The Welsh NHS Confederation s response to the inquiry into cross-border health arrangements between England and Wales.

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1 Welsh Affairs Committee. Purpose: The Welsh NHS Confederation s response to the inquiry into cross-border health arrangements between England and Wales. Contact: Nesta Lloyd Jones, Policy and Public Affairs Officer, Welsh NHS Confederation Nesta.lloyd-jones@welshconfed.org Tel: Date created: 18. Introduction 1. The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to respond to the inquiry into. There are a number of patients from Wales who receive healthcare services in England and a number of patients who reside in England who receive services in Wales. While the numbers are relatively small, these patients should receive coordinated healthcare no matter in which country they are receiving the service. 2. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent. 3. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members involvement underpins all our various activities and we are pleased to have all Local Health Boards (LHBs) and NHS Trusts in Wales as our members. 4. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales. Summary 5. Working in collaboration: While the protocol for cross-border healthcare services has led to improvements in communication, healthcare providers in England and Wales need to maintain close links to ensure that patients receive the treatment they need regardless of their country of residence. The decision-making process on each side of the border needs to be more coordinated, coherent and transparent. 6. Cross-border citizen engagement: Many patients on both sides of the border are generally unaware of devolution and the potential for divergence between Welsh and English health services. Better information for patients in border areas must be actively made available, where the patient choice of a Welsh or English GP may have implications for later healthcare services. 1 Submission by the Welsh NHS Confederation to the inquiry into

2 7. Awareness of border issues when producing policy within the Department of Health or Welsh Government: While the number of patients receiving cross-border healthcare is relatively small, there still needs to be improved coordination between the Department of Health and the Welsh Government. Health policy in England and Wales should be 'border-proofed' to ensure diverging policies do not have unintended consequences for patients. Cross Border Patients: The statistics 8. Primary care: There are more English patients registered with Welsh GPs than vice-versa. Around 20,200 England residents are registered with Wales GPs, which is higher than the approximately 15,100 Wales residents who are registered with GPs in England. i Geographic convenience is the main reason behind cross-border travel for primary healthcare. 9. Secondary care: The cross-border flow is generally from Wales to England and occurs more often in Mid and North Wales. This is partly due to geographic convenience, but also because of the lack of secondary care provision in the immediate locality, for example Powys teaching Health Board has no District General Hospital within its boundaries. In about 50,700 Welsh residents travelled to England for treatment, but only 10,400 residents from outside Wales were admitted to Welsh LHBs (1.3% of hospital admissions in Wales). ii 10. Tertiary Care: Tertiary care centres are mainly located in areas of higher population density and the relatively small population size of North and Mid-Wales means that there is simply not the critical mass of people needed to support more local specialist centres. Cross-border flows of patients for such care are therefore mostly from Wales into England. The number of Welsh residents receiving tertiary care in England is not readily available. Terms of Reference i) The impact of the increasing policy divergence in the health systems of England and Wales on cross-border healthcare services, and on medical practitioners and patients in border regions in England and Wales; 11. The context in which healthcare is organised within England and Wales is different and this can, in some circumstances, have a potential impact on cross-border healthcare services. The examples highlighted below could cause confusion for patients in border regions due to a lack of awareness of devolution and policy divergence. Commissioning arrangements 12. The commissioning arrangements and governance arrangements in England and Wales are very different. Within the NHS in England the Health and Social Care Act 2012 sets out a new clinicallyled commissioning structure for the NHS with 211 local Clinical Commissioning Groups, held to account by the independent NHS Commissioning Board. Most public health functions have also transferred to Local Authorities and decisions on local planning and priorities are informed by Health and Wellbeing Boards. 2 Submission by the Welsh NHS Confederation to the inquiry into

