Welsh Affairs Committee
Oral evidence: Cross-border health arrangements between England and Wales, HC 404
Tuesday 2 December 2014
Ordered by the House of Commons to be published on 2 December 2014.
Written evidence from witnesses:
Members present: David T.C. Davies (Chair); Jonathan Edwards; Nia Griffith; Simon Hart; Jessica Morden; Mr Mark Williams
Questions 82–148
Witnesses: Tony Chambers, Chief Executive, Countess of Chester Hospital, Caroline Smith, Senior Quality Manager, Engagement and Inclusion, Gloucestershire Clinical Commissioning Group, and Dr Julie Davies, Director of Strategy and Service Redesign, Shropshire Clinical Commissioning Group, gave evidence.
Q82 Chair: Good morning. Ms Smith and Dr Davies, can I start by asking whether you have a rough idea of how many patients you are dealing with over the primary, secondary and tertiary sectors?
Dr Davies: The population for the Shropshire clinical commissioning group is around 303,000. That is our registered population.
Caroline Smith: In Gloucestershire we have a population of about 610,000.
Q83 Chair: Approximately how many of those would be treated in Wales for some of the services that they require?
Caroline Smith: In Gloucestershire, we have very few who would go to Wales for their treatment, but we have a cohort of about 8,000 patients who are English residents, but are registered with a Welsh GP.
Dr Davies: For us, I do not know the specific figure, although I will send that through to you. Typically, we probably have a similar order of magnitude across the border. We have patients both ways on the Shropshire-Wales border. Some Shropshire residents are registered with Welsh GPs and some Welsh residents are registered with English GPs, just because of where the GP boundaries are and which is more convenient for them.
Q84 Chair: Is it fair to say that the vast majority of people in your area who are going over to Wales are English residents going over to see GPs? Are any going over for secondary health care as well?
Dr Davies: We have some patients who use the Wrexham Maelor hospital for their secondary care because that is the closest acute hospital to where they live, particularly in the north-west of our county around the Oswestry area.
Q85 Chair: Do any of the funding formulas take account of the cost to the Welsh NHS of Welsh GPs treating English patients?
Dr Davies: My understanding of how the funding works is that GP practices are funded based on their list size—they are funded to provide care for the number of patients they have registered with them. If there are English residents who are registered with a Welsh GP, their care is funded through the Welsh system; if there are Welsh residents registered with an English GP, we are funded to provide that. If they use either English or Welsh secondary care, we would be funded to pay for that, with the exception of A and E and minor injury services. They are not split out like that; they are on a hosted basis.
Q86 Chair: I have not brought you in yet, Mr Chambers, but feel free to add anything on this point.
Tony Chambers: On the A and E hosting issue, that is almost like a block payment. In the north, typically the residents of Deeside and Flintshire will have their A and E services from the Countess of Chester. Those are paid for on a block, which is an historic block. At the moment, we have not seen any increase for demographics or growth. It probably works on a very similar level down in Shropshire.
Dr Davies: It does not, actually; that is the strange thing. Where we have Welsh patients who use the A and E services at Shrewsbury and Telford hospital or the minor injuries units along the border—for example, there is one in Oswestry—English commissioners pay for that care. It is not a block; it is done on a cost and volume basis. We have seen an increase over the past few years in the number of patients coming across to use those services.
Q87 Nia Griffith: Could you explain what you mean by a cost and block mechanism, and how the money changes hands—or does not change hands?
Dr Davies: At the moment, for example, Welsh patients can use the A and E services at Shrewsbury and Telford hospital. That cost is picked up by English commissioners. For every A and E attendance in England, there is a national tariff. There are different types, depending on the severity of the attendance and the diagnostics and treatment needed, but we pay for that. If there are any English-responsible patients who go to the A and E services at Wrexham, for example, we do not pay for that, but we know about it because we have to monitor those data under our contractual arrangements with Wrexham and with Shrewsbury and Telford hospital. We know that at the moment that is a significant net cost to us. For this year, it is estimated to be about £740,000.
Q88 Nia Griffith: Could I clarify this? When you talk about a Welsh patient, do you mean simply a person who is resident in Wales, or do you also mean a person who is resident in England but is registered with a GP in Wales?
Dr Davies: We mean anyone who is registered with a Welsh GP.
Q89 Nia Griffith: So they could, in fact, be English residents.
Dr Davies: Absolutely—but they are Welsh-responsible.
Q90 Nia Griffith: They are registered with a Welsh GP, so they are classified as Welsh patients. You are saying that if they turn up at A and E in England, effectively it is the English side that pays for them, and if they turn up at A and E in Wrexham, it is the Welsh service that pays for them.
Dr Davies: Yes—the local health board.
Q91 Nia Griffith: Is this system of registration based on the definition of Welsh or English effective? Would it be better to have it done by where they are resident, or is it more convenient to have it done by where their GP is?
Dr Davies: That is the difficulty. As I understand it, local authorities are funded on a residency basis, but health services are funded on a responsible basis—based on a registered population. Clearly that poses a significant challenge, because not all GP boundaries fit with the geographical boundaries for patients. It is more about whether a practice is closer to their place of residence. That is what is really important.
The other challenge around “responsible” and “resident” that we are concerned about is NHS constitutional rights. That is not clear. To my understanding, it is again on a residency basis, because it is based on parliamentary boundaries. If you are an English resident, in theory you should have your health care under the NHS constitution. However, if because of where you live you are registered with a Welsh GP, you will not have your constitutional rights met because you will be treated under the Welsh system, and the targets and waiting times associated with that. That is a grave concern to people who live on the border.
Q92 Nia Griffith: May I follow up on that? We have spoken to patients in the area, living on both sides. What attempt has been made by any of the border areas to rationalise things so that people living on the English side go to English GPs and people living on the Welsh side go to Welsh GPs? Has there been any step forward in terms of creating new GP surgeries or whatever? We heard about people in Herefordshire who could not get on to Herefordshire GP lists and were therefore going to Wales. That is when you get all these convoluted systems. I was wondering what your local areas have done. Has Gloucestershire or Shropshire taken that on board?
Caroline Smith: In Gloucestershire, historically, when we were a primary care trust some years ago, we looked at the issue to see whether there was any potential for providing additional GP services on the English side of the border. In conjunction with MORI, we did a poll of all those residents and had a very good response rate. It showed that the majority of patients did not want to change their GP; they had quite a long-standing relationship, with continuity of care and trust. The attraction for them was that they wanted to maintain that.
