hope to science research and developments are on a par with have a meeting soon with Sir Leszek Borysiewicz, the rest of the United Kingdom? In the past, the Chief Executive of the MRC—who, fortunately, historically, we have— although you might be misled by his name, is as Mr Morgan: Historically it never has been no. It has Welsh as they come. been very sad the way that has evolved. We are trying to put it right. It is not really a cross-border service Q608 Mark Williams: I would like to follow up on in the way this Committee has defined it, but it is a the mechanisms available to you to influence the cross-border issue that has arisen recently, that, in cross-border education debate. I very much agreed the drive in England, which is very understandable, with what you said about Aberystwyth, in to reduce the number of quangos, sometimes they particular, having to rely on students from England have merged a UK quango, like the Medical and much further afield. What role is there in the Research Council, with an England-only quango, Joint Ministerial Committee for you to push the such as the research agency of the National Health agenda, particularly the implications of the decisions Service in England. We now have one quango with on raising the cap? two functions, one of which is UK and one of which Mr Morgan: We have not sought to put it out to the is England. OSCHR, the new body, is a result of that Joint Ministerial Committee. It is an interesting merger and we were brought into that very late.2 Of point as to whether we should, but that would really course, we tend to emphasise that it is a UK body, only arise if there was interest in Scotland and and they tend to emphasise the fact that it is Northern Ireland as well as in England and Wales on England-funded, “Where’s your subscription to doing so. Anything can be put on the agenda of the this?” We say, “It’s a UK body.” The Medical JMC. It has been restructured now under the Research Council is no longer a UK body; it now has guidance of Paul Murphy, the Secretary of State for an England-only function added to it. We 3 Higher Education Funding Council for Wales 2 OYce for Strategic Co-ordination of Health Research 4 Medical Research Council Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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Wales, with his other hats on really, and we are going Q611 Mark Williams: It is a highly competitive to have the first meeting of the revamped Joint market, particularly in North-East Wales. Does that Ministerial Committee Summit later this month. not just leave those across the border in England to Jack Straw will chair it, but Paul Murphy is the oVer that benefit. person charged by the Cabinet in general to revamp Mr Morgan: Yes. That is not what is driving it, the JMC machinery and to reset the clock—because though. It is whether you get 10 straight As from it had not met really, apart from the JMC Europe, Estyn. If Yale gets 10 straight As from Estyn, you for six or seven years. It had rusted away and now it know that they could well do foundation degrees has been taken out of the garage and is being given without breaking sweat. That is basically it. It is not a good scrub up and it is restarting later this month. competition from England; it is how good you are. We can put anything on the agenda for that, and, now that you have mentioned it, science funding Q612 Mark Williams: You have mentioned the might be something on which I will have to cogitate Webb Review. On capital funding in Wales, Sir as to whether that should be there. It might be too Adrian stated “we are in serious danger of allowing late to put it on the agenda for this month, but the estate to fall into decay”—again the divide certainly for a subsequent meeting. between funding in England, particularly capital funding. I think students regard it as a competitive market in terms of the facilities on oVer in diVerent Q609 Mark Williams: That would be welcome news institutions. Given that funding divide, is there not a in mid-Wales, as well as elsewhere. Cross-border danger that we will lose out to English colleges issues now in relation to further education colleges beyond the border? being able to award foundation degrees. Is that an Mr Morgan: It is a variable picture throughout issue of concern? Does the Welsh Assembly Wales. We have set certain priorities for FE colleges Government have any intention to address the issue? to drive their capital investment and course Mr Morgan: The Scottish percentage of foundation provision. Some colleges are doing well out of that degrees done by further education colleges is and are able to open new campuses (Llandrillo being extraordinarily high. About 30% of all of their a good case in point, opening a big campus in Rhyl, degrees are done in further education colleges. We and Ystrad Mynach opening a new campus in know the Scottish system is diVerent: they leave Rhymney in the heart of the heads of the valleys school at 17 not 18, they do not have an A-level then, area) and other colleges are screaming blue murder but, even so, that is a remarkable diVerence. We are because they do not tick all the boxes of the priorities much the lowest. England have about 6% and we that we are getting. It is the losers from change who have 1% of degrees coming out of further education scream, and the winners quietly go oV in a corner colleges. The big further education colleges and the and spend the extra money they are getting and do successful further education colleges, especially the not talk about it very much. There is an inevitable successful arc along North East Wales and part of the management of change. You have to have Pembrokeshire, the big, strong, successful FE change and you have to set priorities. We are doing colleges like Yale, like Deeside, like StaVordshire, that, and some colleges come out of it very well and like Pembrokeshire, could easily, I am sure, do much some do not. more by way of providing foundation degrees. Q613 Mr David Jones: Turning to transport, what are your views on the proposal in the Local Q610 Mark Williams: Would you welcome that? We Transport Bill to abolish the Transport had the discussion in light of the Further Education Commissioner for Wales? and Training Act of last year. Is that something the Mr Morgan: Perhaps I could turn to Tony Parker. It Welsh Assembly Government would be pushing for? is a matter which is a plain and simple Department Mr Morgan: We have just had the Webb Review. We for Transport responsibility, as I understand it, but are digesting the consequences of the Webb Review. do we have a right of consultation on it? The Webb Review has recommended that we merge Mr Parker: I am not aware that we have been certain FE colleges because they are too small. We consulted on it. have tried to cover some of the FE deserts—and I am not going to specify where they are—where there is Q614 Mr David Jones: You have not been consulted not enough FE provision. We have tried to at all? encourage back-oYce mergers—not mergers of the Mr Morgan: I am only aware of it as a political issue, college but mergers of the financial function. I was not a consultation issue. pleased, when I was up in Yale recently, to hear that Mr David Jones: I think that answers the question, Yale and Deeside are trying to start talks on merging Chairman. their back oYces, which is brilliant. The Webb Review has injected a big reform agenda in the FE Q615 Mrs James: There is currently a process for the world. I am not sure we are ready yet to say, “Okay, regional transport plans and national road and rail we’ve digested everything from Webb, now you transport plans to fit together and into the Wales move ahead,” but it is possible that the big, viable, Transport Strategy. What procedures are there to very solidly rated by Estyn FE colleges, like the three ensure that Welsh plans and the regional/local in North-East Wales plus Pembrokeshire, could transport plans (in England) also dovetail in terms of move ahead tomorrow almost if they wanted to. integration and timetables? Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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Mr Morgan: They do not. It is a big problem. The provision. Already some of my pensioners have A483 south of Wrexham towards Swansea is very picked up on the fact that, despite what has been said much bedevilled by the issue. Where it goes into publicly, they will not be able to use their passes England, Oswestry, and south from there, through cross-border when English passes come in. Llanymynech, before it goes back into Wales and Mr Morgan: The key diVerence between the English near Welshpool, that has been dropped under the pass and the Welsh pass is that the English pass is West Midlands regional assembly priority setting confined to non-peak hours and the Welsh pass is for process, and they are not interested in the bit in any time of day, et cetera. English local authorities England of the A483. They regard it as a Welsh and Welsh local authorities are simply funding the highway. We did not draw the border. We cannot lost income to the bus operators, they are supposed control the fact that there is this ten-mile stretch in to be reasonable and practical and not be too fussy England, from Gobowen down through about cross-border flows: in and out of Chester, the Llanymynech—something like ten miles in England, Deeside strip, across the border, down the borders, would it be? It is of no interest in England. If they do down to Gloucester and Abergavenny across to not do their bit, we could do our bit and all of a Lydney or wherever it might be. But there are a few sudden you would have a lot of crashes where you problems emerging because of that diVerent have to slow down from 60 mph to 30 mph, as you definition of the availability of the bus pass. have to do now when you reach the village of Pant— Mr Parker: There are one or two other things that which, although it sounds Welsh is in England. are diVerent. Within the Welsh scheme, that is funded on the basis of actual usage; that is, journeys Q616 Mrs James: But it has been identified as the made. In England, it is funded through the regional main route between South and North Wales, has it support grant. There are winners and losers, not? therefore, between local authorities under the Mr Morgan: It is, yes. Absolutely. It is a key North- English system. We do it on the basis of actuals, Wales/South-Wales route. It is an important freight journeys that have been made, so we know exactly road, probably more important, than the A470— what is being done. We also have two pilot schemes although David may not agree with that. That is a going for 16- and 18-year-olds and also for the big problem. The east-west route, the Welshpool to severely disabled on community transport. In terms Buttington Cross route, has also been dropped, and of what the Welsh scheme might look like, it is we have a problem where you cross the river. We necessary for us to conclude those pilot schemes to see what results they give us. In terms of those have tried to find a way of doing our bit and then V terminating at the river or across the river. Tony, you di erences and those uncertainties, our position is might want to say a bit more about that. that there are quite a few things that need to be Mr Parker: Both these schemes were classified as sorted out before we can really start talking about an being of regional importance only by the Highways entirely integrated system across England and Agency/Department for Transport, so they were Wales. consigned to the regional funding allocation process which was administered by the regional assemblies. Q618 Mrs James: Because of the system we are using The Buttington scheme, which is the link between in Wales, the practicality is that people want to go to Welshpool and Shrewsbury, was not considered by the popular destinations: to Porthcawl, for example, the West Midlands regional assembly within that or Bristol Zoo, as my pensioners have mentioned to process—therefore it achieved no status at all— me. Some authorities would be taking a greater share therefore, as it was not part of the Highways of responsibility, above and beyond the normal Agency’s targeted programme of improvements, transport patterns. there was no funding allocated for it. They had been Mr Morgan: Tony, is Swansea to Bristol Zoo with us during the process of public consultation, available under the free bus pass scheme, or is that but at that point where there was no funding regarded as interregional and not local? allocated for it, the Department for Transport Mr Parker: There is an accommodation under the elected not to engage with us in announcing a Welsh scheme whereby, if people have a natural preferred route. centre where essential services are across the border, Mr Morgan: This does relate back to health to some which is nearby, we give the discretion to the local degree. If, for instance, the Shrewsbury and Telford authority, through which this is funded, to allow Trust decides to commit more and more of its those journeys to be made and to be funded under resources to the Telford Hospital and not to the the concessionary fares scheme. Shrewsbury Hospital, then it is very important. The Mr Morgan: But does Bristol Zoo count as a natural patients from the northern half of Powys, who use destination? the Shrewsbury and Telford Trusts are going to be Ms Lloyd: I think we are talking about post oYce disadvantaged by that. Unless there is a very good services and the like—so slightly more essential road through from the Severn Valley and across into services than that. not just Shrewsbury but also Telford, it is going to be Mr Morgan: It sounds to me like a try on, Siaˆn. a longer journey. Mrs James: I think so, but they like to go.
Q617 Mrs James: Another quirky cross-border issue Q619 Mr David Jones: I have a supplementary issue that has been raised with me in my constituency is going back to the cross-border road building issue. how we can integrate the concessionary free travel From a Welsh perspective, I have been very Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford concerned that we may have a missed opportunity Mr Morgan: Would the A5117 be big enough to under the Planning Bill which is going through the qualify to be IPC? House at the moment, which, as you know, provides for the establishment of an Infrastructure Planning Q622 Mr David Jones: It joins a motorway and the Commission which would have overall A55 expressway. responsibility for major national infrastructure, Mr Morgan: All right. I am only guessing, but my including roads. However, in respect of road impression is that they want to confine the IPCs’ building, policies of national significance are deemed throw to the big strategic issues: nuclear power to include roads within England only, and therefore stations; strategic level ports, not small ports; cross-border routes would be subject to the existing strategic level, airports, not small airports. They regime, which has given us, for example, the A5117 keep emphasising that. link between North Wales and the north of England. Have the Welsh Assembly Government had any dealings with DCLG over this, because it does seem Q623 Mr David Jones: And major roads? to me unfortunate that, whilst England is going to Mr Morgan: What is a major road? That is the issue enjoy a streamlining of powers in respect of road really, is it not? building projects within its borders, Wales will not be the beneficiary in terms of cross-border routes? Q624 Mr David Jones: I do not want to take up too Mr Morgan: This is not an Act of Parliament yet, so much time on this, as I am conscious that we have I would hesitate to get too much involved with been here a long time already, but it seems to me that something which is subject to amendment possibly from a Welsh perspective we are missing a huge in its final stages. opportunity by not becoming involved in that process so far as cross-border routes are concerned. Mr Morgan: If it is a big enough road project to Q620 Mr David Jones: If I could interrupt you, First qualify for IPC treatment, it would then be in a Minister, I happen to be involved from a front bench national policy statement of the Assembly if it is a position, where I did raise this issue with the road that is all in Wales. It would be a Department responsible Minister. for Transport policy if it is all in England. I am not Mr Morgan: I was going to say that we have been sure about if it is a very big, cross-border road, big heavily involved, where relevant, on the IPC enough to qualify for IPC but in Wales and in concept, but obviously we are not the body England. Because it is a cross-border issue, I think responsible. That is clearly in Westminster, the we are going to have to think about that and see parliamentary responsibility as of now, to determine what has been considered. whether the Bill goes through and becomes an Act. Chairman: Perhaps you could take that back to the On the IPC, we will accept whatever happens Assembly. according to how Parliament determines, but I think the structure of the IPC, unless it is amended, is that Q625 Mr Martyn Jones: You are aware, of course, a national policy statement will determine the policy that one of the fastest growing areas in travel terms and a panel will be empanelled to determine the local is the Deeside hub: Wrexham, Chester, Deeside and site issues in the usual public inquiry way but it will Merseyside. not be able to re-fight the battles over what the policy Mr Morgan: Indeed. should be. Whether that is good streamlining or a “democratic deficit”, as I heard it described Q626 Mr Martyn Jones: That is creating a problem. inevitably on the Today programme last week, I do A lot of people are commuting into west Cheshire not know. It is not for me to judge. What is and Merseyside from North East Wales. Do you important is that, if it involves something that recognise that problem as regards the Assembly? is devolved, it is our national policy statement that is Mr Morgan: Absolutely. I think there is a very relevant; if it is something that is not devolved, it extensive commute both ways. Airbus is the is a Westminster government’s national policy manufacturing plant which is the jewel in the crown statement that is relevant (for instance on electricity of the manufacturing industry in Britain and in power stations, et cetera). If it is cross-border, I must Wales. I think 38% of their workforce comes from admit I have not thought of that one. I do not the north-west of England, and even down to know—Tony, perhaps you have come across that. Shrewsbury and the West Midlands. Mr Parker: There is a provision for consultation with Welsh Ministers on issues that cross the border. Certainly on rail matters. Q627 Mr Martyn Jones: Are there any proposals to alleviate the problems for the commuters? Mr Morgan: We lost a recent public inquiry, did we Q621 Mr David Jones: I can understand that but the not, on one particular element of improved new streamlined procedures will not apply to cross- communication? The last time there was joint co- border routes. What worries me, as someone who operation on a real project was over the Woodbank has to commute quite frequently down all the routes junction, but that worked okay. It was in England that the First Minister has mentioned, is that the but it was our pressure that caused the Department prospect of getting that upgrading quickly is for Transport to agree that they would improve the probably receding as a result of the new procedure dreadful Woodbank junction, which is the key not applying to these cross-border roads. junction for commuting on to the M56. Processed: 20-03-2009 10:44:09 Page Layout: COENEW [E] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford
Mr Parker: That is a project that was jointly Mr Morgan: The big cross-border routes are not our funded—a fairly modest contribution from our side franchises. The Virgin franchise to Euston and the of the border, but it did work. In terms of the inquiry FGW franchise from Swansea to Paddington are not that we have not made the draft orders on, inevitably our franchises. that will give us pause for thought. Inevitably we will be looking at which options we need to look at in the Q632 Albert Owen: Do you have input into that as light of the findings and recommendations of the the consultee? inspector. That will include an appreciation of how Mr Morgan: Not as much as we would like. The much of the burden of cross-border movements can invitation to tender came in just before the new be taken by public transport, in addition to possibly Railways Act came in—which would have given us a scaled-down version of the road scheme, which a right to be consulted. For instance, when Virgin was really the bone of contention at the public decided quite abruptly to abandon the early inquiry. morning discount, which produced this colossal increase from £60 to £220 to travel from North Wales to Euston, we were not consulted on that at Q628 Mr Martyn Jones: You mentioned public all. I do not even know whether the Department for transport. Of course, one of the problems is that the Transport was consulted on that, but it is a terribly railway link between Wrexham and Bidston (in sad day for rail travel to Euston. On our franchise Merseyside) and Chester is not brilliant. I wondered through the Borders—it is our franchise although it whether the Welsh Assembly Government has any is partially in England—we have a good working plans to enhance that? relationship with Arriva. We have put a lot of Mr Morgan: I think we and Network Rail are jointly subsidy money in to improving the services on this funding a study into the potential electrification of big hook really from Maesteg to Holyhead via the Wrexham-Bidston line currently. Let us wait Bridgend, CardiV, Newport, Cwmbran, up through until the outcome of that scheme. I have been on it Hereford, Ludlow, Shrewsbury, Wrexham, et cetera, a few times myself: it stops at an awful lot of stations, and all the way along the North Wales coast. It is an it does not make very quick progress, it has to be odd-looking route when you look at it, but it has said, and it finishes up in Bidston and not in helped to provide services, some of which are Liverpool. It finishes up in the middle of the reasonably quick, some of which stop at an Wirral—which is a bit of an oddity really, to be extraordinary number of stations, but then you have honest. But it is a valuable service, and if it was to have collective services as well as the express electrified and could be properly linked up with services. It has meant that the service from North Mersey travel then it could play a much more Wales to South Wales through the borders is far valuable role in linking North East Wales and the superior to what it was. People say, “There should be Merseyside conurbation. a first-class coach” or “You can’t work on it because it is too popular” or “You can’t get a nice meal on it” et cetera, and that is true, but it is an awful lot better Q629 Mr David Jones: Getting back to than it was. I use it frequently now in preference to electrification, First Minister, that appears to me to the car. have been put on the backburner as a result of your coalition with Plaid Cymru. Is that a fair comment? Mr Morgan: Electrification of the network Bidston Q633 Albert Owen: I do find that Arriva trains are to Wrexham? leaving about two minutes before a London train gets into Crewe, and my big concern is that the emphasis is on Chester as a hub rather than Q630 Mr David Jones: Yes. integrating with Crewe as the main UK hub. I will Mr Morgan: No, not at all. I cannot remember when just leave that thought with you. On air links, a huge the decision was made, but I think it was subsequent success has been the Anglesey-CardiV link. Some to the formation of the coalition. The decision was people are saying that it is over expectations. I made to jointly fund the feasibility study with thought a bigger plane would be flying by now Network Rail, was not? anyway. Are there any plans for the development of Mr Parker: Yes. that route and other routes? When we talk about Wales with cross-border, there is the possibility with Belfast and other destinations from CardiV, and Q631 Albert Owen: I think the priority of that has possibly linking up with Anglesey and with the four slipped, to be absolutely frank. I am worried that capitals of the United Kingdom. investment in railways in North Wales, in particular, Mr Morgan: I hate to use the expression “pilot has slipped back, particularly since the franchise. phase” about an aircraft service, but it is a pilot When we had Arriva in front of us with regards to phase. It is a three-year pilot. The first year has gone the franchise, they said that they were short of cash. exceptionally well, and better than people had I feel the cash is drying up and they cannot enhance. expected. I think the size of the aircraft and the level In North Wales we have seen ticket increases and of fares was pitched about right. It has proved too overcrowding rather than improved services. Again, that Valley is viable as a civilian airport. Alongside with First Great Western we have seen issues with all the amazing things that are happening there on regards to South Wales. What is your department the military side, it is all good news for Valley at the doing to improve those positions? moment, but then whether we should already be Processed: 20-03-2009 10:44:09 Page Layout: COENEW [O] PPSysB Job: 407416 Unit: PAG1
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12 June 2008 Rt Hon Rhodri Morgan AM, Ms Ann Lloyd, Mr Tony Parker and Mr Mark Drakeford leaping ahead to run other services from there to awareness within the Cabinet on UK-wide issues? It Belfast or Dublin, et cetera, I do not know. We want occurs to me that on issues such as research councils to really make sure this gets past the pilot phase and and the NHS Constitution which the Prime Minister is into the unsubsidised phase, building up a is going to be announcing at some stage, there is the consistency and expectation that people will use potential for an input from Wales on the Joint Valley-to-CardiV and CardiV-to-Valley. Ministerial Committee. We have heard from the First Minister that that has been in abeyance for a Q634 Albert Owen: Is there a development long time, and I wondered whether there could be programme for that to happen now? The fear is that much more engagement with the cross-border issues, the subsidies are stopped and then it is not as much more engagement beyond what we already attractive for other airlines to come in. know in terms of the bilateral meetings which one Mr Morgan: I certainly hope not. The pilot phase is hears about and which do take place. there to prove the viability of the place, Valley. In a Mr Drakeford: Thank you, Chairman. I think way, it is not central to North Wales. The people in special advisers can provide an early warning system Wrexham would not use it because it is far too far in which ideas that are at a development stage in east, and they have much easier ways of getting to Whitehall or, indeed, in Wales can be communicated CardiV. Was there enough population in Anglesey across the border where there is going to be an and Gwynedd that would use the service from interest on either side. For the First Minister’s Valley? Yes. The proof of the pudding so far is that OYce, I tend to be more engaged with those cross- at least from the western half of North Wales there border issues that also cut across portfolios. Some of has been a big boom, and for the people from CardiV the ideas you have just mentioned will be of interest, it is a big saver because it is one hour instead of about not simply to an individual Minister at the Welsh five hours. Assembly Government, but will need a more collective, cross-border portfolio type of response. Y Q635 Albert Owen: The other part of my question— Through the First Minister’s O ce, I am able, I and I am trying not to be too parochial—is the issue hope, to provide that sort of contact at a preparatory of linking CardiV up with other United Kingdom stage in policy thinking and then, where necessary,to capital cities. I think it is important for the whole try to make sure that the range of Welsh Assembly Welsh economy that that happens. There seems to Government Ministers who are likely to have an interest in that topic get a chance, early on, to take have been some contraction in that. Is that Y something you are looking at as a government, for advice from their policy o cials, to develop their thinking, so that as much as possible we are able to air travel development in the future? have not just a last-minute alerting system, in which Mr Morgan: We have proposals to continue to you are aware of what is going on, but a bit of cross- subsidise certain routes. We cannot subsidise fertilisation in which ideas can be fed in more at a through the Route Development Fund, which helps formative stage of policy. to subsidise the Valley service. We are using that to Mr Morgan: My Private Secretary and me would try subsidise services to Paris. We did it for Brussels, but to set out which decisions involved me speaking to there was not enough to keep it going. We use it Gordon Brown, me speaking to Alistair Darling, me strategically. You cannot use it to develop North speaking to Paul Murphy. Or is it Edwina Hart Atlantic routes; that is not allowed under various speaking to Ben Bradshaw or to Alan Johnson, or is treaties. We try to use it as constructively as we can it Ann Lloyd speaking to Nigel Crisp or Sir Leszek, to provide the services that people do need—not for or is it, as quite often to start with, using the back fun, but for reasons of business or whatever. We channel of the special adviser to the special advisers, think we are doing a reasonable job on that. On the in order to see to what extent this apparent conflict North Wales service, of course we did receive a is in fact just a misunderstanding that can be dealt terrific shellacking from the environmental with by the special advisers? movement, who said this was wasting carbon Chairman: This has been, to quote Raymond dioxide, it was a terrible thing to do. The Sustainable Williams, “a journey of hope”. Today has been a Development Commission said, “We’re never long journey. Could I thank you for your evidence speaking to you again,” and so forth, but we resisted today. I have almost forgotten what was said at the that and said, “We don’t care, we’re going to do it,” beginning, but I do remember two words that were and we are doing it. I think the proof of the pudding mentioned by you: “pragmatic” and “practical”, has been in the support the service has had. and we will go away and reflect on those very important words. We look forward to receiving Q636 Albert Owen: And reducing road surface further evidence. We are one-third of the way journeys between North and South. through this particular journey. We will be taking Mr Morgan: Absolutely. further evidence on health and we will be moving swiftly into education and transport in the autumn. Q637 Chairman: I would like to end with one final We do look forward to receiving evidence from all question to Mr Drakeford. As a special adviser to three Ministers with their respective portfolios. the First Minister, are you engaged in raising Thank you very much. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [SE] PPSysB Job: 400105 Unit: PAG2
Ev 98 Welsh Affairs Committee: Evidence Written evidence
Memorandum submitted by the Association of The British Pharmaceutical Industry (ABPI) Cymru Wales
Introduction
1. Thank you for the opportunity to respond to this inquiry. In our response we confine ourselves to examining matters related to health provision as aVected by cross-border services. We are happy to support or supplement our observations with further oral or written evidence if that is helpful. 2. The Association of the British Pharmaceutical Industry (ABPI) represents more than 80 pharmaceutical companies in the UK that are engaged in the research, development, manufacturing and supply of prescription medicines. ABPI member companies manufacture and supply more than 80 per cent of the medicines that are prescribed through the NHS, and export medicines to countries all over the world. 3. ABPI Cymru Wales was established in 2003 in recognition of the growing distinctiveness of the health agenda in Wales. 4. The ABPI Cymru Wales Industry Group was formed in 2001 and is made up of over 30 companies who have a particular interest in Wales. 5. Both ABPI Cymru Wales and the ABPI Cymru Wales Industry Group work closely in partnership with Welsh Assembly Government, the National Assembly for Wales, NHS Wales and other key stakeholders to help address the distinctive health needs of the people of Wales. 6. This paper is a joint submission by ABPI Cymru Wales and the ABPI Cymru Wales Industry Group and focuses in particular on the provision of cross-border services in the field of health and social care.
Cross-Border Access to New Medicines
7. Patient access to new medicines is a key priority for ABPI Cymru Wales, and we have ongoing concerns that the uptake of new, innovative medicines is far slower in Wales and England than in most other European countries. 8. The National Institute for Health and Clinical Excellence was established in 1999 to provide national guidance to the NHS on the prevention and treatment of ill health and to promote equal access to medicines. The pharmaceutical industry has had a number of concerns about the NICE appraisal process over the years. Most especially it was felt that the Institute was becoming a “fourth hurdle” in terms of access to new medicines, rather than a means to promote access, because of the length of time it took to carry out appraisals and the reluctance of NHS organisations to allow clinicians to prescribe medicines until they had gone through the appraisal process. These concerns are further exacerbated when it is recognised that even when given positive NICE guidance, consistent and equitable implementation is rare. 9. Delays in providing guidance were overcome in part in Wales by the establishment of the All Wales Medicines Strategy Group (AWMSG) in 2002. An AWMSG appraisal was established in order to provide interim guidance to the Welsh Assembly Government prior to NICE guidance being published. But whilst this speeded up the appraisal of medicines, it also created a situation where patients on diVerent sides of the border had diVering access to new medicines, even when treated by the same clinician. 10. The ABPI welcomed the introduction of a new, faster Single Technology Appraisal process for NICE in 2005. NICE is now able to produce much more timely guidance on new medicines for both Wales and England. 11. ABPI Cymru Wales therefore believes that any proposals to further broaden the role and remit of AWMSG would create further unnecessary duplication. More importantly we believe having diVerent levels of access to, and funding for, new medicines and therapies on diVerent sides of the border may cause confusion and worry for patients and perhaps clinicians. We believe any such disparities in terms of access to medicines on diVerent sides of the border would be diYcult to justify, and that Wales should therefore continue to work with NICE. 12. NICE guidance also needs to be implemented in a consistent way on both sides of the border. As already mentioned the current adoption and implementation remains inconsistent and results in postcode prescribing. It remains unclear who is responsible for policing the implementation of NICE guidance in Wales. The funding and implementation processes of Local Health Boards, Health Commission Wales and their equivalents over the border in England need to be more transparent. Currently it is diYcult for patients in cross-border areas to understand which organisations are responsible for making decisions about their treatment. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Cross-Border Accountability 13. Although health is a devolved policy area, there are several examples of statutory bodies which have an England and Wales remit. There is a degree of accountability to the National Assembly for Wales and Welsh Assembly Government for health bodies with an England and Wales remit; however it would be useful to map these bodies and ensure that the National Assembly, as well as Westminster, takes proper account of their role and function. For example, with access to modern medicines being such a prominent issue it would perhaps be appropriate that NICE develops a convention whereby representatives make themselves available for scrutiny at the National Assembly on an annual basis.
Cross-Border Impact of Wales only Policy Initiatives 14. Free prescriptions and, prior to that, the gradual reduction in prescription charges were a major policy initiative for the Welsh Assembly Government. Without commenting on the desirability and eYcacy of the policy, it is worth noting that the necessary bureaucracy to implement the system was not in place when the policy divergence between Wales and England first began. Although there are now systems in place to prevent “health tourism” across the border, these were slow in coming. It is hard to quantify the extent of the issue in previous years but this was certainly a factor noted by the media and stakeholders. 15. The net eVect was bound to be increased pressure on the medicines budget of aVected Local Health Boards. It also caused problems for Welsh patients using English-based GPs and pharmacies that could not provide the reduced cost service enjoyed in Wales. Although the past cannot be undone, implementation confusion could have been reduced if more attention had been given to examining the practical application of the Welsh border to Wales-only health policy.
Cross-Border Availability of Ultra Orphan Medicines 16. Orphan medicines are defined by the EU as medicines intended for the diagnosis, prevention or treatment of a life threatening or serious condition, aVecting not more than 5 in 10,000 persons in the EU. Ultra-orphan medicines are informally defined as orphan drugs that are licensed for the treatment of diseases with a UK prevalence of less than 1 in 50,000. This equates to around 60 prevalent cases in Wales. 17. AWMSG now has a policy in respect of ultra-orphan drugs. This states that: “Consideration for the approval of ultra-orphan drugs should initially be based on the same criteria of clinical and cost-eVectiveness as those applied for other drugs. The rarity of the disease is not, in itself, a reason why an economic assessment cannot be made. However, ultra-orphan drugs are invariably expensive and for this reason, incremental cost-eVectiveness ratios almost always exceed conventional thresholds of cost-eVectiveness, making most ultra-orphan drugs cost-ineVective.” AWMSG therefore applies additional criteria for ultra- orphan appraisal based on severity; whether the drug can reverse, rather than stabilise the condition; budget impact; whether the drug may bridge a gap to a “definitive” therapy; and the innovative nature of the drug. 18. ABPI Cymru Wales remain concerned that this policy does not extend to all orphan medicines and may give rise to cross border concerns for a particularly health-deprived patient population. ABPI Cymru Wales recommends that the current national HTA bodies such as NICE and AWMSG do not consider orphan medicines, and that a specialist, UK wide, commissioning process is introduced.
Cross-Border Research and Development 19. The UK pharmaceutical industry is a world leader in the field of research and development and invests more in medicines research than government, charities and the academic world put together. This investment results in improvement in patient care as it provides funding for centres of excellence and equipment that the NHS can draw upon. 20. The ABPI is working closely with the UK and Welsh Assembly Government to make Wales and Border areas attractive for global pharmaceutical investment. However, concerns were recently raised by the health research community in Wales that the funding settlement for research and development in Wales appeared to be lower than that planned in England. It is vital that the Welsh and UK Government continue to invest equitably in research and development, and for both Governments and the NHS to work in partnership with the industry in order to make Wales and Border areas attractive places for the industry to invest. Thank you again for the opportunity to contribute to this debate and I hope we can be of further assistance. March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted I have been notified of the inquiry regarding cross-border services and felt you may like to hear of my experience to use as an example. My seven year-old son has a large mole on his face and has been asking to have it removed, we saw our GP on 8 November 2008, who agreed it would be beneficial to have it removed and referred us to our local hospital, Hereford County some 26 miles away in Hereford. We received an appointment for 14 December to see the consultant, Mr Vigh. My husband and I both took the day oV from work, but when we finally got to see the consultant he told us it was a complete waste of our time and his as he could not do anything for us as we live in Wales and Hereford is in England. As you can imagine I was livid and I contacted Kirsty Williams AM, our local newspaper and we appeared on the Welsh news. We now have to travel all the way to Swansea to see a consultant when we will then have an appointment for surgery. For your information we are still awaiting this appointment. I feel we would have been seen by now if the original referral had been to Swansea, instead we had to go back in the system to wait again. To me the whole system is crazy especially as we are supposed to have a system in place to enable cross- border services to be accessed. I feel that we are being punished because we live in mid Wales, we have a total lack of all public services. I did not choose to move here for the scenery my family have lived in this area for many, many years, indeed when tracing my family tree we have been within a 25 mile radius for over 250 years and that’s as far as I have got! I feel this proves what a complete waste of time all services are these days and leaves me wondering as to what is this country coming to. April 2008
Memorandum submitted by Bishop Dominic Walker, Bishop of Monmouth
A. Executive Summary 1. This submission is restricted to the subject of health and cross border issues. It recognises the diYculties faced by people living near the Welsh English border as well as wider ideological issues concerning health care in England and Wales. 2. It attempts to avoid repeating issues which are being raised by the Bishop of Hereford although the writer shares his concerns. 3. It recognises the particular circumstances in Wales which are brought about as a result of poor health and social deprivation. 4. It provides examples of some of the practical problems that result from diVerent political approaches and values regarding the NHS. 5. It accepts that there will be diVerences in approaches to health care between England and Wales (because there are diVering health needs and political principles), but recognises a need for a pragmatic approach to serve the needs of people and to share the common goal in providing the best possible patient care. 6. It seeks to oVer some suggestions as to a way forward to solve the cross border diYculties.
B. The Writer 1. I was elected Bishop of Monmouth in the Church in Wales in December 2002 and succeeded Dr Rowan Williams five years ago. Before that I was the Bishop of Reading for six years and I have been a parish priest for most of my ministry. 2. Some of my post graduate work was in Religion and Mental Health. I am a member of the Spiritual Interest Group of the Royal College of Psychiatrists. 3. I was a member of the working group of theologians and doctors that produced A Time to Heal,a major report on the ministry of healing produced for the Church of England in 2000. I am a patron of the Guild of Health. 4. My diocese is the old county of Monmouthshire and includes the eastern valleys, part of CardiV, the city of Newport (where I live) and rural Monmouthshire. To the east it borders onto the English dioceses of Bristol, Hereford and Gloucester. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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5. Along with the other Bishops of the (Anglican) Church in Wales, I support devolution, take seriously the implications of the Government of Wales Act and value being consulted on matters that concern the well being of the people of Wales.
C. Factual Information
1. Cross border issues are not confined to those living relatively near the Wales/England border. For example, a patient in West Wales requiring heart transplantation would need to travel to England for surgery. The same is true for specialist paediatric care. Nevertheless, there are particular issues that are regularly encountered by people living near the Welsh English border. 2. Studies show that the general health of people in Wales is worse than in England. Wales has a higher incidence of people with asthma, hypertension, coronary heart disease, insulin dependent diabetes in males and non insulin dependent diabetes in males and females, stomach, colorectal, breast and prostrate cancers with subsequently higher age-related morbidity rates from cancer, respiratory disease, and cerebral infarctions. Life expectancy is lower; child obesity and infant mortality are higher. The suicide rate for males under 25 is 35% higher than England. (Sources: Health in Wales & UK (Chapter 2), Mental Health Wales, OYce of National Statistics). 3. There are diVerent philosophies, values and political approaches to health care in England and Wales. The document The Structure of NHS Wales states, “Although the NHS in Wales has had slightly diVerent policy and structural arrangements from England for most of its existence, these have diverged more markedly since devolution in an attempt to find distinctively Welsh solutions for specifically Welsh problems. Wales has some of the highest rates of cancer, heart disease and deprivation, whilst part of its population suVers the worst health status in Europe”. 4. One study goes further. In Developing Policy, Diverging Values? which examines the NHS in the UK, the authors write, “diVerent systems make diVerent choices because policymakers diVer in their meaning and priorities they assign to diVerent values. Devolution is about not just diVerent means but diVerent ends”. 5. The diVerences in philosophies, values and political approaches between England and Wales are inevitable given that there are particular health care issues in Wales which the Welsh Assembly Government wishes to address, but this can lead to confusion and to the detriment of vulnerable patients when they are caught up in cross border health care. For example, my 88 year old mother lives in Monmouth and has macular degeneration. She was referred to a specialist in Hereford who said he would need to write to CardiV to discover what treatment might be available to her there. Although she has been given plenty of literature to read, she feels she is caught between two systems and nothing is happening. 6. Those living near the border can find that some care packages are not open to them and that they are caught in a postcode lottery. If you are living in England but registered with a GP in Wales, you only get the Wales package (even if referred to a hospital in England)—the targets are diVerent; choice is diVerent. When English/Welsh policies kick in, hospitals can find themselves operating two diVerent waiting lists and funding approaches for patients with the same problems. Patients in the same hospital with the same clinical needs can be on diVerent waiting lists because of which side of the border they live. Even clinicians get confused. 7. In Wales the target is to reduce waiting time for primary care treatment to 26 weeks by 2009; in England it is 18 weeks. 8. The WAG policy to provide all services from within Wales can run counter to its policy of putting patients first. For example, a patient in North Wales requiring neurological treatment is likely to be sent to Swansea whereas Walton Hospital in Liverpool is much nearer. It might require a journey of five hours or more to reach Swansea whilst being less than an hour to Walton. Being such a distance from home, the patient is less likely to have regular visitors and in any holistic approach to health care the proximity and support of family and friends is considered significant. 9. Another example of where policy appears to come before patients’ interests is that clergy and their families in Wales can no longer use St Luke’s Hospital for the Clergy in London because Wales will not pay for any tests that need to be carried out in London but only for tests carried out in Wales. St Luke’s is a charity hospital that does not charge fees and the consultants give their services free of charge. The use of St Luke’s Hospital would save Wales about £300,000 a year and free up beds because St Luke’s would not charge Wales for consultations, surgery or hospitalisation but only for tests. 10. Wales seeks to be independent and self-suYcient in all clinical areas but with a population of less than 3 million, there are bound to be certain medical conditions for which there is an insuYcient critical mass to make it possible. In attempting to make it work, patients are required to travel from north east to south west Wales rather than be referred to an English hospital nearer to them. 11. In cases where it has been arranged for patients resident from one side of the border to be taken to a hospital on the other side, ambulances have only been able to take them one way. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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D. Recommendations for Action 1. There needs to be a simple, pragmatic approach with the well-being of the patient as paramount. Patients should have access to centres of excellence with consideration being given to geographical proximity. A system is needed to ensure equality of treatment for patients with the same clinical needs. 2. Hospitals should not be required to operate two systems regarding waiting lists. A reciprocal agreement needs to be reached about funding patients who receive treatment across the border so that the funding follows the patient. 3. I would make a particular recommendation regarding St Luke’s Hospital for the Clergy (and there may be other charity hospitals in similar situations) so that Wales follows England and benefits from the financial and bed savings. 4. There needs to be a dialogue that can lead to a Memorandum of Understanding or an Agreement to remove the present cross border anomalies. February 2008
Memorandum submitted by Bishop Anthony Priddis, Bishop of Hereford
Section AExecutive Summary 1. The submission considers issues to do with the ability of Welsh residents to access health services, especially, in England. 2. It considers the funding needs of English hospitals, and the medical needs of patients, not least to do with their safety and the way that that is itself aVected by “distance decay”. Other issues like transport and Welsh language are also considered, as are the particular needs of patients with cancer. 3. Time-critical conditions are also considered together with the needs of the elderly, and those with mental health problems. 4. Particular issues relating to prescriptions and dentistry are referred to. 5. The lack of cross-border issues being considered in strategic health planning is especially highlighted. 6. Transport issues are referred to next. 7. The absence of higher education institutions in Herefordshire and South Shropshire is referred to, as are some of the other educational issues, particularly relating to parental choice for schools. 8. Finally, the submission observes that farming, planning and schools are not included in the 6 areas that the Select Committee is considering, and assumes that they are dealt with elsewhere since they, too, are crucial. 9. The submission concludes by encouraging the Select Committee to put its weight behind the need for cross-border dialogue and for mechanisms that enable both discussion to take place and solutions to be found, as well as the political will for that to happen.
Section BThe Writer 1. I have been Bishop of Hereford for nearly 4 years and Bishop of Warwick for 8 years before that. My initial training was as a biochemist (MA Cantab) followed by a Diploma in Theology at Oxford. I was ordained in 1972 and worked as a parish priest, (with the exception of being Chaplain at Christ Church, Oxford for five years), until being made Bishop of Warwick. 2. Among other things, I am a Fellow of the College of Emergency Medicine, having been the lay member of their Board for nearly six years. 3. The Diocese of Hereford which I serve covers all of the County of Herefordshire, South Shropshire, and about 20 parishes in Wales including Presteigne, and a small part of Worcestershire. 4. One of the roles I hold nationally is to chair the Rural Bishops’ Panel of the Church of England. I am very conscious of cross-border issues for farmers, in addition to the 6 items which the Select Committee is particularly considering. Indeed, it was the farming issues which contributed to our Agricultural and Rural Life Chaplain, in his regional role, to work for the “Memorandum of Understanding” which was signed a year ago. That document is enclosed and you will know that it is part of our Diocesan attempt, in partnership with others, to address some of the cross-border issues. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Section CFactual Information Included With This Submission 1. Memorandum of Understanding. Signed on 5 March 2007 by the Minister for Environment Planning and the Countryside, Carwyn Jones AM, on behalf of the Welsh Assembly Government, and by Cllr David Smith, Chair of the West Midlands Regional Assembly
Section DMy Submission 1. When first contacted about making a submission to the Welsh AVairs Committee, I was told that you would be considering your 6 areas sequentially beginning with Health. Subsequently, I have been told that you are in fact considering all 6 areas together but I had already worked on the information I was first given and so the bulk of what follows will be about health issues.
Health Issues 2. One of the main problems for those who live in proximity to the English Welsh Border is the ability to access services which are on the “other side” of the border. This is particularly important with respect to health care since the provision of specialist services generates a high incidence of cross-border traYc. Hereford and Shrewsbury Hospitals, in particular, draw a large number of patients from mid-Wales and those which require cancer treatment may have to travel into Gloucestershire. It should be recognized as well that Primary Care Trusts in England operate to diVerent targets from those of the Local Health Boards in Wales, for example waiting time targets for operations, prescription charges etc., are diVerent. There has been discussion for some years about which branch of healthcare (English or Welsh) pays for the treatment when a patient has to cross the border to access the service. 3. Currently, Herefordshire receives funding for 10% of its patients who come from Powys. Those living nearer to the English border than to hospitals in CardiV, Swansea or West Wales are naturally the ones who are most drawn both to the County Hospital in Hereford and in Shrewsbury. The needs of patients on the eastern border of Wales to be able to continue to access hospital care in England are vital, not only for them but also for the English hospitals. 4. Hereford Hospital NHS Trust is in the advanced stage of seeking Foundation Trust status. As I understand it, there is no model for Foundation Trusts in Wales. The success of a Foundation Trust for Hereford Hospital will be dependent upon the funding arrangements which will include the need for there to be funding from a network of patients, including those in Wales who use the hospital. 5. If, for example, elective services were discontinued for Welsh patients and only emergency services from Hereford Hospital funded, then this might be enough to tip the balance of financial viability for the Hereford Hospitals NHS Trust in terms of it receiving Foundation Trust status. Were that to happen, then not only would the reduction of income for Hereford Hospital be disastrous but that in itself would impact on the provision of healthcare in Herefordshire. The total population of Herefordshire is less than 170,000 (some of whom live nearer to Worcester or Gloucester than they do to Hereford) and if the number of people being served by Hereford Hospital no longer included those from Wales, then I understand that there might be a risk that some of the provision of healthcare currently provided by Hereford Hospital could be transferred to Worcester or Gloucester. Others will be able to give you factual information about this. 6. The Royal Shrewsbury Hospital serves a catchment area of over 300,000, many or indeed most of whom live in rural areas. There is anecdotal evidence that people are less inclined to either go for treatment initially or follow it up subsequently when they have large distances to travel. This is borne out by the factual experience of the Emergency Department (A & E) of the Royal Shrewsbury which sees 1 in 9 of the population in a year, as compared to the more urban proportion in the rest of the country of 1 in 5. This causes a “double whammy” in that not only is the hospital, because of its rural context, serving a smaller total number of other people than nearly every other county town hospital, but also a smaller proportion of that smaller total number are attending it. 7. The Emergency Department needs to be staVed at a level which provides cover 24/7, which is costly but necessary. 8. The phenomenon known as “distance decay” is of concern. This is where there is a proven reduction in the rate of service use as the distance from the source of health care increases; put another way, the closer the service the more likely it will be used (see 6 above). Rural and remote populations are aVected by distance decay anyway, but it is more acute across a border where the transport networks may not be harmonized because they operate across two or three diVerent counties, and where free social transport rarely applies (eg hospital car schemes) because of the distances and resources involved. Most funding streams for transport operate either in England or Wales, but not in both (see also 10 below). 9. EYcient ambulance services are diYcult to provide: to cover the border catchment areas needs more vehicles, if not, then the response-time is compromised. Each vehicle will travel further with a patient than the urban counterpart and the crews will see smaller numbers of cases each shift. Crews have to provide care for longer with each case. There are not enough staV on board to provide eVective resuscitative care en route (only one paramedic with the patient which is not enough to both ventilate a patient, defibrillate and administer drugs). Without an additional first responder scheme there may be delay to defibrillation and Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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other immediate care which compromises survival. Without pre-hospital thrombolysis, given the travel times involved, there can be delays in achieving national target time response (call to needle time less than an hour in England). 10. Another aspect of the transport problems is that patients, brought from Wales to an English hospital as an emergency, may then have major diYculties accessing transport back home. This problem is now being addressed in Shropshire through the Care Co-ordination Centre run by the Shropdoc organization. 11. While reconfiguration of hospital services has been mooted in North Wales, it is hard to see how that could ever be achieved, given the rural geography and population distribution served by Wrexham District General Hospital, along with the other hospitals along the border. 12. Probably less acute in mid-Wales, but of importance in the north, are cultural barriers to accessing health care. Welsh language speakers, especially those in emotional distress, may prefer Welsh language consultants and doctors, rarely found in English hospitals. (More common as a language barrier is in fact Polish in our areas.) 13. There is documentary evidence of the eVect of distance decay on rural health: for example, mortality rates for asthma and cancer are worse than in urban areas, cancer is diagnosed at a later stage and intervention rates for coronary disease are lower. Breast screening uptake is lower, especially for women aged over 65. Anecdotally,I know of people with cancer who have begun treatment but, as a result of the travelling distances involved, have decided not to continue with chemotherapy. A study published in 2005 looking at referrals from Montgomeryshire to cancer genetics services concluded that distance, time, travelling and accessibility by car and public transport were all perceived to have an impact on a patient’s decision to attend a clinic appointment. Some of these patients were referred to services in England (compare 6 above). 14. Another study giving clear evidence that mortality increases with distance travelled is that in Emergency Medicine Journal 2007 (24, 665–668) from Nicholl et al, showing a 1% increase in mortality for each 10km travelled. 15. One of the clergy in our Diocese, who lives in Wales,was diagnosed with cancer a few years ago but treated in Hereford and Birmingham, thank goodness successfully. The experience of the clergy in parishes near the border is, by and large, that cross-border emergency and urgent provision is generally excellent but inevitably takes longer, and that those just over the Herefordshire border into Wales are mostly seen in Hereford for emergencies, but less urgent or chronic conditions requiring hospitalization are often seen in CardiV or Swansea. These are a great deal further for most of them to travel and such a requirement therefore has major consequences for families and friends visiting them. The anecdotal evidence is that it is often the elderly who seem to be sent to Swansea. One suggestion made to me as well is that this seems to happen more often at the end of the financial year when budgets are running out, but I would not know whether that is true or not. 16. There is also an issue for the treatment of acute time-critical conditions. Medical and surgical emergencies are all time-constrained, in the sense that speed of treatment improves the patient outcome. Therefore the provision of emergency services in rural areas is of concern, and again the ability to cross the border is an issue. In rural areas the local GP is often the first on the scene for heart conditions, for example, but the closest GP may live across the border. Clinically it would make sense for ambulances to cross the border: administratively it is problematic. 17. The rural areas in both England and Wales, and especially the counties along the border, face a growing demographic challenge as the proportion of elderly within the population continues to grow. The rising cost of social and health care is one of the drivers that prompted Herefordshire PCT and Herefordshire Council to examine ways of sharing administrative costs and engage in a more rational approach. It is sometimes diYcult to ascertain whether looking after older people is a “medical” or a “social” issue. The provision of specialist care for the elderly and the higher costs of providing residential and sheltered homes in rural areas applies in both locations. Of particular importance is the ability to provide care close to existing family networks. Even where care is provided, there is a recognized shortage of homes that can cater for people with dementia where secure accommodation and specialized nursing services are required. 18. I am told that cutbacks in Wales mean that there is now no psychotherapy available to a woman in Powys who moved to Wales 8 years ago but had lived in England prior to that where she had received psychotherapy. This particular woman has certainly experienced deterioration in not only the healthcare provision but also her own health as a consequence by moving across the border. In her case, she was admitted to Hereford Hospital recently when she attempted suicide yet again but it would seem that only in extremis, like that, is she able to come to England for treatment. 19. There are diYculties about prescriptions as well. As you will know, there is currently no prescription charge in Wales but if someone living in Wales receives a prescription written by a doctor or dentist working in England then they do have to pay at a Welsh (or English) pharmacy. 20. This situation can result in Welsh patients who are seen in the Emergency (A & E) Department of an English hospital decline a prescription that it has written for them because they want it written by their own Welsh GP so as to avoid a prescription charge. This clearly adds to everyone’s time and other costs. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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21. Even more strangely, I understand that for some in Wales, their emergency dentist will be in England so that if they need to see that dentist and she or he needs to write a prescription, they will then be charged for it. 22. While on the subject of dentists, the shortage of NHS dentists on both sides of the border continues to be a major concern. I know of people in Presteigne who wanted to sign up with an NHS dentist in Leominster but were told they were not eligible to do so because they live in Wales. It would seem that a Welsh resident can be treated for cancer in England on the NHS but not get a tooth filled. 23. Of general concern to the Rural AVairs Forum of the West Midlands, and one of the reasons that prompted the development of the cross-border “Memorandum of Understanding”, was the lack of recognition that seemed to occur in strategic health planning of the cross-border traYc in people, and of the significance of District General Hospitals in remote rural areas to a constituency that was much wider than the county boundaries. Regional NHS strategists expressed some surprise that Herefordshire had a campaign for a specialist cancer unit and felt that we would never justify the degree of specialism required given our perceived catchment area. 24. The National Health Service Regional Health Strategy for the West Midlands (which deals with the provision of NHS services) simply fails to address the significance of cross border issues, and is generally unhelpful to a rural context. The Regional Health and Well-Being Strategy (which is about promoting good health in its widest context) expresses some of the rural issues but says very little about our proximity to Wales. 25. The Darzi Report, which is due to be published in July, will be making the points that the NHS needs to be fair, personalized, eVective and safe. This is clearly of enormous significance in rural areas. Some of these issues have been touched on above, including that of “distance decay”, as well as the personalized needs of those in remoter communities needing to be able to get to whatever GP,dentist or hospital is nearest to them, and providing the services they require, and not having to travel longer, taking more time, and so making them less safe. 26. It is perhaps worth noting that the Darzi Report is based on a model adopted from London with its centralization of major and specialist services, but which could not be replicated in, say, Herefordshire.
Transport 27. Some of the issues touched on above (6) refer to the fact that we are bad at integration within a region, but integration of transport systems across the national boundary is even more problematic. In Herefordshire and Shropshire transport links tends to be north/south rather than east/west, but for some people employment, education, health etc require east/west links more than north/south. 28. Some villages are establishing “dial a bus” facilities but this is extremely patchy, which, as a result, places enormous pressure on even the poorest families in remote areas to have a car. It is worth noting in that connection, that South Shropshire District is the poorest rural district in England. Deprived households are likely not to be grouped together, in the way that they would be in urban areas, and therefore do not figure in quite the same way statistically, and furthermore their needs are, therefore, even more diYcult to address.
Education 29. You will be aware that Herefordshire has no university or institution of higher education within it. The University of Worcester, formed 18 months ago, looks to make some provision, including providing training for nurses in Hereford Hospital. As a consequence, people are unlikely in the main to come across the Welsh border into Herefordshire or indeed into South Shropshire for higher or further education. 30. The situation with regard to schools is of course quite diVerent and here there is movement in both directions according to where people live and local quality and reputation of primary and indeed secondary schools, together with crucial issues of transport which may well themselves be connected with where parents work if they are taking children to school themselves.
Farming and Planning 32. It surprises me that neither farming nor planning, nor indeed schools in themselves, are among the areas of cross-border issues being considered by the Select Committee. I am sure that there must be good reason for this but, if you wanted us to speak to these issues or write more about them in the future, then please do let us know. 32. To provide one slight example of the bureaucracy and diYculties faced by farmers over cross-border issues, consider the situation of a sheep farmer with adjacent fields on diVerent sides of the border. If he or she wishes to move sheep from the English field into the Welsh field they have to pay £4 per animal because of the current diVerent regulations arising from blue-tongue zones. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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33. Another example would be that of Single Farm Payments which have to be applied for by a Welsh farmer with land in both countries, to each country separately. The English application is then sent back to Wales for approval. The bureaucracy and complications of the two diVerent systems are a nightmare for small farmers.
Section ERecommendations for Action
1. It would be extremely helpful if the Select Committee would put its weight behind the need for cross- border dialogue (as described in the “Memorandum of Understanding” attached document, the need for which is highlighted again and again above) and for mechanisms that enable not only discussions to take place on the above issues, but also solutions to be found, and the political will to carry them out. The experience of farmers, for example, highlights the diYculties of two diVerent political and bureaucratic systems, but the diYculties are there in all the areas referred to above.
2. The need for proper funding of elective medicine for those in Wales near the border who need to come to Hereford, Shrewsbury or Chester Hospitals, is of paramount importance. Wrexham hospital has the same need from the other direction. This need for proper funding carries with it the inevitable implication, which eVects funding on both sides of the border, that in order to provide emergency medicine and other care within a “relatively safe” distance, then there will be a higher proportion of posts per patient than in densely populated urban areas.
3. There are equivalents in all the other areas mentioned above. 18 February 2008
Supplementary memorandum submitted by Bishop Anthony Priddis, Bishop of Hereford
CENTRAL WALES—WEST MIDLANDS
MEMORANDUM OF UNDERSTANDING ON CROSS BORDER COLLABORATION
The parties to this Memorandum of Understanding aim to achieve eVective cross border collaboration between Central Wales and the West Midlands on both policy development and service delivery.
Draft
Version 3
Context
1. The border between Central Wales and the West Midlands winds for over 150 miles through deeply rural “Marches” communities. While the boundary will have historic roots, in most places it is now an artificial line which bears little relationship to the patterns of life for communities in Central Wales and the rural West Midlands.
2. Communities in these rural areas face similar challenges, opportunities and needs. There are strong social and economic links across the border and a shared reliance on the opportunities provided by urban centres such as Hereford and Shrewsbury. There is a complex pattern of inter-dependence by local communities on services sourced from one or other side of the border.
3. However, while the England/Wales border appears an artificial one for local communities it does define operational units for national, regional and local governments and for most other public sector organisations and partnerships. As those organisations have evolved they have developed their own strategies, plans and policies, their own funding streams and modes of service delivery. This can lead to diVerences in policy, funding and services between Central Wales and the West Midlands which can have a detrimental impact on border communities.
4. The parties to this Memorandum of Understanding recognise this risk and are keen to build stronger cross border collaboration. The Welsh Assembly Government has committed in the Wales Spatial Plan to establishing collaboration with West Midlands organisations in order to address key issues of common Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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concern. These same cross border issues have been recognised by the West Midlands Regional Assembly and the West Midlands Rural AVairs Forum. The Forum commissioned research in 2005 to explore these issues and since then a Central Wales-West Midlands oYcer group has been established to develop arrangements for more eVective collaboration.
Nature and Status of this Memorandum of Understanding 5. This Memorandum of Understanding is a voluntary arrangement rather than a binding agreement or contract and so does not create any legally enforceable rights obligations or restrictions. It does not create any rights to be consulted or prevent consultation beyond that required by statute. Any failure to follow the terms of this Memorandum of Understanding is not be taken as invalidating decisions taken by any of the parties.
Scope 6. It is intended that this Memorandum of Understanding should apply to all public sector organisations and public sector-led partnerships operating at the national, regional or local level in Central Wales and the rural West Midlands. 7. Voluntary Sector and Private Sector organisations operating in Central Wales and the rural West Midlands (such as County Voluntary Councils, transport operators and utility providers) are also encouraged to follow the principles set out in this Memorandum of Understanding. 8. This Memorandum of Understanding is intended to embrace all aspects of policy development and service delivery which impacts on social, economic and environmental well-being and sustainability in Central Wales and the rural West Midlands.
Collaboration Arrangements 9. The parties to this Memorandum of Understanding will so far as is reasonable and practical and within the resource capacity of their respective organisations: (a) share non-confidential information relevant to the development of policies and services which will impact on border communities in Herefordshire, Powys and Shropshire; (b) “border proof” all proposals for change in policy, funding or service delivery which would apply to border communities, in order to ensure that any detrimental consequences for those communities are identified and mitigating action taken; (c) consult each other in good time on proposals for change in policy, funding or service delivery that could impact on communities on the opposite side of the border; (d) seek out opportunities for collaboration on policy development and service delivery wherever this could provide eYciencies and/or added value; (e) share experience of good practice in rural policy development and service delivery across Central Wales and the West Midlands. 10. The parties to this Memorandum of Understanding will establish a Central Wales—West Midlands Strategic Forum to oversee the implementation of this Memorandum of Understanding, to address strategic policy issues and opportunities for collaboration. That Strategic Forum will meet at least once a year. It will report to the Welsh Assembly Government through the Central Wales Spatial Plan Ministerial Group. In the West Midlands it will report to the Government OYce, the Regional Assembly and Advantage West Midlands. 11. The Strategic Forum will be supported by a Core OYcer Group drawn from the parties’ respective organisations. Specialist task and finish groups will be established to address specific issues of cross border concern, reporting to the Strategic Forum. 12. A sub-group of the Strategic Forum will be established to monitor and annually review the eVectiveness of the arrangements set out in this Memorandum of Understanding.
Confidentiality 13. Each party to this Memorandum of Understanding accepts that it can expect to receive information in confidence only if that information is treated with appropriate discretion. The party providing the information will state what, if any, restrictions there should be upon its usage and each party will treat information it receives in accordance with any such restrictions. Disclosure of information will be subject to the requirements of any relevant legislation, such as that relating to data protection, freedom of information, disclosure of environmental information, and any relevant code of practice relating to access to information. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Launch Signatories For the Welsh Assembly Government*
...... Carwyn Jones AM Minister for Environment, Planning and the Countryside
* Until the Government of Wales Act 2006 is fully implemented, the Welsh Assembly Government is simply the executive arm of the National Assembly for Wales, constituted under the Government of Wales Act 1998 and the Minister signs this Memorandum of Understanding on behalf of that Assembly. When section 45 of the 2006 Act takes eVect, references in this Memorandum of Understanding to the Welsh Assembly Government will be construed in accordance with that section., For the West Midlands Regional Assembly
...... Cllr David Smith Chair—West Midlands Regional Assembly
Memorandum submitted by Brecon and Radnor Community Health Council
Health and Social Care The Brecon and Radnor Community Health Council would wish to draw attention to a number of concerns that they would wish the Committee’s inquiry to concentrate on: 1. Prescriptions and how this is being provided for residents living in England with Welsh based GP services. 2. The diVering waiting times for English based and Welsh based residents attending same GPs, with residents asking why, as they believe it is a UK health service. 3. Health Commission Wales reducing certain specialist services based just inside the English border and reproviding the services in North, South or West Wales many miles further away. 4. The possibility of Powys LHB changing its future role as both commissioner and provider, with Welsh based trusts providing the service and not wishing patients on the border to use English based District General Hosptial (DGH) services, but use their services which may well be many miles further away. 5. The major impact on finance to Hereford Hospital if Powys residents were not permitted to use their service. 6. The associated problems for the ambulance service if they have to take people to hospitals further away. 7. The potential problems for border residents regarding 999 calls having to be taken much further to a DGH. 8. Public transport reflects population requirements and not cross border issues and would seriously disadvantage many people attending appointments, visiting arrangements/hospitals if they were not allowed to use English based DGH’s. 9. Both central Government and Welsh Assembly Government talk about choice, but more for political reason than population requirements they may be denied this. 10. The problems associated with diVering charging and the impact this has on Powys LHB. 11. The NHS is paid for principally out of taxes, the services it provides should be universally available to the population of Great Britain. As one of the main areas bordering England, the Community Health Council would welcome the opportunity to discuss these matters further. Bryn Williams 12 March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Supplementary memorandum submitted by Brecknock & Radnor Community Health Council I was pleased to have the opportunity to meet with the members of the Select Committee at the House of Commons on Tuesday 13 May and indicate the views and expressions of the Brecknock and Radnor Community Health Council to matters across the border into England. During the course of the presentation, I was asked specifically for evidence relating to health contracts being repatriated into Wales from English regions. I am, therefore, enclosing documented evidence to this eVect. The letter refers to a specific patient and there are copies of minutes from this locality. I trust this will be of value to you and your committee.
Re Ongoing provision of your Artificial Limb or Orthosis We regret that funding is no longer being provided from your local area to allow us to manage your treatment within our services. Therefore, I am sorry to inform you that we are no longer able to provide or maintain your prosthesis (artificial limb) and any associated items, or any orthotic equipment that has previously been provided from the West Midlands Rehabilitation Centre. We will, therefore, be arranging for you to be tcansferred to the appropriate local Welsh centre who will be responsible for the continuing provision of your prosthesis/orthosis and should hope to have completed this within the next 10–14 days. In the interim, if you should require an appointment then we suggest that you should contact your GP in the first instance. We regret that this matter is entirely beyond and outside our control but if you should have any queries or concerns then you should discuss them with your GP. The staV at our Centre will be happy to discuss your care with their colleagues in Wales if this is appropriate. Prosthetic and Orthotic Services South Birmingham NHS Primary Care Trust December 2007 Thank you for raising awareness of my situation in the Assembly and sharing information with Roger Williams. It has certainly generated a lot of interest in the plight of cross-border services. As requested here is a brief resume of my medical history. I have been an insulin dependent diabetic since 1992, registered partially sighted in 1999, becoming registered blind a few years later. In February 2001 I developed a foot ulcer that progressed into severe cellulitis, which led to me being admitted to The County Hospital, Hereford. Because of this long-term infection and resultant oedema I developed nephrotic syndrome secondary to diabetic glomerulopathy, then had to have a below knee amputation in August 2001, all this time being an in-patient in Hereford. In the week prior to the operation, the orthopaedic consultant, referred me to a consultant in Rehabilitation Medicine, at Selly Oak, Birmingham. Follow up letters were sent to make appointments for my mobilisation and after care. Although I was referred to Selly Oak, Birmingham, all patients from Hereford are seen in the satellite clinic at Belmont Abbey, Hereford. I was discharged from the care of the orthopaedic surgeons in Hereford in September 2001 and continued attending the limb clinic every four weeks for the first four months. Once the stump had settled I went to the clinic twice yearly for maintenance and recasting if required. During these visits I built up a rapport with the orthotist, technician and physiotherapists, who I saw frequently. At the first visit to the clinic I was introduced to the Social Care and Benefits Advisory Service who negotiated me through the social service benefits enabling me to claim the appropriate allowances. So you can see that it was very traumatic for me to receive a letter transferring my care to another hospital, away from people and environment to which I had become accustomed. The letter that I received in early December 2007 from South Birmingham, Primary Care Trust, stated, “funding was no longer being provided from your local area to allow us to manage your treatment within our services”. It was implied that I would be contacted by the appropriate Welsh centre within 14 days, or have to be referred by my GP if necessary. Enclosed was a map for Wrexham, so we assumed that would be where I was going. Living in Mid-Wales we are accustomed to having to travel some distances for hospital appointments, Hereford is a 90 mile round trip, whereas Wrexham is nearly twice as far at 160 mile round trip. As I am unable to drive and am not eligible for hospital transport, either my wife has to take days leave from work or I use Rhayader Community Support Volunteer Car Scheme. It is very tiring, and time consuming to have to travel so far. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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I find this whole situation very distressing, and annoying as I have not been contacted by any Welsh agencies to explain the situation. I am sure that there must be many other people are in the same plight as myself, thank you again for looking into this. If you require any more information please contact me. March 2008
BRECON AND RADNOR COMMUNITY HEALTH COUNCIL
Notes of the Meeting on 29 April 2008 Y said there was a clear directive at one time to commission services in Wales and withdraw from England. This has relaxed lately probably because HCW are more tied up with issues relating to reorganisation of Health Services in Wales but try and reduce services across the border. There is a special need for some services to be accessed across the border—namely some orthopaedic work like spinal problems, cardiac provision and ENT provision, although these services (ENT) are being transferred to Worcester. There are diYculties of funding. From a re-provision perspective in Wales—amongst the issues involved are: 1. Significant diYculties in lengthy travelling to access the services. 2. DiVerences in pricing systems in England, generally price is based upon the procedure—say hip replacement with universal cost—same for everyone, but in Wales the cost will be diVerent say in Wrexham to Gwent to Bronglais, etc, etc, with substantial diVerences in some instances. The usual and standard amount of time spent on the ward with relevant procedures, etc in England is built into the pricing mechanism based upon what is expected. However if there is an extension to the stay or services then additional costs can be incurred with extra bed days. In Wales if the patient is in hospital two days or 20 the price is still the same. Another issue associated to this of course is about eVectiveness and eYciency. One hospital may be seeing 20 patients in a given time another 40 patients, prices should reflect this issue. (This is an issue that should be part of a policy debate at a high level). The Powys LHB at present are responsible for 12% of the work at Shrewsbury DGH and 20% of the work at Hereford DGH. At Hereford there are some diYculties where they are looking to introduce a local pricing system with inflation built in. New contacts have been introduced across providers in Wales based upon the WH Circular WHC(2008)004. The cross border arrangements have rolled on since 2005 WHC(2005)12 now WHC(2008)019.
Waiting Times We are disadvantaged in Wales based upon the diVerent waiting times in England to Wales. In England from referral to treatment including outpatient, inpatient, etc a total time of 16 weeks. Whilst in Wales it is five months (20 weeks) for inpatient treatment. This is a gross imbalance of provision. The Powys LHB have been administering the waiting list for Powys patients. Although it now seems that the diYculties associated with this function seem to be problematic and the English DGH’s are taking back this function and embracing the list into their common waiting pool. There are issues around this in as much as the English DGH’s are looking to the Welsh contractors to buy into the English waiting times. From the Robert Jones and Agnes Hunt Orthopaedic Hospital perspective, they are happy to take the inpatient list but leave the outpatient list to Powys.
Other Issues 1. A copy of the L report to be sent. 2. A report from the Mental Health Manager will be going to the LHB Board highlighting the limited resources of the Mental Health Advocacy Scheme and the need to increase the money available to the contract especially now the legal input has greatly reduced. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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3. The All Wales information on IMCA statistics to be made available. Bryn Williams Chief OYcers 21 May 2008
Memorandum submitted by The British and Irish Orthoptic Society
Introduction The British and Irish Orthoptic Society welcomes the opportunity to respond to the consultation document and anticipates the prospect of future involvement.
Response to the Consultation Documents
1. The National Board The British and Irish Orthoptic Society supports option 1. That there should be one National Board responsible for (or advising on) funding and planning services for LHBs and NHS Trusts. This should be a Special Health Authority (Option 1). To address governance issues there is a need for patient/public representation on the new board. The National Board should have non-oYcer members and both these and the oYcer members should be selected from the public, voluntary organizations, healthcare professions from a range of healthcare organisations and service users (expert patients). To ensure that the National Board is sensitive to local needs the views of local people must be taken into account. This could be achieved using stakeholder forums, expert patients and encouraging members of the public to join the National Board as advisory members that are consulted electronically, by post or in group forums.
2. The Structure of Local Health Boards The British and Irish Orthoptic Society agrees with the proposal to reduce the LHBs from twenty-two (22) to eight (8) in Wales (including Powys Local Health Board). The British and Irish Orthoptic Society would welcome assurance that larger LHBs will continue to engage with their local population and leaders in order to increase the responsiveness of the NHS to local needs and experiences of health care delivery and to meeting global health challenges.
3. The Management of Community Services The British and Irish Orthoptic Society do not agree with this proposal. The British and Irish Orthoptic Society is concerned that by transferring responsibility for managing and providing services from the NHS acute Trust to LHBs that patient care may be compromised. Since the merger of acute and community Trusts there has been a demonstrable benefit to patients. Patient care pathways facilitate the provision of a seamless service from the acute and community providers. The British and Irish Orthoptic Society are concerned that this proposal may lead to fragmentation of current Orthoptic services. We are also concerned that this proposal could have a detrimental impact on clinical governance and professional development and may eVect the rotation of staV between community and acute settings. The British and Irish Orthoptic Society support the continuance of NHS Trust management of community services.
4. Engaging People Locally LHB’s must work at a local level to ensure that healthcare provision is meeting the needs of the local population. Smaller units of engagement at sub-local authority level would facilitate dialogue with healthcare providers and the local population. Scrutiny and advocacy roles on Community Health Councils should be undertaken by appropriately trained and competency assessed individuals and equity of provision across Health Boards is essential. It is vital that Boards include lay representatives that are representative of a cross section of the local community. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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5. The Structure of LHB Boards The British and Irish Orthoptic Society support the current stakeholder model and would welcome the continuation of feedback through WTAC. Members must be “truly” representative of the group for which they represent ie they should be formally elected. The remit for these members is to act as a conduit for information to and from the LHB. These members should have experience of service provision and organization at a senior level within their profession or organization. The British and Irish Orthoptic Society would welcome the opportunity to assist in the recruitment process of these individuals.
6. The Structure of NHS Trust Boards The British and Irish Orthoptic Society support the Stakeholder model. Representatives of the Trusts Boards should have membership of the National Board. The recruitment process would be enhanced by working in collaboration with the professional bodies. The name NHS Trust is understood and the British and Irish Orthoptic Society does not have any reason to suggest an alternative.
7. Support Services A range of support services could be considered as a single shared body to improve eYciency and in particular reduce duplication of eVort regarding the development of polices and procedures. Shared support services such as catering, domestic, laundry, facilities could be considered. Rosie Auld Chairman British and Irish Orthoptic Society and British Orthoptic Society Trade Union July 2008
Memorandum submitted by British Dental Association (BDA) The British Dental Association (BDA) welcomes the opportunity to present evidence to the Welsh AVairs Committee on the provision of cross border public services. The British Dental Association (BDA) is the professional association for dentists in the UK. It represents over 20,000 dentists working in general practice, in community and hospital settings, in academia and research, and in the armed forces.
The Historical Situation
Until the introduction of the new dental contract in April 2006 we were unaware that there were any problems with the cross border provision of dental services. There was a flow of patients from the border counties of Wales into England for specialist services within primary care which included orthodontic treatment—mainly from north Wales to Chester. Children born with cleft lip and/or palate have historically been treated in Liverpool Alder Hay and in Bristol in collaboration with the Welsh regional centre in Swansea in the south and with outreach clinics in north Wales. We are led to believe that this continues and is satisfactory.
The Current Situation
Post April 2006 north Wales has had diYculties with the provision of orthodontic treatment. Historically many referrals were made to specialist practices in and around the Chester area. The Primary Care Trust (PCT) in Cheshire decided to invest in additional orthodontic services as it too had concerns about the current level of provision but in doing so banned the practices from taking on new patients from north Wales (CH6 and above postcodes). This had two eVects, firstly it vastly increased waiting lists within north Wales— which had inadequate services anyway and secondly, it destabilised the business plans of the practices that had proposed developing their own services as they relied on patients from north Wales using the new provision. In terms of general dental practice there appear to have been few problems. What there have been are mainly around the direction by Local Health Boards of patients needing referral for specialist care. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Differences between England and Wales The Performers’ list regulations are diVerent so if a dentist wishes to come to Wales to work, they will have to submit an application to be placed on the “all Wales” list. This application will be scrutinised by a committee of the Dental Postgraduate Department, the business service centre in Swansea which handles these applications and the Local Health Board where the applicant wishes to work. It may be approved but subject to conditions. This may deter applications to practice in Wales. Patient charges for dental treatment are diVerent. In Wales they are lower and have not been increased for a number of years. Prescriptions are not charged in Wales but whereas this benefit is only available to Welsh patients, there is no restriction on patients from England seeking and obtaining dental treatment in Wales.
