CBH0019

Written evidence submitted by Arthritis UK

1. Arthritis UK welcomes the opportunity to contribute to the Welsh Affairs Committee’s inquiry into cross-border healthcare arrangements.

2. Arthritis UK is the UK’s largest arthritis charity, changing lives through research, campaigning and support. Over 10 million people in the UK have arthritis. That’s one in six living with the pain, fatigue and disability it can cause. Many more live with arthritis but remain undiagnosed, untreated and unsupported. For a condition affecting so many, far too little is done. Arthritis UK won’t rest until everyone with arthritis has access to the treatments and support they need, with real hope of a cure in the future.

3. Arthritis and related musculoskeletal (MSK) conditions affect 20.8 million people in the UK, including almost a million people in Wales,[1] and are the leading causes of pain and disability in the UK. Analysis by the York Health Consortium found in 2017 that the two most common forms of arthritis (osteoarthritis and rheumatoid arthritis) were projected to cost the NHS £118.6 billion over the next decade[2]. Based on this analysis, in 2025, treating these two conditions is projected to cost the NHS £13.2 billion. MSK conditions accounted for the third largest area of NHS programme spending at £4.7 billion in 2013 to 2014[3] [4].

4. This submission addresses the following questions set by the inquiry:

• What are the most pressing issues for those accessing cross-border healthcare, whether through a GP, hospital, or specialist care?
• How can the use of data and digitalisation improve the experience of patients using cross-border healthcare and the information available to clinicians? What changes are needed to ensure cross-border compatibility?  
• How will recently announced reforms, including the abolition of NHS England and the UK Government's 10 Year Health Plan, impact on cross-border healthcare? 
• What is the experience of patients in England and Wales who are reliant on the use of healthcare services on the other side of the border?

Summary points:

5. Arthritis UK has identified the following issues related to the cross-border healthcare arrangements between England and Wales impacting on people with arthritis.

• The UK and Welsh Governments previously announced a partnership to strengthen cooperation between NHS England and NHS Wales to reduce waiting lists on both sides of the border. Despite the stated intention to enable mutual aid, there is currently no indication of actions taken to increase orthopaedic surgery provision in England for Welsh residents. Giving patients who are willing and able to travel the option to access surgery across the border could help reduce waits for orthopaedic care and avoid prolonged pain and loss of independence.
• Powys Teaching Health Board (THB) has asked English hospitals that provide elective services to Powys residents to extend waiting times for Powys residents above those experienced by residents on the English side of the border. Consequently, Welsh patients are waiting longer for treatment such as orthopaedic surgery even when there is capacity in English hospitals to undertake the operation sooner, due to funding constraints within Powys THB.
• Extending waiting times for orthopaedic surgery can be detrimental for patients with arthritis as it can cause further deterioration of their physical, mental and social wellbeing. Moreover, waits over 6 months for hip and knee surgery can have detrimental impacts on a patient’s quality of life. Many people on such waiting lists experience severe and worsening pain as they wait.
• Sharing patient data across the border can be disjointed. Media reports have stated that transfers of information regarding a patient’s referral or test results are on occasions still done by post or fax.
• We understand that the NHS Wales app does not allow patients from Powys to access England health services information, such as hospital appointment times. We also understand that there is no timescale for resolution of this issue.
• There is uncertainty regarding cross border access to new Neighbourhood Health Services located on the English side of the border for people based just over the border in Powys.

Our recommendations for change

6. Arthritis UK believes that the following changes and measures could be made by the Welsh Government and Department of Health and Social Care to improve cross-border access:

6.1       Explore opportunities for greater cross-border activity and cooperation to reduce orthopaedic waiting times in Wales.

• Given the scale of the backlog and the unacceptably long waiting times for orthopaedic surgery in Wales (see 7.2 for further detail), NHS Wales and Welsh Government should explore short-term opportunities to buy in additional capacity from English providers to help reduce waiting times and clear the backlog as quickly as possible.
• The UK and Welsh Governments should provide greater transparency on the progress and outcomes of their September 2024 partnership.
• Arthritis UK has called on the Welsh Government to develop regional and national capacity action plans to identify workforce and facilities requirements to meet current and projected demand through an expanded network of local and regional surgical hubs.
• Arthritis UK has also called on the Welsh Government to develop ambitious new waiting times targets. We believe the Welsh Government’s current target of clearing two-year waits should be regarded as a milestone / roadmap target to support a return to the pre-pandemic NHS Wales 26-week waiting times target, rather than a standalone waiting times target.
• See point 7 for background detail.