More recently, we looked at the issue again with NHS England. One of our local GPs has extended his boundary so that he can take some patients from that area. We understand that a very small number have transferred to that particular GP practice, but the majority have chosen to stay as they are. Mainly, the issue is around access. They have a branch surgery of a Welsh practice within a five or 10-minute walk, as opposed to an eight or nine-mile drive if they want to access the English GP. That is still causing some problems, but there has been some movement. Our local health board, on the opposite side of the border, has also put in some arrangements around the protocol that mean that our local residents can access secondary care without prior approval at a selected number of hospitals. That has resolved some of the issues about choice, but not all of them.
Q93 Jonathan Edwards: I have a few quick questions for the commissioning boards. Would you say that there are more Welsh patients registered with English GPs over the border, or more English patients registered with Welsh GPs across the border?
Caroline Smith: In Gloucestershire, certainly, there are more English patients registered with Welsh GPs.
Q94 Jonathan Edwards: What are the reasons for that, in your view? Is it just because it is more convenient, or is it because of policy differences like free prescriptions?
Caroline Smith: It is historic. They have been registered, and it is just the way in which the boundaries have worked. They are in relatively small villages right on the boundary edges, and they are actually closer to the main Welsh practice than they would be—
Q95 Jonathan Edwards: What sort of difference in numbers are we talking about?
Caroline Smith: We know that about 8,000 patients are registered with a Welsh practice but live in England. Their branch surgery is in England, and I understand that that is where they see their GP the majority of the time.
Q96 Jonathan Edwards: To reiterate the questions from Nia Griffith, as far as you are concerned they are Welsh patients.
Caroline Smith: Yes, they are. We as a clinical commissioning group do not receive any funding for those patients.
Q97 Jonathan Edwards: In terms of free prescriptions—
Caroline Smith: They still have free prescriptions.
Q98 Jonathan Edwards: And the Welsh taxpayer is paying for those.
Caroline Smith: Absolutely.
Q99 Chair: Do you know whether the formula that is used to allocate money to the Welsh Assembly takes account of the net extra patients who are resident in England and treated in Wales by Welsh GPs?
Caroline Smith: I do not, I am afraid.
Dr Davies: I think it varies. In parts of Shropshire, we have more the other way around.
Q100 Chair: Looking through the evidence, there was a net increase of 5,000 over the whole of Wales, so Wales has treated 5,000 more.
Dr Davies: It is based on communities. That is the key thing for individuals when we ask them. It is because the GP practices are part of their local community. They feel comfortable with them, as they have built up a relationship over the years.
Q101 Jonathan Edwards: That is a large number of people, isn’t it? There have been a lot of stories about the longer waiting times for people registered in Wales, but that does not put off people from the English border. Is there any evidence of people swapping GPs if they need secondary care or an operation?
Dr Davies: We have had some examples of that. It has not been linked particularly to waiting times; it has been linked to differences in policy—for example variations in fertility policy—that have driven some patients to move their registered GP from one side of the border to the other. I am not aware specifically of any around waiting times.
One of the key things is to have this information readily available to individuals. I am quite anxious about the fact that not all patients are aware of it. We really encourage our GPs to explain the differences when referring a patient so that that patient is making an informed decision. I worry that sometimes people who are able to do some home-based research are better informed, and therefore are potentially making different decisions. I am conscious that there is an equity issue here.
Q102 Simon Hart: I can understand that in primary care, as you have mentioned, there may be a geographical as well as a personal loyalty to the GP you have spent most of your life with, but in secondary care, the numbers seem to be a little more distinct. The number of people going from Wales to England for secondary care treatment far outweighs, by a ratio of 5:1, the flow the other way. We are told that there are similar numbers in tertiary care. What is the reason for that?
Tony Chambers: In the north, it is slightly different. At the Countess of Chester hospital, you could literally throw a stone into Wales from the car park. It is right on the border, so you may have English patients who are registered with Welsh GPs, and vice versa. However, the secondary care flows will always be into the Countess of Chester, because we are the local district general hospital provider for the populations of Deeside and Flintshire, and have been for 30 years.
Where there have been problems, and where we have seen people moving their registered list or even their residency, those are the result of policy decisions around access to secondary care—changes around their being able to receive cancer services and so on. That is now largely a historical thing and is resolving. In the conversations that we are now having locally with the health board in the north, we are trying to formalise the position that the Countess will, in effect, be the local provider of services for Deeside and Flintshire.
Some 20% of our patients come from Wales, across all specialities, but only 14% or 15% of our income comes from Wales, so there is a gap. A whole range of things drive that gap. Also, 20% of our staff are Welsh, so in a sense we see ourselves very much as a Welsh hospital, but on the borders of England.
Q103 Simon Hart: That suggests that the whole problem relates only to border counties. Jonathan and I—and one or two other Committee members—are from west Wales, yet this is a phenomenon we have come across ourselves. It is not just people popping over the border, a stone’s throw across the car park. In some cases, people are making a two-and-a-half or three-hour journey.
I do not know whether there are any statistics that break down the 51,000 people from Wales who go to England for their secondary care treatment—if anybody can answer the question, that would be great—and show how it is spread across the whole of the Principality, not just down the border counties. Can you shed some light on that?
Tony Chambers: You probably need to get some information from the specialist commissioners in England. Typically, it would be groups of patients from the west—from Pembrokeshire and so on—who are accessing very specialised genetic services that are available in only one or two centres in the UK. The numbers will be very small, but the distances to travel will be great.
Q104 Jonathan Edwards: This is a question for Mr Chambers. How do Welsh local health boards pay for treatment provided to patients in England?
Tony Chambers: There are probably two mechanisms for that—or maybe three. The first is probably the most easy and straightforward, and that is in relation to activity-based payments by results. For secondary care services, if a patient has a hip replacement at the Countess of Chester, there is a tariff payment and we have a contractual relationship with the local health board. That represents probably the bulk of the payments.
A and E services are slightly different; we had a conversation about those earlier. The A and E service is hosted on behalf of Welsh residents by a local CCG. Typically, that will be something that looks a bit like a block payment, but will be based on historic baseline activity numbers. We have seen that those payments have not been increased to reflect current demand, so the net position is that it creates a pressure for us of about £500,000.
Public health services, such as sexual health services, will again be hosted. With the changes to health and social care arrangements in England in recent times, the public health services have moved into local authorities, which are now taking the view that those are for local populations. There need to be some real conversations about how those services can be supported for Welsh residents, who historically have always accessed them. There is a bit more work to do, particularly on those public health services. There are block, PBR and local authority payments.
Q105 Jonathan Edwards: The local health boards say in evidence to the Committee that there is no problem dealing with two different funding mechanisms—one on the Welsh side of the border and one on the English side. What is your view? What are your experiences?