Dentists in Training Once graduated dentists will usually go on to do one year of vocational training in a supervised environment within dental practice (VDP). The funding for dental vocational training diVers across the border. In Wales it is held centrally by the dental postgraduate department whereas in England it is devolved to the PCTs. One of the training schemes (the Marches scheme) has historically used training practices in England but the new contract and the way in which vocational training is funded has made this extremely diYcult as the PCTs appear unwilling to fund VDPs working in an English practice but undergoing additional training in Wales. There are some other issues where diVerences between the two countries contrive to make life diYcult for practitioners rather than patients. For example, we seem to be heading for diVering cross infection control regulations. We cannot and should not work with diVering standards in each of the home countries. The Welsh Assembly Government is proposing to register and regulate private dental practitioners. As we have a UK organisation regulating the profession (The General Dental Council) we can see no reason to duplicate. 19 March 2008
Memorandum submitted by the British Medical Association (Wales)
About the BMA The BMA is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.
Defining Specialist Healthcare In order to understand the issues around cross-border healthcare, it is important to define what is meant by “specialist healthcare”. Secondary medical care—usually provided in a District General Hospital (DGH) setting—is medical care provided by a physician who acts as a consultant at the request of a primary physician. With the exception of large parts of Mid Wales most Welsh patients access this level of care at their “local” DGH. As a consequence, there is a widespread acceptance that Welsh patients are able to access uniformly high quality of care in their community. This care is provided as close to the patient’s home as is compatible with high quality, safe and eVective treatment. In contrast, tertiary healthcare is specialised consultative care, usually on referral from primary or secondary personnel, by specialists working in a centre that has personnel and facilities for special investigation and treatment. Specialist cancer care, neurosurgery, burns care and plastic surgery are all examples of tertiary care services. Research and patient satisfaction surveys consistently find that patients are willing to travel to access specialist care. Patients are willing to travel for expert services for which the quality of care and the expected outcome would be better than if treated locally where they may not be the appropriate resources or expertise to deal with the situation. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Cross Border Regions Welsh life, our social network and communications infrastructure do not stop at the English border—the same is also true of our health services. Wales can be broadly divided into three main cross border regions. North Wales with its close links with Merseyside and Greater Manchester; Mid Wales with its close links to the English Midlands; and South Wales with its much denser population, but close links to the South West of England.
Cross-border Secondary Care Secondary medical care for many Welsh patients is provided in English health settings. In 2001–2002, there were some 21,000 elective operations for Welsh residents in England and 2,800 elective operations for English residents in Wales. In 2002–2003, there were 20,000 elective operations for Welsh residents in England and 2,800 elective operations for English residents in Wales. In 2000–2001 over 25,000 elective patients from Wales were treated at hospitals in England, mainly in Chester, Shrewsbury, Oswestry (Gobowen), Hereford, Liverpool, Walton, Manchester, Gloucestershire and Bristol. To give some idea of the over reliance of Welsh patients in North Wales on English health services, there were 19,500 Flintshire residents treated in English hospitals in 2002–2003. As a consequence, the importance of these cross-border ties has resulted in an eVective and co-ordinated secondary care health system. Health service commissioners on both sides of the border have worked together relatively successfully to ensure health services are available to Welsh patients in areas where there is insuYcient critical mass in the population. The Royal College of Surgeons of England (and Wales) in a recent consultation on reconfiguration of services, Delivering high-quality surgical services for the future, maintain that for an acute or district general hospital providing the full range of facilities, specialist staV and expertise for both elective and emergency medical and surgical care requires a population of between 450,000—500,0001 residents. This partly explains (in addition to lack of suYcient transport infrastructure) why North and Mid Wales residents are referred to English providers in much greater numbers than in Welsh health settings: the population is not suYciently large to merit its own secondary services.
Devolution—Equality of Access to Secondary Health Services? Devolution has provided Wales with an opportunity to develop policies that respond to diVering circumstances and political priorities from other parts of the UK. Wales has already seen significant divergence in health policies. Most significantly, Wales has not witnessed the same use of the private sector and policy has focused on long-term health issues, which has been broadly welcomed by the medical profession. The new Labour/Plaid Cymru One-Wales Government has also signalled a continued divergence in health policy. Free prescriptions will continue, there is a commitment to end the internal market and eliminate the use of private hospitals by 2011 and a ruling out of the use of private finance and the ending of compulsory competitive tendering for cleaning contracts. These are all policies that diVer from those pursued over the border in England. However, devolution has not been a complete success nor has it meant a positive experience for all Welsh patients. The length of time that Welsh patients have to wait for specialist treatment remains a concern. The One Wales Government has a policy commitment to reduce waiting times to a maximum of 26 weeks from referral to treatment, including all or any waits for therapies and diagnostic tests in Wales. This is in contrast to England’s waiting time target. In England, a maximum wait of 18 weeks from the time of referral to a hospital consultant, to the start of treatment has been established. Put simply, Welsh patients are waiting longer for their specialist treatment compared to those waiting over the border in England. This is not a criticism of devolution per se, rather a criticism of a Welsh Assembly Government that is willing to set a waiting time target that is longer than that in England.
Specialist (Tertiary)Care—The Case of Neurosurgery To help illustrate the diYculty of providing specialist tertiary services in Wales then we can use the recent example of neurosurgery, especially as it aVects North Wales patients. Services in Chester, Manchester and Liverpool are much closer in travel time than services in South Wales; and there is a complex inter-meshing of medical and clinical links involving clinics, staV and technology with English Centres.
1 Royal College of Surgeons, Delivering high-quality surgical services for the future. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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North Wales has an existing and sophisticated arrangement with the North West of England, to supply integrated tertiary services—these can usually be reached by road within less than two hours. Serious head injuries in North Wales currently go to Walton in Liverpool if adult and Alder Hay for children (as this remains the children’s hospital for North Wales). These form the bulk of referrals and it would be clinically unsafe to send them any further. In 2004–05 870 patients from Wales were treated at the specialist unit and, in 2005–06, that number had risen to 1,025. In all, there have been 53,000 incidents of north Wales patients crossing the border for treatment. Considerable concern—especially amongst north Wales patients—was raised by the suggestion that in order to sustain two centres of excellence in South Wales (CardiV and Swansea) North Wales patients would travel to south Wales for their treatment. Whilst denied by the Welsh Assembly Government, this caused widespread concern that the well established network of patients from North Wales would be forced to travel to South Wales. A review by Edinburgh-based neurosurgeon, James Steers, is currently taking place and will make recommendations on providing high-quality, safe and sustainable adult neuroscience services for the population of Wales, as close to home as possible. The outcome of the review is expected in the summer of 2008.
Clinical Requirement for Specialist Services Responsibility for strategic planning and commissioning of services in Wales rest with Local Health Boards (LHBs), with highly specialised services being commissioned by Health Commission Wales (HCW). A full list of specialist services and Commissioning arrangements by Health Commission Wales in 2007/ 2008 is available at http://new.wales.gov.uk/topics/health/hcw/NHSplanning/hcwcommissioningplan?lang%en. Highly specialised services highlight the need to concentrate workload, expertise and training opportunities in fewer centres. Additional pressures on the centralisation of highly specialised services include shortened hours under the European Working Time Directive (EWTD), the need to provide an appropriate level of training within specialist units and the requirement to ensure surgeons have suYcient volume of surgical activity to avoid de-skilling.
Ensuring Patient Safety The former Chief Medical OYcer for England and Wales, Dr Kenneth Calman, produced a report into specialist cancer services. More commonly referred to as the Calman-Hine report, this report argued that cancer centres are intended to serve populations of one to two million and should be able to oVer the full range of specialist cancer services including treatments for rarer cancers. Such a population base is necessary if the specialists are to see suYcient numbers of patients to ensure that the relevant expertise is built up and maintained. This is purely a patient safety issue. The reality is that so many diseases occur so infrequently that it remains economically unfeasible to support a specialist service, especially when Wales with all typography has just a population of under 3 million people. In addition, staV providing such a service would be unable to maintain their specialisation for that illness if their catchment area did not supply enough cases. Therefore if we apply economies of scale, the population is too small to support a fully comprehensive service in some specialised clinical areas.
Conclusions There are a number of issues that the Committee will need to consider when examining cross border health issues: — Wales has long and established procedures for patients receiving their specialist services in other parts of the UK. — Many parts of Wales lack suYcient population and transport infrastructure to sustain all specialist services. — Wales—and North and Mid Wales patients—rely on specialist services in England. There is little, if any, evidence to suggest that Wales can sustain all specialist services and will continue to rely on Welsh patients travelling to other parts of the UK for their treatment. — Patients accept where specialist services are not available locally then they are willing to travel for their treatment. — Waiting times for specialist treatments should be uniform across the NHS. The Welsh Assembly Government needs to question whether it is acceptable that Welsh patients have to wait longer for specialist treatment than patients in other parts of the UK. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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— Political dogma should not interfere with delivering specialist services to patients. The location where a patient receives their treatment should be based on what is in the best clinical interest of the patient.
BMA Cymru Wales January 2008
Memorandum submitted by Carmarthenshire Community Health Council (a) Some paediatric and cardiac surgical cases do go to Bristol from our Trust area for treatment. (b) Some cases from the cardiac unit in Swansea go to St Mary’s in London for oblation (correction of over rapid pulse which cannot be drug controlled. (c) There are some individual cases where patients aVected by severe Crohns/Behcets Disease are treated by a specialist in St Mary’s.
Memorandum submitted by Children’s Commissioner for Wales The Children’s Commissioner for Wales is an independent children’s rights institution in line with the Paris Principles. The Commissioner’s remit covers all areas of the devolved powers of the National Assembly for Wales insofar as they aVect children’s rights and welfare. Evidence in this submission will not necessarily deal with issues aVecting adults. 1.1 Specialist post 16 education placements are commissioned for a small number of learners with learning diYculties and/or disabilities on a cross border basis. These placements are made for those learners whose needs cannot be met on a day to day basis in any of the 25 FE institutions in Wales. These placements are identified by a number of professionals. Great care is needed when placing these young people in specialist residential placements. The Children’s Commissioner for Wales is concerned about the involvement of the young people in the planning of these placements and how the young people’s welfare is safeguarded in these placements by Welsh local authorities or the Welsh Assembly Government. Given the special needs of learners, there needs to be a clear commitment to ensuring the quality not only of the learning experience but also the pastoral elements of the specialist educational placements. 1.2 We are aware that these placements can cause considerable disruption within families and that, although there are appeal mechanisms in place, these may be not be available to children and young people. Through discussions with the Welsh Assembly Government we have been notified of plans to amend the appeals procedure to allow children and young people themselves to raise an appeal to the Special Educational Needs Tribunal for Wales (SENTW) and would welcome a similar policy change in other areas of children’s services. 1.3 Estyn’s2 evidence to the Additional Learning Needs Legislative Competence Order Committee of the National Assembly for Wales highlights a number of other issues for post 16 learners. Of particular concern are the statements at paragraph 21 about the lack of guidance for post-16 learners and the diYculties around the transfer of records leading to disruption of the young person’s education and the statement about the lack of access to transport at paragraph 27.
2. Post-16 Providers
2.1 The lack of a statutory framework and supporting guidance for post-16 learners with additional learning needs hinders the process of transition from school to further education, training or employment. Careers oYcers help pupils with SEN to gain access to post-16 provision that is appropriate for their needs. However, schools and LEAs do not normally pass on pupils’ records, statutory assessments or statements to post-16 providers. As a result, post-16 providers often have to make a fresh start with assessments, leading to delays in providing the necessary support. 2.2 Estyn produced reports in 2004 and 2005 on provision for learners with additional learning needs in further education (FE) colleges and work based learning companies.
2 The proposed National Assembly for Wales (Legislative Competence) Order: Additional Learning Needs 2007 Committee. Response to consultation by Her Majesty’s Chief Inspector for Education and Training in Wales (Estyn) http://www.assemblywales.org/bus-home/bus-committees/bus-committees-third-assem/bus-committees-third-aln-home/ bus-committees-third-aln-agendas.htm?act%dis&id%60175&ds%11/2007 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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2.3 These two reports highlighted many ways in which going to FE college makes a positive diVerence to the lives of young people with additional learning needs. However, there were also some shortcomings, including the limited opportunities for progression within or from FE for learners with severe or profound learning diYculties, the lack of support for challenging behaviour and limited access to specialist mental health services. 2.4 Overall, the main focus in work-based learning is on immediate programme outcomes, such as securing employment or a qualification, with less attention paid to learners’ other needs. 2.5 Few learners with additional learning needs progress from college to work-based learning or employment. Many of these learners need much more support to enable them to use public transport because they lack the skill and confidence to travel independently. 2.6 By extending the scope of legislation to education and training for “all persons”, irrespective of age, the proposed order will open the way for improving transition arrangements from school to other providers. 2.7 It is, however, very important to recognise that lack of access to transport is a major barrier to equality of access to education and training for learners with additional learning needs and disabilities.
3. Specialist Health Provision
3.1 There are a number of areas of specialist health provision that are of concern and have been raised by health professionals with the Children’s Commissioner for Wales. One such area is that of neonatal care in Wales. In North Wales, the three NHS Trusts often work together in order to ensure that services are available if any one Trust is at a crisis point. This can often result in young patients and their parents and carers having to travel considerable distances and often over the border into England. Unfortunately, in some cases there can be a diYculty in getting records transferred back from English inpatient areas. In South Wales, there are no managed clinical networks for neonatal care as yet. The lack of a dedicated and properly equipped neonatal transport system within Wales was another concern. Given the recent report into maternity services in England, this is an area that requires further consideration. 3.2 Many health professionals expressed concern that Health Commission Wales undertook a review of neonatal services in Wales but that the report of this review has still not been published. 3.3 Child and Adolescent Mental Health Services (CAMHS) is another area of serious, long term concern in Wales. In 2007, the Children’s Commissioner for Wales produced a report, Somebody Else’s Business, which attempted to scope the accessibility and provision of CAMHS across Wales. The report highlighted concerns around the specific exclusion from access to CAMHS services (stated within Health Commission Wales’ commissioning guidelines) of young people aged 16 to 18 who are not attending full-time school and for those children and young people with a primary diagnosis of a learning disability. There is also a severe lack of specialist provision within Wales for those children and young people whose challenging or violent behaviour requires medium and high secure CAMHS placements, which result in placements being made in England. There is currently no provision for inpatient treatment of eating disorders within Wales. Children and young people are required to travel to England for treatment. There are often problems with the long term funding of these placements by Health Commission Wales. In some cases funding ends before therapy is complete. 3.4 Some areas of Wales have a concentration of residential children’s homes as well as many foster care placements. Research has shown that 49% of looked after children aged 11–15 have mental health problems.3 Powys Local Health Board have reported to us that two thirds of all referrals to CAMHS are made in connection with looked after children from out of county (including from English local authorities) who have been placed in Powys. This causes a great strain on services in the county. 3.5 We are aware that children have been placed in England from Wales without notification to the relevant English social services and health services (as set out in the Welsh Assembly Government guidance, Towards a Stable Life and a Brighter Future). This has led to inappropriate service provision and placing the child at risk. We have intervened on occasion to safeguard the child’s welfare and to secure funding. Advocacy service providers based in England are often not available or may not provide advocacy when a child is placed over the border. This oYce has often strived to fill this gap to safeguard children’s welfare and rights. In addition visits by social workers or independent visitors do not appear to be happening regularly, despite a statutory requirement to visit every six weeks, leaving these children potentially more vulnerable. 15 February 2008
3 The mental health of young people looked after by local authorities The Stationery OYce. ISBN 0 11 621651 4. http://www.statistics.gov.uk/pdfdir/hel0603.pdf Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Conwy Federation of Community Health Councils
CASE SUMMARY MR Y
CONTINUING HEALTH CARE FUNDING ISSUE This case involves a gentleman resident of Llandudno—a Mr Y. He was 56 years of age. He came into Community Health Council on 9 June 2006 to discuss his case. It was with regard to having surgery in the Royal Hallamshire Hospital in SheYeld where he needed deep brain radio-surgery. It had been an ongoing case—he was referred from Walton to the Royal Hallamshire where they were going to perform an operation where they gave him gamma rays to break down the tumor, which meant he didn’t have to undergo life threatening brain surgery. Background information—was actually seen on 7 October 2005 at SheYeld Teaching Hospital where Walton had referred him and it was agreed that surgery was necessary. On February 2006 Mr Y was seen at the clinic and it was agreed that because of the risks etc. that they would be happy to give him the treatment with the gamma rays. Treatment was then based as a funding issue, as he was a resident of Wales. In May 2006, Mr Y wrote to Brian Gibbons Minister, Welsh Assembly Government because he was concerned that there had been no decision on the funding for his operation based in SheYeld. He received a letter back dated 24 May 2006 explaining that Health Commission Wales are the commissioners responsible for authorising the funding for Neurosurgery for Welsh patients. Health Commission Wales had confirmed that they had not yet agreed a contract with the Royal Hallamshire Hospital in SheYeld for 2006–07—now that was a concern because obviously the financial year starts April and here we are 24th May having a letter from the Minister stating that they still hadn’t agreed the funding for Welsh patients. DY—Advocate met with Mr Y to discuss his concerns and case and it was agreed that we should write to Conwy & Denbighshire NHS Trust as the Minister had rightly said they had received no instruction from Conwy & Denbighshire NHS Trust with regard to funding the operation in SheYeld—that letter was dated 9th June and a copy also was sent on the request of Mr Y to Denise Idris Jones AM who was also acting on behalf of Mr Y. DY—Advocate also wrote to Chief Executive of National Centre for Stereotactic Radiosurgery, SheYeld Teaching Hospitals NHS Trust with regard to this case wanting to know why there had been such a delay in treating Mr Y, also pointing out that his health was deteriorating, that he would appreciate treatment as soon as possible and he was available to attend at short notice. His concern was that his health would deteriorate too much and that he would not be fit enough to survive the operation. DY was then in contact with Denise Idris Jones and her husband who were pushing for what was going on. On 13 June 2006 a letter was sent to Health Commission Wales from DY asking why the agreement had not been set up with SheYeld Hospital for patients in Wales and also stating that the CHC felt that Welsh patients were being disadvantaged. We did note that there were already lengthy waiting times for neurology for Welsh patients but we did understand that progress was being made to improve this certainly over at Walton, DY was then in contact continuously with the patient and Conwy and Denbighshire NHS Trust and also SheYeld Teaching Hospitals NHS Trust. There was an email from Conwy & Denbighshire NHS Trust to say that they had not been involved with the case—this would be a matter for the Local Health Board. DY then forwarded a letter with all the documentation to Chief Executive at Conwy Local Health Board chasing again for why there is a delay in the commissioning funding for this patient and resident of Conwy. A reply was received on 21 June 2006 from Chief Executive, Conwy Local Health Board saying that the funding for the specialist treatment for this patient was the responsibility of Health Commission Wales and the Chief Executive of Local Health Board has raised the issues with them this morning and they had been advised that SheYeld had been informed that funding is now available and Mr Y can now receive his treatment. DY spoke with the patient and he confirmed that he had received a letter to say that surgery was now scheduled for 26 July 2006—great news! Health Commission Wales wrote back to the CHC on the 19 June 2006 saying that they confirmed that the agreement of contracts is a technical issue between commissioners and NHS Trusts, there are no implications for patients as the Trust will continue to apply to Health Commission Wales for funding on an individual patient basis. Response was received on 1 July 2006 from SheYeld Teaching Hospitals NHS Trust from the Chief Executive, saying that they too had been pushing for the funding and they make plans for each patient. They said that there had been a delay in receiving the “authority to treat” for Mr Y however on 1 June 2006 they finally had the go-ahead and a provisional date was set for the 27 July 2006—good news. All information was then sent to the patient and to Denise Idris Jones AM and letters of thanks went out to SheYeld Teaching Hospitals NHS Trust for their response and for confirming that surgery would go ahead on 27 July 2006. 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In the meantime, the patient had correspondence from an MP (MI) with regard to the case—Some months later (rather delayed to say the least) to say that the funding only may be available and Mr Y was then left thinking that his already confirmed and planned surgery was to be delayed. However when DY—Advocate spoke to MPs Secretary to point out that surgery had been planned it was then highlighted to them that their response was so delayed it had added further stress to Mr Y as he read it that his surgery was to be cancelled. Advocate then wrote to the MP to draw attention to the stress it had caused and suggested they write a personal apology to Mr Y, which I understand he did receive and accepted their apologies for the delay in their responding. I can confirm Mr Y had his surgery with great success although he is still not 100%—there was an article in the local paper the Daily Post on 29 August 2006 with a large picture following his treatment. I would like to say since then he has done remarkably well—I feel that the stress caused by the initial referral back in February 2006 to July 2006 certainly put a lot of stress and trauma on Mr Y and could have had a detrimental eVect on his well-being and obviously his survival rate for the delays that occurred.
CASE SUMMARY MR X
CONTINUING HEALTH CARE FUNDING ISSUE The Community Health Council became involved when the Chairman of Conwy West spoke to DY— Advocate with regard to Mr X and the problems he was having with getting the funding for treatment outside of Wales—that was on 5th September 2006. Background to the case—Mr X had had a hospital appointment at Ysbyty Glan Clwyd and it was confirmed that he had pseudomyxoma secondary to an aopoendiceal neoplasm, which is cancer of the appendix—there is a one in a million chance of contracting this cancer. The patient had been seen in Ysbyty Glan Clwyd but treatment can only be delivered by specialist hospitals—such as Christies in Manchester and a hospital in Basingstoke. The consultant in Ysbyty Glan Clwyd had referred Mr X to Christies, however it became a commissioning issue as he was a resident of Wales. Christies had approached Health Commission Wales to say they were looking into the details of the patient—Ysbyty Glan Clwyd had said that all treatment—any biopsies etc.—should be done at Christies as they are a specialist hospital and are happy to take the patient. All delays in providing treatment was now down to funding. Mr X was first made aware of his diagnosis and treatment on 24 August 2006. The Chairman of Conwy West contacted the Community Health Council with regard to this concern on 5 September 2006. DY—Advocate then contacted Mr X with regard to the CHC assisting with his concerns/complaint and discussed gaining consent and background information with regard to his complaint. DY—Advocate prepared a draft letter to go oV to Mr D the then Chief Executive of Health Commission Wales on behalf of Mr X questioning why there were delays especially when Christies had accepted to take Mr X. Also questioned and wanting to know why there was a delay, when the funding would be made available and also the reasoning behind the decision not to have the funds readily available when consultants agreed that this treatment needed to be done. Mr X also informed the Community Health Council that AM’s were also involved and they were aware of the subject and they were acting on his behalf also. The letter to Mr D Chief Executive of Health Commission Wales was dated 6th September 2006. Mr X made available a letter which was sent from Miss O Consultant Surgeon of Christies Hospital to Mr R Consultant at Ysbyty Clan Clwyd dated 30 August 2006 typed on 31 August 2006 which clearly states that it is highly likely that Mr X is suVering with the rare pseudomyxoma secondary to an aopoendiceal neoplasm and that she is quite happy to accept all these referrals but more recently the Health Commission Wales seem to have been putting barriers to that process. She herself had written to the Chief Executive of the Health Commission Wales to outline her views on the matter and basically she said that until she has clearance from Health Commission Wales she is not even able to see the patient in clinic. Following this Mr X paid privately to go and see Miss O Consultant Surgeon of Christies Hospital to have all the information confirmed and necessary tests done. Mr X’s friend Councillor E also took up the case with Mr T of Conwy Local Health Board and they have sought advice from him as to where they go from here. understand that an email was sent which we have a copy in our its dated 7 September 2006 to say that “The patient’s diagnosis has not yet been confirmed by biopsy as per the pathway specified in our commissioning policy” a copy of which we have in the file. He understood that the case was being referred to the experts and until there is an exact diagnosis the result was that funding would be withheld but as said previously they needed to have the biopsies done to confirm diagnosis and Christies was the best place for this to be done. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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On 12 September 2006 there is an email received from Mr X to the Community Health Council saying that he had received a phone call from Christies and an appointment had been set for 6:30pm on 21st September 2006 and it would be a private consultation, which he was paying for in a hope that it would assist in progressing the matters. On 13 September 2006, DY—Advocate telephoned Mr T in Conwy Local Health Board to find out what was happening with regard to this issue the funding for Mr X—Mr T was not available so requested that I speak with Mr W who was also unavailable. DY—Advocate rang Mr X’s wife to see if there were any updates, she then obtained the email address for Mr T Conwy Local Health Board. DY—Advocate sent an email to Mr T—Conwy Local Health Board to ask if he could assist with the case. Mr T Conwy Local Health Board emailed back on 14 September to say he had been involved in the case— he understood a letter went to Health Commission Wales on Wednesday to the consultant at Ysbyty Glan Clwyd asking them to undertake some procedure to support the diagnosis. Various emails and telephone conversations then ensued and it was agreed that Mr X would have his private appointment at Christies and then he was to have a CT scan at Ysbyty Glan Clwyd. There was to be a multidisciplinary team meeting at Christies on 18 September 2006 to see what further action could be done. The Community Health Council received a response to their letter dated 6 September 2006, the response from Health Commission Wales was received on 18 September 2006—letter dated 13 September 2006—to say that there had been a lot of conversations back and forth with regard to the treatment of Mr X and also referrals that were out of area ie out of Wales. Mr X’s surgeon at Conwy & Denbighshire NHS Trust had been requested to perform the procedure as soon as possible with regard to a biopsy and then Health Commission Wales would then consider the request for any specialist treatment in light of the pathology report following the biopsy. Health Commission Wales also confirmed that they had contacted Mr X with regard to the above information. Mr X had his biopsy performed at Ysbyty Glan Clwyd on Friday 13 October 2006. The Community Health Council on Monday 16 October 2006 wrote to Health Commission Wales to confirm that a biopsy had been undertaken and whether they could now confirm whether Mr X falls within their policy in treatment intervention that is to be oVered by the specialist centres out of Wales and asked when he could commence his treatment. We also reiterated that Miss O Consultant Surgeon of Christies Hospital had written to support his case. Telephone conversation with Mr X, on 18 October 2006 to say that he had heard that Health Commission Wales were having a panel meeting today and a decision should be made and costings had been requested. Following the conversation with Mr X the Community Health Council emailed direct to Health Commission Wales to the attention of Mr D Chief Executive apologising for the error and to confirm that the biopsy did not go ahead under the instruction of two doctors of Ysbyty Glan Clwyd and that the Community Health Council understood that there was a meeting today at Health Commission Wales to discuss the case and the way forward. DY—Advocate then requested that HCW let Conwy Community Health Council know the outcome of the meeting as soon as possible. 18 October 2006 Mr X rang late in the afternoon to say that there had been a decision and that the decision was positive. He’d heard that the treatment could go ahead. Health Commission Wales had agreed the treatment at Christies so the Community Health Council left a message of congratulations and asked that the Community Health Council be informed. That decision had taken from the first date that he had been diagnosed on 24 August 2006 and the final decision had been made 18 October 2006 almost two months later. Mr X’s son emailed the Community Health Council to inform us that his father had had the surgery on 1 November 2006. They were informed that this was done successfully but now the big thing is to see where they go from here and whether chemotherapy could progress. The Community Health Council never did get a response to the email sent 18 October 2006 for the attention of Mr D Chief Executive of Health Commission Wales when the treatment would start but we did get a letter dated 21 November saying that they do apologise for the delay however, as we were probably aware, Mr X’s case had been considered at an Individual Patient Commissioning Panel. They had supported the treatment program proposed by his consultant. DY—Is kept in regular contact with Mr X via his website to see how he is progressing with his treatment. The Community Health Council was thanked for all their support and assistance with this case. It was just unfortunate that it took so long for HCW to make a decision, which delayed his treatment for around two months. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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EXPERIENCE OF PATIENT ACCESSING PET SCANNER Husband had a chest X Ray in August 2006. This was reported as abnormal. In September he had a CTScan and bronchoscopy which was inconclusive. Following a case conference at Ysbyty Gwynedd it was decided to send him to Mount Vernon for a PET Scan. We had 2 days notice and the appointment was for 4pm. He was not very well at the time. Our friends took us to London as they were going to see their daughter who lived nearby. It would have been diYcult for us to get a train to Harefield as the timing was wrong. The whole process took about an hour and a half, and he was in great pain during and following the procedure. We had to get a taxi to Watford Junction (£20!) and get a train home. We could not stay overnight as he was radioactive and it would have meant two rooms, and he was not well enough for me to leave by himself. The cost of the train journey home was £186 (single). We could not book a railcard, as there was not enough notice. On the train he was advised not to sit near anyone for long as he could have contaminated people especially pregnant women and children. You can imagine how busy the train was and during a phone call to our son passengers overheard him say about contamination and fortunately moved away. On getting home he was very ill and exhausted for many days. We had to wait two weeks for the result, which showed a Hot Spot, and he was then treated with Radiotherapy at YGC. My husband was only the 6th person to go to Mount Vernon in Harefield from Ysybty Gwynedd. Most other patients were too ill or too poor to be able to aVord the journey. I was told that there was a PET Scan in Liverpool but was not funded by the Assembly. Mount Vernon was a private facility, very costly for North Wales residents and put them at a disadvantage regarding their diagnosis and prolonging appropriate treatment. People in the London area were able to access the PET scan almost immediately. January 2008
Memorandum submitted by Countess of Chester Hospital
Executive Summary 1. This submission explains current cross-border issues in relation to financial arrangements between Welsh commissioners of health services and the Countess of Chester Hospital NHS Foundation Trust and comments briefly upon the impact of diVering health care policies along the border. 2. The key points made within the submission are: (a) Current Welsh Assembly policy is that English healthcare providers should be funded on the basis of a historic (1991) financial and activity baseline with only the marginal costs of additional activity funded each year. (b) As a result over time the actual costs of providing health services to Welsh residents has considerably outstripped the funding provided by Welsh Local Health Boards. The forecast underlying deficit in 2008–09 in funding provided to the Trust for services to Welsh residents is £2.2 million. The Trust believe that it is eVectively subsidising the Welsh Health Service to this extent. (c) It is highly unlikely that negotiation based on current cross-border financial arrangements will resolve this long-standing issue and the Trust believe that revised cross-border financial arrangements based on a standard approach agreed between the two governments is necessary. (d) Suggestions of a policy of repatriation whereby all Welsh residents would be ultimately treated within Welsh hospitals would not be in the best interests of Welsh patients and their safety. (e) DiVerences in policies relating to waiting times, prescription charges and car parking charges can be confusing and of concern to many citizens along the border, however we accept these as a natural consequence of devolution and the relative priorities of the diVerent governing bodies within the UK.
Introduction to Submitter 3. Peter Herring has been Chief Executive of the Countess of Chester Hospital NHS Foundation Trust for approximately eight years and is submitting this evidence on behalf of the Board of Directors of the Trust. 4. For brevity I will occasionally refer to the Foundation Trust as “the Trust” or “the Countess”. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The Countess of Chester Hospital NHS Foundation Trust 5. The Countess of Chester Hospital is a 580-bed, single site general hospital situated on the outskirts of Chester. The Trust has over 3,000 employees and provides acute emergency and elective services, primary care direct access services and obstetric services to a population of approximately 250,000 residents mainly in Chester and surrounding rural areas, Ellesmere Port and Neston and the Deeside area of Flintshire in North Wales. 6. The Trust provides hospital services to approximately 30% of the population covered by Flintshire Local Health Board in Wales, and smaller volumes in other North Wales Health Board areas. Welsh patients represent approximately one fifth of the total workload of the Trust. In 2007–08 the forecast number of Welsh patients treated is as follows:
Elective (non-emergency) inpatients and daycases: 4,200 Emergency inpatient admissions 6,700 Outpatient attendances 41,750
7. The Countess of Chester Hospital was established as one of the first 10 NHS Foundation Trusts on 1st April 2004 under the Health and Social Care (Community Health and Standards) Act 2003. Essentially a Foundation Trust is an autonomous organisation established in law as a Public-Benefit Corporation and free from central government direction and control. 8. Foundation Trusts are only established in England, they do not exist in Wales but English Foundation Trusts have a duty of care embodied within their Terms of Authorisation to treat patients whatever their country of residence and to co-operate with the commissioners of health services—Primary Care Trusts (PCTs) in England and Local Health Boards (LHBs) in Wales.
Funding Issues Relating to Cross-border Services 9. The Trust income relating to Welsh patients in 2007–08 comprised £18.2 million representing 15% of total income from health service commissioners, although Welsh patients represent 20% of the total patient workload of the Trust. 10. In England, Trusts, whether they be Foundation Trusts or traditional NHS Trusts still under Department of Health control, are largely paid through the Payment by Results (PbR) system whereby for each patient treated the Trust is automatically paid a “price” based on tariVs established by the Department of Health. The national tariV varies according to the type of patient (eg outpatient, day-case or inpatient) and the condition of the patient. 11. In relation to Welsh residents, the Local Health Boards will not recognise the Payment by Results system and the funding for services is subject to negotiation between the provider and the commissioner based on a historic funding position established we believe in 1991. Flintshire Local Health Board insist that they are only prepared to meet the marginal costs of additional activity over and above the historic baseline and that this reflects the national cross-border policy. 12. This position ignores that fact that: (a) The current relevance of a baseline established nearly 17 years ago is highly questionable. (b) Funding at marginal cost over a long period ignores the step changes in costs necessary to meet service improvements, and to fund the quality and infrastructure requirements of a 21st century health service. As a result over time the full costs of providing health services to Welsh residents has considerably outstripped the funding provided by the Local Health Board. 13. Whilst negotiations with Flintshire LHB have recently provided for an additional £1 million of funding, irrespective of this, for the forthcoming year 2008–09, we estimate that the funding provided to the Trust will be approximately £2.2 milliion less than the actual cost of providing services to Welsh residents. If the required level of activity were to be reimbursed on the basis of English national (PbR) tariVs we would expect an additional £3.8 million over the current funding level. 14. In addition, in respect of English border hospitals the funding ofA&Eattendances and sexual health clinic attendances until 2005 were traditionally the responsibility of the host Primary Care Trust. Since these services were “de-hosted” in 2005 Flintshire LHB have refused to fund A & E and sexual health growth (equivalent to £200k), arguing that this remains the responsibility of Western Cheshire PCT. The Trust is therefore not being paid for additional activity in these areas by either commissioner. 15. It is not unreasonable for a provider of services to expect the commissioner to pay a fair price for the services provided—it is clear that as our basic costs are not even being covered, the Trust is eVectively subsidising the Welsh Health Service and thereby compromising its full potential to provide services to both English and Welsh residents alike. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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16. Flintshire Local Health Board have insisted that they are complying with cross-border policy and that resolution of any underlying deficit in funding will only be resolved by the Department of Health in England transferring funds to Wales. The Department of Health, however, resist this and believe it should be resolved through local agreement. 17. The Welsh Assembly’s position was expressed in a letter from the Chief Executive of NHS Wales to myself on 30 March 2007 as follows: “The Welsh Assembly Government position is clear, in that we expect Welsh commissioners to agree contracts with providers that reflect, as far as can be determined, the cost of service provision. This position has not changed in Wales since 1991”. 18. Whilst this initially seemed to support the principle of a provider’s actual costs of service delivery being covered, a subsequent letter from the Director of Finance for NHS Wales supported Flintshire Local Health Board’s contention that they are only required to meet the marginal costs of additional activity over and above the historic baseline. It appears unlikely therefore that the underlying deficit with Flintshire will be resolved through negotiation whilst this policy is maintained and supported by the Welsh Assembly. 19. The Local Health Board have refused to enter into a formal contract arrangement with appropriate dispute resolution arrangements arguing that they are forbidden to do so by the Welsh Assembly.In the event of a dispute of this nature as an individual provider of NHS services the Trust has very little ability to reach agreement with a local commissioner supported by its government and national policy. 20. The simplest and most transparent solution to cross-border financial arrangements would be to reimburse English providers on the basis of a tariV arrangement whether this be equivalent to English tariVs or specific to Wales; a tariV system does not exist within Wales itself however. 21. Alternatively, English based Trusts use a standard national system to identify their actual costs for each type of activity and patient. This is produced in accordance with guidance established by the DOH and is subject to annual external audit to verify its accuracy. These are known as reference costs within England and they inform the construction of the national tariVs each year. No comparative system exists within Wales. In addition to reference costs, Trusts require a surplus to fund quality and capital investment and an agreed percentage oncost could be added. 22. Either way we believe a standard approach would be helpful to remove the reliance on local negotiation which has proven to be ineVective in reaching a satisfactory resolution to cross-border funding disputes. 23. Whilst the DOH has no direct responsibility to help resolve a matter between a Foundation Trust and local commissioners, the Minister of State for Health Services, Mr Ben Bradshaw has been very supportive in attempting to facilitate a resolution of these matters with the Welsh Assembly, as have local English and Welsh Members of Parliament and certain Welsh Assembly members. 24. Whilst we believe these matters are being addressed by the two governments the Trust would urge the rapid introduction of revised cross-border financial arrangements for future years to avoid English providers of health services to Wales (and their patients) being disadvantaged by historic arrangements that do not meet the requirements of a modern commissioning relationship.
APolicy of Repatriation? 25. Suggestions have been made from a number of sources that a policy of “repatriating” Welsh residents might be adopted. In other words Welsh commissioners would as a matter of policy direct that all Welsh patients were treated in Welsh Hospitals. This has indeed been alluded to on a number of occasions in response to the Trust’s pursuit of financial equity. 26. The Countess of Chester Hospital is approximately two miles from the border with Wales and for the population of Deeside the Countess is their natural local hospital of choice and the closest in terms of patient safety for emergency cases. 27. Together with other English providers along the border, the Countess has provided health services to Welsh residents since the inception of the NHS. The Countess of Chester Hospital NHS FT value the services we provide to Welsh residents very highly. To pursue a policy of repatriation would in our view seriously compromise the best interests and safety of Welsh patients in our catchment area. The Trust sincerely hopes that such a policy will not be adopted by the Welsh Assembly and that we will be allowed to continue to provide high-quality health services to Welsh residents.
Differences in Health Policies and Waiting Time Targets 28. By the end of March 2008 (December 2008 for most other English Trusts) the Countess will be delivering for English patients a maximum waiting time of 18 weeks from the point of referral by a GP to the time of a patient’s first treatment (that is encompassing any diagnostic requirements, outpatients and an inpatient stay or operation if this is required). Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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29. For Wales the maximum waiting targets at the end of March 2008 are: — 22 weeks for an outpatient appointment. — 22 weeks for an inpatient or daycase appointment. Further improvements in Welsh waiting times are being pursued over the next two years so that by December 2009 no Welsh resident will wait more than 26 weeks from the point of referral by a GP to the time of a patient’s first treatment. 30. Whilst the Trust would ideally wish to provide the same access to patient care irrespective of the patient’s point of residence, Welsh patients on average now wait longer compared to English residents as result of the diVering policies, although generally waiting times for Welsh patients at the Countess are still much lower than average waiting times in Wales. 31. This situation clearly creates additional administrative complexities and costs in arranging appointments and admissions in respect of Welsh residents and can create confusion and concern for patients along the border when they see their close neighbours getting swifter access to healthcare. 32. Free prescription charges and the recently announced free car parking arrangements are other examples of the diVering policies experienced along the border. 33. My Board accept these as a natural consequence of devolution and the relative priorities of the diVerent governing bodies within the UK and it is appropriate that we respect these diVerences and comply with the requirements of Welsh healthcare commissioners.
Conclusion
34. This concludes my evidence to the Committee. My Board and I would welcome any support the Committee may be able to oVer to help encourage a resolution of the matters considered in this paper. 12 March 2008
Letter from Susan Davies to the Chairman Members of the public being provided with primary and secondary health services, whether they are the English receiving services in Wales, or the Welsh receiving services in England should also be able to question local health authorities when those services do not meet required standards. What is the process of their representation should they want to be involved? Something that is not addressed in your report. I am Welsh, my mother was Welsh and I battled with Welsh health authorities for a period of 10 years when she had dementia and eventually went into nursing care. I then submitted a retrospective appeal for the return of all her nusing care fees and won. This money was gifted to Alzheimer’s Wales for respite care under the procedure of Deed of Variation (legal changes to a will after death). I now wish to bring your attention to a situation that I find myself in when I was asked by Monica Dennis to represent Dignified Revolution (CardiV based voluntary group) on a Welsh Assembly Dignity in Care National Co-ordinating Sub group on Social Care. I readily accepted this role. The first meeting took place in CardiV on 7 October. On 16 October Gareth Morgan Project Manager NSF Older people and Long Term Care policy Directorate on behalf of the Welsh Assembly emailed Monica Dennis dismissing me from representing Dignified Revolution purely because I live in England. I enclose a copy of that email and my initial observations on it. This is outrageous behaviour and I have instigated the complaints procedure. So in light of your report—anyone living in England and chooses to have health services from Wales and wishes to complain about those services cannot be represented on Assembly committees because of their country of residency being England. In view of the volume of “cross-border” movement for primary and secondary care services that has been highlighted in your report the attitude taken by Welsh Assembly staV and their representatives clearly needs to be looked at. I look forward to hearing your views on this situation and on the behaviour of Welsh Assembly Government. 24 November 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by the Department of Health 1. The Department of Health is pleased to have this opportunity to provide a Memorandum to the Welsh AVairs Committee on the provision of cross-border health and social care services. 2. This memorandum covers: — The extent to which cross-border health and social care services are currently provided for, and accessed by, the Welsh population. — The arrangements currently in place to co-ordinate cross-border service provision, including inter- governmental protocols. — The commissioning, funding and quality of cross-border services. — The extent to which health and social care policy has diverged across the UK since the introduction of devolution, and the impact that this has had. — The extent to which mechanisms are in place for identifying and resolving cross-border deficiencies. 3. The Memorandum focuses primarily on health care. The commissioning and provision of social care services is the responsibility of individual local authorities and there is no centrally-held data on the extent to which local authorities in Wales commission services for their population from providers in England. The main flows across the border are placements for looked after children, and residential care for older people, who are normally able to exercise choice over their care provider.
Cross-border Health Services Accessed by the Welsh Population 4. The border between England and Wales does not represent a barrier to the provision of health care. People resident in Wales have always accessed health services in England and people resident in England have done the same in Wales. 5. This is particularly the case in a number of border areas where the nearest GP practice to a person’s home might well be on the other side of the border. 6. There are also well-established relationships and flows of patients between GPs and commissioners in one country and hospitals in the other. Welsh residents particularly access services in Cheshire, Wirral, Herefordshire, Shropshire, Gloucestershire and Bristol, as well as specialist services further afield, (such as specialist cancer and children’s centres). 7. In 2007, around 19,000 patients resident in England were registered with a GP in Wales. An estimated 14,000 who were resident in Wales were registered with a GP in England—a net flow of 5,354 from England to Wales. 8. The number of Welsh residents using English hospitals has increased in recent years. Almost 227,000 attended outpatient appointments in 2006–07. The previous year there were 216,000, and in 2004–05 the reported total was 140,600. (NB It is believed that the reported increase after 2004–05 is in part due to an increase in the completeness and quality of the outpatients data). 9. The number of Welsh residents admitted to English hospitals has also increased. In 2006–07 there were 57,000, compared with 55,000 the previous year. In 2004–05 the number was 48,000). 13,000 of these patients were admitted via A&E departments in 2006–07, compared with 11,000 and 10,000 in the two previous years respectively. 10. The number of English residents treated at Welsh NHS Trusts is significantly smaller. In 2005–06 there were fewer than 13,000.
Arrangements to Co-ordinate Cross-border Service Provision,Including Inter-governmental Protocols 11. A devolution concordat was agreed in 2001 to provide a framework for co-operation between the Department of Health and the departments or directorates concerned with health and social care in the UK Department of Health, Cabinet of the National Assembly for Wales and Department of Health, Social Services and Public Safety Northern Ireland. This sets out the over-arching principles within which the Department of Health and Welsh Assembly Government co-ordinate cross-border services. 12. The Department of Health has responsibility for all of the UK (England, Scotland, Wales and Northern Ireland) in some areas where national co-ordination or leadership is required. These include: — International and EU business, including the negotiation of legal agreements. — Co-ordination of planning for pandemic influenza. — The licensing and safety of medicines and medical devices—led by our Executive Agency the MHRA. — Certain ethical issues such as abortion and embryology. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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13. An inter-government protocol is in place to address commissioning responsibility issues. The legislative positions in England and Wales have not defined precisely which local NHS body is responsible for commissioning care for people who live on one side of the border but are registered with a GP on the other. In Wales a Local Health Board is responsible for the care of its resident population. In England a PCT was previously responsible for people registered with its GPs. This changed when SI 2003 No 1497 came into eVect, establishing that PCTs in England are responsible for the care of their resident population. (They do, however, remain legally responsible for commissioning services for Welsh patients registered with their GPs).
14. The Department of Health and Welsh Assembly Government agreed that the practical implications of the change to responsibility on the basis of residence needed to be phased for border commissioners, to ensure that patients receive the services they require and can fully understand the implications of accessing the other country’s healthcare system. In 2005 an interim protocol was agreed to address this, and to take account of the legislative anomaly.
15. The interim protocol relates to patients living along the border in Flintshire, Wrexham, Powys, Monmouthshire, Denbighshire, Cheshire West, Shropshire County, Herefordshire, Wirral and Gloucestershire. It confirms that for people resident in these LHB and PCT areas the commissioner which has operational responsibility for their care will be determined by GP registration in all cases, rather than residence. (The legal responsibility remains with the body covering the area in which the person is resident). This protocol has been renewed annually since 2005 and is currently in place until April 2009 (see Annex 1).
16. The principles according to which service providers in either country treat patients from across the border have been established in WHC (2005) 12, and in letters from DH to the Strategic Health Authorities. They confirm that Welsh providers are required to work to the standards and targets that are set by the Welsh Assembly Government for all the patients who they see and treat. This means that patients from GPs in England who choose assessment or treatment in Wales will be seen or treated within the maximum waiting time targets and other standards applicable to the NHS in Wales.
17. English providers are required to work to the standards and targets that are set out by the Department of Health for patients that are the responsibility of English commissioners. Welsh commissioners will commission work from English providers for patients that they are responsible for so as to ensure that clinical priorities are met and that Welsh maximum waiting times for patients are delivered. These patients will be reported in the English provider data-sets but will be separately identified and the independent Healthcare Commission have agreed that any breaches of the English maximum waiting times by patients who have been referred by a Welsh GP will not be included in the Trust’s performance rating.
18. The following table illustrates the waiting times standards which apply to patients covered by the interim protocol in the range of circumstances identified above. (Note that in columns 3 and 4 the hospital in Wales is expected to meet the standards and targets set by the Welsh Assembly Government. However the responsible commissioner in England would still be expected to secure services for their patients which meet the standards set by the Department of Health).
APPLICABLE WAITING TIMES TARGETS:
12345678 Patients resident in: England Wales England Wales England Wales England Wales Patient registered with a GP in: England England England England Wales Wales Wales Wales Treated in a provider in: England England Wales Wales England England Wales Wales Are subject to the waiting times standards set by the DH/govt. in: England England Wales Wales Wales Wales Wales Wales
19. The NHS Strategic Tracing Service (NSTS) is available to providers in England and Wales to determine the responsible commissioner for patients in England. The NSTS is a national (England and Wales) database of people, places and NHS organisations
20. The General Medical Services (GP) contract is a UK-wide contract for services, agreed between NHS Employers, on behalf of the Department of Health, and the BMA’s General Practitioners’ Committee. Scotland, Wales and Northern Ireland are all party to discussions on any changes to this contract. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Department of Health oYcials have regular meetings with colleagues in the Scotland, Wales and Northern Ireland administrations to ensure, as far as possible, consistency of approach in the delivery of primary medical care in the four countries. There will always be some diVerences to reflect the diVerent circumstances in each country but these tend to be on the margins of the contract. 21. OYcials of the Devolved Administrations are routinely invited to join English colleagues in various groups in which services which have cross-border implications are discussed and planned.
The Commissioning,Funding and Quality of Cross-border Services 22. In England, PCTs are responsible for funding the healthcare provision of all patients registered with GPs in practices forming the PCT. PCTs are also responsible for residents within their geographical boundaries who are not registered with a GP. 23. The Department of Health provides funding to PCTs to meet these responsibilities. Revenue allocations are made to PCTs on the basis of the relative needs of their populations, to enable them to commission similar levels of health services for populations in similar need. A weighted capitation formula is used to determine each PCT’s target share of available resources. The components of this formula include the size of the population for which PCTs are responsible, their relative need (age and additional need) for healthcare, and unavoidable geographical diVerences in the cost of providing healthcare (known as the market forces factor). 24. Similarly, the Welsh Assembly Government allocates resources each year to Local Health Boards and Health Commission Wales (which commissions specialised services) to pay for the costs of hospital treatments provided by NHS trusts and other independent healthcare providers. 25. PCTs, LHBs and HCW commission services to meet the needs of their population through contracts or service level agreements with service providers. 26. The NHS Plan (July 2000) introduced the Government’s intention to link the allocation of funds to hospitals in England to the activity they undertake. It stated that in order to get the best from extra resources there would be major changes to the way money flows around the NHS and diVerentiation between incentives for routine surgery and those for emergency admissions. Hospitals would be paid for the elective activity they undertake through a system of payment by results. 27. This reformed financial system oVers incentives to reward good performance, to support sustainable reductions in waiting times for patients and to make the best use of available capacity. It is based on a nationally-agreed set of prices or tariVs for services at specialty level based on volumes adjusted for casemix using Healthcare Resource Groups. 28. Payment by Results is being implemented incrementally both in terms of scope and financial impact. In terms of scope, the system began in a small way in 2003–04, was extended in 2004–05, and, for the majority of trusts, included only elective care in 2005–06. In 2006–07 the scope of payment by results was extended to include non-elective, accident & emergency, out-patient and emergency admissions for all trusts. 29. In future Payment by Results will be extended to a range of other services such as specialist mental health services and ambulance services. 30. The system of Payment by Results operates only within England. The Welsh Assembly Government has chosen not to introduce it to the NHS in Wales, and it is not applicable to Welsh Local Health Boards and Health Commission Wales for the services they commission from English hospitals. The funding of these services is determined by local negotiation and agreement between the Welsh commissioner and English provider. As a result an English hospital might provide a service to Welsh patients at a higher or lower price than that paid by English commissioners. 31. Welsh commissioners spent £146 million on non-Welsh NHS bodies in 2005–06. The vast bulk of this was in England, with small proportions in specialist providers in Scotland and Northern Ireland, but the exact split is not available. 32. The Department of Health in England makes an annual financial transfer to the NHS in Wales—£5.6 million in 2007–08—to cover the extra net costs of providing hospital services for English residents registered with GPs in Wales.
Divergence in Health and Social Care Policy Across the UK Since the Introduction of Devolution 33. While the core principles of the NHS apply across the UK, an inevitable consequence of devolution has been some divergence in health and social care policy between the nations. The key health policy diVerences which have emerged in the NHS between England and Wales have included the following diVerences: Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Wales England Free prescriptions for all4 Shorter waiting time standards in secondary and Free dental checks for people under 25 and over primary care 60 New policy to extend opening hours of GP surgeries Free car parking at NHS hospitals Choice of any provider for routine elective care Choice of provider, treatment and setting for patients with Long-Term Conditions Choice of maternity care Diversity of provision and competition (varies by type of service)—includes standard contracts and promotion of services by providers Independent standards and inspection body, the Healthcare Commission
34. The Welsh Assembly Government has given a commitment, set out in One Wales5 to ‘move purposefully to end the internal market. Commissioning will be replaced by an improved planning system. The number of Local Health Boards in Wales will be reduced from 22 to eight and funding will be provided directly from the centre to NHS Trusts and to Local Health Boards. A consultation has recently begun on these proposals. 35. The NHS in Wales has given particular emphasis to an integrated approach to public health. The National Public Health Service for Wales acts as an advisory body to local health boards and local councils. 36. In England, there has been a strong emphasis since the publication of The NHS Plan, in 2000, on achieving improvements in the quality and performance of health services through a significant programme of investment and reform. This has been underpinned by a range of national targets, particularly in areas like waiting times.
Waiting Times 37. The following table sets out diVerences in the targets that have been announced for hospital waiting times between England and Wales.
ANNOUNCED WAITING TIMES TARGETS:
2005 2006 2007 2008 2009 Max Outpatient wait from referral to first outpatient appointment England 13 weeks Wales 12 months 8 months 22 weeks 10 weeks Inpatient and daycase wait from decision to treat to admission England 6 months Wales 12 months 8 months 22 weeks 14 weeks Whole patient journey from GP referral to start of treatment England 18 weeks Wales 26 weeks
38. It is diYcult to make direct comparisons on hospital waiting times between the two countries due to the diVerences in recording information, and diVerent targets and timings. In England, the key figures to note on waiting times are: — For inpatients/day cases, at February 2008 11,547 people had been waiting longer than 18 weeks. In terms of longer waits, 179 people had been waiting over six months. — For outpatients 677 people had been waiting over 17 weeks at February 2008 for their first outpatient appointment. — On cancer waiting time, 97.1% of those referred for cancer treatment were seen within 62 days. — On A&E waiting 97.9% of patients were seen within the four hour target in the year ending March 2008. 39. There are diVerences in the governance, incentives and structural approaches between the two countries in the way the NHS is run. These are summarised in the following table.
4 NB: The majority of prescriptions in England are exempt from charges on grounds of age or need 5 Welsh Assembly Government One Wales: A progressive agenda for the Government of Wales; June 2007 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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SUMMARY OF DIFFERENCES IN STRUCTURES/SYSTEMS:
Aspect of the system England Wales Governance model Increasingly decentralised system, Consultation document proposes with separation of many decision- changes to governance model in which making responsibilities, though still NHS Trusts and (a reduced number core Ministerial accountability. of) Local Health Boards will receive Key targets and priorities set funding directly from and be nationally, but with local flexibility to accountable to Ministers through a decide priorities beyond national National Health Service Board for requirements. Wales. Service delivery Diversity of provision, including The NHS delivers services through greater independence and autonomy Local Health Boards (LHBs) and for state-owned providers (NHS NHS Trusts across Wales. foundation trusts); and the growing Consulting on proposals to abolish use of the private and voluntary the Internal Market. Welsh Assembly sector. Governmnent emphasises cooperation Choice, competition and rather than competition as the contestability support performance bedrock of public service delivery. and quality improvement. Commissioning PCTs commission services to meet the Local commissioning by a single body needs of their population according to for the full range of health services quality, capacity, waiting times etc will cease under proposals in the from a range of providers. consultation document. A system of Payment by Results has Emphasis to be on planning rather been introduced with a standard tariV than commissioning services or for a wide range of procedures. patient choice. A standard NHS Contract is in use for hospital services; equivalents are being developed for other services. GPs are placed at the centre of decisions on redesigning services through Practice Based Commissioning. Patient choice is expected increasingly to incentivise high performance. NHS Choices website provides quality indices and facilities information to inform patient choice and referrers. Audit/Review System-wide monitoring and The Welsh Assembly Government performance measures. Comparative monitors the performance of the NHS and developmental measurement. through various measures and The independent Healthcare standards. Organisations provide a Commission undertakes annual health quarterly balanced scorecard report to check on NHS providers and provides the Welsh Assembly Government. a publicly available, easily comparable Healthcare Inspectorate Wales is rating. responsible for reviewing the quality The independent Healthcare and safety of patient care Commission also registers and reports commissioned and provided by on the performance of private healthcare organisations in Wales. It healthcare providers. endeavours to support and encourage continuous improvement in the New independent Care Quality provision of health services. Where Commission will register all health there are specific concerns, it has the and adult social care providers in the powers to undertake special reviews same way whether public, voluntary and investigations. or private. NHS Choices website provides quality indices (with an increasing focus on clinical quality and safety), not just for services subject to patient choice. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Aspect of the system England Wales
Independent sector bodies (eg CHKS and Dr Foster) also provide information on organisational and individual performance. Clinical NICE technology appraisals, clinical NICE technology appraisals and guidelines and public health guidance clinical guidelines apply, but not applies. NICE looks at the most public health guidance. important new drugs and issues “gold standard” advice to the NHS in England (and Wales), which has statutory force. National Service Frameworks set out clinical good practice and standards in key areas.
40. One of the main diVerences in social care policy is the establishment of a post of Commissioner for Older People in Wales. There is no equivalent post in England.
Mechanisms for Identifying and Resolving Cross-border Deficiencies 41. A number of mechanisms exist for addressing cross-border service issues. 42. The fact that the English system of Payment by Results does not apply to Welsh commissioners using English hospitals, or to English commissioners using Welsh hospitals, has given rise to some tensions between a number of providers and commissioners regarding the agreement of appropriate prices for services. 43. The diVerences in entitlements for patients in the English and Welsh systems also has implications for patients who live on one side of the border and are registered with a GP on the other which need to be considered. 44. A group of oYcials from the Department of Health and Welsh Assembly Government has been formed, with support from the NHS and the Wales OYce, to address these matters. Consideration is being given specifically to issues such as the funding arrangements for Welsh patients who use English hospitals. (For example around 20% of the activity of the Countess of Chester hospital relates to Welsh patients not covered by the tariV system). Arrangements for resolving disagreements between providers and commissioners are also being reviewed. Discussion also takes place at ministerial level. 45. A range of formal and routine mechanisms are also in place to bring oYcials and NHS managers and clinicians together on specific policy issues.
Moving Forward 46. Devolution has provided a tremendous opportunity for each part of the UK to innovate and experiment with diVerent models for the provision and organisation of healthcare services, within a common framework of NHS principles. It is for the Welsh Assembly Government to determine its own health policies and priorities to meet the needs of people in Wales and we welcome the opportunity to learn what is successful in their diVerent approaches, and in the approaches adopted in Northern Ireland and Scotland. 47. The Department of Health is committed to continue to work closely with the Welsh Assembly Government and with the NHS in England and Wales to ensure that patients receive the best possible care and that taxpayers obtain the best value for the use of NHS resources on both sides of the border. Patients will not be disadvantaged as a result of any of the diVerences in the two systems. Department of Health May 2008
Annex 1
PROTOCOL FOR CROSS-BORDER HEALTHCARE COMMISSIONING BETWEEN THE HEALTH AND SOCIAL CARE DEPARTMENT, WELSH ASSEMBLY GOVERNMENT AND THE DEPARTMENT OF HEALTH 1. This protocol sets out the agreed procedures for commissioning NHS healthcare to residents in England who are registered with a GP in Wales and for residents in Wales who are registered with a GP in England. The protocol only applies to those residents living along the England and Wales border covered by the following Local Health Boards (LHB) and Primary Care Trusts (PCT): Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Local Health Boards Bordering England Primary Care Trusts Bordering Wales Flintshire Shropshire County Wrexham Herefordshire Powys West Cheshire Monmouthshire Wirral Denbighshire Gloucestershire
For patients resident elsewhere in England or Wales who are registered with a GP on the other side of the border, their healthcare commissioning will remain based on the PCT or LHB where the patient defines their usual place of residence. For the purpose of the protocol the definition to be used is at Annex 2. The systems for identifying the responsible commissioner between PCTs within England and between LHBs within Wales remain the same.
Duration of Protocol
2. The protocol will take immediate eVect and will run until 31 March 2009, after which time commissioning responsibility between the two countries will revert to the residency based responsibility, unless the protocol is renewed.
Responsibilities
3. In compliance with SI 2003 No 150 (W20) LHBs will retain responsibility for their resident population who are registered with a GP in England. However until 31 March 2009, the PCT will be responsible, on the LHB’s and HCW’s behalf, for the commissioning of healthcare services to those residents. 4. In compliance with SI 2003 No.1497, PCTs will retain responsibility for their resident population who are registered with a GP in Wales. However the LHB (and for specialised services, the HCW) will be responsible, on the PCT’s behalf, for the commissioning of healthcare services to those residents. 5. This protocol does not aVect the protocol currently in place for cross-border NHS funded nursing care in care homes in Wales and England, which is based on the care home’s location.
Criteria
6. The following table summarises the commissioning responsibility and responsible body.
Residency GP Location Commissioning Responsibility Legally Responsible Body Wales Wales LHB/HCW LHB/HCW England England PCT PCT Wales England PCT LHB/HCW England Wales LHB/HCW PCT
7. LHBs and HCW, acting on the PCT’s behalf for English residents registered with a Welsh GP, will commission on the basis of clinical need and, as a minimum, the Welsh Assembly Government’s standards for access to healthcare irrespective of the location of the provider. 8. PCTs, acting on the LHB’s and HCW’s behalf for Welsh residents registered with an English GP, will commission on the basis of clinical need and, as a minimum, on the basis of the Department of Health’s standards for access to healthcare irrespective of the location of the provider. However if a patient chooses to be seen and/or treated at a hospital in Wales having been oVered an appointment or admission within the Department of Health’s standards, they will be excluded from the Healthcare Commission’s performance rating assessment.
Financial Consequences
9. In carrying out this protocol there will be no financial shortfall on the part of any responsible commissioner to provide healthcare services to the other country’s residents. To ensure this financial recording arrangements will be agreed between the Health and Social Care Department of the Welsh Assembly Government and the Department of Health with a view to a timely and appropriate adjustment of finances. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Performance Management Arrangements 10. For Wales this will be based on residency. 11. For England this will be based on the commissioner monthly returns.
Reaching Agreement on the Responsible Commissioner 12. Where there is a uncertainty about who is the responsible commissioner, LHBs/HCW and PCTs need to work together to reach agreement speedily and fairly. 13. The patient’s safety and well-being must be paramount at all times. No treatment must be refused or delayed due to uncertainty or ambiguity as to which commissioner is responsible for funding the healthcare provision. If a Trust has admitted patients to its hospital there should be an automatic assumption that treatment would proceed. Until such time as agreement is reached, the commissioner responsible for the immediate care of the patient should be based on: — the last known GP registration, for the named Local Health Boards and Primary Care Trusts in the protocol, and the usual place of residency for others; or — if no such information is available at the time, the commissioner should be the one where the patient is currently residing. 14. Undertaking the commissioning role in these circumstances would not prejudice the final agreement. 15. The process by which local commissioners will reach agreement is as follows: (It is not intended to use this procedure to reach agreement on issues outside this protocol however a similar process may be applied more widely if the Service Level Agreements and Long Term Agreements do not adequately meet need).
Maximum timescale
Stage 1. Local resolution The LHB or Health Commission Wales and the PCT must try to reach an agreement locally on which is the responsible commissioner using the joint guidance from WAG and DH. All reasonable eVorts must be made by oYcers (escalating to Chief Executives and finally to Chairs if necessary) of the LHB and PCT or Health Commission Wales to reach agreement locally.
Stage 2. Resolution at Regional/Strategic Health Authority Level Week 4 (i) In exceptional circumstances, the LHB/HCW and the PCT Chief Executives may agree that they cannot reach local agreement and so decide to refer onto the relevant Regional Director of the Health and Social Care Department’s Regional OYce and the SHA. In a case involving HCW the matter should be referred to the Regional OYce in whose area the patient is either residing or registered with a GP. (ii) The joint submission should provide the following information at Regional referral: — a background summary of the patient’s case; — confirmation that the patient’s care is not at risk; — who is currently taking responsibility for the patient; — the reason why the commissioners are in disagreement as to who is responsible for funding the patient’s healthcare; and — what has been done to try and resolve matters. Discussion will take place between the Regional OYce and the SHA to resolve the issue based on the facts and guidance. The decision will be final and binding on both commissioners. A joint letter advising of the decision will be issued to both the commissioners.
Stage 3. National Level Week 12 In the extra-ordinary event of an agreement not being reached between the Regional OYce and the Strategic Health Authority by week 12 guidance should be sought from the respective central policy departments. Both departments will liaise with one another to agree the policy interpretation for the case and provide joint advice to both the Regional OYce and Strategic Health Authority to ensure a resolution is achieved. Week 14 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Annex 2
PROCEDURE FOR CROSS-BORDER HEALTHCARE COMMISSIONING BETWEEN ENGLAND AND WALES: Defining usually resident for the purpose of establishing the responsible commissioner within the protocol 1. For the purpose of the protocol, the arbiter of the patient’s residence should be the patient. The principle is that the patients’ perception of where they are resident (either currently, or failing that, most recently) is the criterion. If there is any doubt about where a person is usually resident, the person shall be treated as usually resident at the address given by him or her to the person or body providing him or her with the services. Where a person doesn’t give such an address, he or she shall be treated as usually resident at the address which he or she most recently gave to the person or body providing the services. 2. Where a person’s usual address cannot be determined in such ways, the person shall be treated as usually resident in the area in which he or she is physically present. Certain groups of patients may be reluctant to provide an address. It is suYcient for the purpose of establishing financial responsibility that a patient is resident in a location (or postal district) within the LHB/PCT geographical area, without needing a precise address. Where there is any uncertainty, the provider should ask the patient where they usually live. Individuals remain free to give their perception of where they consider themselves resident. Holiday or second homes are not considered as “usual” residences. 3. By way of illustration, if patients consider themselves to be resident at an address, which is, for example, a hostel, then this should be accepted. If they are unable to give an address at which they consider themselves resident, then the address at which they were last resident could be used. 4. Where a patient is unable to, or incapable of, giving either a current or most recent address and an address cannot be established by other means eg by the next of kin advising of the patient’s address, then a patient’s district should be taken as being that in which the unit providing the treatment is located. 5. Special rules apply in relation to the usual residence of prisoners. The responsible commissioner for the commissioning of psychiatric care for people transferred from prison to hospital under sections 47 or 48 of the Mental Health Act will be on the basis of their GP registration prior to sentencing for LHBs and PCTs named in the protocol and district of residence for the other commissioners. This also applies to patients subject to court hospital orders under Sections 35-38 of the Act. For prisoners not registered with a GP and for whom a previous address cannot be determined, usual residence should be interpreted as being in the area in which the oVence was committed, or if pending a trial, the area where the alleged oVence was committed. (Reference: DH Guidance on Responsible Commissioner issued July 2003.)
Supplementry memorandum submitted by the Department of Health 1. The Department of Health makes an annual transfer to the NHS in Wales to cover the costs of English residents registered with Welsh GPs. This amounted to £5.6 million in 2007–08. 2. The transfer covers the cost of the net flow of cross-border patients, ie the number of English residents registered with Welsh GPs minus the number of Welsh residents registered with English GPs. 3. It covers the cost of Hospital and Community Health Services (HCHS) for these patients but excludes the cost of primary care and prescribing, because funding for these services has always been on a registered, rather than resident, population basis. 4. The net flow of patients from England to Wales is about 5,000 patients. 5. The Department of Health is discussing with the Welsh Assembly Government a proposal to replace this annual block transfer arrangement. The funds would be allocated to the PCTs concerned to enable them to reach local agreements with the relevant LHBs. May 2008
Letter from the Minister of State for Health Services to the Chairman I promised to drop you a note regarding whether there should be a national (UK) fund for commissioning super-specialised services for people with muscular dystrophy. The National Commissioning Group (NCG) commissions 40 highly specialised services from a small number of English hospitals for English patients with rare conditions or who need rare interventions. The NCG also commissions services for the residents of Scotland, Wales and Northern Ireland under specific contractual arrangements with the Devolved Administrations. There is no mechanism for services to be commissioned on a UK basis. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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For a service to be nationally commissioned by the NCG it will usually involve fewer than 400 patients and, in order to concentrate expertise, be provided in two to four centres in the country. This often means that patients have to travel long distances to receive their specialist treatment. In some cases, the specialist centre is able to see patients and then advise more local services about the most appropriate ongoing care and treatment pathways. The Report “Building on the Foundation: Focus on Physiotherapy” notes that there “Over 1,000 children and adults for every 1 million of the population are aVected by muscle wasting neuromuscular conditions in the UK”. Given the numbers of individuals involved, Specialised Commissioning Groups are best placed to commission services for patients with this group of conditions. South West Specialised Commissioning Group (SCG) has responded promptly to concerns regarding the level of service provision in the South West as expressed in the Muscular Dystrophy Campaign’s (MDC) document “Building the Foundations: the Need for a Specialist Neuromuscular Service in England” (December 2007). South West SCG has, as part of a project to raise standards of care for MD patients, established a stakeholders group which includes commissioners, clinicians, healthcare professionals and patients plus representatives from the MDC charity. The group’s first task is to identify gaps in local service provision. The ultimate aim will be to put in place a more complete care pathway in the South West for patients with muscular dystrophy. Ben Bradshaw MP July 2008
Letter from the Minister of State for Health Services to the Chairman You requested a response to two claims made by the Muscular Dystrophy campaign. Diagnostic data is collected from all NHS providers in England on a regular basis. Data is collected on 15 key diagnostic tests on a monthly based and a census takes place every quarter covering all diagnostic tests. Data is also collated for all English commissioners on the 15 key diagnostic tests on a monthly basis so that those patients not being seen in an English provider will be included in these figures. The diagnostic waiting times for each test are published regularly and are available at the following website http://www.performance.doh.gov.uk/diagnostics/index.htm The waiting times data published on the Department of Health website covers all patients waiting at a particular organisation irrespective of whether the test has been commissioned by a commissioner in England or Wales. Therefore it is not true to say that the data for Welsh patients is kept separate. Whilst Welsh patients are not separately identifiable the data for all patients waiting at English NHS providers is being revealed to the public. Departmental analysts would be happy to provide more detail on this if you would find this helpful. The Healthcare Commission protocol refers to how the data should be treated when the commission is assessing the delivery of healthcare by English NHS provider to patients for whom English commissioners are responsible. In this particular set of circumstances it is right and proper that patients who are not the responsibility of English commissioners are excluded from the assessment. It is also worth noting the Healthcare Commission indicator for diagnostics, and for referral to treatment, applies to patients for whom English PCTs are responsible and awaiting NHS-funded treatment therefore it will capture those patients crossing of border and receiving their tests, or care, outside England. I hope this reply is helpful Ben Bradshaw MP July 2008
Letter from the Minister of State for Health Services to the Chairman You asked about mechanisms for commissioning services on a UK-wide basis, and how the National Commissioning Group in England links with the devolved administrations. There are no formal UK-wide commissioning institutions because commissioning responsibilities are devolved. However, there are a range of UK-wide arrangements and relationships. The National Commissioning Group commissions a small group of services on behalf of the residents of Wales, Scotland and Northern Ireland, for example, choriocarcinoma, craniofacial, and liver transplants. These are longstanding agreements that date back to before 1991. The funding for these is in the NCG baseline. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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The NCG commissions a larger number of services on behalf of Scottish residents. They have a contract with the National Services Division of NHS Scotland for these services and invoice them on an annual basis. Representatives from each of the devolved health bodies (service commissioners) sit as observers on the National Commissioning Group. Representatives from each of the DAs also sit as observers on the overarching National Specialised Commissioning Group. A representative from the National Specialised Commissioning Team sits as an observer on the National Services Advisory Group, which is broadly equivalent to the National Commissioning Group. Given the sizes of the populations of the DAs, there are also key linkages between the DAs and the 10 English Specialised Commissioning Groups (which each have an average population of five million). To this end, representatives from each of the devolved health bodies sit on the Specialised Commissioning Group Directors’ Network, a group co-ordinated by the NSC Team. This cross-representation allows for significant dialogue between the English specralised commissioning function and those of the DAs. Outside of these meetings, there is considerable co-operation and joint working at both a policy and sometimes, individual patient level. Ben Bradhaw July 2008
Memorandum submitted by Flintshire and Wrexham Local Health Boards The response from Flintshire and Wrexham LHBs regarding evidence in support of the inquiry into the provision of cross-border public services for Wales is set out below. Flintshire and Wrexham LHBs were established as statutory bodies as from 1 April 2003.