6.2       Urgent action should be taken by Powys THB and Welsh Government to address the current delays and inequity in accessing England-based elective orthopedic services provided to Powys residents.

• Cross border access to treatments at English hospitals for Powys residents should be on an equal basis with residents on the English side of the border who are on the same waiting lists for the same procedures, and care should not be delayed or postponed due to funding arrangements.
• The Welsh Government’s guidance on health care principles for people accessing cross-border healthcare services states that:
  ‘The safety and well-being of patients is paramount. The overriding principle of this statement is that no treatment will be refused or delayed due to uncertainty or ambiguity as to which body is responsible for funding an individual’s healthcare, or due to differing rules as to the level of services available under each country’s health system.’ [5]
• Powys THB and Welsh Government should work collaboratively to ensure the above principle is reapplied to arrangements between Powys THB and English hospital as soon as possible.
• We would welcome the Welsh Government issuing clear guidance to all health boards that commission services from England, ensuring that Welsh residents can access treatment in English hospitals on an equal footing with England based residents on the same waiting lists...
• Ensure improved data collection and reporting on cross-border patient flows, and waiting times in order to understand the impacts of current arrangements on waiting times.
• See point 8 for background detail.

Evidence on pressing issues for those accessing cross-border healthcare

7. Underutilisation of cross-border collaboration to reduce orthopaedic waiting times.

7.1 In September 2024, the UK and Welsh Governments announced a new partnership aimed at facilitating the exchange of best practice and enhancing cross-border cooperation to reduce NHS waiting lists on both sides of the border[6]. The partnership was framed as enabling mutual aid between NHS bodies to improve patient care and explore opportunities for cross-border collaboration. While this announcement demonstrates the intention to strengthen cooperation, we are not aware of any significant actions to increase the provision of orthopaedic surgery in English hospitals for Welsh residents, despite the ongoing backlog in Wales.

7.2 The latest Trauma and Orthopaedic (T&O) waiting list figures in Wales (for the end of January 2026, published March 2026) is still 48% higher than the average figure for the last full pre-pandemic year, 2019. 29% of cases on the T&O Wales list have been waiting over a year (compared to 4% average in 2019), 13% have been waiting over 18 months (compared to 1% average in 2019) and 1,334 cases have been waiting over two years.

7.3 Given the stated aim of this partnership is to enhance cross-border cooperation and enable mutual aid between NHS bodies, it should represent a clear opportunity to explore whether greater use could be made of available capacity in English hospitals to help reduce the NHS Wales backlog and waiting times for Welsh patients.

7.4 Allowing greater cross-border choice for patients willing to travel could shorten waits for trauma and orthopaedic surgery in Wales if capacity in NHS England be provided to NHS Wales through a cooperation agreement.

7.5 Long waits for trauma and orthopaedic procedures often mean prolonged pain and loss of independence. We believe patients able to travel for operations should have the option to do so. This approach warrants consideration by the Welsh Government. Please see point 9 for additional detail on the impact on individuals of longer orthopaedic waits.

8. Inequitable access to treatment in English hospitals for Powys patients due to funding constraints has detrimental impacts.

8.1 Powys THB announced in July 2025 a change to their cross-border arrangements with NHS England hospitals. The THB effectively requested England based service providers delay access to surgery for Powys residents to align their waiting times more closely with significantly longer Welsh Government waiting times targets [7]. This decision was made in relation to Powys THB attempting to reduce their £38.4 million deficit[8].

8.2 The decision means in effect that Powys residents who are on the same orthopaedic waiting list, for the same procedure, at the same hospital as an England resident, will be expected to wait much longer for their surgery than their England based counterparts.

8.3 David Chadwick MP has reported that as a result of the HB’s decision, waiting times for some procedures have doubled[9].

8.4 We believe that the Powys THB decision to extend waits for Welsh resident accessing English hospitals clearly contravenes the principle below set out in the Welsh Government’s guidance on health care principles for people accessing cross-border healthcare services:

‘The safety and well-being of patients is paramount. The overriding principle of this statement is that no treatment will be refused or delayed due to uncertainty or ambiguity as to which body is responsible for funding an individual’s healthcare, or due to differing rules as to the level of services available under each country’s health system.’ [10]

8.5 We believe it is vitally important that Powys THB follows the above principle in all cross-border arrangements, this is particularly important in relation to orthopaedics, as delays to treatment can have serious detrimental impacts on patients. Please see point 9 for additional details on the impact on individuals of longer orthopaedic waits.

