Written evidence submitted by the British Medical Association (CBH 42)

 

About the BMA

 

The British Medical Association (BMA) is the voice of doctors and medical students in the UK. We are an apolitical professional association and independent trade union, representing doctors and medical students from all branches of medicine across the UK and supporting them to deliver the highest standards of patient care. We have a membership of over 153,000 which continues to grow each year. This includes over 7,000 members in Wales.

 

Please find below a summary of the main points made within this submission:

 

Executive Summary

 

 

Introduction

 

The BMA welcomes the opportunity to submit evidence to this inquiry into cross-border health arrangements between England and Wales. Doctors in Wales believe that the provision of cross-border healthcare, whilst generating various operational challenges, should be regarded as a fundamental and desirable element of health care provision. Our Welsh members have numerous concerns about perceived barriers to such provision. Many of our members’ concerns focus on general practice, for instance, differences in the way health care is provided, may impact detrimentally on both the viability of rural GP practices and the experience for patients living in border areas. There are also many issues surrounding recruitment and retention, IT and training. We hope that you find our submission useful.

 

Impact on rural Welsh practices

 

  1. Many rural Welsh GP practices are already threatened by recruitment challenges and issues over their financial stability related to the on-going phasing out of Minimum Income Practice Guarantee (MPIG) funding1. Such practices should not experience additional strains through barriers in terms of their ability to attract patients from the English side of the border.

 

  1. Although more English patients register at Welsh general practice than Welsh at English, a perception of unfairness in terms of hospital access may encourage patients domiciled in Wales more likely to register with an English GP 2. These factors can further contribute to the loss of viability of Welsh border practices on which the Welsh Government’s strategic delivery programme for primary and community services, Setting the Direction3, is reliant.

 

Waiting times and targets

 

  1. We note that the referral to treatment (RTT) target has slipped across many Welsh Local Health Boards from 26 to 36 weeks, thus making patient waits longer as part of a mechanism for controlling expenditure4. Waiting times in English trusts, whilst struggling to remain below 18 weeks, are achieving much lower waiting times than their Welsh counterparts5. We look forward to the forthcoming WAO report on elective waiting times in this respect. Despite this, BMA members in border areas in Wales (e.g. Gwent), report that patients are often told they may not be referred to an English trust even when this would mean them being referred somewhere closer with better transport links.

 

  1. Lack of cross-border mobility for secondary care referrals has clear individual health consequences. We understand that resources are finite, and the difficult financial position that NHS and Foundation Trusts in England find themselves in6. However, prioritisation and waiting time targets should not be imposed anywhere within the UK wide NHS other than for reasons of clinical need. Welsh BMA members have found it difficult to explain such referral decisions to individual patients who are taxed exactly the same whether they are referred to secondary care in England or Wales.

  1. It is the experience of our members that differential waiting time targets on either side of the border can lead to problems for Welsh-registered patients; particularly when the District General Hospital (DGH) they have been referred to in England is close to breaching such targets. This inevitably drives these DGHs to treat English-registered patients ahead of Welsh-registered patients in order to avoid suffering the financial consequences of not meeting more stringent English targets.

 

Recruitment and retention

 

  1. Welsh GPs have raised concerns that there is perceived to be a growing income differential for GPs across the border. As a result, we believe this is having a detrimental impact on recruitment of GPs in Wales in relation to both in-hours and out-of-hours care 7.The differing commissioning arrangements for primary care between England and Wales also cause tensions for recruitment and retention. We note, for instance that GP Federations (such as Taurus Healthcare in Herefordshire8 are now able to offer a level of remuneration for salaried GPs in England that is potentially in excess of what is available in Wales7.

 

  1. We believe that consideration should be given to developing training rotas which operate across the England-Wales border. For example, we note that it is easier to commute from North Wales to the Northwest of England than it is to South Wales. Having training rotas which operate on an all-Wales basis inevitably acts as a disincentive for some people to train as doctors in Wales. This may be particularly the case for doctors in training who have young families, and who might therefore be concerned at potentially having to spend significant periods of time during their training as much as 4-5 hours’ travel time away from their families.

