Written evidence submitted by the Minister for Health and Social Services in Wales (CBH 51)
Health services in Wales are a devolved matter and are the responsibility of the Welsh Government. The NHS in Wales comprises seven integrated local health boards that are responsible for their population’s health from community health, through to primary and secondary care provision, as well as the provision or commissioning of tertiary care. There are three all Wales NHS Trusts: Velindre NHS Trust, Public Health Wales and the Welsh Ambulance Service NHS Trust. The Welsh Health Specialised Services Committee (WHSSC), is a joint committee of the seven health boards, and has responsibility for the planning of specialised and tertiary services on their behalf.
The length and porous nature of the border between England and Wales inevitably leads to a large population flow between the two countries including for health services. The Welsh Government has been keen to ensure the approach to cross-border patient flows is sensible and pragmatic, focused on providing the best care to all those people who need it.
The cross-border flows between the Welsh and English healthcare systems exist both in primary and secondary care services. In primary care, both Welsh and English patients along the border currently choose whether to register with a Welsh or an English GP. For the majority of individuals, convenience is likely to be the main reason for registering with a particular GP. Along the Wales/England border however choice of GP practices may be limited. Patients access to secondary care services will depend on their choice of GP. However, there are also cross border flows of patients that do not result from an individual’s choice of GP – for example Morriston Hospital in Swansea, serves as the specialist burns centre for Wales and the South West of England, and Velindre Cancer Centre in Cardiff, which provides specialist cancer services for Wales as well as treating patients referred from England.
In recognition of the need for there to be a flow of patients across the border, both the UK and Welsh Government Ministers signed a set of principles at Ministerial level which underpin the cross border protocol. The protocol puts in place pragmatic solutions to the practical issues that emerge as a result of patient flows. The aim of the protocol is to ensure those patients living along the border do not fall between two different health systems and that they receive the care and treatment they require irrespective of their country of residence. The Welsh Government remains committed to having a workable protocol in place. The existing protocol was revised, renewed and agreed by both Welsh and English Ministers as recently as April 2013, and would be reviewed again after three years.
I am aware the Committee has been inviting evidence on six specific issues and I have therefore organised the submission of my evidence on this basis.
Prior to the passage in Westminster of the Health and Social Care Act 2012, both the organisation and policy of healthcare provision in the two countries were not that dissimilar. However the 2012 Act has created a much sharper divergence in approach with the creation of NHS England and the Clinical Commissioning Groups. These changes have resulted in two very distinct organisational differences in the Welsh and English NHS systems.
Wales has an integrated healthcare system with local health boards who are responsible for meeting both the primary and secondary care needs of their population. The Welsh NHS is based on a planning system rather than a competitive commissioning model.
However, there are many areas of similarity that remain between the two systems and much of this is centred around our NHS staff and their practice. The bodies that oversee the training, standards and the professional regulation of staff such as the General Medical Council and Nursing and Midwifery Council operate across Wales and England. The revalidation of doctors is one specific example of this. Similarly UK professional bodies and Royal Colleges provide advice and guidance to promote service improvements and the provision of evidence-based care, alongside the work of bodies such as NICE. On both sides of the border, NHS organisations and their staff participate in national clinical audits and outcome reviews which enable services to be reviewed and benchmarked against common standards.
Directives to improve patient safety also transcend our borders such as advice issued by the Medicines and Healthcare Products Regulatory Agency (MHRA). Similarly all NHS organisations report patient safety incidents to the National Reporting and Learning System (NRLS) to identify themes and solutions to bring about improvements in patient safety.
Legislation
The devolution settlement means that Wales makes legislation to address the needs of the people of Wales and this has resulted in some distinct differences between the two countries. Key pieces of legislation include:
The Mental Health (Wales) Measure 2010
All persons registered with a Welsh GP, whether resident in England or Wales can be referred to the Local Primary Mental Health Support Services (LPMHSS) covering that GP area. LPMHSS are however usually provided on a residency basis and as such if a Welsh resident was registered with an English GP, that person could request to be seen by the LPMHSS covering their area of residence. Although in line with the cross border protocol they would normally receive a service from the mental health provider that serviced the GP with whom they were registered.
As part of the Measure all those in receipt of Welsh secondary mental health services have a statutory right to a care and treatment plan and a care co-ordinator. If discharged from these services patients are also able to directly refer themselves back for assessment within 3 years if they believe their mental health is deteriorating.