8.6 We also have concerns regarding how waiting time standards are being interpreted and/or presented by the Powys Teaching Health Board. We believe that the current Welsh Government’s focus on eliminating two-year waits should be understood as a backlog recovery milestone target rather than a standalone measure of an acceptable standard of access to treatment. We strongly believe it should not be used to justify delaying care where earlier treatment is available. Where treatment can be provided sooner, patients should be able to access that care rather than remain in avoidable pain for administrative or financial reasons.

8.7 On 8 August 2025, we wrote to the Welsh Government’s Cabinet Secretary for Health and Social Care to raise concerns on both the lack of clarity regarding progress with the September 2024 UK and Welsh Government partnership on cross-border cooperation and on Powys THB’s decision to delay Powys residents access to English services. The response we received from Welsh Government stated: ‘Our national waiting times guidance clearly indicates that all patients should be seen in order of their clinical priority, which is a decision for the relevant consultant to make based on the priority of all patients on the waiting list and their length of wait.’ However, patients are waiting longer for treatment in English hospitals because of funding constraints rather than clinical need. We struggle to see how this is consistent with the principle that patients should be treated according to clinical priority.

8.8 Opposition MSs have argued that the Welsh Government’s £120 million fund for Welsh Health Boards to cut waiting times does not include provision to adequately fund Powys THB to address issues relating to Powys residents treated in England[11]. An opposition Powys Member of the Senedd has claimed that Powys patients are being treated as ‘second-class citizens’.

9. The harms associated with delayed joint replacement surgery.

9.1 For people with arthritis, long waits for treatment can cause further deterioration of their physical, mental and social wellbeing[12]. Survey results from Arthritis UK’s Left Waiting, Left Behind report revealed that 66% stated that waiting for treatment had impacted their mental health ‘somewhat’ or ‘a great deal’ and 68% of respondents said their ability to work had been impacted ‘somewhat’ or a ‘great deal’[13]. These impacts can have significant effects on their quality of life and those with financial responsibilities may be disproportionately affected[14].

9.2 A study found that waits over 6 months for hip and knee replacement surgery have been shown to negatively impact on health-related quality of life and frailty[15]. Two thirds of patients also expressed that their health had worsened as a result of waiting. This highlights why it is so important that patients are treated as soon as possible, as prolonged waits worsen health, leaving people to endure avoidable suffering for longer than they should. We therefore believe that the Welsh Government’s current focus on eliminating two-year waits should therefore be understood as a backlog recovery milestone (to support returning to pre-pandemic 26-week targets), rather than an acceptable standard of access to treatment.

9.3 People with arthritis already face significant barriers to accessing treatment. The Left Waiting, Left Behind report revealed that 60% of respondents cited issues with the cost of treatment (paying for treatment privately), 37% cited difficulties travelling to get treatment and 21% cited difficulties taking time off work[16]. Living in rural areas like Powys can make travelling to access treatment difficult and a painful experience. On top of these existing barriers, there is now an additional policy barrier introduced for financial reasons in Powys.

9.4 Sally, 47 lives in Newtown, Powys and has Rheumatoid arthritis. She received joint replacement surgery with NHS England in November 2024, after 8 months on the waiting list but has friends who have been waiting two years or more.

9.5 Sally shared her experience as a resident living in Powys and has raised several issues. She lives 2 hours away from her nearest A&E, the hospital in Newtown has a limited range of services and she doesn’t have a car, so she travels an hour to medical appointments, usually having to find someone to take her every time, which can be a challenge.

9.6 This highlights how crucial it is for someone like Sally to be able to access cross-border care seamlessly. Sally commented on the waiting times in response to an NHS waiting times story in Powys back in January 2025. She stated “If you’re asking patients to wait longer again, it makes it more of a postcode lottery. I’m scared we’ll be left with even less medical help than we already have.”

9.7 Sally’s experience reflects the real life impact of these policy changes and feeling fearful about losing access to care is not an unreasonable reaction when waiting times are extended and options are reduced for non-clinical reasons.