1. The extent to which cross-border health and social care services are currently provided for and accessed by the Welsh population 1.1 LHBs, as set out in the establishment regulations, are responsible for patients who are “usually” resident in their area. 1.2 LHBs are responsible for assessing health need, planning and commissioning health services on behalf of all persons who are usually resident (as defined in the regulations) in the area, except for those specialist services (as set out in the regulations) which are the responsibility of Health Commission Wales (HCW). 1.3 There have been long standing links between North Wales and the North West of England with respect to the provision of health services at individual, population and clinical level.
1.4 Primary Care Services 1.4.1 For the majority of residents there is no diVerence between their country of residence and GP registration. However there are a significant number of residents from Flintshire and Wrexham who are registered with GP out of county—likewise there are patients registered with Flintshire and Wrexham GPs who are resident out of county. Choice of GP is available to individuals regardless of residency.
The position as at 1st October 2007 was as follows:
Wrexham Flintshire English Patients with a Welsh GP 6,181 594 Welsh Patients with an English GP 3,335 4,769
1.4.2 GMS Out of Hours 1.4.2.1 The GMS Out of Hours Service for Wrexham is provided by Shropdoc 1.4.2.2 The GMS Out of Hours Service for Flintshire is provided by Flintshire LHB 1.4.2.3 As from 1 April 2008 a new service, NEWDoc, based at Deeside and Wrexham, will provide GMS Out of Hours Services for both Wrexham and Flintshire. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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1.5 Community Health Care Services
1.5.1 Community health care services are commissioned from North East Wales NHS Trust for the populations of Wrexham and Flintshire.
1.6 District General Hospital Services
1.6.1 Secondary Care (DGH) services are commissioned mainly from the North East Wales NHS Trust (Wrexham Maelor Hospital), Conwy and Denbighshire NHS Trust (Ysbyty Glan Clwyd), Countess of Chester Hospital NHS Foundation Trust, and the Robert Jones and Agnes Hunt Hospital (Gobowen). Appendix A identifies the full range of Hospital Services which are commissioned and delivered on behalf of North Wales residents where the value exceeds £250,000. As will be noted from this information there is a significant flow of patients into England for care, and the associated resources flow from LHBs to Trusts in England. 1.6.2 Unlike the position within Wales itself, LHBs currently commission services from England on a registered GP population basis for out-patient, in-patient and day case services. The imbalance of patient numbers commissioned on this basis is clearly shown in paragraph 1.4.1. 1.6.3 A & E services are commissioned by the host LHB/PCT, ie, LHBs commission A & E services in Wales and PCTs commissionA&Eservices in England irrespective of residency of user. 1.6.4 Access to services is via GP referral for planned care. Emergency access is via A&E, GP referral or emergency ambulance.
1.7 Specialist Tertiary Services
1.7.1 Health Commission Wales are responsible for commissioning specialist services for the whole of Wales, including many specialist centres throughout England. Health Commission Wales will be able to provide all contract details.
1.8 NHS Funded Nursing Care and Continuing Health Care
1.8.1 The independent care sector accepts placements from both English and Welsh counties, small numbers from Ireland and elsewhere. Placements may be residential, NHS funded nursing care or Continuing Health Care (CHC). Each placement has implications for the LHB in relation to primary and secondary care, prescribing as well as NHS funded nursing care and CHC fees. NHS Funded Nursing Care is the commissioning responsibility of the county within which the home is situated, continuing health care responsibility is based on patient residency. Patients whose care needs change and who are subsequently eligible for CHC are then the responsibility of the area within which their residential/ nursing care is provided. 1.8.2 There is an increasing trend in homes specialising around certain client groups, ie, neurological degenerative conditions, mental health, young disabled etc. These homes will often attract a patient flow across the border. 1.8.3 Similar situations exist for children’s homes with children often being placed across the border to meet their care needs. Recent changes in regulations require that the specialist health needs of children in such placements are to be met by the LHB/PCT from whose area the child is placed.
2. The arrangements currently in place to co-ordinate cross-border service provision
2.1 The LHBs in North Wales have identified a lead LHB commissioner for secondary care contracts (as set out in Appendix A). The lead is responsible for establishing arrangements for contract monitoring and commissioning discussions. This avoids significant duplication of eVort and streamlines communication with providers. The detailed service discussions with providers vary according to the nature of each contract. Issues arising from these contracts which aVect all LHBs are discussed on a monthly basis. 2.2 There are several Clinical Networks established across North Wales that naturally link into Networks within England. For example, the Cardiac Network has well defined links and service relationships with the Cardio Thoracic Centre at Liverpool, and the North Wales Cancer Network has established links with the North West Cancer Network. Links have also been established between the North Wales and Cheshire and Mersey Critical Care Networks. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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3. The commissioning, funding and quality of cross-border services
3.1 LHBs are funded via WAG allocations to deliver services for their resident population within Wales. They also receive an allocation for patient flows to English providers. This allocation is based upon historic data relating to GP registrations across the border, which varies from current registration patterns over time. 3.2 Services are commissioned via contracts agreed between the commissioner (LHB) and provider (Trust). These contracts are generally block and cost and volume contracts with any activity change resulting in a resultant marginal cost change in the contract reflecting the additional cost of service delivery. 3.3 Each new service commissioned by the LHB, whether it be based in England or Wales, is made on the basis of health needs and evidence of clinical eVectiveness. All commissioning decisions of major services are ratified by the Board. 3.4 Flintshire and Wrexham LHB monitor closely the referral patterns of all of its GP practices, including the number of referrals being sent to English Trusts. These referrals do form part of the monitoring arrangements set by the Welsh Assembly Government for eYciency and productivity. 3.5 Services are commissioned in line with identified local need and in order to meet Welsh Ministerial targets and priorities. 3.6 Where the LHB is the minority commissioner of services (as with English providers), we will commission services in line with the main commissioner’s quality requirements unless there are specific Welsh requirements..
4. The extent to which health and social care policy has diverged across the UK since the introduction of devolution, and the impact that this has had
4.1 A number of policy initiatives have led to divergence which has led to an increased administrative complexity and occasional confusion. These include: 4.1.1 DiVerent basis of funding/allocation of resources The Department of Health and Welsh Assembly Government determine allocations to LHBs and PCTs using their own distinct formulae approach. LHBs commission services on the basis of allocations as determined by Welsh Assembly Government. 4.1.2 Organisational form/responsibility NHS Wales is structured with LHB as commissioners of health care on behalf of its population except for specialist services which are provided by Health Commission Wales. Hospital and Community Services are provided by integrated Trusts. There are no Foundation Trusts in Wales. 4.1.3 Waiting times Although there is a diVerence in the maximum waiting time targets between England and Wales patients are treated on the basis of clinical need and the majority of patients are treated well within the maximum waiting time targets. 4.1.4 Patient choice/patient voice Hospital care for Welsh residents is accessed by a GP referral following discussion with their GP. 4.1.5 Free prescriptions As from 1 April 2007 free prescriptions were introduced by the Welsh Assembly Government. Welsh residents with a Welsh GP who have the prescription dispensed in Wales receive free prescriptions. Welsh residents with an English GP receive an Entitlement Card which allows them to obtain all prescriptions free when dispensed in Wales. Welsh residents who are referred for treatment to an English hospital, or receive dental care from an English dentist, will have to pay the prescription charge if they receive an English prescription, irrespective of whether the prescription is dispensed in England or Wales. 4.1.6 DiVerent contract currencies and payment methodologies Wales has not adopted the Payment By Results commissioning directive. Wales does not in general pay for English services by this tariV approach, nor in general do English PCT pay PBR tariV rates to Welsh provider Trusts. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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4.2 The position is that both commissioners and providers of health care seek to ensure that patients are treated on the basis of clinical need and any diVerences in policy between England and Wales are managed in order to ensure that any impact on patients is minimal.
5. The extent to which mechanisms are in place for identifying and resolving cross-border deficiencies
5.1 Regular contract monitoring/commissioning meetings are in place to discuss main issues at LHB/ Provider level.
5.2 There are clear protocols in place which have been agreed by the Department of Health and Welsh Assembly Government for dealing with any contractual issues between commissioners and providers.
5.3 We are aware that there are arrangements between the Welsh Assembly Government and the Department of Health to discuss the implications of policy diVerences, including any financial issues. March 2008
Annex
SUMMARY OF 2007–08 CONTRACTS (£250,000
North Wales Providers
Summary 2006–07 Lead LHB Provider Contract Value Total OP Elective Emergency £ IPDC Gwynedd/Anglesey North West Wales Trust 193,623,341 158,852 25,646 23,763 Denbighshire/Conwy Conwy & Denbighshire Trust 194,597,633 200,310 46,686 22,823 Wrexham/Flintshire North East Wales Trust 174,708,923 191,530 21,268 19,772
Non North Wales Providers
Provider Contract Value £ Anglesey CardiV & Vale 273,179 186 32 37 Gwynedd Ceredigion & Mid Wales 2,823,290 3,336 850 822 Gwynedd Powys Healthcare 469,326 772 22 19 Flintshire Aintree Hospitals 420,886 912 371 115 Flintshire Countess of Chester (including PHLS) 18,234,555 49,375 9,706 8,001 Conwy Liverpool Womens Hospital 579,925 1,014 375 10 Wrexham RJ & AH (Gobowen) Hospital 11,214,57 13,515 3,013 236 Conwy Royal Liverpool University Hospital 2,115,761 3,204 689 159 Conwy Royal Liverpool University Hospital 575,358 Included in above figures CPC (Blood Products, Vascular Surgery & PDT) Wrexham Shrewsbury & Telford NHS Hospital 440,929 Data not 246 106 Trust available Wrexham South StaVordshire PCT 253,511 Data not available Anglesey Southport & Ormskirk Trust 516,569 72 2 14 Gwyneed South Manchester University Hospitals 617,355 674 221 68 Flintshire Wirral NHS Trust 644,160 1,178 161 117
Supplementary memorandum submitted by Flintshire and Wrexham Local Health Boards
Further to the oral evidence given by Andrew Gunnion and myself on 31 March, we have, as requested by the Committee, sought information regarding the relative waiting times positions between Wales and England prior to devolution.
The attached Statistical Bulletin was produced by the Welsh OYce in November 1997 and shows the diVerence in patient numbers experiencing long waiting times from England and Wales. This shows clearly the diVerential position that existed at that time. We trust that this information is of help. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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COMPARISON OF ENGLAND AND WALES WAITING LISTS (RESIDENT BASED)
Waiting Lists by Time Band—England (Resident Based)
Month Waiting time All patients Less than One year to More than one year 18 months 18 months (000s) (000s) (000s)
31 March 1997 1,101.0 30.1 143 1,131.2 31 March 1998 1,209.8 67.2 0 1,277.0 30 June 1998 1,199.3 72.1 0 1,271.4 31 July 1998 1,183.6 68.9 0 1,252.4 31 August 1998 1,164.3 65.2 1 1,229.5 30 September 1998 1,137.7 63.0 0 1,200.7
Waiting Lists by Time Band—Wales (Resident Based)
Month Waiting time All patients Less than One year to More than one year 18 months 18 months
31 March 1997 61,335 4,872 1,402 67,609 31 March 1998 65,417 5,882 2,120 73,419 30 June 1998 65,866 6,497 2,784 75,147 31 July 1998 66,164 6,579 3,207 75,950 31 August 1998 66,443 6,334 3,239 76,016 30 September 1998 64,602 6,357 3,310 74,269
— Between the end of August 1998 and the end of September 1998 the English list fell by 2.3%; the Welsh list also fell by 2.3% during this month. — Between the end of March 1998 and the end of September 1998 the English list fell by 6%; the Welsh list rose over the same period by 1.2%. — At 30 September 1998 there were no English residents waiting over 18 months; there were 3,310 Welsh residents waiting over 18 months. — Patients waiting over 12 months accounted for 5.2% of the English list, but 13% of the Welsh list at the end of September 1998. — The English list at the end of September 1998 was 6.1% above the level at the end of March 1997; the Welsh list was 9.9% above the level at 31 March 1997. April 2008
Supplementary memorandum submitted by Flintshire Local Health Board
THE PROVISION OF CROSS-BORDER HEALTH SERVICES FOR WALES: INTERIM REPORT I refer to the publication of the above report, and only have a couple of comments to make surrounding funding responsibilities. Paragraph 39 onwards highlights the diVerences in financial regimes between England and Wales. Whilst the major issues are identified, issues such as the diVerences in commissioning responsibility for services such as Accident and Emergency access and certain other self referral services are also an issue. These paragraphs tend to focus on hospital care, and it would be fait to point out that, admittedly minor, concerns have been raised on certain primary care services as well, dental for example. Colin Jenn Director of Finance Flintshire Local Health Board Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Gloucestershire Partnership NHS Foundation Trust
CROSS-BORDER SERVICES—WALES
Services that we Provide
General Service Level Agreement (SLA) Contracts We only have one and that is with Monmouthshire LHB. This SLA covers any patients with a Monmouthshire GP that are referred to us for access to any of our 5 Strategic Service Units (Specialty Care Groups: Adult MH, Substance Misuse, Child & Adolescent, Older Age Adults and Learning Disabilities). It also covers all of our Points of Delivery (Inpatients, Outpatients and Community). These contracts are agreed at an annual contract meeting between us and the LHB with formal documentation drawn up afterwards.
Individual “Named” Patient SLA’s We have had three individual patient SLA’s for patients staying in our Low Secure Unit (Adult MH). These are with: Gwent Healthcare NHS Trust, Bridgend LHB and Rhondda, Cynon, TaV LHB These contracts are usually agreed by e-mail with confirmation of our daily rate and that the commissioner is agreeing to payment (on the clinical side there are obviously the necessary procedures undertaken). The Welsh commissioners are also asked for an authorisation code. We do not have any problems with either of these contracts.
Non-Contractual Agreements These are picked up from our information systems, which produces exception reports for all patients without a “local” Gloucestershire GP. These are then collated and a single invoice raised to each commissioner each quarter. The problem we have with these contracts is that the Welsh Assembly (unlike the DoH) will only recognise emergency treatments for payment and will not make any payment for elective activity, unless the trust has got permission to treat (with authorisation code) in advance of contact/admission. Generally contacts are only identified and subsequently invoiced after the event.
Health Contacts to patients placed into Gloucestershire Residential Homes by Welsh Authorities (Establishing the Responsible Commissioner guidance) Where people with Learning Disabilities have been placed by their LA into a residential home, and that placing authority have undertaken to fully fund that placement for the life of that person (or as long is necessary with that ongoing medical condition), we invoice the PCT/LHB or LA for any contacts that our specialist Learning Disability teams makes to that person. (As our teams are specialist any referral to them is deemed to be linked to a high care need). There are two main problem areas with this: — With some organisations there is dispute as to the interpretation of the guidance. — With the Welsh there is the additional argument as to residency, where they judge responsibility not by GP (and thus PCT) as under DoH but by where geographically the person resides. (So some of the Welsh authorities are arguing that as the “patients“ are resident in England, then they aren’t responsible for them). Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Gloucestershire Partnership NHS Foundation Trust Agreed and Paid/Paying 2006–07 2007–08 £000’s £000’s Patient Specific Contracts—Low Secure Unit Rhondda, Cynon TaV LHB Admitted 17 January 2007 Discharged 23 August 2007 38.2 76.8 Gwent Health NHS Trust Admitted 12 January 2007 39.3 186.7 Bridgend LHB Admitted 21 June 2007 0.0 151.0 77.6 414.5 General Service Level Agreement/Long Term Agreement Monmouthshire LHB 211.0 216.3 Non-Contractual Agreements Neath Port Talboth LHB 1.4 0.0 Health Contacts to patients placed into Gloucestershire Residential Homes by Welsh Authorities Powys LHB 6.4 7.2 Total 296.4 638.0 92.8% 99.8% Disputed and Not agreed to Pay Non-contractural Agreements Caerphilly LHB 2.2 0.0 CardiV LHB 14.2 0.0 Powys LHB 0.1 0.0 16.6 0.0 Health Contacts to patients placed into Gloucestershire Residential Homes by Welsh Authorities Carmarthenshire County Council 5.2 1.6 1.2 0.0 6.4 1.6 Gwynedd LHB 23.0 1.6 7.2% 0.2% Totals 319.4 639.6
April 2008
Memorandum submitted by Gloucestershire Primary Care Trust Patients who live on the border between England and Wales can experience diVering levels and entitlements relating to health care depending on a number of factors including: — The GP they are registered with (whether they belong to an English or Welsh practice). — Their postcode.
Waiting Times Welsh Trusts are currently working towards a combined waiting time of 16 months (outpatients and inpatients). English Trusts are currently working towards a combined waiting time of 18 weeks (from referral to treatment).
Choice of Welsh Trust Gloucestershire patients cannot choose to be treated at a Welsh Hospital through the Choose and Book system (which applies to English Trusts only). However, a Gloucestershire GP could choose to make a paper referral to a Welsh Trust. Welsh patients can choose to be treated at an English Hospital, however the Welsh wait time target applies not the English. Hospitals Trusts close to the Welsh border (for example, Gloucestershire Hospitals NHSF Trust) hold contracts with Welsh Local Health Boards where there are patient flows from Wales to England for treatment.
Interventions Not Normally Funded (INNF) Gloucestershire has an INNF policy which applies to patients registered with Gloucestershire GPs. Wales also has a similar policy, but this is managed directly by the Welsh Assembly and applies to the whole of Wales, rather than being the responsibility of individual Welsh Local Health Boards. Therefore, there is the potential for diVerential treatment when looking at available treatment in practices/villages close to the border in Gloucestershire, as this will depend on GP registration. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Patient Transport For a Gloucestershire resident receiving treatment at Gloucestershire Hospitals NHS Foundation Trust, the practice would apply to Great Western Ambulance Service (GWAS) for the transport.If the patient has a Welsh address and needed transport, Gwent Ambulance Service would be approached.
Social Care In Gloucestershire, Social Services are responsible for the population in the “GL” postcode rather than GP registration.
Prescribing Whether a patient pays a prescription charge or not is based on whether they are registered with a Welsh GP, and is not dependant on where the patient lives. Therefore, if patient lives in Gloucestershire but has a Welsh GP address/postcode on the prescription then they will not be charged if this is presented to a Welsh pharmacy for dispensing (but will be charged if this is presented to a pharmacy in England). If a prescription is presented to a Welsh pharmacy with an English GP address on, then whether the patient lives in Wales or England, they will be charged for the prescription.
Screening programmes Gloucestershire responsible patients access screening services run by Gloucestershire Hospitals NHSF Trust. Until recently this service was not available in Wales and practices with both Welsh and English patients would need to identify those eligible for screening. Now Gwent are running a similar service to Gloucestershire. The main diVerence between the service is the screening round lengths. The only exception is retinopathy screening—this is not postcode driven but for all registered at Practice and is now being organised by Gwent for Welsh responsible practices. Breast screening: Gloucestershire PCT oVers breast screening to all women in the county between fifty and seventy years of age. In Wales, breast screening is also oVered to women between 50 and 70 years of age (the upper age limit increased from 64 in 2006). Cervical screening: Women in Gloucestershire between twenty and thirty-four years of age are invited for cervical screening every three years. Women aged between 35 and 64 are invited for cervical screening every five years. In Wales, cervical screening is oVered to women aged 20 to 64 years of age every three years.
Health Visiting The Gloucestershire PCT Provider Arm (Care Services) receives funding from Wales to pay for Health Visiting services across the border. Gloucestershire PCT provide services to the PCT’s responsible population (registered with a Gloucestershire GP), regardless of location, however Welsh services only work within their own geographical area.
District Nursing In-hours: The GPCT District Nursing service may receive contact from patients that live in Gloucestershire but are registered in Wales. If this occurs the patients will be treated as necessary but the DNs will transfer care to Wales when appropriate. Out of hours: For the twilight service, there is a historical arrangement that exists for up to three named patients that live in Gwent and are registered in Wales. If these patients need to access the service this is commonly for assistance with insulin. 15 March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Hafal
1. Background and Introduction to Hafal 1.1 Hafal is the principal organisation in Wales working with people recovering from severe mental illness, their families and carers. Every day our 150 staV and volunteers provide help to nearly 1,000 people aVected by severe mental illness across all the 22 counties of Wales. 1.2 Hafal is run by the people it supports: people with severe mental illness and their families and carers. The charity is founded on the belief that people who have direct experience of mental illness know best how services can be delivered. In practice this means that at every project our clients meet to make decisions about how that service will move forward and the charity itself is led by its 1000 members, almost all of them people with severe mental illness and their carers, and managed by a board of elected Trustees, most of whom have either had severe mental illness themselves or are the carers of a person with a mental illness. 1.3 Hafal has been actively involved in several strategic reviews and forums concerned with mental illness, and which also relate directly to the theme of cross-border public services. Hafal staV, and service user consultants with extensive experience have been key contributors to these. They include the following: (i) the Assembly Government’s Implementation Advisory Group, concerned with the implementation of the National Service Framework and mental health issues generally, (ii) the Welsh Assembly Government Strategic Review of Secure Services in Wales, (iii) the Welsh Assembly Government Review of Mental Health Services, (iv) the Welsh Assembly Government Reducing Re-oVending Task Group. Further information and associated publications produced by Hafal are also available on our website: www.hafal.org
2. Hafal’s Key Points and Concerns in Respect of Cross-border Public Services Relating to Mental Illness 2.1 Acute mental health services: Hafal has no doctrinaire position against the right kind of cross-border provision and understands the context for and supports appropriate cross border arrangements especially in respect of acute mental health services, where these work eYciently and eVectively in the interests of the individual service user: however, in practice such arrangements are by no means always in the interests of service users. In some areas Welsh patients are obliged to access acute mental health services in England, for example, people living in the Welshpool, Montgomery, and Newtown areas of Powys access acute services in Shrewsbury. This arrangement is long–established, and the co-ordination and continuity of care between the two areas appear to work adequately with, for example, staV from Powys regularly attending ward rounds in Shrewsbury. In the recent past, Hafal was commissioned to produce Welsh language materials for Welsh-speaking patients accessing the Trust service in Shrewsbury. In the absence of accessible alternative provision, this arrangement appears to work adequately, and is supported by the Central Wales—West Midlands Cross Border Collaboration Agreement. In North-East Wales patients from Flintshire have previously accessed acute services in Chester but disinvestment from Chester (which is currently being re- invested in new and additional provision in Wrexham) will mean Flintshire residents no longer accessing Chester services. While this investment means improvement in care in Wales, we are told that the Wrexham option does not provide easier access to some Flintshire residents. 2.2 Specialist low secure mental health services: Hafal supports Local Health Boards’ eVorts in actively seeking the repatriation of individuals and investment from low secure provision in England back into Wales, ensuring family and other local social / support networks is key to individuals’ progress to recovery. There is a paucity of low secure provision available to patients in Wales resulting in many people being accommodated in England at some distance from family and other social support networks. It is clear from the experiences conveyed to us by our service users and carers that more low secure provision should be made available in Wales. 2.3 Specialist medium and high secure mental health services: Hafal appreciates issues of proportionality in respect of the number and location of specialist medium and high secure mental health services. However, we strongly argue that there is scope for significant change and improvement in respect of: (i) more sensitive placement of Welsh individuals in existing provision based both on location and level of need and risk, and (ii) the need for some new and additional provision in Wales. There are only three medium secure units in Wales, and no high secure provision. These places are commissioned and funded by Health Commission Wales. As part of the Strategic Review of Secure Mental Health Services in Wales Hafal undertook a survey of Welsh patients in high secure provision in England which highlighted (among other things), a high level of homesickness and issues resulting from the lack of Welsh language facilities. This is the result of being placed so far away from home making it diYcult to sustain family and other social support relationships— in one case, an individual reported not having seen their family for several years because of the distance and cost of transport. In addition, the work called into question whether individuals were suitably placed at the right level of provision in the context of the level of need presented and risk posed. Hafal believes a large number of the patients currently in high secure hospitals in England could be placed in specialised medium secure (or indeed less intensive) provision. The Fallon Enquiry Report (1999) recommended, among other Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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things, that high secure provision should be developed as smaller units across the UK. We also believe that in the future a high secure unit could and should be established in Wales along the lines of this recommendation. 2.4 Criminal Justice System: Hafal is concerned by the need to significantly improve the interface between the criminal justice system and mental health services for the benefit of individuals with serious mental illness who commit oVences—in particular: (i) access to appropriate mental health services and secure provision for individuals with serious mental illness in custody, (ii) the need to divert individuals with serious mental illness away from the criminal justice system (at the point of arrest/sentencing), and (iii) the need to ensure continuity and co-ordination of care on release from prison (especially diYcult for women with mental illness in custody in England). There are four prisons in Wales, all located in south Wales, all of which cater for men only. Welsh women are largely held in custody in HMP Eastwood Park in Gloucestershire, and HMP Styal in Cheshire. Mental illness is a significant issue for many prisoners and Hafal is concerned that significant improvement is required in the criminal justice pathway to divert those with mental illness away from the criminal justice system and into appropriate mental health services at the point of arrest and / or sentencing. Furthermore, once in the criminal justice system, those with serious mental illness should be able to access/be transferred to appropriate mental health services at the point that they are needed/and required. Finally, significant improvements are required in the continuity and co-ordination of care on discharge from prison to ensure a seamless transition back into the community. 2.5 Commissioning: Hafal is concerned by the number and configuration of commissioning bodies responsible for funding mental health services, which is exacerbated by financial constraints and lack of locally accessible provision resulting in perverse incentives which delay transfers to appropriate provision when individuals’ circumstances change. With 22 Local Health Boards, 22 local authorities and Health Commission Wales all responsible for commissioning mental health services and funding individual placements, there is no doubt that the excessive bureaucracy of internal commissioning arrangements in Wales has led to over-use of services outside Wales. Local Health Boards specifically commission Trust services, and low secure provision delivered by Trusts and the independent sector. Health Commission Wales specifically fund medium and high secure services delivered by Trusts and the independent sector. Feedback from our client group and the work undertaken with criminal justice agencies clearly illustrate the diYculties experienced in the communication and co-ordination of activity between Local Health Boards and Health Commission Wales in respect of the transfer of individuals between low and medium secure provision, and between prisons and Health Commission Wales in respect of transfers out of prison to appropriate secure provision. March 2008
Memorandum submitted by Mark Harper MP
Living near a Border
Welsh Local Health Boards plan and purchase health services for the patients of GPs who are registered in Wales, although both patients and GPs can be based in either Wales or England. Funding for Welsh patients is via the Welsh Assembly Government whilst funding for English patients is from the appropriate English Primary Care Trust. There are three notable diVerences between the provision of health care services between England and Wales as follows:
1. Prescription Charges
The Welsh Assembly fund prescription costs for all patients of Welsh-registered GPs whether the patient is resident in England or Wales. These patients do not pay for a prescription so long as it is dispensed at a Welsh pharmacy. Curiously, this includes Welsh-registered General Practices based on the English side of the border (it is not known how this strange state of aVairs came into being). Funding for this comes from the residents English Primary Care Trust.6 The Welsh Assembly do not intend to fund prescription costs of Welsh residents registered with English practices. However, anecdotal evidence does indeed suggest that Welsh residents registered with an English GP can still successfully have a prescription dispensed free at a Welsh pharmacy or even at the GP’s practice if he has a dispensary. There appears little willingness to police the system. In 2006–07 prescriptions cost the Welsh Assembly some £29.5 million.7
6 Allan CoVey Chief Executive Monmouthshire Local Health Board, Private communication, May 2006 7 Mark Harper, Standard letter to constituents re.prescription charges, 2007 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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2. Hospital Waiting Times Target waiting time from GP’s referral to hospital consultation in Wales are set by the Welsh Assembly Government. Target waiting times are lower in England than Wales. By end 2008, English targets are set to be 18 weeks whereas Welsh targets are set to fall to 26 weeks by end 2009. Referrals can be to hospitals based anywhere in the UK and hence hospitals operate multiple waiting lists to accommodate the variable targets and funding provided by the diVerent National Health Boards.8 English patients of Welsh-registered GP’s are subject to waiting times decreed by the Welsh Assembly whereas Welsh patients registered with an English GP are subject to waiting times decreed by the English government. However, it is easy for a Welsh resident to re-register with an English GP to avail themselves of the shorter English waiting times. This appears to be placing burdens on the Welsh Local Health Boards because they have to fund it. Funding for an English resident registered at a Welsh practice is from the residents English Primary Care Trust. The quanta is identical to that provided for those registered with an English practice. Currently, the Department of Health fund English residents on the basis of £1,390/person whilst the Welsh Assembly Government fund Welsh residents on the basis of £1,470/head. Hence, the Welsh Assembly provide extra funding for English residents registered at a Welsh practice—a source of concern for the Welsh Assembly. Therefore, two English patients will experience a diVerence of some eight weeks, depending on whether their doctor is registered in England or Wales, depending on where their GP is registered. GPs in England can be registered in Wales. In 2005–06, English Primary Care Trusts provided Welsh Local Health Boards with some £2.1 million for the English residents registered with Welsh GP’s. UK and Welsh Assembly Government Ministers need to resolve the long standing discussions on transferring responsibility and funding based on where the patient lives, not on where their GP is registered.
Conclusion English people who have to deal with public services in Wales can either be put at a disadvantage with Welsh people, in the case of public transport, or other English people, in the case of healthcare. People very close to each other can therefore find that their experience of public services in border areas is very diVerent. This is a direct result of certain aspects of the devolution settlement. Part of the problem with this system is that English people use Welsh public services in a variety of circumstances, but have no ability to influence services through the ballot box. There is also perceived unfairness in the amount of money that devolved nations get from the UK government and the resulting improved services—for example, free prescriptions in Wales. The Government compounds this problem by referring to national schemes to mean England only, not the UK. Clarity of meaning and communication is therefore also essential. Future developments in the process of devolution need to consider the impact changes in the policy will have on those that live close to the border and how local services in border areas will be aVected.
Memorandum submitted by Hereford Hospitals NHS Trust
THE PROVISION OF CROSS BORDER PUBLIC SERVICES FOR WALES
1. Executive Summary 1.1 Hereford Hospitals NHS Trust provides the full range of District General Hospital services to the population of Herefordshire, mid Powys (Radnorshire), southern Powys (Brecknockshire) and northern Gwent (Monmouthshire). 1.2 The size of Powys’ population and the distribution of that population preclude the development of a dedicated District General Hospital. An analysis of drive times suggests that it would not be practicable to insist that Powys residents access alternatives to NHS England District General Hospitals. 1.3 Activity provided to the Powys Local Health Board is critical to the clinical and financial viability of Hereford Hospitals NHS Trust. 1.4 NHS England and NHS Wales employ diVerent systems for funding hospital care. This is not sustainable. 1.5 Powys Local Health Board seeks to manage the referral process between GP and the Trust. This is not sustainable.
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1.6 There is confusion about the eligibility for treatment in NHS England hospitals of patients resident in Wales and registered with an English GP. 1.7 There is considerable potential for the increased local provision of outpatient, day surgery and diagnostic services in Powys by Hereford Hospitals NHS Trust which is frustrated by a range of problems currently inherent in cross border working. 1.8 With technology enabling hitherto centralised services such as chemotherapy to be devolved to local hospitals such as Hereford, there are benefits in terms of convenience and access for Welsh patients crossing the border 1.9 Recommendations are as follows: — That Welsh patients are encouraged and enabled to access NHS England hospitals where this is in line with ease of access and their clinical needs. — That Local Health Boards (LHBs) remunerate NHS England hospitals using Payment by Results (PbR) tariV payments. — That LHBs do not manage NHS England provider waiting lists. — That Welsh patients accessing NHS England hospitals benefit from NHS England waiting time targets. — That appropriate cross border arrangements for delivery of care in Wales by NHS England providers are encouraged and enabled. — That Welsh patients are encouraged on the grounds of choice and convenience to access services such as chemotherapy where they are decentralised to hospitals close to the border eg Hereford County Hospital.
2. Hereford Hospitals NHS Trust—Profile 2.1 Hereford Hospitals NHS Trust (HHT) provides a full range of District General Hospital (DGH) services ie: — Accident & Emergency. — Emergency medicine and emergency surgery. — Elective (“cold”) surgery. — Non-acute medicine. — Obstetrics/midwifery. — Paediatrics. — Diagnostic services. 2.2 The Trust’s catchment area covers Herefordshire and mid Powys (Radnorshire). A smaller number of patients from southern Powys (Brecknockshire) and Gwent (Monmouthshire) also access their DGH services from the Trust.
3. Issues for Consideration by the Committee 3.1 Powys residents access their DGH care from a number of hospitals in Wales and England. The size of the Powys population base and the distribution of that population do not permit the development of a local DGH. The map at appendix 1 sets out an analysis of travel times from Llandrindod Wells to NHS DGHs in Wales and England. It should be noted that Nevill Hall Hospital in Abergavenny is scheduled to be downgraded within the next five years with services being concentrated to a greater degree in the Cwmbran/ Newport area. It would not be a practicable proposition to require Powys residents who have traditionally accessed HHT to use an alternative Welsh provider. 3.2 Activity undertaken for Local Health Boards accounts for in excess of 10% of HHT’s overall activity and budgeted income. Activity for LHBs and the income this represents are integral to the continuing clinical and financial viability of HHT. 3.3 Increasingly, English NHS Trusts are remunerated on the basis of a predetermined national tariV for each patient under the Payment by Results system. The tariV includes an element for service development, replacement of capital and cover for contingencies. As the tariV system has been expanded, NHS England Trusts increasingly have no access to other sources of income. The PbR system formally does not apply in Wales—instead cross border contracts between LHBs and English providers continue to be based on locally negotiated prices. The consequences for English providers adjacent to the border are diVerential pricing and cross subsidy between contracts. For HHT the position is even more stark: the contract with Powys LHB is £1 million lower than would be the case if the national tariV were applied which eVectively means that English commissioners (primarily Herefordshire PCT) are subsidising Welsh patients. This is not sustainable as an equitable arrangement. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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3.4 The maximum waiting time targets set for commissioners in England by the Department of Health and in Wales by the Welsh Assembly Government are now very diVerent—the 18 week target to be achieved in England by December 2008 is significantly lower than its Welsh equivalent. For a Welsh resident living close to the English border this is particularly emotive because of the close proximity of patients in England who have quicker access to hospital services as a consequence. 3.5 For English providers close to the border, such as HHT, this divergence of policy on access increasingly means running diVerential waiting times and separate waiting lists for English and Welsh residents. This represents a significant administrative burden and an ineYcient use of limited capacity. Indeed Powys LHB as a commissioner has taken this arrangement further as a commissioner by controlling referrals to HHT (in eVect intervening between the referring GP and the consultant) in order to ensure that the maximum wait is achieved and no better, within the agreed contract financial value. This “drip feed” referral mechanism does not make eYcient use of provider capacity. 3.6 The divergence of policy also extends to patient choice which is more fully developed in the English healthcare system, to the extent that “free choice” will be available to all English patients through the Choose and Book system from 1 April. The same opportunity is not available to Welsh residents and any restriction of well established patient flows into England would be in stark contrast to the English choice agenda. 3.7 LHB catchment populations are based on district of residence whilst English Primary Care Trusts catchment populations are based on registration with GP practices. This can result in confusion about the eligibility for treatment in NHS England hospitals of patients resident in Wales and registered with an English GP. 3.8 HHT believes that a greater volume of care can be provided by its clinicians to mid Powys (ie Radnorshire) residents through the decentralisation of outpatient, day surgery and diagnostic services and their provision on an outreach basis in community hospitals (particularly Llandrindod Wells). This would have a number of benefits: — Powys patients would have improved local access to services with a reduced requirement to travel to a DGH. — Patients would have the safety net of a referral to see the same clinician at their catchment DGH in Hereford in the event that more complex treatment were required. — The future viability and cost eVectiveness of Powys community hospitals (an important subject for local residents) would be enhanced. — Services would be better underpinned in terms of clinical governance arrangements. However these benefits for patients in mid Powys can only be achieved if there is an acceptance in policy terms that English providers have a legitimate role in providing services on an in-reach basis in Wales and if appropriately incentivised financial arrangements are developed in support. There will also need to be a collective cross border commitment to overcome practical diYculties eg those associated with establishing IT links. 3.9 The NHS in England recognises that continuing technological advances enable certain services hitherto provided at specialist centres to be devolved to a local setting, thereby improving access for patients. This is particularly pertinent to HHT: for example 90% of chemotherapy services for local residents are now provided at the County Hospital whereas historically patients had to travel to Cheltenham or further to a tertiary centre. HHT is embracing such advances and developing services to meet needs with support from visiting specialist clinicians providing services locally. This decentralised model equally benefits Welsh residents from mid Powys whereas centralisation of services would reduce both choice and access. 3.9 In the same vein, the new national Cancer Reform Strategy for England focuses on travel times to access radio therapy services, recommending a maximum of 45 minutes journey time for treatment. On this basis, the Trust in conjunction with the local PCT is exploring the option of satellite radiotherapy at the County Hospital which would again improve access for Welsh residents.
4. Recommendations The following recommendations for action are respectfully submitted for consideration by the Committee: 4.1 That Welsh patients are encouraged and enabled to access NHS England hospitals where this is in line with ease of access and their clinical needs. 4.2 That LHBs remunerate NHS England hospitals using PbR tariV payments. 4.3 That LHBs do not manage NHS England provider waiting lists. 4.4 That Welsh patients accessing NHS England hospitals benefit from NHS England waiting time targets. 4.5 That appropriate cross border arrangements for delivery of care in Wales by NHS England providers are encouraged, incentivised and enabled. March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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APPENDIX 1
TRAVEL TIMES FROM LLANDRINDOD WELLS, POWYS (30, 60, 90 MIN)
NHS DGH
Powys Community Hospital
Supplementary memorandum submitted by Hereford Hospitals NHS Trust I am pleased to be able to comment on written comments made by Lord Livsey of Talgarth to the Chairman of the Welsh AVairs Committee as set out below: The planning of the PFI hospital in Hereford (which opened in 2002) was predicated on a reduction in beds against the former bed provision. However, in practice, because of increased patient demand and the drive to reduce patient waiting times, we are continuing to operate with 67 beds more than was planned for in 2002. These beds are currently provided in hutted wards but will be replaced in new build provision over the next 18 months or so. As a Trust, we consider the services which we provide for Powys patients to be as important as those provided for Herefordshire patients. With bed numbers at the level I have indicated, we are more than able to accommodate the needs of our Welsh patients both currently and in the future. Indeed, our capacity to do so is being enhanced because of the eVorts we are putting into speeding patient discharge, thereby reducing overall levels of bed occupancy. These points made, we acknowledge Lord Livsey’s point that the treatment of Welsh patients at Hereford County Hospital is complicated by the diVerent waiting time targets that apply in the two countries. Waiting time targets in Wales are higher than in England and Welsh commissioners (Powys Local Health Board Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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included) generally only commission to these targets and no more. In essence, we would be able to treat Welsh patients to the English waiting time targets (18 weeks maximum from referral to treatment by December 2008) if commissioners in Wales were prepared to pay accordingly. Matters would also be simplified if the financial regimes were synchronised with the adoption of payment by results in Wales. This would ensure equity of pricing for cross border services whether provided by English or Welsh hospitals. Welsh patients are hugely important to us at the Hereford County Hospital and we believe strongly that it is in the interests of patients from Powys in particular (but also the Monmouth area) that we continue to provide and develop these services. That is an explicit part of our strategy and we would welcome any initiative by the Welsh AVairs Committee to enhance cross border services. Martin Woodford Chief Executive 15 May 2008
Memorandum submitted by the Institute of Rural Health
Executive Summary The IRH has built up a wide range of knowledge and expertise in rural health and wellbeing. Access to services is the key issue for rural populations and proximity to the England/Wales border has brought additional challenges to patients, commissioners and providers of care on both sides of the border since devolution. Traditional care pathways for rural patients do not follow political boundaries but are determined by geography and its influence on transport systems. The IRH supports access to cross-border specialist services for Welsh patients and believes that this should continue. Health planning should take into account the needs of border populations and how they access care in order to avoid duplication of services and destabilisation of existing services. Evolving health policies should take into account the need for compatible electronic communications, mutually recognised education and training qualifications, the impact of longer referral distances on patient outcomes and appropriate resourcing of commissioners in order to respond to the diVerent funding regimes. Devolution has provided the opportunity to do things diVerently but has also provided a chance for the NHS in both England and Wales to learn from each other and as a result oVer better and equitable services. Close contact should be established and maintained between the providers and commissioners of care on both sides of the border in order to address the needs of the border population of Wales.
1. The Institute of Rural Health 1.1 The Institute of Rural Health (IRH) is a UK-wide independent organisation that is working to inform, develop and promote the health and wellbeing of rural people and their communities through its three main programme areas: — research and projects (contributing to the evidence base); — education and training (developing a workforce fit for purpose); and — policy analysis (including rural proofing). 1.2 The IRH was established in 1997 and has built up a wide range of knowledge and expertise in rural health and well-being. More information is available on the web site at www.irh.ac.uk
2. Rural Health 2.1 Rural populations are frequently peripheral populations. In rural areas the population is dispersed, and sparsely populated areas may not be taken fully into account in public services planning. The concept of rural proofing is well established in England but has not been similarly taken up and applied in Wales. Border populations in Shropshire, Herefordshire and Powys have many similarities but access to public services is vastly diVerent. 2.2 People cross the England/Wales border in both directions along its full length to access specialist health services. In the central region, there is no district general hospital in Powys and patients cross the border to access specialist health services in Shrewsbury, Telford and Hereford (and possibly further afield in the West Midlands). 2.3 Health policy has changed on both sides of the border since devolution in 1999 and continues to do so. This is not only an opportunity but also a challenge for border populations who have traditionally crossed the border and continue to do so to access services. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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3. The Issues The IRH would like to make the following points with regard to the provision of cross-border specialist health services for Wales:
3.1 Care pathways Patients follow traditional care pathways that are influenced by geography, ease of access and availability of public transport. Patients, and clinicians, have strong links and referral patterns with the DGHs (District General Hospitals) across the border that have been built up over many years. Patients in Montgomeryshire, for example, who may be as little as half an hour from the Royal Shrewsbury Hospital, choose to be referred there rather than attend a Welsh DGH at Wrexham or Aberystwyth which incur much greater travelling times and challenges of access. Transport infrastructure is such that it is also much easier to travel to Shrewsbury than west through the mountains to Aberystwyth. It is similar in South Powys.
3.2 Travel Patients will travel when they need access to highly technical and specialised care such as neuro-surgery or specialist burns treatment (but would prefer ongoing care to be managed more locally). For other procedures patients prefer to be as close to home as possible. Main routes in Powys are generally east west, and public transport routes (rail and bus) facilitate access to services in England. Travel to Welsh DGHs could involve substantial journey times for patients living on the border and without the availability of direct public transport links. Specialist dental services are an example here: patients in north Powys have traditionally been referred to the Royal Shrewsbury Hospital but are now also being referred as far away as to the Prince Charles Hospital in Merthyr. This can mean a minimum 2.5 hour journey for patients, even using their own transport, as no direct public transport is available.
3.3 Duplication of care 3.3.1 As stated in point 3.2 patients are prepared to travel when they need access to highly technical and specialised care. Current examples are neuro-surgery for north Wales populations, specialist paediatrics for Powys, orthopaedics for Welsh patients. In all these cases there is expert care available in England that is accessible to Welsh patients: Liverpool for neuro-surgery (as opposed to Swansea), Liverpool and Birmingham for Paediatrics (as opposed to CardiV), Stoke-on-Trent for Cardiac Surgery (as opposed to CardiV) and Oswestry for orthopaedics (as opposed to CardiV, and dentistry (as above). 3.3.2 Powys does not have a DGH and its patients access other specialist services in other parts of Wales and for east Powys across the border in Hereford and Shrewsbury. The need for a DGH in Powys has been considered on many occasions (although there is not the population to support a Powys DGH) and would need to be carefully considered as existing care pathways are well established and the creation of a new DGH could impact on existing services. Health planning should include peripheral (rural) populations and consider the provision of cross border services as duplication is both costly and could destabilise existing services.
3.4 Time limited conditions 3.4.1 Medical and surgical emergencies should be dealt with as soon as possible but certain conditions are time limited, that is, when a specific treatment must be given within a specified time frame in order to optimise patient outcome. For critical life threatening conditions each additional 1 km travelled leads to a 1% increase in mortality. An example is Acute Myocardial Infarction requiring defibrillation or Thrombolysis. Referral pathways are crucial for rural patients and changing pathways could have a serious impact on outcomes for patients. Innovative approaches would need to be taken to ensure that the appropriate therapies can be given within the right time limit. 3.4.2 Rural ambulance services in Powys are already stretched to the limit and do not have good performance in terms of targets. If ambulances had to travel further to Welsh DGHs this would have a knock on eVect on the ambulance service.
3.5 Continuity of care/communication 3.5.1 Rural areas often have a network of community hospitals and Powys is a good example of this. Continuity of care is recognised as being extremely important to patient outcomes and satisfaction and it is essential that there are cross border links as patients are referred back in to their communities from specialist services for ongoing management and care. DiVerent IT systems have not facilitated communication Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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between England and Wales. The diVerences are apparent at the diagnostic (see 3.6 below) and referral stages, for example, “Choose and Book” is being introduced in England but not in Wales which poses additional challenges as the border DGHs will receive referrals in diVerent ways. 3.5.2 Communication in an emergency situation is obviously critical. The e-patient record is still some way oV but it will be essential that patient e-records can be read wherever the patient presents for care.
3.6 Diagnostics 3.6.1 Many diagnostic procedures can be undertaken in community hospitals, which improves patient access considerably. If results are interpreted at a Welsh DGH, eg for x-rays, but the patient is referred to an English DGH, tests may have to be repeated as there is no access to the original results by the consultant. This can result in additional trips for the patient. 3.5.1 In 2002 the IRH reported on the use of cancer genetic services by general practitioners. The research had been commissioned as there was a lack of uptake of services available in CardiV by Powys GPs. There was a lack of recognition of the border—or edge eVect, patients/clinicians were found to be accessing the equivalent cancer genetics services in England.
3.7 GP choice and confidence The systems in England and Wales have diversified considerably in recent years and it is appreciated that this is one of the opportunities of devolution. Unfortunately for border communities this has also created challenges and problems, not least for the general practitioners who have both English and Welsh patients on their lists and will be referring both English and Welsh patients for specialist care. Welsh patients do not have the Choice agenda or Choose and Book and the NHS in Wales is not subject to Performance by Results. GPs need to have the freedom to refer patients to the most appropriate hospital, which may or may not be the nearest, but (as has been referred to in paragraph 3.1) there are well established care pathways from Welsh GPs to English specialist hospitals and consultants. Good working relationships have been built up and the English consultants engage locally with the CPD (continuing professional development) programme. It would be unrealistic to bring consultants from CardiV, Swansea or North Wales to CPD events on a regular basis, particularly evening meetings, which are extremely popular and beneficial to local healthcare professionals.
3.8 Destabilisation of GP practices There is anecdotal evidence that English patients, registered with Welsh GPs, are changing practices to register with English general practitioners in order to benefit from the (substantially) shorter waiting times in the English NHS for specialist health services.
3.9 Recruitment of community specialists 3.9.1 Rural communities are ageing communities. Service demand is going to increase. The drive to provide services as close to home as possible is to be welcomed but quality community care involving the essential specialities will be vital. Seamless care will be important for the patient and good communications between the health professionals involved will be essential. Currently much community specialist provision for the border populations of Powys comes as advice only from England and is provided by a local community nurse. For example there is no respiratory rehabilitation in Powys and Welsh patients are not able to access services available in Shropshire. The same is true for patients diagnosed with Chronic Fatigue syndrome. These are significant issues. 3.9.2 In-house specialist care can be developed in Powys but the professional support required and the maintenance of clinical skills must be addressed and provided on a pragmatic basis. Anecdotal evidence indicates a lack of mutual recognition for training, particularly for nurses, where Welsh nurses may attend a course in England but this may not be accredited by a Welsh NHS employer. Training on both sides of the border should be respected and acknowledged or it could lead to future recruitment issues as well as duplication of eVort and funding.
3.10 Patient Choice Patients in Wales should have the same degree of choice as English patients. For the border communities it is fundamental that they retain the choice to use the most appropriate hospital for their condition (in terms of clinical care and taking access into account), even if in some cases this is in England. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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3.11 Inequity within the National Health Service People living in Wales pay tax and national insurance to the same level as in England and the benefit system is the same. There is inequity for Welsh patients in the quality of care that is provided as a consequence of devolution, and because of the proximity of the border there is much greater awareness than in other parts of Wales. The post code lottery has not been removed as a consequence of devolution. Welsh GPs who have both English and Welsh patients are in the uncomfortable (and inequitable) position of no longer being able to oVer all their patients the same quality of care.
3.12 Funding issues Payment for specialist services is on a diVerent bases in England and Wales. Where commissioning of services in England for Welsh patients is unavoidable the Welsh Commissioner should be funded at a level to support the commissioning process. Underfunding the Welsh commissioner puts additional restrictions on the availability of services to Welsh patients.
4. Recommendations for Action The IRH welcomes the opportunity to contribute to the inquiry and would like to make some key recommendations: 4.1 Cross-border access to specialist services for Welsh patients should continue. 4.2 Health planning should take into account what is available and accessible to patients on either side of the border in order to avoid duplication of services and destabilisation of existing services. As health policy continues to change and evolve in both England and Wales the challenges for people living along the border and the service providers should be addressed. A “Border Health Commission” could be set up. 4.3 Electronic communications should be compatible in order to facilitate communication between clinicians, particularly in emergency situations. 4.4 Education and training qualifications and skills should be mutually recognised or will again lead to duplication but also impact on recruitment. 4.5 More research is needed to examine the impact of longer referral distances on patient outcomes. 4.6 DiVerent funding regimes should be addressed and commissioners should be resourced to the appropriate level. 4.7 The opportunity should be seized for the NHS in both England and Wales to learn from each other and as a result oVer better services. Close contact should be established between the providers and commissioners of care on both sides of the border. March 2008
Memorandum submitted by Dr D Alun Jones MD BSc DPM FRCPsych, Consultant Psychiatrist
POST TRAUMATIC STRESS DISORDER CROSS-BORDER ISSUES 1. My evidence is based principally on my experience with traumatised ex-Servicemen and the problems arising with treatment for them. Much of this was on a cross-border basis throughout the UK. 2. My work with ex-Servicemen began in 1981 when a patient was referred to me by his General Practitioner at my clinic in Dolgellau. The referral was for depression and alcoholism in a man who had been pensioned out from a family firm in Lancashire and retired to the Cardigan coast. As part of my normal clinical assessment it emerged that at the age of 18 he had been shot down whilst on a night mission over Holland. He was the only survivor. He made his way across France almost to the Pyrenees but was captured and had a horrific time. 3. This was before DSM (Diagnostic and Statistical Manual) and Post Traumatic Stress Disorder, but clinically I thought he showed a state which had been continuous throughout since that experience. 4. At that time I only knew vaguely of the War Pensions Agency but thought there should be some benefit for him. He was much too anxious to deal directly himself and I wrote with my report asking that correspondence should come to me. 5. I received a very helpful reply from Dr W R O Eggington, Senior Medical OYcer at War Pensions Agency, Norcross dated 2nd December 1981. [Not printed]. 6. I had also directed him to his then local MP for advice, Dafydd Elis Thomas, now Lord Elis Thomas Presiding OYcer of the Welsh Assembly. [Letter not printed] Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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7. Shortly after that I was approached by a field oYcer of Combat Stress on another case and mentioned this gentleman. I was then asked to act as Honorary Consultant for Combat Stress and did so for many years. 8. I found myself being asked to report on increasing numbers, many from outside North Wales. Many were travelling great distance. Most were referred by Combat Stress for help with War Pension Claims. I saw them at my clinic in Chester. Many were travelling from the Manchester area and in collaboration with the Combat Stress oYce in Manchester I established a clinic there. I was then asked by the Field OYcers of Combat Stress whether I would help “the other side of the Pennines” and I started a clinic in Leeds. Cases were coming from as far as Hull and I started work there. This process continued until I was holding ex- Service clinics in most parts of the UK. 9. The connection in Scotland began at a meeting in Manchester when a young Gulf Veteran from Scotland pleaded for help there and I agreed to hold a clinic in the Glasgow area if they found a venue. This later led to another clinic at Perth. 10. I still have about 26 locations across the UK and was visiting on a cycle of about two months. Over the years I have seen around 2,500 ex-Service men and women. 11. With my retirement from the Health Service in 1995 I continued and expanded this work which was then funded by part of the Ty Gwyn fees. 12. With the closure of Ty Gwyn there was no funding from any source and I have been trying to maintain the contact as best as I can. 13. When consultant contracts and sessions were reviewed in the 1980’s my Health Authority recognised the work as a special clinical interest and allowed sessional time for it. I do not know of any other Health Authority in the UK which designated clinical sessions for a civilian NHS consultant psychiatrist to deal specifically with traumatised ex-Servicemen. 14. Consultant colleagues became aware of my interest and made referrals. Over the years many General Practitioners became aware and referred ex-Servicemen. Other agencies referred from all over the UK— SSAFA, RAFA, Army Benevolent, British Legion, NGVFA, Probation Service, Prison Medical OYcers, the courts and others. Ty Gwyn was registered under the Mental Health Act 1983 and was able to take patients from the Courts and from prison for treatment or assessment. 15. Overall the outcome at Ty Gwyn was very good. Marriages were preserved; social disruption and oVending behaviour was prevented and quality of life greatly improved for many who came. 16. Because of the isolation that many felt and the lack of treatment facilities in the UK inevitably many ex-Servicemen came by word of mouth on introduction by ex-Service comrades with whom they remained close. 17. I noticed that each conflict tended to produce its own characteristic reactions. Knowing this was often a key to establishing rapport with men who had rarely spoken to anyone of their experiences. Appendix 1 lists the campaigns from which I have seen ex-Servicemen. 18. In addition I found myself dealing with trauma cases from the other emergency services: Police, Fire Service and Ambulance. 19. In 1988 I was invited to give a paper at a psychiatric symposium at the Royal Army Medical College on long term eVects of trauma in ex-Service personnel. 20. In 1990 at the Annual Meeting of the Royal College of Psychiatrists I gave a paper on “Long-term EVects of Service Trauma in General Psychiatric Practice”. 21. In 1997 I presented a paper at a joint meeting of the Welsh Psychiatric Society and the Societe de Neuropsychiatrie de l’Ouest describing the first 170 Gulf War Illness cases I had seen by then. 22. I presented a paper at the European Conference on Traumatic Stress in Berlin in May 2003. This described the series of 440 Gulf War Illness cases that I had seen up to that time. The number is now about 500. 23. The veterans of the first Gulf War certainly impressed me as diVerent. They give a diVerent impression of illness, a common malaise; sallow young men walking with sticks. 24. In 2004 I gave evidence to the Independent Enquiry into Gulf War Illnesses conducted by Lord Lloyd of Berwick. 25. The mode of leaving the Forces was striking. Although these men and women were clearly unwell, very few were medically discharged. Many left by PVR (Premature Voluntary Release) or SNLR (Service No Longer Required) where the underlying ill health was a significant causal factor. 26. Although a surprisingly high proportion of the ex-Servicemen I have seen had had psychiatric contact in the Forces, very few engaged with any civilian psychiatric services. This despite the clear priority in the NHS directed by statute for War Pensioners. 27. My involvement with psychiatry in North Wales began as a Junior Doctor at the North Wales Hospital, Denbigh in October 1958. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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28. I then spent three years from 1959 to 1962 on a Epidemiological Research Project with Dr Gwilym Wynne GriYth, MoH of Anglesey, on mental disorder and mental health needs in Anglesey. This served as the basis for much of my subsequent work. 29. I then spent a year and a half at the Bethlem and Maudsley Hospitals for further training then returned as Consultant to the North Wales Hospital in Denbigh. 30. There were about sixteen hundred patients in the hospital at that time and I as Consultant had responsibility of the whole of the female side with about nine hundred patients. 31. Within three years that hospital population was reduced to about six hundred and a number of new special units were established with the resources released. Most of those units have survived the closure of the hospital and continue elsewhere as exiting services. 32. These initiatives are reflected in my work with ex-Servicemen suVering Post Traumatic Stress Disorder. 33. Many ex-Servicemen suVering Post Traumatic Stress Disorder have alcohol or drug problems. 34. In the 1980’s I had established an Alcohol Treatment Unit and later a Drugs Treatment Unit at the North Wales Hospital, Denbigh. At the same time, and with much community support, I established CAIS, now the biggest Drug and Alcohol Charity in Wales. 35. After the closure of Denbigh the drug and alcohol beds were relocated in 1997 to Hafan Wen, a new 25 bed purpose built unit on the Wrexham NHS District General Hospital site, where CAIS provides this service to Welsh patients under contract to the Welsh Assembly Government through the Local Health Boards. 36. Because of recent reduced commissioning in Wales CAIS has had to look to commissioners over the border and paradoxically a significant part of the work at Hafan Wen is now done with English patients. 37. With the recent reduction in commissioned Welsh beds there are now three Welsh patients waiting for each bed and CAIS is making urgent representations to the Assembly on the matter. 38. Many traumatised ex-Servicemen suVer personality and behavioural eVects. 39. I established at Denbigh a Treatment Unit for disturbed young people with personality disorders which took many youngsters, particularly from the Courts and the Probation Service but this was lost with the closure of North Wales Hospital, Denbigh. 40. I drew on the therapeutic structure and the mode of treatment however in the therapeutic unit that I established for ex-Servicemen in Llandudno. 41. Shortly after the 1990 NHS Act I initiated an in-patient facility at Ty Gwyn in Llandudno, exclusively for traumatised ex-Servicemen. I agreed with the management the resources that I would require, and that it should accept only NHS funded patients through the ECR system (Extra Contractual Referral). I insisted that a bed should cost no more than a bed in my local psychiatric hospital at Denbigh where I had established a number of special units. Ty Gwyn worked solely on funding from the Health Service with some minimal charity contribution from the Army Benevolent Fund. 42. NHS funding became increasingly diYcult and barely one in five applications were approved. It was a matter of great distress to those patients who were refused and great professional distress to myself that I was unable to treat them. 43. The table below shows the number of patients listed at each of my clinic venues at the time of the closure of Ty Gwyn in October 2005 and the number of patients then waiting for approval for treatment.
Clinic Location Cases Welsh Birmingham 114 3 Bradford 100 Chepstow/Swansea 130 76 Chester 116 36 Cleethorpes 15 Doncaster 85 Glasgow/Perth/Belfast 189 Hull 121 Kidderminster 8 Llandudno 200 200 Luton, Peterborough, Cambridge, 121 Basildon Manchester 201 Newcastle 153 Nottingham 125 Portsmouth 49 Preston 91 Shrewsbury 18 6 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Clinic Location Cases Welsh Stoke 38 Talwrn 16 16 Taunton 18 Prison 5 Total 1,898 337 Waiting treatment 90 25 26 locations
44. Traumatised ex-Servicemen do not generally settle in civilian treatment units. They can be very frightening and intimidating to other patients but they also feel ill at ease in an environment where they do not identify and where they feel that their experiences are not known or understood. 45. A considerable number were in fact ex-Servicemen who had been admitted to one of the Combat Stress establishments but had consumed alcohol or transgressed in an unacceptable way and had been excluded. 46. I felt that Ty Gwyn complemented the broader work of Combat Stress and I would have been very happy to collaborate all the more closely, as indeed would the management of Ty Gwyn. 47. Colonel Simon Brewis of the Army Benevolent Fund wrote when Ty Gwyn was closing: “Combat Stress provides a service in providing respite treatment at its 3 centres and welfare care in the community, but it does not have the facilities to take on patients who suVer from chronic PTSD and who have associated disruptive, alcohol and drug problems. Ty Gwyn will take on all these categories”. 48. At the time of closure in October 2005 Ty Gwyn had treated over 600 cases. The majority of admissions to Ty Gwyn were from outside Wales but they enabled the unit to function well and to provide treatment for those in Wales. 49. Many local ex-servicemen who could not be funded and who could not be admitted made contact and looked to Ty Gwyn for continuing support which was always given. Likewise a substantial number of other ex-Servicemen who were rootless and homeless settled in the Llandudno area after treatment in Ty Gwyn and still remain there. 50. They looked to Ty Gwyn for continuing support and many still maintain contact with former Ty Gwyn staV and with myself. They have been able to lead much enhanced lives; reducing much of their social conflict. 51. At the present time there is no specialised treatment for traumatised ex-servicemen with severe challenging problems or with alcohol or drug problems anywhere in the UK. 52. With the closure of Ty Gwyn the then Chief Executive of CAIS said that this was a service that CAIS would be willing to provide. They have staV trained in PTSD and most of this patient group have drug and alcohol problems for which CAIS is recognised as a leading UK provider of treatment. 53. I was delighted with this suggestion; I still chair CAIS; and I saw this as a way to achieve stability for the service and to draw in younger consultants to carry on the work. 54. CAIS identified premises and prepared clinical and business proposals and submitted these to the Assembly and to the local Health Boards but regrettably to no avail and was unable to proceed. 55. CAIS still holds an interest in this and if oVered collaboration from the Welsh Assembly could reinstate the service and would look also to the Department of Health in England and corresponding body in Scotland. 56. Barely a third of the ex-Servicemen known to me are employed. This raises the possibility of European Convergence funding for treatment and rehabilitation and CAIS would pursue this. 57. CAIS has been designated by 12 of its colleague Drug and Alcohol Treatment Agencies in Wales to lead on the submission of a major bid being submitted in the next 14 days under the European Convergence and Competiveness programmes. 58. The Ty Gwyn unit before it closed was an example of a cross border service where a unique facility in Wales was drawing funded referrals from all parts of England and Scotland to their benefit, and to the benefit of patients in Wales for whom there would otherwise have been no service, as now occurs. 59. It is doubly ironic that that cross border service has gone and that the excellent drug and alcohol and detox facility provided by CAIS at Hafan Wen in Wrexham is now serving a significant number of cross border referrals from England to the detriment of service to Welsh patients. 60. To answer specifically the questions put to me “in the field of post traumatic stress disorder”. 61. My answers relate to my special interest in traumatised ex-Servicemen. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Question 1 The extent to which cross-border health and social care services are currently funded for and accessed by the Welsh population Answer 1: Patients suVering from post traumatic stress disorder (PTSD) have very limited access to treatment facilities. Combat Stress provide respite care in their several units in England and Scotland but no specialist provision exists anywhere in the UK for patients suVering from severe PTSD with associated active drug and alcohol problems.
Question 2 The arrangements currently in place to co-ordinate cross-border service provision Answer 2: I have extensive experience in the treatment of PTSD particularly in ex-service personnel and many patients seek my assistance. I no longer have anywhere in the UK to refer these patients.
Question 3 Commissioning, funding and quality of cross-border services Answer 3: The Welsh Assembly Government and many Local Health Boards satisfy themselves with a modest arrangement with Combat Stress, but again no service exists for severely traumatised ex-service personnel with associated drug and alcohol problems, and no place for transfer from police custody or prison.
Question 4 The extent to which health and social care policy has diverged across the UK since the introduction of devolution and the impact that this has had Answer 4: It would appear to me that devolution has had little impact in the area of PTSD and commissioning in Wales follows the pre-devolution pattern.
Question 5 The extent to which mechanisms are in place for identifying and resolving cross-border deficiencies Answer 5: Welsh Assembly Government, Local Health Boards and statutory commissioners seem to have little understanding of this group of the most severely traumatised ex-service personnel. These people almost invariably have associated major drug and alcohol substance misuse problems. There is now nowhere in the UK where this severely traumatised group can access meaningful treatment. 62. In summary: the cross-border flow now remains of Welsh patients to the Combat Stress homes, but this does not provide for those with challenging or oVending behaviour or alcohol and drug problems that was provided at Ty Gwyn. Dr D Alun Jones Consultant Psychiatrist. 18 March 2008
APPENDIX 1 Total ex-Service cases approx 2500 These included most spheres of WW2 Campaigns and postings post WW2 — Aden 1960’s — Afghanistan — Bangladesh flood relief — Beira blockade S Rhodesia — Belize — Borneo — Bosnia — Canada Training — Christmas Island — Colombia — DERA — Falklands — Gulf War 1 — Gulf War 2 — Hong Kong — Iceland cod war Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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— Ireland — Kenya — Korea — Lockerbie — Malaya1950’s — Namibia — Oman — Sierra Leone
APPENDIX 2
Memorandum submitted by Llandrindod Wells & District Volunteer Bureau/Community Support The Volunteer Bureau/Community Support oYce in Llandrindod provides community transport for clients accessing health appointments. Many of our clients go across the border to Hereford to access District General Hospital services—43 miles each way—cost to client approx £36 based on 40p/mile. In 2007–08 we did 147 trips to Hereford. There is also a direct bus route for those with appointment times that enable its use. CardiV and Swansea are not accessible from Mid Wales—CardiV approx 75 miles each way—cost to client £60. The journey time is obviously much longer. South Wales is not just inaccessible for patients but what about visitors? Few people would be able to visit patients in CardiV on a regular basis given the distance and the cost—bearing in mind that Powys is a low wage area with the highest petrol prices in Wales. Public transport is extremely poor between Mid and South Wales and it would be impossible to use it for hospital appointments—it could mean an overnight stay. It seems to me that people are not considered as individuals just numbers and targets. Please can we continue to have services for this area provided in Hereford, or better still more services provided at a local level under agreements with Hereford. Cancer treatment is a problem, being linked to Hereford means that services are accessed in Cheltenham which is a distance but still slightly more accessible than CardiV. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Services for the treatment of anorexia are sadly neglected in Wales and better connections between Wales and England are needed. I have a friend who has moved from Wales to Ross on Wye simply because Gloucestershire has an NHS clinic for anorexia suVerers and her daughter has had the condition for several years and treatment in Wales has been non-existent. July 2008
Letter from Lord Livesey of Talgarth to the Chairman My understanding is that the Welsh AVairs Committee is conducting a major inquiry into the provision of cross-border public services for Wales, and I am very pleased indeed that this is taking place. You will know that I am an ardent pro-devolutionist, but I have to admit that the provision of cross- border public services for the NHS in Powys remains a vexed question, mainly because there are two diVerent models of NHS administration in place on either side of the border. This undoubtedly compounds the length of patient waiting-lists for many types of clinical treatment—some of it very urgently required. The matter is further complicated by a lack of suYcient acute beds in Hereford County DGH, and by funding issues. Please may I urge the Committee to take evidence from Hereford NHS Trust. The evidence should be taken from at least two witnesses. One should be a clinician who is in the frontline, and the other should be a very senior member of the Management of Herefordshire Primary Care Trust, which has responsibility for financial management. Martin Woodford, the Chief Executive of Herefordshire PCT, was formerly the Chief Executive of Powys NHS Trust, and would therefore make a good witness. The replacement of hospital facilities in Hereford over the last decade or so, illustrates very well the sort of problems which can occur. My former constituency of Brecon & Radnorshire is served by Hereford County Hospital. Twenty per cent of its patients originate from Powys. This statistic was factored in, to assist Hereford in obtaining its new hospital, and the number of beds proposed echoed the previous bed provision. The Health Authority (as it was at the time) had to agree by direction of the UK Government that the hospital be built by PFI contract. The result was, that the number of beds was reduced to 25 fewer than the former bed-provision. One does not have to be a mathematical genius to gauge the impact which this has had on patients from Powys being treated in Hereford. Waiting lists are now much longer, finance has become a major issue, and patients from the Brecon, Talgarth, Hay, Builth, Llandrinded, Rhayader, Knighton and Presteigne areas have suVered, as there is no DGH in Powys. Distances in this sub-region of Powys can be as much as 50 miles to Hereford Hospital, and population sparsity is a really major issue. Further down the line, investment in the NHS in Gwent will remove acute services to Cwmbran from Nevill Hall DGH in Abergavenny, rendering services even more remote for patients in south-east Powys. This will undoubtedly have a “knock-on” impact upon the Hereford Hospital connection. These are all cogent reasons why it is vital for your Committee to interview witnesses from the Herefordshire Primary Care Trust, thus hopefully collating this material together with the evidence from Powys LHB, and Brecon & Radnor Community Health Council. 27 March 2008
Memorandum submitted by Meirionnydd and Gogledd Gwynedd Community Health Councils (CHC) The arrangements for provision of cross-border commissioning, funding and quality of services and the attendant issues which are under consideration by the Committee are common to all areas covered by the North Wales CHCs. We have accordingly discussed the submission of evidence with our colleagues in Clwyd and Conwy Federations of CHCs who will be submitting written memoranda and contributing oral evidence to the Committee in Knowsley later this month. It has therefore been agreed, for the avoidance of duplication of information, that Conwy CHC will also be mindful of and represent the interests of patients within Meirionnydd and Gogledd Gwyneed CHC areas in their submissions. We are most grateful to our colleagues. We trust that this will be in order and thank the Committee for giving us the opportunity of contributing to the enquiry. Pat Billingham (Mrs) Chief OYcer 18 March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Dr David Fearnley, Medical Director & Deputy Chief Executive, Mersey Care NHS Trust
1. Executive Summay This submission provides evidence about the provision of the high secure service for Welsh men at Ashworth Hospital, Merseyside.
2. Introduction I am currently the Medical Director & Deputy Chief Executive of Mersey Care NHS Trust. This Trust was created in 2001 and as part of its broad range of services provides high secure services at Ashworth Hospital, Merseyside. High secure services for the rest of England are provided at Rampton and Broadmoor Hospitals. In 2004, the women’s service at Ashworth Hospital closed and Rampton Hospital became the national provider. Rampton Hospital also provides the national deaf service and learning disability service for the high secure hospitals, which may have Welsh patients from time to time. 3. I have been a consultant forensic psychiatrist at Ashworth Hospital for over seven years and have had clinical responsibility for Welsh patients during that time, and practical experience of liaison with colleagues in Welsh secure units and prisons as part of the admission, treatment and discharge process. I am also at present the executive director on the Board at Mersey Care NHS Trust who has responsibility for the high secure service.