Tony Chambers: Contractually, there are not a huge number of problems. Sometimes there are issues with getting the data systems to talk to each other. Without getting too technical, England has a SUS system—I am not sure what the abbreviation stands for—that is different from the Welsh one. There needs to be some validation and reconciliation of the data, which can cause a bit of a problem.
For us, the material issue is the tariff mechanism itself. The English tariff has had a reduction base to support CQUIN—the quality improvement initiatives—of about 2.5%. Provided that the providers deliver those quality improvements, they will get the CQUIN payment. In a sense, it is to incentivise innovation and change. We do not get the same top-up CQUIN payment on PBR from the health board, so that in itself creates a pressure for us. The net position for us is about another £1 million.
Q106 Jonathan Edwards: Do the commissioning groups want to say anything about funding arrangements?
Dr Davies: Our arrangement is slightly different. In effect, the cost pressure that Tony receives with the historic block agreement is not felt by our local acute trust because we are paying cost and volume for that activity, based on the English tariff, which gives us a significant pressure.
On sexual health services, it would be helpful to review the protocol in light of the changes, with services now being the responsibility of local authorities. In particular, I suggest that there needs to be a reciprocal arrangement. For example, on public health, we are one of the lowest funded per head of population yet, because of the fact that the local authority now provides sexual health services, probably about 10% of those services are provided to Welsh patients. It would be helpful to review that in the light of the new responsibilities.
Q107 Mr Williams: I wanted to ask all of you about the mechanisms that should be in place, in particular regarding the problems over A and E attendance and its cost, but you have answered that question already. On the back of what you have just said, I note that the net cost to Shropshire CCG for 2013-14 was £670,000. You talked about that being a big sum of money—indeed it is—and about hopefully changing the protocol to address those things.
When we took evidence last week in Newtown in Herefordshire, we talked a lot about the protocol and how quickly protocols become outdated. What mechanisms do you have in place—or should be in place—to update and monitor that protocol? It strikes me that a lot of the things that we have seen—I will talk about them in a minute or two—are quite historical problems that have still not been addressed, but should have been addressed a long time ago.
Dr Davies: We should be a bit smarter in how we exchange data. Everybody wants to be funded and to pay for the care that patients they are responsible for receive, but it has got a little bit muddied—particularly, as I said, around A and E services and the new responsibilities for local authorities. The protocol almost becomes, “If we can record the care that is delivered and we have a pricing mechanism, that sorts itself out.” In effect, it does not need a protocol if the activities are counted, the data are shared and the respective commissioning bodies have access to that information, because then it just flows. Based on what has been used, the income follows the patient and the expenditure, and I think that would help.
The other thing for me is information around performance. Some of the data systems are not joined up. For example, if a patient in Shropshire for whom we are responsible chooses to have their cancer treatment in Wrexham, I would not receive the information to tell me whether that patient had received their treatment within the right time frame, whereas I monitor all the cancer performance information for our local acute trust. Within that, you do pick up Welsh patients—quite rightly, as in my head, it does not matter where they are from—and it is important that they receive the treatment within the right time frame. However, as a responsible commissioner, I cannot do the same for my patients who have chosen to go to a Welsh provider by checking on them. I would very much welcome a reciprocal arrangement around those data. It is important to patients and commissioners alike.
Q108 Mr Williams: You are saying that as a commissioner and a health service professional. When Joe Average is asking for health treatment, that is a real concern and a worry. It goes back to the earlier point that you made about the lack of information on the arrangements, not just within the health professional sector, but for patients.
Dr Davies: Yes, for patients—absolutely.
Q109 Mr Williams: I will give a couple of examples. They are slightly historical, and this is one of the reasons why I ask the question. In 2011, Liverpool heart and chest hospital banned patients from north Wales from having elective surgery, after Betsi Cadwaladr university health board failed to provide funding for treatment. Going back a little further, to 2008, North Bristol NHS trust refused to admit patients from Wales after the Welsh NHS refused to pay the “going rate” for treatment, whatever that was. In 2006—this is the last example—the Robert Jones and Agnes Hunt hospital in Oswestry threatened to refuse to treat Welsh patients after the Powys health board stopped paying its bills. Anecdotally, I can think of other examples involving the Hywel Dda health board; Mr Chambers, you have great experience of that board. At Gobowen, in particular, there were difficulties in accessing funds for my constituents over the border.
Those are pretty dramatic examples, which were well publicised at the time. Is that still a problem? Why does that situation occur? It relates to what my colleague Simon Hart has just said about the natural flows for specialist services for those of us in the west, which head in an east-west direction to Gobowen, and sometimes to Chester and sometimes to Frenchay hospital in Bristol. Does that still happen? To your knowledge, are patients still being denied treatment because of problems? Why did that happen in the first place? On a positive note, have we moved on?
Tony Chambers: I will be quite parochial and talk about what I know, which is the border in the north. It sounds as if we have probably moved on. I am glad that our hospital is not on that list. We are slightly unusual, in that we have always been the local hospital for that population—way before devolution, as the hospital has been there for 30-plus years.
The relationships that exist between GPs and local consultants, and between the hospital and local residents, are very strong. The kinds of conversations we get into go beyond what you would describe as normal or routine activity, such as activity to reduce waiting times. There may be an initiative to do some of that work. There will then inevitably be a conversation between health boards and other providers. There will be a relationship that says, “Yes, we can do that work,” or, “No, we can’t do that work.” It is not done on the basis that somebody will arrive at a hospital and then be turned away.
I cannot really comment on the stuff about Liverpool heart and chest hospital, but I suspect that it would have been some sort of contractual relationship in respect of either additional waiting list work, or the protocol differences that there can be between prior approvals for certain treatments, where there may be one set of rules for a CCG in England and a slightly different set of principles across the border in Wales. The other witnesses can describe the things prior approval stuff is typically for, but I suspect that that is the nature of it.
Q110 Mr Williams: So my constituents could have legitimate concerns about the process and the delays in getting them that treatment.
Tony Chambers: It is really difficult to say that without looking at the absolute specifics. The principle of the whole NHS, whether in Wales or England, is always that we will provide the service.
Dr Davies: The Robert Jones and Agnes Hunt hospital is in our county. I know that historically there were some issues. I do not know the details—whether it was waiting list issues or just general activity—but a few years ago, when we were still a primary care trust, there were issues with bills being paid. I know that some of the hospitals made a point, almost saying, “We won’t accept any more patients until you’ve paid for the activity you’ve had.” I am pleased to say that I am not aware that there have been any of those issues since we have been clinical commissioning groups.
