Written evidence submitted by Shropshire Council (CBH 24)
This response is submitted by Cllr Karen Calder, Portfolio Holder for Health, Shropshire Council, and Professor Rod Thomson, Director of Public Health, Shropshire Council.
Shropshire Council perceives cross-border cooperation as a significant and important issue. For many communities along the Marches the England/Wales border does not reflect the natural community flows that occur, nor does it reflect the personal decisions that individuals and families make to utilise commercial and public services on either side of the border.
This response has been prepared in conjunction with our partner organisations including Shropshire’s Healthwatch. We have hosted a workshop for our elected members to enable them to contribute their views and experiences to the response. This workshop session had representatives from Powys Teaching Health Board and Shropshire’s CCG in attendance.
We have liaised with our Shropshire CCG partners and Cheshire West & Chester Council and support the statements that they have submitted.
1.1. Shropshire Council is a large, rural, unitary authority formed in 2009. The county has approximately 306,000 residents. Shropshire Council shares a substantial proportion of its border with Mid and North Wales. Shropshire Clinical Commissioning Group (CCG) organises the delivery of NHS services to the area and Shropshire Public Health is responsible services to the population including those relating to health promotion, health protection, emergency planning and a core offer to the CCG. Shropshire’s Health and Wellbeing Board works to improve health and wellbeing and to help identify and meet need across the local authority area in order to tackle health inequalities. There are two hospitals within the local authority area: one secondary care provider, the Royal Shrewsbury Hospital; and one tertiary care provider, the Robert Jones and Agnes Hunt Orthopaedic Hospital.
1.2. Shropshire Council has one of the lowest per capita Public Health grants in England, receiving a baseline allocation of only £26 per head of the population (the England average is £47). For comparison, Telford & Wrekin Council received £61 per head and Westminster receives £128. Provision of services cross-border (and in some cases with no availability for reimbursement) can have a significant impact upon funds.
1.3. This Inquiry provides opportunity for Shropshire Council and its partners to contribute to, and highlight the importance of, the working relationship between England and Wales for the provision of health services. The ability to ensure high quality of service and equity of access for residents is of great priority to Shropshire Council.
2.1. There are a number of areas of concern which have been raised with NHS England and PHE over the last six months in regard to activity and cross-charging for the provision of sexual health services:
2.2. Following transition of Public Health to local authorities on 1st April 2013, Shropshire Council understands that financial allocations transferred were based upon a Public Health ring-fenced formula relative to the local authority resident population size. Shropshire has one of the lowest per capita Public Health grants in England, and is not in a position to deliver services where there is no mechanism for recharge.
2.3. Shropshire Council retendered its contract for Community based Integrated Sexual Health Services with effect from 1st April 2013. The contract was awarded on a block contract basis, with indicative activity across all three levels of sexual health provision. The services are provided in line with national guidance and offer open access services.
2.4. Subsequently, attendance activity for Welsh patients has had an impact upon available activity in the services and has produced a cost burden to the detriment of Shropshire residents. If the patients had been residents from any other area of England the local authority would have been able to recharge the local authority of patient residence.
2.5. To indicate the financial implications this activity has had upon Shropshire Council services during the period April 2013-April 2014, the following activity has been reported by our provider:
Summary of Attendance Activity | ||
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2013/14 | Number | Cost (£) |
Counselling |
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New appointment | 1 | 40 |
Follow up Appointment |
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Integrated Sexual Health Attendance |
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New appointment | 117 | 11,700 |
Follow up Appointment | 9 | 225 |
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GUM Attendance |
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New appointment | 383 | 52,088 |
Follow up Appointment | 206 | 21,012 |
GRAND TOTAL | 716 | 85,065 |
2.6. Prices are based on local average costs and national payment by results tariff. No current formula exists for reporting complex or standard Sexual and Reproductive Healthcare (SRH) attendances.
2.7. The annual contract value for Shropshire’s Community Based Integrated Sexual Health Services is £813,404; therefore the cost pressure for Welsh patients attending equals approximately 10.5% of the total contract value and a loss of 716 attendances.
2.8. The figures above do not take into account the number of patients resident in Wales who are accessing contraception services in Shropshire.
2.9. Concerns for the Future
2.9.1. The opening of a new university in Shropshire (from September 2014) may result in increased levels of activity. It is possible that a proportion of this increased activity will include patients who are resident in Wales.
2.9.2. The retirement of one of the main contraception providing GPs in Newtown, Powys may have an impact upon services in Shropshire with anticipated increased demand. Shropshire continues to monitor demand from across the border.
3.1. Differences in policies between England and Wales in the delivery of screening services have resulted in inequity of access for residents.
3.2. For example, as part of the National Cervical Screening Programme, the launch of the new HPV triage and test of cure programme in 2013 was offered to residents registered with a GP practice in England. Shropshire residents who were registered with a GP practice in Wales were not offered access to the programme.
3.3. Similarly, there are differences in provision of maternity and antenatal and new-born screening as England and Wales operate different care pathways, this includes the pathway for screening for Down’s Syndrome.
4.1. Stop smoking services in Shropshire (Help 2 Quit) are available for anyone living within the area or anyone registered with a GP practice in Shropshire. Therefore people living in Wales but registered with a GP in England can access the Help 2 Quit service. An informal, reciprocal arrangement is in place with Stop Smoking Wales to ensure clients who do not meet the criteria are always referred to relevant service.
4.2. An agreement is also in place with the acute trusts; at Robert Jones and Agnes Hunt Orthopaedic Hospital over half of the patients seen come from outside of Shropshire, however an arrangement is in place for Help 2 Quit to act as the hub to accept all referrals for stop smoking services then to inform the patient of their relevant service. This service can currently be accommodated within existing capacity though cross-charging may have to be explored should demand increase.