4. Key Facts I have attached a summary of key trends over the past nine years in relation to Welsh patients at Ashworth Hospital. The key figures to note are that currently Ashworth Hospital provides care and treatment under the Mental Health Act (1983) for 41 Welsh patients (all males), and there has been a consistent pattern of referral and discharge over the years. Most of the patients are from South Wales, but a small number are being monitored by the team at Ty Llewellyn Regional Secure Unit, North Wales. 5. At present, the English secure services operate a case manager approach to commissioning, which appears to be invaluable in co-ordinating admission to and discharge from high security. There appears to beadiVerent arrangement in Wales which at times has perhaps made it more diYcult to co-ordinate services eVectively. However, there are mechanisms in place for identifying and resolving these issues with the commissioners and the clinical teams at the respective provider units. 6. The clinical teams at Ashworth Hospital have endeavoured to co-ordinate planning meetings for Welsh patients for the convenience of both staV from the Welsh medium secure units, and also the families of the patients involved. We have arranged annual planning meetings for Welsh patients on the same day to reduce the number of trips that staV and family members would need to take. We also have invested in video conferencing facilities which will enable better communication in place of meetings which are sometimes diYcult to arrange at a distance. David Fearnley 25 March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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WELSH REFERRALS APRIL 1999 TO MARCH 2008 WELSH REFERRALS APRIL 1999 TO MARCH 2008
Final Decision % Final Decision for Year Admit for Reject— Admit for Reject— Year Received Admit Assessment Reject Other Year Received Admit Assessment Reject Other
1999–2000 14 3 1 6 4 1999–2000 14 21.4% 7.1% 42.9% 28.6% 2000–01 17 6 6 5 2000–01 17 35.3% 35.3% 29.4% 2001–02 18 9 6 3 2001–02 18 50.0% 33.3% 16.7% 2002–03 14 6 5 3 2002–03 14 42.9% 35.7% 21.4% 2003–04 10 5 4 1 2003–04 10 50.0% 40.0% 10.0% 2004–05 7 5 2 2004–05 7 71.4% 28.6% 2005–06 9 5 2 2 2005–06 9 55.6% 22.2% 22.2% 2006–07 24 12 2 8 2 2006–07 24 50.0% 8.3% 33.3% 8.3% 2007–08 9 5 3 1 2007–08 9 55.6% 33.3% 11.1% 122 56 3 42 21
WELSH ADMISSIONS APRIL 1999 TO MARCH 2008 WELSH ADMISSIONS APRIL 1999 TO MARCH 2008
Source of Admission % Source of Admissions for Year High High Year Admitted Secure MSU Prison Other Year Admitted Secure MSU Prison Other
1999–2000 4 2 2 1999–2000 4 50.0% 50.0% 2000–01 6 1 3 2 2000–01 6 16.7% 50.0% 33.3% 2001–02 10 4 6 2001–02 10 40.0% 60.0% 2002–03 1 1 2002–03 1 100.0% 2003–04 6 2 2 2 2003–04 6 33.3% 33.3% 33.3% 2004–05 5 2 3 2004–05 5 40.0% 60.0% 2005–06 4 2 2 2005–06 4 50.0% 50.0% 2006–07 9 1 2 6 2006–07 9 11.1% 22.2% 66.7% 2007–08 8 2 6 2007–08 8 25.0% 75.0% 53 1 17 31 4
WELSH TRANSFERS/DISCHARGES APRIL 1999 TO MARCH 2008 WELSH TRANSFEERS/DISCHARGES APRIL 1999 TO MARCH 2008
Destination % Destination for Year Average Transferred/ LoS High Transferred/ High Year Discharged (Years) Secure MSU Prison Community Year Discharged Secure MSU Prison Community
1999–2000 10 8.3 8 2 1999–2000 10 80.0% 20.0% 2000–01 4 4.5 3 1 2000–01 4 75.0% 25.0% 2001–02 8 6.0 7 1 2001–02 8 87.5% 12.5% 2002–03 7 7.5 4 2 1 2002–03 7 57.1% 28.6% 14.3% 2003–04 5 8.8 1 4 2003–04 5 20.0% 80.0% 2004–05 4 2.9 4 2004–05 4 100.0% 2005–06 7 9.3 6 1 2005–06 7 85.7% 14.3% 2006–07 3 6.4 3 2006–07 3 100.0% 2007–08 5 9.1 5 2007–08 5 100.0% 53 6.4 1 44 6 2
WELSH RESIDENT POPULATION AT AT WELSH RESIDENT POPULATION AT AT 14 MARCH 2008 14 MARCH 2008
Admit Source % Admit Source for Year Average Age on Admission High High Year Admitted (Years) Secure MSU Prison Year Admitted Secure MSU Prison
1980–89 4 31.2 1 3 1980–89 4 25/0% 75.0% 1990"99 5 26.0 1 1 3 1990–99 5 20.0% 20.0% 60.0% 1999–2000 1 29.0 1 1999–2000 1 100.0% 2000–01 4 38.5 1 3 2000–01 4 25.0% 75.0% 2001–02 3 29.1 2 1 2001–02 3 66.7% 33.3% 2002–03 1 38.5 1 2002–03 1 100.0% 2003–04 2 37.0 1 1 2003–04 2 50.0% 50.0% 2004–05 2 37.7 1 1 2004–05 2 50.0% 50.0% 2005–06 4 28.6 2 2 2005–06 4 50.0% 50.0% 2006–07 7 25.2 1 2 4 2006–07 7 14.3% 28.6% 57.1% 2007–08 8 32.9 2 6 2007–08 8 25.0% 75.0% 41 30.85 3 13 26
Memorandum submitted by Ministry of Defence
1. This Memorandum aims to provide the House of Commons Welsh AVairs Committee with relevant background information to aid their inquiry into cross-border provision of public services for Wales. In accordance with the Committee’s invitation to the Ministry of Defence to submit evidence, this Memorandum focuses on the provision of healthcare for Armed Forces personnel, their families, veterans and Reservists. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Provision and Funding of Healthcare to the Armed Forces 2. Members of the regular Royal Navy, Royal Marines, Army and Royal Air Force have access to a wide range of medical and dental services. The range of services in the UK includes: Primary Healthcare; Dental Services (including dental hygiene); Secondary Healthcare in NHS hospitals; Rehabilitation Services provided by the Defence Medical Rehabilitation Centre (DMRC) and at the Regional Rehabilitation Units (RRUs) and Mental Health Services provided by regional military community-based out-patient and private sector in-patient facilities. MOD also provides healthcare outside the UK at our permanent bases or on deployed operations; details are outside the scope of this memorandum.
Primary Healthcare
Service Personnel 3. The MOD funds primary healthcare for Service personnel and provides primary care facilities at major military population centres. Service personnel are also entitled to access NHS primary care on an emergency or immediate care basis. In addition, Service personnel can register on a temporary basis with a NHS GP for up to 3 months should the individual be unable to use a reasonably accessible military facility. 4. The MOD provides a range of Primary Care Services including medical centres located throughout the United Kingdom. The size and “skill mix” of each medical centre varies depending on factors such as location and the size and health needs of the population served. The typical medical centre provides access to General Practitioners, Practice Nurses, Military Medical Assistants and Physiotherapists and Remedial Instructors. Some of these personnel will be uniformed Defence Medical Services (DMS) personnel and others will be civilian practitioners. The medical centres provide medical diagnostic and treatment services similar to those provided by a civilian medical practice, but they also provide occupational medical services, which is a major component of their activity. In the main, Service personnel have access to a medical centre in the immediate vicinity of their unit but in some areas where the serving population is few in number, personnel will have access to a military medical centre elsewhere or, occasionally, a NHS practice may be contracted to provide this service.
Dependants 5. In the UK, dependants of Serving personnel are entitled to NHS provision of primary care and the majority are registered with NHS GPs. In a few locations, military GP practices in the UK register families so that the practice can meet the criteria required of a GP training practice (so that military GPs can attain the appropriate qualifications) or because the military practice has spare capacity. No funding flows from the local PCT or Local Health Board to MOD in such cases. The medical centre at MOD St Athan treats about 350 dependants, and the one at RAF Valley treats around 200.
Dental Services including Dental Hygiene
Service Personnel 6. The Defence Medical Services provide unit- and regionally-based dental centres. These centres operate under the command of the Defence Dental Service (DDS). The DDS provides local access for Serving Personnel to Dentists, Dental Nurses and Dental Hygienists. These specialists provide routine diagnostic and treatment services, but also oVer valuable occupational screening services ensuring that serving members of the Armed Forces are “dentally fit” to undertake their role.
Dependants 7. Dependants of Service personnel are entitled to NHS provision of dental care. They are not entitled to DDS dental care in the UK.
Secondary Medical Care in the UK
Service Personnel 8. All Service personnel are entitled to access the full range of NHS secondary care and community services. The MOD no longer runs its own secondary care facilities (“military hospitals”) in the UK. Funding is allocated to PCTs and Local Health Boards (LHBs) based on the National Census (with Service residents included). The MOD informs the Health Departments in the various parts of the UK if there is likely to be a significant reduction (such as a base closure) or increase in the local Service population. The military population is included when the calculations take place for funding allocation from the Department of Health to PCTs in England; and from the Welsh Assembly Government to the LHBs. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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9. In addition to accessing local NHS secondary care by referral from local (military or civilian) GPs, the MOD will in some circumstances purchase accelerated access from a small number of NHS providers at additional cost, for any medical condition, in order to meet operational requirements. These providers are the NHS Trusts hosting Ministry of Defence Hospital Units9 (MDHUs) and University Hospital of Birmingham Foundation Trust (UHBFT) where the Royal Centre of Defence Medicine (RCDM) is based. The MDHUs are situated in areas with a higher military population. Personnel based in, or living in, Wales who are sent for accelerated access treatment, are usually treated at UHBFT, but it may be at one of the other MDHU host trusts, depending on the particular patient’s circumstances. 10. In addition to the accelerated access purchased from the MDHU Host Trusts, the MOD has developed a specific orthopaedic fast track programme to meet the relatively high incidence of musculo- skeletal cases arising within the military population. For Service patients with these conditions the MOD arranges rapid access to diagnosis and—for the minority who are then found to need it—surgery in NHS facilities. Those needing only physiotherapy or rehabilitation treatment (the majority) are treated in MOD’s own Regional Rehabilitation Units (RRUs)—so no NHS waiting list issue arises. If surgery is necessary (for the minority of cases) we can and do arrange fast access to surgery in the MDHU Host Trusts or other NHS Trusts, typically within 6 weeks of the decision on their treatment path.
Dependants. 11. All secondary care and community services for the dependants of Service personnel in the UK are obtained from the NHS. The MOD provides no funding for this care.
Operational Healthcare for Armed Forces
Selly Oak Hospital. 12. Since 2001, the Royal Centre for Defence Medicine (RCDM), based at the University Hospital Birmingham Foundation Trust (UHBFT), has been the main receiving unit for military casualties evacuated from an operational theatre overseas. In the Birmingham area, military patients can benefit from the concentration of five specialist hospitals (including Selly Oak Hospital) to receive a very high standard of care. Indeed, Selly Oak is at the leading edge in the medical care of the most common types of injuries (eg polytrauma) our casualties sustain. The medical needs of the Armed Forces are best served through access to facilities and training in a busy acute care hospital that is managing severe trauma on a daily basis. 13. Additional funding has been provided to help meet the travel and accommodation costs of patients’ families who need to travel to Selly Oak. Accommodation available includes seven flats, plus a number of family rooms. Some of the flats have benefited from recent refurbishment funded by the Soldiers, Sailors, Airmen and Families Association (SSAFA), which is helping to provide a more suitable environment for the families of the patients concerned. Additional transport for patients and families is also being provided from public funds.
Defence Medical Rehabilitation Centre (DMRC) and Regional Rehabilitation Units (RRUs). 14. MOD has made considerable investment in rehabilitation in recent years and now adopts a tiered approach. Most primary care centres have been reinforced by physiotherapists. When necessary, patients are referred to one of 15 Regional Rehabilitation Units (RRUs) which focus on the assessment and treatment of musculoskeletal injuries and sports medicine and are staVed by specially trained Doctors, Physiotherapists and Rehabilitation Instructors. 15. Military patients requiring further rehabilitation care may be referred to the Defence Medical Rehabilitation Centre (DMRC) at Headley Court in Surrey, which is the principal medical rehabilitation centre run by the Armed Forces. DMRC also accepts direct admission from hospitals, and most combat casualties are referred directly to DMRC from Selly Oak. DMRC provides both physiotherapy and group rehabilitation for complex musculo-skeletal injuries, plus neuro-rehabilitation for brain-injured patients. The Complex Rehabilitation and Amputee Unit, based within DMRC, provides high quality prosthetics and adaptations, manufactured on site and individually tailored as necessary for the specific patient. Where possible, the provision of prosthetics aims to enable Service personnel to resume service duties.
Mental Health 16. It is our policy that mental health issues should be properly recognised and appropriately handled and that every eVort should be made to reduce the stigma associated with them. The Ministry of Defence recognises mental illness as a potentially serious and disabling condition, but one that can be treated.
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Diagnosis and treatment of mental illness in the Armed Forces is undertaken by fully trained and accredited mental health personnel. 17. Our mental health services are configured to provide community-based mental health care in line with the guidelines and standards set by the National Institute for Health and Clinical Excellence and the National Service Frameworks. We do this by providing outpatient assessment and treatment at our 15 UK military regional Departments of Community Mental Health (DCMH) centres sited in military bases staVed by either military mental health care professionals or civilians employed by the MOD. This means that serving personnel usually remain with their units and receive outpatient care in a military environment. 18. In-patient care, when necessary, is provided regionally in specialised mental health units under a contract with the Priory Group, and when appropriate in NHS hospitals. The in-patient contract is due to expire at the end of November 2008 and we are currently conducting a competitive tendering exercise to place a new contract. 19. Close liaison is maintained between local DCMHs and the Priory Group to ensure that all Service elements relating to in-patient care and management are addressed. This has worked very successfully, with appointed Service Liaison OYcers regularly attending Priory facilities where Service patients are admitted. They attend consultant ward rounds and influence the care plan of these patients. The aim is to stabilise and return the individual to the community for onward management. This has helped limit the length of stay for the majority of patients.
Armed Forces Personnel Based in Wales
20. The Army has two medical centres in Wales: one at Cawdor Barracks, near Haverfordwest serves a military population of around 650; the second, at Brecon, which also has a bedding-down facility, serves around 460 personnel. In addition there is a medical centre at Beachley Camp, near Chepstow, serving a military population of around 630. Although the town of Chepstow is in Wales, the camp and Medical Centre are in England. Some dependants living in England will be registered with Welsh GP practices.
21. There is also a small number (less than 30) of Army personnel based in North Wales who are treated in Chester Medical Centre.
22. The RAF’s medical centre at MOD St Athan provides primary and occupational health care, including a physiotherapy department, to a military population of almost 1800. These include Serving personnel from all three Services, but primarily the Army and RAF, and some dependants. The RAF also runs a medical centre at RAF Valley in Holyhead, looking after almost 700 people, including some dependants.
23. For emergencies (A&E) as well as for minor requirements Service Personnel based in Wales use NHS hospitals in Wales. For elective secondary care referrals they may go to Birmingham or to local Welsh NHS hospitals. Service Personnel based in England but on courses, exercises or adventure training in Wales receive emergency secondary health care from NHS hospitals in Wales if required.
24. MDHUs have not, thus far, been created in the Devolved Administrations. They have an important role in maintaining and developing the skills of our military doctors, nurses and other health professionals. When they were set up, the locations of the MDHUs were selected to take advantage of existing links and proximity to the then-remaining military hospitals. This does not, however, mean that Service patients based in Wales do not have access to the same standard of care that applies in England. Most personnel receive treatment in local NHS hospitals and our Service medical personnel have developed good working relationships with local NHS units to help achieve excellent secondary care for Service personnel.
25. There may be circumstances when Service personnel based in Wales might be asked to attend a Host Trust in England. This is often for a specific occupational assessment but may also be in order to benefit from the contracts for accelerated access for elective referrals agreed with the MDHU Host Trusts, as explained earlier, or to access a particular specialism not available locally. If it is necessary for a Serviceman or woman to travel for a medical appointment then their expenses will of course be paid. For those admitted to hospital, there are support provisions in place to provide transport and accommodation for close family members to visit if the appropriate medical authority considers that it would assist the patient’s recovery.
26. There is no RRU or DCMH in Wales at present, although this is kept under review, particularly with the planned expansion of MOD St. Athan in around five years’ time. Service personnel living in or based in Wales who require treatment at a DCMH go to the Centre at Donnington. Those requiring treatment at a RRU go to a number of units in England depending on the workload of the units and the individual’s personal circumstances. However, in May 2008 a new RRU is to open in Lichfield and it is likely that many personnel based in Wales will receive treatment there from that date. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Reservists 27. Whilst mobilised, reservists are treated exactly the same as members of the Regular forces. If a medical oYcer assesses that a mobilised member of the reserve forces requires treatment or rehabilitation, they will be treated in exactly the same way as regular personnel. This may include treatment and rehabilitation at a military RRU or the DMRC at Headley Court, Surrey, or—if the problem is related to their mental health— treatment at a military Department of Community Mental Health (DCMH) or admission to the Priory Group. 28. When reserve personnel are demobilised, they are given a medical assessment. During this process, if it is identified that they are in need of hospital care they may be referred to NHS hospitals hosting Ministry of Defence Hospital Units (MDHUs) or the RCDM at Selly Oak Hospital. They will be treated within military timeframes which can in some cases oVer faster access to treatment than is the case for NHS patients. Reserve personnel will receive treatment for injuries sustained on operation until they are deemed to have reached a steady state of fitness. They are then demobilised, and taken through a transition from military to NHS care, if they have continuing healthcare needs. The patient may express a preference for treatment in a hospital nearer to their home, which may be a non-MDHU hospital. In accordance with NHS protocols, if they are referred on to a non-MDHU hospital, then access to treatment is according to clinical priority. 29. Prior to mobilisation and following demobilisation, medical care including dental care is the responsibility of the reservist’s own local NHS primary care trust and the majority of reservists’ physical and mental health needs are met by these provisions. All reservist personnel while on duty (whether mobilised or not) are eligible for emergency treatment from the Defence Medical Services (DMS) but with the current structures of both the DMS and NHS, non-mobilised Reservist casualties requiring further treatment in the UK will transfer to NHS care. If seriously injured on duty they will receive the most appropriate clinical care from facilities available through the DMS, if such facilities are not available in the NHS, following their initial emergency treatment. 30. In addition, the MOD recognises that it has an expertise to oVer in certain specific circumstances, and in November 2006, it launched a new initiative—the Reserves Mental Health Programme (RMHP). The RMHP is open to any current or former member of the UK Volunteer and Regular Reserves who has been demobilised since 1 January 2003 following an overseas operational deployment as a reservist, and who believes that the deployment may have adversely aVected their mental health. Under the RMHP,the process of self referral can be initiated by the reservists or the individual’s GP and oVer a mental health assessment at the Reserves Training and Mobilisation Centre in Chilwell, Nottinghamshire. If diagnosed to have a combat-related mental health condition, we then oVer out-patient treatment via one of the MOD’s 15 UK DCMHs. If more acute cases present, the DMS will assist access to NHS in-patient treatment. We are working with the UK health authorities to ensure that GPs across the UK are aware of the initiative.
Deployment of Welsh Field Hospital Reservists 31. The Committee may wish to be aware that 46 Reservists from 203 (Welsh) Field Hospital (Volunteers), based in CardiV, are to deploy to operations in Afghanistan for three months from April 2008.
Veterans 32. When personnel leave military service their healthcare becomes the responsibility of the NHS. That has been the policy of successive governments since 1948.
Priority treatment for Veterans in Wales 33. In November 2007, the Welsh Assembly Government Health Minister announced that all veterans suspected of having a health condition related to their military service will get priority NHS treatment and care, subject also to clinical need. 34. Previously, only those in receipt of a war pension or an award under the Armed Forces Compensation Scheme were entitled to priority treatment. These measures will extend the arrangements to any of the UK’s five million veterans whose conditions are suspected of being due to service. Beneficiaries of this move include any former member of the Armed Forces with a condition recognised as being due to service, whether related to conflict (eg the operations in the Falklands, Afghanistan and Iraq) or to service more widely. 35. It is not expected that there are many veterans who will come forward for priority treatment for service-related conditions who did not already qualify, but it is hoped that this change will benefit a small number of people whose conditions become problems after discharge and who have not yet applied for a War Pension. The main conditions are likely to be mental health, audiology and orthopaedics. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Mental Health services for veterans 36. Ex-service personnel are entitled to receive treatment through their GPs but we recognise that many health professionals may have limited experience of dealing with veterans with mental health symptoms arising from their service experience. In addition, the military ethos of strength and self-reliance may, for some veterans with mental health symptoms and illness, be an obstacle to accessing civilian health care; we are also aware that some veterans are concerned that there will be no or only limited understanding by GPs of the context of their illness. 37. In conjunction with the Department of Health and Health Departments in Wales and Scotland, we are now launching a number of community mental health pilots for veterans. CardiV is one of six sites across the UK taking part in the two-year pilot scheme which, if proved successful, may be rolled-out to other locations. The facility will have a trained community veterans’ mental health therapist and veterans will be able to access this expert service directly or through their GP, ex-service organisations, the Veterans’ Welfare Service, or Social Service departments. This is on top of the mental health services to which GPs can refer patients, including in-patient treatment or referral to a specialist service if that was clinically appropriate. 38. The facility will be based at the University Hospital of Wales, CardiV and will cover the CardiV and Vale, Pontypridd & Rhondda and North Glamorgan Trust areas. The facility will be funded by the Welsh Assembly Government and Ministry of Defence. 39. For areas not yet involved with the community mental health pilots the MOD has extended the scope of the Medical Assessment Programme (MAP), based at St Thomas’ Hospital in London, to any veteran suVering mental health problems who has served in operations since 1982. 40. MOD also provides funds in respect of the fees for individual war pensioners undergoing remedial treatment at Ex-Services Mental Welfare Society (“Combat Stress”) homes. MOD is the single biggest contributor to Combat Stress. Last year we gave them £2.5 million by way of individual fees, and the Minister for Veterans recently announced a further increase of 45 per cent in the rate of fees to be met by the Department.
Rehabilitation Study to Support Ill 1990–1991 Gulf Veterans 41. The Medical Research Council recommended that further research into Gulf War illnesses should aim to improve the long-term health of Gulf War veterans with persistent symptoms. The Ministry of Defence is therefore looking to place a contract with the aim of designing and testing a programme of rehabilitative interventions to meet the needs of this vulnerable group of veterans. This work might have wider application to other groups similarly aVected by debilitating illness. 42. The aim of the Rehabilitation study entitled, “Trial platform to support ill 1990/1991 Gulf veterans achieve optimal health and well being”, led by Dr Jonathan I Bisson, Clinical Senior Lecturer in Psychiatry at CardiV University, is to identify and address physical, personal, psychological, social and occupational obstacles to recovery and functioning. There is a strong evidence base showing that paid work is generally good for physical and mental health with benefits in well-being, self esteem and social skills. The CardiV team were selected to undertake this programme because of their special expertise in this field.
MOD Relations with the NHS and Welsh Assembly Government 43. MOD maintains regular contact at both working level and the highest oYcial levels with counterparts in the health departments and Veterans’ units of the Devolved Administrations to ensure that health issues aVecting both Serving personnel and their families and veterans are given the consideration they deserve. As well as in these specific areas, the MOD has a Head OYce team responsible for managing Devolution issues in general as they aVect the Department and maintaining relations with the Devolved Administrations and Territorial OYces. We recognise that, with devolution increasingly leading to more varied provision and delivery of public services across the UK, there is an increasing challenge to educate Service families, who continue to rely on locally delivered services, about what they may expect in diVerent areas of the UK.
Partnership Board 44. The key outputs of the DMS are supported by a close working relationship with the NHS, supported by the MOD/Department of Health (DH) Partnership Board. A Concordat, which sets out how the DMS and the NHS will work together to further their individual and mutual aims of delivering high quality healthcare to both the UK Armed Forces and NHS patients, was extended in March 2005 to include the Health Departments of Scotland, Wales and Northern Ireland. 45. The Partnership Board, chaired at senior oYcial level, typically meets 3 times a year and is a forum designed to strengthen further the working relationship between the Department of Health, the Devolved Administrations, NHS and MOD. The Partnership Board has established 3 working Groups to take individual workstreams forward between Partnership Board meetings. The focus of the forward work Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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programme is on tackling key strategic issues in order to produce real improvements in the quality of health of and healthcare provision for Service personnel, their dependants and veterans and in the delivery of deployable operational capability.
Veterans Forum 46. The Under Secretary of State for Defence chairs the Veterans Forum where he meets regularly with oYcials from the Devolved Administrations and other stakeholders to discuss and address issues of concern to the veterans’ community. He also speaks with Ministerial counterparts where issues of concern justify engagement at this level and spoke most recently to Edwina Hart on a range of veterans issues on 4 December 2007. 47. OYcials also have regular contacts and a good working relationship with oYcials in the Welsh Assembly Government on veterans matters. 20 March 2008
Memorandum submitted by John Howard, Chief OYcer, Montgomery Community Health Council
Background Powys has a population of approximately 120,000 people within an area of 2,000 square miles. It is approximately one third of Wales but has no District General Hospital. It accesses these services from adjacent health bodies in England and Wales. Consequently the people of Powys are at the forefront of the stark diVerences in health provision between England and Wales, and often health professionals are seemingly more concerned in highlighting these diVerences than treating the patient’s condition. As a very sparsely populated area, perception is that the needs of the area are not fully included in health service planning. The pragmatic assessment of the impact of changes proposed to health communities in cross border areas is not undertaken, consequently continual polarisation of health services causes increased diYculties for the people dependent on cross border access.
Details of Concerns
Care Pathways Patients have historically followed natural catchment areas not political ones that were influenced by close relationships with GPs, patients and the appropriate hospital, many fund raising initiatives were undertaken to provide added extras for “their” hospital in other places. Access times and public transport reinforce these close links, Montgomeryshire (part of North Powys) provides the Royal Shrewsbury Hospital with some 12% of its business, any significant change in commissioning may precipitate a destabilising of service. Any change in the site of delivery will impact hugely on the patients concerned, for example a patient in Llanfyllin who used to have a bone density scan at Gobowen in England—12 miles and one bus journey away, has now been redirected to Aberystwyth 66 miles away, as the crow flies, but four diVerent buses and 90 miles on the road. This patient is an 84 year old female without relatives who can transport her. Travel in Mid Wales is comparatively slow with little or no dual carriageway and no motorway. It is considered essential that the existing care pathway should continue unless a better service is possible for the patient.
Access Patients are used to having to travel to access specialist services although how they travel varies. Much of the transport is private and public transport is neither destination nor dignity appropriate. People travelling for dialysis or chemotherapy require a suitable, relaxing mode of transport, not found in the public sector. There is evidence of discharged patients from English A&E hospitals being left to their own means to get home in pyjamas/dressing gown. What appears to be a short distance on a map can be a much longer travel time on the road due to road type, single lane and rural traYc etc. a 26 mile journey from Newtown to Llandrindod Wells—part of the spine of Powys—takes at least 40 minutes whatever the weather. Travelling by rail from Mid Wales requires a trip to Shrewsbury before catching the main line south down to Gwent and CardiV, or north to Wrexham. Ease of travel is not a concept that people recognise without the use of a private car. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Emergency Ambulance response times with a national standard target of eight minutes have recently recorded response times of 45–60 minutes. An emergency ambulance call resulting in a visit to the A&E department in England can result in the ambulance being oV-station for some three hours with the consequential reduction in service. Patient travel time or access time is often a half-day commitment or more.
Waiting Times Wales NHS and the English NHS have diVering targets for patients awaiting services. As independent observers the CHC are unsure as to what the determining factor is—is it the capacity to provide the service or money? The CHC’s view is that no patients using the same facility/service provider should have a diVerent length of wait; all “customers” should get the same quality of service. Patients from Wales are regularly used as political footballs being told—“you’re Welsh, you will have to wait”, or “why not come and live in England and you will be treated better”. The diVerence between the payment by results and the historic method is a major problem. If as seems evident there is only a small percentage of aVected people, why shouldn’t the WAG pay the going rate rather than commission a reduced service? The information that the CHC has is that services in English Hospitals are as good as any in Wales and the tariV paid to the English Hospitals is lower than any other reasonable provider alternative in Wales. The management of waiting times by Powys LHB for the English Hospital providers is far from well received by the patients. There is evidence of patients falling into black holes, being on no waiting list despite being referred some years ago and patients expecting to go to a hospital being redirected to another. There must be added administrative systems and costs by having waiting lists at sites that are apart,
Prescriptions Wales’s patients (residents) are now able to get prescriptions free of charge but only on a Welsh prescription sheet/pad in a Welsh pharmacy/dispensary, however, when a Welsh resident is taken to A&E in an English hospital (no choice) and is given drugs they are expected to pay the English charge, often sent by invoice. If the charge is disputed debt collection agencies become involved. Similarly dentists giving prescriptions are subject to the same rule. The CHC will be interested to observe the possible introduction of free parking at hospitals when Welsh residents have to access services in English hospitals.
Equity and Equality With the NHS being driven by finance, equity when dispensed on a per capita basis deprives low populated areas of equality of services. The basic core service takes a higher percentage of the sum total due to minimum core levels that have to be provided, leaving less flexibility or variable money for discretionary services or lower priority services. Consequently rural/sparse communities are disadvantaged in a per capita allocation when the cost of rurality provision is not recognised.
Ambulances In a relatively large, sparsely populated area without a District General Hospital, having to access services outside the area puts demands on an ambulance service as it cannot be on call until it is back on its patch. This results in individual calls taking up to three hours. Fast access to hospital care can aVect recovery rate and thereby reduce cost to the NHS, it is imperative that ambulances can access the nearest A&E.
Transfers of Care There are often problems with Transfers of Care as there are diVering requirements. Powys Local Health Board does not always follow the same rehabilitation course that English patients would follow, sometimes preferring to send patients to Welsh Schemes. There is evidence of Welsh patients attending a rehabilitation course at Royal Shrewsbury Hospital and being told you cannot have a kit because Powys doesn’t pay for it. When you are one or two patients in a class of eight or ten this can be very demeaning.
Record Transfer There is evidence of patient records not being similar/compatible, maternity patients rushed to an English hospital do not have notes that are readily transferable or understandable because they are set out in a diVerent way. It is essential that there are minimum communication problems to avoid patient distress. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Education and Ongoing Personal Development As England is often the provider of quality health services for Welsh patients it seems logical that there should be strong links between the hospital sites and the community networks that cross the boundaries to reach the communities within the catchment areas. Integrated information systems and databases would improve knowledge around the cross border services and help refine patient pathways.
UK Integrated NHS The CHC is convinced that specialist services that have relatively low numbers would be better linked covering a safe clinical network embracing the whole of the UK, there may be instances where Wales does not have the critical numbers to maintain safe services.
Partnership There is now considerable good-will and partnership working at a local level. Powys Local Health Board, English Primary Care Trusts, Hospital Trusts, Patient Bodies etc., are working together to minimise operational problems, the strategic and policy level are often the restriction that causes patients to be confused, bemused or frustrated.
Summary 1. There are ethical problems concerning the provision of diVering standards of service to patients using the same hospital—this should not happen. 2. If services are to improve the “managers” must be given the authority to minimise the problems at a local level, the continual ongoing creation of diVerences does nothing to reduce patient frustration with politics. 3. The increased desire to specialise and strategically place these specialised sites required most patient input to travel costs and the more people have to travel creates a less green environment. Recent changes in the consultant contract have caused reductions in clinics in rural areas. 4. The additional cost of delivering a health service in rural areas is not realistically reflected in the funding formula. 5. From where the CHC sits, no one seems to care about resolving/reducing the diVerences, it seems that people should accept what they are given and be grateful. 6. There is almost a rule that maximum waiting times are minimum waiting times.
Supplementary memorandum submitted by Montgomeryshire Community Health Council 1. Terms of Reference for the cross border group. The issue here is more with concern of how to address issues that are outside the group’s control. There is currently work being undertaken to collate evidence from all the representatives to present to the appropriate bodies. 2. Statistics on the number of residents receiving GP services from a diVerent country to their residence. You will note that more people from Wales get treatment in England than vice versa and that Welsh residents treated by Shropshire GPs is increasing slightly with time. 3. I enclose a copy of a letter reflecting a diVerence in service commissioned by Welsh Commissioners at Shrewsbury Hospital.10 4. Whilst I have not seen any directive on ring fencing Welsh NHS spending in Wales, there is actual commissioning evidence as follows: (a) Dialysis Unit proposal at Welshpool to be clinically managed by Welsh. Providers not Shrewsbury (the current renal service provider). This does not seem clinically logical. (b) Bone Density Scans now done at Aberystwyth not Oswestry. (c) Children’s Services (Community) were recommended to be managed/commissioned from Telford & Wrekin, but Welsh Assembly Government vetoed the decision. 16 May 2008
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CENTRAL WALES—WEST MIDLANDS
MEMORANDUM OF UNDERSTANDING ON CROSS BORDER COLLABORATION
Health and Social Care Task Group Terms of Reference
Introduction The Memorandum of Understanding (MoU), was agreed and signed by representatives of the Welsh Assembly Government and the West Midlands Regional Assembly on 5 March 2007. The aim of the MoU is to promote better collaboration between partners and organisations that operate both along and across the border between Wales and England, exploring the potential for cross border co-operation, adding value to the regeneration of the West Midlands/Mid Wales border area and exploring and identifying ways in which this could be achieved.
Health and Social Care The relative importance of health and social care within and across the border communities calls for examining and determining priorities and helping to make decisions as to the focus for activity and investment. The picture is complex, full of interconnecting factors to do with economics, geography,identity, cultures and behaviours. Inequalities within the cross-border area are marked; it is often not specific areas that need support and investment but specific groups of people, eg migrants in farming villages, single pensioners living in remote rural areas, low income families in rural honey pots, unemployed men in ex-industrial villages, etc. Some of these are needs in cross-border areas rather than needs of cross-border areas and face the same complex challenges of diagnosis, intervention, dosage, etc as their equivalents elsewhere. The headline issues include the growing divergence including the legal incompatibility since 2003 resulting from qualification by residency in Wales versus individual registration (with GP) in England. Each year, ministerial dispensations have to be sought. Because of policy diVerences, hospital providers get diVerent rates for English and Welsh patients; there are diVerent standards applied in each hospital with variations in waiting times and patient experience, which is inevitably more stressful. There are diVerent policies at Government level and also at Local Authority level. People tend to use “natural” boundaries rather than political when seeking the services they require.
Health and Social Care Task Group The Task Group will develop and promote closer cross-border working and collaboration specific to health and social care in order to realise the aims of the MoU and oversee subsequent implementation has gained momentum in recent months. The workshops held after the signing of the MoU in 2007 highlighted that health & social care is a significant contributor to peoples’ wellbeing and their quality of life but some very real and important challenges exist.
Membership The membership is to be drawn from the public, private and voluntary sectors at Cabinet/Chair Level in recognition of their expertise in achieving the aims of this group: Powys County Council—Elected Members and Social Care Directors Shropshire County Council—Elected Members and Social Care Directors Herefordshire County Council—Elected Members and Social Care Directors Herefordshire Alliance Montgomery Community Health Council Brecknock & Radnor Community Health Council Gwent Community Health Council Clwyd Community Health Council Powys Association of Voluntary Organisations (PAVO) Powys Local Health Board Shropshire Primary Care Trust Herefordshire Primary Care Trust Institute of Rural Health Welsh Public Health Group West Midlands Public Health Group WMNHS Welsh Assembly Government West Midlands Regional Assembly Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The above membership list will include providers from across the public, independent and the voluntary sectors. The list can be extended to include other organisations with the agreement of the Chair and it is expected, from time to time that expert advisers will be co-opted for a short period.
Chair Joanna Newton, Chairman of the Herefordshire Primary Care Trust agreed to chair the Task Group for the first six months thereafter the position would be reviewed and a system of rotation agreed.
Meetings Members will determine the frequency of the meetings. It is anticipated that the Task Group may meet more frequently in the initial stages and then three to four times per year.
Secretariat Support for the Group Whilst additional specialist support may required at a policy level, Herefordshire Partnership have agreed to co-ordinate and provide the appropriate secretariat support for the Task Group.
Modus Operandi The Health and Social Care Task Group will focus on policy and delivery of activity that is centred round areas of need or relevant thematic or geographic connectivity. The Group will be represented on the Cross-Border Core OYcer Group through the Chair and will be expected to: — Provide reports to the Core OYcer Group on working group activity; — Consider requests by the Core OYcer Group for relevant activity to address emerging issues or opportunities. In turn, the Core OYcer group will: — Provide support to the working groups in the delivery of cross border collaborative activity; — Provide the platform for sharing of best practice; — Identify and promote cross cutting issues and ensure cohesion of activity within working groups. In adopting the principles laid down by the Memorandum of Understanding the Health and Social Care Task Group also agrees to: — Share non-confidential information relevant to the development of policies and services which will impact on border communities in Herefordshire, Powys and Shropshire; — Assist with “border proofing” all proposals for change in policy, funding or service delivery which would apply to border communities, in order to ensure that any detrimental consequences for those communities are identified and mitigating action taken; — Consult each other in good time on proposals for change in policy, funding or service delivery that could impact on communities on the opposite side of the border; — Seek out opportunities for collaboration on policy development and service delivery wherever this could provide eYciencies and/or added value; — Share experience of good practice in rural policy development and service delivery across Central Wales and the West Midlands.
Role To develop and promote closer cross-border working and collaboration specific to health and social care in order to realise the aims of the MoU and oversee subsequent implementation. — To consider Health and Social Care Policy developments across the border area, and potential impacts.
Review and Dissolution — The Task Group will remain task orientated and be subject to regular review to ensure that it remains fit for purpose. — Members should periodically seek legitimacy from their sectors/organisations to continue to serve on the Working Group. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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STRUCTURE OF THE CROSS BORDER GROUPS
Central Wales West Forum Midlands Strategic Sub-group Forum
Core Officer Group
Working Working Working Working Group Group Group Group
Shropshire Residents Herefordshire Total English registered with Residents residents Powys medical registered with registered with practices Powys medical Powys medical practicesa practices 01/04/2001 1,796 1,602 3,398 01/04/2003 1,832 1,631 3,463 01/04/2004 1,834 1,661 3,495 01/04/2005 1,791 1,655 3,446 01/04/2006 1,748 1,647 3,395 01/04/2007 1,708 1,589 3,297 01/04/2008 1,669 1,585 3,254
Powys Residents Powys Residents Total Powys registered with registered with residents Shropshire Herefordshire registered with medical medical English medical practices practices practices 01/04/2001 4,365 1,700 6,065 01/04/2006 4,530 1,669 6,199 01/04/2008 4,678 1,605 6,283 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by the Muscular Dystrophy Campaign
Introduction 1. The Muscular Dystrophy Campaign, in conjunction with leading neuromuscular clinicians in Wales and England, welcomes the opportunity to provide evidence to the Welsh AVairs Committee’s inquiry examining the provision of cross-border services for Wales. 2. We have a number of serious concerns regarding the coordination, eVectiveness and funding arrangements of the cross-border provision of specialist health services. The provision of cross-border health and social care services varies greatly and there are many cases where an inconsistent, haphazard approach by Local Health Boards and Health Commission Wales is evident.
Summary 3. Patients with neuromuscular conditions in Wales require specialist multi-disciplinary care. Some Welsh patients, particularly those in North Wales and Mid Wales, fail to receive such a package of care and need to access services across the border. 4. The Muscular Dystrophy Campaign has uncovered evidence illustrating delays and barriers in accessing such cross-border services, a failure by some Welsh Health Boards to pay for cross border services and an inconsistency in funding cross border diagnostic tests. 5. Local Health Boards in Wales must pay for those cross-border services used by local patients, particularly those services such as physiotherapy currently provided by the charitable sector. 6. There is little accountability when failures relating to cross border issues occur and greater transparency in the system is urgently required. An improved protocol between the Welsh Assembly Government and the Department of Health must be arranged to deal with any discrepancies on cross- border issues.
Note re Submission of Evidence 7. This written evidence has been submitted by Robert Meadowcroft, Director of Policy and Operations, on behalf of the Muscular Dystrophy Campaign.
Nature of the Conditions 8. There are more than 60 diVerent types of muscular dystrophy and related neuromuscular conditions. It is accepted that over 1,000 children and adults for every 1 million of the population are aVected by muscle wasting neuromuscular diseases in Wales. Therefore it is estimated that around 3,000 people are aVected by a neuromuscular condition in Wales. Many neuromuscular conditions are low-incidence conditions and indeed some are ultra orphan. Neuromuscular conditions can be genetic or acquired. 9. A number of these disorders, such as Duchenne muscular dystrophy, are aggressive and cause progressive muscle wasting and weakness, orthopaedic deformity, cardiac and respiratory compromise and result in premature death. Neuromuscular disorders such as these are often present in childhood or young adult life. 10. It has been shown that a lack of specialist neuromuscular diagnosis, treatment and care, particularly for those patients with life limiting conditions, can aVect their life expectancy. In those conditions where neuromuscular specialist services have a less dramatic improvement in life expectancy, there is nonetheless a major improvement in quality of life. 11. The majority of patients with muscular dystrophies have heart related problems. Muscle weakness is often associated with poor ventilatory ability and respiratory failure. These are often overlooked by professionals unfamiliar with these conditions. Pain management is a common feature as these conditions can cause nerve deterioration or neuropathy. 12. Despite the above points, neuromuscular services are not designated as a specialist service by Health Commission Wales.
The Need for Specialist Multi-Disciplinary Care [See Appendix 1] 13. Specialist multi-disciplinary care has been developed by leading clinicians as the best model for delivering eVective care for such complex, multi-system diseases. The provision of expert physiotherapy, orthotics, early cardiac monitoring and intervention and corticosteroids has been shown to improve muscle function and maintain independent mobility.i Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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14. The judicious use of spinal surgery and expert respiratory services (including non-invasive positive pressure ventilation) helps to improve quality of life, delay the onset of respiratory failure and prolong the life of these patients.ii 15. The medical specialists that can deliver diVerent facets of diagnosis and care vary from neurologists (adult and paediatric), to inter alia clinical geneticists, paediatricians, rehabilitation physicians, cardiologists, orthopaedic surgeons, pathologists and palliative care specialists. In addition, specialist physiotherapists, occupational therapists, speech and language therapists and various specialist nurses relating to the above groups have important roles in supporting and monitoring the patient and their family. 16. The development of services for patients with neuromuscular diseases in Wales has been inconsistent and heavily dependent on the research interests of dedicated individuals who have developed a clinical interest in a neuromuscular disease. There is no current strategy in place for succession planning, leaving the services fragile and vulnerable in view of their heavy dependence on the lead clinicians.
Lack of Specialist Multi-Disciplinary Care in Wales 17. Many patients in Wales with a neuromuscular condition do not have access to such multi-disciplinary specialist care. The Muscular Dystrophy Campaign undertook a survey of the 22 Local Health Boards (LHB) in January 2008 in order to build a picture of access to healthcare services for people with neuromuscular conditions. The authors asked the Health Boards to provide information regarding services commissioned locally for people with neuromuscular conditions. 18. Out of the 20 LHBs that have so far responded, the following picture has emerged: — 75% of LHBs who responded do not support a muscle clinic that oVers a service to adults with neuromuscular conditions. — 70% of LHBs who responded do not support a muscle clinic that oVers a service to children with neuromuscular conditions. — 70% of LHBs who responded do not support any adult or child muscle clinics within their area. [See Appendix 2] 19. Health Commission Wales (HCW) responded to our enquiries by stating that none of the contracts set up by HCW contained the level of specification requested. HCW cited weekly adult muscular dystrophy clinics in Swansea run by two consultants. Two English centres oVering specialist multi-disciplinary muscular dystrophy clinics at Alder Hey Hospital in Liverpool and at the Wolfson Centre for Inherited Neuromuscular Disease in Oswestry were highlighted. HCW failed to mention paediatric or adult neuromuscular services in CardiV. 20. There is no requirement within the commissioning structure to ensure that the staYng levels within, for example, paediatric neurology departments in Wales include a specialist in neuromuscular diseases. Most departments rely on the individual interests of applicants for posts rather than recruiting directly a specialist with an interest in a neuromuscular disease. 21. In CardiV part of the adult muscle management services are provided by Clinical Geneticists. There is a serious concern amongst senior clinicians about the threat to prevent them conducting muscle clinics, because this has been deemed outside of the National Definition of the role of a Clinical Geneticist.
Examples: Ventilation 22. Ventilatory support can enable many people with compromised respiratory function to live a longer and better quality life. It is vital that ventilatory services are available for people with neuromuscular conditions if and when they are needed, and that these services are provided by multi-disciplinary teams with experience in managing individuals with neuromuscular disease. 23. Commissioning of services for non-invasive ventilation across Wales is uncoordinated and is varied. For some areas, the LHBs and the specialist commissioner HCW are unclear on whose responsibility this is. This leads to delays for patients in receiving their treatment and equipment to aid them with their breathing.
Physiotherapy 24. Physiotherapy intervention exists in some paediatric clinics. However, these community physiotherapists are not specially trained nor do they have expertise in neuromuscular conditions. These services are reliant on the interest of the therapist and are not strategically planned. 25. The services that are available are dependent on the locality of the patient. A patient from outside the Local Health Board area who is attending the clinic would not be eligible to receive any physiotherapy. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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26. Specialist neuromuscular physiotherapy is not available for patients at any adult muscle management clinic in Wales, other than a specialist respiratory physiotherapist attending most of the bi-monthly neuromuscular ventilation clinics in CardiV. 27. The importance of specialist professionals should not be understated. Specialist neuromuscular physiotherapy for example, has been shown to prevent and minimise contractures, improve mobility and the quality of life of patients for adults and children. 28. A specialist physiotherapy service and specialist muscle pathology services exists across the border at the Oswestry Neuromuscular Centre and neuromuscular physiotherapy services are provided at the Neuromuscular Centre in Winsford, Cheshire.
North/South divide
29. Evidence from the LHBs, clinicians and patients shows those services which are available exist in South Wales. Furthermore, the degree to which they provide a comprehensive service is highly variable. 30. In North Wales and mid Wales there is no dedicated service for patients—adults or children—with neuromuscular conditions. In addition, one of the few lead clinicians in South Wales with a special interest in neuromuscular conditions is retiring in the autumn 2008. It is essential that steps are taken to recruit a successor who is also a neuromuscular specialist to ensure the service continues. In West Wales, a clinic is run, but only in the clinician’s own study time. 31. Many patients cannot access these services and receive inferior services or, indeed, may receive no services at all. 32. Patients from North Wales often travel to the Walton Centre in Liverpool for treatment. It is much easier for them to access specialist services just across the border than to make the long journey from north to south Wales, for example to CardiV or Swansea. The need to access services in England for South Wales patients is less apparent due to existing clinics in CardiV, Newport and Swansea. 33. For a number of reasons, patients from all over Wales may need to be referred further afield, for example for specialist treatment in London hospitals. Some patients in Wales have to travel great distances and at a huge expense to access specialist multi-disciplinary care. [See Patient case A]
Problems Accessing Services Outside of Wales:Neuromuscular Centre (NMC) in Winsford
34. Eight patients from Wales travel to the Neuromuscular Centre (NMC) in Winsford regularly to receive physiotherapy. The Neuromuscular Centre provides a range of specialist physiotherapy with the sole aim of improving the quality of life for adults with neuromuscular conditions. There are currently five patients from Flintshire LHB receiving treatment at the NMC. These five patients travel to the centre every two to three weeks for specialist physiotherapy, which is essential in maintaining their health and independence. 35. However, Flintshire LHB refuses to pay the NMC for the treatment, despite referring the patients indirectly for physiotherapy. Of these five patients, three were referred from Flintshire LHB to the Orthopaedic hospital in Oswestry–a consultant then referred them to the Neuromuscular Centre. One was referred from Flintshire to the Walton Centre for Life and then on to the Neuromuscular Centre, and one patient from Flintshire to the Wrexham Maelor Hospital, where a consultant referred them to the Neuromuscular Centre. 36. Wrexham LHB currently refuses to fund one patient receiving physiotherapy regularly at the NMC. 37. The essential clinical care these patients receive is funded by NMC rather than these Health Boards in Wales. The NMC is a charitable organisation and relies on contributions from LHBs and PCTs for services they use, as well as its own fundraising eVorts. Flintshire LHB use services provided by the NMC at a total cost of £11,000 per annum. All other Local Health Boards using these services provided by the NMC fund their treatment and pay the NMC.
Wolfson Centre for Inherited Neuromuscular Disease, Oswestry:
38. Dr Ros Quinlivan, a specialist in Neuromuscular Disease at the Wolfson Centre for Inherited Neuromuscular Disease, Oswestry, received a copy of a letter via the appointments manager in December 2007 from one Local Health Board which stated that the hospital was not allowed to see any patients from that particular LHB area until April 2008, due to funding constraints. Until then, “provisions would be made to treat patients locally”. Dr Quinlivan replied to the letter asking what provisions could be made Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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locally for patients with neuromuscular conditions, but no reply was received. One patient is known to be currently waiting for an appointment. Such provisions would be impossible to be provided locally, due to the highly specialised nature of care required to treat patients with neuromuscular conditions.
The following are further examples of long waits and problems for patients requiring specialist care from across the border at Oswestry: 39. A young child aged 18 months with a gait disorder. An urgent referral for an appointment was requested. Despite several requests to this eVect and letters from his Paediatrician, approval to see him was delayed by the Local Health Board until 18 months later. 40. A six year old boy with waddling gait had a similar experience. The child had to wait 18 months despite requests for urgent appointments. 41. A woman with dermatomyositis. The referral letter was intercepted before reaching the consultant and the GP informed her that she must wait eight months. The original referral letter was received by the consultant three months later (ie letter dated 30 June 2007, arrived 2 October 2007). 42. Two English patients have been referred to the muscle service clinic in CardiV. Those referrals were refused on the grounds that the patient is from outside Wales. 43. A request for a DNA sample from a Duchenne patient to be sent to London for specialised genetic testing that cannot be performed in Wales was recently refused.
Diagnostic tests 44. Welsh commissioners will not consistently fund diagnostic tests for Welsh patients at recognised specialist centres in England. To ensure timely and accurate diagnosis, it is essential that patients are able to access diagnostic services at recognised specialist centres in the UK. Welsh health commissioners are reluctant to finance the sending of lab samples to recognised specialist centres in England for diagnostic services including: specialised diagnostic stains for muscle pathology and Genetic DNA tests for specific rare disorders. The result is that some Welsh patients receive inadequate diagnosis compared with the rest of the UK. 45. A consultant paediatric neurologist in CardiV reports delays in requests for DNA to be sent outside of Wales for tests. The geneticists have a committee who decide whether or not to agree to tests requested, so some weeks elapse between making the request and the DNA being sent. 46. One SEPN1 analysis (a DNA sample) requested 18 months ago was at first refused, causing delay for the patient and a waste of the clinician’s time in having to follow this up. There is unnecessary work involved for clinicians in Wales trying to organise tests rather than, more simply, putting them through the National Commissioning Group, (formerly known as the National Specialist Commissioning Advisory Group) if they could use the same mechanism as clinicians in England.
Conclusions and Issues for the Committee 47. The Muscular Dystrophy Campaign, in conjunction with leading clinicians both in Wales and England, has made the case that access to specialist services for children and adults with muscle disease is essential. For some patients living with a neuromuscular condition in Wales, this means accessing services across the border. 48. The Muscular Dystrophy Campaign is concerned to hear evidence submitted to this inquiry suggesting that considerable savings can be made for the Welsh health system by ensuring treatment does not occur in England. 49. Local Health Boards in Wales and Health Commission Wales must accept responsibility for the commissioning and funding of treatment provided at specialist neuromuscular centres in England—Welsh patients require access to necessary services. 50. The alarming lack of consistency in the funding of cross-border services by certain Local Health Boards means that when funding is refused, Welsh patients may not be able to access high quality specialist services in England and therefore do not receive the treatment that they are entitled to. 51. An improved protocol between the Welsh Assembly Government and the Department of Health must be arranged to deal with any discrepancies on cross-border issues. Transparency in the system must be improved by ensuring mechanisms are in place for identifying and resolving cross-border deficiencies and patient waiting times. 52. Waiting times held for cross-border patients must be included in all oYcial performance statistics. [Appendix 3] Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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53. For diagnostic tests, the UK Government should consider establishing a centralised fund for rare conditions. Clinicians in England are able to put diagnostic tests for these rare conditions through the NHS National Commissioning Group. 54. Commissioners in Wales must recognise the problems arising from the mix of rural, urban and valley areas that exist across Wales, meaning services are particularly inaccessible and inadequate from some areas; 55. NHS Wales and Health Commission Wales should conduct an urgent review of existing specialist neuromuscular services, in order to establish current gaps in service provision in Wales. 56. A neuromuscular managed clinical network should be considered, utilising specialist services and expertise on both sides of the border.
APPENDIX 1
THE NEED FOR A MULTI-DISCIPLINARY TEAM As these are complex multi-system diseases, a specialist centre requires a multi-disciplinary team approach to care. Most often this involves a network of highly specialised clinicians who are not always based in the same centre. This team comprises: — Adult clinician with specific training in muscle diseases including myasthenia — Adult neurologist with specialist training in neuropathies — Adult and paediatric neurologist with specialist interest in congenital myasthenia — Two Paediatric Consultants with specialist training in neuromuscular disease — Adult and paediatric respiratory physicians who run non-invasive ventilation services and appropriate support staV — Adult and paediatric cardiologists with specialist interest in NMD — Clinical neurophysiologists with a special interest in NMD including single fibre EMG — Clinical geneticist — Genetic counsellor — Specialist Neuromuscular physiotherapist — Occupational therapist — Neuromuscular Regional Care Advisor/patient advocate — Neuromuscular nurse specialist — Clinical psychologist with a special interest in NMD — Muscle and nerve pathologist with a special interest in NMD — Orthopaedic and Spinal surgeons with a special interest in NMD — Orthotist — Dietician with a special interest in NMD — Neuromuscular speech and language therapist Preliminary evidence from a study in progress at the Newcastle Centre in England (highlighted below) has established the benefits for patients of the specialist multi-disciplinary care model.
Benefits of specialised multidisciplinary care—Preliminary evidence from a Qualitative Research Study: The care provided to the families attending the paediatric muscle clinic at Newcastle has recently been assessed by a PhD student who studied the availability of and satisfaction with Home and Community Based Services for Children with Neuromuscular Disorders. The results of this study oVer the first concrete evidence of a positive benefit derived from the care model of a Muscle Centre with multidisciplinary input in improving the experience of patients with chronic disability. These parents were not experiencing the same level of diYculty described in most previous research about the support needs of disabled children and families. Part of the reason for this was felt to be the support provided by the specialist Muscle Team. This qualitative study, supervised by Professor John Carpenter, initially of the University of Durham but now in Bristol, aimed to explore children and young people with neuromuscular impairments and their parents’ experiences with education, health and social care services. The study used the accounts of children and young people themselves and those of their parents or carers, exploring their perceptions of education, health and social care services. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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APPENDIX 2
MDC SURVEY OF LOCAL HEALTH BOARDS IN WALES
Introduction The purpose of the survey was to identify which areas in Wales’s commission specialist muscle clinics for children and adults with neuromuscular conditions.
Method In December 2007, the Muscular Dystrophy Campaign contacted by email 22 Local Health Boards in Wales and under the Freedom of Information Act asked the following questions: — Does your Local Health Board currently support a muscle clinic that oVers a comprehensive service to (a) children and (b) adults with a neuromuscular condition? — If you do support a muscle clinic for children and/or adults, where is the clinic located and who is the lead clinician/Head of service? — If patients are referred out of the local area, I would be grateful if you could indicate this and provide details.
Local Health Boards Who Responded Out of the 20 LHBs that have so far responded, the following picture has emerged: — 75% of LHBs who responded do not support a muscle clinic that oVers a service to adults with neuromuscular conditions. — 70% of LHBs who responded do not support a muscle clinic that oVers a service to children with neuromuscular conditions. — 70% of LHBs who responded do not support any adult or child muscle clinics within their area.
Services Identified The following table and graph set out the percentage of responding LHBs who commission a muscle clinic.
Percentage of LHBs Age group without clinics Have child clinic but no adult clinic 5% Have neither adult or child clinic 70%
Percentage of LHBs without clinics
have neither adult or child clinic age group
have child clinic but no adult clinic
0% 10% 20% 30% 40% 50% 60% 70% 80% Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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It can be said from the evidence submitted by the LHBs that there is limited provision of muscle services in Wales, with a large concentration of the services in the southern regions. Where services are provided, it is often unclear how specialised the service is and patients have to travel long distances within Wales and to London to receive this treatment. Approximately 50% of the LHBs responded by saying that the Health Commission of Wales should be contacted for information on the services provided. Health Commission Wales responded to our enquiries with the following information. None of the contracts that HCW has set up contains the level of specification that was requested. There are weekly adult muscular dystrophy clinics in Swansea run by two consultants. Two English centres highlighted were specialised multi-disciplinary muscular dystrophy clinics at Alder Hey Hospital in Liverpool and Oswestry. The lack of contracts set up with the level of specification sought after is of serious concern. Action is urgently required regarding the paucity of clinics in Wales and the reluctance to commission specialist English services situated close to the Welsh border.
Patient Case A
Rees is seven years old, lives in South Wales and has a life limiting disease—Duchenne muscular dystrophy. He had previously lived within the area of a recognised neuromuscular centre of excellence in England—the Hammersmith Hospital in London. Rees continues to attend this recognised neuromuscular centre for his bi-annual management clinic as there is no equivalent specialist service in Wales. Even then however, this is a round trip of 300 miles, requiring an overnight stay and time oV work for his parents. Despite this, Rees’s parents consider this worthwhile as at the Centre of Excellence he is assessed and reviewed by a multi-disciplinary team of specialists who have expertise and are familiar with neuromuscular conditions like Duchenne muscular dystrophy. Here, his care is managed by a specialist neuromuscular consultant, a specialist physiotherapist, specialist nurse and a family care oYcer who are all trained and experienced in dealing with muscle diseases and the related matters. His health and fitness are reviewed—such as his respiratory health, as are his drugs, physiotherapy regime and also any orthotics and equipment used. In addition, the specialists advise of any other aspects of his management and can be referred to other specialists such as ophthalmologists (in case of cataract development as a side-eVect from taking steroids), a specialist clinical psychologist and also a general discussion about social care and education.
APPENDIX 3 To: SHA Chief Executives Date: 4 February 2005
HANDLING CROSS BORDER ISSUES BETWEEN ENGLAND AND WALES
Arrangements for Secondary Care Service Providers
Welsh providers are required to work to the standards and targets that are set out by the Welsh Assembly Government for all patients who they see and treat. This means that patients from GPs in England who choose assessment/treatment in Wales will be seen/treated within the maximum waiting time targets of the NHS in Wales. These patients will be reported in the commissioner data-sets of the English NHS but the Healthcare Commission have agreed that any breaches of the maximum waiting time in England will not be considered as part of the performance ratings if there is a clear record that the patient has been oVered an alternative appointment/admission that is within the English maximum waiting time. English providers are required to work to the standards and targets that are set out by the Department of Health for patients that are the responsibility of English commissioners. Welsh commissioners will commission work from English providers for patients that they are responsible for so as to ensure that clinical priorities are met and that Welsh maximum waiting times for patients are delivered. These patients will be reported in the English provider datasets but will be separately identified and the Healthcare Commission have agreed that any breaches of the English maximum waiting times by patients who have been referred by a Welsh GP will not be included in the Trust’s performance rating. March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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References i Drachman DB, Toyka KV and Myer E. Prednisone in Duchenne muscular dystrophy. Lancet 1974; 2:1409–1412 and subsequent studies by inter alia Dubrovsky et al (1998) and Manzur et al (2004) ii Annane D, Chevrolet JC et al. Nocturnal ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. The Cochrane Database Issue of Systematic Reviews 2000, 1. Art. No CD001941; Vianello A, Bevilacqua M, Salvador V, Cardaioli C and Vincenti E. Long-term nasal intermittent positive pressure ventilation in advanced Duc henne muscular dystrophy. Chest 1994; 105:445–448; Simonds AK, Muntoni F, Heather S and Fielding S. Impact of nasal ventilation on survival in hypercapnic Duchenne muscular dystrophy. Thorax 1998; 53:949–952.
Supplementary memorandumm submitted by the Muscular Dystrophy Campaign
Waiting Time Statistics The lack of publicly available statistics for the waiting times of Welsh patients in England and English patients in Wales means that problems in this area of service provision are not properly identified and addressed. It is not clear whether the data is being formally collated, but it is certainly not revealed to the public and is kept separate from the data for waiting times of patients within the same country. It seems from the Department of Health Protocal (cited as Appendix 3 of the Muscular Dystrophy Campaign’s Written Evidence) that the Healthcare Commission has explicitly approved a procedure which allows Secondary Care Service Providers to withhold vital information relating to cross-border waiting times. The management of the performance ratings of Trusts and LHBs in England and Wales is therefore deemed to be more important than identifying issues requiring urgent attention concerning waiting times. Publishing these statistics is necessary to contribute to the improvement in cross-border health services through highlighting the problems. June 2008
Memorandum submitted by Elizabeth Newman I live in Kington in Herefordshire, a very small market town, in Herefordshire and just under two miles from the Welsh Border. Locally I am a Town Councillor, the Vice Chairman of the Herefordshire Association of Local Councils and also a Board Member of the West Midlands Regional Assembly, but I submit this evidence as an individual. I became aware only last week of this Select Committee’s present work on Cross Border Public Services. Our town has half its social and economic hinterland in Powys, these are people who use local services in Kington, shop here, socialise here, and use the doctor’s practice here. In the past it has proved to be very diYcult to co-ordinate grant aid and social issues because of the diVerent sets of rules with Development Agencies and other bodies each side of the border and consequently border communities regularly lose out. There are many examples of that. There needs to be a flexibility with the Development Agencies, and other funding bodies when project funding limits itself to Wales or England as the border communities find themselves frequently disadvantaged when agreement on projects and initiatives which need to cross the border to be eVective are caught up in red tape and prove to be impossible to progress as there seems to be no permeability of OVa’s Dyke on these matters. A recent and most welcome cross border initiative, begun in Kington and now developing further along the border is the working together of the local police in West Mercia and Dyfed Powys who are stationed along the border communities. This means the nearest available oYcer attends an incident, or both forces work together on a larger incident close to the border area. This is welcome and is saving time and eVort, and undoubtedly when a road traYc accident is involved, it is saving life and further accidents. This type of arrangement needs to also work with ambulances and first responders in a cross border co- operation. I believe there is an informal arrangement, but this needs to be formalised and its continuance ensured when the West Midlands Ambulance Trust has a its new central call centre fully operational.This is a concern to border residents. Regular meetings of Health Service professionals and users from both sides of the border would assist in identifying where Health Authorities and other services can work together to give a better service to the communities who are isolated from major centres of population in their locations along the Welsh Border. I would request that the Select Committee investigate this possibility. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The future of Knighton Hospital is of concern to communities on both side of the Welsh Border who use its facilities. The local doctors’ practices have patients in both Wales and England, and this can be confusing to people who live in Powys with a Herefordshire address and postcode, who get taken to Hereford Hospital after a 999 call, then moved to a Powys Hospital, with social care for elderly coming via Powys County Council and Health Authorities, who travel many miles to visit patients on the border when there are Herefordshire facilities nearer. This happened to my elderly in laws who live in Powys as the border runs along their garden edge. It confused them a lot. The issue of radiotherapy being made available in Hereford for patients from both side of the border is a very high profile concern at present. Patients from Herefordshire and Mid Wales, as far away as Llanidloes have to travel to Cheltenham Hospital for radiotherapy, as I did, only a 125 mile round trip for me, but twice that for some people from Mid Wales on three days a week. Chemotherapy will soon be available in Hereford for cancer patients, and there is a campaign to also bring radiotherapy to Hereford to stop these very long journeys which many people do not continue with after a few treatments, or do not wish to go again if the cancer returns. Provision of an important facility like this in Hereford, will benefit cancer patients from Mid Wales as well as those in Herefordshire, and I would request that the Welsh AVairs Select Committee take evidence from the person from Kington who is leading this campaign, Allan Lloyd to hear the vast amount of evidence he has gathered from across Mid Wales in support of this. There is presently an initiative developing from the Memorandum of Understanding between the West Midlands Regional Assembly and the Welsh Assembly to bring about regular dialogue between Town and Parish Councils located along the borders of Herefordshire and Shropshire. This will be a way of taking information to a grass roots level, and also a way that the border communities can exchange views, experiences and identify problems which arise from location along a national border. I believe that there is still a place for someone to come along to give evidence to the Select Committee on the cross border heath issues, and would ask that consideration is given to this being someone who lives in a border community and experiences the diYculties on a day to day basis as an individual or a health professional. The people who live along the border are the people who know what it is like and where improvements or changes might be made to make life easier for border communities. 20 March 2008
Memorandum submitted by the NHS Confederation The NHS Confederation is the independent membership body for the full range of organisations that make up today’s NHS. Our membership includes over 95% of NHS organisations—acute trusts, ambulance trusts, mental health trusts, primary care trusts (PCTs), foundation trusts and special and strategic health authorities. The Welsh NHS Confederation is the part of the NHS Confederation which represents all Local Health Boards and NHS Trusts in Wales. We represent NHS organisations on workforce issues through NHS Employers and independent sector members who provide NHS services are also part of the NHS Confederation. The NHS Confederation welcomes the opportunity to give evidence to the Welsh AVairs Committee inquiry on the provision of cross-border public services for Wales. This evidence sets out our views on the provision of cross-border issues as they aVect health and social care, based on feedback from a cross-section of our member forums and networks. Executive Summary — The way the health systems are developing is creating diYculties on both sides of the border when they interact with one another. — Our members believe these diYculties cannot be solved by purchasers or providers and needs clarity from Government.
Overview Devolution has created four diVerent health systems in the United Kingdom and each shares the same core values although there are diVering approaches to the use of mechanisms, for example, competition. The period since devolution has been unique in the history of the NHS as it was essentially the same across the UK before 1999. Since then, England has given priority to market-based reforms and has concentrated on cutting waiting times and oVering patients more choice. Wales and Scotland have taken a diVerent, less- market orientated approach. Wales has also introduced free prescriptions and Scotland now oVers free personal care. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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It is too early to know which system is more successful. Each has its advantages and disadvantages. However, as time passes, these diVerences will become greater and the health systems will diverge to an even greater extent. This is not necessarily a problem. In fact, communities are diVerent and, in each health system, local decisions planned and executed by managers and clinicians can best meet local needs. The extent to which cross-border public services are currently provided for and accessed by the Welsh population The diVering legislative frameworks in England and Wales (outlined in appendices one and two) have resulted in a lack of clarity with regards to commissioning arrangements for patients who were living in border counties between England and Wales, and who were registered with a GP on the other side of that border. The NHS Confederation convened a meeting of members from both sides of the border and, as a result, the Department of Health and the Welsh Assembly Government agreed an interim handling strategy to help commissioners and providers manage cross border flows of patients. This is made more diYcult by the diVerent emphasis on commissioning in the two countries. PCTs have held many more powers than local health boards (LHBs). Patients resident in the area of specified Primary Care Trusts but registered with a GP in specified Local Health Board areas in Wales — LHBs in border areas will be responsible (on behalf of the PCT where the patient is resident) for the commissioning of services for patients who are resident in the named PCT but registered with a GP in the LHB’s area. This will also apply to services commissioned by the Health Commission Wales (Specialist Services, HCW) which will be responsible for the operational commissioning specialist services for such patients on behalf of the specified PCTs. Patients resident in the areas of specified LHBs in Wales but registered with a GP in specified PCT areas in England — Those specified English commissioners (PCTs) will be responsible (on behalf of the LHB where the patient is resident) for the commissioning of services for patients who are registered with a GP in their area but resident in one of the specified LHB areas in Wales.
Summary: Separation of commissioning role for patients resident in each country The table below summarises the previous paragraphs. It indicates which commissioner, either the English primary care trust or Welsh local health board, is responsible for the commissioning of services depending on where the patient resides and which area their GP is based.
GP practice based in . . . England Wales Patient registered in . . . England Primary Care Trust Local Health Board Wales Primary Care Trust Local Health Board
The PCTs bordering Wales and covered by these issues are Shropshire County, West Cheshire, Herefordshire, Wirral and Gloucestershire. The LHBs are Flintshire, Wrexham, Powys, Monmouthshire and Denbighshire. The operational responsibility for actually commissioning between PCTs and LHBs is undertaken by NHS contracts. The financial flows are dealt with centrally and LHBs are expected to meet Welsh targets, and PCTs English targets. OYcials from the Department of Health and the Welsh Assembly Government continue to work together to explore issues arising from the implementation of the policy position on cross border commissioners. In the meantime the Interim Protocol remains in place.
The arrangements currently in place to co-ordinate cross-border public service provision, including funding issues The growing diVerences between the provision of health care in Wales and England, including diVering financial policies, make it clear that there are a still number of issues to be addressed between the two countries. These include:
Allocations
— The diVerent allocation mechanisms and, therefore, the diVerent resources available make it diYcult for both providers and commissioners. A technical solution between the two governments is needed if the problems for the service and for patients are not to increase. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Information Issues — The lack of common patient databases and information systems make it diYcult to track and monitor cross-border flow, its impact on services, as well as design properly integrated patient pathways.
Choose and Book & GP Referrals — This policy does not apply in Wales and this makes it diYcult to deal with split lists for patients registered with a GP both sides of the border.
Waiting Times — The two governments have adopted significantly diVerent waiting time targets. This makes it very diYcult as provider trusts are being asked to maintain two systems. Clinicians find it very diYcult to have diVerentiated standards for groups of patients. This is likely to get worse as the 18 week target is met within England.
Prescribing — As from 1 April 2007, Welsh residents pay no prescription charges.
Practice-Based Commissioning — The eVect on PBC near the border needs scoping, with consideration of possible mitigation (as PBC may only be able to be applied to part of GP lists, as Wales is not currently implementing this policy). As with the GP Contract position, this does represent a challenge to whole systems working along the care pathway.
Payment By Results — The payment by results (PbR) tariV, ie the amount hospitals receive for a specific diagnosis, is set nationally in England. The hospital receives the full tariV for every patient treated. This is not a method used in Wales, where contracts are predominantly block and where excess cases are paid at a marginal rate. The impact of this is that hospitals are paid less for treating Welsh patients. — For example, one foundation trust is in the position that 20% of its activity derives from Wales— a significant proportion of their income. The foundation trust has had a long-standing dispute with Welsh commissioners over the funding of the work carried out in England by the foundation trust. There is a gap of at least £1.5 million between the money that the trust would receive for treating English patients and the income it receives from Wales. The foundation trust reached an interim agreement with the Welsh commissioners to pay £1 million towards a cost of providing services of tariV of £2.5 million. — The issues stem from the fact that the Welsh commissioners hold a position which means they will only fund marginal costs for extra activity. Critically they do not recognise any equivalent to PbR income. If the foundation trust were being paid on the basis of PbR they would be receiving around £4.5 million. — Any trust or foundation trust has no leverage in the system to be able to resolve this situation with their LHB. Similarly, the LHB does not have an allocation suYcient to cover its costs at the PbR tariV rate. The participants in these situations are finding it a very diYcult issue to engage with. — Clearly, hospitals in England do oVer diVerential waiting times and deliver the waiting time required by either country. This is ethically and organisationally challenging for these hospitals. — Waiting times are an issue that highlight some of the diYculties that cross border working can present. Cross-border service provision adds administrative complexity and, from a patients’ perspective, it is diYcult to understand that, for example, one side of a street can be in Wales, another in England, and they will have diVerent waiting policies, prescription charges. This can cause confusion and concern among patients who will try to change GPs to get round the system. — Evidence from the University of SheYeld’s review of ambulance travel times suggests that for some patients, particularly respiratory conditions, increased travel time can have an adverse eVect. In conditions such as trauma, stroke and heart attack being able to go the nearest centre with highly specialist expertise is important. It would be regrettable if rules about funding were to cause either of these two adverse eVects. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Specialist services — Concern has been expressed by English providers of specialist services about proposals to route patients to tertiary services in Wales. For residents of North Wales providers of these services in England are much more convenient. It is also their view that for some highly specialist services, the population of Wales is significantly too small to provide a clinically and financially safe and viable population base. Our members would argue that patient choice of where to be referred needs to be considered. NHS Confederation March 2008
APPENDIX ONE
Legal Position in Wales 1. Regulation 2(2) of the Local Health Boards (Functions) (Wales) Regulations 2003 (SI 2003/150 (W.20)) provides that Local Health Boards (LHBs) are responsible for patients who are “usually resident in their area”. If there is any doubt as to where a person is usually resident, regulation 2(3) indicates how “usually resident” is to be interpreted. 2. Save for the specialist services that are set out in the Schedule, as amended, to the Local Health Board (Functions) (Wales) Regulations which are the commissioning responsibility of Health Commission Wales (HCW), LHBs are responsible for commissioning medical services on behalf of all persons who are usually resident in the area for which they are established. LHBs have both the legal and operational responsibility for commissioning health and well-being services for their resident populations. 3. References in this document to Local Health Boards should be construed as referring to HCW where the specialist services, prescribed in the Schedule, as amended, to the Local Health Board (Functions) (Wales) Regulations are to be commissioned.