I talked to both our local providers before coming here today, and there are no ongoing issues. I know that Welsh patients account for about 10% of the activity and income for Shrewsbury and Telford hospitals, and there are no issues there. If anything, since we have been a clinical commissioning group, our relationship with the Powys teaching health board has improved a lot. There is much more dialogue at all levels: in front-line services, among senior management and at executive—even chief executive—level. It feels as if those relationships have improved. Where issues become apparent, we will do everything that we can to ensure that the patient is not disadvantaged. We will ensure that the patient gets the treatment and sort out any contractual issues outside that.
Q111 Mr Williams: The caricature of this inquiry, quite rightly, is that we are talking about service providers across the border—literally from Powys into Shropshire, Herefordshire, Chester and elsewhere. Are you aware of any outlying problems further afield or to the west—in areas that the three of us on this side of the Committee represent?
Dr Davies: No, I am not aware of any.
Q112 Mr Williams: I have one general question. Mr Chambers answered it earlier, but he may want to say a bit more. It is an obvious point, but Mr Chambers said that 20% of his patients and 20% of his staff are from Wales. How important are Welsh patients in enabling English hospitals to remain financially viable? We heard a very positive message about that when we went to Herefordshire, where it is important. What about your particular areas?
Dr Davies: As I said, it is about 10% for Shrewsbury and Telford. It is equally important for the patients of mid-Wales to have that hospital. When we did the reconfiguration around the trauma network, it was found that the two hospitals that needed to have trauma unit status were Hereford and Shrewsbury, because of travel times for patients from mid-Wales. If they had an accident, they could be taken there and stabilised before being taken to a major trauma centre. While the income is important, there is also an issue around travel times and making sure that some of the populations in mid-Wales have access to that urgent trauma care on the border.
Q113 Mr Williams: One issue I picked up in Newtown was maternity services, particularly in north Powys. I think that I am correct in saying that the services have moved from Shrewsbury to Telford. Could you say a little about that in terms of the time factor you have just alluded to?
Dr Davies: There remains a paediatric assessment unit at Shrewsbury, seven days a week. Should any patients urgently need that care, they can be seen there and then be transferred to Telford. Clearly, it is a challenge for patients from north Powys. Through the work that we are doing around looking to reconfigure hospital services, we have done a number of engagement exercises with the populations there, and talked to their health boards, members of the public and their councils. We are involved with that.
You are right to say that it is important to understand the travel times for patients from mid-Wales and Powys. The teaching health board has been very supportive in that process and is contributing to it. It is part of that and it has a seat on the programme board for those decisions.
Q114 Jessica Morden: I agree with what Mark Williams has said. When we met the group of patients and medical practitioners in Newtown, the maternity issue came up, and so did the issue of future fit, which you have just alluded to. They felt quite strongly that they had not been included in any of the consultations about how services were going to affect them. That was the message that we had from them. How exactly are you engaging patients and the local health boards regarding the possible movement of those services?
Dr Davies: I have a briefing on our communications, if I may refer to it. Obviously there have been discussions with Powys health board. There is clinical leadership from its north locality GP, Andy Raynsford, who has been part of those, and it has engaged with the population of Powys. I do not have a specific reference to Newtown, but I am pretty sure that it has held consultation meetings there. I shall get the details and send them to the Committee.
We have commenced a pre-consultation engagement. We have not yet shortlisted the options for the formal engagement, but we are doing a pre-consultation exercise. We have delivered a number of public meetings and a telephone survey of Powys residents. We have co-produced a number of workshops, which ran in August and September. Two workshops took place in Newtown, which gave local people the opportunity to learn about future fit and to participate in shaping the long list of options for hospital services in Shropshire.
Q115 Jessica Morden: So you would argue that you have.
Dr Davies: Whatever we do, it may never be enough, but we have certainly had two in Newtown.
Q116 Jessica Morden: The Welsh NHS Confederation told us in evidence that it would welcome a formal protocol for a programme such as this, where you are consulting when services impact on the population across the border. Do you agree?
Dr Davies: Yes, I think so.
Tony Chambers: It works both ways, don’t forget. You have to remember that we are the district general hospital for a big chunk of the population on the Welsh side of the border, so when there are changes there, we see their impact only after they have happened. It is not just an English phenomenon. We need to be smarter. If there are changes in community services, community hospitals and so on, they will have an impact on the flows and we will very quickly see a change in the A and E profile of activities.
Dr Davies: We can support that. We have seen a significant increase since the change to minor injuries provision in Chirk, which we were not aware of. Effectively, those patients are now flowing into minor injuries at Oswestry. The capacity is there to treat them—that is not an issue—but it is helpful to know about changes in advance. Clearly, it is within the health board’s authority to make those decisions, but when they have implications across the border for capacity and for the planning of health services, it would be helpful to know of them in advance.
Q117 Chair: I hear the story you are telling. If I may be just a little cynical—this is not to criticise in any way—in reality you answer to the English Government and to English MPs. Are you really going to take as much note of the needs of people in Wales when, effectively, it is a completely separate NHS? Why would you do that?
Caroline Smith: We are trying to put some processes in place for the cohort of patients in Gloucestershire who are English residents with a Welsh GP. They are almost a hidden group. You would not immediately think about them if you were looking to make changes around community services or—
Q118 Chair: I accept that in the case of English residents, but my question concerns the needs of purely Welsh residents. I suppose that this is more for Dr Davies than anyone else, but we had the impression from them—I can see that it would be illogical—that you might not take as much account of their needs as of the needs of those living on the English side of the border.
Dr Davies: Granted, it is a smaller number, but I would argue that the challenge for us is more about rural and urban changes in health rather than whether people are Welsh or English. Our challenge for the far west of our county, which is right on the Welsh border, is clearly to ensure equity of provision for the people who live there. From my perspective, we plan services for the patients on the border, whether they happen to be resident in Shropshire but registered with a Welsh GP, or resident across the border in Wales and registered with a Shropshire GP. That population needs to have access to services so, as I said, they are factored into our plans. The Powys health board has a place on the programme board and has a vote, just as the Shropshire CCG and the Telford and Wrekin CCG do, so its voice on that programme board is proportionate.
Q119 Simon Hart: We have not touched on the cancer drugs fund in great detail, but we have heard some evidence that people are moving to England for cancer treatment. Do you think there should be a single system for those people who might require the sort of drugs and treatment that are not covered by NICE? Do you have any thoughts on that?
Dr Davies: Yes. As a drugs fund, I think that it should be across borders. Fundamentally, it is not equitable. I would certainly support wider use of a fund like that.
Q120 Simon Hart: Your colleagues are nodding. If you are equally enthusiastic about that view, that is interesting.
My other quick question is this: the Department of Health is considering cross-border protocols; there is a sort of review under way. If you had the opportunity, what would you change? If you had a wish list and there was one wish that could come true, what would it be?