Whilst the Mental Health Act 1983 applies in both England and Wales there are differences between the two countries, particularly in the provisions on Independent Mental Health Advocates. As part of the Measure, Wales has introduced a significantly wider definition of the patients who qualify for IMHA. This has meant all those receiving treatment for their mental disorder in hospital in Wales are now eligible for IMHA services. In Wales, IMHA services are commissioned by Local Health Boards, while in England they are now commissioned by local authorities.
Human Transplantation (Wales) Act 2013
From 1 December 2015 Wales will operate a soft opt-out system for consent to organ donation for the purposes of transplantation. This means that an adult living in Wales for 12 months or more, who also dies in Wales, may be considered to have no objection to organ donation unless they have stated otherwise. This is also known as deemed consent.
The change to the system of consent in Wales is being taken forward within the context of the existing UK-wide system for organ donation and transplantation. This means that although Wales will have a different system of consent to the rest of the UK, other aspects of the process will remain unaffected. For example, there will still be a UK-wide waiting list and organs will be offered in accordance with clinical need and priority to suitably matched patients wherever they live in the UK.
In order to preserve the UK-wide nature of the allocation and use of organs, the UK Government has agreed to lay a Section 150 Order before Parliament shortly. This will amend the Human Tissue Act 2004 in order to allow the transplant of organs retrieved under deemed consent into patients in England and Northern Ireland. It will also ensure that appointed representatives made under the new law in Wales are recognised in other parts of the UK and vice versa.
The Welsh Government is currently engaged in a two-year information campaign ahead of the Act coming into force on 1 December 2015. As part of this work, communities along the England and Wales border will be specifically targeted in order to ensure that people understand which system will apply to them. The key issue is that a person must be ordinarily resident in Wales for the new deemed consent provision to apply. English residents registered with a Welsh GP cannot be caught within the deemed consent arrangements because an individual has to be ordinarily resident in Wales for at least 12 months for it to apply. It makes no difference which GP an individual is registered with, only whether the person actually lives in Wales. In practice, when a person dies in circumstances where they might be able to donate, then questions of residency would have to be established as part of the discussions with the family.
NHS Blood and Transplant is developing suitable training for clinicians both in and outside Wales to ensure they are aware of the implications of the change in specific clinical situations.
The NHS Organ Donor Register is being redeveloped in order to ensure that decisions not to donate (opt out decisions) can be recorded – this is particularly important for the new Welsh system since people will need to be given the opportunity to register a decision not to donate, otherwise the default position of deemed consent may apply. There will be a single register for the whole of the UK, which means that citizens of all four UK countries will be able to record an organ donation decision, either to be a donor or not to be a donor. However, it is only in Wales where deemed consent can apply.
Social Services and Well-being Act (Wales) 2014
GP registration is not a factor in deciding whether local authorities have a duty to assess or meet the care and support needs of adults, children or carers.
Where a person is considered (or ‘deemed’) to be ordinarily resident is crucial in deciding which local authority is required to meet his or her care and support needs. ‘Ordinary residence’ is one of the key tests which must be met to establish whether a local authority is required to meet a person’s eligible needs.
The test for ordinary residence, applies differently in relation to adults with needs for care and support and carers. For adults with care and support needs, the local authority in which the adult is ordinarily resident will be responsible for meeting their eligible needs. For carers, the responsible local authority will be the one where the adult for whom they care is ordinarily resident. Establishing responsibility for the provision of care and support for carers, therefore, requires the local authority to consider the ordinary residence of the adult needing care.
Ordinary residence is not a condition of the duty to meet the care and support needs of a child. Section 37 of the 2014 Act requires only that the child is within the local authority’s area and that their needs meet the eligibility criteria or the local authority considers it necessary to meet their needs in order to protect the child from abuse, neglect or other harm (or the risk of abuse, neglect or other harm).
There is no definition of ‘ordinary residence’ in the Social Services and Well-being (Wales) Act, and the term should therefore be given its ordinary and natural meaning. In most cases, establishing a person’s ordinary residence is a straightforward matter. However, there will be circumstances in which ordinary residence is not as clear-cut (for example, when people spend their time in more than one area, or move between areas). Where uncertainties arise, local authorities should always consider each case on its own merits. There is substantial body of case law on how the phrase ‘ordinary residence’ should be interpreted. The leading case is R-v-Barnet LBC ex parte Shah [1983] 1 All ER 226.