 

Patient experience

 

  1. Different individuals who register with a GP across the border from where they live will have different reasons for doing so. For many it may simply be down to convenience relating to the location of the practice. For some Welsh-domiciled patients, their decision may be influenced by a belief they will have shorter waiting times for treatment in England. At the same time, some English-domiciled patients may be attracted to register with a Welsh GP because they could then gain the ability to access free prescriptions to which they might not otherwise be entitled.

 

  1. It is often more convenient for patients being referred into secondary care by border situated Welsh GPs to be referred to English Trusts. For patients living in North and Mid Wales, for example, it may be far more convenient in terms of accessibility for them to be referred to tertiary services in Liverpool or Birmingham, rather than to South Wales which may involve significantly greater travel. For many Powys patients, it also needs to be accepted that Hereford or Shrewsbury may be the first and automatic choice for secondary care.

 

  1. Cross-border referrals for Welsh-registered patients should be being properly funded by Welsh Local Health Boards9.Contrary to impressions that may have recently been given by the UK Secretary of State for Health10, they should not be causing undue strain upon the NHS in England and indeed may be contributing to the viability of some English-based services.

 

  1. Our members in Wales report, however, that attempts at cross-border referrals to tertiary care in England, both by secondary care and directly by Welsh GPs, may be challenged by Welsh Local Health Boards. This can be extremely frustrating for patients.

 

  1. Welsh GP members also report that patients registered with them often express frustration at being denied the freedom of choice patients registered with GPs in England receive. English patients have via the Choose and Book system the ability to choose the place, date and time of their first outpatient appointment in a hospital or clinic11.

 

  1. As we previously indicated in our evidence to the Welsh Government on the implementation of the EU directive on cross border health care and patient mobility12, it is concerning that a patient’s right to seek treatment in England for a Welsh patient is less than the right to seek treatment elsewhere in the EU.

 

Effectiveness of existing protocols

 

  1. The Protocol for Cross-Border Healthcare Services9 adopted by the Department of Health and the Welsh Government in April 2013 has served, in our view, to clarify where responsibility lies for providing and funding health care for those patients who choose to register with a GP on the other side of the border. We note that the protocol requires a timely and appropriate adjustment of finances between the Welsh Government and the Department of Health to cover the net difference in cross-border primary care registrations. We are not aware, however, of the extent to which any funding transferred as a result of this provision is then further transferred using an appropriate distribution to reimburse Welsh Local Health Boards or local Clinical Commissioning Groups in England for any additional costs they may be incurring.

 

  1. We would certainly support the Silk Commission Part II recommendation for specific local protocols on cross-border health between Welsh Local Health Boards in border areas and neighbouring trusts in England13. In the experience of our members, whilst there is some degree of co-operation at present, there is little evidence at ground level primary care of specific shared pathways or clear protocols operating at such a local level. Most border practices therefore have to contend with differential systems and, in many cases, we would note that these are diverging further.

 

Cross-border ICT issues

 

  1. GP members in Powys report that work is being undertaken locally to address incompatibilities that exist between different ICT systems used on either side of the border, but that barriers still remain in place. Such incompatibilities may, for instance, prevent GPs on the Welsh side of the border from straightforwardly emailing consultants for advice on the English side of the border as they are not within Welsh NHS systems. Additionally, Welsh practices are not able to utilise the Welsh Clinical Communications Gateway (which has been put in place to enable an effective interface between ICT systems in primary and secondary care in Wales) to refer patients for secondary care treatment in England. There is also a lack of connection from Wales to the Choose and Book system which operates in England. These incompatibilities complicate the processes for making cross-border referrals to secondary care, which in turn has a cost in terms of time and staff resources.

 

Separate GP performers lists in England and Wales

 

  1. Welsh BMA members have commented that having separate performers lists for England and Wales has a number of detrimental impacts. For instance, we are aware that there has been a negative impact on recruitment to GP practices in Wales, since GPs on the English performers list may not as a result be immediately able to take up vacancies that may exist within practices in Wales.