Caroline Smith: Bearing in mind the cohort of patients I am mainly talking about, who are English residents, it would be for them to have their rights under the NHS constitution—to allow those patients who live in England but are registered with a Welsh GP to have the NHS constitution rights on choice and waiting times.
Tony Chambers: For us, it would be to break down some of the fragmentation that often occurs between services, on an individual pathway basis. It would be around having a clear view with the local health board that we were the accountable provider for community and acute services for a defined population, and planning it on that basis, in the way that Wales organises itself. I see no reason why we could not be a provider under that model. That is the kind of conversation that can build clinical relationships, break down some of the pathway difficulties that we see and give clear accountability to defined populations, irrespective of which practice they are registered with.
Q121 Simon Hart: Do you think that patients, whether they are in the border county areas or further west, in the sorts of areas that we represent, have a clear understanding of all these distinctions?
Tony Chambers: Why should they? On one basis, there is a very clear view that people expect the NHS to deliver safe, compassionate care, locally if possible; if not, there needs to be really good communication between the providers. There is work to do on that, but the ambitions of the Welsh system, in which I have worked, and the ambitions of the English system are exactly the same. The issues that we are trying to overcome are exactly the same. The financial challenges may be a few noughts different, but the scale of the challenge is the same, the demographic challenge is the same and the ambitions are exactly the same. When you get it on to an individual patient basis and a clinical pathway basis, the border just breaks down.
Q122 Simon Hart: Do you think that, whether we like it or not, the existence of a border contributes to making those objectives more difficult to achieve? Going back to my previous question about whether patients are aware of the complexities, you said, “Why should they?” I agree that it is more a political problem than your problem, but when they are requiring the services that you provide, presumably at a time when things are not going particularly well health-wise, do you detect that sometimes these cross-border complications are contributing to a frustration—“All we want is for the system to work, and we are coming up against some bureaucratic obstacles that are the consequence of a political border rather than a geographical one”? Is that a fair assessment?
Tony Chambers: That is probably the experience for many. I know that one of my clinicians is giving evidence on behalf of the Royal College of Physicians next week. It might be worth teasing out some of the real clinical patient anecdotes that can give a flavour of all of that. We should be able to overcome it, but wherever there is a border, whether it is a national border or a border between CCGs, there can sometimes be frictions.
Q123 Nia Griffith: On that point, given the new system in England with the clinical commissioning groups, are you finding similar cross-border issues between parts of England, in terms of funds having to be transferred and things having to be accounted for?
Dr Davies: No, because we have the mechanisms—for example, on our borders with Herefordshire and Worcestershire. In the south of Shropshire, we have the small market town of Cleobury Mortimer, where the natural patient flow is to Worcester. We have a contract with Worcester, so when any of our patients go there we pay for that, based on whatever they use. Within the local authority boundaries, it feels, at least at the moment, that it is easier. There are border issues within counties of England, but in local authorities there are mechanisms to cross-charge. Because those are more consistent and are expected, they flow much more easily than, potentially, across the border with Wales.
Q124 Nia Griffith: Are there some lessons that we could learn about the way in which transactions could be done between England and Wales?
Dr Davies: I think so; that is one of the points that I made earlier. If we could do something to make the information flows more consistent, it would not take away from changes in policy or decision making, but it would allow us to count and monitor that, to ensure that the appropriate resources were going to where the expenditure was being incurred.
I agree about the constitution. That would have been my first wish around the protocol. I know that there is a cross-border agreement on ambulance services, but that is an area I am particularly concerned about. There seems to be a difference in operational policy. I do not know whether this is just at Wrexham hospital or whether it is a Welsh policy, but if ambulances are queuing outside A and E departments at Wrexham, they leave the patient in the back of the ambulance, whereas at Shrewsbury and Telford, they will take the patient off the ambulance and into A and E.
Because of the number of ambulances and the length of time that they are having to queue, we are finding that that has all sorts of ramifications. First, paramedics understandably do not want to put their patients at risk, so they will phone ahead. If they think that there is going to be a long wait, they will convey the patient to Shrewsbury, even though their natural flow would probably have been to Wrexham, because they do not want to be managing the risk of that patient beyond what is absolutely necessary.
Likewise, I would ask you to ensure that we have sufficient ambulance resources on the border, because we find that when ambulances are tied up there, it pulls down resources from other parts, particularly Cheshire. The problem is that while an ambulance is queuing at a hospital, it is not available to respond to a life-threatening call. I am anxious that that is putting patients at unnecessary risk. If there is anything that we could do within the protocol to add more consistency around how we manage that, it would be very much appreciated.
Q125 Nia Griffith: On the issue of waiting times, we have had anecdotal evidence that Welsh patients feel that they are left at the bottom of the list or whatever. What is the exact position in terms of the instructions your staff are working under when dealing with whether to treat one patient before another?
Dr Davies: Mr Chambers is probably better placed to answer this. Again, there is a slight difference. English trusts operate to waiting lists. They will operate to the Welsh target of 26 weeks and to the target of 18 weeks for English patients. They run that parallel system. All patients should be treated in order, but to those targets. We find that if English-responsible patients go to Wrexham, for example, they have to be treated within the Welsh targets. The Welsh providers do not offer a dual service for the English-responsible patients, even though we would pay for that.
Q126 Nia Griffith: Could we clarify that? If something is happening in Shrewsbury hospital, the consultant may quite rightly say, “I have to do my English people by 18 weeks and my Welsh people by 26 weeks, so I can leave my Welsh people a bit longer.” When they go to Wrexham, whether they are English or Welsh, they all fall into the 26-week category.
Dr Davies: Yes.
Q127 Nia Griffith: You raised the issue that what you call English patients should be treated in line with English targets. Do you mean those who are taken to Wrexham, or do you also mean those who are registered with a GP in Wales? If they are registered with a GP in Wales, does the consultant go by their address and count them as English, or does the consultant go by the fact that they have been referred by a Welsh GP?
Dr Davies: They take it from the GP who has referred them. Although our statutory obligations are to the patients we are responsible for, clearly I would want this to be consistent for the English-responsible patients who choose to go to a Welsh provider. I would like them to have the same targets, but again it comes down to the constitutional rights issue and the variation between “resident” and “responsible”. Personally, I think that it is only a matter of time before an English resident who is registered with a Welsh GP challenges that.
Q128 Chair: In the courts?
Dr Davies: Yes.
Q129 Nia Griffith: Following on from that, what talks have any of you had with colleagues in Wales about looking to change waiting times in Wales? Is that a live discussion between yourselves and any of the Welsh health boards?
Dr Davies: We have annual contract discussions. We raise that every year and make that request. So far, we have been told that they will work only to the Welsh targets.