Where doubts arise in respect of a person’s ordinary residence, it is usually possible for local authorities to decide that the person has resided in one place long enough, or has sufficiently firm intentions in relation to that place, to have acquired an ordinary residence there. Therefore, it should only be in rare circumstances that local authorities conclude that someone is of no settled residence. For example, if a person has clearly and intentionally left their previous residence and moved to stay elsewhere on a temporary basis during which time their circumstances change, a local authority may conclude the person to be of no settled residence.
A local authority may conclude that a person arriving from abroad is of no settled residence, including those people who are returning to Wales after a period of residing abroad and who have given up their previous home in this country. A local authority’s duty, and in other circumstances its discretion, to meet a person’s needs for care and support will also apply to a person of no settled residence but who is within the local authority’s area.
Where a person goes into hospital, or other NHS accommodation, there may be questions over where they are ordinarily resident, especially if they are subsequently discharged into a different local authority area. For this reason, section 194 of the Social Services and Well-being (Wales) Act makes clear what should happen in these circumstances.
A person for whom NHS accommodation is provided is to be treated as being ordinarily resident in the local authority where they were ordinarily resident before the NHS accommodation was provided. This means that where a person, for example, goes into hospital, they are treated as ordinarily resident in the area where they were living before they went into hospital. This applies regardless of the length of stay in the hospital, and means that responsibility for the person’s care and support does not transfer to the area of the hospital, if this is different from the area in which the person lived previously.
This requirement also applies to NHS accommodation in another part of the UK. If a person who is ordinarily resident in Wales goes into hospital in England, Scotland or Northern Ireland, their ordinary residence will remain in Wales (in the local authority in which they resided before going into hospital) for the purposes of responsibility for the adult’s care and support.
Where a person is placed in a care home but is not eligible for NHS Continuing Health Care, the funding responsibilities for NHS Funded Nursing Care rest with the receiving LHB, or Clinical Commissioning Group (CCG) in England. Cross-border arrangements with Scotland and Northern Ireland are to be confirmed.
Public Health White Paper
The Public Health White Paper was consulted on in Spring 2014, and outlined a series of bold and practical legislative proposals aimed at meeting some specific public health challenges in Wales. The proposals are rooted in principles of prudent healthcare and take a preventative approach, by proposing action at points with potential for significant long term benefits. The proposed actions in areas such as tobacco and electronic cigarettes, alcohol misuse and the practice of cosmetic piercing, tattooing and other procedures, all contribute to meeting the Welsh Government’s responsibility to provide social conditions in which people can be healthier, and where unnecessary harm to health can be avoided. Following the White Paper consultation, the Welsh Government intends to bring forward public health legislation for consideration by the National Assembly for Wales in 2015.
Differences in entitlement
Free Prescriptions
Since 2007 NHS patients in Wales have received free prescriptions. Patients resident in England are eligible for free prescriptions if they are registered with a GP based in Wales and have their prescriptions dispensed in a Welsh pharmacy. In addition patients who live in Wales, but registered with a GP in England due to the proximity of their address to the England/Wales border, are issued with 'entitlement cards’. These cards allow exemption from payment if they present the card and the English prescription at a Welsh pharmacy.
However, there are still patients who, although registered with Welsh GPs, regularly receive treatment within English NHS Trusts, or out of hours services based in England, and may, following that treatment be issued with English prescriptions. When they take these to a Welsh pharmacy for dispensing they have to pay the English charge as they do not qualify for an entitlement card. To address this inequality a payment refund system (when evidenced by proof of payment) can be obtained via the NHS Wales Shared Services Partnership.
New Treatments
Wales and England are signed up to NICE as the best way of providing new treatments that are both clinically and cost effective. In addition in Wales we have the All Wales Medicines Strategy Group (AWMSG) which supplements the work undertaken by NICE and strengthens our evidence based approach to the provision of treatment for all conditions.
The Welsh Government recently announced improvements to speed up the system even further in Wales so that we can continue to ensure speedy access to drugs which are known to be clinically cost effective. A study published in the British Journal of Cancer in February 2014 comparing access to cancer medicines acknowledged Wales had a faster uptake of these medicines.
Operational Issues
Service Change
Changes to services on one side of the border can obviously impact on patients on the other side. In such circumstances we would expect the relevant health organisations to work together to ensure the new service meets the needs of all patients, and provides them with the best possible outcomes. For example, Betsi Cadwaladr University Health Board, Powys Teaching Health Board and Shrewsbury and Telford Hospital NHS Trust are working together in relation to the Trust’s decision to make changes to maternity and obstetric services in its area. The fundamental purpose of the cross border protocol is to provide consistent and practical resolution of such issues.