4.3. During 2013/14, Help 2 Quit accepted 22 referrals for patients who are Welsh residents but access a GP service in England.
5.1. Shropshire Council has a statutory responsibility to ensure provision of the NHS Health Check to all eligible Shropshire residents aged 40-74 years. Shropshire Council offers the Health Check to all patients registered with a Shropshire GP practice. This includes patients who are registered with a Shropshire practice but are resident in Wales.
5.2. The NHS Health Check is not offered in Wales and so Shropshire Council is providing this service to Welsh residents with no method of reimbursement or the availability of a similar service to Shropshire residents attending Welsh GP practices.
6.1. There is a lack of clarity about charging for the provision of school nursing services. There does not appear to be a national agreement for financial responsibility. Currently, Shropshire Council is invoiced for work completed by school nurses with children who do not have Shropshire postcodes. It is believed that this work is outside of the contract.
6.2. For ease, it would improve provision if school nurses could be contracted to work with all children attending schools in the county, including those who are resident across the border. If this policy were to be implemented nationally, this would ensure that young people receive an equitable service and there would be a reduction in bureaucracy.
7.1. Shropshire expects to experience similar issues to those relating to school nursing services when the local authority takes responsibility for health visiting and delivering the healthy child programme to the resident population in October 2015. Previously this service was provided to those who were registered with a Shropshire GP practice.
7.2. Shropshire anticipates that there may be information sharing implications going forward for health visitors in ensuring that they receive information about children who are resident in Shropshire but are registered with a Welsh GP practice. In particular there is concern with collecting information or being notified in relation to the birth of a child and of safeguarding/child protection concerns. It is essential that this information is easily and readily shared across the border.
8.1. CCG healthcare associated infection (HCAI) reduction targets for MRSA bacteraemia and Clostridium Difficile infections (CDI) are based upon cases amongst the population for which the CCG is responsible. CDI cases are attributable to the CCG whether they were acquired in acute hospitals (within or outside the local health economy) or within the community. Where this is not possible, the cases are attributed to the ‘lead’ CCG for the trust reporting the case.
8.2. Shropshire CCG is designated as the lead organisation for the local acute trust, Shrewsbury and Telford Hospital (SaTH). Therefore, when the laboratory at SaTH tests samples sent in by GP practices in Powys and these test positive for CDI, these numbers count against Shropshire’s CCG targets.
A workshop event was held with Elected Members to allow them the opportunity to contribute experiences and thoughts from their communities to this Inquiry. Shropshire Healthwatch has also provided us with their comments regarding cross-border health arrangements.
9.1. Ambulance Services
9.1.1 Elected Members felt that the difficulties with ambulance hand-over at Wrexham Maelor Hospital (and associated delays for patients waiting to be admitted) are having a negative effect upon Shropshire residents. Residents were concerned by the fact that ambulances are off the road for long periods of time and that this would have an impact upon service coverage across the local authority area. It was also felt that as a result of the delays in hand-over, English ambulances were less likely to take patients to Wrexham Maelor Hospital, resulting in an increased number of emergency admissions at the Royal Shrewsbury Hospital and increased demand upon services at the Shrewsbury site.
9.1.2 Concerns were also expressed in regard to the future relocation of all Women and Children’s Services to the Princess Royal Hospital in Telford from September 2014 (currently these services can be accessed at the Royal Shrewsbury Hospital). Elected Members felt that women living in the Powys area would be required to travel long distances to receive consultant-led care and delivery and that this may have a negative impact upon their health and experiences.
9.1.3 The use of Community First Responders (CFRs) was highlighted as an area where there is discrepancy in the provision of cross-border care. CFRs based in England are occasionally called to attend emergency calls in Wales, but it is rare that CFRs based in Wales are called to respond to emergencies in England. It was stated that there are difficulties in decisions to be made regarding governance of the CFR and which ambulance service has responsibility for the CFR if they are attending an emergency across the border (this includes requesting that the CFR attends an emergency). It was suggested that it would be better to use the CFR across a radius rather than limiting their use to a particular catchment area of an ambulance service, and not using the closest available resources.
9.1.4 Shropshire Healthwatch highlighted that it is important that there should be no barriers to patients (residents of England or Wales) registered with GP practices in Wales from accessing acute services in England. Similarly, for patients living along the border, it is essential that the closest ambulance is despatched when an emergency call is received rather than the nearest English or Welsh ambulance, depending upon the location of the emergency. Healthwatch highlighted that patients need to have confidence that they are receiving the fastest response possible.
9.1.5 Shropshire Healthwatch emphasised the importance of cross-border patients in contributing towards the viability of the Shrewsbury and Telford Hospital Trust (SaTH) and that it is essential that these patients are considered when planning service delivery in Shropshire.
9.2. Local Decision Making
9.2.1. Elected members felt that it was of significant concern that residents of England who are registered with GP practices in Wales (and vice versa) are unable to influence health policy in the area in which they receive treatment as their vote is for the area in which they reside. It was expressed that individuals who are resident in areas such as Montgomeryshire are particularly disadvantaged in this respect as there is no district hospital within the region and patients must seek treatment outside of their resident area.
9.2.2. Suggestions were made to encourage better links with other counties, or for the border areas to work together developing a ‘Marches’ approach for systems or policies along the border between England and Wales.
9.3. Transparency of Arrangements
9.3.1. Elected Members felt that there was a need for more transparency and clarity of the differences in health arrangements between England and Wales. This view was expressed particularly in regard to the availability of treatment and waiting times.
It is apparent that there are variations in health arrangements between England and Wales. It would be beneficial to all communities along the border to consult and produce joint messaging for residents of the Marches. This would help to ensure that individuals are appropriately informed about their healthcare.
20 August 2014