Caroline Smith: In Gloucestershire we are slightly different. As far as we are aware, as a commissioning group, acute hospitals do not run two lists, so all the patients they see are treated within the English wait times. The majority of those patients would be English-resident, even if they were registered with a Welsh GP. The flows the other way across the border are minimal but, as far as we are aware, our acute trusts do not run two lists; they treat everybody to the English standard. The number of patients we have who are English and go to Wales is very small, so we do not have those conversations with the local health board.
Tony Chambers: There are no national quality targets in Wales as there are in England, but we report on the quality targets for Welsh residents as we do for English residents—we treat them exactly the same. The cancer targets for England and Wales are exactly the same. The Welsh target for relisting two weeks following cancellation is a good one, which neither Wales nor ourselves are achieving at the moment, unfortunately. In terms of the differential elective wait time targets, basically we follow the commissioned instructions. If the commissioners are commissioning a 26-week pathway, we will deliver to that; if it is an 18-week pathway, we will deliver to that as well.
In terms of the emergency pathways, patients are treated exactly the same. That is where some of the cost pressures occur, because that is where there has not been a rebasing of financial arrangements based on activity. A lot of the CQUIN payments have related to improving emergency care flows, which Welsh residents get the benefit of but have not contributed to. Those are the conversations that go on on a contractual basis. On a clinical basis, we have good working relationships between the Countess of Chester hospital and the Maelor hospital, in particular. We have joint rotas. They provide our upper GI cancer services. We have cancer physicians working in the Maelor and the Countess, and bariatric services working across the two. In a sense, there is the political will, there is the border and then there is real life. In terms of what is going on in the clinical footprint, there are very good working relationships.
Q130 Jonathan Edwards: You mentioned the different waiting time targets for Welsh-resident patients and English-resident patients. How would the Welsh targets go down? Would it be for the Welsh Government to set a different target, or would it be for them to pay more money to the English commissioning bodies?
Tony Chambers: It would need to be a political position—“This is the national standard that we want to set as a Welsh NHS.” There would be a cost implication for everybody if that was the case, particularly for the Welsh NHS, because a lot of backlog activity would need to be cleared to deliver it. Sustaining the lower target is a different issue, but clearing the backlogs would be very expensive.
Q131 Jonathan Edwards: Are the payments and charges for operations the same? Would there be a different charge for a Welsh patient?
Tony Chambers: No. The payments are tariff payments and are based on the English tariff. As I have said before, that has had a reduction for CQUIN. I have been trying to remind myself what that stands for; it is commissioning for quality and innovation. It was a 2.5% reduction in tariff to force providers, in a more supportive way, to be more innovative and to focus on quality changes. The tariff payment in England has been reduced by 2.5%, so what you as a Welsh commissioner would pay has been reduced by 2.5%. Provided that the providers deliver that quality improvement, they will receive a separate top-up payment from the English CCG, but not from the Welsh commissioner. That is what creates the financial gap for us.
Dr Davies: We pay a different price for treatments in Welsh hospitals because they do not operate to the English tariff system. We have a contract that is cost and volume, at a local price set by the Welsh hospital. There are some block elements to the contract, particularly around audiology and community services, but the vast majority of it is at cost and volume. However, it is at a different price, so you could not compare them. An out-patient price for a patient going to Wrexham will be different from an out-patient price in England.
Q132 Chair: Ms Smith, when the Aneurin Bevan health board decided to stop sending rheumatology patients to Hereford hospital in 2012, did that cause any problems for your commissioning group?
Caroline Smith: None that I am aware of for us in Gloucestershire. It has since put in the amendment that allows patients to go to the Wye Valley NHS trust.
Q133 Chair: Dr Davies, earlier you mentioned the possibility of a court case. Have you sat down and discussed as a group what might happen if that took place? Is it something you have prepared for?
Dr Davies: We have discussed it, but we have not prepared as well as we would like. We are unsure. We have made some inquiries with NHS England around what would happen with an English resident who was registered with a Welsh GP. That has not happened so far, but we are conscious of it. We have dealt with it at the moment by making very sure—this is the thing that is in our gift—that if a Shropshire GP is referring a patient to the Wrexham Maelor, for example, we ask the GP to inform the patient that they will be treated under different waiting times and so on, and to make them aware of that, so that, in effect, they are making an informed decision. However, if anyone challenged it in terms of why their rights were not being met, at the moment we would not have a satisfactory answer.
Chair: Thank you very much for coming down.
Examination of Witnesses
Witnesses: Councillor Darren Mayor, Portfolio Holder for Adult Social Services, Powys County Council, and Frederick Geoffrey Davies, Vice-Chair of the Visiting, Monitoring and Scrutiny Committee, Brecknock and Radnor Community Health Council, gave evidence.
Q134 Chair: Mr Davies and Councillor Mayor, thank you very much for coming along this morning. We have already had a bit of an answer to this, but could you briefly explain the nature of the cross-border health flows that take place from Powys to England?
Geoffrey Davies: I hope you do not mind if I refer to my notes. Because we represent both parts of the county, we have prepared a brief in compliance with the questions.
In terms of the cross-border flows, approximately 80% of the area of Montgomeryshire looks to acute services in England, principally the Royal Shrewsbury and the Princess Royal at Telford. The western half of Montgomeryshire looks to Bronglais. Specialist orthopaedic services are at the Robert Jones and Agnes Hunt. For the eastern side of Brecknock and Radnor, from Hay to Hereford county hospital, Hereford is the principal one.
Hospitals in Shropshire and Hereford provide out-patient, day care and in-patient services for approximately 45% to 50% of the population of Powys. In 2013-14, Powys teaching health board spent £45 million with English NHS acute providers and £44 million with Welsh NHS acute providers. The exact number of Powys patients treated in a year by NHS England can be obtained via Powys THB, but we are talking of several thousand in total.
Councillor Mayor: You are well aware of the fact that in Powys there is no general hospital. Basically, all our acute care has to go out of county, so there is a massive outflow from Powys—either west, east, north or south—and hence the high figures.
Q135 Chair: Does either of you know of any patients—or have you heard anecdotally of any—registering with English GPs deliberately in order to get access to the lower waiting times?
Councillor Mayor: Last week, when I was with you in Newtown, we had a number of people who were giving their personal experience; we can forward you the name of one, rather than name that person. It was to do with cancer treatment. As they live in Montgomery, it was very clear that it warranted them to move their practice from Montgomery over to Shropshire and to register with a GP there in order to receive the drugs that would prolong their life, which were not available, and to receive the eventual operation, which might have been delayed if they had remained in Powys.
Q136 Chair: Conversely, have you heard of patients from England wanting to register in Wales to get access to free prescriptions?