Waiting Times
The divergence in both policy and approach in the English and Welsh healthcare systems is brought into sharp focus for those who access GP services along the border. When referring on to secondary care providers, the policy in Wales is that Welsh patients who are treated in England should be treated in order of clinical priority, and within Welsh waiting times. English patients being treated in Wales should be seen in order of clinical priority, and within Welsh waiting times. This is underpinned in the cross border protocol and is aimed at providing a pragmatic approach to the practical issues arising from the two different health systems and to prevent referral into the respective systems being used in a way not based on clinical priority.
The divergence of policy and approach has resulted in an increasing tendency for comparisons in performance (in particular in referral to treatment times) to be made between the English and Welsh systems. However, whilst the desire for comparisons is increasing, the ability to make sensible comparisons is actually decreasing.
There are now many differences in measurement systems between England and Wales, including:
Overall, therefore, it is important to understand that direct comparisons between RTT in Wales and in England are difficult and unreliable. The differences between the systems mean that, in relative terms, the Welsh RTT position and total waiting list includes around 20% more patients than the English RTT position.
A number of independent reports have highlighted the differences and anomalies in the different RTT systems in the UK, these include:
Looked After Children with Specialist Mental Health Needs
We are informed by services of an emerging concern English Local authorities are sending Looked After Children (LAC), some of whom have specialist or mental health needs, without appropriate discussion/notification with health boards for placement in Wales. Recent published data shows there are 360 English LAC placed in Wales. Generally a proportion of such cases then require Children and Mental Health Service (CAMHS) or paediatric input. The needs of such young people can be very complex and are already known to their local CAMHS teams in England. We are aware that high levels of health interventions including admissions have been required for a significant number of such children which in very rural areas where health services are planned on the basis of local need can be very challenging.
Information provided by LHBs shows significant numbers of English LAC currently in Betsi Cadwaladr University Health Board and Powys LHB areas alone. In Powys 60% of LAC are reported to be out of county and placed by distant English authorities i.e. not their neighbouring English LA areas. The healthcare needs of this group are also significantly higher than average. An ONS survey confirmed high levels of mental health need among LAC, particularly those in residential care. 45% were assessed as having a mental health disorder, rising to 72% in residential care. Two thirds also had at least one physical health complaint. This places considerable burden on health services in Wales.
There is a voluntary cross border protocol in place for LAC which specifies when a looked after child is placed in Wales, from England, the placing authority must inform the local authority and the health care provider prior to the placement, and no later than 10 days thereafter. The placing and receiving organisations should liaise in order to ensure that their duties in relation to the health and wellbeing of the child are met. We would wish to see more evidence in practice that this guidance is being adhered to by English placing authorities and the case for it to be revisited has been raised via Wales Office Ministers.
Death Certification
The Welsh Government and the Department of Health (DH) work together to implement the new death certification reforms in England and Wales. In particular, communication between the two administrations will need to be closely aligned to ensure a consistent message and sound understanding of the changes being implemented. Without a fully aligned system there could be difficulties in ensuring the proper authorisation for the disposal of bodies in Wales or cross border disposals. Discussions continue between the two administrations to ensure the risks are mitigated.
Complaint Handling
Revised arrangements were introduced on 1 April 2011 for the handling of concerns about the health service in Wales. The arrangements are set out in the NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. One of the main changes was the introduction of the concept of ‘Redress’. Redress places Welsh NHS bodies (Local Health Boards and NHS Trusts) under a duty to consider whether there is a qualifying liability in tort, if the patient is thought to have been caused harm as part of their treatment. The arrangements allow for lower value claims of up to £25,000 to be settled without the need for legal action. Patients whose cases are considered under the Redress arrangements will be offered legal advice, free of charge, at certain points in the proceedings.
In Wales, Community Health Councils (CHCs) are in place to ensure patients’ views and needs influence the policies and plans being developed and implemented by LHBs across Wales. They play a fundamental role in ensuring the patient voice is heard and will monitor the quality of NHS services from a patient’s perspective.
If an English resident wants to complain about a Welsh GP or NHS service then this will be handled under the ‘Putting Things Right’ arrangements. The CHC will normally only provide advocacy for people living in their area but they can help them with a complaint about the English NHS.