 

  1. Members have also reported that having separate lists can prevent GP colleagues in nearby practices on either side of the border from simply being able to cover for each other in the way that might often happen between practices on the same side of the border.

 

  1. In similar vein, having separate lists also limits the availability of locums for border practices, as locums on the English performers list aren’t able to undertake shifts in Welsh practices and vice versa. This can therefore cut by half the choice of locums available to border practices. As a result of these concerns, we believe there should be a unified performers list which operates across England and Wales.

 

Conclusion

 

Our members believe that the provision of seamless cross-border healthcare is both desirable and necessary. Throughout this submission we have drawn attention to areas that doctors in Wales feel are preventing this vision from becoming reality. The potential viability of border general practices within Wales is being threatened through a misalignment of policy across the border.  Training, IT and funding all need to be better aligned to ensure that cross-border healthcare between England and Wales operates smoothly into the future.

 

 

24 November 2014

 

 

 

 

References

 

1. BMA General Practitioners Committee Wales. (2014) GPCW Chair's speech to the national LMC Conference 2014. May 2014. Web page. http://bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/gpc-wales/lmc-conference-speech. 25 November 2014.

2. South Wales Argus. (2014) 'More English patients using doctors in Wales' - MPs hear. 18 November 2014. Newspaper article. http://www.southwalesargus.co.uk/archive/2014/11/18/11609288._More_English_patients_using_doctors_in_Wales____MPs_hear/. 25 November 2014.

3. Welsh Assembly Government. (2010) Setting the Direction: Primary & Community Services Strategic Delivery Programme. February 2010. http://www.weds.wales.nhs.uk/sitesplus/documents/1076/Setting%20the%20direction.pdf. 25 November 2014.

4. Auditor General for Wales. (2014) NHS Wales: Overview of Financial and Service Performance 2013-14. Wales Audit Office. 14 October 2014. http://www.wao.gov.uk/system/files/publications/470A2014_NHS_Wales_ENG.pdf. 25 November 2014.

5. NHS England. (2014) NHS Performance Report - Paper NHSE111402. November 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/item4-board-1114-fin.pdf. 25 November 2014.

6. McKeon A, Lafond S, Arora S, et al. (2014) Into the Red? The State of the NHS' Finances. Nuffield Trust. London: 10 July 2014. http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/into-the-red-report.pdf.

7. Health and Social Care Information Centre. (2014) GP Earnings and Expenses 2012/13. 19 September 2014. http://www.hscic.gov.uk/catalogue/PUB14924/gp-earn-ex-1213-rep.pdf. 19 September 2014.

8. Taurus Healthcare. Website. http://www.taurushealthcare.co.uk/home.aspx. 25 November 2014.

9. Department for Health and Social Services of the Welsh Government and the NHS Commissioning Board. (2013) Protocol for Cross-Border Healthcare Services. April 2013. http://www.england.nhs.uk/wp-content/uploads/2013/03/england-wales-protocol.pdf. 25 November 2014.

10. BBC News Wales. (2014) Wales NHS 'second-class' claims health secretary Hunt. 21 October 2014. News Report. http://www.bbc.co.uk/news/uk-wales-politics-29708982. 25 November 2014.

11. NHS. (2012) Choose and Book. Website. http://www.chooseandbook.nhs.uk/. 25 November 2014.

12. BMA Wales. (2013) Consultation on Cross Border Health Care and Patient Mobility European Directive - Welsh Government Consultation Paper. 13 March 2013. http://bma.org.uk/-/media/files/pdfs/about%20the%20bma/what%20we%20do/lobbying/wales/walesresponsecrossborderhealthcareeudirective.pdf. 25 November 2014.

13. Commons Select Committee. (2014) Silk Commission Part II Report: Devolving legislative powers to Wales. www.parliament.uk. http://www.parliament.uk/business/committees/committees-a-z/commons-select/welsh-affairs-committee/news/silk-commission-part-ii-report/. 13 March 2014.