Councillor Mayor: Personally, no. The majority of people on the borders are very much aware that if you are in need not of emergency care—as we heard earlier, at the point of access, emergency care is provided regardless—but of any kind of operation, it does not seem productive, for the sake of saving a few pounds a month on prescription charges, to be registered in Wales. You are far better remaining within the Shropshire footprint, rather than coming across to Powys. Personally, I have not heard of it.
Geoffrey Davies: As the CHC, we do not have numbers or people’s reasons for moving, but recently we asked the Powys teaching health board for those numbers. Of course, we are very much aware of the difficulty of attracting GPs to the mid-Powys area, which is causing problems.
Chair: We shall come to that later.
Q137 Nia Griffith: I simply want to pick up the point about waiting times, which you will have heard from the previous witnesses. How do you think this needs to be resolved? You are acutely aware that Welsh patients have different waiting times. They are very aware of that situation when they go to English hospitals.
Councillor Mayor: It is interesting that we remark on the difference in waiting times of 18 weeks in England and 26 weeks in Wales, but we also have to be mindful of the 36-week waiting time that is normally given for more complex cases. In my experience from talking to residents, it is also often used as the limit, rather than the 26 weeks. When they go across the border and it is identified that they come from Wales, not the 26-week waiting list but the 36-week one is used. I just wanted to throw that in at this point.
In terms of resolving that, again it needs to be a political decision. I cannot see it changing in any other way, despite all the great intentions of the clinicians who want to treat people at the point of need, put them on the waiting list and go through that. Because of their targets, if they see a Welsh patient who needs treatment, they just get bumped. That is not anecdotal—that is everybody’s experience. There needs to be a political decision to change the waiting list.
Geoffrey Davies: Absolutely. This has caused immense frustration and dissatisfaction. It is the root cause of why there are so many complaints. With the odd extension of waiting times, the good will of a patient towards the NHS will prevail, but the strain on them is such because of these political decisions about funding, that that is highlighting the cross-border issue, which is the subject of this review, and the issue of health provision in central Wales, which is the subject of another review. It all relates back to the basic dissatisfaction of the average Welsh patient, especially in a county such as Powys, where funding is such a problem.
Q138 Nia Griffith: The previous witnesses suggested that to clear that backlog would be a major challenge.
Councillor Mayor: It is. In the world we live in today, with the financial pressure that there is, that is the reality of it. It is not a hidden agenda; it is a very obvious agenda. Basically, we just do not have the money to do it. There may be the will to do it, but not the financial means. However, that is a big fundamental question about what we value most. We need to put in our funding according to what we think is valuable, but it is a political decision.
Geoffrey Davies: From the patient’s point of view, obviously one appreciates what my colleague has just said, but the patient is desperate to have someone explain what Councillor Mayor has just said: “You can’t have it, and this is why, but you will have it.” Then you take away the frustration. In business, if you are going to be late delivering to the customer, you ring him an hour before the time to say, “Don’t come at 5. We won’t be ready for you until tomorrow because there has been a hitch.” If that policy is adopted, the patient can be made aware. It is all about the business of communication. That is where it falls down.
Q139 Jessica Morden: Councillor Mayor, earlier you mentioned cancer treatment and the person who came to the session we were at who had moved to an English GP to get drugs that they could not get in Wales. Would you like to see a single system across England and Wales for treatments that are not approved by NICE?
Councillor Mayor: Very much so. It was very interesting listening to the first session. We were encountering the fact that we have this national health service, but we do not have a national health service. We have an English national health service and a Welsh national health service, and they are different. Particularly on the borders, you see acutely the difference in the treatments that you receive. We need to have equalisation of policy in terms of what drugs are available and an equal funding system to do it. It was very ironic listening in. My personal view is that we do not have a national health system any more, because there is a two-tier system. If we want to have a national health service again, we need to have correct funding and policies that are equal across the border.
Q140 Jonathan Edwards: That leads me to the next question: how can that equal situation be achieved in a devolved context? We have a Welsh health service, an English health service, a Scottish health service and a Northern Irish health service. How can it possibly be achieved in a devolved context?
Councillor Mayor: I hope that you do not mind my referring back to a question to the previous panel about “your wish”. It is not going to happen. Basically, if we could reverse the devolution of the health service to the Welsh Government, it would be fantastic, but we understand that that is not going to happen. Or is it; who knows? That is the only answer. I do not know how else to do it. There needs to be the political will to do something about this.
Geoffrey Davies: That is the basic concern of the average patient, especially in Powys. If you were to ask one of your constituents about a particular health matter, they would refer to what was in the Daily Mail the day before, believing that it belonged to them. People do not appreciate the fact that there are two health services.
When we were devolved, we were promised consensus politics. If we could have that and the NHS could cease to be a political football, that would be the wish. That is what we want—a cross-party investigation, root and branch. We could get somewhere then. For as long as it remains a political football, it is frightfully frustrating for everybody—most of all for the patient.
Q141 Mr Williams: We all agree on the political football point; that is very regrettable. Jonathan did not respond to the comments that you made about repatriation of health back to Whitehall. The question that I asked before was about the need to get the protocols right, which manifestly has not happened so far, because we have these problems. It is the responsibility of both the Assembly Government and the UK Government to work at those.
I want to return to one very practical issue, which we touched on in the earlier session. In many ways, it is a manifestation of a lot of the problems we have talked about, to do with incompatible systems, particularly incompatible IT systems. The Welsh NHS Confederation reported, “The delay in information sharing” between both health services “could potentially put Wales’s patients post-discharge at a higher risk than English patients from the same hospital,” as files may have gone missing and there is not that compatibility. In your experience, is that a real problem that people have been experiencing? We can talk about big political goals and aspirations, but that is something very practical that needs to be addressed.
Geoffrey Davies: You know the operative word only too well—“communication”. That is the root cause of the problem.
In our written evidence, at paragraph 3.3, we refer to the incompatibility of the IT systems. If I may read from my notes, the CHCs do have details of individual cases where a delay in receiving, for example, a test result is part of a complaint being handled by the CHC, but we do not have the individual patient’s permission at this stage to divulge the details. From regular meetings that our chief officer—the CHC chief officer—has had with senior officials from the NHS Wales information service, we know what progress has been made in NHS Wales to unify IT systems so that GP practices and hospitals can talk to one another using digital technology to make referrals, receive test results and receive patient discharge letters.
Within NHS England, the policy structure focuses on individual autonomous NHS trusts. Fortunately for Powys patients, through the commissioning discussions that Powys THB has had with NHS trusts in England, information service IT staff have been having discussions about digital links between Powys GPs and hospitals in England that serve Powys. We understand that trials are proceeding at some GP practices in the north of Powys. The CHC supports that work. Indeed, we are very pleased that it is being done.