Ambulance Services
It is well established that Welsh ambulances will often convey patients to English hospitals where this is in the best interests of the patient and vice versa. There is a memorandum of understanding in place between the Welsh Ambulance Service NHS Trust and three ambulance Trusts in England and they work together under this agreement.
Funding
I believe one of the issues raised as part of this enquiry relates to the lack of knowledge around funding for cross border patients and the Committee has asked for this to be clarified in my evidence.
The funding of relevant treatment is set out in the cross border protocol, which confirms that there will be no financial shortfall on the part of any LHB or Clinical Commissioning Group (CCG) in providing secondary healthcare services to the other country’s residents. In implementing the protocol, the responsible LHBs and CCGs will be appropriately funded to commission secondary healthcare services for the other country’s residents. A timely and appropriate adjustment of finances will occur between the Welsh Government and Department of Health, based on the existing methodology of reimbursement on a per capita basis for the net difference in primary care registrations between England and Wales which occurs as a result of arrangements in this protocol. LHBs’ allocations will be amended as appropriate by the Welsh Government.
An agreement was made at Ministerial level for an annual payment in recognition of the additional costs incurred by Welsh LHBs in paying for secondary care for the net number of English residents registered with Welsh GPs. The current figure of approximately £6.800m per annum is based on 20,758 English residents registered with Welsh GPs compared to 14,932 Welsh residents registered with English GPs, therefore, a net import of 5,826 English residents. This figure is then multiplied by the Hospital and Community Health Service (HCHS) spend per resident of £1,145. The principle of this payment is in line with the protocol.
The annual payment has not been uplifted since 2008/09 when the HCHS spend per resident was uplifted by 5% from £1,091 to £1,145, resulting in the annual payment increasing from approximately £5.600m to £5.800m. The HCHS calculation excludes the cost of primary care and prescribing, because funding for these services is on a registered, rather than resident, population basis.
With regards to patients receiving secondary care, for Welsh residents treated in England, Welsh commissioners (LHBs and the Welsh Health Specialised Services Committee) will pay English providers providing treatment as per the payment by results (PbR) tariff. The rate of payment for treatment of English residents in Wales is agreed locally by the Welsh provider (health board) as there is no standard tariff rate used within NHS Wales.
The National Survey for Wales is a large-scale face-to-face survey of people across Wales. This survey is carried out transparently and to the highest standards, and is independently recognised for its quality by the UK Statistics Authority. Each year 14,500 people aged 16 and over are asked for their opinions on a wide range of issues affecting them and their local area. Respondents are selected at random and the survey has a high response rate of 70%. This means we can be confident that the results are representative of people across Wales – not just those who are easy to reach or have a particular view that they want to put across.
Key findings from the 2013/2014 survey included:
Improving access to GP services is a key Welsh Government commitment. Published GP access statistics for 2013 indicate over 90% of GP practices within health boards located along the England border offer appointments at any time between 5.00pm and 6.30pm at least two week days. The Welsh Government is also committed to improving the ability of people to make appointments convenient for themselves through encouraging more GP practices to offer on line appointments.
Wales uses other methods of assessing patients’ experience including surveys, observations of care, complaints analysis, GP Participation Groups, Fundamentals of Care (2003), as well as the NHS Wales Framework for Assuring Service User Experience (2013), which outlines the 4 types of feedback all health organisations are expected to secure from their service users:
In Wales there is an expectation that healthcare organisations will co-operate and work together to deliver high quality services for patients, which does not stop at the England/Wales border. The use of services provided by Velindre Cancer Centre and Morriston Hospital in Swansea by Welsh and English patients is an example of shared use of specialist equipment. Indeed such co-operation is all the more important along the border to make sure people do not fall between the two health systems.
Some specific examples include:
Public health
Early in 2014 late amendments were made to the Children and Families Bill, now the Children and Families Act 2014, in relation to tobacco. I gave very careful consideration to the subject matter of the amendments, and proposed Legislative Consent Motions, which received the Assembly’s approval, so they could apply to Wales as well as England. Those amendments allowed the UK Government to take forward legislation on the retail packaging of tobacco products. They made it an offence for adults to purchase tobacco products for persons under 18 (proxy purchase). They also allowed regulations to be made to prevent the sale of e-cigarettes to persons under 18, and introduced a proxy purchase offence for these products, as well as giving specific regulation making powers to Welsh Ministers to make regulations prohibiting smoking in private vehicles carrying children. This has meant our existing regulation making powers are on a stronger footing. Taking advantage of the proposed amendments to the Children and Families Bill enabled us to bring in these protections for young people in parallel with changes in England.