APPENDIX TWO
Legal Position in England 1. Under regulation 3(7) of the NHS (Functions of Strategic Health Authorities and Primary Care Trusts and Administrative Agreements) (England) Regulations 2002, as amended, Primary Care Trusts (PCTs) are responsible for commissioning: (1) services listed in regulation 3(7)(b) (eg accident and emergency services and ambulance services) for all persons present in their area; (2) other services for: (i) patients of persons providing primary medical services in respect of whom the PCT is “the relevant PCT” under the Regulations: (regulation 3(7)(a)(i)). This does not include prisoners. They will fall instead under (ii). Subject to one exception, they will be treated as usually resident at the prison in which they are detained: (regulation 3(8A) and (8B); (ii) persons who are not the responsibility of another Primary Care Trust by virtue of 3(7)(a)(i), but are either usually resident in the PCT’s area, or are non-UK residents present in the PCT’s area regulation 3(7)(a)(ii)). 2. Therefore, in general terms the English system operates on GP registration but if a person is not registered with a GP in a PCT area (including if they are registered with a Welsh GP) there is a default to the PCT where the patient is usually resident. PCTs have both the legal and operational responsibility for commissioning health services for their resident populations. February 2008
Memorandum submitted by North Bristol NHS Trust 1. North Bristol NHS Trust (NBT) is a large teaching trust based on two main sites in north Bristol. We provide a comprehensive range of services to the local population and some specialist services on a wider regional basis, across the South West of England. Our total income is £420 million. 2. We have service level agreements (SLAs) with all the primary care trusts (PCTs) in the South West of England who pay on a mainly cost per case basis in line with the NHS national operating framework. We also treat some patients from further afield in England under the non contract agreement rules, which require PCTs to pay for all treatment, with prior approval (from the PCT) only required for treatments that will cost over £10,000. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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3. Whilst parts of Wales are closer geographically we only have an SLA with Monmouthshire Local Health Board (LHB) incorporating GP practices identified as “cross border”. Only five of the 14 practices within the contract allow referrals across the border. For all other activity, either within the Monmouthshire LHB SLA or for Non-contracted Activity (NCA) elsewhere in Wales there is a requirement to obtain prior authorisation (from the LHBs or HCW) for each elective episode of care. 4. Health Commission Wales (HCW) purchases on a cost per case basis all specialist activity for Welsh patients defined by resident postcode or by registered GP practice for the cross border practices. The Welsh specialist definition set has not been updated since its production (2003), although HCW has set out to implement changes to the definitions based on historic resource mappings which are either diYcult for an acute Trust to implement or have been challenged by the Local Health Boards expected to pick up the financial impact of these changes. 5. In total the Trust receives about £2 million in income from Wales. This is invoiced at the same tariVs as for English PCTs. 6. Welsh patients attending the Trust are mainly treated within English waiting time standards, although the longer Welsh waiting times may be deployed if this helps the Trust where there are capacity constraints. Shorter English waiting times may be an incentive for Welsh GPs to continue to refer, despite the Welsh Assembly and LHB’s requirement for Welsh patients to be treated within Wales under existing block contracts. 7. Welsh GPs continue to refer (some 500 patients per annum), as do consultants from Welsh tertiary centres, without obtaining prior authorisation from the commissioning body. Seeking prior approval or returning referrals to GPs (some 20% are rejected for approval) causes delay and uncertainty for the patient and is contrary to the Choice and Access agendas operated in England. 8. In addition the Trust has to carry out additional administrative work to gain such approval, often for minor financial values. The financial risk is entirely with the Trust to monitor access to the hospital. Even in cases where authorisation is requested and received, the final invoice will often be challenged if the patient’s care exceeds the estimated cost of the funding requested, eg if the patient requires ITU/HDU which was not factored into the original request. Queries on invoices are slow and significant patient detail is requested to support invoices for both emergency and elective work. Emergency activity is not settled if there are queries on elective activity within the same invoice. 9. Undertaking care for unauthorised welsh patients represents a financial risk to the Trust under the current arrangements. 25 March 2008
Supplementary memorandum submitted by North Bristol NHS Trust I am writing in response to the Committee’s request for clarification of North Bristol NHS Trust’s arrangements for the provision of care to Welsh patients in relation to the article in the Western Mail on 23 April 2008. In March 2006 the Welsh Assembly Government published updated guidance on Cross Border Financial Flows.11 Paragraph 8 sets out what “English providers to seek prior authorisation for any elective activity undertaken for Welsh Commissioners not covered by contract”. In practice this has meant that a referral from a Welsh GP cannot be accepted without approval from the Local Health Board (LHB) or Health Commission Wales (HCW) for specialist treatments. This is an additional control over and above the English process whereby only treatments costing over £10,000 require further approval and therefore in most cases the GP referral is an agreement to pay. Since that date Welsh Commissioners have rigorously applied that guidance and have refused to pay in cases where the Trust has not obtained prior approval. Over the last two years the Trust has sought to ensure that internal procedures within the Trust act as an eVective gatekeeper such that prior approval is always obtained from the commissioner. Unfortunately that has not always been the case and so reminders have been sent out to staV notifying them of the necessity to obtain approval. The article in the Western Mail is based on a leaked version of one such reminder. The reminder to North Bristol NHS Trust staV stated that Welsh patients must not be booked onto waiting lists until prior approval from the commissioner has been obtained. The journalist chose to quote only the first part of this message and not the important second element. A North Bristol NHS Trust spokesperson did clarify that this briefing was about obtained approval prior to booking the patient onto the waiting list.
11 www.wales.nhs.uk/documents/WHC-2006-012.pdf Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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The approach taken by Welsh commissioners places an additional administrative burden on English providers, but whilst they operate this policy North Bristol NHS Trust will not book Welsh patients onto waiting lists unless and until approval has been obtained, thus ensuring that we are not financially exposed. May 2008
Memorandum submitted by North Cheshire Hospitals NHS Trust I write to confirm that given our limited activity with our Welsh PCT colleagues I do not feel that the Trust would be able to add value to your inquiry. I enclose an overview of our activity profile of Welsh residents since 2004–05 for the purpose of your inquiry.
Activity for Welsh PCTs—PCT Code Begins With 6 Data as at 9 February 2008
A&E/MIU ATTENDANCES
Site 2004–05 2005–06 2006–07 2007–08 Warrington 179 178 173 157 Halton 62 59 66 31 Grand Total 241 237 239 188
ADMISSIONS
Site 2004–05 2005–06 2006–07 2007–08 Warrington 66 73 76 71 Halton 22 15 13 3 Grand Total 88 88 89 74
OUTPATIENT ATTENDANCES
Site 2004–05 2005–06 2006–07 2007–08 Warrington 166 178 159 149 Halton 69 58 46 32 Grand Total 235 236 205 181
Allan Massey Chairman North Cheshire Hospitals NHS Trust February 2008
Memorandum submitted by North East Wales Institute of Higher Education (NEWI)
PROVISION OF CROSS-BORDER PUBLIC SERVICES FOR WALES The North East Wales Institute of Higher Education (NEWI) is an expanding Higher Education Institution (HEI) with approaching 8,000 students, that is in the final stages of its application for taught degree awarding powers and university title. NEWI has been a full member of the University of Wales since 2004 and is based in Wrexham. With that comes an essentially Welsh ethos. The Institute has close collaborative links with HEIs and Further Education Colleges (FECs) and with businesses in both Wales and England. Given its location less than ten miles from the border with England, NEWI is uniquely qualified to comment on cross-border provision of public services following devolution, informed by both consultancy work and practical experience. NEWI welcomes the call for evidence. The Senior Executive at NEWI would be supportive of any further work on cross-border issues, both by entering into debate with the Committee and by taking forward research into these issues. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Health and Social Care Issues The first few years of devolution have been relatively easy years because governments at the Assembly and Westminster have been of similar political persuasions (Jackson-Read & Watkins Young 2005). With the Conservative party making inroads into the long standing Labour majority at Westminster however, the prospect of two diVerent parties being in power at CardiV and London becomes more likely.This brings with it the possibility that diVerences in health and social care provision between UK nations, already emerging, may become increasingly evident, with implications for choice and cross border and, perhaps in particular, near border experiences. Despite Labour Governments being in place at Westminster and CardiV (until 2007) diVerences have developed in relation to health and social care services. Bogdanor (1999) suggests that a “diVerent standard of social welfare” (p.169) has come to exist in Wales and England. Keating (2005) suggests Labour Governments in Scotland and Wales face more electoral competition from left facing nationalist parties and hence have stuck more to traditional social democratic philosophies of public service delivery. The First Minister, Rhodri Morgan refers to his philosophy as “21st century socialism” that establishes “clear red water” between Westminster and CardiV. Accordingly, the emphasis in Wales in health and social care has been on public services working together to deliver improved “universalist” services to all people. The emphasis in England has been on driving up standards through competition and privatisation with increased targeting of health and social care funding in particular. As an example of how this translates in practice in social care, whilst in England some of the money given to the Children’s Fund was ring-fenced for services to children and young people who had oVended, the Welsh Assembly Government delegated the money to local authorities without any ring fencing conditions. Giving evidence to the Richard’s Commission, the head of the Youth Justice Board perceived this as creating very diVerent experiences for children and young people caught up in the youth justice system in England and in Wales. Giving evidence to the same commission the “Disability Wales” group recorded their view that the Assembly had used its powers to the advantage of disabled people in Wales with charging policies for social care services being significantly less stringent than in England. According to Davies (2003), in the health field Welsh Labour has made limited use of the private finance initiative, has rejected foundation hospitals and the use of private diagnostic and treatment centres. Rhodri Morgan objects to foundation hospitals because, “the experiment will end not with patients choosing hospitals, but with hospitals choosing patients”. His preference is for hospitals to “develop specialisms through collaboration rather than competition between trusts”. Political philosophies aside, Wanless (2003) argues that health and social care demands in Wales are very diVerent from those in England and hence on purely pragmatic grounds there has been the need for diVerent policies in Wales. Wales has a greater proportion of elderly people and an ageing population that experiences greater the impact of socio-economic factors on general health and well being (with lower than UK average life expectancy). Equally it is a country with a dispersed rural population. His report recommended a series of reforms, with an emphasis on prevention rather than cure. A particular issue in relation to cross border Health and Social care provision relates to language and culture. In Wales, Welsh speakers make up around 20.8% of the population. Welsh speakers required to access services in England may not be aVorded the equality of access to services in the language of their choice as they might do under the provisions of the Welsh Language Act in Wales. Research suggests that Welsh speakers, who do not receive services in the language of their choice, feel that the service they receive is inferior (Misell 2000, Cwmni Iaith 2002, Irvine et al 2006).
1. The extent to which cross-border public services are currently provided for and accessed by the Welsh population. Being primarily home based, concerns about cross border social care provision have primarily arisen in respect of a perceived post code lottery in terms of charging policies within Wales and between England and Wales. There is published evidence of lack of capacity in terms of in-patient health service provision in Wales however. This relates to specific conditions, including patients with heart disease, patients requiring haemodialysis and those suVering from muscle disease. The British Cardiology Society set up a working group to investigate variations in services and clinical activity and to explore their origins. The report discloses compelling evidence of major diVerences in service provision, activity and aspirations between the developed nations. Wales and Scotland fare badly in terms of access to coronary angiography and Wales has the lowest overall rates of revascularisation (Brooks 2005). Most haemodialysis patients are elderly and dependent, and therefore require centralised dialysis units rather than home treatment. As White et al. (2006) points out, a small number of Welsh residents obtain treatment across the border in Shrewsbury, Hereford, Liverpool and Chester, and a few English residents receive treatment in Wales. Only one centre in Wales (CardiV) undertakes renal transplants, but patients from North Wales are transplanted in Liverpool. Dialysis capacity in Wales is overwhelmed with areas of relative under-provision and over 20% of the population living more than a 30 minute drive from a dialysis unit (White et al. 2006). Philip Butcher, chief executive, said: “People with rare illnesses are living longer Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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thanks to medical advances and yet NHS services in Wales are failing to meet this demand” (Lister 2008). Moreover, as the Welsh Secretary Paul Murphy has admitted, patients in Wales with muscular dystrophy are also not getting the service they are entitled to. CardiV MP Jon Owen Jones attacked the assembly government’s lack of enthusiasm for Private Finance Initiatives and warns that rejecting foundation hospitals will mean there is a danger that English foundation hospitals do not have an obligation to treat Welsh patients from over the border (Davies 2003). In addition to the above published information, further evidence from Flintshire LHB revealed that approximately 36% of Flintshire patients have NHS secondary care services provided by English NHS Hospitals due to the County bordering England. This will be the same for Powys and other counties bordering England.
FIGURES FOR SECONDARY CARE ACTIVITY FOR 2006–07 WERE:
Emergency Hospital Outpatient Inpatient Day Case Admission Split NEWT 12,607 1,658 2,534 4,880 33% C&D 12,962 1,265 2,816 3,482 31% COCH 13,421 1,198 3,301 5,650 36% Total 38,990 4,115 8,651 14,012
North Wales’ patients also receive specialist tertiary services from English Trusts (such as Neurology, Cardiothoracic, specialist Cancer Treatment, Orthopaedics (Gobowen) etc). No contract activity is available (see section on funding below).
2. The arrangements currently in place to co-ordinate cross-border public services provision Cross-border health care provision between England and Wales is provided for by the Welsh Health Circular WHC (2007), which states that where patients are resident in an area of a specified Primary Care Trust (PCT) in England, but registered with a GP in a specified Local Health Board (LHB) in Wales, the LHB in the border area is responsible for the operational commissioning of services. Likewise, if patients reside in an area of a specified LHB but are registered with a specified PCT in England, the PCT in the border area is responsible for operational commissioning. This applies specifically to Shropshire County, West Cheshire, Herefordshire, Wirral and Gloucestershire PCTs. Despite this arrangement, however, there is published evidence of lack of co-ordination of cross-border health care provision. For example, a report from the Muscular Dystrophy Campaign indicated that despite treatment being available on the border at a unit in Oswestry in Shropshire a Welsh health board said funding constraints meant it could not commission services (Lister 2008). This is recognised by Tory MP for Clywd West, David Jones, as a flaw in cross-border health care, which particularly aVects patients in north- east Wales who often travel to Chester, Liverpool and Manchester for specialist treatment. This means that although patients in Wales pay the same taxes as those in England, they do not get health services of equal quality, thus resulting in a postcode lottery within the NHS (Lister 2008). We therefore need “a policy across the NHS that the prescription of drugs for serious conditions and the treatment of serious conditions should be determined on a UK-wide basis, and such a policy should be agreed by the Labour party in all parts of the UK” (Lister 2008). Local evidence from Flintshire LHB, suggests that cross-border arrangements/ commissioning for secondary care services in terms of Long Term Agreements are the responsibility of the individual LHB, albeit the process is managed on a North Wales Consortium basis. In terms of tertiary services, these are commissioned by Health Commission Wales. The arrangements include the monitoring against Welsh Assembly set targets, so there are some issues about two patients from Wales and England waiting for the same treatment that may have diVerent waiting times due to the diVerent access targets.
3. The funding of cross-border public services A DoH (2007) protocol for cross-border issues for NHS-funded nursing care in care homes in England and Wales provides guidance on funding of care homes. This states that where cross-border placements are made from England to Wales, and vice versa, and the resident is entitled to NHS funded nursing care, the council and the health body in the country that the resident is moving from should inform the council and the health body in the country that the resident is moving to. Furthermore, the level of funding will be that in operation in the destination PCT/LHB. More specifically,the protocol distinguishes between those already in care homes at 1 April 2004 and those admitted after this date. For those already in a care home at 1 April 2004, who previously lived in Wales, but are now in an English care home, assessment and funding is the responsibility of England, whilst for those previously living in England, but now residing in a Welsh care home, assessment and funding is the responsibility of Wales. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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In relation to residents moving into a care home after 1 April 2004; for those who previously lived in Wales, but entered an English home, assessment and funding is provided by England before admission, but if this is not possible, the LHB will assess and then inform the destination PCT. For those who previously lived in England, but entered a Welsh home, assessment and funding is provided by Wales before admission. Again, if this is not possible, the PCT will assess and then inform the destination LHB. Local Authority funding arrangements are also provided in the same protocol. In relation to residents in LA care homes at 1 April 2004, those living in English care homes, but funded by a Welsh LA are assessed by the PCT, which then informs the Welsh LA who then fund the place. In contrast, those living in a Welsh care home funded by an English LA, are assessed by the LHB, which then informs the English LA who then pay for the place. DiVerent arrangements apply for residents entering a care home providing nursing care after 1 April 2004. Those living in England and planning to move to a Welsh care home are assessed by the PCT, which informs the LHB of needs. The Welsh LHB then funds the place. Those living in Wales who plan to move to an English care home are assessed by the LHB which then informs the PCT of needs. The PCT then funds the place. The protocol also makes provision for payment and contractual arrangements where cross border relationships exist, in which partnership arrangements involving lead commissioning and or/pooled budgets should be developed. Local evidence from Flintshire LHB outlines arrangements for LHB funding of treatment for secondary care. The agreement is for LHBs to pay on a historical contract process basis and not Payment by Results (PbR) which is the English TariV. Health Commission Wales commissions tertiary services, some of which will be provided in England. They have an annual budget, some of which will be spent with Wales’ specialist providers (usually South Wales) and some with English Trusts for North Wales’ patients. Their commissioning plan for 2007–08 is attached via the link below (this is a public document) http://wales.gov.uk/dhss/publications/healthcommission/2011176/hcwcommissionplane.pdf?lang%en Some other issues, as they apply in Flintshire, are that England has PALS (Patient Liaison OYcers who replaced Community Health Councils some time ago) and the Choice initiative whereby a patient can choose which hospital they are treated by. Wales still has Community Health Councils and some Welsh Trusts have implemented a slightly diVerent version of PALS but we do not have Choice. In relation to Primary Care, there will be some patients who live in Wales and who are registered with an English GP and their care is the responsibility of the PCT and is funded by them (Saltney, Saughall etc). There will also be some patients living in England and registered with a Welsh GP. The relevant local health board would be responsible for the commissioning and funding for those patients. The references for this section on Health and Social Care issues appear at the end of this written evidence.
Conclusion Despite its proximity to the border NEWI is firmly rooted in Wales. One advantage of this is the comparatively easy access it has to ministers and civil servants at the Assembly Government. The Institute believes this relationship sometimes allows NEWI’s views to be reflected in the policies and strategies emanating from the Assembly Government. An example of this is the Wales Spatial Plan which recognises the geographical influences on North East Wales and advocates further collaboration across the border while at the same time expanding the role of Wrexham (and NEWI) as a major centre within North East Wales. Professor Michael Scott Principal North East Wales Institute of Higher Education March 2008
References Bogdanor, V (1999) Devolution in the United Kingdom. Oxford: Oxford University Press. Brooks N (2005) Cardiac Services in the UK: are some areas more equal than others? The British Journal of Cardiology vol 12, no 3 pp67–168 Cwmni Iaith (2002) An overview of the Welsh Language Provision in Care Homes for older people in Wales’ Eight Most Welsh-Speaking Counties. Welsh Language Board. CardiV Davies S Devolution stirs policy evolution Health matters issue 54, Winter 2003, pages 12–13 DoH (2007) Protocol on cross-border issues for NHS-funded nursing care in care homes in England and Wales. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Irvine, F, Roberts, G, Jones, P, Spencer, L, Baker, C and Williams, C (2006) Communicative Sensitivity in the bilingual healthcare setting: A qualitative study of language awareness. Journal of Advanced Nursing vol 53, no 4 pp. 1–13 Jackson-Read,C and Watkins-Young,L (2005) West midlands Mid-Wales Cross Border Issues: Framework for Action: research and Consultation Report. Rubus, Worcestershire. Keating,M; Stevenson,L and Loughlin,J (2005) Devolution and Public Policy: Divergence or Convergence. Available at http://www.devolution.ac.uk/Keating2.htm Lister S (2008), Postcode lottery’ in Wales on muscle disease Daily Post Misell, A (2000) Welsh in the health service: The scope, nature and Adequacy of Welsh language provision in the NHS in Wales. Welsh Consumer Council. CardiV. Welsh Health Circular WHC (2007) 036—renewed protocol until 31 March 2008 White P,James D, Ansell D, Lodhi V and Donovan K L (2006) Equity of access to dialysis facilities in Wales. QJ Medicine, 445–452
Memorandum submitted by the North East Wales Trust North East Wales Trust (hereafter referred to as NEWT) is pleased to provide evidence on cross border issues as they aVect health care provision for our Welsh residents. Our services cover the counties of Wrexham and Flintshire, which border the English counties of Shropshire and Cheshire. Evidence is presented in narrative form. Quantification in relation to each item can be provided at a later date if required. The evidence is based around the following themes: (a) Tertiary Service Provision (b) Clinical Networks (c) Local cross border collaborative working (d) Impact of policy diVerences (e) Potential risks arising from cross border issues
(A) Tertiary Service Provision
The vast majority of Welsh residents receive care from the Welsh health care providers however where highly skilled and specialist services are needed for the management of specific conditions, patients access English NHS and Foundation Trusts. North East Wales residents receive a wide range of highly specialised care through tertiary centres of excellence predominantly located in the North of England. The relationships with these specialist centres have developed over a considerable period of time and are supported with technological links, joint clinical working, training links and with the presence within NEWT premises of clinics held by visiting tertiary centre consultants. Whilst surgical care for highly specialised and complex cases is likely to be undertaken in the tertiary centre, the patient experience is supported with good transport links to the North of England, availability of relative accommodation on some sites, and local follow up and after care provision. Examples of tertiary services provided across the border for NEW residents include: — Cardiac Surgery — Specialist Paediatric Surgery — Neurosurgery — Transplant surgery — Specialist Pancreatic and Liver disease management — Thoracic surgery — Major cleft lip and palate surgery — Eating disorders and forensic mental health services The relationships between clinicians in secondary and tertiary centres are well developed with evidence of good communication and examples of joint clinical management for patients with shared care arrangements. North East Wales also provides tertiary services in some specialist areas to both Welsh and English residents, the latter commissioned by English PCTs. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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For example formal arrangements exist for Upper GI cancer services whereby English and Welsh patients have their surgery at the North East Wales Trust acute hospital based in Wrexham provided by a clinical team of four surgeons, (two from NEWT and two from the Countess of Chester Foundation Trust). Referral, discharge and after care are carefully managed between organisations to support patients irrespective of their residency. Other examples of NEWT providing specialist services to English residents include the specialist diabetic foot service managed via the Orthopaedic foot and ankle team. There are also areas where gaps in care provision within Wales result in patients receiving care outside Wales. Examples would be in the areas of specialist continuing care arrangements. Whilst every eVort is made to optimise the clinical care of patients cross border policy diVerences and commissioning arrangements do not always support the needs of patients. This can lead to diVerential management of Welsh residents in English Trusts based on diVerential access or waiting time targets and contractual arrangements. The development of the Upper GI surgical centre at NEWT demonstrates however that on some occasions these obstacles can be overcome.
(B) Clinical Networks A small number of patients will always need services from highly specialist centres that due to the population in North Wales, cannot be safely provided locally. Clinical networks play a vital role in helping to secure high quality and safe services and to further the development more locally of expertise. Examples include: — Orthopaedics—consultants on shared contracts between Robert Jones Agnes Hunt (RJAH) and North East Wales Trusts, with RJAH providing significant capacity for both secondary and tertiary orthopaedic care to North Wales residents. — Vascular surgery—well established clinical network exists to provide 24/7 emergency vascular surgery services between NEWT and Countess of Chester Hospital (COCH) — Urological services –a well-established clinical network exists for urological emergencies between NEWT and the COCH — Orthotic services are provided on site at NEWT via a contractual relationship with the Orthotic service at RJAH — Other complex diagnostics are provided either via shared care arrangements or via contractual arrangements with English providers such as the shared use of the catheter lab for angiography based at the COCH, contractual arrangements for PET scanning for Lung and Upper GI cancer patients at Christies, EMG studies etc.
(C) Local Cross Border Collaborative Working Examples of cross border working exist between organisations, health care professionals and teams. Working with Shropshire PCT has enabled NEWT to become a local service provider for Shropshire GPs under Choose and Book. The benefits for patients to choose are self-evident. Any disruption to this system creates risks for the PCT, the GPs involved and for the Trust in terms of services provided for Shropshire patients.
(D) Impact of Policy Differences —DiVerential Access Targets and Contractual Arrangements Policy diVerences have resulted in shorter access time targets for English residents. However as the waiting time targets have become more challenging and contracting arrangements have also diVerentiated between English and Welsh patients we have seen Welsh patients being treated diVerentially by English Trusts in accordance with waiting time targets. This means that Welsh patient can wait longer than an English patient for routine treatment by an English provider. The move to referral to treatment times in both England and Wales looks to narrow the existing access times gaps, but this is not the case. In reality diVerences in definitions mean that the remaining gap will continue to be larger as the English target of 18 weeks includes tertiary care whereas the Welsh target of 26 weeks excludes tertiary care. — Choose and Book As electronic booking of secondary care access from primary care increases through choose and book programmes it will become increasingly challenging to support access for patients who have English GPs and wish to access Welsh hospitals. It should be noted that some of these patients are Welsh residents. The Trust has explored the provision of choose and book technology to support this patient flow but due to IT contractual issues it has not been possible to achieve full access to this system and so short term work arounds are in place. It is doubtful as to whether these can be sustained once full electronic booking is achieved in England. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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— Payment by Results The existence of payment by results compared to block contract arrangements in Wales has resulted in transitional arrangements between organisations being required to manage financial flows without de- stabilising organisations. With the proposed introduction of Activity Based Costing in Wales it is likely that the 2 systems will move closer together. — Residency v GP practice registration The continuity of the diVerent basis for commissioning eg residency in Wales and GP registration in England has an impact for some patients on the border. For instance patients resident in Wales registered with an English GP have in theory 2 commissioners—the English PCT and the Welsh Local Health Board (LHB) and their resulting activity, waits etc are reportable to both DOH and WAG. However patients resident in England with a Welsh GP have no commissioner and are not theoretically reportable from an activity or waiting time to either England or Wales. North East Wales have undertaken some work to quantify these patient numbers. In practical terms patients are managed in accordance with clinical need irrespective of these contractual overlaps or gaps with issues arising not in the care of the patient but with the monitoring and performance management comparators.
(E) Potential Risks Associated with Cross Border Issues
Risks associated with cross border issues arising from policy diVerences, organisational systems, technological development and process diVerences between the systems are mitigated through pragmatic approaches to cross border working by clinicians, managers and commissioners. However, concern remains that as targets for delivery become more challenging some of the pragmatism could be lost to the detriment of Welsh patients and financial impact could result in adverse eVects on Welsh health care providers. 20 March 2008
Memorandum submitted by North Somerset PCT North Somerset PCT is the co-ordinating Commissioner for Weston Area Health Trust. The Trust has in the past provided some orthopaedic services for some Welsh patients in response to waiting list initiatives but is not currently providing these services. The Trust does provide Emergency Services for Welsh patients when they are on holiday or temporarily resident in the area. There are no specific arrangements in place to manage patient or financial flows. Patients are managed and charged for in the same way as any other patient that attends the Trusts. The Trust bills the referring commissioner in line with the Payment by Results tariV. The PCT has not experienced any particular problems with managing patient or financial flows for Welsh people or for North Somerset patients who are treated at Welsh acute trusts. March 2008
Memorandum sumbitted by Nottinghamshire Healthcare NHS Trust I am Dr Mike Harris, Executive Director: Forensic Services and Chief OYcer for High Secure Care for Nottinghamshire Healthcare NHS Trust, c/o Rampton Hospital, Retford, Nottinghamshire, DN22 OPD. I have been invited by the Welsh AVairs Committee at the House of Commons to provide written evidence relating to cross-border issues. I have been the Executive Director for Forensic Services for Nottinghamshire Healthcare since August 2001, as well as a 22-month period acting as Chief Executive of the Trust, and as such have had the responsibility for managing all the Forensic Services for the Trust during this time. Nottinghamshire Healthcare NHS Trust provides three levels of Forensic Services, two of which are relevant to this inquiry. The Trust provides Low Secure Community Forensic Services purely to the citizens of Nottinghamshire. The Trust provides Medium Secure Services to the East Midlands and South Yorkshire, and this is provided from two Medium Secure Units, Wathwood Hospital in Wath-upon-Dearne, South Yorkshire, and Arnold Lodge in Leicester. Arnold Lodge also has in its service a Medium Secure Personality Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Disorder Service for men, with two wards of 20 beds, one of which takes men coming out from the Personality Disorder wards of Rampton High Secure Hospital; and a Women’s Service, providing Medium Secure beds for women predominantly from the East Midlands and South Yorkshire, but also an Enhanced Medium Secure Service for Women which is part of the national provision of Enhanced Medium Secure Services for Women, to which I will return. Nottinghamshire Healthcare is also responsible for managing Rampton Hospital in Nottinghamshire, which is one of the three High Secure Hospitals in England and Wales. Rampton Hospital provides beds for men with Mental Illness and suVering from Personality Disorder to approximately one-third of the English and Welsh population, but concentrating predominantly on the eastern third of England. The Hospital is one of the two High Secure Hospital providers of services for men with Dangerous and Severe Personality Disorder, as well as then having three specialist services which are unique for the whole of England and Wales: that is services for Women requiring High Secure Care; services for Men with Learning Disability requiring High Secure Care; and services for Men with Deafness requiring High Secure Care. The three specialist services, ie Women’s Services, Deaf Services and Learning Disability Services, are provided to the whole of England and Wales. At the present time Rampton Hospital has five women from Wales in its patient population, and five men from Wales. By current 1983 Mental Health Act Section there are two patients from Wales detained under Section 3; one under Section 37; two under Section 47 three under Section 37/41; one under Section 41(5); and one under Section 47/49. By diagnosis, one patient has Mental Illness and Personality Disorder; two are suVering from Mental Illness, Personality Disorder and Mental Impairment; one has Mental Impairment and Personality Disorder; one has Mental Impairment, Mental Illness and Personality Disorder; four are, suVering from Personality Disorder; and one is suVering from Personality Disorder and Mental Illness. We can provide specific details suitably anonamysed on individual patients if this would be helpful. There are three providers of Enhanced Medium Secure Services for Women in England and Wales. These are Arnold Lodge in Leicester, part of Nottinghamshire Healthcare NHS Trust, which has a dedicated unit of ten beds; Guild Lodge at Preston which has six beds and a larger women’s ward; and Orchard Unit, part of West London Mental Health Trust, which has 45 beds, of which 30 are currently commissioned. The Enhanced Medium Secure beds for Women were part of a plan to reduce the number of High Secure Women’s beds from an original 150, approximately 50 in each Hospital, on the basis that the majority of women in High Secure Women’s Services did not require high security but required enhanced levels of care and relational security. It was recognised that there was a need for a continuing number of beds for women requiring High Secure Services. As such, women from Wales requiring Enhanced Medium Secure Services may find themselves in the beds at Arnold Lodge, but at the present time there aren’t any. At the present time Welsh patients are treated at Rampton Hospital in the specialist services. Referrals are taken from courts, prisons, solicitors and other psychiatric units, particularly Medium Secure Units for patients who are felt to require high secure care. Assessments are made on these patients by Clinical Teams from Rampton Hospital, and then a referral is made to the Hospital’s Admissions Panel, where a decision is made as to whether or not the person requires high secure care or can be managed in lower degrees of security. The issue of funding is a moot one from the perspective of Nottinghamshire Healthcare NHS Trust. Our money comes to us via our Lead Commissioners, currently Leicestershire County Teaching PCT, who in turn have to recoup the money from the individual commissioners in diVerent parts of the country. Therefore, questions about the actual funding should be directed to the Specialist Services Commissioners at Leicestershire County Teaching PCT, the Director of which is Mrs Kate Caston. From the perspective of the Trust and the Hospital, the commissioning arrangements are identical for Welsh patients as they are for any other patients, and the monitoring of the standards of care and levels of care given is in fact undertaken by the Lead Commissioners at Leicestershire County Teaching PCT and the Performance Manager from NHS East Midlands, the Strategic Health Authority. The eVect of devolution has not impacted particularly on the provision of high secure care, and it would be true to say that there has been negligible eVect on the provision of beds for patients from Wales or their repatriation to Wales when they no longer need high security. The final question you ask is the extent to which mechanisms are in place for identifying and resolving cross-border deficiencies. There are diYculties here which are predominantly centred around the diYculties of finding appropriate beds for patients in Wales when they no longer need to be cared for in conditions of high security. This has in the recent past proved quite diYcult, with a lack of provision for suitable beds, but it is noticeable in the last few months that this appears to have been largely rectified with negotiation between the Specialist Services Commissioners in the East Midlands and the Welsh Commissioners. High level diYculties are discussed at the National Oversight Group for High Secure Care, which is an English and Welsh group responsible for strategic planning for high secure psychiatric care, and has representatives of the Welsh Parliament, the Welsh OYce, the Ministry of Justice, the Department of Health, the Commissioning PCTs and the providers of services. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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If the Committee would like any further evidence I would be happy to provide it, either in writing or by means of giving oral evidence to the Committee. 20 March 2008
Memorandum submitted by Kate Spall, Founder of The Pamela Northcott Fund
Section AExecutive Summary 1. The submission will focus on the inequitable situation currently facing Welsh cancer patients, unable to access life extending treatments available to English cancer patients. 2. I will discuss the role of commissioning renal cancer treatments in Wales and compare them with the English system. 3. To illustrate the situation I will be recounting the experience of my mother Pamela Northcott, a Welsh kidney cancer patient. 4. The submission will include anecdotal evidence from other Welsh patients denied cancer treatments available in England. 5. Finally I would like to thank the Committee, on behalf of Welsh cancer patients who to date have felt they have been denied a voice. Devolution has been no friend to rarer cancer patients in Wales. Their access to new targeted cancer treatments is the worst in the UK. They cannot comprehend a system where they are left to die prematurely when fellow suVerers in England are receiving the treatments they so desperately need.
Section BThe Writer 6. My mother Pamela Northcott was refused treatment for advanced kidney cancer in early 2007. She was an exceptional and vibrant woman of 57 years old and desperate to fight for her life. I will consider her story in detail in the main submission. In summary, after a six month battle for treatment we eventually won funding from Denbighshire Local Health Board for a two month trial of the new cancer drug Sorafenib (Nexavar). The fight for treatment took so long that she was in a hospice with just days to live when we finally won the treatment. However she lived for another four months, and died on 12 August 2007. We are all convinced she may be alive today if she had been treated in England. 7. I founded The Pamela Northcott Fund in 2007, in memory and as a tribute to Mum. Many patients began contacting me when they heard I was fighting for a new treatment for Mum, it was her wish that I continue helping other cancer patients access new cancer drugs—specifically for kidney cancer. However I am now receiving requests from other rarer cancer patients and have begun taking on their cases. The Pamela Northcott Fund is a patient led voluntary organisation with charitable aims, providing unique and unprecedented advocacy and support to cancer patients denied access to new drug therapies, yet to be approved by NICE. It oVers a bespoke one to one service to patients and their carers, by taking on their individual appeal for treatment and representing them at their Primary Care Trust or Local Health Board Appeal panel. 8. I have now successfully won funding for nearly 50 individual cancer patients. I have to date advised 15 welsh patients with renal cancer, many were refused life extending treatment recommended by their oncologist due to a negative AWSMG decision. All decision panels were made aware that the only available option without the treatment was palliative care. I have only overturned five of these judgements. The others have now died or are without treatment. 9. I am a wife and mother of two young children, my previous career history is in media, PR and marketing and latterly working for the voluntary sector advising organisations on governance and trustee training and support. I gave up work when caring for Mum and now work voluntarily full time to help cancer patient’s access new treatments and therapies through The Pamela Northcott Fund.
Section CFactual Information Included With This Submission 10. National Cancer Research Institute Renal Group Expert Opinion Document on new therapies for Kidney Cancer. 11. Letter from leading renal oncologist to AWSMG in response to their appraisal of new cancer drug, Sorafenib. 12. Prof Hawkins Director of Medical Oncology Christie Hospital—treatment plan for renal cancer. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Section DMy Submission
Commissioning cancer treatments 13. Today in Wales, if you suVer from a rarer cancer, specifically kidney cancer your prognoses will be worse than a fellow patient in England. A combination of factors leads to this predicament; most prevalent is lack of access to new treatments and therapies. 14. The commissioning situation in Wales is complex. I endeavoured to access the current commissioning guidelines for new cancer drugs when fighting for treatment for my mother. This took me six months to begin to unravel, during this time I took advice from my local MP, AM, Health Commission Wales, OYce of Health and Social Care, Clwyd Community Health Council, Regional Cancer Network, Conwy & Denbighshire NHS Trust and Denbighshire Local Health Board. I did not receive a definitive answer from one of them. 15. It is further complicated by the work of the All Wales Medicines Strategy Group—they issue interim guidance to medicines though all decisions are superseded by subsequent NICE guidance. Whilst their aim is worthy—to speed up access to treatments to welsh patients whilst awaiting a NICE decision—the reality is very diVerent. The AWSMG serves as another blocking mechanism to patients trying to access treatments. 16. The kidney cancer drugs appraised and rejected by the AWSMG in 2007 were given FDA approval and licence in 2005 and are now the standard treatment for all kidney cancer patients in USA. In fact, in 2005 the licence application for Nexavar (Sorafenib) was fast-tracked by the Center for Drug Evaluation and Research—the FDA equivalent of NICE—due to the significance of the clinical trial data. 17. In 2006 the EMEA (EU Commission) appraised both Sutent and Nexavar and agreed to immediate licence, even though the phase III trial results had not been published. The published phase I and II results had shown remarkable impact, particularly in relation to progression free survival. 42 organisations contributed to the appraisal for the EU and it endured a rigorous process. 18. In the rest of Europe the EMEA licence is accepted as the gold standard and countries will then oVer treatments to its’ citizens from this licence. Indeed in the UK this licence is used by the private health insurance and they will fund all EMEA licensed cancer treatments. NICE will then appraise the drugs focussing on the cost eVectiveness of the treatments. 19. In the UK all non NICE approved treatments can be prescribed to patients on a case by case basis, as reissued Department of Health guidance states in their reissued December 2006 guidance: Reiterating the Message of HSC 1999/176 “It is not acceptable to cite a lack of NICE guidance as a reason for not providing a treatment. A key role of the NHS is to make decisions about the use of new interventions and this has always been the case, long before NICE was established.” 20. The key point is that a clinician is able to prescribe a non NICE approved cancer therapy to a patient if they assess the patient will clinically benefit. This system works well in England and ensures that patients are not placed at risk due to the long NICE appraisal process. However this system leaves rise to the well known “postcode lottery” so regional commissioning bodies in England have been guided by their expert clinicians and now the new kidney cancer drugs are available immediately to all advanced kidney cancer patients in: — The North West Strategic Health Authority from Cheshire to Cumbria encompassing 25 Primary Care trusts. — The North East Strategic Health Authority encompassing 13 Primary Care trusts. — Commissioners from the West Midlands have agreed to fund the treatments in the Pan Birmingham region including Sandwell, South Birmingham, Solihull, Birmingham East and North and Heart of Birmingham Primary care trusts. — The North Trent Cancer network have agreed to fund these treatments including: Barnsley, Bassetlaw, Rotherham, SheYeld, Derbyshire County and Doncaster Primary Care Trust. — Further English commissioning networks are expected to follow suit in the near future. 21. Welsh kidney cancer patients cannot understand why the AWSMG has deemed these drugs “not clinically or cost eVective”. Are we to believe that the AWSMG panel has greater expertise than the EMEA, FDA, and most importantly for patients—than their clinical consultant explaining to them that these are the best treatments but you cannot access them in Wales? 22. The National Cancer Research Institute is the leading hub of expertise on cancer treatments in the UK. In December 2006 the Clinical Studies Group for Renal Cancer state in their Expert Opinion document: “Existing standard therapies for metastatic renal cell cancer are inadequate. Both sorafenib and sunitinib significantly prolong progression free survival in metastatic renal cell cancer and should now be made routinely available in the management of this disease in the UK.” Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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23. We feel their expertise overrides any opinion of the AWSMG panel and patients feel let down and condemned to a premature death by a group of people without the expertise needed to make this decision. 24. We feel decisions should be reached diVerently when discussing an orphan drug as in this case. Orphan drugs are “medicinal products intended for the diagnosis, prevention or treatment of life-threatening or very serious diseases aVecting less than five in 10,000 persons in the Community”. 25. Local Health Board’s are able to use the interim guidance by the AWSMG to deny patients. Renal oncologists are furious with the decision; patients are now dying prematurely due to the decision. The AWSMG decisions have contributed to the inequitable situation of denying new kidney cancer treatments to patients in Wales, which are available in England. However, clinicians are able to apply for individual funding for the drugs to a specialised panel at the LHB. This can take months for a decision, most patients are left devastated when panels refuse to fund the treatment. We have found only five patients that have successfully won funding through this procedure.
Pamela Northcott’s case study
26. In April 2005, at the age of 56 Pamela was given an ultrasound scan for back problems, during the scan a renal mass was discovered. Her mother died of kidney cancer at the age of 51 years old, so she informed the medical team of this, however the mass was contained within the kidney and not treated as urgent. She underwent a radical nephrectomy 64 days later—delayed as the surgeon was on holiday but wished to undertake the procedure himself. We had no reason to doubt that this was a fair timescale. After the operation, histology results indicated that Pamela had an extremely rare and aggressive sub type of kidney cancer—during the waiting time period for the operation the tumour had broken through the kidney and spread—her fate was sealed. When kidney tumours are excised early enough whilst still contained the prognosis is very good. Once spread, kidney cancer has one of the worst prognoses of between three and 10 months—tragically Mum was in the latter category. 27. The treatment options were extremely limited, an immunotherapy drug which subsequently we found out has a less then 7% response rate was the only active treatment oVered to her. This was unsuccessful. It was then I began researching other options and was told of two new cancer drugs that were used as standard treatment in the rest of the western world and had just received European Licence to treat advanced kidney cancer. Our nearest renal oncologist was Professor Hawkins at the Christie Hospital Manchester, we have since found out that due to rarity of the cancer it is vital to see a dedicated renal oncologist—the only one in Wales to our knowledge is Professor WagstaV at the Singleton Hospital in Swansea—but this was too far away. Professor Hawkins on examination believed the only treatment option viable for Mum was the new targeted therapy drug Sunitinib or Sorafenib. 28. Our oncologist in Wales stated that he could not put an application in for treatment to Conwy & Denbighshire NHS Trust as “they would not pay for it”. We implored him to put the application in and after a six month battle we won funding for her for a trial period of two months. However, by this time she was extremely ill. Both my sister and I had taken unpaid leave from work to care for her at home. She was now unable to get upstairs, eat, bathe unaided and the only support we were oVered was a district nurse for 30 minutes per day to change a dressing on her back—an open wound where a tumour had pushed through her back and caused her tremendous pain and discomfort—to the extent that she had to sleep sitting up on her sofa. We had no one to call and were terrified of the responsibility. Her oncologist had kindly given me his home number and despaired that he was not allowed to take patients into the cancer unit unless they were on treatment. I called the local hospice and they kindly agreed to care for her. She never left the hospice. She lived for another four months on a quarter dose of Sorafenib. The treatment was too late. 29. Our experience of Mum’s illness has been horrific. We fought throughout the whole two year journey for help, support, diagnostic tests, results and most importantly the best treatment. Her suVering both physical and psychological is extremely hard to come to terms with. She never found the peace we were told was common in terminal cancer patients during their last days. She fought for every breath and left this world feeling completely betrayed by the Welsh NHS.
Further Welsh case studies
30. Tragically I have heard Mum’s story many times during my subsequent voluntary work with The Pamela Northcott Fund. The patients below are just some of the cases I have encountered: 31. Joss is 60 years old and has worked all his life; he now cares for his disabled wife. He was diagnosed with kidney cancer in early 2006 and due to the size and location of the tumour was unable to have the standard nephrectomy. He could not benefit from the immunotherapy drug as it is clinically ineVective on primary tumours. His oncologist put in an application for the new targeted therapy drug, Sutent in May 2007. The LHB refused treatment, even though they were told that without the treatment he would die Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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prematurely and be oVered palliative care only. His family started a petition, produced car stickers, lobbied the panel and finally went face to face with them and literally begged for his life—he was again refused. Joss has received no treatment for terminal cancer and it is a miracle he is still alive. His sister Rosie says: “I was absolutely devastated when I found out we’d lost the appeal. We’ve done everything we can but I feel useless. It’s like they’ve handed him a death sentence, like they are waiting for him to die so the problem will go away. I feel ashamed to be Welsh. Jocelyn is deeply upset. He’s even talking about funerals; it’s so hard for him. We worked out that he’s contributed about £410,000 in tax in his life—but what’s it doing for him?” 32. Ruth is a 67 year old grandmother diagnosed with kidney cancer three years ago. The diagnosis took 10 years after a failure to provide diagnostic tests for her, after years of urological problems. Her oncologist put in an application for Sutent to the LHB panel in July 2007 explaining that “in denying her this treatment you are holding the only eVective treatment from metastatic renal cell carcinoma from her”—they were still awaiting a final decision in December 2007 when they contacted The Pamela Northcott Fund. Her husband has collected 4,500 names for a petition locally to fight for her treatment. He states: “I can’t believe it’s come to this, driving around and knocking on doors, asking people to sign a petition. We have enough to deal with without this. We have always worked, we’ve never been spongers and we’ve done our bit for good causes. Doctor’s say she needs the drug—so why aren’t they listening. Everyone in Wales should be aware it could be them next. People locally can’t believe it—they are very angry and worried.” The Pamela Northcott Fund submitted a ten page appeal to the panel on their behalf and after nine months of fighting the panel overturned the judgment and she began treatment last week. 33. Gerald is 57 years old, bright and active. He benefited from a work related private health policy and in August 2007 his oncologist prescribed Sunitinib for advanced kidney cancer, paid for through his private health care. His tumours have reduced by over 50% in six months and his quality of life has been increased considerably. His insurers will only fund treatment for nine months and he has applied for his LHB to continue funding this for him, supported by his oncologist who cites it is “imperative” he continue this treatment. The LHB refused to continue treatment on the grounds of the AWSMG decision making specific reference to the fact that the AWSMG stated it “clinically ineVective”. Gerald has shown them his scans and oncology reports stating the amazing clinical eYcacy it has proved to be in his case. We have asked the panel to reconsider his case. They are eVectively withdrawing successful treatment to a cancer patient—a fact that is causing Gerald and his family absolute devastation. 34. I was recently contacted by a North Wales MP to help with a patient diagnosed with advanced kidney cancer. Keith had been told by his urologist that the only treatment that could help him is the new targeted therapy Sorafenib or Sunitinib. He requested his oncologist put in an application to the panel for the drug. The oncologist refused, stating he “wasn’t allowed to put an application in for these new cancer drugs”. He had been told this by management. Not only is this morally reprehensible, it is unlawful. After my involvement and a strong letter stating the correct procedure for applying for treatments on a case by case basis—an application was duly put forward. 35. This is not the first occasion I have been told by a Welsh clinician they have been instructed by management not to put in applications for new cancer drugs. It is shocking in the extreme and just highlights the need for an absolute overhaul of the system. For as long as health economists are given the role of making clinical decisions, Welsh cancer patients will be left at the bottom of the pile when it comes to treatment access.
Section ERecommendations for Action 36. All AWSMG decisions on orphan drugs including Sorafenib and Sunitinib need to be reviewed. The panel should meet with commissioning panels across the border and initiate meaningful dialogue. We cannot support a situation where a country is denying life extending cancer treatments freely available across the border. 37. The WAG should be patient focussed as oppose to geographically focussed. It is unsustainable to expect that all cancer services can be delivered within Wales. Patients must be given funded access to the best centre of expertise, especially relevant for rarer cancers. 38. Clinicians need to be given more power in the commissioning process for rarer cancer treatments. They are the local experts and their opinion must be given more weight when deciding on treatments for individual patients. Some oncologists are currently not submitting applications for new treatments due to a lack of information. This needs to be addressed as a matter of urgency. 39. There needs to be an urgent review of treatment access for rarer cancers in Wales. This would also look at the role of the AWSMG and investigate the necessity of the organisation. Is it just another layer of bureaucracy adding to an already complex commissioning structure? 24 March 2008 Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Targeted Therapies in the Management of Metastatic Renal Cell Carcinoma
EXPERT OPINION FROM CLINICIANS ON THE NCRI RENAL CANCER CLINICAL STUDIES GROUP
Introduction Sorafenib and sunitinib have received FDA and EMeA approval for the treatment of metastatic and locally advanced unresectable renal cell carcinoma (RCC). Both drugs result in clinically important stabilisation of disease and approximately double progression free survival when compared to placebo, interferon, or historical controls. Both are now standard of care for this patient population in the US. They represent a major advance for patients with RCC, a disease for which there are no other adequate therapeutic options.
Metastatic Renal Cell Carcinoma and Efficacy of Current Standard Treatments There are approximately 6,600 new cases of renal cell carcinoma (RCC) annually in the UK. 50% of patients either present with, or go on to develop metastatic disease. In 2004 there were 3,300 kidney cancer related deaths in the UK. The median survival once metastatic disease has developed is only 10 months (Motzer, Mazumdar et al. 1999). Systemic treatment options in RCC have been extremely limited. Standard care for metastatic disease in the UK is with single agent interferon-α which has a 15% response rate and at best increases one year survival from 31% to 43% (1999). High dose interleukin-2 is licensed by the FDA for the treatment of metastatic RCC and gives durable benefit in approximately 5% of patients at the expense of very significant toxicity (McDermott, Regan et al. 2005). It is largely not used in the UK due to its poor therapeutic index. There is therefore very significant clinical need for more active agents.
Evidence for Activity of Multi-targeted Kinase Inhibitors Two small molecule orally active multi-targeted kinase inhibitors have demonstrated significant eYcacy in multicentre clinical trials. Sorafenib (Nexavar, Bayer) and sunitinib (Sutent, Pfizer) received their FDA approvals for the treatment of metastatic renal cell carcinoma (line of treatment not specified) in December 2005. The European Medicines Agency (EMeA) gave a positive opinion on initial marketing authorisations for both sorafenib and sunitinib in April 2006 for the 2nd line treatment of advanced RCC. Both are now commercially available in the UK.
Sorafenib Marketing authorisation for sorafenib has been given on the basis of published phase II data and unpublished phase III data which are now in the public domain. The recommended phase II dose of 400mg bd was examined in a randomised discontinuation phase II study (Ratain 2005). Of the 202 metastatic RCC patients entering the study,144 (71%) had tumour shrinkage or disease stabilisation at 12 weeks. 65 patients entered the randomised phase and after a further 12 week period 16 (50%) of patients on sorafenib were progression free compared with six (18%) of patients on the placebo arm (p%0.0077). The median progression free survival (PFS) from randomisation was 24 weeks for sorafenib compared with six weeks for the placebo arm (p%0.0087). Preliminary data from a randomised placebo controlled phase III trial in the second-line treatment of 903 patients with metastatic renal cell carcinoma has been reported in a planned interim analysis after 220 events. A 10% partial response rate and 74% disease stabilisation rate was seen on the sorafenib arm compared with 2% and 53% respectively on the placebo arm. The median PFS was 5.5 months vs 2.8 months (HR: 0.51). The median overall survival was 14.7 months in the placebo arm and at the time of analysis had not yet been reached in the sorafenib arm (HR: 0.72, p%0.018). All subsets (age, prognostic group, sites of metastasis, previous cytokine treament) appeared to derive equal benefit (Escudier 2005). Following the confirmation of a highly significant PFS benefit, patients in the placebo arm were allowed to cross over to sorafenib. Despite this crossover, there remains an overall survival benefit from sorafenib (HR: 0.77, p%0.015) (Eisen 2006). Final data are expected in the winter of 2006.
Sunitinib Two 2nd line phase II studies in metastatic RCC are published and interim data from a phase III randomised 1st line study against interferon-α were presented this year. Results from both phase II studies (Motzer, Michaelson et al. 2006; Motzer, Rini et al. 2006) have been combined giving a total of 168 patients. The combined response rate was 42% with an additional 24% having stable disease for greater than three Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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months. The combined median progression free survival was 8.2 months. The median PFS for patients attaining a complete or partial response was 14.8 months. Median overall survival for the first study was 16.4 months and at the time of reporting had not yet been reached for the second study. Interim data from the phase III study (Motzer 2006) demonstrated a median PFS of 47.3 weeks (95% CI 40.9, not yet reached) for sunitinib vs. 24.9 weeks (95% CI 21.9, 37.1) for IFN-α [hazard ratio 0.394 (95% CI 0.297, 0.521) (p ' 0.000001)]. The objective response was 24.8% (95% CI 19.7, 30.5) for sunitinib vs. 4.9% (95% CI 2.7, 8.1) for IFN-α (p ' 0.000001). In summary, both sorafenib and sunitinib significantly prolong progression free survival in this refractory disease and should now be made routinely available.
Recommendation Existing standard therapies for metastatic renal cell cancer are inadequate. Both sorafenib and sunitinib significantly prolong progression free survival in metastatic renal cell cancer and should now be made routinely available in the management of this disease in the UK.
References MRC Collaborators(1999). “Interferon-alpha and survival in metastatic renal carcinoma: early results of a randomised controlled trial. Medical Research Council Renal Cancer Collaborators.” Lancet 353(9146): 14–7. Eisen, T, R M Bukowski, M Staehler, C Szczylik, S Oudard, W M Stadler, B Schwartz, R Simantov, M Shan, B Escudier for the TARGETs Clinical Trial Group (2006). “Randomized phase III trial of sorafenib in advanced renal cell carcinoma (RCC): Impact of crossover on survival.” J Clin Oncol 24(18S): 4524. Escudier, B, Szczylik, C, Eisen, T et al (2005). “Randomized phase III trial of the multikinase inhibitor sorafenib (BAY43-9006) in patients with advanced renal cell carcinoma (RCC).” Proc ECCO 13 Paris, 30th 0ctober—3rd November: Ab 794. McDermott, D F, M M Regan, et al. (2005). “Randomized phase III trial of high-dose interleukin-2 versus subcutaneous interleukin-2 and interferon in patients with metastatic renal cell carcinoma.” J Clin Oncol 23(1): 133–41. Motzer, R J, M Mazumdar, et al. (1999). “Survival and Prognostic Stratification of 670 Patients With Advanced Renal Cell Carcinoma.” J Clin Oncol 17(8): 2530-. Motzer, R J, M D Michaelson, et al. (2006). “Activity of SU11248, a multitargeted inhibitor of vascular endothelial growth factor receptor and platelet-derived growth factor receptor, in patients with metastatic renal cell carcinoma.” J Clin Oncol 24(1): 16–24. Motzer, R J, B I Rini, et al. (2006). “Sunitinib in patients with metastatic renal cell carcinoma.” Jama 295(21): 2516–24. Motzer, R J, T E Hutson, P Tomczak, M D Michaelson, R M Bukowski, O Rixe, S Oudard, S T Kim, C M Baum and R A Figlin (2006). “Phase III randomized trial of sunitinib malate (SU11248) versus interferon- alfa (IFN-) as first-line systemic therapy for patients with metastatic renal cell carcinoma (mRCC).” J Clin Oncol 24(18S): LBA3. Ratain, M J, Eisen, T, Stadler, W M, Flaherty, K T, Gore, M, Desai, A, Patnaik, A, Xiong, H Q, Schwartz, B, O’Dwyer, P (2005). “Final findings from a phase II,placebo-controlled, randomized discontinuation trial (RDT) of sorafenib (BAY 43-9006) in patients with advanced renal cell carcinoma (RCC).” Proc. Am. Soc. Clin. Oncol. 23: Ab 2454. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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APPENDIX
Pivitol study* Support study 100 100 Median TTP: 8.1 months 90 90 Median TTP: 8.7 months (95% CI: 7.6, 10.4) 80 80 (95% CI: 5.5, 10.7) 70 70 60 60 50 50 40 40 30 30 20 20
Estimated TTP probability (%) Estimated TTP 10 probability (%) Estimated TTP 10 0 0 0 3 6 9 12 15 18 21 24 0 3 6 9 12 15 18 21 24 Time (months) Time (months)
Supportive study Pivitol study* 100 100 90 90 Median OS: 16.4 months 80 80 (95% CI: 10.8, NA) 70 70 60 Median OS: not yet reached 60 50 50 40 40 30 30 20 20 Estimated TTP probability (%) Estimated TTP Estimated TTP probability (%) Estimated TTP 10 10 0 0 0 3 6 9 12 15 18 21 24 0 3 6 9 12 15 18 21 24 Time (months) Time (months) Sunitib Progression Free Survival (PFS) and Overall Survival (OS) in Pivotal and Supportive Studies (phase II 2nd Line) Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Progression-Free survival (Independent Central Review)
1.0 Sunitinib Median: 11 months 0.9 (95% CI: 10-12) 0.8 IFN-α 0.7 Median: 5 months (95% CI: 4-6) 0.6 0.5 0.4 0.3 0.2 Hazard Ratio = 0.415 0.1 (95% CI: 0.320-0.539)
Progession Free Survival Probability 0 P <0.000001 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Time (Months) No. at Risk Sunitinib: 235 90 32 2 No. at Risk IFN-α: 152 42 18 0
Progression-Free survival (Independent Central Review)
1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 Sunitinib (n=375) 0.2 Median not reached Hazard Ratio = 0.65 0.1 (95% CI: 0.449-0.942) IFN-α (N=375) Median not reached Progession Free Survival Probability 0 P = 0.00219* 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Time (Months) No. at Risk Sunitinib: 341 190 84 15 1 No. at Risk IFN-α: 296 162 66 10 0 * The observed p-value did not meet the pre-specified level of significance for this interim analysis
Sunitinib interim phase III 1st line data vs interferon Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Targets Progression-free survival Benefit*
1.00
Median PFS Sorafenib = 5.5 months Placebo = 2.8 months 0.75 Hazard ratio (S/P) = 0.51
0.50 Sorafenib Placebo Censored observation
0.25 Proportion of patients progression free
0 0 2 4 6 8 10 12 14 16 18 20 Time from randomization (months) *Based on investigator assessment B Escudier
Targets Planned Interim anaylsis of Overall Survival*
1.00
0.75
0.50 Median OS Placebo = 14.7 months Sorafenib = Not reached Hazard ratio (S/P) = 0.72 p-value = 0.018** 0.25 Sorafenib
Proportion of patients progression free Placebo Censored observation 0 0 2 4 6 8 10 12 14 16 18 20 Time from randomization (months) *Results are from a planned interim analysis as per protocol (220 events) and are considered preliminary ** Threshold for significance of interim analysis was p<0.0005 B Escudier
COMMENTS ON AWMSG/0307—THERAPEUTIC DEVELOPMENT ASSESSMENT OF SORAFENIB TOSYLATE (NEXAVAR)
The AWMSG document provides a reasonable technical appraisal of the currently published data but makes a series of flawed conclusions.
1. Best supportive care is the only rational comparator in the 2nd line setting. There is no standard treatment other than sorafenib/sunitinib for the 2nd line treatment of advanced RCC after cytokine failure. The potential other therapies mentioned are either unproven, inappropriate for the vast majority of patients or inactive. The lack of comparative studies is therefore not an issue in a clinical setting where there are no other standard treatments. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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2. The majority (approximately 70%) of renal cell carcinomas have a clear cell component. The data shows significant clinical activity in this group of patients. It is reasonable not to oVer sorafenib to patients with non-clear cell histologies. 3. Published data is in the MSKCC good and intermediate prognosis groups. It is therefore currently reasonable not to oVer poor prognosis patients (who comprise approximately 20% of the advanced RCC population) treatment with sorafenib. Studies are underway to clarify this. 4. Disease stabilisation is a common feature of many new targeted therapies which have proven clinical activity—this should not be perceived as a negative feature. 5. Overall survival benefit—throughout the document the lack of statistically significant survival benefit at the interim analysis was referred to. The fact that this almost reached significance at an interim analysis was impressive and together with the proven doubling of progression free survival indicates significant clinical activity.Given the significant benefit seen at this analysis it was deemed unethical to carry on with the placebo arm and patients were therefore oVered crossover. The overall survival benefit will ultimately be diluted by the crossover eVect. The fact that this occurred is a reflection of the activity of the drug. The OS benefit used for cost-eVectiveness calculations will therefore undervalue the drug’s activity and over estimate the QALY.
Summary
The body of opinion from renal cancer specialist oncologists in the UK is that sorafenib and sunitinib should be made available for the treatment of patients with advanced RCC. This is a reflection both of the published clinical evidence and our experience of managing significant numbers of patients on clinical trials with these drugs who have had major clinical benefit. It is also reflected by the fact that these agents have become standard of care in the major economies across Europe and North America. Commissioning groups in the UK who are currently deciding whether to fund these agents should be clear that their decisions are purely economic. The clinical view from those who have best insight and expertise in both the management of the disease and the activity of these drugs is that they should be made available. The data is also robust enough to convince the FDA, EMEA and MHRA that the drugs are active enough to be licensed. It is disingenuous for commissioning groups to state that their decisions not to fund drugs are on the basis of flaws or inadequacies in the clinical data. Commissioners must be aware that their health economic appraisals are flawed. Crossover of patients on clinical trials (which occurred because it would have been ethically indefensible to deny patients access to a drug with proven activity) will dilute the overall survival benefit and artificially raise the cost-benefit ratio of these drugs. It would be justifiable on the clinical data available to justify sorafenib use in the 2nd line setting following cytokine failure, or in the 1st line setting for patients who are considered inappropriate for cytokine treatment. It is reasonable to limit current use to those whose tumours have a clear cell component and who fall into the MSKCC good and intermediate prognosis categories. Dr Paul Nathan Consultant Medical Oncologist
SUMMARY OF TREATMENT POLICY FOR RENAL CANCER 2007–08 — Both Sunitinib and Sorafenib are licensed for the treatment of advanced and/or metastatic renal cell carcinoma. — Both drugs have been shown to be clearly beneficial. — Both are oral preparations and generally well tolerated although they do need careful monitoring and dose modifications. — The benefit is largest in those patients with good/intermediate prognosis so we would target treatment to those groups. — Whilst the costs per patient are significant the numbers of patients are limited. — Treatment options for this group of patients are very limited as standard chemotherapy and radiotherapy are largely ineVective. — NICE reviews will not be available until 2008 at best and we should not delay a formal decision any longer. — Both drugs are licensed based on large multinational trials in which the Christie took part as a major UK centre (as did other major UK centres). Thus although the lead for the trials were not in the UK and they were published in US based journals they represent a global view of best current practice and are not specific to any country. — The availability of Sunitinib and Sorafenib are recommended by European expert groups. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Evidence for Sunitinib
First line treatment — A large randomised Phase III study has shown Sunitinib to be a more eVective treatment than interferon. The overall time to progression was increased from five months to 11 months with no detriment to quality of life. — The response rate to Sunitinib was 46% vs 12% for interferon. — The eVect on overall eVect on survival is unclear because of cross-over (both ways). However, based on projections at the time of cross-over the survival benefit is estimated to be 9.8 months. — The estimated cost of treatment per life year gained is about £25,000 and per quality adjusted life year is £29,000. — The median actual cost of treatment per patient (following price reduction) is £18,800 according to the company.
Key Paper Motzer RJ, Hutson TE, Tomczak P, Michaelson MD, Bukowski RM, Rixe O, Oudard S, Negrier S, Szczylik C, Kim ST, Chen I, Bycott PW, Baum CM, Figlin RA. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med. 2007 Jan 11;356(2):115–24.
Second line treatment — After treatment with cytokines (IL2 or Interferon) treatment with Sunitinib can still be eVective. — The response rate is similar at around 40%. — The time to progression is eight months and the median survival is around 23 months. — There is no randomised trial but these results are so spectacular compared to any other drug that they led to licensing in US and Europe. — At the Christie we have audited all 80 patients we have treated “second” line and have found similar results. The time to progression is 8.3 months and median survival is (20 months (projected 22 months). The survival has been compared with that expected based on a well recognised “prognostic score”. The predicted survival for our group of patients is 13 months so there is a clear survival gain. — The estimated cost per patient is £15,000 according to the company but we estimate it to be lower (about £14,000) as more patients experienced dose reductions in our patient group.
Key Paper Motzer RJ, Michaelson MD, Redman BG, Hudes GR, Wilding G, Figlin RA, Ginsberg MS, Kim ST, Baum CM, DePrimo SE, Li JZ, Bello CL, Theuer CP, George DJ, Rini BI. Activity of SU11248, a multitargeted inhibitor of vascular endothelial growth factor receptor and platelet-derived growth factor receptor, in patients with metastatic renal cell carcinoma. J Clin Oncol. 2006 Jan 1;24(1):16–24. Motzer RJ, Michaelson MD, Rosenberg J, Bukowski RM, Curti BD, George DJ, Hudes GR, Redman BG, Margolin KA, Wilding G. Sunitinib eYcacy against advanced renal cell carcinoma. J Urol. 2007 Nov;178(5):1883–7. Epub 2007 Sep 17.
Sorafenib The evidence in favour of sorafenib as a first line treatment is not strong so we will only consider its use second-line even though the license is also for those who are not suitable for cytokine therapy.
Second line treatment — The main evidence for benefit comes from a large Phase III trial of Sorafenib vs Placebo after cytokine treatment. — This showed a low response rate—10% on Sorafenib vs 2% for placebo. — The time to progression was however doubled from 2.8 to 5.5 months. — Assessment of overall survival was also complicated by cross-over but the best estimate is that the median survival increases from 15 to 19 months. — The SMC estimated a cost per QALY of £35,500. — The estimated cost per patient is £ 14,900. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Key Paper Escudier B, Eisen T, Stadler WM, Szczylik C, Oudard S, Siebels M, Negrier S, Chevreau C, Solska E, Desai AA, Rolland F, Demkow T, Hutson TE, Gore M, Freeman S, Schwartz B, Shan M, Simantov R, Bukowski RM; TARGET Study Group. Sorafenib in advanced clear-cell renal-cell carcinoma. N Engl J Med. 2007 Jan 11;356(2):125–34.
Recommendations for Management of Renal Cancer in Manchester (See flow chart (below for details) — First line treatment for most patients will be Sunitinib or Interleukin-2 (intereukin-2 is curative for a small number of selected patients). — Second line treatment can be with cytokines or preferably in a trial unless Sunitinib has not been used first line in which case Sunitinib or Sorafenib can be considered.
Overall Cost It is always hard to estimate the overall cost of new interventions but my best estimate is to suggest a budget increase for a full year of about £1.5 M for our full population of three million—so we could say £50,000 per 100,000 population would be a good estimate (ie 50 p each!). Robert Hawkins Professor of Medical Oncology / Renal Cancer Specialist—Christie Hospital Flow Chart Outlining Proposed Management of Metastatic Clear Cell Renal Cancer for 2007–08. For all patients a trial should always be considered when available.
Metalstic / Locally Advanced RCC patient Assess Prognastic Score (MSKCC) Review History (for IL2 score)
Favourable Any Unfavourable Histology History Histology
Good/Intermediate Poor Good/Intermediate Prognosis Prognosis Prognosis
First line Symptomatic Care First line Interleukin-2 or Sunitinib Temsirolimus sunitinib or IL2 Sunitinib First First Clinical Trial Second Line Clinical Trial or Second Line Second Line Consider Interferon sunitinib or Trial or Sorafenib Interferon (rarely IL2)
For non-clear cell patients (all are rare): 1. When available a trial is preferred option—interferon has been standard for many years. 2. Chromophobe tumours appear to respond well to Sunitinib and there is a good theoretical rational. 3. Some evidence that Papillary tumours respond to Sunitinib but trial is preferred. Temsirolimus will be licenced shortly and may be the best treatment. At present it is available free of charge. 4. Oncocytomas—little evidence of benefit. 5. Collecting Duct or Transitional Cell tumours should be treated with chemotherapy. Processed: 20-03-2009 13:33:10 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Lembit O¨ pik MP, received from a Consultant at the Royal Shrewsbury Hospital It fills me with some dismay to see a copy of your letter related to Vacuum Assisted Closure technologies. As you will fully appreciate, your own study of the 11 published randomised control trials at that stage do not always give a full view, particularly when the anatomical region for VAC therapy is slightly diVerent. There is no doubt that in my experience, and that of my colleagues, that VAC closures for dealing with complex diabetic heel ulcers in the presence of arterial disease, is one of the only dressings that produces dramatic improvements in the ability of the wound to granulate over the calcaneum and to restore healing. Without this therapy I would have undoubtedly performed some additional amputations in the below knee position due to failed healing and resolution of the wound. It also concerns me that there continues to be a great disparity in the equality of health care oVered to both English and Welsh patients (Powys). Whilst you state that each individual patients may be treated on his or her own merit through an appeal process, we unfortunately do not have the luxury in terms of timing, to wait for the result of an appeal before eVective management is instituted. Hospitals, as you will be well aware, are not the best of places to reside for long unnecessary periods, purely based on the requirement to provide an appropriate dressing. Mr P has been ready for discharge for some time and due to the restrictions on access to certain therapies and your failure to provide approved funding in his case, he has and probably will, stay in hospital for a significantly longer period of time and I will ensure that our financial Director is aware of the time periods in order that appropriate costs can then be applied. What would be extremely helpful for me as a Vascular Surgeon and that of my colleagues, is for you to write to me categorically to state that you accept the clinical risks associated with your failure to fund future patients with VAC therapy.On receipt of this letter I will inform all Surgeons within the Trust that no patients should receive such VAC therapy and we will therefore work with your patients in a slightly more restrictive fashion. Clinically I find this situation unacceptable, but like many things it is driven by cost reduction rather than appropriate medical care, it is wrong to purely justify the reasons for withdrawal of treatment from a limited number of randomised controlled trials of varying quality. May 2008
Memorandum submitted by the Parkinson’s Disease Society The need for access to cross-border specialist health care for people with Parkinson’s Disease in Wales is crucial. At present many people with Parkinson’s in Wales access specialist services and support from hospitals and centres in England and will continue to need to do so. This is particularly true in North Wales where people with Parkinson’s access services from the Walton Centre in Liverpool. This provision is much more convenient and manageable for people with Parkinson’s and their carers, who would otherwise have to travel to South Wales, incurring long journeys each way. In addition, Deep Brain Stimulation, which is a form of neurosurgical intervention for some people with severe movement disorders, including Parkinson’s Disease, is not performed in Wales, only being available from specialist centres in England. Though it is not currently funded for people living in Wales (as it is in most of the UK, and this is a current Parkinson’s Disease Society campaign to get this funding reinstated since it was ceased in 2006), even if it were funded it would need to be carried out in England as that is where the expertise lies. Whilst we support the development of specialist centres within Wales, there is a need to be pragmatic and realistic about the range of specialisms which can be provided from within this country and to acknowledge the benefits of having eVective cross-border provision in public services. Carol Smith Campaigns, Influence and Service Development OYcer in Wales 20 March 2008
Memorandum submitted by Powys Local Health Board
1. Executive Summary 1.1 Powys Teaching Local Health Board commissions a significant range of health services from English NHS Trust providers. 1.2 Funding to English NHS Trust providers is based predominantly on historic baselines as the Health Service in Wales does not recognise English tariV. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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1.3 The tLHB is content with the quality of services provided to its population from its English NHS Trust providers, but notes there are continued diYculties and tensions over the matter of tariV and diVerential waiting times.
2. Introduction (to Powys tLHB) 2.1 Powys Teaching Local Health Board (the tLHB) both commissions and provides a range of healthcare services to the population covered by the county borough of Powys. The county runs along the border between England and Wales. 2.2. The circa 120,000 population is of rural status and having no District General Hospital within its boundaries, is serviced from several English and Welsh District General Hospitals outside of the borough.
3. Extent to which Powys Population Accesses Cross Border Health Services 3.1 Whilst the largest element of expenditure on secondary healthcare by Powys tLHB is on its own provider function, the Powys population receives the majority of its acute care via District General Hospitals (DGHs) outside of boundaries of the county borough. The most significant English NHS Trusts providing these DGH services to Powys are Hereford Hospitals NHS Trust and Shrewsbury and Telford Hospitals NHS Trust 3.2. To put some context on the scale by which Powys tLHB commissions services from English NHS Trusts, of the total secondary care expenditure incurred by Powys tLHB, approximately 23% (just under £30million) is with 13 English NHS Trusts with the largest provider within this category being Shrewsbury and Telford Hospitals NHS Trust (12%).