Mentioning the north of Powys, I am charged by my colleagues on the CHC to say how much better, as far as Powys is concerned, the links are in the north than in the south, where I am. The link there is much better. For example, in May, Ann Mathias, the chairman of South Powys CHC, and I made a monitoring group visit to Hereford hospital. I take it that you are all familiar with visitor monitoring groups; they are the part of the committee that goes in and looks. The area of prime concern to us was the transfer of stroke patients from Hereford back to Powys and the delays that are occurring. You may know that we transferred the stroke rehabilitation unit from Bronllys to Brecon.
Discussions with the two sisters on the ward at Hereford revealed horrendous bed blocking. Having discussed it with them in the third week of May, I said, “Wouldn’t it be possible for us, during the month of June, to chart exactly the progress of patients from Powys through Hereford and back into the community, either to Brecon for rehabilitation or to home care facilities?” I was told, “Fine; no problem,” but we are still waiting. That was deemed to be a perfectly simple one.
When I talk about communication, this is the basis of the problem. We heard our clinical colleagues say earlier that they are not really interested in who comes from where, but rather that the patient is treated. Here we were saying, “This is a perfectly simple operation.” At the moment, this communication between Hereford and us has got to CHC chairman level, with each person writing individually and saying, “It will be the Minister next stop if we don’t get an answer.”
Q142 Mr Williams: Is that problem compounded by the border? I have the problem within a health board between hospitals and social services on the ground in the delivery of community services, so it is a problem within Wales as well. You are saying that it is exacerbated by cross-border issues.
Geoffrey Davies: Yes, it is exacerbated by cross-border issues.
Q143 Simon Hart: I return to what you said a few minutes ago about political footballs. As long as you have two different health services administered by two Parliaments—irrespective of who might be in office—isn’t there always going to be an element of political football about the service? Secondly, is that not also entirely healthy? Is that not precisely what we should be doing as politicians or parties—highlighting successes and failures in individual health services, if that warrants it?
Councillor Mayor: You are right in the sense that it is very important that we highlight the problems, but do we address those problems and actually do something about them? What we are talking about here is not a new problem. It has not happened in the last couple of weeks or months, or even the last couple of years. It has been known for a long, long time.
In essence, what has happened? What are we doing about it? It comes back to the fact that when Mr Joe Public or whoever turns to the NHS, they expect the same service that their colleagues, friends or relatives are receiving in Gloucestershire, Hertfordshire or wherever it may be, but that is not the case. We are part of this United Kingdom. We pay all our taxes in exactly the same way, but we are receiving a different service.
You are right—it is always going to be a political issue. The challenge is: what are the politicians doing to address this kind of issue to make sure that the service we pay for is the same as the one our neighbours pay for?
Geoffrey Davies: It may be good for there to be an element of political football, but it should not dominate the whole situation, as it does now. I agree that there should be an element of variance—that is fine—but only an element. It should not be the political football that it is at the moment. The avowed attempt in the early days of AMs was that we would have consensus politics, which we are not getting.
Q144 Simon Hart: To follow up on this, is there not a downstream consequence of the two-tier system, if I can call it that, which is recruitment? I will quote a local example. There are some difficulties within the Hywel Dda health board; you might say across NHS Wales, if you wanted to. That is having a negative effect on recruitment.
I accept that that can go both ways. It is not a case of money. The money is there, but you cannot get GPs to apply for jobs in parts of west Wales simply because the reputation, rightly or wrongly, is that the service is not as good as the English equivalent. Therefore, the people you are trying to recruit to the area, who may be from away, are not coming because they do not think that the service there is the same as that to which they would be able to refer their patients back in England. That is an ongoing issue in my particular patch. It may not be anywhere else, but it certainly is in mine. I wonder whether this is something you have come across before.
Councillor Mayor: On the GP issue, there is a lot of difficulty attracting GPs to practices in Powys, particularly at the border, because of being on the performance list. Over in England, registration is different from in Wales. That creates another barrier to the ease of GPs becoming locums, because they have to go through another process. That does not help to attract GPs across. They may be living in Wales, but they are registered in England and have gone through that process. It is another barrier if they have to go through the whole process again to be registered in Wales and to go on that list. That is another contributory factor. Because of the borders and the two different health services that we have, it exacerbates the problem of trying to attract and retain GPs to work in Wales.
Q145 Simon Hart: The poor recruitment in my part of Wales has already had a consequence, which is yesterday’s rumoured downgrading of A and E in Withybush hospital—and so it goes on.
Councillor Mayor: Yes. It becomes a downward spiral. How do you reverse that?
Q146 Simon Hart: You can reverse it only, dare I say it, by politicians getting up, shouting loudly and inflicting a certain amount of pain, but then we are accused of making it a political football—we cannot win.
Geoffrey Davies: That is the acceptable element, but it is not dominant. I believe that when Helen Birtwhistle appeared before you she mentioned the problem of recruiting GPs to mid-Wales. I cannot readily find it in my notes, and I do not want to delay everybody, but if you refer back to what she said, there is something from the GPs’ professional association on how they migrate between the two. English GPs cannot get on to Welsh lists. There is something of that nature.
Q147 Nia Griffith: We have a note from them.
Geoffrey Davies: It was good to notice that.
Funding is the root cause of the Powys problem. Mr Davies and Ms Morden know from another aspect I have dealt with in the last 10 years—the magistrates service—that any public service in Powys is the most expensive in England and Wales to provide. That was acknowledged in the Williams report. Maybe—not maybe; I certainly believe this—what he suggests is the answer to an awful lot of the problems, to be perfectly honest. If you speak to any of the senior health professionals, they will tell you that while social services and the health service are not operating on the same budget, all that we want is not going to happen, because each is guarding his own patch.
Q148 Chair: I have one last question, which is about the redress system. It operates in Wales for Welsh patients and English patients, but there is no equivalent in England for Welsh patients. Is that a particular problem?
Councillor Mayor: That is what I understand to be the case. There is that discrepancy. If you have any cause for redress, it is not available. You have a note there, don’t you?
Geoffrey Davies: I do.
Councillor Mayor: On the extent to which redress is a problem, my personal experience and that of constituents I have talked to in my ward is that when they receive their care across the border that is not an issue. The standard of care has not been a problem. There have been a very small number of official complaints. Between April 2013 and March 2014, only three complaints were received for the Shrewsbury and Telford hospital, which is very insignificant, although not for those people who made a complaint. The need for redress does not relate so much to the service that was received. For many people, the problem was the delay in having that service given to them.
Chair: That probably answers the question, to be honest. Thank you very much for coming along.
Oral evidence: Cross-border health arrangements between England and Wales, HC 404 2