As a result, a further consultation has been undertaken on standardised packaging of tobacco products on a UK basis, and draft regulations have been notified to Europe. The required standstill period has been extended to 2 March 2015. Final regulations cannot be made until after that date.
An England and Wales consultation on the age of sale and proxy purchase of e-cigarettes is expected shortly.
We have consulted on proposals to prohibit smoking in private vehicles carrying under-18s, with the draft proposals mirroring those in England.
I believe there is a strong case to devolve responsibility for alcohol licensing and we made a strong case for this as part of the Welsh Government’s evidence to the Silk Commission. However, whilst we have consistently argued that powers in respect of licensing of the sale and supply of alcohol should be devolved to the National Assembly for Wales so we can action specifically tailored to the situation in Wales, we still wish to work closely with the UK Government to help meet its overall policy objective of reducing alcohol related harm. For example, we participate with observer status in the UK Government led Public Health Responsibility Deal arrangements and have put forward two areas in Wales as Local Alcohol Action Areas.
Reciprocal healthcare arrangements for major events
An example where cross border co-operation has worked well between the UK countries, not just England and Wales, is around reciprocal agreements for major events, such as the Olympic Games in 2012, the Commonwealth Games, the IPC European Athletics Championships in Swansea and of course the NATO Summit, all this year. The Welsh Government and the NHS in Wales through these agreements ensured access to NHS healthcare, for which they would not ordinarily be entitled to, for all those taking part in these events.
IT Systems
Patient safety and care particularly along the border requires effective integration of IT systems. This is a matter which Wales and England need to consider in more detail and how working collaboratively can be developed. I chair the NHS Wales Informatics Management Board which oversees all NHS Wales informatics activity. This includes ownership of the technical infrastructure and the running of all informatics services.
The NHS Wales Informatics Service is in the process of establishing electronic referrals between Welsh GPs and English hospitals. Pilots have taken place between a number of GPs in Powys and English hospitals and will be extended to additional practices in Powys.
Ebola
Ebola is a good example where all four UK countries are working constructively together. An exercise has recently been undertaken involving the four UK Health Ministers, and Wales has shared experiences of suspected Ebola cases with the other countries. Regular teleconferences are taking place between health officials of the four UK health departments as well as teleconferences with the UK health protection agencies. In addition there is an agreed Ebola communications strategy in place. The World Health Organisation has asked the UK for support to assist them with a number of African countries (currently without Ebola) in their preparedness arrangements for managing the virus in the coming weeks. Public Health Wales is linked in collaboratively with Public Health England to respond to this request and have been asked to develop a package of support (similar to that being provided to the health boards) which includes providing on-site training for people in a number of English speaking African countries.
The purpose of the cross border protocol between England and Wales was to provide a pragmatic approach to practical issues. It ensured that those patients living along the border did not fall between two different health systems (one based on planning and one based on commissioning). From this perspective it can be said that the protocol has met its objectives, as it has ensured that patients along the border have received care and treatment irrespective of their country of residence and issues arising have been resolved.
Since its inception, the protocol has been reviewed regularly and from April 2013 Ministers on both sides of the border agreed to broaden the protocol, signing off overarching high level principles which underpin the protocol itself. The purpose of the protocol is to help ensure the smooth interaction between the NHS on either side of the England and Wales border to support better patient outcomes and avoid the fragmentation of care. It allows patients to acquire a GP over the border and secure health services in a fair and equitable way, as well as ensuring there is clarity about the standards of services to be secured across the border.
The Department of Health in England has asked that the protocol be reviewed again as it is concerned that English residents registered with Welsh GPs are not accessing their right to choice under the NHS Constitution, and that they believe the protocol is inconsistent with legislation applicable in England. From a Welsh Government perspective there is no similar concern with the statutory basis of the protocol. This is purely an English issue. The Department of Health in England is now seeking to address the perceived non-compliance with its legislation. Discussions are taking place between the Welsh Government, the Department of Health, NHS England and the Wales Office to explore how the proposals might work in practice.
The Welsh Government is awaiting a formal response from the UK Government on the Silk Commission Part II recommendations. Any actions taken will need to ensure that equitable access to high quality and safe care continues to be provided along the Wales/England border, placing the patient at its centre.
18 December 2014
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