4. Arrangements in Place to Co-ordinate Cross-Border Service Provision 4.1 Powys tLHB has NHS contracts in place with the majority of its English NHS Trust providers. The tLHB uses the template documentation issued by the Welsh Assembly Government as the basis for the majority of its contracts. 4.2 The contracts are agreed on an annual basis and are negotiated based on anticipated demand for services and applied inflationary increases. 4.3. Regular review meetings are held with providers to consider and agree the actual performance and corresponding funding against contracted baselines.
5. Funding and Quality of Cross Border Services 5.1 The tLHB funds the services provided by English NHS Trusts based on the resource mapped funding provided to it on its establishment in 2003/04, adjusted annually for movements in activity and uplifted for inflationary increases. 5.2 The tLHB seldom receives complaints regarding the quality of services provided by English NHS Trusts and has no cause for concern regarding this matter.
6. The Extent to which Health Policy has Diverged across the UK since Devolution 6.1 There are several diVerences between England and Wales in terms of the approach to securing healthcare services for their respective populations. The two which predominantly impact on the relationships between Powys tLHB and its English NHS Trust providers are: — Implementation of tariV. —DiVerential waiting times targets. 6.2. As noted in paragraph 5.1 above, the tLHB funds all providers based on historic funding baselines adjusted for movements in activity and uplifted for inflation/recognised pressures. 6.3. The implementation of Payments By Results or “tariV” would normally have meant Powys tLHB paying a higher price for the same level of service received by English NHS Trust providers. The tLHB has not received funding from the Welsh Assembly Government to recognise English tariV and has therefore received the support of the Welsh Assembly Government to only pay against historic funding baselines. 6.4. This has not however, prevented several providers still pursing the tLHB for additional funding. 6.5. The implementation of diVerential waiting times has also had an impact both on the management arrangements for meeting targets and on managing the population’s expectation of services provided between England and Wales. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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6.6. For example, with Hereford Hospitals NHS Trust, the tLHB has taken on the management of the waiting list because the Trust has refused to operate diVerential waiting lists between English and Welsh commissioners. This has placed an administrative burden on the tLHB as we now manage the waiting list both for ourselves and that of Monmouthshire LHB. 6.7. Similarly, the English providers who have continued to operate diVerential waiting times between English and Welsh commissioners have had additional administrative burden placed upon them. 6.8. In addition, the tLHB has to manage both patient and clinician perception of operating diVerential waiting times between England and Wales which has resulted in letters of complaint due to the confusion over the diVerences.
7. Mechanisms for identifying and resolving cross border deficiencies 7.1. As outlined above, the tLHB maintains regular contact with its English providers and any issues requiring resolution are, where possible resolved locally. 7.2. However, the issue of price has in the past and still today caused tensions with English providers. The tLHB has already been through arbitration over this matter and it is possible that this will occur again. 7.3. The process for resolving this type of dispute is through an arbitration process via the relevant Strategic Health Authority and the Welsh Assembly Government.
8. Recommendation 8.1. Powys Teaching Local Health Board has no specific recommendations to make to the Committee, but asks the Committee to note the contents of this memorandum. March 2008
Memorandum submitted by Professor Charlie JeVery, University of Edinburgh
Introduction 1. This memorandum draws on findings from research supported by the Economic and Social Research Council under its research programme on Devolution and Constitutional Change, which ran from 2000–06 under my direction. In particular it draws on work done in collaboration with the Institute for Public Policy Research as reported in books on Devolution in Practice. Public Policy Variations in the UK in 2002 and 2005. 2. It is an inherent feature of devolved systems of government that the packages of public policies experienced by citizens vary from place to place. Devolution in the UK, as elsewhere, is intended, inter alia, to bring greater proximity of decision-making and in that way to reflect better diVerent territorial preferences and identities in public policy in diVerent jurisdictions. 3. It is no surprise, therefore, that devolution here, as elsewhere, has produced greater divergence of public policy. Indeed, post–1999 divergences have built on long-standing practices of territorially diVerentiation of public policy that are in part rooted in the diVerent terms of union among the diVerent nations of the UK, and the administrative practices developed before 1999 by the Wales, Scotland and Northern Ireland OYces. The UK has long experience of territorial policy variation.
The Structure of Devolution 4. But the UK also has a structure of devolution that is very, and in comparative terms, unusually open to far-reaching policy variation and lacks the mechanisms employed elsewhere to balance divergent territorial preferences with overarching state-wide concerns. 5. There are three features of that structure that promote variation. The first is the relatively tidy division of powers between those reserved to Westminster and those variously devolved in Wales, Scotland and Northern Ireland. The division is neatest in the Scottish and Northern Irish cases, though Wales after the 2006 Government of Wales Act is moving in a similar direction, all the more so if a referendum is held and won on full legislative powers. The tendency is to establish four discrete jurisdictions in a range of important policy fields, including health, education, local government, planning and so on. 6. The second feature promoting variation is the UK’s system of financing devolution through block grants transferred to devolved administrations by central government. These grants are transferred unconditionally; the devolved administrations in principle have complete discretion in how they spend those grants. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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7. The third feature promoting variation are the diVerent terms of political competition in Wales, Scotland and Northern Ireland as compared to Westminster. Westminster is dominated by a classic left-right contest between Labour and the Conservatives. The Conservatives are very weak in Wales and Scotland, and left-leaning Nationalist parties pull party competition there to the left (while also introducing constitutional questions into party competition that are generally marginal at Westminster). The terms of political debate in Wales and Scotland therefore diverge significantly from those at Westminster, as they do in Northern Ireland, where there is an entirely distinctive party system and constitutional debate. 8. Discrete policy responsibilities, full discretion on spending, and diVerent terms of party political competition have already fostered—and are likely to do so all the more over time—notable territorial policy variations in Wales, Scotland and to a lesser extent Northern Ireland. These extend some way beyond those variations inherited from pre-devolution arrangements. There are few institutional counterbalances to that dynamic of variation. In particular the UK lacks those forms of systematic intergovernmental coordination that exist in most other decentralised states to identify and pursue common objectives across jurisdictional boundaries and to build understandings of the legitimate scope of cross-jurisdictional policy variations and the implications for cross-border relationships that arise.
Cross-Border Policy Variation 9. There is a growing number of examples of policy variation. Some of the innovations of the devolved administrations—for example in children’s policy in Wales and on smoking in Scotland—have prompted UK-wide changes. Other devolved innovations—on free personal care, prescription charging, the licensing of NHS treatments, or tuition fees—have not been generally emulated. As significant a source of variation has been Westminster in its role as legislature for England. Its changing approach to the structure and performance management of public services has not been emulated and in many cases has been rejected by the devolved administrations. England also is a force for divergence. 10. A patchwork of diVerent territorial packages of public services has resulted. This—it bears repeating—is entirely consistent with the purposes of devolution. But without an institutional framework for a discussion of the cross-border and UK-wide coordination issues and other implications of cross- jurisdictional policy variation, the UK’s policy patchwork is and will remain ad hoc, inconsistent and confusing for the citizen. 11. Some have pointed to the potential for territorial policy variation to corrode the UK’s “social citizenship”, the postwar commitment to a welfare statehood that treated all citizens equally irrespective of income or place of residence. Public attitudes surveys suggest that citizens in all parts of the UK share broadly the same values on the role and scope of the state and the obligations of citizens to one another. They also suggest (without the same depth of evidence) that citizens in their majority disapprove of the idea of territorial policy variation (even while endorsing devolved, and therefore potentially divergent decision- making in clear majorities outside England). 12. In these circumstances an under-coordinated structure of devolution runs the risk of producing perceptions of inequity that might lend themselves to political mobilisation. One example of this on a small scale was the recently reported (and, no doubt, methodologically suspect) commercial opinion poll in Berwick-on-Tweed which suggested that the majority of Berwick’s population would prefer re-unification with Scotland to enjoy what are perceived to be better public services there. Equivalent pollster-led skirmishes are conceivable on the Anglo-Welsh border, where in particular diVerent prescription charging policies have been contentious. 13. On a larger scale there have been repeated contributions in some sections of the London-based media, in parts of the Conservative Party, but also parts of the Labour Party in London and in northern England (and more mischievously the Scottish National Party in Scotland) that the arrangements for devolution outside of England are unfair to people in England. A particular focus has been on the seeming connection between the higher level of per capita public spending in Wales, (especially) Scotland and Northern Ireland as compared to England, and the perceived generosity (in some views, profligacy) of public services outside England. 14. These contributions have largely been misguided. They tend to misunderstand both the system used to allocate funding to the devolved administrations, and the pattern and sources of post-devolution policy variation, much of which has been driven by Westminster in England, and in many cases might be said to produce there ‘better’ or ‘more generous’ public services than those available outside England. However misguided, these contributions point to a potential for the political mobilisation of territorial diVerence.
Mechanisms of Cross-Border Coordination 15. To summarise: the post-devolution political system: — has a lack of institutional counterbalances to a structure that promotes territorial policy variation; and — runs the danger—in part through widespread misunderstanding of the reasons for policy variation—of causing conflict over perceived inequities between the component parts of the UK. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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16. Other political systems provide examples of how more robust institutional balances and more rounded understandings of cross-jurisdictional equity and coordination can be achieved. Among the institutional techniques used elsewhere, but absent in the UK, are: — Statewide policy-making by intergovernmental agreement between central and devolved governments. — Statewide framework legislation leaving a wide scope for detailed regulation and implementation at the devolved level. — Joint central-devolved funding of agreed common policy objectives. — Specific-purpose transfers of central funding to devolved administrations to achieve statewide objectives. — Systems of fiscal equalisation to ensure all jurisdictions have suYcient resources to deliver equivalent levels of services. 17. Typically, such institutional techniques are underpinned by codified, routinised and systematic processes of intergovernmental coordination. These processes provide forums for identifying common purposes, resolving any disputes that may arise, managing the interfaces between jurisdictions, and pursuing joint decision-making. They also, through their codes and routines, generate enduring common understandings about the purposes, benefits and limits of territorial policy variation as balanced against statewide objectives. 18. The UK’s system of post-devolution intergovernmental relations is extraordinarily underdeveloped. It would be diYcult to assess it as fit for purpose. The UK does have codified arrangements—for example Joint Ministerial Committees—but these in most cases are not used. Intergovernmental relations instead work typically through ad hoc, case-by-case interactions among diVerent and changing groups of oYcials. There is an absence of routine and as a result a failure to embed understandings of the “rules of the game” in balancing UK-wide and devolved interests. Without clear, enduring common understandings of balance the devolution arrangements remain vulnerable to their own inconsistencies and the consequent danger of partisan mobilisation of territorial conflict.
Choices
19. This is an unsatisfactory situation. Its uncertainties are reflected in formal debates about constitutional relationships in Wales and Scotland, and at the UK level in the constitutional “review” or “commission” under discussion by the three main unionist parties. A number of options might be considered in this context: 20. The status quo. The discussion above suggests that the ill-coordinated ad-hockery of current arrangements is not the optimal route forward. Two alternative trajectories appear possible. 21. Renewal of union. Some mixture of the types of technique listed under paragraph 16 are introduced, and underpinned by a more systematic approach to intergovernmental relations. This option would involve the identification of, and measures to achieve, UK-wide objectives across jurisdictional borders. In doing so, it may require some restrictions on the current scope of devolved responsibilities; it is not clear that the devolved administrations would be willing to accept this. A more systematic approach to joint decision- making would also require a conception in Westminster and Whitehall of power-sharing with the devolved administration in the identification and pursuit of common objectives; it is not clear that Westminster and Whitehall would be willing to accept this. 22. A state of the autonomies. This option would not involve the pursuit of a wide range of shared objectives, but rather the acceptance of growing territorial policy variation by the devolved administrations and by Westminster acting for England. In eVect England would be governed as a unitary sub-state of the UK by Westminster, while Scotland, Wales and Northern Ireland would pursue autonomous objectives, no doubt on the basis of a fuller devolution of powers than at present, including extensive fiscal autonomy. The eVect would be to harden the UK’s internal borders and limit the scope of citizenship rights enjoyed uniformly across the UK. It is not clear that this option would receive public support, for reasons stated above in paragraph 11. 23. These alternatives are presented here in bald terms. Presented baldly they each appear to present diYcult problems. No doubt there are elements in them that are reconcilable (for example the Liberal Democrats’ Steel Commission in Scotland proposed devolution arrangements with greater autonomy alongside measures to strengthen the UK union). Yet put baldly they raise issues of principle whose resolution would appear a precondition for sustainable reform: do we want a more consciously integrated union than at present, with limits on the scope of cross-border variations; or are we happy to see far-reaching diVerentiation in what the UK state does for its citizens from one part of the UK to the next? Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by Radiotherapy Campaign Hereford Following introductory correspondence to Dr Hywel Francis MP, it has been requested locally that an initial dossier be forwarded to the Welsh AVairs Committee concerning the high profile campaign for comprehensive cancer treatment facilities at Hereford County Hospital—a campaign launched in November 2005 and still very active. As past long standing Chairman of Herefordshire Community Health Council and Chairman and later member of Herefordshire Primary Care Trust Public and Patient Involvement in Health Forum, my local contacts including that of the media proved invaluable to the success thus far of the campaign. Also following personal experience of the distress of frequent long journeys to Cheltenham to access treatment—my wife underwent chemotherapy and radiotherapy treatment during 2005—it was considered that doing nothing was not an option. During the course of that year we travelled some 7,000 miles on health related journeys. We live on the Welsh border, but other patients from central Powys have even greater journeys to access such treatment. The Three Counties Cancer Network, based at Cheltenham, serves the counties of Gloucester, South Worcester, Hereford and a substantial slice of Powys extending as far west as Llanwrtyd Wells to include the centres of population of Builth Wells, Rhayader and Llandrindod Wells. Some of these patients travel upwards of 100 miles each way to access cancer treatment at Cheltenham. Hereford is geographically central in the above designated catchment area. The campaign, initially resulting in over 600 items of correspondence from patients and families, illustrated that approximately 10% of patients diagnosed with cancer either refused treatment or failed to complete the prescribed course of treatment because of the time and distance of the journey. Examples of such comments, as published in the Hereford Times are attached together with a summary of the first batch of responses. As a direct result of this overwhelming vocal public response, Macmillan Cancer Relief supported the campaign, the outcome of which is the sanction and guarantee of a new oncology unit and chemotherapy department at Hereford County Hospital [with footprints for future radiotherapy linear accelerators or linacs], to be operational by 2010—the critical decision relative to the provision of radiotherapy facilities is due in September 2008. £1.5 million was raised for this project since the start of the campaign. Although the campaign has been narrowly focused on a particular health issue, general cross border issues and concerns have been noted. The campaign aims at maintaining awareness of such issues and exerting pressure as appropriate. At present the campaign approach is being centred on the National Assembly for Wales. Please excuse the amount of supportive material in this initial and “limited” exercise. Allan W Lloyd 18 March 2008
CAMPAIGN FOR RADIOTHERAPY TREATMENT AT HEREFORD
Extracts from Patients’Comments “Two years ago my specialist wanted me to go to for treatment, I also suVer from arthritis and could not face the daily journey. I am now 97 and if Hereford is chosen I fear it will be too late for myself, but I hope . . .” “Cheltenham was a nightmare. The journey there was an ordeal—Robert used to be nearly in tears at the commencement of each trip, and when he had to go for 14 successive radiotherapy treatments, the toll was devastating. At times I wondered if I was going to get him home, he was so sick and ill. Did it do any good? Robert finished the course of treatment on 3 August and died on 6 August. All that anguish for nothing. I would rather he had had the time at home and not faced the nightmare of all those hospital visits—it sickens me now to think of it. Fight on, those who will be diagnosed in the future deserve better.” “. . . he was so ill after each treatment and drive back from Cheltenham to Ludlow that he towed his caravan there and stayed in a farmers field caravan park for the duration.” “I cannot put in words the sheer exhaustion of travelling and dealing with the various side eVects of the treatment. Many a time I sat on a chair and said ‘I can’t do this anymore’. On several occasions I had to resort to staying over in a hotel as I couldn’t face the journey home.” “At 76 years of age I am dreading the long journey to Cheltenham [from Rhayader]” Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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“You have to be a very fit person to endure all that stress and travelling.”
“My late father in law had prostate and bladder cancer, and at the age of 78 had to make the daily trek to Cheltenham for six weeks for radiotherapy. The problem was that he only had a bladder capacity of about 20 minutes. Initially he coped by carrying a screw top jam jar everywhere he went. But there were often other patients in the car, some of them ladies.”
“We had to make the 92.5 mile journey each way to Cheltenham [from St Harmon, Powys] for radiotherapy from end of June to 13 August 2004. The journey caused Phyllis much distress as we had very hot weather at this time, she was often quite ill by the time we arrived home. Unfortunately Phyllis died on 20 September. I am sure that the long journey to Cheltenham contributed to shortening her life.”
“In total we must have made about 80–100 trips to Gloucester and Cheltenham.”
“So far I have remained in remission [nearly four years] but I have to say that should a recurrence happen I doubt I would have the strength to face those journeys again knowing how horrendous it all was. To be diagnosed with cancer is awful enough without the torture imposed by so much travelling.”
“I ended up by staying in B&B in order to limit the trauma of daily travel.”
“We would not be allowed to put a dog through such an ordeal—we would be had up for cruelty. I know that if my cancer comes back and I am asked to travel to Cheltenham, I shall refuse treatment.”
“Patients, already frightened and delicate from the eVects of treatment, cannot bear to face another round trip, and give up.”
“The chemo comes to an end soon, but the trips to Cheltenham for radiotherapy start after Christmas. What a mountain to face, at the worst time of year, weather wise. It would be marvellous if the journey was only to Hereford.”
“Travelling such a distance is soul destroying when one is anxious and frightened anyway.”
“The only down sides, said Dr Sean Elyan [Consultant], were (1) possible hair loss (2) likely extreme exhaustion after the treatment (3) ‘and probably the worst aspect’ to quote him, ‘the journey to and from Cheltenham’.”
“The journey from the Welsh Border to Cheltenham and back whatever the weather took us from 1.30 pm. and we got back home around 7.00 pm. It was stressful for both of us, and I shall never go to Cheltenham again.”
“An example of a postcode lottery within the NHS.”
“A few weeks ago we learned that my 89 year old mother has breast cancer. Fortunately, her tumour is oestrogen-receptive and she is being treated with Arimidex which should shrink it. Had it not been oestrogen-receptive, she was told she would have to have radiotherapy to shrink it. She said she would have refused as she could not possibly face the journeys to Cheltenham.”
“It seems ironic that people needing this treatment have to undergo journeys that a healthy person would find tiring!”
“The location of a new Dialysis Centre in Hereford has proved a life-line to Dialysis patients in the area—and so would Radiotherapy at Hospital”
“I do hope your campaign goes well, as I (for one) would have to think very seriously about another series of trips to Cheltenham. I am now 72 and still attend out patients’ clinic every six months at the County Hospital.”
“However, she became too weak to complete the treatment at Cheltenham, having to travel from Mortimer’s Cross, Kingsland.”
“Should patients have an accident or relapse during their journey from Cheltenham—what then?”
“At times I felt that I would prefer to suVer the condition and forego the treatment rather than face the endless journey.”
“We discussed the matter and the consultant said the side of eVects and the travel problem would be pretty horrible. I asked about alternatives and he told me about a course of three monthly injections for life. I opted for this and am due to have an assessment in January. Hopefully all will Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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be well. I was very impressed by the consultant’s willingness to admit that the Cheltenham option was a bit of a nightmare, the more so because nine months ago my wife’s cousin died of cancer, aged 57, and he admitted the visits to Cheltenham were hell and he opted out of them.” “My opinion is that it is this feeling of not wanting to be a nuisance to others [‘the uncomplaining suVers’] which is the very reason why it has gone on so long without being challenged: keep up the good work.” “The nightmare of a journey to Cheltenham in the bleak winter months or baking summer days is obscene and horrendous.” “I suVer from cancer widespread in my bones; at present I am having medical injections. If I am advised by my Doctor that radiotherapy would be advisable I would dread the journey to and from Cheltenham for a period.” “During this period of time and partly as a result of travelling, I collapsed several times: one of which necessitated me staying in Intensive Care at Cheltenham for eight days.” “As we have a motor home and are used to staying in it, we decided to book into a caravan site just outside Cheltenham. However, it did cost in the region of £400.00 for site fees.” “By the end of the treatment I was exhausted and considerably out of pocket. However, what really upset me was when the receptionist took a call from Kington and reported to the Senior Radiographer that Mr. X, an elderly man, would not be continuing his treatment as he felt too ill to undertake the journeys anymore. I thought that distance should not determine a person’s chance of recovery or remission.” “Unfortunately Phyllis died 20 September 2004. I am sure that the long journey to Cheltenham contributed to shortening her life.” [Dr. DB Marriott] “My neighbour who formerly was a volunteer driver for such visits has had to give up partly because of the time element, but also because he found the trauma of concern about patients in obvious distress diYcult to contend with.” “A friend was oVered treatment and refused it. She is eighty years of age, lives in Powys, but faced with the choice of going several times a week on such a horrendous journey whilst suVering pain and illness, chose the alternative of dying in her home.”
RADIOTHERAPY CAMPAIGN HEREFORD
Background Information Rallying call to the public: “Doing nothing is not a viable option”. The two health trusts in Herefordshire have pledged to fight for radiotherapy treatment for cancer to be based in Hereford. At present this treatment is only available for local patients at Cheltenham where there are four linear accelerators providing the treatment. Predicted demand, based on the fact that cancer rates are expected to rise and carry on rising for the foreseeable future, indicates that a minimum of an extra four machines or linear accelerators will be required locally before the end of the decade. However, it is only feasible to have, at the most, two treatment centres— Cheltenham and either Gloucester, Hereford or Worcester. The Herefordshire trusts have been advised to develop a case for getting radiotherapy services, with a decision as to preferred placement expected by Autumn 2006. Geographically Hereford is the most obvious site: the city is placed at the centre of the designated catchment area, which not only includes the three counties of Gloucester, Hereford, South Worcester, but also a substantial slice of Powys extending as far west as Llanwrtyd Wells. The researched timed journey from the far west of the catchment area to Cheltenham is up to three hours each way. This is a powerful argument for the provision of treatment on a linked site such as Hereford. This is an opportune time to campaign for linear accelerators to be installed at Hereford. For it has been confirmed that Hereford Hospitals Trust is in serious negotiations to finance the redevelopment of the Charles Renton Cancer Unit with new build possibly in conjunction with the phased replacement of the hutted hospital wards. It would be logical to provide a minimum of two bunkers to house the radiotherapy accelerators in the early building design of such redevelopment. The bunkers that contain the machinery are the most expensive pieces of equipment: the NHS would provide the linear accelerators. Simon Hairsnape, Chairman of Three Counties Cancer Network, aYrms that a Hereford centre for radiotherapy is clinically feasible. David Rose, Chief Executive, Hereford Hospitals Trust is strongly in support of such a provision. The said provision would aVord Hereford Hospital the chance to become a centre of excellence for the treatment of cancer to the benefit of patients in Herefordshire, Powys and the Shropshire border. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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The key message is that demand for radiotherapy treatment has already outstripped capacity, and that the people of Hereford and neighbouring districts, especially that of Powys, should be given a voice to express their support for new provision to be based in Hereford. In July 2005, Sir Nigel Crisp, Chief Executive of the NHS, produced a paper entitled “Commissioning a Patient led NHS” in which he emphasised the need to achieve patient and public involvement in health. A public voice in support of Herefordshire’s campaign to obtain radiotherapy facilities at the County Hospital would be in line with these stated ideals.
Such support cannot guarantee success, and such a campaign must never raise expectations, but a loud voice from west of Cheltenham and Worcester should at least be heard—and as soon as possible.
It is requested that those members of the public who feel strongly in support of a campaign to provide such facilities at Hereford County Hospital, contact us in writing at my home address or by email.
Patients and partners’ comments received to date have proved harrowing, emotionally draining and humbling in the extreme.
Many examples illustrate the eVects of the long tedious journeys to Cheltenham, the direct result of which: — patients have failed to complete the course of cancer treatment; — patients, now in remission, would never go through it again if the symptoms reappeared; and — elderly patients diagnosed with cancer, have actually refused treatment because of the incredibly long journey to Cheltenham—in some cases a round trip of just under 200 miles: certain radiotherapy treatments required 35 consecutive week day visits to Cheltenham.
As a result of the comments received the message to the public has “hardened”:
“TRAVELLING TIME AND DISTANCE TO CHELTENHAM IS PROVEN TO BE A POTENTIAL KILLER”
Cancer Treatment Facilities at Hereford County Hospital
The new £3.4 million Macmillan Renton Oncology Unit and Chemotherapy Department at Hereford County Hospital, is projected to be operational by 2009. Provisional allocation to accommodate radiotherapy treatment facilities has been included in the plan with a footprint for three linear accelerators or radiotherapy machines. However, the decision relating to the provision of radiotherapy at Hereford has been delayed until September 2007.
Discussion at present centres around the provision of a possible sixth linear accelerator at Cheltenham. However, only limited opportunities exist for further physical expansion of the Oncology Centre at Cheltenham General.
Cheltenham is already experiencing diYculties in meeting its access targets for radiotherapy. The Department of Health projects an increase in the demand for radiotherapy treatment of 10% per year. It would seem that a satellite site linking up with Cheltenham is inevitable.
New radiotherapy machines with supporting staV are very expensive irrespective of where they are situated. Admittedly, the costs of a satellite site will be higher whether centred at Worcester or Hereford. For the patient, Hereford would seem to be the most logical site as it is geographically situated in the centre of the catchment area of the Three Counties Cancer Network administered from Cheltenham.
It is diYcult to equate financial cost with the resulting human cost if Hereford is not given the opportunity to provide radiotherapy treatment. It is estimated that 10% of cancer patients either refuse such treatment or fail to complete the course of treatment because of the time and distance of travel. Patients in Herefordshire and Powys have daily journeys of between 100 and 200 miles to access treatment at Cheltenham.
Macmillan Cancer Support is oYcially backing Hereford’s bid to get radiotherapy facilities. Macmillan has declined an invitation to back Worcester’s bid.
The recent 39-page report by the National Radiotherapy Advisory Group (NRAG), published 26 February 2007, has now been circulated within the NHS for consideration at local level. As a member of the Project Team for Radiotherapy Bid for Hereford, a request has been made for me to approach various administrations in Powys to determine reaction to certain suggested development possibilities at Hereford County Hospital. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The NRAG report is not prescriptive in its recommendations, and it seems unlikely to be funded advice. Nevertheless the findings in the report are significant: The projected need for radiotherapy has been underestimated in the past—evidently a proven gap of 63% exists between current activity levels and optimal treatment levels. This underestimate of need, coupled with increasing demand especially in areas where the population of the elderly is proportionally high, places inevitable pressure on the limited physical capacity available at Cheltenham even with increased use of existing facilities. But by far more important to Hereford’s campaign is the realisation expressed in the NRAG report that the burden of access travel time and distance must be addressed. Equity of access is recognised—with a professional statement that no more than 45 minutes travel time should be considered as good practice to access treatment. In our area journeys in excess of 180 minutes have been recorded. The report statement that a drive time analysis for radiotherapy has shown that 87% of the population already live within 45 minutes of a radiotherapy centre, further emphasises what must be a high proportion of patients in our area among the remaining 13%. March 2008
Memorandum submitted by the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust
1.0 Introduction
1.1 The RJAH Orthopaedic Hospital is a specialist provider of orthopaedics and musculo-skeletal related services based near Oswestry in Shropshire, United Kingdom. The Trust has provided services to Shropshire, North Wales, Mid Wales and Cheshire for many years and is a recognized provider on a national level, undertaking specialized services to the above populations and to the wider English West Midlands, Wales and North West England.
2.0 Services Provided to Wales
2.1 Geographically the Trust is situated in Gobowen and borders North and Mid Wales in close proximity. The service links with Wales pre-date the establishment of the NHS and geographical position means it is well placed to serve the wider rural catchment areas into Wales. A large proportion of the Trusts staV live in Wales and are Welsh speaking. 2.2 The following general and specialist services are provided to the populations of North and Mid Wales, and also to wider Wales: — Adult orthopaedic surgery including major joints, both primary and revision, spinal surgery and very specialist work including bespoke reconstruction — Complex children’s orthopaedic surgery. — Spinal Injuries, Acute Injury and rehabilitation—one of ten UK centres(commissioned via Health Commission Wales). — Bone sarcoma surgery (one of six UK centres). — Paediatric Neuromuscular Service (one of 4 UK centres). 2.3 The Trust provides outreach clinics into Wales and has a long established strategic partnership with North East Wales Trust 2.4 The Trust is host on a landlord basis to Maternity Services provided by the Shrewsbury & Telford Hospitals NHS Trust 2.5 The Trust has service agreements with Local Health Boards in Wales and treats patients to the standards and waiting times required for Welsh commissioners. Activity for Welsh patients represents 31% of our total activity as a Trust. The ability to access orthopaedic and related specialised services for North and Mid Wales patients at Gobowen prevents long journeys to South Wales, Birmingham and Liverpool which would be required for alternative specialist centres. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Funding Under the English funding system most Local Health Board commissioned activity is reimbursed at national “tariV” rates. For Welsh Local Health Board’s the pricing of contracts reflects historic arrangements and is agreed through Service Level Agreement negotiations. Wendy Farrington Chadd Chief Executive April 2008
Memorandum submitted by Dr Quinlivan, consultant in Neuromuscular Disorders, Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust I see adult and paediatric patients with rare neuromuscular diseases. I have worked as a consultant for 13 years. From a clinical perspective on the whole there is not a major problem with diVerential waiting times between England and Wales. There have, however, been occasional diYculties caused by diVerential waiting times. Two children waited 18 months for a new appointment, even though I had prioritised them as urgent. One adult with a serious inflammatory muscle disease, was informed by his LHB that he would have to wait eight months to be seen. Fortunately, the general practitioner wrote to alert me to this fact and I was able to expedite the appointment. As a clinician, I would like to prioritise appointments on clinical grounds, it makes better sense for the patient. I am often asked to complete pre-referral forms for patients from Wales. These take time and I am already very busy. The forms are designed for patients being referred for surgical treatment. The questions asked are on the whole irrelevant and not applicable to my service. Funding is usually approved. I agree with Mr Farrington-Chadd, these forms simply add delay to the patient pathway. I have had diYculty investigating Welsh patients, LHBs have refused to allow me to refer patients for neurophysiology in England. Neurophysiology is a specialised investigation for neuromuscular disease, sometimes I need to refer patients to a specialised (rather than general) neurophysiology service for a specific test. I have been refused permission to send genetic samples out of Wales for diagnostic testing, recently, I was refused permission to send DNA sample to London for Duchenne genetic analysis. I have referred patients from North Wales to the Neuromuscular Centre in Winsford for specialist physiotherapy. This is the only centre of its kind in the UK. It is within reasonable travelling distance from Wrexham. Most of these referrals are refused funding by the LHBs, even though no specialist physiotherapy services for neuromuscular disease exist in Wales. June 2008
Memorandum submitted by Mr and Mrs M and J Robinson of Hay-on-Wye 1. We are Mr and Mrs M and J Robinson of Hay-on-Wye. 2. We would like to acquaint the members of the Committee with our personal views on these matters. We believe that in general the evidence which you are taking does not include that of residents in the Marches of Wales, those, in fact, who actually experience the day to day provision of such services. We further note that few members of your committee represent border constituencies and therefore may not receive much information from the public on these matters. We cannot comment on social care but would like to submit our experience of health care as it has aVected our family over past years. For 16 years we lived two miles into England and for the past five years we have lived one mile into Wales. Our doctors’ practice is, and has always been, in Hay on Wye (Wales) During our residence in England attendance at hospitals has been: Hereford County Hospital: A&E, Eye treatment, various scans but with follow-up care of Physiotherapy at Bronllys (Wales), other scans Abergavenny(Wales) Since living in Wales: Hereford County Hospital A&E followed by Physiotherapy Bronllys; convalescent care and terminal care also at Bronllys. 3. In an area of low population density we feel that cross-border services are essential. We fully appreciate that our widely dispersed and small (by city standards) hospitals need to concentrate on areas of care, especially to uphold clinical excellence. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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4. Remember that Powys does not possess a major A&E dcepartment. Therefore Hereford or Shrewsbury are often the nearest A&E though possibly as much as 50 miles away. The current poor performance of the Welsh Ambulance trust can hardly be helped by emergency vehicles being oV station for long periods of time. 5. Hereford Hospital depends on 30% of its patients coming from Powys. Without that input Hereford Hospital is probably not viable in the long term. Some current government thinking about the critical mass of population which should be served by a general district hospital does not seem to take such rural areas into account. Without the convalescent beds at Bronllys and other small hospitals along the border, there would be bed- blocking in Hereford. 6. Without cross-border provision many patients and their visitors would have to travel even greater distances than those they suVer now. Economic and environmental impacts of such journeys—rarely possible by public transport—should be taken into account. Westminster and the Welsh Assembly should be encouraging, ie funding, the rapid development of remote diagnostic and consultative facilities. In such ways the excellence of NHS services at many levels will be optimised and patients will, in as many instances as possible, receive treatment at points of delivery convenient to them. Whether this is at local facilities (Hay, Bronllys), district (Hereford, Abergavenny) or tertiary (Birmingham, Gloucester, Cwmbran—in the future, CardiV) should be based on medical grounds and not on political or accounting boundaries. 7. The idea that keeping services within Wales enhances National identity falls down if people are forced to receive services at great inconvenience and risk to their health. Cross border links have enormous benefits in this rural area. 8. We cannot comment directly on: — Provisions for co-ordination — Funding arrangements But we welcome current eVorts in Powys and Herefordshire at increasing collaboration between Health and Social Services and we trust that the Welsh AVairs Committee will strongly press for the removal of administrative and budgetary constraints and obstacles to the continuing and indeed enhanced provision of Cross Border Public Services. M G and J H Robinson 13 March 2008
Memorandum submitted by the Royal College of Midwives UK Board for Wales 1. The Royal College of Midwives aims to promote and advance the profession of the midwife. The College represents over 95% of the UK’s midwives and is one of the world’s oldest and one of the largest midwifery organisations. It is also a trade union. We have oYces in London, Leeds, Edinburgh, and Belfast, as well as in CardiV. 2. The College’s evidence has a specific focus on Powys. We believe that cross-border issues have a particular importance to the maternity care provided there, not least because of the length of its border with England. We further believe that policymakers must continue to facilitate cross-border cooperation and enable it to take place, as examples like Powys demonstrate that it can have positive local eVects. We have kept our evidence short to maintain its sharp focus. 3. We recognise of course that cross-border issues aVect North Wales too. In that part of Wales however, transfer to England (from Bangor to Liverpool, for example) will involve a much smaller proportion of women that in Powys. Furthermore, it tends to be for neonatal reasons, rather than for childbirth; that stated, women there may also travel to England for some aspects of antenatal care as well as very specialist high-risk maternity care. 4. There is no district general hospital anywhere in Powys, so women at medium or high risk are often transferred to hospitals in England to receive that level of obstetric care. Not all such women are transferred to England; depending on where they are, they may also be transferred, within Wales, to either Gwent to the south or Ceredigion to the west. 5. What makes Powys diVerent from North Wales is the large proportion of women who transfer for obstetric care to England. 6. These transfer arrangements allow for managers and midwives in Powys to concentrate on providing a midwifery service over a large rural area, which promotes normality in pregnancy and birth. It is the arrangement the local NHS has with the neighbouring English trusts that allows it to pursue its valuable work. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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7. Midwives in Powys rotate to district general hospitals across the border to update their practice and to ensure their continuing professional development. This means that when Powys midwives accompany a woman transferring to an English hospital, they know the relevant policies and procedures, and may even know the staV, which can only have a positive impact on the experience of the woman being accompanied. 8. If barriers were to be created between England and Wales in a way that made such cross-border arrangements untenable then that would not serve the best interests of women in Powys. Barriers could be intentional, if either the UK Government or the Welsh Assembly Government sought for whatever reason (eg to resolve funding disputes) to limit cross-border cooperation; barriers could also be unintentional, perhaps purely as a result of “devolutionary drift” if health policies in England and Wales were to diversify so markedly as to become incompatible. 9. If such barriers limited cross-border services to the extent that the current arrangements for Powys were curtailed, the excellent rural midwifery services currently oVered to women in the county would probably have to be cut back so that funds could be transferred to pay for obstetric care locally. That would be unfortunate, especially as rural services are already under threat across the board. 10. We recommend that the UK Government and the Welsh Assembly Government actively monitor the ability of NHS healthcare providers, including NHS maternity care providers, along the border to cooperate in the provision of NHS care; we further recommend that they take no action that deliberately threatens such cooperation, and that they actively consider and assess what impact future health policies may have on cross-border cooperation, so that such impacts can be minimised. June 2008
Memorandum submitted by the Royal College of Physicians We are pleased to submit evidence to the inquiry. The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. The College has a Regional Adviser for Service in each region of England, Wales, and Northern Ireland. The geographical boundary for each region is normally co-terminus with that of the local Deanery although in some parts of the country there are exceptions to allow for local circumstances and practicality. Regional Advisers for Service are Fellows of the College, normally an NHS consultant in one of our “mainstream” specialties (as recognised by PMETB). They are elected initially to the Associate role, by Fellows within their region from candidates who are willing to devote time and energy on behalf of the College, and through that for the wider benefit of the NHS. For the purposes of this inquiry we have consulted with our Regional Advisers for Service in Wales and the bordering counties in England. We would like to make the following points: The subject of the inquiry has certainly become an issue over the last few years. There are concerns in both directions. We are currently aware of problems for certain patients in Wales who have been unable due to boundary issues to access certain treatments (eg Enzyme replacement Therapy, Gender Reassignment Surgery). There are also patients from English Regions managed in Welsh Hospitals who are unhappy that they have to wait longer for treatments than friends from the same village who are managed in a neighbouring English Trust. Conversely, there are also patients from English Regions who go to Wales to receive free prescriptions. The College believes it is important to identify the scope of the possible problems (medical, political and financial—in particular the tariVs under Payment by Results). We feel there should be further opportunities to highlight some of the more unfair diVerences, once the Select Committee has reported. 20 March 2008
Memorandum submitted by the Royal National Institute of Blind People (RNIB)
About Us As the largest organisation of blind and partially sighted people in the UK, RNIB is pleased to have the opportunity to respond to the Committee’s call for evidence. We are a membership organisation with over 10,000 members who are blind, partially sighted or the friends and family of people with sight loss. 80% of our Trustees and Assembly Members are blind or partially sighted. We encourage members to be involved in our work and regularly consult with them on government policy and their ideas for change. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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As a campaigning organisation of blind and partially sighted people, we fight for the rights of people with sight loss of all ages in each of the UK’s countries. We work to: — improve access to treatment for sight threatening conditions and raise awareness of eye health; — improve provision within health and social care services; — increase the amount and range of accessible information; — promote equal access to learning throughout the lifecourse; — tackle discrimination in employment and get more blind and partially sighted people into work; and — ensure a secure income for blind and partially sighted people unable to work or who have retired. We also provide expert knowledge to business and the public sector through consultancy on improving the accessibility of the built environment, technology, products and services. RNIB welcomes the opportunity to contribute to the Committee’s inquiry and second round of evidence gathering, following publication of an interim report.
Overview of our Comments We wish to focus on one aspect of health service provision that has caused significant controversy over the last year; provision of new sight saving treatments on the NHS for people with wet Age-related Macular Degeneration. The provision of this treatment across the UK has varied substantially, with treatment being approved in Scotland in June 2007. However, in relation to England and Wales, NICE is currently considering appeals in relation to its Final Determination, issued in April 2008. In the absence of NICE guidance, PCTs in England and Local Health Boards have adopted diVerent policies in evaluating which patients are funded for treatment. Over half of PCTs in England are now funding treatment but others still have unacceptably restrictive funding policies. Within Wales there are serious capacity issues, with long waiting lists for treatment across North Wales, leading to dangerously long delays, when patients can start losing sight within as little as three months if not treated.
How Many People have AMD? 220,000 people registered blind or partially sighted have AMD. The total number of people living with AMD is likely to be closer to 400,000. It includes up to 20% of people who are eligible to be registered, but are not registered as well as all those who have not reached the registration threshold (visual acuity of less than 6/60) but are struggling with everyday tasks such as driving or reading.
Treatment in Wales,England and Scotland As members of the Committee may be aware, across the UK there has been a substantial diVerence in provision of anti-VEGF treatments. In June 2007 the Scottish Medicines Consortium recommended that Lucentis be used in the treatment of wet age-related macular degeneration (AMD). Lucentis is the second licensed anti-VEGF drug to be approved by the SMC for the treatment of wet AMD—the leading cause of sight loss in the UK—Macugen was approved in August 2006. In relation to Wales and England, NICE issued a final appraisal determination document (FAD) in April 2008 recommending the use of Lucentis to treat patients with wet AMD who meet a number of clinical criteria including a visual acuity between 6/12 and 6/96. It contained welcome changes meaning that all patients in Wales and England with wet AMD could soon get the sight-saving drug Lucentis on the NHS. This final guidance has been improved significantly from NICE’s initial proposals. Two parties lodged an appeal against this decision, which was heard on 30 June. A decision about whether or not to accept any of the grounds for appeal is due. Depending on the outcome, final guidance will either be issued at the end of August 2008 or further discussions will be held by the Appraisal Committee with final guidance likely later in the autumn.
Differences between Wales and England Over 50% of PCTs in England are funding treatment, but using various criteria. However, some PCTs we believe until recently had funded no treatments. On this basis RNIB recently supported three patients with wet AMD to judicially review Warwickshire PCT, who, as far as we were aware, had not funded any treatments. The case has recently been resolved without going to judgment, with the PCT agreeing to fund treatment for the three patients and other patients in Warwickshire with wet AMD. The Committee may also be aware of the very recent developments in relation to treatment for AMD in Wales. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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£5 Million Funding for Lucentis Treatment in Wales At the end of June Edwina Hart, Welsh Assembly Government Minister for Health and Social Services, announced £5 million of funding for Lucentis treatment for first and second eye patients with Wet AMD in Wales from this autumn. On 4 July the Minister issued a statement outlining the service that she wanted to be provided by Autumn 2008: — treatment of Wet AMD for both first and second eyes using the drug Lucentis or a suitable eVective alternative; — gradual phasing in of treatment centres across Wales to provide appropriate delivery meeting the prerequisites of best practice and equity of access; and — appropriate referrals from primary care optometrists—working to strict protocols—to ensure that patients are referred urgently in order to be assessed for treatment and to deliver the maximum visual benefit. This service will be delivered from the autumn of 2008. She also announced that Chris Martin, Chair of Pembrokeshire LHB, would audit Welsh LHBs practice prior to the statement and then to audit their application of the policy over the next six months. The work will include an assessment of the success and suitability of the treatment facilities that are being established to facilitate treatment.
Delivering in Wales On 16 July, Mr Chris Blyth, Consultant Ophthalmologist at the University Hospital of Wales and Royal Gwent Hospital and Chair of the Welsh Retinal Group, spoke at the All Party Parliamentary Group on Eye Health and Visual Impairment on AMD treatment and the current situation in Wales. Whilst welcoming the funding announcement he expressed concerns that ongoing capacity issues would be a problem in delivering the new service, potentially leading to the de-prioritisation of other treatments, such as cataracts, in order for patients with wet AMD to be treated.
Conclusion Funding of treatment for wet AMD has clearly highlighted the very diVerent situations that patients can find themselves in, depending on where they live in the UK. Whilst recent progress in securing funding for treatment from PCTs and LHBs has been encouraging, the treatment has been available in Scotland since 2007. Looking within England, more than half of PCTs are already providing sight-saving treatment to patients who need it, but others still have unacceptably restrictive funding policies. Within Wales, capacity issues remain, with long waiting lists across North Wales, leading to dangerously long delays in treatment, when patients can start losing sight within as little as three months. July 2008
Memorandum submitted by Shrewsbury and Telford Hospital NHS Trust
The catchment population for my NHS Hospital services comprises 440,000 English residents and 60,000 Welsh residents. 1. I manage the two large District General Hospitals in Shrewsbury and Telford. We also provide outreach services in community hospitals and our maternity unit at the Robert Jones and Agnes Hunt NHS Trust in Oswestry provides midwifery-led maternity services to Welsh residents. 2. In a previous post I was Deputy Chief Executive of the former Shropshire and StaVordshire Strategic Health Authority whose remit was to develop and performance manage all Acute Trusts and Primary Care Trusts who serve a significant part of the English/ Welsh border.
Executive Summary 3. Our cross border health service provision covers Accident and Emergency services together with acute services to 60,000 of the population in Wales which are predominantly purchased by the Powys Local Health Board in a contract valued at £15 million per annum. We also provide renal dialysis facilities for this population at the Royal Shrewsbury Hospital which is purchased by Healthcare Commission Wales— Specialised Services. 4. The services we provide to this population are based on contracts negotiated by Welsh Commissioners under annually negotiated contracts with specified maximum waiting times as determined under Welsh NHS policies. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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5. The services provided to English resident patients (and Welsh residents registered with an English general practitioner) are funded under the English NHS Payment by Results system at a national tariV price and maximum waiting times as determined by the English NHS. 6. We provide separate data to each of our commissioners to enable them to monitor our performance in accordance with each contract.
7. We include the Welsh population in any public consultation processes and during any public consultation period we hold public meetings in Wales. We have recently undertaken a public consultation process on our application to become a Foundation Trust under the English NHS system and still consulted in Wales and made documents available in the Welsh language on request. We have included Montgomery in our calculation of the number of public governors, and positively encouraged Welsh residents to become Members of the Foundation Trust. We have allocated Partner Governor places to Powys Local Health Board and Montgomery Council. On our Stakeholder Panel for the Foundation Trust application we have representatives from Montgomery Community Health Council and Powys LHB, and my Trust endeavours to be fully inclusive to the Welsh residents in all aspects of our business. Our three principal commissioners in England and Wales have all fully supported the Foundation Trust application. Tom Taylor Chief Executive February 2008
Supplementary memorandum submitted by Shrewsbury and Telford Hospital NHS Trust Payment by Results (PbR) is a system where providers in England are paid for the number and type of patients they treat at a national tariV. It was first introduced in 2003–04 with four aims: — To enable faster access to more appropriate, patient responsive services; — To enable commissioners and providers to focus on quality; — To ensure fairness and transparency of funding; — To drive eYciency. The introduction of the system has been phased in over four years to buVer some of the adverse financial impact on individual organisations. It is a single rules-based approach to paying for acute and specialised hospital services with the intention to develop it to mental health and some community based services. It is designed to support the wider NHS system reform agenda including the development of Foundation Trusts and patient choice allowing the money to follow the patient. A national tariV is set annually by the Department of Health for each type of service based on Healthcare Resource Groups (HRGs) which are standard groupings of clinically similar treatments that use similar levels of healthcare resource. The system therefore moves away from locally negotiated contracts based on local prices with often only a tenuous link to activity. The system does allow adjustments to payments to providers for unavoidable cost diVerences in delivering services in diVerent parts of the country. This is undertaken by a function called the Market Forces Factor (MFF) which is continually reviewed by the Department of Health to ensure a robust and fair approach is maintained to ensure the system has credibility with users. This also demonstrates that PbR is a complex tariV driven system where the quality of information is critical to both commissioners and providers alike. The provision of more meaningful information, along with financial incentives has undoubtedly increased clinical engagement in financial matters. The need to understand the market and the potential competition has also increased the commercial skills of provider Trusts in the internal NHS market place. Independent providers can also compete for activity but they will only receive the PbR tariV. The Audit Commission has recently undertaken a review of the operation of PbR between 2003–07 and concluded that is now an established part of the NHS financial regime in England but that four steps needed to be taken to strengthen it: 1. The information infrastructure needs to be strengthened; 2. The national tariV should be made more flexible; 3. It would be helpful to introduce some normative tariVs for some HRGs based not on average costs but on costs of high performing eYcient providers that provide a quality service; 4. Separate funding streams for capital should be considered as is the case in international PbR systems. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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This system does not however operate in Wales where local contract negotiations with local prices still apply. This means that Trusts who provide services to the populations of both countries have to cope not only with the diVerent policy issues either side of the border eg diVerential waiting time targets for elective procedures but also diVerential payment levels and income streams for the same treatments when the cost of providing the treatment does not diVer.
In the majority of cases the payments made by Welsh Commissioners are lower than that provided for under PbR tariV. Accordingly the income stream received by an English provider organisation can be substantially less than if all activity is provided solely to English commissioned patients. This can amount to several million pounds for an individual Trust whose cost base is no diVerent irrespective of the country from which patients come.
By way of example, the Shrewsbury and Telford Hospital NHS Trust receives £16 million from Welsh Commissioners for the activity purchased. If this same activity had been purchased by English Commissioners under PbR tariV the Trust would have received £18 million.
It is however not practical for the Trust to only treat English patients because (a) many of the Powys residents rely on the Royal Shrewsbury Hospital for their services, particularly emergency services (b) it breaches the principals under which the NHS was established in 1948 and (c) if the Trust were to lose £16 million of income from Wales it would then have to cut its staV costs by £11 million (given that 70% of costs relate to staV) and £5 million of other costs to break even financially.
One possible solution is for Welsh Commissioners to be funded at a suYcient level to operate both the English and Welsh systems at parity i.e. they receive their current allocation to fund patients treated in Welsh Trusts and also receive additional “top up” funding based on English PbR tariV for the actual activity purchased, from English providers, which can easily be audited to ensure the money is ring fenced solely for that purpose. Tom Taylor Chief Executive August 2008
Memorandum submitted by Shropshire County Council
It is well understood that communities on both sides of the English/Welsh border access the services they require in a way that meets their needs rather than in a way which adheres to administrative boundaries. As a result, for many years colleagues from diVerent departments throughout Shropshire County Council have developed and maintained operational relationships with public service delivery partners in Wales. This relationship was formalised and brought into the strategic arena during 2007 when Shropshire County Council became a signatory to the Memorandum of Understanding on Cross Border Collaboration. In respect of the Memorandum we feel that it is our duty to respond to this current call for evidence particularly with reference to social care and health and transport.
Social Care and Health
With respect to social care and health, we specifically wish to draw the “Supporting People” programme and adult social care collaboration to your attention.
“Supporting People” is a national programme which is delivered locally. In Shropshire, the programme is delivered through a partnership of all the local authorities, the PCT, the Probation Service and the voluntary sector. It funds the provision of housing-related support to vulnerable people with the aim of developing or maintaining an individual’s capacity to live independently. Support is delivered to anybody aged 16 and above who is assessed as being vulnerable and in need of support (subject to a financial eligibility test).
Support is delivered through provider organisations that are contracted via the Supporting People programme. Shropshire County Council administers the programme locally. When an individual commences a support programme, the provider must complete a Client Record Form (CRF) and submit it to a national database. The CRF records the local authority of origin of the service user. “Wales” is the originating authority for anyone accessing our services from across the border. We can also identify which service is being accessed and therefore what the service user’s needs are most likely to be, ie why they required the service in Shropshire. We are able to confirm that most of the cross border services provided are for access to the Women’s’ Domestic Refuges in Shropshire. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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We are unsure from the information we have ready access to, how many people from Shropshire are accessing Supporting People services in Wales. The following figures show how many and which services people from Wales have accessed in Shropshire for the whole of 2006–07 and Quarters1&2of2007–08:
2006–07
Total number of Service Users originating from Wales % 15 Of these: 11 accessed domestic violence refuges at an average cost of £199 per service user per week. 3 accessed young peoples (aged 16–25) hostels at an average cost of £184 per service per week. 1 accessed a general housing support service at an average cost of £58 per service per week.
2007–08 (first two quarters)
Total number of Service Users originating from Wales % 12 Of these: 10 accessed domestic violence refuges at an average cost of £220 per service user per week. 2 accessed mental health/learning disability support at an average cost of £204 per service per week. There is no provision for cross-charging the originating authority because the Supporting People Grant Conditions (from CLG) disallow it by preventing a Local Connections policy for accessing Supporting People services.
Adult Social Care Collaboration
Hospital and Social Work Teams. Welsh service users accessing health care in Shrewsbury hospital are provided with an equal level of assessment by the hospital based social worker who completes an initial screening visit with ward staV and records the outcome on the Referral Form. This information will be faxed to the relevant district team in Wales. The hospital social worker will continue to oVer information, advice and counselling where appropriate. Where an action request indicates a need for a full community care assessment, this will be passed directly to the relevant Community Services Department.
Service Provision
Service users that reside in Wales but are located close to a Shropshire County Council run establishment eg day care centre, are entitled to use the service, the costs of which are recovered from the Welsh Local Authority. In this instance, the Welsh Local Authority is responsible for arranging transport and collecting a client contribution towards the cost of this service.
Assessment and Care Management
Currently when a service user moves from a Welsh Authority to Shropshire, then a new assessment is carried out by the Shropshire Assessment and Care Management Team. Although the assessment information will have been sent to the Shropshire Social Work Team, a further assessment will take place which will take into account any changes to circumstances. There is an argument for closer collaboration and acceptance of each others assessments and outcomes in order to prevent duplication at what can be a stressful time to the service user. Penny Spencer Director of Economy & Environment 9 March 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by the Statistical Directorate, Welsh Assembly Government
Background The Welsh AVairs Select Committee requested information on health care statistics specifically relating to cross-border provision.
General Points Since devolution, the Welsh Assembly Government has set targets for the NHS in Wales. These targets are frequently diVerent to those set for the NHS in England, so are often measured in a slightly diVerent way. This means that some statistics cannot be used to compare England and Wales. Some statistics published in England do not have an equivalent in Wales (and vice versa). The coverage of data in England and Wales also varies slightly. Since the Welsh Assembly Government sets targets for all Welsh residents, data is collected on this basis. This means that people who are resident in England but registered with a GP in Wales are not necessarily recorded in Welsh waiting times data (though the health services in either country may take responsibility for these patients).
(a) People registered with a GP across the border There are no restrictions on cross-border registrations—Welsh residents can be registered with a GP in England, and vice versa. The Statistical Directorate does not currently collate or publish figures for the number of GP registrations in England and Wales. However, some data has been collected internally within NHS Wales, and shared with the UK Department of Health. In April 2007:
South-East Mid and Wales West Wales North Wales TOTAL Welsh patients registered with 760 6,295 8,038 15,093 English GPs English patients registered with 10,204 3,297 6,685 20,186 Welsh GPs Source: NHS Wales Business Service Centres These figures are produced by NHS Wales for internal management purposes, and should be considered as a guide only. However, this is the only source available that includes data on English residents registered with GPs in Wales. The Welsh NHS Administrative Register database contains a more complete record of Welsh residents registered with English GPs, but not vice versa.
Local Health Board of Patients registered residence with English GP Flintshire LHB 4,772 Monmouthshire LHB 765 Powys LHB 6,127 Wrexham LHB 3,333 Total 14,997 Source: Health Solutions Wales (1 May 2008)
(b) People treated across the border We can estimate the number of people treated across the English-Welsh border using information from the Patient Episode Database for Wales (PEDW). This counts the number of times that a new patient is admitted to a Trust for treatment (ie not including follow-up visits). In 2006–07, there were 48,944 Welsh residents admitted to English Trusts (6.4% of all admissions for Welsh residents). In the same year, there were 12,671 English residents admitted to Welsh Trusts (1.7% of all patients treated in Wales). Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The way this information is collected has changed since 1999–2000, so any direct comparison between years would be flawed. However, data for 2006–07 has also been recalculated using the old methodology to allow for comparisons, as shown in the table below.
1999/2000 2006/2007* Patients Per cent Patients Per cent Welsh residents treated in 32,742 5.0% 42,609 6.3% English Trusts English residents treated in 9,890 1.6% 12,123 1.9% Welsh Trusts * calculated using the methodology used in 1999–2000 for comparative purposes only Data on hospital admissions from 1999–2007 is available from Health Solutions Wales on their Internet site (http://www.wales.nhs.uk/hsw-healthstats). Figures for 2006–07 were released on 22 April 2008.
(c) Waiting times for Welsh people being treated in England At the end of February 2008, there were 6,251 Welsh residents waiting for their first outpatient appointment at English Trusts. Of these, none have waited more than 36 weeks and 304 have waited more than 22 weeks (4.9%). In February 2008, there were 3,159 Welsh residents waiting for inpatient and day-case admissions at English Trusts. Of these, one has waited more than 36 weeks and 310 have waited more than 22 weeks (9.8%). The majority of these (around two-thirds) were referred from Local Health Boards in North Wales, with fewer from Mid and West Wales and South East Wales. There were no clear diVerences between the waiting times in each region. The percentage of Welsh residents waiting more than 13 weeks for an out-patient appointment at an English Trust has fallen from 32%–22% since April 2007. Note that these figures include waits for consultant to consultant referrals as well as waits for referrals from GPs. In England, only GP referrals are monitored. Data on waiting times for diagnostic tests for Welsh residents in English Trusts is not currently included in the monthly statistical collection. This collection is limited only to patients waiting for diagnostic tests in Welsh Trusts. Targets for “referral to treatment” times have been set for March 2009 in Wales, and data is due to be released in 2008/2009 to monitor progress. The StatsWales (http://www.statswales.wales.gov.uk) website has further information on waiting times, including cross-border issues. The site allows the user to design reports which can break down waiting times by Local Health Board and by month.
(d) Waiting times for Welsh people being treated in Wales At the end of February 2008, there were 146,446 Welsh residents waiting for first outpatient appointments at Welsh Trusts. Of these, none had waited more than 36 weeks and 5,261 had waited more than 22 weeks (3.6%). In February 2008, there were 48,894 Welsh residents waiting for inpatient and day-case admissions at Welsh Trusts. Of these, none have waited more than 36 weeks and 2,686 have waited more than 22 weeks (5.5%). The percentage of Welsh residents waiting more than 13 weeks for an out-patient appointment at Welsh Trusts has fallen from 31%–22% since April 2007. Note that these figures include waits for consultant to consultant referrals as well as waits for referrals from GPs. In England, only GP referrals are monitored. In February 2008, there were 42,934 people waiting for the specific diagnostic tests that are monitored at Welsh Trusts. Of these, one has waited more than 36 weeks and 1,875 have waited more than 14 weeks (4.4%). Targets for “referral to treatment” times have been set for March 2009 in Wales, and data is due to be released in 2008–09 to monitor progress. The StatsWales (http://www.statswales.wales.gov.uk) website has further information on waiting times, including cross-border issues. The site allows the user to design reports which can break down waiting times by Local Health Board and by month. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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(e) Waiting times for English residents The Welsh Assembly Government does not generally collect information about English residents waiting for treatment in Wales. While English residents are included in the figures of those waiting for diagnostic tests in Welsh NHS Trusts, they are not separately identifiable.
(f) Median Waiting Times Median waiting times for patients admitted to hospital (through a waiting list or booked admission) were released for the first time in Wales on 22 April 2008. These are not calculated on the same basis as the earlier waiting times information, and are taken from the PEDW database for patients who already have been treated rather than those who are still waiting for treatment at the end of each month. During 2006–07, English residents had a median wait of 48 days before admission to Welsh Trusts. This compares to 45 days for all patients admitted to Welsh Trusts. During 2006–07, Welsh residents had a median wait of 44 days before admission to English Trusts. This compares to 45 days for all Welsh residents admitted to any Trusts.
(g) The cost incurred by Local Health Boards for the treatment of Welsh patients in England The Statistical Directorate do not collect any information on costs of health care across Wales. However, we are able to reproduce information from the 2006–07 annual accounts of the Local Health Boards on the border between England and Wales. Figures are only available for secondary and community health care (which are combined in the individual tables below). Although other Welsh Local Health Boards also incur costs for patients referred to English Trusts, the LHBs on the border incurred the largest part (£57.3 million) of the total amount spent on English Trusts by all LHBs in 2006–07 (£74.5 million).
Flintshire Local Health Board
Expenditure to non-Welsh NHS Trusts Countess of Chester - £16.6 M Robert Jones and Agnes Hunt Orthopaedic - £2.0 M Royal Liverpool and Broadgreen - £570,000 Wirral Hospitals - £430,000 Cheshire and Wirral Partnership - £340,000 Other non Welsh NHS trusts - £1.2 M (all figures rounded)
Wrexham Local Health Board
Expenditure to non-Welsh NHS Trusts Robert Jones and Agnes Hunt Orthopaedic - £4.6 M Royal Liverpool and Broadgreen - £530,000 Countess of Chester - £400,000 Royal Shrewsbury - £340,000 Shropshire County - £340,000 Telford and Wrekin - £95,000 Liverpool Women’s - £90,000 Other non Welsh NHS trusts - £600,000 (all figures rounded)
Powys Local Health Board
Expenditure to non-Welsh NHS Trusts Royal Shrewsbury - £12.6 M Hereford Hospital NHS Trust - £6.4 M Robert Jones & Agnes Hunt Orthopaedic - £3.2 M Shropshire County - £1.0 M Other non Welsh NHS trusts - £1.3 M (all figures rounded) Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Monmouthshire Local Health Board
Expenditure to non-Welsh NHS Trusts Gloucester Hospitals NHS Trust - £1.8 M Hereford Hospital NHS Trust - £1.4 M North Bristol NHS Trust - £590,000 Gloucester Partnerships NHS Trust - £210,000 United Bristol Hospital NHS Trust - £180,000 Other non Welsh NHS trusts - £490,000 (all figures rounded) In 2007–08, there is a funding agreement between the Department of Health and the Welsh Assembly Government to provide for patients living at one side of the border and accessing primary health care at the other side. Since there were more English residents accessing primary health care in Wales than vice versa, the Department of Health provided an additional £5.56 million to the Welsh Assembly Government to reflect the net diVerence in primary health care provided across the border. The Statistical Directorate cannot provide information about the costs incurred by English PCTs for the treatment of Welsh patients. May 2008
Memorandum submitted by John Tyler Living close to Hay on Wye I find myself, like many other people, in the position of travelling some distance to receive medical care from specialist clinics and hospitals. Excluding the minor hospitals such as Builth and Brecon and focussing on those that have significant services, the 40 minute journey to Hereford, in England, is far closer than the 90 minute trip to CardiV or even the 50 minutes to Abergavenny. These journey times are given for car travel, but some of my elderly neighbours do not have the luxury of being able to rely on a car and use public transport; this is exceedingly diYcult in this area, with the most reliable service by far being to Hereford, and when public transport is unsuitable it is hard for old folk to ask a friend for a lift to CardiV when Hereford is so much nearer. I am very disappointed that so-called nationalism seems to be placing the symbolism of an artificial border above the needs of the people of Wales. I sincerely hope that cross-border services will continue to operate successfully and eVectively to the great benefit of myself and all the other residents of this lovely border area. March 2008
Memorandum submitted by Huw Thomas and colleagues
SUBMISSION FROM A GROUP OF RETIRED PEOPLE WHO HAVE PLAYED A PROMINENT ROLE IN THE NHS AND IN PUBLIC LIFE IN NORTH WALES The report entitled “Neurosurgery and Specialist Hospital Services for the People of North Wales” is submitted to the Welsh AVairs Committee for their consideration. The report is set out in three parts: Part 1 is a thorough review of neurosurgical services to the people of North Wales, together with a list of detailed objections to the proposal that elective neurosurgical cases should be redirected from The Walton Centre, Liverpool to Morriston Hospital, Swansea. We are firmly of the view that the proposal should be abandoned. The current arrangements should continue with all neurosurgical cases admitted to Walton, unless the patient and their relatives choose to go to another centre. Part 2 sets out our concern that the proposal for neurosurgery is a model for other specialist hospital services, and there is an agenda that patients from North Wales requiring specialist acute hospital care will be redirected to CardiV. We base our concern on actions and statements made by the Minister for Health. We consider this apparent shift of policy is not in the best interests of patients and their relatives and carers. Our view is that there should be a firm commitment to continue with the present pattern of referral to specialist hospitals in North West England. Although we are sure Health Commission Wales undertake their role in a very professional manner, we consider that once the air is cleared over future policy, there should be a more positive approach to commissioning of services from specialist hospitals in North West England. This approach should involve Local Health Boards and NHS Trusts in North Wales more in the process. We believe that there are a number of improvements in services that could be achieved for patients in North Wales, without large additional expenditure. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Part 3 raises the issue of the disparity between waiting times for patients from Wales compared to those from England, attending the same specialist hospitals in England. We state in our report that this issue came up relatively late in our review. We have written to three of the specialist hospitals asking for more precise information. None have replied. We can understand why this is so; the Trusts will not wish to jeopardise their working relationships with Health Commission Wales and the Welsh Assembly. We would, however, point out that managers in tertiary specialist hospitals in England stated they have a good working relationship with the staV of Health Commission Wales. From our informal discussions it would appear that the discrepancies between waiting times for Welsh and English patients are considerable. We are not talking of a week or two. In some cases we were told the diVerence could be 15 to 20 weeks. We do not consider this is acceptable. These assertions need to be tested out. It is public knowledge that maximum waiting time targets in Wales are longer than in England. For example, maximum time from referral from a GP to first appointment in Wales was 52 weeks in 2006, but was 18 weeks in England. Since then targets in Wales have been tightened. As at March 2008 the Welsh standard will be 22 weeks and by March 2009, 10 weeks. In Walton the waiting time is now three to four weeks for English patients. At Alder Hey the maximum wait target is 11 weeks and in 2008 will reduce to five weeks for English patients. We fully accept maximum waiting times are not the most meaningful indicator (although they do present a comparative picture). Mean, or average, waits for a patient from referral from a GP to first out-patient appointment, and then admission to hospital, present a more reliable measure. The whole issue is complex and although we could pursue the matter further, requesting information under the Freedom of Information Act, we do not consider this approach will be fruitful. We recommend that the Welsh AVairs Committee undertake their own investigation and commission an audit and a study by experts. A possible approach would be to compare waiting times at specialist hospitals for patients from North Wales compared with an area in England, say Cheshire. Some of the information that would be helpful to obtain would be: Health Commission Wales: — Policy on waiting times for Welsh patients in specialist hospitals in England. — What are the detailed requirements in contracts? — What is the cost per procedure, and is it the same for Welsh specialist hospitals as in England? — Are ther3 disputes with English Trusts about payments? English Trusts: We suggest the Committee concentrate on those English Trusts where there are a significant number of elective cases from Wales, eg: — Alder Hey Children’s Hospital. — Broadgreen Cardio-Thoracic Centre. — Manchester Royal Infirmary—cardiac centre. — Robert Jones and Agnes Hunt, Gobowen—spinal injuries and specialist orthopaedics. — The Walton Centre. The issues that need exploring include: — What is the discrepancy between waiting times for patients from Wales compared with those from England, both for maximum and for mean waiting times? — Have they the capacity to reduce waiting times for Welsh patients to be the same as for English patients? If so what would be the cost? — Are there disputes with Health Commission Wales about payments? The aim should be to identify the cost of first equalising waiting times for out patient appointments, then for in-patient admission. Once the costs are known, then there can be an action plan introduced to achieve parity. We do not consider these questions to be exhaustive, and as stated above, we recommend the Welsh AVairs Committee undertake their own investigation into a subject which we consider is very important. Much publicity is given to individual cases where a patient from Wales is denied treatment that would be available to a patient from England. This issue of disparity of waiting times is one that aVects a much larger number of people. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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NEUROSURGERY AND SPECIALIST HOSPITAL SERVICES FOR THE PEOPLE OF NORTH WALES This report has been compiled by a group of retired people who have played a prominent role in the NHS and in public life in North Wales. We are strictly non-political. We are deeply concerned about: 1. The bizarre proposal that adult patients requiring elective neurosurgery should be referred to Morriston Hospital, Swansea as opposed to The Walton Centre, Liverpool. 2. The apparent shift in Welsh Assembly policy from referral of patients requiring specialist tertiary care from hospitals in North West England to hospitals in South Wales. 3. The disparity between waiting times for patients from Wales attending specialist hospitals in England, compared with those from England. This disparity appears to be increasing. Dr Pat Barry MB, ChB, FRCA. Formerly Consultant Anaesthetist, Ysbyty Gwynedd Mr Michael Crumplin MB, BS, FRCS, FHS. Formerly Consultant Surgeon, Ysbyty Maelor Dr Cedric Davies MB, BSc, MRCS, LRCP, DPH. Formerly Director of Public Health Medicine, Gwynedd Health Authority Mr Chris Davies FRCS, DM, MCh. Formerly Consultant Surgeon, Ysbyty Glan Clwyd Dr Harry Edwards OBE, MB, ChB, DRCOG, FRCA. Formerly Consultant Anaesthetist, Ysbyty Gwynedd and Chairman of the Welsh Medical Committee Noreen Edwards CBE, SRN, SCM. Formerly Chairman, Gwynedd Health Authority Dr Ellen Emslie MB ChB, FRCP. Formerly Consultant Dermatologist, Ysbyty Glan Clwyd Annwen Carey Evans OBE. Formerly High SheriV Gwynedd D B Carey Evans OBE, FRAS. Elizabeth Colwyn Foulkes MBE, FRIBA, DL Sir William Gladstone BT, KG. Formerly Lord Lieutenant Clwyd Dr JeVrey Green MD, FRCP. Formerly Consultant Cardiologist, Ysbyty Glan Clwyd Michael GriYths CBE, FRAS, DL. Formerly Chairman, Clwyd Health Authority and Chairman Conwy and Denbighshire NHS Trust Dr Idris Humphries MB, ChB, FRCGP. Formerly a GP and Chairman of the Welsh General Medical Services Committee Mr O M Jonathon FRCS, MD. Formerly Consultant Surgeon, Ysbyty Glan Clwyd Professor David Jones OBE, Hon DSc, FRCN. Formerly Chief Nursing OYcer, Gwynedd Health Authority and Professor of Nursing, SheYeld University Mr David Jones FRCS. Formerly Consultant Orthopaedic Surgeon, Ysbyty Gwynedd and at Great Ormond Street Children’s Hospital, London Trefor Jones CBE. Lord Lieutenant Clwyd and formerly Vice Chairman Conwy and Denbighshire NHS Trust Dorothy Keddie RGN. Formerly Assistant Director of Nursing, North Wales Health Authority Mr Hywel Oliver FRCS, MS. Formerly Consultant Surgeon, Ysbyty Gwynedd Bill Owen FCCA, CPFA. Formerly Director of Finance, Gwynedd Health Authority Professor Robert Owen OBE, FRCS, DL, MB, BS, MCh Orth. Formerly Consultant Orthopaedic Surgeon Robert Jones and Agnes Hunt Hospital, Gobowen and Professor of Orthopaedics Liverpool University Sir Meuric Rees CBE, FRAS. Formerly Lord Lieutenant Gwynedd Dr David Roberts MB, ChB, MRCS, LRCP, DPH, MFCM. Formerly Consultant in Public Health Medicine, Gwynedd Health Authority Hilary Stevens. Formerly Chairman, Conwy and Denbighshire NHS Trust Professor Eric Sunderland CBE, MA, PhD, LLD. Formerly Vice Chancellor, University of Wales (Bangor) and Lord Lieutenant, Gwynedd Dr J Gwyn Thomas MB, DCh, DRCOG, BSc, FRCGP. Formerly a GP and Chairman of the Welsh Branch of the Royal College of General Practitioners and Provost of Merseyside and North Wales Faculty of the RCGP Dr Mari Thomas MB, BS, FRCGP. Former GP and Chairman of MENCAP North Wales Huw Thomas BA, DSA, AHA. Formerly Chief Executive, Gwynedd Health Authority Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Part 1: Neurosurgical Services in North Wales
Background
Since the development of neurosurgery [surgery performed on the nervous system, especially the brain and spinal cord] as a separate specialty, patients have been referred from North Wales to Walton Hospital, (now known as The Walton Centre for Neurology and Neurosurgery) Liverpool. A Strategic Review of Neuroscience Services for Wales was undertaken for Health Commission Wales, reporting in December 2005. It was a very comprehensive study of all aspects of neuroscience services. The key finding of the review was that the present configuration of services is ineYcient and expensive. In terms of acute services the review took account of medical workforce and training issues, sub- specialisation, technological change, regulation and clinical governance. A number of recommendations were made, including a key one that there should be one neurosciences centre in South Wales, including provision of neurosurgery services for the whole of South, Mid and West Wales. The preference was that the centre should be in CardiV. The consequence was that neurosurgery would cease to be undertaken at Morriston Hospital, Swansea. (The review also recommended that The Walton Centre should continue to provide neurosurgery services for North Wales, and should be designated as the neuroscience centre for the North Wales region). The Minister for Health did not accept the recommendation and announced on 4 July 2007 both neurosurgical centres in South Wales (The University Hospital of Wales, CardiV and Morriston Hospital, Swansea) should remain open. The Minister also announced a proposal that patients from North Wales requiring elective (non urgent) neurosurgery should be redirected to CardiV and Swansea. This move was aimed at bolstering the viability of the Morriston unit. The proposal has been met with considerable opposition in North Wales. The proposal is now in abeyance, awaiting a review of Neurosciences Services in Wales being undertaken by an Expert Review Group, chaired by Mr James Steers, an eminent neurosurgeon from Scotland. It would appear from recent press reports that the Minister is backtracking on the issue. However, the proposal that elective neurosurgical patients from North Wales should be redirected to Morriston has not been withdrawn. Even if Mr Steers was to recommend that the current service ie both elective and emergency cases should continue to be admitted to The Walton Centre, the Minister is not bound to accept that recommendation.