9.8 The following patient accounts from media reports illustrate the practical and personal impact of cross-border access challenges on individuals in Powys:

• Following the announcement of the changes in waiting times endorsed by Powys Teaching Health Board, Mel Wallace, 59 from Howey, Powys was initially meant to wait 12 months for her hip replacement surgery. She has already waited 59 weeks and was then subjected to a further 45 weeks’ wait as a result of the change in waiting times. For Ms Wallace, who enjoyed activities such as walking her dogs or gardening, is now struggling with getting out of her car or putting on socks[17].
• Stephen Evans, 65 from Builth Wells, was scheduled for a double knee replacement surgery and was told in May 2025 his operation would take place in the next few weeks. After calling them he was notified that it wouldn’t be for another year, but he had never received any notice of this before from the health board or Welsh NHS.
• John Silk, 92 from Talgarth was a regular golfer and would go to the gym until his osteoarthritis condition worsened. He uses a walking stick and finds driving a car a difficult task. John’s operation was due in June 2025 in Hereford, but it was delayed and he must wait for another year due to budget cuts.
• Marina Bowles has arthritis and is registered blind. She is from Rhyadar and has always travelled to England for treatment. Previously she waited over a year for an operation, and proposed changes would cause further delays for patients like her. She commented “Powys isn’t the place to get old. It’s a forgotten county.”[18]

9.9 These cases highlight that no one should have to wait for prolonged periods for essential surgery; patients deserve timely treatment to relieve pain, maintain independence and continue participating fully in their everyday lives.

10. Issues with digital systems and patient information transfer causes inefficiency and frustration for patients.

10.1 Patients accessing cross-border care may also face challenges relating to the transfer of medical records between NHS Wales and NHS England systems. MP Helen Morgan raised this issue in Parliament citing “after 25 years of devolution, NHS England and NHS Wales still cannot share patient record properly (…) referrals, test results and discharge letters are still moving by post or fax, which is an absurd situation in 2025[19].” This can cause delays, incomplete information transfer and patients needing to repeatedly recount their medical history.

10.2 Arthritis UK’s helpline received a call from an individual whose details are anonymous. The caller moved to Wales before lockdown and none of his medical records were transferred. As a result, significant information was not communicated to his new GP, including that he is under rheumatology care, has osteoarthritis and a history of pain, is an army veteran with complex PTSD, has leukaemia and is on blood thinners. The caller informed our helpline that subsequent to the failure of information transfer, he experienced poor mental health. This highlights how crucial it is for systems to be joined up to improve patient experience when accessing care.

10.3 Moreover, recent news reports revealed that due to technical failures, NHS Wales app does not allow patients from Powys to access health services in England and there is no timescale for resolution of this issue[20]. For a population that depends heavily on cross-border care, this represents a digital connectivity gap. This reduces transparency and increases administrative burden. In rural areas like Powys where travel distances are significant and alternative pathways are limited, this digital exclusion compounds existing barriers for patients with arthritis.

Announced reforms impacts on cross-border healthcare

11. Neighbourhood Health Plan: a core pillar to the NHS 10-year plan in England is the implementation of neighbourhood health which aims to create healthier communities and enable people to live well[21].

11.1 The government began to roll out neighbourhood health services in 43 wave 1 sites which are backed by £10 million[22]. Chosen areas include Herefordshire and Shropshire, which are near the Wales border and residents of Wales frequently visit for treatment.

11.2 Neighbourhood health services have great potential to support people with MSK conditions to self-manage. People with arthritis and MSK conditions often require access to a combination of different services including physiotherapy, weight management services and rehabilitation services. However, managing these conditions can be physically and financially demanding, particularly when the services are fragmented. Therefore, it would be beneficial if they could access the support they need in a way that is holistic and closer to home.

11.3 General practices will be used as the cornerstone of new neighbourhood teams to deliver care closer to home,[23] suggesting these services are designed around registered patient populations of local GP practices. There is a possibility that residents of Wales with an English GP in a neighbourhood health pilot area will be able to access these services, however access may be impacted by funding decisions made by Powys THB. Moreover, Welsh residents registered with a GP based in Wales may be excluded despite living nearby. While Wales has a similar framework called the Primary Care Model[24], in rural areas such as Powys where patients already face travel distances and reliance on cross-border healthcare, it will be important that access to the nearest neighbourhood services is determined by proximity and practicality, rather than solely by GP registration.

27 March 2026