Services Provided by the Walton Centre to North Wales
The Walton Centre provides a neurosciences (neurosurgery and neurology service) to Merseyside, parts of Lancashire, North Wales and the Isle of Man, a total population of 3.2 million. It is one of the largest specialist neuroscience centres in the UK, with 118 beds, including nine Intensive Care and four High Dependency beds. It has close links and shared staV with Alder Hey Children’s Hospital, also in Liverpool, where children and young adults requiring neurosurgery are admitted. The workload undertaken in 2007 was:
Outpatients 63,690 In-patients 3,428 Day patients 6,627 The figures for patients resident in Wales in 2007 were:
Neurosurgery Outpatients—new 356 Outpatients—follow up 1,609 In-patients—elective 246 In-patients—emergency 291 Neurology Out-patients—new 3,222 Outpatients—follow up 5,942 In-patients—elective 105 In-patients—emergency 38 Day cases 214 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Welsh residents make up approximately 20% of the total workload of The Walton Centre
StaYng Medical staV: 13 neurosurgeons 28 neurologists, including 5 academic staV 9 neuro-anaesthetists 3 pain specialists 3 neurophysiologists 2 neuro-pathologists The Walton Centre works closely with Alder Hey Children’s Hospital, where children (and some adults up to the age of 19 with “paediatric” brain tumours) requiring neurosurgery are admitted. Some staV are shared:
4 paediatric neurosurgeons (shared with Walton) 3 paediatric neurologists 1 paediatric neuro-physiologist (provided by Walton) 1 paediatric neuro-pathologist (provided by Walton) “one clinical neuroscience service, two centres” Nursing staV: 370 nurses. Trained to untrained ratio 2:1 15 specialist/consultant nurses Medical Outcomes: (Success rates of treatment) Using Risk Adjusted Mortality Rates, Walton scores well. MRSA rates are low and falling. Inspection reports have been favourable. Long Term Support: Approximately 300 patients resident in Wales continue to need to visit Walton on a regular basis, continuing over many years. Patient Satisfaction Surveys: Surveys show a high level of patient, relatives and carer satisfaction with the services provided. Bilingual Service: There are a number of Welsh speaking nursing staV. Arrangements can be made with two Welsh speaking Ministers of Religion to provide a translation service for patients and their carers who request it. Sub-specialization: There is sound evidence that for all forms of surgery, the volume of cases undertaken by a surgeon is directly related to the surgical outcome. In other words, if a surgeon undertakes 200 of a particular type of operation in a year, as opposed to 20, the results for the patient will be better. The principle applies equally to neurosurgery. Best practice is now that all neurosurgeons have a high level of expertise in core competencies of treating head injuries, acute spinal cord compression, intracranial haemorrhage and blocked shunts, but each neurosurgeon also specializes in one of the major sub-specialty areas. At Walton these include neurovascular surgery, skull base surgery, functional neurosurgery including surgery for pain, neuro-oncology, spinal surgery and, in conjunction with Alder Hey Hospital, paediatric neurosurgery. Neurologists also have core competencies, combined with sub-specialisation. At Walton these include epilepsy, multiple sclerosis, movement disorders (most commonly Parkinson’s), headaches, unusual strokes and motor neurone disorders. Sub-specialisation is needed to provide a very high level of expertise. A unit needs at least two people undertaking each sub-specialty because of absences due to annual leave and study leave. Fortunately, the prevalence of some of the conditions is comparatively rare. Therefore, there needs to be a concentration of a significant number of specialists, serving a large population of 2–2.5 million in order to maintain the sub- specialists’ expertise. These conditions are achieved at The Walton Centre. Neurosupport: Patients and their carers from North Wales are able to have access, both directly and by telephone, to Neurosupport [formerly The Glaxo Centre] in Liverpool, an independent charitable trust that provides advice, information and support to people with neurological conditions. Future Plans: NICE (The National Institute for Clinical Excellence) guidelines are that a patient with a severe head injury, even if no neurosurgical operation is required, should be treated in a specialist neurosurgical unit, because mortality has found to be halved compared to similar patients looked after in other hospitals. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Some clinicians in North Wales have been concerned that there have been problems transferring patients to Walton, because of pressure on beds there. Future plans for Walton include doubling the number of Intensive Care beds from nine to 18. This will ease the admissions from North Wales. There are also plans to undertake more spinal work, treat more acute neurology cases and improve rehabilitation. Consultants in North Wales hospitals would wish to see improvements in transmission of clinical images, the out of hours service for reading MRI and CAT scans and an improved neurophysiology service.
Services provided by The Walton Centre in North Wales 1. Neurology Support Consultant neurologists visit district general hospitals in North Wales to undertake out-patient clinics and also ward rounds to accept referrals from other specialists and to give advice. The schedule of visits each week is: Ysbyty Maelor, Wrexham — 3 sessions, outpatient clinics — 3 sessions, ward rounds — 2 sessions by GPs with a specialist interest in neurology Ysbyty Glan Clwyd — 4 sessions, outpatient clinics — 4 sessions, ward rounds — 2 sessions by GPs with a specialist interest in neurology Ysbyty Gwynedd, Bangor — 3 sessions, out-patient clinics — 3 sessions, ward rounds 2. Community Outreach Service There are two specialist multi-disciplinary teams based in North Wales providing community support for patients with Multiple Sclerosis and Epilepsy 3. Reading Scans There is a direct communication link between the three district general hospitals with The Walton Centre allowing CAT and MRI scans to be sent electronically, so that consultant neuroradiologists at Walton can read the scans and advise their colleagues in North Wales. Out of hours this service is currently provided by the on call neurosurgical team. This is an important facility, which is used in conjunction with telephone discussion of the patient’s clinical history and condition, to aid diagnosis and to determine whether a patient can be cared for locally or a transfer to Walton is advised. 4. Neurology telephone helpline For an hour per day a duty neurologist is available, on a dedicated telephone line, to give advice on patients with neurological problems to GPs and consultants.
OBJECTIONS TO THE PROPOSAL FOR ELECTIVE CASES TO BE REDIRECTED TO MORRISTON North Wales patients, their relatives and carers receive a good service from The Walton Centre. It is outrageous that this service could be jeopardised, on the mistaken premise that by referring elective patients to Morriston that hospital would be bolstered and the present service secured in West Wales. We would stress we take no position on the debate about having one or two neurosurgical centres in South Wales, but that it is an issue that has to be sorted out in the context of South Wales, leaving patients from North Wales out of the equation.
Detailed Objections
1. Time and Distance It is glaringly obvious that the journey from towns and villages in North Wales is much greater to Swansea than Liverpool. Apart from the increased time and distance, the journey is more diYcult. The cost to patients, their relatives and carers would be significantly more. It must be remembered that for patients it would not just be one journey for surgery, but at least one pre-operative and two post operative out-patient appointments. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Some of the comparative distances, times and costs are set out below.
COMPARATIVE TIMES, DISTANCES AND COSTS OF TRANSPORT FROM NORTH WALES TO WALTON AND MORRISTON
By car Miles Time Holyhead to Morriston 181.4 miles 4 hours 24 minutes Holyhead to Walton 98.4 miles 2 hours 15 minutes DiVerence 83 miles 2 hours 9 minutes
Bangor to Morriston 162.1 miles 3 hours 59 minutes Bangor to Walton 77.1 miles 1 hour 49 minutes DiVerence 85 miles 2 hours 10 minutes
Llandudno to Morriston 161.3 miles 3 hours 59 minutes Llandudno to Walton 62.4 miles 1 hour 28 minutes DiVerence 98.9 miles 2 hours 31 minutes
St Asaph to Morriston 157.7 miles 3 hours 54 minutes St Asaph to Walton 55.5 miles 57 minutes DiVerence 102.2 miles 2 hours 57 minutes
Wrexham to Morriston 132.2 miles 3 hours 4 minutes Wrexham to Walton 45.6 miles 1 hour 6 minutes DiVerence 86.6 miles 1 hour 58 minutes Source: Automobile Association website. Note: Times will vary according to time of day, road works etc. Due to the time taken to reach Morriston drivers would be advised to take one break. Add 20 minutes to the journey. Our estimate is that the majority of people living in the counties of Wrexham, Flintshire, and Denbighshire can reach Walton by car within 1 hour; 52% of the population of North Wales. (We have not included the whole population of the three counties.) Apart from the most westerly parts of Meirionnydd and Anglesey, journeys from all parts of North Wales take less than 2 hours to Walton. Estimate: 96% of the population.
By rail Time Cost Holyhead to Swansea 6 hours 45 minutes £65 Holyhead to Fazakerley (Walton) 3 hours 24 minutes £23.50 DiVerence 3 hours 21 minutes £41.50
Llandudno to Swansea 5 hours 20 minutes £53.20 Llandudno to Fazakerley 2 hours 19 minutes £14.00 DiVerence 3 hours 1 minute £39.20
Wrexham to Swansea 4 hours 25 minutes £39.60 Wrexham to Fazakerley 1 hour 47 minutes £11.20 DiVerence 2 hours 38 minutes £28.40 Note: Add to the journey time to Morriston Hospital the time from Swansea railway station to the hospital, say 30 minutes. Fazakerley station is a short walk from The Walton Centre. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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By coach Time Cost
Bangor to Swansea Change Birmingham 9 hours 25 minites £46.50
Bangor to Swansea Change Aberystwyth 6 hours 53 minutes £5.00
Bangor to Liverpool 3 hours 10 minutes £16.60
Note: For Walton add 30 minutes from Liverpool. For Morriston add 30 minutes from Swansea coach station to the hospital.
2. Stress to patients Patients facing any form of surgery will naturally be anxious. The level of anxiety is perhaps greatest of all for patients who face neurosurgery. Although surgical techniques are well advanced and there is an increasing use of endovascular techniques (less invasive), it still means the surgeon has often to open up the skull or spine and perform procedures on the brain or spinal cord. Patients know the rehabilitation programme can be relatively long, with the possibility of some residual physical impairment. Apart from the stress of anxiety, some patients awaiting surgery will have unpleasant symptoms such as severe headaches, diYculties in walking and suVering fits. As well as physical and possibly psychological problems faced by patients, ill health is frequently accompanied by financial problems. A number of patients and their partners or carers will be elderly. It is not just the stress faced by patients; there are the problems and anxieties faced by families and carers. The additional distance, time and costs involved would mean significant extra burdens on families, when a patient needs maximum support. Visiting a patient in Morriston would require an overnight stay, no matter what form of transport was used. The journey to Walton, even from Anglesey is relatively straight forward and visitors can travel and return in half a day. For visitors from North East Wales the travel is not a significant problem. Apart from time, there is the issue of the ease of a journey. To Walton the journey is on main roads. To travel by train would involve one change and there is a railway station (Fazakerley) near the main entrance to the hospital. Journeys to Morriston involve travelling on slower, winding roads. Travel by train would also involve a journey from Swansea centre to Morriston by bus or taxi. The coach journey from North Wales involves a half hour wait in Aberystwyth. Regularity of services is also important. Obviously journey times are dependent on traYc conditions or train delays, but in broad terms the journey time to Morriston is between 2 and 3 times that to Walton, and the cost also between 2 and 3 times more. To subject patients, some of whom will be elderly, feeling very unwell and anxious, to the additional diYculties of travel would be inhumane. To subject their relatives and carers to all the additional unnecessary complications of travel and expense would also be inhumane.
3. Division between elective and emergency neurosurgery In most cases it is possible to diVerentiate between emergency (eg head injuries with the risk of extra-dural (sub-dural) haematomas and patients with sub-arachnoid haemorrhages) and elective cases (eg slow growing tumours). However, it is not always a clear cut separation. While on a waiting list the condition of a patient can deteriorate, requiring emergency surgery. In a small percentage of patients (1- 2%) there will be post operative complications, that require to be treated urgently. Patients suVering a complication after surgery in Morriston will almost certainly have to return to Morriston for treatment of the complication. The proposal to separate the two categories of patients would lead to confusion between the responsibilities of the two centres. We consider this division between Morriston and Walton will lead to unsafe practice.
4. Links between neurosurgery and neurology 40% of referrals to neurosurgeons are from GPs, 60% from other specialists, particularly neurologists (specialists in study and treatment of nerve systems). These two specialties work closely together at Walton for diagnosis and treatment of patients. Neurologists from Walton also come to district general hospitals in North Wales (26 sessions per week in North Wales) to advise other specialists, such as general physicians and orthopaedic surgeons, and to hold out-patient clinics. This teamwork at both Walton and in North Wales is a vital component in providing eVective diagnosis and treatment. It is not clear if Morriston would send a team of neurologists to provide some of the service in North Wales. What is clear is that the split between the two hospitals would create confusion of responsibilities. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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5. Rehabilitation
For patients undergoing neurosurgery, the follow up and rehabilitation of patients post operatively are as important as the surgery. At present this is done initially at Walton and subsequently at Clatterbridge and various centres in North Wales. Some patients remain under the overall care of doctors at Walton for many years after they have been discharged from hospital. It is not clear if arrangements for rehabilitation and after care would be shared between the two centres. It is also not clear if elective patients from North Wales would receive their rehabilitation in Swansea. It is unlikely that it would be undertaken at the Walton Centre. There would be more scope for confusion, and extra journeys for patients and their relatives and carers from North Wales.
6. Patient choice
In England, under the “informed choice” scheme patients can choose from four hospitals for elective surgery. In Wales the policy is diVerent in that there is no patient choice programme. However, GPs can refer patients to any hospital trust with whom the Local Health Board has a contract. All hospital trusts have to meet the maximum guaranteed Welsh waiting time for elective surgery. If a GP wants to refer the patient outside the contract then sometimes this is done on a cost per case basis. We inquired from the Welsh Assembly whether the same arrangements applied to specialist tertiary cases, eg elective neurosurgery. If so, it would mean patients requiring elective neurosurgery could be referred to any hospital with whom Health Commission Wales (the body responsible for commissioning specialist tertiary services) have a contract, currently the University of Wales—CardiV, Morriston Hospital—Swansea and The Walton Centre—Liverpool. Our reading of the situation appears logical, but to date we have not had a response to our query. We believe the vast majority of patients in North Wales would opt to be referred to Walton. This being the case, the Minister would have to cancel the contract with Walton to admit elective patients, so forcing patients to go to Morriston. We believe this compulsion would be unprecedented in the NHS. Patients would be denied choice. The only choice left would be to be referred to Morriston or to become a private patient. This we consider to be totally unacceptable, and possibly contravenes the human rights of a patient. If a patient wishes to be referred to a neurosurgery centre in South Wales that should be their right, but also to Walton if they wish.
7. General Practitioners
GPs have a duty to provide the best possible service for their patients within the resources available. A GP would be forced into an ethical dilemma if they felt that due to the clinical needs of a patient and the eVect on their family, it would be in the patient’s interest to be referred to a neurosurgical centre much nearer their home. GPs should not be put into this position, which is completely unnecessary.
8. Ambulance Service
There would be significant extra costs for the ambulance service and also mean a significant depletion of availability of cover in North Wales. In 2007 there were 246 patients referred for elective neurosurgery from North Wales to Walton. It is assumed half, 125, would require ambulance transport, with a paramedic and technician. The cost of such an ambulance and crew is currently £38 per hour. Each patient would need at least one pre-operative and two post operative out-patient appointments, in addition to attending for surgery. Times will vary from diVerent places in North Wales, but an average ambulance return journey time to Walton is three and a half hours and eight hours to Morriston. On these assumptions:
Morriston: 125x4return journeys x 8 hours x £38 % £152,000 Walton: 125x4return journeys x 3.5 hours x £38 % £66,500 Extra cost: % £85,500 These calculations are for the minimum number of journeys and take no account of extra out-patient appointments or rehabilitation. It is a very conservative estimate. In addition the loss of cover would need to be covered by extra staV and vehicles. Carers and relatives may travel with the patient if they fulfill certain criteria. Some will not, and would face the additional costs of the longer journey by car or public transport. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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9. Impact on Morriston Hospital We would stress we are not doubting the professionalism of the staV and care given to patients in Morriston Neurosurgical Department. Superficially it might appear that there is an advantage to Morriston if an extra 246 patients were referred there each year. However, on closer examination we would challenge this. There is the issue of possible confusion of responsibilities between Morriston and Walton, which we believe is against the principles of sound clinical governance. Patients in North Wales would expect some element of comparability with the present service. This would involve consultant neurologists from Morriston undertaking sessions in each of the three district general hospitals in North Wales. Whereas consultants from Walton can drive over in the morning, do an outpatient session and a ward round and go back to Liverpool the same evening, consultants from Morriston would need an overnight stay, thus depleting the service in Swansea.
The Way Ahead At least the Minister’s initiative has spotlighted Neurosciences Services in North Wales and stimulated discussion. Four options have been raised:
1. A Neurosurgery Unit for North Wales? A suggestion has been made that there should be a free standing neurosurgery unit in North Wales, possibly attracting some patients from North West England. We do not consider such a scheme could possibly be viable. In order to justify a unit and ensure staV and equipment were fully utilized, it would need to serve a population of at least 2 million. The population of North Wales is 663,397. We consider it is extremely unlikely that patients could be attracted away from the established centre in Walton. It certainly could not be used for the basis of planning such a unit. Such a unit would require at least five neurosurgeons to ensure adequate cover. If it just served North Wales, the consultants would have insuYcient work. The capital costs would be very considerable and the facilities would be underused. It is extremely unlikely it would receive approval for training from the Royal College of Surgeons and there could be problems of recruiting consultant staV. Such a unit would face the same problems as those faced by Morriston, which serves a larger population than North Wales.
2. A Neurology Centre for North Wales?
It could be argued that it would be possible to have a free standing Neurology Unit (as opposed to a comprehensive Neurosciences Unit, including neurosurgery) in North Wales. Our view is that establishing such a unit would be extremely costly and there could be problems of obtaining recognition of training from the Royal Colleges, and problems of recruitment of consultant staV. It is not clear what links there would be, if any, with Walton and how it would aVect cohesive care requiring integration with neurosurgery, neuroradiology, neuropathology and neurophysiology services. The existing neurology service now provided by Walton is good, and we would not consider a free standing neurology service would provide a significantly better (and possibly more limited) service. We do not consider it a high priority. It is certainly far less pressing than the need for improved rehabilitation services.
3. Rehabilitation Services for Neurosurgical patients We welcome the announcement by the Minister on 27 February 2008, that the Frank Burns Review of Services at Llandudno General Hospital includes a recommendation to provide an 8 bedded in-patient acquired brain injury unit, which alongside the stroke rehabilitation service could build the reputation of the hospital as a neurological rehabilitation centre. Such a centre would work closely with the excellent North Wales Brain Injury Unit based at Colwyn Bay, which provides day care, advice and community support. We hope this recommendation will be supported by Mr Steers’ Expert Review Group, and will eventually become a reality. Our review has identified a fragmented rehabilitation service, with the main weakness of neurosciences services in North Wales as the lack of sub-acute rehabilitation facilities (for patients who are emerging from coma in a minimally aware or globally confused state). Length of stay in such a unit would be six weeks to three months. Such a sub-acute unit, together with the unit at Colwyn Bay would form the hub for rehabilitation. However, these facilities would not provide a comprehensive service for the full range of rehabilitation required. We consider there is need for various agencies in North Wales to work with staV from Walton to produce a comprehensive plan. We would stress the importance of a bilingual service at the rehabilitation phase of treatment, particularly the need for intensive speech therapy. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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4. Continuity with the Walton Centre We are not claiming the service from the Walton Centre is perfect, but it provides: — a comprehensive neurosciences service to North Wales, with a significant outreach service; — a patient centred service; — a full range of sub-specializations, backed up by comprehensive diagnostic facilities; — a close link with children’s neurosurgery at the nearby Alder Hey Children’s Hospital; and — a commitment to North Wales, combined with a willingness to engage in a dialogue to improve services further.
Conclusion We consider the following action should be taken: (a) The Minister makes a formal announcement that the proposal to refer elective neurosurgical patients from North Wales to Morriston Hospital is withdrawn. (b) The Minister makes a formal announcement that the long term relationship of all North Wales neurosurgical patients being referred to The Walton Centre should continue, unless the patient prefers to be referred to a centre in South Wales. (c) Mr Steers Expert Review Group supports the proposal to develop an in-patient acquired brain injury unit at Llandudno General Hospital. The group also to consider this recommendation in the context of their wider examination of a comprehensive rehabilitation service for patients with all neurological conditions.
PART 2
THE SHIFT OF POLICY BY THE WELSH ASSEMBLY FOR TERTIARY SERVICES We are concerned that the proposal by the Minister that elective neurosurgical patients should be referred to Morriston Hospital as opposed to The Walton Centre, is the model for all referrals of tertiary (highly specialized) cases to be to South Wales instead of hospitals in North West England. Our evidence for this is the various decisions and statements made by the Minister.
Background We start from the supposition that health care should be provided as near as possible to a patient’s home, balanced against the need to provide this as safely as possible, and in an economical way. In this report we are concerned about acute hospital services only. The vast majority of patients (97%) from North Wales receive their acute care at the Maelor Hospital, Wrexham, Ysbyty Glan Clwyd, Ysbyty Gwynedd and Llandudno General Hospital. There is a small minority of patients (3%) who require very specialized care that is not provided in North Wales. This care is mainly provided in Liverpool, but also in Oswestry and Manchester. The reason the services are not provided in North Wales is that the conditions they treat are relatively rare and require very specialized expertise, particularly from consultant medical staV. To be viable and to be able to attract specialist staV, such units need to serve a population of 2 to 3 million. The population of North Wales is 663,397. Over time an increasing number of conditions have been treated in hospitals in North Wales as expertise has been developed and funds made available. We firmly believe this process should continue (some of us have been involved in these developments). However, there will remain some very specialist services it is not viable to provide in North Wales. For these services patients will continue to need to travel to specialist centres. The main hospitals outside North Wales to which patients travel for specialist care are: — Alder Hey Children’s Hospital—Liverpool. — Christies—Oncology (cancer)—Manchester. — Clatterbridge—Oncology—The Wirral. — Robert Jones and Agnes Hunt—Spinal injuries and specialist orthopaedics—Oswestry. — Royal Liverpool and Broadgreen—Mainly cardio-thoracic. — Manchester Royal Infirmary—Mainly cardio-thoracic. — Whiston Hospital—Burns and plastic surgery. — The Walton Centre for Neurology and Neurosurgery. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Historical Policy and Practice Patients from North Wales have been referred to specialist hospitals in North West England for many years. In July 2000, the Acute Services Development Group (ASDG), chaired by Dr Ruth Hall the then Chief Medical OYcer for Wales, reported on acute general hospital services. The report entitled “Access and Excellence” was a very thorough review taking into account patients’ needs; waiting times; emergency admissions; survival rates for major illnesses; the balance between services provided locally consistent with safe and eVective care; comparability of standards of care with the rest of the UK; provision of a skilled workforce; buildings; access to diagnosis; eVective standards of clinical governance and acute services as part of an integrated system of health and social care. Among other conclusions was a framework for the future scale at which acute hospitals should be planned and coordinated to be increased beyond the existing boundaries of Welsh Health Authorities and Trusts. “There are ‘natural’ aYliations between clinical services and existing patient flows evident in Wales, that can be developed to create new ‘health economies’ for acute services. These ‘health economies’ include critically important links with acute services in England. ‘Health economies’ should become the focus for the development of acute services in Wales”. The report continued, “‘Health economies’ are natural groupings and are not intended to reflect existing organizational boundaries. They reflect the critical importance of relationships with services in England and are therefore centred on the Welsh population rather than the Welsh geography”. The report identified five “health economies”: — Wales as a whole, including its links with the NHS in England, particularly in the provision of specialized health services (the latter includes relationships with specialized hospital services in London). — North Wales, including links with Liverpool, Manchester and Chester. — Powys (Mid Wales) including links with Aberystwyth, Wrexham, Abergavenny, Merthyr and Swansea in Wales and Hereford, Shrewsbury and Birmingham in England. — South West Wales, linking services in Dyfed with those in Swansea, including Neath and Bridgend. — South East Wales, comprising Gwent and Bro Taf, including links with Bristol. Some of the names have changed, but we consider these groupings are a logical and sensible basis on which to continue to plan and provide acute services. We do not consider devolution alters the underlying common sense of the arrangements.
Action and Statements by the Minister There are a number of actions and statements by the Minister which flag up to us what appears to be a major shift in policy: 1. In the debate at the Welsh Assembly on 4 July, the Minister made a statement on Neurosurgery Services, “My overriding aim is to secure as many services as can be safely provided within Wales’s boundaries. Of course, there will always be rare conditions and highly specialist services that can only be supported by populations greater than the population of Wales. This means that, in order to get the best possible treatment, there will always be some patients who must travel outside Wales for the services they require. However, where the Welsh population base is suYcient to support an in-country service, that is the way in which I wish to proceed. Therefore, in the case of adult neurosurgery, the approach that I now intend to adopt is one in which we will look as actively as possible at redirecting additional elective work generated inside Wales to the two centres in Swansea and CardiV”. Our reading of the Minister’s statement is that in future, the whole population of Wales will be used when assessing what acute specialist hospital services are provided in Wales. We would challenge this concept. In our view the criteria used in the past, treating North Wales as having separate links with North West England, should continue. Planning of specialist acute hospital services should be on the basis of separating the population of North Wales from the rest of the country. The geographical reality is that Holyhead is 205 miles from CardiV and 98 miles from Liverpool. Wrexham is 133 miles from CardiV and 41 miles from Liverpool. There are excellent specialist hospital facilities in North West England and access is much easier than to CardiV. Our fear is that there will be a drift to lump the whole population together to justify units in South Wales, and patients from North Wales would be redirected to CardiV. This we believe is not in the best interests of patients, their relative and carers. It would also be a denial of patient choice. The proposal to redirect elective neurosurgical patients to centres in South Wales could be the model of things to come. 2. In the same debate, the Minister also stated “I have been struck by the fact that we have no purpose- designed spinal surgery unit in Wales”. We would point out there is already the excellent Midlands Spinal Injuries Unit at the Robert Jones and Agnes Hunt Hospital at Gobowen, near Oswestry, which serves patients from the West Midlands and North and Mid Wales. The hospital serves a population of 8.5 million, staV have great experience and expertise in treating spinal injuries and liaise closely with staV in Accident Departments in hospitals in North Wales. The hospital has been rated as excellent. About 10% of admissions are from North and Mid Wales. There are over 40 Welsh speaking staV. The hospital is 21 minutes drive Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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from Wrexham, and even from Anglesey takes less than two hours. If patients had to travel to a centre in South Wales, most would literally pass within half a mile of the hospital entrance, before heading south for a further three hours. 3. In the debate at the Assembly on 4 July, the Minister stated: “I have a problem with foundation hospitals”. Hospitals in England can apply for Foundation Trust status. It is the policy in England to encourage them to do so. The advantages to the hospital are that if granted, they are allowed greater freedom from the control of their Strategic Health Authority (the equivalent of the Assembly Health Department), have an ability to carry forward financial surpluses and being more accountable to the local population. In order to be granted Foundation status, the hospital has to demonstrate a sound financial position and to prove it has achieved high standards of patient care. The policy of granting Foundation status has been rejected in Wales. We fully support that decision and agree the arrangement is not appropriate in Wales. The Minister did not elaborate on her problems with Foundation Hospitals. We would point out that all the hospitals providing specialist tertiary services to patients in North Wales have either been granted Foundation status or are in the process of applying. All are very happy to continue to treat Welsh patients. It would be helpful if the Minister could clarify why Foundation status appears to be a bar to treating patients from Wales.
Conclusion From actions and statements by the Minister there appears to have been a shift in policy about referral of patients to hospitals in England. This creates concern and confusion. We recommend: (a) The Minister makes an unequivocal statement that the existing pattern of referral for patients from North Wales to tertiary hospitals in North West England will continue. (b) If this is not the case, then there should be a detailed consultative document issued by the Welsh Assembly setting out reasons for change, and for there to be an open debate on the issues. It is not acceptable to rely on cryptic remarks made by the Minister. (c) We would reiterate that our view is that where it is safe and economically viable, acute services should be developed at hospitals or one hospital in North Wales. With advances in medical techniques the scope for this increases (eg invasive cardiology). Where there are specialist services that require a much larger population base, these should be provided in North West England. A long term commitment should be made to these centres, and a greater involvement with these hospitals to improve services and accessibility for Welsh patients, with more outreach services and specialist community support in North Wales.
PART 3
WAITING TIMES, COMPARISONS From our informal discussions with staV at specialist hospitals in North West England, certain issues arise: — doctors are frustrated that there are two standards for waiting times, between patients resident in Wales, compared with those in England. They would prefer to treat all patients by the same criteria; — most specialist hospitals have the capacity to reduce the waiting times for Welsh residents to the same as those from England; — that some of the hospitals are driving down their waiting times, and achieving significantly shorter times than the English standard; — the policy in Wales appears to be that it is satisfactory as long as Welsh minimum standards are achieved; — it would appear, therefore, that the disparity between the standards is becoming greater; — it is acknowledged that the Assembly has announced improved standards for waiting times. However, there are continued improvements in England. These issues arose relatively lately in our review, and are based on informal discussions with doctors. We have raised questions with managers of some specialist hospitals. Perhaps not surprisingly, they have been somewhat coy about providing detailed information. There is much publicity given to individual cases where a patient from Wales is denied a drug or operation which is available for English patients. In our view a much bigger issue, and one which aVects a much larger number of patients from North Wales, is the considerable and apparently growing disparity in waiting times. We consider our assertions need testing out. There is a need to obtain detailed information and statistics to illustrate clearly the extent of the disparity, not just between oYcial targets, but the actual situation in each specialist hospital. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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This should be done by an oYcial body that can obtain information more easily than by a group of private individuals. The information obtained should be made public. Whatever the facts about the actual extent of the disparity, it remains an issue that waiting time standards are better for patients from England as opposed to Wales. We consider the public in North Wales is entitled to know the facts and that the Assembly should require Health Commission Wales to produce an action plan to remedy the situation.
SUMMARY 1. Background to the proposal by the Minister to redirect elective neurosurgical patients from Walton to Morriston Hospital, Swansea. 2. A description of the services provided by The Walton Centre, including workload, staYng, medical outcomes, sub-specialization and future plans. 3. A description of services provided by Walton in North Wales, including out-patient clinics, community services and reading scans from local hospitals. 4. Objections to the proposal to redirect elective neurosurgical cases from Walton to Morriston, including extra time and distance to be travelled by patients, their relatives and carers; additional stress to patients; problems with dividing emergency from elective care; the important links between neurosurgery and neurology; rehabilitation; patient choice; general practitioners; the ambulance service—extra costs and reduced cover; the impact on Morriston Hospital. 5. Possible options for the way ahead. Opposition to establishing a neurosurgery unit in North Wales or a free standing neurology centre. Support for improved rehabilitation facilities for sub-acute cases at Llandudno General Hospital. 6. Conclusion that the proposal is withdrawn, a long term commitment should be to continue with both emergency and elective neurosurgical patients admitted to Walton; and Mr Steers Review Group examine a comprehensive rehabilitation service for patients with a neurological condition. 7. Concern at the apparent shift of policy by the Welsh Assembly that all patients requiring specialist acute care would be redirected from specialist hospitals in North West England to South Wales. 8. A statement of the background, together with the reasoning for the present pattern of referrals. 9. Analysis of recent statements by the Minister about neurosurgery, spinal injuries and foundation trusts that appear to confirm the change of policy. 10. Conclusion that the Minister should confirm the existing pattern of referrals to North West England or if not, there should be a full public debate. Recommend that acute services continue to be developed in North Wales and a long term commitment made for specialist services to continue to be provided in North West England. 11. A statement about the disparity between waiting times for Welsh patients compared with English patients at hospitals in England, and the need for a comprehensive study of the issue, and an action plan to address the situation. 20 March 2008
Supplementary memorandum submitted by Huw Thomas and colleagues
1. Our Statement We submitted a report to the Welsh AVairs Committee that had been circulated widely entitled “Neurosurgery and Specialist Hospital Services for the People of North Wales”. We highlighted: (a) Our concern regarding the proposal that adult patients requiring elective neurosurgery should be redirected to centres in South Wales, particularly Morriston Hospital, Swansea as opposed to The Walton Centre, Liverpool (b) The apparent shift in Welsh Assembly Government policy from referral of patients requiring specialist tertiary hospital care from hospitals in North West England to hospitals in South Wales (c) The disparity in waiting times for patients from Wales attending specialist hospitals in North West England, compared with patients from England attending the same hospitals. The disparity appeared to be increasing. We also submitted a report specifically to the Welsh AVairs Committee, confirming our views set out in the main report. We expanded on the point about cross border specialist hospital services by recommending that once the air was cleared over future policy, there should be a more constructive and positive partnership Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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approach to planning of specialist services. This would involve staV from the appropriate Trusts in North West England being fully involved in the planning process in North Wales [eg staV from Walton would be involved in planning and developing neuroscience services in North Wales]. From our informal discussions we reported that there were significant discrepancies between waiting times for Welsh and English patients at specialist hospitals in England. We gave some examples and recommended that the Welsh AVairs Committee pursued its own investigations. We recommended that there should be an Action Plan to achieve equalization.
2. Neurosurgery We welcome the announcement by the Minister for Health on the 16th July that patients from North Wales would continue to receive neurosurgery at Liverpool’s Walton Centre. We note the announcement was made following the submission of a first stage report from Mr James Steers, dealing with neuroscience services in North Wales. We also welcome that Mr Steers considered there was scope to bring many services currently provided in England to be closer to people in North Wales. We are particularly pleased with the recommendation that an inpatient rehabilitation centre should be established in North Wales [one of our key recommendations]. We note the Minister for Health has asked the Health and Social Services North Wales Regional OYce to co-ordinate the development of a costed plan to be implemented within five years. In our view the Minister has come to a wise conclusion on the issue of neurosurgery for the people of North Wales. We would press that the planning process for the implementation of the proposals from Mr Steers includes staV from the Walton Centre from the beginning. We also consider it is essential that organizations representing patient groups should be integral members of the planning team [eg The Wales Neurological Alliance].
3. Cross Boundary Health Services We are grateful to the Welsh AVairs Committee for having produced such a masterly analysis of the issues relating to cross border issues as they aVect health. We have noted the First Minister’s acceptance of the principle of “excellent services provided as close as possible”. We have also noted the answers given by the First Minister to Members of the Welsh AVairs Committee at the meeting of the Committee on Thursday, 12 June. We do not consider the answers were suYciently explicit on the issue of a continued commitment to specialist hospitals in North West England. We entirely accept that there should be a pragmatic approach on certain issues eg PET scanners. We also reiterate our view that specialist services should be developed in North Wales when these are clinically and economically viable. However, we consider the First Minister’s contention that the Minister for Health was only floating an idea about adult patients requiring elective neurosurgery being redirected to hospitals in South Wales, is not borne out by the Minister for Health’s statement to the Welsh Assembly on the 4th July 2007. This statement makes it clear that patients would be redirected to centres in South Wales and a Task and Finish Group would be established to implement the proposal. Whilst it might be considered that this whole matter is now “water under the bridge”, we consider suspicions in North Wales about stopping links with specialist hospitals in North West England have not been allayed. The fact that the Minister for Health apparently refused to appear before the Welsh AVairs Committee compounds this suspicion. We have noted the answers from the First Minister to the Committee, while enlightening, did not in our view, constitute any firm commitment to maintaining and strengthening links with specialist hospitals in North West England. In view of the concern generated by the proposal to redirect adult neurosurgical patients, we consider it is essential that the Welsh Assembly Government makes a clear statement on the issue of links with all specialist hospitals in North West England, not just Walton. We would hope that this will emerge from a formal response by the Welsh Assembly Government to the Interim Report of the Welsh AVairs Committee. We note with concern that while the Westminster Government is obliged to respond to the Report within a two month period, the Welsh Assembly is not obliged to respond. If it does not, the deep suspicions in North Wales will remain.
4. Robert Jones and Agnes Hunt Hospital,Gobowen The Terms of Reference of the Expert Review Group, chaired by Mr James Steers included consideration of the spinal injuries service. This matter was not dealt with in his first stage report dealing with services in North Wales. As the deadline for submitting evidence to the Welsh AVairs Committee is 30 September, and Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Mr Steers final report has not yet been published, we reiterate our view that patients from North Wales should continue to receive their spinal injuries service mainly from the Robert Jones and Agnes Hunt Hospital, Gobowen, which is the spinal injuries centre for the West Midlands, and has an international reputation.
5. Waiting Times
In our report we pointed out the apparent significant disparity between waiting times for Welsh and English patients at specialist hospitals in North West England. We note in the answers given by the First Minister to the Welsh AVairs Committee that he explained the disparity in terms of waiting times for elective surgery in Wales as being only one day longer than in England. We do not dispute this, as it covers waiting times for all specialties, eg hips, cataracts, etc. Our concern was on the more specific issue of disparity for specialist hospital services provided in England. We are pleased the Committee has examined the matter in greater detail. We would hope that the results of the survey would be made public, and the facts of the situation demonstrate as to whether there is a significant disparity and if so, to what extent. We are informed the Wales Neurological Alliance is collecting information on the experience of individual patients and carers, which will be of interest to the Committee.
6. Formal Government Response to the Interim Report
We understand that the formal responses to the Committee’s Interim Report is as follows: (a) The Committee published its Report on 1 July 2008. The requirement is that responses from Government Departments to all Select Committee Reports are received within two months. (b) Due to the Parliamentary recess, the Welsh AVairs Committee will not meet until 7 October. It has been agreed with the Department of Health of the Westminster Government that the Committee would be happy to receive the response in time for the meeting. (c) The Wales OYce will co-ordinate the UK Government’s response in time for the meeting of the Committee. [The two commenting Departments will be the Department of Health and the Wales OYce]. We have two concerns: (a) The Committee’s Interim Report states on the key issue of a proposed protocol between the Department of Health and the Welsh Assembly on cross-border provision of health services that “Minister of State for Health Services Ben Bradshaw MP indicated in evidence to the Committee on 3 June that agreement on the proposed protocol should be reached by July 2008”. We understand that the protocol has not yet been agreed. This delay is particularly disappointing as it would be a key factor in solving current problems and according to Ben Bradshaw the “cross border financial conflicts are resolvable at a comparatively modest cost”. We would hope agreement can be reached by Christmas, 2008. (b) The Welsh Assembly Government is not required to respond to the Interim Report, but the Welsh AVairs Committee welcomes all contributions to the inquiry. On the 14th August we wrote to First Minister, Rhodri Morgan enquiring whether there would be a formal response from the Welsh Assembly Government to the Interim Report. We received a reply from Minister for Health, Edwina Hart on 8th September stating “I have read with interest the Interim Report of the Committee and I am currently considering whether I wish to respond formally to the Report, in particular whether to provide further evidence to the Committee”. We enquired again on 23 September, but have not yet had a response. Whilst recognizing the formal situation that the Welsh Assembly Government is not required to respond to the Report, we consider it would be an outrage and demonstrate a contempt for the people of North Wales if no response is made. The sensible recommendations of the Committee would be to the benefit of the people of North Wales. It would be a bizarre situation if Government Departments that speak for the English population, who are largely unaVected by these proposals, respond; yet the Welsh Assembly Government, which is there to look after the interests of Welsh patients, who desperately need improvements, does not. A response by the Welsh Assembly Government to the Interim Report, aYrming the link with specialist tertiary hospitals in North West England and a commitment to agreeing a protocol for cross boundary services would allay legitimate concerns. 29 September 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Memorandum submitted by the United Bristol Healthcare Trust Thank you for inviting the Trust to respond to the House of Commons Welsh AVairs Select Committee’s Call for Evidence. UBHT treats significant numbers of Welsh patients across a variety of specialties. Emergency treatment is provided as per Department of Health (DH) Cross Border Emergency Treatment, Gateway Ref 7057. Activity and income is summarised in the table below and a detailed summary is attached as an Appendix. Year LHB Actual Value £’s HCW Actual Value £’s Total Actual Value £’s 05–06 Total 1,129,191 4,899,629 6,028,820 06–07 Total 1,066,236 5,445,171 6,511,407 Q1–3 07–08 Total 804,303 4,317,737 5,122,040
1. Financial Issues There are continuing issues with payment of invoices for cross border activity outside of contracts. Disputed invoices total: Local Health Boards £128k outstanding from 05/06 £356k outstanding from 06/07 £212k outstanding from 07/08 YTD Health Commission Wales Outstanding debt for 2007–08 is £395k, though agreement has been reached and UBHT is expecting payment before the end of the financial year. 05/06—07/08 YTD this totals £1,091,000 When payment is received from HCW the revised total will be £696,000 There is a lack of consistency between HCW and the LHBs over which services HCW is responsible for, with HCW claiming that they were not resource mapped for all the services outlined in Welsh Circular 63 (2003). Providers get caught in the middle of these intra-Wales disputes over funding, with payment being severely delayed or invoices remaining unpaid. There is also a lack of clarity around the PbR tariV, with English trusts adopting tariV as per English national guidance, the Welsh Assembly guidance stating “do not recognise English TariV”, but then also stating “do not pay more than English TariV”, and neither oVering any further guidance on the matter.
2. Prior Approval Schemes
2.1 Local Health Boards An increasing number of LHBs are moving to cost per case/NCA and away from contracts. This appears to be both because neither the Welsh nor the English model contracts are appropriate for cross border commissioning, and because it is easier to dispute billing. This places a huge administrative burden on the trust and causes delays in the patient pathway. Whilst UBHT is supportive of the drive to repatriate referrals where appropriate, the prior approval requirements do not appear to be built around improving patient care, rather a desire to save money. Guidance issued by the Welsh Assembly and the Department of Health on treatment of NCAs is contradictory. The trust is reluctant to reject all Welsh referrals before clinical triage in order to ensure urgent cases where delays in treatment could be critical are identified. This further increases the burden on the trust. Not all LHBs require prior approval, and UBHT has good working relationships with these organisations.
2.2 Health Commission Wales In 2007–08, UBHT was asked to implement two diVerent referral management schemes for HCW patients: prior approval for adult routine elective patients, whereby referrals must be authorised in advance by HCW, and Tertiary Referral Management, whereby paediatric routine elective referrals must be accompanied by authorisation from a gatekeeper. It appears that neither scheme has been implemented within Wales, with the trust receiving only a handful of referrals accompanied by either form of approval, and, it is understood, there is limited clinical support within Wales for these schemes, with no Welsh gatekeepers identified for key areas such as Paediatric T&O. Again, clinical triage of referrals is necessary to minimise clinical risk. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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3. Summary To summarise, the ability of Welsh patients to access cross-border services is dependent on the policies of the organisation funding the referral rather than clinical need. UBHT would welcome the development of cross border care pathways for Welsh patients, and is hopeful that this review will result in improved partnership working. Robert Woolley Director of Corporate Development March 2008
APPENDIX
ACTIVITY AND INCOME FOR 2005–06, 2006–07 AND Q1–3 2007–08
Worktype Description Year LHB Actual HCW Actual Total Actual Value Value Value £’s £’s £’s Day Cases 05/06 £172,094 £157,856 £329,950 New Outpatients £61,607 £34,676 £96,283 Other £0 £448,795 £448,795 ELECTIVE IN-PATIENTS £401,746 £2,241,665 £2,643,411 ELECTIVE EBD’S £21,065 £95,145 £116,210 NON ELEC IN-PATIENTS £194,092 £1,693,268 £1,887,360 NON ELEC SHORT STAY £58,574 £16,075 £74,649 FOLLOW UP OUTPATIENT £190,993 £86,812 £277,805 REGULAR NIGHT ATTEND £1,232 £1,232 L/Stay Unfinish FCEs £0 £2,292 £2,292 NON ELEC EBD’S £27,788 £60,147 £87,935 REGULAR DAY ATTENDER £0 £62,898 £62,898 05/06 Total £1,129,191 £4,899,629 £6,028,820 Day Cases 06/07 £145,292 £189,698 £334,990 Emergency Inpatients £161,927 £977,595 £1,139,522 New Outpatients £71,431 £31,483 £102,914 Other £168,542 £789,075 £957,617 ELECTIVE IN-PATIENTS £124,542 £2,482,863 £2,607,405 ELECTIVE EBD’S £17,960 £70,066 £88,026 EMERGENCY SHORT STAY £51,512 £3,035 £54,547 EMERGENCY EBD’S £7,133 £15,874 £23,007 NON ELEC IN-PATIENTS £77,425 £771,884 £849,309 NON ELEC SHORT STAY £0 £0 £0 FOLLOW UP OUTPATIENT £196,593 £97,296 £293,889 REGULAR NIGHT ATTEND £2,082 £2,082 R/therapy OP Courses £37,756 £37,756 L/Stay Unfinish FCEs £3,180 £0 £3,180 NON ELEC EBD’S £861 £6,849 £7,710 REGULAR DAY ATTENDER £0 £9,453 £9,453 06/07 Total £1,066,236 £5,445,171 £6,511,407 Day Cases 07/08 £106,374 £124,464 £230,838 Direct Access £42 £42 Elective Excess Beddays £6,735 £93,865 £100,600 Elective Inpatients £110,987 £2,363,973 £2,474,960 Emergency Excess Beddays £6,953 £2,552 £9,505 Emergency Inpatients £99,884 £516,645 £616,529 Emergency Short Stay Inpatients £43,958 £0 £43,958 Follow-up Outpatients £124,249 £78,611 £202,860 New Outpatients £49,500 £28,928 £78,428 Non-Elective Excess Beddays £11,755 £15,022 £26,777 Non-Elective Inpatients £81,527 £791,115 £872,642 Other £51,800 £50,020 £101,820 PbR Excluded Drugs/Devices £96,695 £245,973 £342,668 Radiotherapy Inpatient Treatments £2,092 £2,092 Radiotherapy Outpatient Treatments £10,952 £10,952 Regular Night Attendances £0 £0 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Worktype Description Year LHB Actual HCW Actual Total Actual Value Value Value £’s £’s £’s Regular Day Attendances £800 £4,707 £5,507 Unfinished Episodes £0 £1,862 £1,862 07/08 Total £804,303 £4,317,737 £5,122,040 Grand Total £2,999,730 £14,662,537 £17,662,267
Memorandum submitted by the Vale of Glamorgan Community Health Council
We represent the catchment population of part of the University Teaching Hospital of CardiV and the Vale NHS Trust and so we find that the local NHS services are almost entirely self suYcient. There are a few cases of very highly specialised work where our patients are referred outside of Wales but we accept that the local population is too small to sustain such specialisms.
There are, however, two areas of work where we are conscious of cross border issues. The first is in relation to the need to send patients for PET scans to London. PET scanning is becoming relatively commonplace and it is diYcult to justify the fact that South East Wales is not self suYcient. That said, there are funded plans in place to remedy the situation.
The other matter is in relation to the lack of provision for some secure and medium secure psychiatric care. We believe it is unfair on such patients and their families for them to be sent so far away from home to England for their care and we also think that it is poor use of public money to have to use the private sector.
In neither case do we have quantified evidence for our concerns and we therefore submit this information on an informal basis and suggest that you might look out for the same points from authoritative sources such as the NHS Trusts, Local Health Boards or Welsh Assembly Government. March 2008
Letter from Rt Hon Paul Murphy MP, Secretary of State, Wales OYce to Hywell Williams MP
You asked for statistics on the number of Welsh people being treated in England, the percentage of Welsh people being treated in England, waiting times, and costs to local health boards.
I can advise you that for the year 2006–07 the number of Welsh patients receiving hospital treatment in non-Welsh Trusts is 48,944. This represents 6.42% of the total number of Welsh patients receiving hospital treatment in 2006–07. These statistics were produced by Health Solution Wales and came from the Hospital Admissions Data On-line.
With regard to NHS Hospital waiting times for Welsh patients in non-Welsh Trusts, as at the end of March 2008 this was as follows:
Length of wait Over 13 Over 22 Up to 13 and up to and up to weeks 22 weeks 36 weeks Total
Outpatients—Aggregate of the non-Welsh NHS Trustees 5,180 924 0 6,104 Inpatients and Daycase admission—Aggregate of non-Welsh NHS Trustees 2,313 473 2 2,788
Taken from Stats Wales report on NHS Hospital waiting times.
Finally, Welsh Commissioners spent £145.9 million on non-Welsh NHS bodies in 2006–07. This includes expenditure on non-contracted emergency activity, where Welsh residents need emergency treatment while away from home, as well as expenditure on regular emergency and elective cross border patient flows. May 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Memoranda submitted by the Walton Centre for Neurology and Neurosurgery NHS Trust The Walton Centre NHS Trust has an annual contract with Health Commission Wales (HCW) for the provision of Neurology, Neurosurgery, pain services and some Neuro rehabilitation for all Welsh residents. The Trust does not contract separately with any of the Local Health Boards in Wales or individual GP’s. The Trust does contract separately with the North Wales general hospitals for the provision of some support services to enable us to provide a satellite service in Wrexham, Clan Clwyd and Bangor. Some Welsh patients are also able to access some of our services at the Countess of Chester satellite service. The 2007–08 contract with HCW has a financial value of £7,250,159. The activity plans underpinning this contract are for 963 inpatients, 3,716 new outpatients and 6,749 follow up outpatients plus cover for high cost services such as critical care, stimulator implants, high cost drugs and other treatments. At the end of January 2008, the contract was “over-performing” in financial terms by 8% (£456k) however; there is no scope for the Trust to recover this over-performance this year. In terms of waiting times, the Trust manages patients in accordance with Welsh waiting time targets; however, due to the type of service we provide, patients tend to be seen very quickly regardless of national targets and based on clinical need. At the end of January 2008 the maximum wait for elective in patient treatment and for referral for a new out patient attendance was 26 weeks. Only 123 outpatients were waiting over 13 weeks from a total waiting list of 704. The Trust is obviously aware of the discussion taking place at the moment regarding the possibility of all elective Neurosurgical activity being provided in South Wales and we are supporting this review as required. In addition to the above points, I have included a summary table highlighting the main issues in terms of potential diVerences between English and Welsh patients and how they are being managed at present. In summary, I would like to close by saying, the Walton Centre aims to treat every patient in an equitable manner. We prioritise treatment on clinical grounds first and foremost and wherever possible, we aim to provide that treatment as locally as we can to the patient. I hope you find this information helpful. Chris Harrop Director of Finance 10 March 2008
Issue England Wales Maximum waiting time for Out 5 weeks 22 weeks Patients as at 31 March 2008 Maximum waiting time for 11 weeks 22 weeks Elective In Patients as at 31 March Maximum waiting time for 6 weeks 14 weeks Diagonostic Tests as at 31 March 2008 NB: English target is now a combined target of 90% of non admitted and 85% of admitted patients to be treated ' 18 weeks by 31 March 2008 Vagel Nerve Stimulators Funded at Cost within agreed Only funded With specific levels approval—via IPC process. Neuro Rehabilitation Funded within Baseline contract Small provision within HCW contract for ex-WCNN in patients—otherwise mainly commissioned from Wirral Hospital via LHBs Disease Modifying Therapy Commissioned and managed via Partly commissioned and (DMT) for MS PCTS—funded in full. managed by HCW partly managed by WCNN (43 patients). Currently no patients waiting for treatment. New requests dealt with on case-by- case basis. Other high cost treatments Excluded from base contract— Excuded from base contract— funded on a case-by-case basis funded on a case-by-case basis. Funding for NICE recommendations are made in Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 246 Welsh Affairs Committee: Evidence
Issue England Wales accordance with the “Welsh National Finance Agreement”. Any cost must be agreed in advance of treatment. Access to Out Patient Care Neurology clinics are provided Neurology clinics are provided both at WCNN and satellite both at WCNN and three Clinics across Cheshire and satellite clinics across north Merseyside. Neurosurgical Wales. Neurosurgical clinics are clinics are provided mainly at provided mainly at WCNN with WCNN with one satellite at one satellite at Chester Chester. Neurology In patients. Neurology patients are treated Neurology patients are treated both at WCNN (particularly both at WCNN (particularly complex cases) and Consultants complex cases) and Consultants attend to in patients in Satellite attend to in patients in Satellite hospitals. Neurosurgical hospitals, Neurosurgical patients are all treated at patients are all treated at WCNN. WCNN. Reporting Serious Untoward Reported to Commissioners if/ Reported to Commissioners if/ Incidents (SUIs) as they occur. as they occur. Reporting activity, waiting times Monthly to Commissioners. Monthly to Commissioners and quality data. Payment for activity above Scope for negotiation of No scope for over-performance agreed levels additional payment for over- payments in current contract. performance at marginal prices.
The following written evidence focuses on the services provided by the Walton Centre to North Wales, but it also illustrates some broader principles relating to specialist medical service provision. (A) A brief account of the WCNN, to reflect its size and breadth. (B) Qualitative and quantitative summaries of the clinical services provided by the Walton Centre for the population of North Wales. (C) Some explanatory notes, in the form of Q & A’s, on some commonly raised issues regarding services for these specialties. (D) Notes on some important clinical issues in providing medical services for North Wales from Liverpool, coordinating with more local services. (E) Some of the “non-clinical” issues which impact upon the level of service which the Walton Centre can provide for the population of North Wales, particularly regarding commissioning and service improvement plans. (F) Service strategic planning. (G) Comments upon the eVects of withdrawal of specialist services.
A. Walton Centre for Neurolog &Neurosurgery,Liverpool
— UK’s only stand alone neurosciences trust. — Integrated neurosciences service for Cheshire & Merseyside, West Lancs., IoM and North Wales. — Aiming for Foundation Trust status 2008. — Adults only. — Deals with any neurological/neurosurgical problems except those requiring machine for stereotactic radiosurgery (national centre in SheYeld).
Catchment Nos of Patients Total 3.5M Outpatients 63,690 pa 1,224/week North Wales 0.67M Inpatients 3,428 pa 66/week Day Cases 6,627 pa 127/week Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 247
StaV Neurosurgeons 13 11.5wte Paediatric 4 Spinal 5 ! 1 Neurologists 28 23wte 2 Professors, 2 S/L, 1 rehab Neuroradiolgoists 5 Neurophysiologists 3 !consultant physiologists Neuropathologists 2 Neuro-anesthetists 9 Pain specialists 3 (! 1) 2.5 (!0.5) 1 prof. (!1 S/L) Specialist/Consultant Nurses 15 Nurses 370 Trained:untrained 2:1 Resources — Beds: — Theatres: 5 ! — ITU 10 (to increase to 18 in next 2 years) — MRI scanners: 2 — HDU 4 — CT scanners: 1 (!) — General 96 — Angiogram suites: 2 — Implant 4 — Telemetry rooms: 3 — Day cases 9 (!3)
Neurology Service “Hub & 14 spokes”
Centre: — All in-patients — All day cases — Almost all sub-specialist clinics — Some general neurology clinics — Most specialist nurses — Most teaching/training
Satellite — General neurology clinic & admin — Ward referrals
WCNN Total 2006–07
Non- New Follow-up Elective elective Day Case patients patients Neurology 462 252 2,337 16,590 29,216 Neurosurgery 1,319 1,365 376 2,438 9,403 Pain Relief 30 0 3,914 2,420 2,623 Total 1,811 1,617 6,627 21,448 41,242
Welsh Outpatients 2006–07
Follow-up New patients patients Wrexham 754 2,256 Glan Clywd 728 1,477 Bangor 451 760 WCNN Neurology 1,289 1,449 WCNN Neurosurgery 356 1,609 Pain Relief 138 113 Total 3,716 7,664 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 248 Welsh Affairs Committee: Evidence
B. Clinical services provided by the Walton Centre for the population of North Wales
North Wales Neurosurgery All surgical activity presently takes place at WCNN. Electronic image transfer greatly facilitates non-elective admissions from Welsh DGHs. Elective referrals may be from GPs or more often are tertiary (from consultants in other specialities in North Wales or occasionally rest of Wales). Neurosurgical services naturally rely greatly on visiting WCNN neurologists for integrated service.
Elective Non-elective Inpatients Inpatients Day cases Out-patients New Follow up 246 291 76 356 1,609
North Wales Neurology Service
Non- INPATIENTS Elective elective Day case Neurology 105 38 214
Follow-up OUTPATIENTS New patients patients Wrexham 754 2,256 Glan Clywd 728 1,477 Bangor (YG) 451 760 WCNN Neurology 1,289 1,449 Total 3,222 5,942
Each Satellite: 2 neurologists — General neurology clinic & admin — Ward referral session — Teaching/training — Wrexham Maelor: 3 days — YG (Bangor): 3 days — YGlan Clywd: 4 days — Also Countess of Chester clinics see many cross-border referrals — TOTAL:10 clinics ! 10 ward referral sessions! — Other practitioners: — MS & epilepsy specialist nurses — GP with special interest x 4 sessions — Little neuro-rehabilitation The number of days that a consultant neurologist visits each DGH is : — Wrexham Maelor: 3 days — YG (Bangor): 3 days — YGlan Clywd: 4 days TOTAL:10 clinics ! 10 ward referral sessions! In addition large numbers of patients (especially from Flintshire and Denbighshire) are seen in the neurology clinics (four days each week) at Countess of Chester Hospital. There are specialist epilepsy and multiple sclerosis clinics at Glan Clywd. Other neurology clinics are more general. There are also supporting specialist nurse services covering patients with MS and epilepsy. In addition there are clinics run by “GPs with a special interest” for patients with epilepsy. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 249
Because of the nature of the symptoms arising from many neurosurgical and neurological conditions, many patients who eventually turn out to require neurosurgery present through the neurology clinic. This is a powerful argument for a fully integrated service. All neurosurgical outpatient work is presently carried out at WCNN, the numbers of patients are very much less than in neurology: about one tenth the number of new patients and a quarter the number of follow ups. Processed: 20-03-2009 13:33:11 Page Layout: CWMEM1 [E] PPSysB Job: 400105 Unit: PAG2
Ev 250 Welsh Affairs Committee: Evidence 2 2 27 1 2 11 16 Outpatients 10 7 138 113 Elective Non-elective New Follow-up Elective Non-elective Day Case Bed Days Bed Days Patients Bed Days patients Patients V Wales OverallTotalLocal Health Board Anglesey NeurologyNeurosurgeryPain ReliefTotalBridgend Neurology Neurosurgery Pain Relief Total 352Cardi Neurology 26Neurosurgery 9Pain Relief 329TotalCarmarthenshire ITU 47Neurology 35 3Neurosurgery 341Pain Relief Total ITUCeredigion 4 50Neurology REHAB 80 4 0Neurosurgery 1 Pain REHAB Relief Total 1 42 436 9Conwy Neurology 0 1 3 28 42 3 0 0 3 1 28 11 0 1 0 0 1 15 1 0 9 0 0 0 3 3,716 4 9 0 7,664 0 0 27 4 33 119 0 0 0 0 162 149 133 0 0 289 0 0 0 0 1 2 1 . 0 1 2 3 1 847 3 1,244 13 Hospital Spells NeurologyNeurosurgeryPain Relief 246 105 1 291 38 0 46 214 81 76 4 436 3 11 3,222 356 5,942 1,609 Processed: 20-03-2009 13:33:11 Page Layout: CWMEM1 [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 251 2 1 1 226 Outpatients 23 12 40 37 32 48 21 22 16 14 684 1,308 248 350 Elective Non-elective New Follow-up Elective Non-elective Day Case Bed Days Bed Days Patients Bed Days patients Patients Wales OverallTotalDenbighshire NeurologyNeurosurgeryPain ReliefTotalFlintshire NeurologyNeurosurgeryPain ReliefTotalGwynedd Neurology 59 33 15NeurosurgeryPain ReliefTotalMonmouthshire 61 45 11Neurology 48 60 20Neurosurgery ITUPain Relief Total 1 51 25 Neath 5 Port 56 Talbot 56 ITUNeurology 7 81 31 16NeurosurgeryPain REHAB Relief 1 0Total 31 3 13 REHAB Powys 88 63 36 2Neurology 47Neurosurgery 90 21 Pain Relief 73 3 122 3 9 18 38 0 1 73 57 20 3 47 6 4 0 0 1 7 2 0 57 10 42 0 0 1 1 1 0 0 42 0 927 1 6 0 0 42 1,525 0 0 313 254 0 82 616 0 0 806 370 68 640 1,715 0 0 724 1,082 252 1,348 0 0 1 0 3 Hospital Spells NeurosurgeryPain Relief 44 58 7 17 90 59 259 Processed: 20-03-2009 13:33:11 Page Layout: CWMEM1 [E] PPSysB Job: 400105 Unit: PAG2
Ev 252 Welsh Affairs Committee: Evidence 12 Outpatients Elective Non-elective New Follow-up Elective Non-elective Day Case Bed Days Bed Days Patients Bed Days patients Patients Wales OverallPain Relief Total 1 ITU 0 ITU REHAB 0 REHAB 0 0 0 0 1 2 Hospital Spells TotalSwansea Neurology Neurosurgery 9 1 2 6 0 0 0 0 34 74 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 253
C. Commonly Raised Issues Regarding Services for these Specialties
Why are neurosciences services best practiced from large centres?
1. Neurosurgery in particular can be practised most successfully and safely in large units: a. Subspecialisation of consultant neurosurgeons produces better outcomes b. Financial reasons 2. Both specialities (neurology & neurosurgery) require easy and rapid integration with each other for optimal outcomes. 3. Both specialities require access to specialised diagnostic departments, which are often involved in therapeutic measures (eg endovascular coiling of aneurysms). 4. Both specialities, but especially neurosurgery, require routine access to neuroscience-orientated critical care beds for best results. 5. The specialisation of skills needs to include nursing and allied health professionals, and diagnostics staV. 6. To be compliant with EWTD, for middle grade medical staV (require at least 11 for neurosurgery rota). 7. To produce a worthwhile and comprehensive training experience for specialist trainees. 8. The incidence and prevalence of individual conditions may be quite low, such that a population of 1 million is thought to be the bare minimum for a viable neurosurgical centre, and preferably 1.5 million upwards. Why are all in-patient services in Liverpool rather than in North Wales? See above. The population of North Wales could not sustain a viable neurosurgical centre for both clinical and financial reasons. The specialist end of the neurology in-patient work relies on integration with neurosurgical and specialist diagnostic services. The less specialised in-patient work can be safely undertaken in DGHs in North Wales, and indeed the acute work of this nature is done there by the general physicians, with ward referral support from the visiting WCNN neurologist. Only those patients needing the extra facilities or skills of the staV at WCNN are transferred to WCNN.
How are out-patient services organised in North Wales?
Neurology out-patient work is performed by WCNN consultant neurologists who travel to the three DGHs in North Wales. On each visiting day the neurologist performs a clinic, does the administration arising from the out-patient work, and then goes to the wards to provide specialist neurological opinions on patients who have been admitted under the care of other consultants but in whom more neurological expertise is required. They will advise on management, which is carried out within the DGH as far as possible, but they arrange transfer to WCNN as required. After in-patient care at WCNN, such patients may be well enough to go home, but if not they are transferred back to their local Welsh DGH for rehabilitation before going home.
What are clinicians attitudes to diVerential waiting times?
1. In general, doctors are uneasy that there are two standards for waiting times, which are much longer for patients resident in Wales compared with those in England. They would prefer equity between patients. 2. We know that we have the capacity to reduce the waiting times for Welsh residents considerably, and eventually to the same as English, if the funding was made available. Doctors are frustrated that policy in Wales appears to be that it is satisfactory as long as Welsh minimum standards are achieved, and activity is geared to meet these and not to do anymore in that financial year. The latter are improving but more slowly that for England, and the disparity between the standards is becoming greater. 3. As clinicians, we maintain the principle that if a patient from Wales requires treatment urgently for sound clinical reasons, we will ensure treatment is carried out within a similar timeframe as for an English patient, even if “elective”. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 254 Welsh Affairs Committee: Evidence
D. Important Clinical Issues in Providing Medical Services for North Wales from Liverpool, Coordinating with more Local Services.
(i) Distance Potentially, distance might prove a problem, though WCNN employs various methods to counter this. Neurological care is delivered as close as possible to the patients’ homes by running out-patient clinics at least 3 times each week in each DGH. In addition, we provide some supporting specialist nurse provision to take care out into the community for patients with epilepsy and MS. Neurological in-patients are managed under the care of local physicians with ward consultation advice from the WCNN neurologist, again at least three days each week. More complex patients, or those whose investigation or treatment requires more specialised facilities or neurosurgery are transferred to WCNN (out-patients or in-patients). After such treatment they may be well enough to go home, but if not they will be transferred back to the local hospital for further rehabilitation. In these ways, problems caused by distance are mitigated as much as possible. For a variety of reasons, there is not at present a similar “satellite model” for neurosurgery and all neurosurgical care is provided at WCNN. Many,but not all, investigations are available locally,including scanning. The recent changes of technology with the ability to send digital images electronically on the internet has dramatically improved services, with the ability for rapid referral and discussion of emergency cases, and also enabling specialist WCNN neuro-radiologist opinion in complex patients.
(ii) Coordination of Services At the local level, the visiting WCNN neurologists coordinate with local services. However coordination of services at a regional level relies on discussion between WCNN and Health Commission Wales (who commission all neurological and neurosurgical services in North Wales, but not neuro-rehabilitation). At the more clinical level, WCNN consultants integrate their services with those of other doctors in North Wales, for example liaising with the North Wales Critical Care Network, and with the North Wales Oncology Network. We participate in Risk Management processes with Welsh DGHs. Of course, provision of both neurology and neurosurgery by one provider, WCNN, ensures integration of these two services.
(iii) Engagement with Patient Groups WCNN consultants engage with patient groups in North Wales, and the Trust consulted with patients and public (in English and Welsh) during its Foundation Trust application process. These meetings are very popular and our speakers comment that the attendance and the welcome are better than elsewhere in our catchment area.
(E) Non-clinical Cross-border Issues Impacting on Clinical Services These relate almost entirely to commissioning, all of which is through Health Commission Wales Specialist Commissioning Team. (i) DiVerent commissioning priorities: mainly expressed as diVerent waiting time targets, but also to a lesser extent in the range of very specialist treatments HCW is willing to fund. (ii) DiVerent mechanisms for obtaining funding on an exceptional basis or “one-oV” requests for certain treatments. (iii) Inability of HCW to fund “over-performance” against contract, even for emergency cases. (iv) The diVerent waiting time targets require WCNN to run two diVerent “systems” for both out- patient and elective in-patient work. However, patients in whom the clinician decides there is a need for urgent treatment on clinical grounds are treated equally with their English counterparts. These diVerences may result in confusion, resentment and frustration in doctors as well as their patients.
F. Service Strategic Planning Despite the outcome of the 2005 review of the provision of neuroscience services in Wales, the situation is still not clear, with the announcement in mid-2007 of the idea that elective neurosurgical patients from North Wales might have to transfer to Morriston Hospital in Swansea. A new review group has been formed under the chairmanship of Mr James Steer, and hopefully will report later this year. Our relationship with HCW has generally been good and constructive in past and present times. However these uncertainties make long term planning for developments in the neuroscience service in North Wales very diYcult for everyone. This is extremely unfortunate in its timing, but the Walton Centre is confident that it will continue to serve all the neuroscience needs of the population of North Wales in the future, to everyone’s mutual benefit, and looks forward to developing and adapting that service according to local needs and future technological advances. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 255
G. Comments Upon the Effects of Withdrawal of Specialist Services The absolute need for a “critical mass” in the provision of specialist services is widely recognised and acknowledged. Such services may have diVerent components: for example emergency and elective services. In the case of neurosciences, there is also the split between surgical (neurosurgery) and non-surgical (neurology) services. It is undeniable that: (a) the “whole is greater than the sum of the parts”. Integration of services is more eYcient and produces better outcomes, clinically, operationally and financially; (b) removal of one part has the potential to destabilise other parts, ie is detrimental to the remainder. It is therefore naive to think that removal of an elective neurosurgical service will not have adverse eVects, both clinical and financial, to other elements of the neuroscience services, both English and Welsh. In particular, there must be an impact upon the emergency service for North Welsh neurosurgical patients, for whom there is no alternative provider. Similarly, it is inevitable that integration of neurology and elective neurosurgery, recognised as so valuable by practitioners, would be diminished; (c) intuitively, having achieved an essential “critical mass” to provide a service it seems perverse to then try to halve the services feeding it; and (d) in the case of elective neurosurgery, it is extremely doubtful that the diversion of patients from North Wales to Morriston would actually bring its throughput up to a level suYcient to sustain a viable critical mass. Dr T P Enevoldson Medical Director Walton Centre for Neurology & Neurosurgery Liverpool 14 March 2008
Memorandum submitted by the Welsh Ambulance Services NHS Trust
Executive Summary 1. The information set out below has been compiled for the Welsh AVairs Committee within the limited time available, in response to their request to submit written evidence for Members to consider on cross- border issues in the field of health and social care, particularly as they relate to the ambulance service in Wales. 2. Information included relates to: — Out of area EMS activity. — Clinical governance arrangements. — Partnership working. — Patient Care Services contractual arrangements. — Divergence issues.
Introduction to Submitter 3. The Welsh Ambulance Services NHS Trust (WAST) was established in 1998 and from 1 April 2007 also incorporates NHS Direct Wales. The Trust serves a population of 2.9 million and operates across the whole of Wales (some 20,640 kilometres). 4. The Trust is divided into three Regions (North; Central and West; and South East) and: — employs 2,576 people—76% are operational—1,310 on emergency duties, 693 on non emergency ambulance and health courier services; — operates from 90 ambulance stations, four control centres, three regional oYces, five vehicle workshops; and — has a National Training College with regional training centres. 5. In 2006–07 the Service responded to 287,594 emergency incidents, 56,282 urgent journeys and transported 1,360,445 non-emergency patients to over 200 treatment centres throughout England and Wales. The increasing number of emergency calls continues to represent a considerable challenge to the Trust. 6. The Trust embarked on a five year modernisation programme in 2006. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 256 Welsh Affairs Committee: Evidence
Factual Information
The extent to which cross-border health and social care services are currently provided for and accessed by the Welsh population
General 7. The Trust is probably unique within the United Kingdom in terms of the length of the border and the number of NHS Trusts that it has a reciprocal arrangement with.
Out of Area activity 8. Out of Area responses are the result of requests either from bordering Ambulance Services/Hospitals for assistance or direct requests from the Police to assist with Road TraYc Accidents. 9. The North Region in particular, undertakes many out of area transfers across the Welsh/English border, for example: — cardiac cases are transferred to Liverpool or Manchester; — neurological cases are transferred to the Walton Centre, Liverpool; — paediatric cases are transferred to Alder Hey in Liverpool; and — patients who have suVered burns are transferred to Whiston, Merseyside. 10. In addition to the above, routinely, crews who are dealing with patients from the Queensferry, Hawarden, Broughton, Saltney and Northop Hall area will convey to the Countess of Chester. 11. The Trust’s Adverse Incident Reporting processes allow for the flagging up of any issues, either clinically or operationally. 12. The table below depicts the geography of WAST resource utilisation outside of Wales for all category types. The Trust’s vehicles attended a total of 40 out of area incidents during February, of which 39 were within the Cheshire area.
Out of Area Activity
Out of Area responses are the result of requests from bordering Ambulance Services for assistance or direct requests from the Police to assist with Road Traffice collisions
Summary of Monthly Resource Utilised outside WAST Area Emergency Responses Urgent Journeys Cat A Cat B Urgent cumulative cycle time for all jobs Unitary Authority Ambulance Trust Within OOS Within OOS Within OOS Total GLOUCESTERSHIRE (23) Great Western Ambulance Service 0 0 0 0 0 0 0 00:00:00 HEREFORD (24) West Midlands Ambulance Service 0 0 0 0 0 0 0 00:00:00 SHROPSHIRE (25) West Midlands Ambulance Service 0 0 0 0 0 1 1 01:37:44 OUT OF AREA (26) Unidentified 0 0 0 0 0 0 0 00:00:00 CHESHIRE (27) North West Ambulance Service 5 5 0 29 0 0 39 45:42:53 WIRRAL/NESTON (28) North West Ambulance Service 0 0 0 0 0 0 0 00:00:00 TOTAL 5 5 0 29 0 0 40 47:20:37
Cheshire continues to be the most active out of area county, with the Trust attending a total of 39 incidents. The following chart shows that the for out of area work is remaining consistant with the activity generated last year.
Cat A Out of Area Resources Year on year comparison 120
100
80
60
Resources 40
20
0 Jul Oct Apr Jun Jan Mar Feb Nov Dec Aug Sep May Month 01 April 2004 - 31 March 2005 01 April 2005 - 31 March 2006 01 April 2006 - 31 March 2007 01 April 2007 - 31 March 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 257
Summary of monthly resource utilised outside WAST’s area 13. Appended is data relating to the number of conveyances to English hospitals, ie. Hereford, Shrewsbury and Countess of Chester over a 12-month period. Please note that Evacuation time/Job Cycle time is the whole job cycle up until the vehicle books clear at Hospital. The drive time back to Wales is not included.
The Arrangements Currently in Place to Co-ordinate Cross-border Service Provision 14. In terms of clinical governance policy and procedure, WAST crews use the Trust’s guidance and are expected to utilise the recognised reporting arrangements in place. For example, crews would complete a WAST adverse incident form to report an incident internally. This adverse incident would then be investigated by contacting the receiving hospital in England. 15. Another mechanism for co-ordinating services is by liaising with the Local Health Board (LHB). A good example of this is WAST’s involvement in the Powys Unscheduled Partnership Board, where the LHB is coordinating plans to reduce the number of incidents of patients being transported/ attending hospitals outside of the County (on many occasions into England).
The Commissioning,Funding and Quality of Cross-border Services
Patient Care Services
North Region 16. Set out below are the proposed contracts that the North Region have for taking patients to treatment centres across the border. The contract is on weighted patients, this means an allowance is made for the condition of the patient, eg. walker, wheelchair bound, stretcher, so it is not the actual number of patients transported which will be a lot smaller.
Contracts with Local Health Boards £67,452 7,294 Foundation Trusts £62,267 7,857 Health Commission Wales £109,907 11,394
17. Also the Trust transfers patients from the main DGH’s to these establishments. These are not included in these figures and are usually done by an emergency crew, and can amount to as many as four a day across the Region. 18. In addition, the Trust does have extra contractual referrals to other treatment centres in England: these can be anywhere and are paid for by the centre providing the treatment.
Central and West Region 19. Central and West have PCS Contracts with the Royal Shrewsbury Hospitals valued at £132K for 7,900 patients and with Hereford valued at £90K for 3,400 patients. The Trust also conveys patients on an out of area basis to many trusts in England.
South East Region 20. South East have PCS contracts for East Gloucester valued at £55K and for 1,600 patients and United Bristol valued at £84K and for 1,000 patients. 21. Wales now has its own eligibility criterion providing equity of access to all Welsh patients attending Welsh hospitals. One of the challenges in PCS is that often the patient meeting the Welsh criteria does not meet the English criteria for their journey. This can result in Welsh patients not receiving transport to treatment centres in England. This can be evidenced by the number of English hospitals asking for authorisation by Hospital Managers before transport can be granted. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 258 Welsh Affairs Committee: Evidence
The Extent to which Health and Social Care Policy has Diverged Across the UK since the Introduction of Devolution, and the Impact that this has had 22. Although NHS Wales and the Department of Health (DoH) have a similar commitment to patients in terms of providing access to services, a good example of divergence is in the terminology used to describe approach for delivering such services. 23. The release of the Delivering Emergency Care Services (DECS) strategy by NHS Wales refers to development of unscheduled care services. The key element to this strategy is that no matter how or when a patient contacts any unscheduled care health and social services, they will be assessed and seen by the most appropriate health or social care professional at the most appropriate time. 24. Similar proposals were put forward by the DoH in its discussion document called Direction of Travel for Urgent Care (2007). The diVerence is in terminology. This document states in the past both patients and staV have been confused as to what the term urgent care refers to and what services are available locally. The document says “urgent care” should replace other terms such as unscheduled, emergency or unplanned care. Urgent care should also include social care needs and should apply in-hours as well as out of hours. 25. Another example of diVerences that directly aVect the provision of ambulance services is how it is commissioned in Wales.
The Extent to which Mechanisms are in Place for Identifying and Resolving Cross-border Deficiencies 26. WAST is involved in the unscheduled care partnership boards of the various health communities in Wales. This includes work with health communities that are most aVected by cross-border services (eg Powys). As stated above, in paragraph 14, WAST is working with these partnership boards to reduce the number of incidents where patients are transported unnecessarily to accident and emergency departments. Work is continuing to enable all patients to easily access a service—either by phone, or face-to-face—and have their problem dealt with straight away by the most appropriate professional. April 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
Welsh Affairs Committee: Evidence Ev 259 APPENDIX 1 English Hospital Transports English Hospital Transports TOTAL Hereford Royal Shrewsbury Countess of Chester TOTAL Hereford Royal Shrewsbury Countess of Chester AS1AS2AS3 7,294 1,695 0 1,152 342 0 2,271 868 3,871 0 485 7,294 1,695 0:48:37 0 0:55:45 0:39:44 0 0:41:19 0:00:00 0:20:18 0:22:35 0:00:00 0:00:00 TOTAL 8,989 1,494 3,139 4,356 8,989 0:50:15 0:40:10 0:20:33 PERCENTAGE 17% 35% 48% Welsh Ambulance Service NHS Trust 1 January 2007 to 31 December 2007 Transports to English Hospitals and Job Cycle Join Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
Ev 260 Welsh Affairs Committee: Evidence
Letter from the First Minister for Wales to the Chairman In the course of checking the transcript of my evidence session, I came across as exchange, where I may have inadvertently misled the Committee. This was on the subject of the one day diVerence between the median waiting time for inpatient treatment for Welsh patients treated in English hospitals and English patients treated in English trusts. While it is pretty clear when I first referred to this one day diVerence that it was between patients from Wales and patients from England both treated in English trusts, in two subsequent references, I have, I believe, given the impression that the same one day diVerence in median waiting times refers to Welsh patients treated in Welsh trusts compared to English patients treated in English trusts. I do apologise for inadvertently misleading the committee. 4 July 2008
Letter from the First Minister for Wales to the Chairman Thank you for supplying a copy of the constructive interim Report of the Welsh AVairs Committee on the provision of cross-border health services. I wanted to point out three factual issues which the Committee will want to see corrected in its final Report. First, I wrote to you on 4 July clarifying a point in the evidence I gave to the Committee on 12 June. The interim Report relies, as it points out, on uncorrected transcripts of oral evidence. The point which needs attention is contained in paragraph 31 of the interim Report. Paragraph 30 contains two further matters which I would wish to draw to your attention. 1. Wales’ intended date for achieving the target maximum wait before treatment of 26 weeks is December 2009, not the end of the current Assembly term. 2. Our target covers all referrals for treatment, not just GP referrals, as happens in England. The number of Welsh patients covered within the 26 week target is 30% higher than would be the case if we followed the same definitional basis as the Department of Health for England. 10 July 2008
Memorandum submitted by the Minister for Health and Social Services, Welsh Assembly Government
General Points 1. Since devolution in 1999, Wales has developed its own health policies, to suit Welsh needs and circumstances. 2. There is recognition that, because of its population size, Wales cannot safely and eYciently be entirely self-suYcient and provide all services within its borders. That said, the precise balance between services provided within and outside its boundaries will change over time. Most of the healthcare needs for the people of Wales can be provided in Wales. This may mean people having to travel for some specialised services. In reality, we are likely to always have a mixed picture of health service provision in Wales, and there will be areas where it is sensible to continue with arrangements for Welsh patients to be treated in English hospitals. 3. It is the responsibility of healthcare commissioners, that is the Local Health Boards and Health Commission Wales (for specialist treatment), to decide whether to enter into agreements with Trusts in England. The policy has not changed. Nor does it impact on very large numbers of patients. 6.3% of all elective/emergency admissions of Welsh residents go across the border into England 4. Although there are diVerences in some areas of policy and practice between England and Wales—such as structures, the role of markets, targets—the basic position on both sides is that patients should not suVer detriment as a result of these. Any issues should be resolved in ways invisible to the public.
(a) Cross-border public services currently provided for and accessed by the Welsh population 5. For decades, there have been arrangements in place to ensure that patients and social services clients receive services promptly and eYciently, though the detail has changed over the years. The current context for service development and delivery is a commitment to creating world-class health and social care services for the people of Wales, with safe, eVective services provided as locally as possible. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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6. Cross border services will be needed particularly for certain groups. These will include patients who reside close to the Wales/England border, and those who need services not routinely provided in Wales. Cross-Border patient flows to England have been a significant aspect of NHS treatment for Welsh residents from North and Mid Wales, less so for those from South Wales. Transport and access issues matter, for example with east-west links often easier than travel north or south. 7. In respect of primary care (GPs, dentists, pharmacists and optometrists), cross border flows of patients are common and routine the length of the border. Patients gravitate to their nearest convenient GP practice. Welsh residents can be registered with a GP in England; equally English residents can be registered with a GP in Wales. At 1st April 2007, 15,093 Welsh residents had an English GP. 8. Use by Welsh residents of hospital services in England varies, depending on population distribution, hospital location, ease of access and distribution of services. Admissions have risen—from 32,000 in 1999/ 00, to 41,000 in 2005/06, to around 43,000 in 2006/07, including both emergency and elective patients. 9. Emergency admissions generally are unforeseen. In these cases, speed of access, and therefore geography, are crucial, and the decision as to which hospital to access is made purely on grounds of accessibility, though patients are generally taken to the nearest hospital. In 2006/07 there were 17,413 emergency admissions of Welsh residents to English trusts included in a total of around 43,000 admissions. 10. Elective admissions are planned and scheduled, In 2006/07 there were 25,196 non-emergency admissions of Welsh residents at English trusts. 11. The English hospitals which are the main focus for Welsh secondary care elective referrals are in Liverpool, Chester, Gobowen (Oswestry), Shrewsbury, and Hereford. To a lesser extent St Helens, Knowsley, Gloucester and Bristol are used. 12. Powys has never had a District General Hospital within its boundaries, its population being relatively small and sparse. The population of Powys is around 126,000. In terms of travel time, Assembly Government oYcials have estimated that some 45,000 lie in the catchment area for Shrewsbury, 11,000 in that for Hereford and the balance in those for using Welsh hospitals. 13. Flintshire’s population looks three ways for hospital services—to Glan Clwyd Hospital, to Wrexham Maelor Hospital, and to the Countess of Chester Hospital. Usage broadly reflects geographical proximity. 14. Some highly specialised services are not available within Welsh borders, especially with regard to cancer, high secure mental health and transplantation. The North West of England continues to provide important specialised services for the population of North Wales. In particular, Cardiothoracic Centre Liverpool for Cardiac Services, Royal Liverpool Children’s Hospital for specialist children’s services, Walton for neurosciences. All of these services have continued to attract increasing investment in capacity and quality. 15. Wales continues to access national specialised services for highly specialised children’s services and transplantation at centres such as Great Ormond Street Hospital and Royal Brompton/Harefield. Investment in all centres has been significant over the past five years. 16. DiVerent issues arise in relation to social services. The biggest groups using cross border services are Looked After Children and children requiring specialist placements reflecting their need for complex care particularly specialist disability needs. Although figures on cross local authority boundary and cross border placements are not compiled centrally, there are known to be significant cross border flows of Looked After Children from England into Wales and a probably smaller number in reverse. They are primarily placements with Independent Foster Care Agencies or independent children’s homes, with a smaller number in residential special schools, mainly in the more rural areas. The Chief Inspector has drawn attention to this and the increased numbers of children placed out of area. Such arrangements make diYculty in maintaining contact for family and services. 17. Policy in England and Wales is for children to be placed close to home (family, friends and school) and usually within their own authority area. Welsh Assembly Government Regulations, which came into force from 1st July 2007, strengthened arrangements for placements out of authority area. The Children and Young Person’s Bill, currently before Parliament, will further strengthen arrangements by requiring local authorities to develop suYcient provision within their area to meet need. 18. In the main, social services departments commission or provide services for their own residents who have been assessed as eligible for care. This is particularly so in respect of domiciliary and day care services. Most cross-border placements will be in residential settings and service users have a right of choice in placements within the usual level of funding provided by the authority. Older people may prefer homes across the border or may prefer to be accommodated close to relatives who would visit. 19. Use of cross border hospital services has implications for access to social services. Local authorities (LAs) in which the hospital is located are not empowered to provide services to people not resident in their area unless they have an agreement with the responsible authority. Welsh LAs most aVected have arrangements in commonly used facilities either through agreements with the English LAs concerned or for outreach from a Welsh base. This works best for access to locally provided aftercare but it tends to Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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undermine social care input to ongoing treatment for example in specialist surgery where there are family complications and tensions which may impact on recovery. This is as true for out-of-area care within Wales as in England. 20. A problem can arise where self-funded residents from out of area acquire local residence and become the responsibility of the local authority (LA) in which they reside when their resources fall to the threshold for public funding. As with young people there is a problem of people moving to Wales who then require NHS treatment. However younger adults with complex needs usually require LA funding and so remain the responsibility of the placing LA for their care costs.
(b) Arrangements currently in place to co-ordinate cross-border public service provision 21. For primary care services, individual patients register with a GP of their choice. However, there is a diVerence in management arrangements between Wales and England in relation to securing secondary care services, the former based on where people live, the latter initially on where their GP is. In Wales, save for specialised services, which are the commissioning responsibility of Health Commission Wales (HCW—see below), Local Health Boards (LHBs) have both the legal and operational responsibility commissioning medical services on behalf of all persons who are usually resident in their area. As LHBs’ commissioning responsibility is based on residency, it complements the role of local authorities, and so assists joint planning and commissioning across the health and social care sector. 22. In England the situation is diVerent. In general terms, the English system operates on GP registration, though if a person is not registered with a GP in a Primary Care Trust (PCT) area (including if they are registered with a Welsh GP) there is a default to the PCT where the patient is usually resident. PCTs have both the legal and operational responsibility for commissioning health services for their resident populations. 23. To deal with the consequences of this divergence, the Department of Health (DH) and the Welsh Assembly Government agreed an interim protocol, which in Wales was published in February 2005 as Welsh Health Circular—WHC(2005)12: Procedure for Cross-Border Healthcare Commissioning between England and Wales (the Interim Protocol). This communication applies only to those patients resident along the England and Wales border, and who live within the following LHB and PCT areas: — Wales—Flintshire, Wrexham, Powys, Monmouthshire, and Denbighshire; — England—West Cheshire, Shropshire County, Herefordshire, and Gloucestershire. 24. The Interim Protocol provides that the legal responsibility for providing services to a patient resident in Wales but registered with a GP in England remains with the LHB but the operational responsibility (the commissioning of health services) falls to the PCT. In England, where a patient is resident in England but registered with a Welsh GP, the legal responsibility remains with the PCT, but the operational responsibility falls to the LHB. LHBs are expected to meet Welsh targets, and PCTs English targets. Under (WHC(2006)05 and WHC(2007)036), the Interim Protocol was further extended until 1 April 2008. 25. Decisions to enter into agreements with Trusts in England regarding mainstream secondary care are made by LHBs. Patient flows to England in secondary care are made within a commissioning framework where decisions to send patients to English NHS Trusts are made for good reasons. Only in the case of Flintshire and Powys are there major flows into England. 26. Tertiary care/highly specialised care is commissioned for Welsh residents by Health Commission Wales (HCW). In 2005 the then Minister, Dr Brian Gibbons, confirmed the objective that patients needing tertiary and specialist services, wherever possible and clinically appropriate, should be seen and treated in Wales. HCW has been pursuing this approach. 27. To assist in planning and managing cross-border activity, a Memorandum of Understanding between Central Wales and the West Midlands was signed in March 2007. The Memorandum is a non-legally binding document, indicating a desire to promote co-operation on policy development and service delivery, in view of the complex pattern of inter-dependence and the need to build stronger cross border collaboration by all public sector organisations. An element of that co-operation will be to consult each other in good time on proposals for change in policy,funding or service delivery that could impact on communities on the opposite side of the border. 28. New arrangements are emerging in social services. In order to enable local authorities to find suitable placements and to plan provision in future, the Welsh Assembly Government has supported the setting up of a Children’s Commissioning Support Resource. This comprises a database of provision across Wales, which identifies vacancies and enables placement of children, supported by work with local authorities to develop better commissioning. The database will in future be enhanced to collect information on cross boundary and cross border flows. 29. Most adult placements will reflect an absence of local services in the face of specialist and complex needs, examples being head injuries, mental health and sensory disability, and a complex mix of disability. Local authorities have a duty to provide social services to residents assessed as requiring such care who meet the authority’s eligibility criteria for services. This can be residential or welfare services. Since devolution there has been no clear mechanism for resolving ordinary residence disputes between a local authority in Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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England and a local authority in Wales over the responsibility for providing such services, and a handful of cases arise each year. To remedy this, interim arrangements have been agreed, and an amendment to the relevant act is contained in the Health and Social Care Bill currently going through Parliament, allowing arrangements to determine such disputes to be put in place.
(c) Funding of cross-border public services 30. LHBs spent £74.5 million with non-Welsh NHS bodies in 2006–07. This includes expenditure on non- contracted emergency activity, where Welsh residents need emergency treatment while away from home, as well as expenditure on regular emergency and elective cross border patient flows. HCW spent £71.4 million in that year. April 2008
Letter from the Minister for Health and Social Services, Welsh Assembly Government to the Chairman In regard to the claim made by the Muscular Dystrophy Campaign that there is a lack of publicly available statistics, I can advise you that the statistics for Welsh residents waiting in England for a first outpatient appointment or for inpatient/daycase treatment are definitely made publicly available. Hospital waiting times figures for Welsh residents are published each month and are recorded for each clinical specialty under the heading “aggregate on non-Welsh NHS trusts”. Information can be accessed at http://www.statswales.wales.gov.uk. I also wish to inform you that Trusts and Local Health Boards in Wales are subject to Welsh policy relating the the management of performance for Welsh residents, and Welsh providers have to apply Welsh maximum waiting times to all their patients. The cross-border protocol established in 2005 supports the access to services to Welsh and English patients on either side of the border. To enable English patients to continue to access services at Welsh providers, the Interim Protocol made provision for PCTs not to breach English standards where English patients had chosen to be seen or treated in Wales. It is for the Department of Health to answer questions about these patients. I can assure you that patient care is the most important element of health care service provision in Wales. 28 July 2008
Letter from the First Minister for Wales to the Chairman I am writing with the additional written evidence from the Welsh Assembly Government on the two points which you raised. First, on the arrangments for the operation of waiting time targets in Wales, I made a statement in my letter to you about the outpatient definition that we use in Wales. As you know, we currently have a component target for a first outpatient appointment of 22 weeks. The definition of outpatient in Wales has to my knowledge always been drawn more widely than in England. For outpatients in England they count only those referred by GPs (or dentists) to a consultant, whereas in Wales the definition extends to all referrals for a first outpatient appointment. This includes consultant to consultant referral and a number of other categories, all of which are excluded in England. English figures do not include: — Patients referred by consultants and other health professionals; — Self referrals and attendances at “drop in” clinics; — Referrals resulting in ward attendances for nursing care; — Referals initiated by the consultant in charge of the clinic. An estimate was made by the Statistical Directorate within the Welsh Assembly Government about seven years ago that this resulted in approximately 30% more outpatients being included in the Welsh waiting times statistics than there would be if Wales had the same outpatient definition as in England. This was an estimate and as far as I know it has not been superceded. I am aware that the Statistical Directorate has already supplied its own evidence to the Committee. That same evidence also deals with your second question, seeking clarification on median waits. We can only supply data for Welsh residents, which my letter of 6 July attempted to clarify. This is clearly set out in the Statistical Directorate evidence provided to the Committee, namely: “During 2006–07 Welsh residents had a median wait of 44 days before admission to English trusts. This compares to 45 days for all Welsh residents admitted to any Trusts”. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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That evidence also adds: “During 2006–07 English residents had a median wait of 48 days before admission to Welsh trusts. This compares to 45 days for all patients admitted to Welsh trusts”. Data on Welsh hospital admissions 1999–2007 is available from Health Solutions Wales on their internet site http://www.wales.nhs.uk/hsw-healthstats. For the first time on 22 April 2008, this included information on Welsh median waiting times, which is 45 days. I am not in a position to answer questions on the details of English median waits, or how they are calculated, although I believe the diVerence in comparing Welsh figures with English figures is that data for Wales is based on completed waits, whereas data for England is based on those patients still waiting. 28 August 2008
Memorandum submitted by the Welsh Consumer Council The Welsh Consumer Council (WCC) is committed to being the authoritative voice of consumers in Wales by working with consumers and related organisations to present their interests and needs to industry and government in order to generate beneficial change. The Welsh Consumer Council, energywatch (Wales) and Postwatch (Wales) will merge on 1 October 2008. The new stronger consumer organisation will be known as Consumer Focus Wales. We recently completed work on behalf of the Welsh Assembly Minister for Health and Social Services, Edwina Hart, on palliative care services in Wales. As part of the review we looked at cross border services and would like to direct you to the report for information. The review itself was conducted through a widescale written consultation, local workshops, desk research and expert evidence sessions. The report found that due to the geography of Wales patients were best served by maintaining links with hospices on the borders of England, such as Severn hospice and Hope House, as well as utilising community and home services. For specialist services, as is the case with many children and young peoples palliative care needs, the links in North Wales to Alder Hey are well established and essential to good quality care. What does appear to be lacking, however, are planning and commissioning arrangements that are formally recognised. This was found to be most pertinent in the Mid and North Wales areas. Standardised commissioning processes need to be developed across Wales that ensure borders do not mean barriers for patients. A full copy of the report can be found on the link below. The successor Palliative Care Implementation Group, led by Baroness Ilora Finlay, will be considering these issues in more detail. http://new.wales.gov.uk/topics/health/publications/health/reports/palliativecare/?lang%en September 2008
Memorandum submitted by the Welsh Language Board Thank you for the opportunity to present evidence to the Committee with regards to the cross-border provision of health services. Below is a summary of our observations and concerns which come in addition to our previous submission to the committee dated 14 February 2008.12 Our main concern is that in modernising and improving services to ensure care of the highest quality, patient language choice and bilingual provision are an intrinsic part of any deliberations and that careful consideration should be given to the language needs of patients in the drafting of any formal protocol between the Department of Health and the Welsh Assembly Government. We have detailed below the role of the Welsh Language Board, the policy context, the importance of language in healthcare, and some examples of situations where cross-border co-operation is essential to ensure patient centred services of the highest quality to Welsh speaking patients and service users.
Summary — When Welsh speaking patients and services users have to use services provided by organisations outside Wales they may be made vulnerable by the lack of services through their language of choice; — Current practice is ad-hoc with regards to language provision in cross-border health services and would benefit from mainstreamed guidance; — The current inspection arrangements on both sides of the border would benefit from the inclusion of a language element with regards to cross border health services;
12 Not printed, submitted in Welsh. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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— Steps should be taken to ensure that the inability to oVer a face to face service through the medium of Welsh does not impair the eVectiveness of the patient’s treatment or care; — Public bodies operating in Wales but relying on services provided in England should give a higher priority to their statutory duties under the Welsh Language Act 1993 with regards to their Welsh speaking patients.
Language and Healthcare 1. The Welsh Language Board believes that there are two core themes guiding the provision of health and social care services to the public in Wales, namely: — that a patient-centred service means a bilingual service; and — that in providing such services, respecting the principle of language equality, means that the service provider oVers linguistic choice to the service user(s). 2. In the Journal of the Royal Society of Medicine in 2006, Harry Cayton, National Director for Patients & the Public at the Department of Health wrote: “language is one of the many tools of medicine. Language can educate and inform or confuse and mislead. Language can inspire or alienate, cherish or insult. It is increasingly recognised that communication between clinicians and patients is one of the most important aspects of the health- care relationship and yet the way language is used in the health service is often opaque, alienating and disrespectful” (Cayton, H. 2006:484). 3. The Welsh Assembly Government’s strategy for creating world class health and care for Wales in the 21st century, Designed for Life, states that: “eVective Welsh and English bilingual services are essential to providing quality care and full recognition will be given to the Welsh Language Act 1993, and the Welsh language schemes of each stakeholder organisation” (Welsh Assembly Government 2005: 13). 4. The Welsh Consumer Council identified older people as one of the key groups for which bilingual health and social care services should be provided. The report evidenced the importance of providing bilingual health care and risks associated with not doing so eVectively, it concluded: “that in the case of Welsh-speaking patients, there are instances where they cannot be treated eVectively except in their first language or in both their languages. This is especially true in the case of those receiving speech and language therapy, and for the following key groups: people with mental health problems; people with learning disabilities and other special needs; older people and young children.” (Misell 2000: 5)
Partnership Working 5. Partnerships increasingly comprise representatives from the private and voluntary sectors and may well include providers based in England. Whilst there is a statutory obligation on public bodies to operate in accordance with Statutory Welsh Language Schemes, the obligations on bodies from other sectors are insuYcient in providing stimulus for these bodies to consider language matters. 6. In terms of engaging with statutory, voluntary, independent, academic research and professional sectors, any move which might take health services beyond the reach of the Welsh Language Act 1993, designed to protect public services, must be avoided in future planning.
Cross Border Co-operation in the NHS 7. The motives for choosing to collaborate include the geographical, historical, financial or practical. The most common cases occur, naturally enough, in the eastern county areas of Wales. In these areas the 2001 Census shows the percentage of those who speak Welsh as follows:
Flintshire 14.1% Wrexham 14.6% Powys 21.1% Monmouthshire 9.3% 8. Such collaboration and even co-dependence is not limited strictly to adjoining Welsh/English counties though, and in the NHS this is even more prevalent with patients being referred to hospitals and services in England from across the North Wales region. The figures for these county areas in the 2001 census are as such:
Ynys Moˆn 60.1% Gwynedd 69.0% Conwy 29.4% Denbighshire 26.4% Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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9. It is the Board’s belief that it is both appropriate in the circumstances and reasonably practicable to expect that any initiative, or arrangement promoting or utilising cross-border services should ensure they operate in a way which respects the principle of linguistic equality as set out in the Welsh Language Act 1993. 10. Some Health Boards already have agreements in place with organisations and service providers in England: Flintshire Local Health Board has agreements with Alder Hey, Walton and Broad Green Hospitals; Powys Local Health Board works in partnership with Royal Shropshire Hospital NHS Trust and Hereford City Hospital NHS Trust. 11. In terms of preferred language such partnerships have regularly focussed solely on written communication. 12. Over the years we have encountered anecdotal evidence of staV across the border with the ability to speak Welsh being able to deliver services through the medium of Welsh. This, however, occurs by accident rather than through co-ordinated planning or service level agreements. 13. It is the Board’s belief that in the development of an accord between the NHS and the Welsh Assembly Government due regard should be given to language considerations in the delivery of cross border services.
Inspection and Review 14. Inspections and Reviews should include indicators with regards to language choice and bilingual service provision. Whether conducted in England or in Wales inspection arrangements should include a Welsh language element, and in those organisations operating immediately on either side of the border care should be taken to continually examine arrangements for cross border services and the Welsh language.
Commissioning 15. It is vital that the commissioning and contract monitoring by both the NHS and local government is done in accordance with statutory commitments made in each organisation’s Welsh Language Scheme, usually under the section entitled Services Delivered by Third Parties.
Workforce Development 16. The Board believes that in order to deliver services to the public in Wales it is necessary to plan for a bilingual workforce. Without the relevant linguistic skills the eVective delivery of services to the public in Welsh will be impossible. 17. The Welsh Language Act 1993 places an emphasis on service delivery. It is appropriate that any new proposals to taking this programme forward give full weight to the principle that in the delivery of services to the public the Welsh and English languages should be treated on the basis of equality. Due consideration should be given to several key areas in this regard: — recruitment of new language skills to the workforce; — training and development of staV and potential staV; and — development of existing skills and confidence levels. 18. The current Electronic StaV Record aVords the opportunity to measure staV ability with regards to language skills. Although there are discussions on the precise data set to be collected we believe that knowing the Welsh language capacity of service providers on both sides of the border would be of immense help in service planning and ultimately delivery.
Current and Proposed Reforms to the NHS in Wales 19. In January 2008 WHC (2008)002 circular was published under the title “Strengthening Welsh Language provision within NHS services in Wales”. The aim of the circular was to inform health organisations of the following expectations to be implemented by 30 April 2008: — NHS Trusts should appoint full time Welsh Language OYcers to promote the work of developing bilingual health care within their organisations; — The Local Health Boards in the Mid Wales, West Wales and South-east Wales regions should pool their resources in order to develop regional Welsh Language Units that will be based on the model that operates in the North Wales region. 20. We believe that as these units are set up, a formal cross-border accord could be much more easily realised and we would encourage an awareness raising eVort amongst the providers on the English side of the border. 21. On 30 September 2008 the Assembly Government Minister for Health and Social Services announced to the Senedd the Government’s intention to further reform the structure of the NHS in Wales by establishing seven new health bodies instead of the present 10 trusts and 22 Local Health Boards within a new commissioning structure. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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22. We will respond formally and directly to the Assembly Government in due course but can confirm that we intend to use this proposed restructure by focussing on the key benefits to patients and especially the best practice that can be adopted across the new organisations. 23. We view this as an opportunity to ensure that the current best practice with regard to the bilingual provision is realised and developed—we are also of the opinion that new opportunities to expand the bilingual provision will arise following any improvements to services and an increase in expertise. For example with regard to the proposed improvements to the referral process, the clinical path and the focus on the patient’s entire period of care, recording the patient’s chosen language and planning and providing for it can be done in a more co-ordinated and eVective way. 24. With the wholesale revision of Language Schemes within the NHS in Wales it may also be appropriate for the Welsh Language Board to explore what formal arrangements the Welsh Language Board can be put in place with regards to cross-border health provision.
Welsh Language Act 1993 25. The Welsh Language Act 1993 is the main act dealing with language issues in Wales. There are three main elements to the act, namely: setting out the principle that the Welsh and English Languages should be treated on the basis of equality; establishing the Welsh Language Board; and placing a responsibility on public bodies to prepare and operate Welsh Language Schemes. 26. To date the Welsh Language Board has approved over 400 statutory Welsh Language Schemes, alongside a growing number of voluntary schemes. It operates a monitoring system through written reports and site visits. 27. The Act places a duty on public organisations serving the public in Wales to do so based on this principle of linguistic equality regardless of where those services come from. 28. The Welsh Language Board may ask any public organisation identified in the Act, either in Wales or elsewhere in the UK, to prepare a Welsh Language Scheme.
European Charter For Regional and Minority Languages 29. The Welsh Language Act is not the only legislation concerning the Welsh Language. 30. The United Kingdom Government signed the European Charter for Regional or Minority Languages on 2 March 2000 and ratified 52 clauses for the Welsh Language on 27 March 2001. The Charter came into force in the United Kingdom on the 1 July 2001. The UK Government declares that the Minority or Regional Languages of the UK are Welsh, Scottish Gaelic, Irish, Scots, Ulster Scots, Cornish and Manx. 31. The Charter notes that the UK Government should formulate periodical reports on the implementation of the clauses ratified. This report must be submitted to the scrutiny of the Council of Europe, who appoints a Committee of Experts (COMEX) for this purpose. COMEX also evaluates the report by carrying out “on the spot” visits to the relevant country to receive oral and written submissions from relevant stakeholders. The UK Government is currently in the process of formulating its third periodical report, and COMEX will examine the UK Government’s implementation of the clauses in late 2008. 32. The Council of Europe encourages Governments to view fulfilment of the Charter obligations as part of core Council of Europe objectives to ensure the protection of minorities as part of promoting human rights, rule of law and pluralist democracy across the continent.
Welsh Language Schemes 33. Although all health organisations within Wales now have a statutory Welsh Language Scheme in place, where services are planned or delivered outside of Wales they mostly fail to include a language dimension. We believe this is due to a very low level of awareness which has led to the needs of Welsh speaking patients and service users either going unnoticed or being so low on the list of priorities that they hardly feature at all. 34. The Board may ask providers, although based in England, to prepare a Welsh Language Scheme in accordance with the Welsh Language Act and it may do so for part or whole of the service as deemed necessary. 35. Although some organisations such as NHS Blood and Transplant have been required to do so, to date this has not happened with the NHS Trusts immediately on the English side of the border as it has not been deemed practicable. 36. On occasions hospitals in England have contacted the Board for advice on best practice. However, our main method of ensuring cross border provision is currently through the sub-contracting measures contained within the Welsh Language Schemes of organisations on the Welsh side of the border. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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37. For a number of reasons the collaborative working culture has made it diYcult for public organisations to meet the requirements of the Welsh Language Act, these include the perceived or actual lack of accountability coupled with a lack of ownership causing the language choice of patients to be sometimes forgotten or overlooked.
About the Welsh Language Board
38. The Welsh Language Board (The Board) was established as a statutory body by the Welsh Language Act 1993 to promote and facilitate the use of the Welsh language. The Act establishes the principle that in the conduct of public business in Wales, the Welsh and English languages should be treated on a basis of equality. The Board has statutory functions and powers which require public bodies to prepare Language Schemes, detailing how they will give practical eVect to the aforementioned principle. Such bodies include all the Health Trusts in Wales, all Local Authorities in Wales, the Welsh Assembly Government, the Local Health Boards, the Commission for Health Improvement, the Welsh Local Government Association, and the National Institute for Clinical Excellence. 39. We would be pleased to oVer further evidence to the enquiry as required either in written form or through presenting oral evidence should the opportunity present itself. Many thanks, once again, for the opportunity to respond to this inquiry. Andrew White Head of Health and Voluntary Sector 8 October 2008
Memorandum submitted by Welsh Local Government Association
Executive Summary
We should expect devolution to lead to a degree of divergence and variation. Accessing public services across the Wales/England border is just one (relatively minor) reason for cross border movements. Several factors underlie decisions to use services across the border (eg distance/convenience; public sector commissioning; choice; migration). Distances people are prepared (expected) to travel for services have increased over recent years—but this is likely to change as the relative cost of travel increases. The eVects of service variations across the border and the ease of travel can be influenced through inter-authority collaboration to encourage more sustainable behaviour. In health and social care there are cross border issues arising in relation to: — introduction of reimbursement charging in England for delayed hospital discharge; —diVerences in assessment and funding policies; —diVerences in regulatory standards; — commissioning decisions taken by local authorities which impact on Welsh Local Health Board / English Primary Care Trust budgets; and —diVerent payment rates for nursing care/care home beds. Cross border collaboration on spatial/land use plans can make an important contribution to more sustainable outcomes. Transport is central to cross border service issues both as a service in its own right and because of the need to use transport to access other services. There are many good examples of cross border collaboration on transport including joint work on strategies, railway development and bus services. The introduction of concessionary fares in England will increase the volume of cross border travel and the escalating costs must be managed eVectively. Community transport can oVer a lifeline to vital services for “deep rural” areas. Priorities for highways are not always the same on the opposite sides of the border. There is potential to work collaboratively across the border to encourage walking and cycling as part of the eVort to promote “greener” tourism. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Introduction
1. The Welsh Local Government Association (WLGA) represents the 22 local authorities in Wales, and the three national park authorities, the three fire and rescue authorities, and four police authorities are associate members. 2. It seeks to provide representation to local authorities within an emerging policy framework that satisfies the key priorities of our members and delivers a broad range of services that add value to Welsh Local Government and the communities they serve. 3. The WLGA welcomes the opportunity to submit written evidence to the Welsh AVairs Committee’s inquiry into cross-border public services for Wales. This report pulls together some of the issues raised by oYcers throughout the WLGA and from advisors in local authorities and transport consortia.
Underlying Factors
4. DiVerences in service availability/provision/cost between Wales and England can generate cross border activity in a number of ways: — some individuals travel across the border to obtain services because that is where the facilities nearest or most convenient to their home are located (eg for many residents of Powys, which has no district general hospital, there is a requirement to travel to Shrewsbury or Hereford for hospital appointments and emergency treatment. In Flintshire, around a third of the population use acute services from the Countess of Chester Hospital). Any proposals to change this “nearest service” will generate public opposition (eg there are reportedly concerns about whether residents in north east Wales will continue to access tertiary health services such as neurology in north west England or have to travel to south Wales). They would also need to be thought through carefully in terms of traYc generation and the duty to promote sustainable development; — some individuals receive a service in the neighbouring country as a result of commissioning decisions (eg specialist out of county placements and residential care paid for by one authority but provided in another authority area across the border); — other individuals choose to travel across the border to obtain services because the perception/ reality is that better or cheaper services are available (eg English residents registering with a Welsh GP to access free prescriptions; students exercising choice of further or higher education establishment; use of leisure facilities); and — some individuals change their place of residence and consequently become eligible for diVerent services. (Cross border diVerences in services are unlikely to be the sole factor here but may be a significant consideration—for example, older parents moving to be closer to their oVspring and, as a result, accessing “better” pubic services upon which they depend). 5. As the distances citizens are prepared (and expected) to travel for work, leisure and for services have increased, the flows of people across administrative boundaries have risen. Local authorities are adopting more collaborative approaches to service planning and delivery, partly in response to these trends (as well as for reasons of eYciency). This collaboration is required in two main areas: — in relation to specific services; and — the transport infrastructure and services needed to facilitate required movements. 6. There are important considerations in relation to equality of access and the increasingly clear need to cut CO2 emissions. In planning and taking decisions on citizen-centred services, local authorities need to ensure a balance between: — responding to how residents/communities want to live their lives, and — providing the community leadership necessary to ensure service delivery “solutions” meet/ contribute to policy goals not only in relation to people’s health, education etc but also equalities, sustainable development and climate change. 7. Joint work between authorities on service variations and transport links can influence individual decisions. If standards of service are based on accepted good practice, the incentive/need to travel will be reduced; investment in quality public transport to points of service provision can encourage public over private means of transport. The converse also applies—policy divergences and poor public transport will generate (avoidable) increases in travel. This paper shows that there is cross border co-operation to achieve sustainable solutions but, policy divergences can introduce new, unintended incentives to travel. More consideration should therefore be given to the traYc generation and transportation implications of new policies. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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The Scale of Cross Border Movement 8. There is a lack of readily available data to quantify the extent of the cross border movement but it is clear from feedback from authorities that some of the flows are significant (although to put this into perspective, only a fraction of the overall total will be because of service divergences resulting from devolution). 9. There are four Welsh authorities with a physical border with English authorities: Flintshire, Wrexham, Powys and Monmouthshire. Of these, Powys has the most cross-border issues as it currently adjoins thirteen other authorities (11 Welsh and two English). All of these authorities experience substantial movements across their borders for reasons of work, leisure/shopping and for educational and medical purposes. 10. Cross border movements are not solely an issue for those with physical boundaries. Long distance commuting and travel for work and for services extends far beyond this. For example, Denbighshire, Wrexham and Flintshire in the north east have strong links to the wider area of Wirral and West Cheshire and are members of the Mersey Dee alliance. According to Passenger Focus, over 30% of all rail journeys in Wales are cross border.
Examples of Cross Border Service Provision and Local Authority Collaboration 11. It would be amiss if we did not mention the “perception” issue that the presence of devolution is creating a diverging policy environment. Clearly devolution must throw up a range of diVerences otherwise it is not working. There is an expectation by the Welsh electorate that “Made in Wales” solutions are part and parcel of the new governance of Wales. Clearly this will lead to divergence and variation. The free prescription charges policy sees English patients benefiting in some border areas while many English hospitals report a 20% occupancy rate of Welsh people. There is possibly greater divergence emerging in other policy areas such as education where the two systems and their funding are now very diVerent. The point, however, in other mature political systems such as the United States is that diVerences of this kind are seen are intrinsic to the nature of a federalised system. Perhaps our problem in the UK context is a failure to explain properly the devolution imperative and what that will mean in service terms to our communities. 12. This section provides some examples of the issues arising for local authorities as a result of cross border service provision. The subsequent section focuses on the related transport issues.
Health and Social Care 13. The Community Care (Delayed Discharge etc) Act 2008 introduced a system of reimbursements for delayed hospital discharges. Whilst this legislation does not form part of Welsh legislation, clear issues arise in relation to patients from Wales who have received their treatment in English hospitals (Shrewsbury, Hereford, Chester) and whose discharge is dependent on having relevant social care in place back in Wales. 14. Some independent residential and nursing units in England are used by Welsh authorities seeking placements for older people, people with learning disabilities and with mental health problems. These services are assessed and funded by the Welsh local authority in the same way as they would be if they were in another authority area within Wales and must meet the relevant regulatory standards. Inter-authority agreements of out-of-county area placements are being developed to avoid confusion (especially for families and carers) where assessment and funding policies diVer. 15. If a Welsh resident is placed in an English (or Welsh) authority other than their own area the nursing care costs have to be met by the host Primary Care Trust (Local Health Board). However, costs for which the resident’s own local authority are responsible must continue to be met by that authority. So if Powys County Council (PCC) places someone in a nursing home in Hereford, PCC must pay the residential element of the cost but Hereford Primary Care Trust must pay the nursing element. In this sense, the commissioning decisions of local authorities in the one country have the potential to impact on the budgetary situation of health bodies in the other. This can have knock-on implications for the local authorities in the “receiving” country in their joint service planning with health. 16. It is worth noting that there are diVerent payment rates for nursing care between England and Wales. Local authorities set their own charges for services and determine the annual inflationary increases, creating further diVerences. As English local authorities tend to pay more for care home beds they are able to secure places that are in scare supply such as for EMH and specialist children’s services.
Summary of Key Issues Needing Attention 23. The following key points can be drawn out in summary: — There needs to be more explicit consideration of the sustainability implications when new policies will result in service variations between England and Wales. — In particular, more attention should be paid to potential traYc generation and transport implications to ensure these are consistent with policies in Transport Plans. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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— It is important that “perverse incentives” leading to less sustainable options/choices are avoided, and these include diVerential charges or restrictions on access/availability which encourage longer than necessary journeys to be undertaken—a particular issue in relation to health and social care services. — Promotion of high quality public transport (eg additional, cheap and more regular bus services) can help to influence behaviour and outcomes. This can be achieved but only if more resources are allocated to enable local authorities to support services until they become established. — The goal of achieving a model shift from private to public transport applies far more widely than simply to cross border services. However, where a volume of cross border trips is necessary/evident, attention to the quality of public transport provision as part of an overall “package” can make a contribution (especially if services are planned in conjunction with other provision, eg for cross border travel to work). — Further cross border, inter-authority/agency collaboration on transport schemes and plans is needed, building on existing good work, to ensure consistency and that the most sustainable options are available and attractive. — Transport consortia, Welsh Assembly Government, Trunk Road Agencies and the Highways Agency need to reach agreement on priorities and develop join Route Management strategies. — Funding arrangements and timescales for transport improvements need to be better synchronised to facilitate joint planning and working. — The potential of Community Transport should be explored more fully—in particular, regulations on routes should be reconsidered to see if there is scope for greater flexibility than exists at present. As requested by the Committee this submission has focused on cross border issues as they aVect health and social care; further and higher education; and transport. Cross-border issues however aVect other areas such as policing and fire. Should the Committee decide to expand the current scope of its inquiry the Association would be pleased to submit further evidence.13
Memorandum submitted by the Welsh Occupational Therapy Service Leads Group (WOTSLGs)
EQUIPMENT PROVISION FOR CROSS BOUNDARY DISCHARGES
1. Introduction
Whilst welcoming the current Welsh Assembly Government initiative for Community Equipment Service Integration, there are concerns that this has to date focused on local solutions and has not yet taken into account the wider issues of cross boundary service provision. This paper aims to outline current concerns and make recommendations which will reduce the current organisational barriers and lead to more eVective service provision for patients.
2. Background
Health and Social Services in Wales are delivered via 11 NHS Trusts and 22 Local Authorities. There will be times when patients access services across the boundaries of these organisations. Wales also borders many of the English Counties and Welsh patients may access services across the border into England. Each of these diVering authorities, both in England and Wales will have diVerent policies and procedures for the provision of equipment, diVerent paperwork, diVerent core equipment which they routinely provide and diVerent staV responsible for this role. Patients are often treated outside their geographical area for both elective surgery and specialist regional services. This can create planning and communication diYculties when implementing discharge plans or future follow up of care. This lack of joined up thinking can result in wastage of clinical time and delayed discharge. Occupational Therapy staV are often faced with the challenge of negotiating arrangements for individual patients, in order to ensure a safe discharge, in the absence of an All Wales agreed system. Clinical staV from Trusts discharging patients from out of area may be forced to spend considerable time being passed from authority to authority in an attempt to make contact with local staV with the appropriate responsibility for authorising the provision of equipment for patients returning from out of County.
13 Evidence relating to Further and Higher Education, and Transport will be printed with the Committee’s reports on those subjects. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Patients are now being oVered elective surgery in a variety of Trusts across the country and the implications for equipment provision are rarely factored into the commissioning and planning of these services. Areas where pre operative screening is completed in partnership with local services are able to plan ahead regarding equipment needs. This is successful in facilitating earlier discharge, but may be compromised when waiting lists are transferred to other providers. Patients are often put at risk where discharge is unplanned, poorly planned, or equipment is considered at the last moment. This puts increasing pressure on the OT or equipment provider in the local area who may have to rearrange or cancel scheduled work to accommodate people returning to the area following inpatient episodes elsewhere. WOTSLGs recently carried out a survey of the current arrangements for the provision of cross boundary equipment. This is attached as Appendix A.
3. Current Concerns 1. There is no clear policy / guidance on respective responsibilities for discharging trusts and local services. This leads to disparity of service provision with some services carrying out home assessments and providing equipment whilst others do not even assess patients from outside their catchment area. A variety of methods of equipment provision currently exist including direct delivery by equipment provider with no further assessment, equipment provided for relatives to fit, home assessment with delivery and fitting of equipment by OT support staV, and occasionally, home assessment by qualified Occupational Therapist. The method is often dictated by lack of agreed systems, lack of OT resources and time pressures rather than clinical need. 2. Usually, the OT assessing the patient pre discharge is not able to assess the home environment and relies on information from patients / relatives / local OT service. This creates a potential clinical risk and it is unclear whether it is the discharging authority, or local service, who retains responsibility for the patient. 3. Service level agreements for elective and emergency treatment do not factor in therapy time and equipment provision. 4. Generally Health provide for short term need, and Social Services provide for long term need but this is not consistent across Wales. Intermediate care teams often bridge the gap, however the availability / criteria for these teams varies across areas. This compounds the confusion over who is responsible for equipment provision. 5. Health care provision is based on the location of the GP and Social Services provision is based on their postcode. This will potentially cause problems with integrated services. 6. Each service provides a diVerent range of equipment as its core stock which makes it diYcult for the discharging OT to identify appropriate equipment to meet a patients needs. 7. Each service may have diVerent criteria for the provision of equipment. 8. Each service may require information in a variety of forms—there is no standardised transfer of information form or equipment requisition form. 9. There is no standard pathway so clinical time is wasted negotiating with equipment providers and local services. 10. Current focus on reducing length of stay increases pressures on both discharging OTs and local services to respond in a timely manner, and lack of services and agreed systems can sometimes lead to unnecessary increases in length of stay.
4. Recommendations 1. Clear All Wales Policy on respective responsibilities of discharging trusts and local services. 2. Acknowledgment of respective responsibilities in Commissioning agreements with consideration given to any resource implications. 3. Agreed All Wales safe systems of work to utilise resources most eVectively including roles of OTs, support workers and equipment providers, adhering to the COT Code of Ethics and Professional Conduct and hpc Standards of conduct, performance and ethics. 4. All Wales agreement on core equipment both type of equipment and criteria for provision. 5. Pre operative clinics for elective surgery should include out of area patients to ensure discharge planning commences prior to admission. 6. WOTSLGs to establish database of OT services and equipment providers. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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APPENDIX A
ALL WALES SURVEY OF CROSS BOUNDARY PROVISION OF COMMUNITY EQUIPMENT
1. Aim of Questionnaire To clarify current arrangements regarding discharge of patients who live outside of the normal catchment area of the Trust/LHB. All OT Services accept referrals for these patients, assessing for post discharge need, however the scope of the services varies between Trusts in Wales and along the borders which interface with England.
2. Methodology Questionnaires were sent out via the All Wales Network of OT Service managers to all services within Health and Social Care. The questionnaire was designed to collect both quantitative and qualitative data relating to equipment provision across Wales. Responses were received from 11 NHS Organisations and six Social Service organisations. The low number of responses from Social Service departments may indicate the current reliance on the NHS to provide cross boundary services to patients being discharged from out of County hospitals.
3. Analysis of Data Responses received: 11 Welsh NHS Trusts/LHB : six Welsh Local Authorities Section 1: Completed by discharging services Section 2: Completed by those services receiving referrals
SECTION 1: NHS Trusts % yes No of yes Comments Does your organisation have 100% 11/11 patients discharged to their home which is out of area? Do you accept referrals and 91% 10/11 1 respondent stated they do not complete hospital based normally carry out hospital based assessments for these patients? assessments for out of area patients as no additional funding is available, demand would increase which would aVect their patients Do you carry out home 73% 8/11 These visits are dependant on assessments out of area? distance (25 miles or 1 hour journey as a maximum) and clinical need such as regional services - normally contact local services to see if they will provide, but often unsuccessful Do you provide required 100% 11/11 equipment for cross boundary discharges? What arrangements do you make Multiple choices for delivery and fitting? dependent on circumstances OT fits on home visit 7 Support staV deliver and fit 6 Stores staV deliver and fit 3 Relative given equipment to fit 8 If you issue equipment to a relative to fit do you: Give verbal instructions 10 Give practical demonstration 10 Give written instructions 6 Record instruction given in notes 6 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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SECTION 1: NHS Trusts % yes No of yes Comments Ask patient/relative to sign to say 2 instruction given 0 Ask patient/relative to sign 0 disclaimer 4
Only issue equipment which does not need fitting Phone patient / relative to check safe use of equipment Do you assess for and prescribe 100% 11/11 It can be diYcult to find out who equipment then refer to local OT should be contacted, resulting in to provide? delayed discharges Some Trusts / LA will cooperate, others refuse to help even if the patient is from their area Some Trusts / LA allow direct access to local Community equipment service via standard requisition forms How do you refer: Phone call only 27% 3 Referral form 45% 5 Transfer of information form 18% 2 Copy of assessment 45% 5 Do you retain responsibility for 55% 6 Not sure—not responsible for the safe discharge arrangements? work carried out by other service. Yes—will ensure arrangements have been made for safe discharge Dependent on distance Not if patient handed over DGH retains responsibility—re WAG policy NB 45% say no—responsibilities unclear due to delegation of provision of equipment to another service which may be equipment provider / OT Service Do you retain responsibility for 1 1 Respondent retains the patient for a time limited responsibility for 4 weeks post period post discharge? discharge Is there a method for follow up / 36% 4 2 respondents follow up with a review of equipment? letter after agreed length of time 2 respondents ask support staV to follow up with phone call On average, how much additional time is taken up by an out of area discharge?
No more time Up to 30 mins 45% 5 30—60 mins 45% 5 1—2 hours 2 ! hours How frequently do you have patients discharged from your Trust to Cross boundary destinations?
Never Less than 6 per year 73% 8 Less than 6 per month More than 6 per month Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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SECTION 1: NHS Trusts % yes No of yes Comments What is the percentage split of Variations in split due to wide emergency and elective variety of Trusts included in admissions for patients admitted survey. to your Trust from out of area Some provide regional services, who are then referred to OT others provide routine DGH services to a variety of Trusts
Emergency 30%, 20%, 15%, 50%
Elective 30%, 20%, 85%, 50% What is the approx % split of As above diagnoses
Elective orthopaedics 10%, 40%, 30% Falls 20%, 15%, 30% Complex rehab eg RTA, Burns 10%, 50%, Other 15% SECTION 2 Will you act on verbal referrals Yes 8 Some DGH have access to local from cross boundary hospitals No 1 stores and can requisition direct
Verbal referral must be followed by written confirmation Do you require written referrals Yes 8 No 1 Do you require a copy of the assessments 5 Yes, before issuing equipment 4 Will issue equipment on verbal referral with documentation to follow No if referring OT is known No, will provide equipment anyway If you accept referrals for equipment provision, do you: 0 Re-assess patient 9 Accept the assessment of referring OT and: Variety / multiple methods 4 highlighted depending on time Provide equipment via support available / complexity of case and staV equipment needed 5 Arrange delivery from store One authority sends letter to 2 original referrer to notify that Arrange for relatives to collect equipment delivery has taken and fit 2 place and that evaluation stage is completed Phone to check after delivery Approx how many patients per year are referred from out of area requiring: Numbers diYcult to assess / Equipment impossible to collect with current Further assessment IT Systems Further rehab Minor adaptations What arrangements are in place 9 replies—no clear policy in place Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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SECTION 1: NHS Trusts % yes No of yes Comments for patients treated privately ? Most areas state that patients returning following private treatment have access to the same services as anyone else COMMENTS 88% of respondents felt a standardised All Wales Transfer of information form would be beneficial
March 2008
Memorandum submitted by West Midlands Regional Assembly
Provision of Cross Border Public Services for Wales The West Midlands Regional Assembly welcomes the decision of the Welsh AVairs Select Committee to undertake this enquiry. We are aware that a number of our partner organisations have already/will be submitting evidence and oVer the following in support of this. With one of the Assembly Partnerships, the West Midlands Rural AVairs Forum, very much the driving force behind the Central Wales-West Midlands Cross-Border Memorandum of Understanding, we thought it might be useful to provide an insight into the important work that is already underway—helping to provide practical solutions to the many very real challenges.
Background Between January and March 2005, research and consultation was commissioned by the Cross-Border Working Group of the West Midlands Rural AVairs Forum, to investigate and address issues raised by its members associated with the English/Welsh Border. The study, published in March 2005, considered the West Midlands’ perspective of its border with Wales, its neighbouring administrative area, together with the practical issues and experiences of people living, working and delivering services in the area. It identified some issues and recommended a framework for action to address those issues. The loosely defined border area of Powys, Herefordshire and Shropshire, comprises around 60 Parish and Community Council areas in some of the most remote rural communities in England and Wales. Around 56,000 people in 23,000 Border households, together with communities further into both England and Wales are directly aVected by issues addressed by the Study.For people living and working in the Border areas, the Border and the administrative boundary it defines are largely irrelevant. However, the boundary and the diVerences in strategic planning, policy and Agency working practices in neighbouring administrative areas, create complexity and disparity in service provision and access for local people.
Discussion The published study concluded that: — There was no formal mechanism for identifying and resolving cross border issues within organisations; — There was little hard evidence of the presence or impact of the Border in the form of statistical data, service evaluation, surveys etc, to validate the scale and impact of issues aVecting the Border area, (yet these do exist and were highlighted by the study); — Issues identified in health and agriculture had the greatest impact on public finances; — Other issues had minimal impact on public finances; — The Wales Spatial Plan from the Welsh Assembly Government, (WAG), had introduced a driver for Agencies in Mid Wales to engage more actively with English Regions; — Policy and services are typically developed to apply within administrative boundaries rather than with reference to “whole communities”. — There appears to be little understanding/awareness among workers in diVerent agencies of processes and structures operating on either side of the Border; — There is little flexibility, particularly in regional/national funding programmes to support “communities of benefit”. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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In the absence of any formal mechanism to monitor and manage cross-border issues, “work-around” and “make-do” solutions have been developed at grassroots level. These are usually based on informal working arrangements, not policy or organisational practice, and could be questioned in public audit or scrutiny processes. The West Midlands Regional Rural AVairs Forum Report made a series of recommendations, and a Working Group of the West Midlands Regional Rural AVairs Forum, comprising, the West Midlands Regional Assembly, Shropshire County Council, Herefordshire Council, AWM, Environment Agency and the GO, together with the Welsh Assembly Government and Powys County Council considered how they could be implemented. A key outcome of the work of the Cross Border Working Group was the development of the Memorandum of Understanding (MoU) that was signed by the Welsh Assembly Government and the West Midlands Regional Assembly in March 2007 at Ludlow. The MoU aims to promote better collaboration between partners and organisations across both sides of the border.
Practical Issues of “Adjoining Communities” At the MoU signing event, a series of workshops were held to look in detail at the key cross border issues, identify mechanisms for addressing the issues and also look at areas of best practice. Workshops were held on housing, rural development, highways and transport, health and social care, education and training, environment and waste management, community regeneration and community safety, utilities and infrastructure, access to services and governance, consultation and collaboration. The relative importance of any of these issues to border communities and those that serve them require priorities to be examined to help make decisions about the focus for activity and investment. The picture is complex, full of interconnecting factors to do with economics, geography, identity, cultures and behaviours. Inequalities in the cross-border area can be very specific; it is often not localities that need support and investment but specific groups of people across a number of localities, eg migrants in farming villages, single pensioners living in remote rural areas, low income families in rural honey pots, unemployed men in ex- industrial villages, etc.
Progress to Date The Governance mechanisms envisaged in the MoU are now in place. The terms of reference for both the Core OYcers and the Strategic Forum have been agreed. The first meeting of the Core OYcers Group took place in November at Shrewsbury. The next meeting is scheduled to be held at Newtown in Powys in February 2008. A number of border proofing opportunities have already occurred involving key regional strategies: the West Midlands Regional Spatial Strategy Phase II Revision, West Midlands Economic Strategy and the Central Wales Spatial Strategy. Meanwhile, a number of expert working groups with a common thematic and geographical connectivity have been set up, exploring the potential for crossborder co-operation, adding value to the regeneration of the West Midlands/Mid Wales border area and exploring and identifying ways in which this could be achieved: — Transport—TRACC—three meetings to date in Newtown, Shrewsbury and Hereford — Health & Social Care—first meeting 20 March 2008 in Ludlow — Town & Parish Councils—conference 9 June 2008 in Knighton Other additions, one tackling environmental issues and another concentrating on the economic drivers, skills and business support are planned. Further, a crossborder sustainable tourism transport project “OVa’s Dyke Country” is in an early planning phase with a wide range of partners.
Border Proofing Opportunities 2008–09 Several aspects of regional & sub-regional strategy & policy will be reviewed during the next 12 months and can present further opportunities for practically implementing the Cross Border MoU and improving the life of residents in Border communities. Led by the Welsh Assembly Government — Wales Spatial Plan Key Settlement Strategies (North East Wales and Central Wales will be of particular interest here). The Wales Spatial Plan Update is out to consultation until April 2008 — Wales Transport Strategy, and Development Plan (WAG) — Central Wales Transport Strategy (WAG) Led by the West Midlands Regional Assembly — West Midlands Regional Spatial Strategy Phase 2 Revision being presented to the Secretary of State in December 2007; public consultation extended to June 2008. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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— West Midlands Regional Spatial Strategy Phase 3 Revision (focuses on critical rural services and quality of environment issues). The website address is www.wmra.gov.uk/wmrssphase3 — West Midlands Regional Economic Strategy “Contributing to Success” launched 10 December 2007 along with the draft Delivery Framework which was out for consultation until 22 February 2008. — West Midlands Rural Regeneration Zone Business Plan & Implementation Plan There are further potential opportunities for closer collaboration and cross-border working in the following work areas: — Local Area Agreements/Local Service Agreements/Local Service Boards — Special events—Provision of services, co-ordination, eg for HayFestival, etc. — Regeneration/Economic Development Plan/Severn Valley Plan under development; potential for cross-border LEADER and other funded projects — Research into the impact of Cross-Border Issues
Additional Documentation Specific to the MoU — Memorandum of Understanding on Cross Border Collaboration — Terms of Reference for the Central Wales-West Midlands Strategic Forum (not printed) — Terms of Reference for the Central Wales-West Midlands Core OYcer Group (not printed) — Minutes of Meeting—Core OYcer Group, 28 November 2008 (not printed) — Border Proofing Opportunities 2007–08 (not printed) — West Midlands signatories to MoU as at March 2008 Specific to Health & Social Care (not printed) — Health & Social Care Task Group Seminar—Report 20 March 2008 Issues and Recommendations for Action — Individual Member response Elizabeth Newman Specific to Transport (not printed) — TraCC Cross Border Liaison Group—Minutes 28 June 2007 — TraCC Cross Border Liaison Group—Minutes 1 November 2007 West Midlands Business Council (not printed) — Transport, Public Services (including education and skills) and Tourism
Conclusion The Wales/West Midlands Cross Border MoU is a practical example of public authorities and agencies working together to improve the benefit of the communities in the rural border areas that they serve. The impact of the work arising from the MoU should be to improve on, iron out inequalities in the provision of jobs, homes and services for remote rural communities. Those signed up to it are anxious to make a real diVerence in terms of policy and practice. We trust that you will find this information of use; we are happy to expand on any of the information provided. March 2008
CENTRAL WALES—WEST MIDLANDS
Memorandum of Understanding on Cross Border Collaboration The parties to this Memorandum of Understanding aim to achieve eVective cross border collaboration between Central Wales and the West Midlands on both policy development and service delivery. 1. The border between Central Wales and the West Midlands winds for over 150 miles through deeply rural “Marches” communities. While the boundary will have historic roots, in most places it is now an artificial line which bears little relationship to the patterns of life for communities in Central Wales and the rural West Midlands. 2. Communities in these rural areas face similar challenges, opportunities and needs. There are strong social and economic links across the border and a shared reliance on the opportunities provided by urban centres such as Hereford and Shrewsbury. There is a complex pattern of inter-dependence by local communities on services sourced from one or other side of the border. Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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3. However, while the England/Wales border appears an artificial one for local communities it does define operational units for national, regional and local governments and for most other public sector organisations and partnerships. As those organisations have evolved they have developed their own strategies, plans and policies, their own funding streams and modes of service delivery. This can lead to diVerences in policy, funding and services between Central Wales and the West Midlands which can have a detrimental impact on border communities. 4. The parties to this Memorandum of Understanding recognise this risk and are keen to build stronger cross border collaboration. The Welsh Assembly Government has committed in the Wales Spatial Plan to establishing collaboration with West Midlands organisations in order to address key issues of common concern. These same cross border issues have been recognised by the West Midlands Regional Assembly and the West Midlands Rural AVairs Forum. The Forum commissioned research in 2005 to explore these issues and since then a Central Wales-West Midlands oYcer group has been established to develop arrangements for more eVective collaboration.
Nature and Status of this Memorandum of Understanding 5. This Memorandum of Understanding is a voluntary arrangement rather than a binding agreement or contract and so does not create any legally enforceable rights obligations or restrictions. It does not create any rights to be consulted or prevent consultation beyond that required by statute. Any failure to follow the terms of this Memorandum of Understanding is not be taken as invalidating decisions taken by any of the parties.
Scope 6. It is intended that this Memorandum of Understanding should apply to all public sector organisations and public sector-led partnerships operating at the national, regional or local level in Central Wales and the rural West Midlands. 7. Voluntary Sector and Private Sector organisations operating in Central Wales and the rural West Midlands (such as County Voluntary Councils, transport operators and utility providers) are also encouraged to follow the principles set out in this Memorandum of Understanding. 8. This Memorandum of Understanding is intended to embrace all aspects of policy development and service delivery which impacts on social, economic and environmental well-being and sustainability in Central Wales and the rural West Midlands.
Collaboration Arrangements 9. The parties to this Memorandum of Understanding will so far as is reasonable and practical and within the resource capacity of their respective organisations: (a) share non-confidential information relevant to the development of policies and services which will impact on border communities in Herefordshire, Powys and Shropshire; (b) “border proof” all proposals for change in policy, funding or service delivery which would apply to border communities, in order to ensure that any detrimental consequences for those communities are identified and mitigating action taken; (c) consult each other in good time on proposals for change in policy, funding or service delivery that could impact on communities on the opposite side of the border; (d) seek out opportunities for collaboration on policy development and service delivery wherever this could provide eYciencies and/or added value; (e) share experience of good practice in rural policy development and service delivery across Central Wales and the West Midlands. 10. The parties to this Memorandum of Understanding will establish a Central Wales—West Midlands Strategic Forum to oversee the implementation of this Memorandum of Understanding, to address strategic policy issues and opportunities for collaboration. That Strategic Forum will meet at least once a year. It will report to the Welsh Assembly Government through the Central Wales Spatial Plan Ministerial Group. In the West Midlands it will report to the Government OYce, the Regional Assembly and Advantage West Midlands . . . 11. The Strategic Forum will be supported by a Core OYcer Group drawn from the parties’ respective organisations. Specialist task and finish groups will be established to address specific issues of cross border concern, reporting to the Strategic Forum. 12. A sub-group of the Strategic Forum will be established to monitor and annually review the eVectiveness of the arrangements set out in this Memorandum of Understanding Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Confidentiality 13. Each party to this Memorandum of Understanding accepts that it can expect to receive information in confidence only if that information is treated with appropriate discretion. The party providing the information will state what, if any, restrictions there should be upon its usage and each party will treat information it receives in accordance with any such restrictions. Disclosure of information will be subject to the requirements of any relevant legislation, such as that relating to data protection, freedom of information, disclosure of environmental information, and any relevant code of practice relating to access to information. For the Welsh Assembly Government* Carwyn Jones AM Minister for Environment, Planning and the Countryside * Until the Government of Wales Act 2006 is fully implemented, the Welsh Assembly Government is simply the executive arm of the National Assembly for Wales, constituted under the Government of Wales Act 1998 and the Minister signs this Memorandum of Understanding on behalf of that Assembly. When section 45 of the 2006 Act takes eVect, references in this Memorandum of Understanding to the Welsh Assembly Government will be construed in accordance with that section. For the West Midlands Regional Assembly Cllr David Smith Chair—West Midlands Regional Assembly
Central Wales—West Midlands Cross-Border Memorandum of Understanding: West Midlands Signatories as at March 2008 Government OYce for the West Midlands Advantage West Midlands West Midlands Regional Assembly West Midlands Rural AVairs Forum Herefordshire Council Herefordshire Local Strategic Partnership Shropshire County Council Shropshire Local Strategic Partnership Oswestry Borough Council South Shropshire District Council Shrewsbury and Atcham Borough Council West Midlands Association of Parish and Town Council Herefordshire Association of Local Councils Shropshire Association of Local Councils Police—West Mercia Constabulary Fire Services—Shropshire Fire and Rescue Service Herefordshire & Worcestershire Chamber of Commerce Community First Community Council of Shropshire Hereford Voluntary Action South Shropshire Voluntary Action Hereford Hospitals NHS Trust, The County Hospital, Union Walk, Hereford HR1 2ER Shrewsbury and Telford Hospitals NHS Trust Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust The Institute of Rural Health Herefordshire Primary Care Trust Shropshire Primary Care Trust Learning and Skills Council, West Midlands Natural England Forestry Commission Environment Agency, Midland Region (Severn Catchment) Processed: 20-03-2009 13:33:11 Page Layout: COENEW [O] PPSysB Job: 400105 Unit: PAG2
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Environment Agency, Wales (Wye Catchment) National Farmers Union Severn Trent Water Authority Shropshire Hills AONB
Memorandum submitted on behalf of a constituent, by Kirsty Williams AM, National Assembly for Wales
Thank you for raising awareness of my situation in the Assembly and sharing information with Roger Williams. It has certainly generated a lot of interest in the plight of cross-border services. As requested here is a brief resume of my medical history. I have been an insulin dependent diabetic since 1992, registered partially sighted in 1999, becoming registered blind. a few years later. In February 2001 I developed a foot ulcer that progressed into severe cellulitis, which led to me being admitted to The County Hospital, Hereford. Because of this long-term infection and resultant oedema. I developed nephrotic syndrome secondary to diabetic glomerulopathy, then had to have a below knee amputation in August 2001, all this time being an in-patient in Hereford. In the week prior to the operation, the orthopaedic consultant, Mr. Reynolds, referred me to Dr J A Lindsay, Consultant in Rehabilitation Medicine, at Selly Oak, Birmingham. Follow up letters were sent to make appointments for my mobilisation and after care. Although I was referred to Selly Oak, Birmingham; all patients from Hereford are seen in the satellite clinic at Belmont Abbey, Hereford. I was discharged from the care of the orthopaedic surgeons in Hereford in September 2001 and continued attending the limb clinic every 4 weeks for the first 4 months. Once the stump had settled I went to the clinic twice yearly for maintenance and recasting if required. During these visits I built up a rapport with the orthotist, technician and physiotherapists, who I saw frequently. At the first visit to the clinic I was introduced to the Social Care and Benefits Advisory Service who negotiated me through the social service benefits enabling me to claim the appropriate allowances. So you can see that it was very traumatic for me to receive a letter transferring my care to another hospital, away from people and environment to which I had become accustomed. The letter that I received in early December 2007 from South Birmingham, Primary Care Trust, stated, “ funding was no longer being provided from your local area to allow us to manage your treatment within our services.” It was implied that I would be contacted by the appropriate Welsh centre within 14 days, or have to be referred by my GP if necessary. Enclosed was a map for Wrexham, so we assumed that would be where I was going. Living in Mid-Wales we are accustomed to having to travel some distances for hospital appointments, Hereford is a 90 mile round trip, whereas Wrexham is nearly twice as far at 160 mile round trip. As I am unable to drive and am not eligible for hospital transport, either my wife has to take days leave from work or I use Rhayader Community Support Volunteer Car Scheme. It is very tiring, and time consuming to have to travel so far. I find this whole situation very distressing, and annoying as I have not been contacted by any Welsh agencies to explain the situation. I am sure that there must be many other people are in the same plight as myself, thank you again for looking into this. March 2008 Processed: 20-03-2009 13:33:11 Page Layout: COENEW [E] PPSysB Job: 400105 Unit: PAG2
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Letter from Ben Bradshaw MP, Minister of State for Health Services to the Chairman Thank you for your letter to Alan Johnson about the Government’s response to your committee’s report. I am very sorry for the delay in producing a response. I wrote to you last year setting out my initial thoughts on your committee’s report but it took longer then I would have liked to produce a command paper and get it cleared around Government. Given the delay as soon as it was finalised, but before it could be laid before Parliament, my oYcials did share a copy of the report with your committee on a confidential basis. The Government welcomes the Committee’s interim report on the provision of cross-border health services for Wales. We have carefully considered the report and the Government response, Command Paper (Cm 7531) was laid before Parliament on Monday, 26 January 2009. The Command Paper discusses the wider context of cross-border health care, including arrangements to co-ordinate service provision, the commissioning, funding and quality of services, and provides the additional information requested by the Committee. As you are aware, the Government and the Welsh Assembly Government operate a protocol to assist with the delivery of healthcare services along the England-Wales border. This protocol has been renewed annually and is currently in place until April 2009. The Government’s response to the Committee’s report was delayed while negotiations on the renewal of the protocol were continuing, as we hoped to include information about the renewal of the protocol and supporting financial arrangements in our response. Unfortunately, these negotiations have taken longer than expected so we have taken the decision to publish our response now, to avoid further delay. The negotiations are almost complete and we hope to have a new protocol in place to coincide with the start of the new financial year. March 2009
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