3 13. The Welsh context is very different with one consistent set of arrangements. There are seven LHBs, each aiming to integrate specialist, secondary, community and primary care and health improvements. Each Health Board holds the full budget allocation and the national direction is towards collaborative planning and not competition. The seven LHBs collaborate for specialist commissioning through a joint committee - the Welsh Health Specialised Services Committee (WHSSC) - and public health is integral to each LHBs work. Differential pricing 14. The English and Welsh healthcare systems have different pricing regimes. The majority of tariffs with English acute providers are informed by the English National Tariff system and are only adjusted for agreed, known items, such as market forces factors, with very little room for local variation. This allows for transparency between the costs incurred in providing the service and the tariffs paid by commissioners for the use of services. 15. The tariff system in Wales is much more for local agreement with prices for similar services differing between English and Welsh providers and also LHB across Wales. For example, Powys teaching Health Board will pay a different tariff for an emergency general medical admission depending on where the admission takes place. 16. In terms of payment for English residents treated in Wales, there is no standard tariff rate used within NHS Wales. The rate of payment for treatment of English residents in Wales is agreed locally between the Welsh provider and English commissioner. The rate of payment should reflect the cost to the Welsh provider of undertaking the activity. 17. The differences in pricing introduce complications into the system, with differing tariffs used for differing providers, and also makes drawing comparisons between providers difficult. Social Care 18. Health and social care are interlinked, with a clear emphasis in Wales towards better integration between both sectors, which causes some issues. When a Welsh resident is being discharged from an English hospital responsibility in relation to social care stops at the border no matter where the patient s GP practice is registered. This leaves GPs in Wales having to work their way through two, and in some cases even three, different Local Authority social care systems, some of which vary very considerably. For example, the amount a patient is expected to pay towards their social care package in England is significantly higher than in Wales. The divergence between England and Wales in relation to social care is only going to increase with the introduction of the Social Services and Well-being (Wales) Act 2014 and the Westminster Care Act Due to the nature of patient care there needs to be integrated and co-operative working across health and social care, often on a long term basis. Due to the nature of care, it is important that social care services in England come to LHB community planning meetings, and vice versa, to ensure that patients receive no delay in their care. 3 Submission by the Welsh NHS Confederation to the inquiry into

4 Community Services 20. There are local issues with the arrangement for people living in one country but registered with a GP in the other. These issues, in many circumstances, have to be resolved locally by agreeing that the community care, post discharge from a District General Hospital, should be provided by the patient s GP practice team. Local Authority Funding Care Home Placements 21. In England the providers have arrangements with Local Authorities that allow them to place patients in care homes and then they can bill to the Local Authority. This is problematic for Health Boards in Wales because they have large numbers of Local Authority delayed transfers of care and the English providers cannot understand why the Welsh Health Board does not place patients in care homes. Cancer Drugs Fund 22. The Cancer Drugs Fund, which applies only in England, is one example where differing policies have to be managed by LHBs in Wales in terms of expectation, communication and on an operational level. 23. In May 2012, the Welsh Government rejected the need for a Cancer Drugs Fund in Wales due to the different processes in Wales. In Wales the NHS relies on NICE guidance and the All Wales Medicines Strategy Group (AWMSG) for its expert advice on medications. The Welsh Government considers that a Cancer Drugs Fund will undermine these processes and could create unacceptable inequalities in the Welsh health system. 24. As well as the AWMSG, the Individual Patient Funding Requests (IPFR) system is designed for patients where a treatment has been appraised fairly and transparently and a negative decision of routine funding has been made by NICE, and/or AWMSG. Applications from English providers where the consultant feels a Welsh patient would benefit from a drug which is available to English patients via the Cancer Drugs Funds are managed through the Health Board s IPFR process. This requires the consultant to prove clinical exceptionality in the case of individual patients where the cancer drug has not been approved for use. 25. The Cancer Drugs Fund is a constant topic of conversation for patients who experience what seems to be a postcode variation in access and who are not aware of the AWMSG or the IPFR process. In addition, there is still a lack of understanding that the drugs within the Cancer Drugs Fund have not been NICE approved and may permit treatments that have no, or very limited, benefit for patients overall. Free Prescriptions 26. The introduction of free prescriptions in Wales has raised the question of how this applies to English residence who are registered with a GP in Wales because all patients registered with a Welsh GP are entitled to free prescriptions from a pharmacist in Wales. Welsh patients who have an English GP are also eligible for free prescriptions, but would need to apply to their LHB for an entitlement card. 4 Submission by the Welsh NHS Confederation to the inquiry into

5 27. Prescriptions are only dispensed free of charge at pharmacies in Wales. Patients who have their prescriptions dispensed outside Wales will be charged at the rates that apply in that country. Patients who qualify for free prescriptions under the English regulations would not be charged. Since October 2009, Welsh patients who are treated at hospitals or out of hours services in England, and are charged for prescriptions at the English rate, are able to claim a refund. 28. While reclaiming the expense for prescriptions is possible many patients do not do this due to lack of awareness or other barriers. ii) The experience of patients in England and Wales who are reliant on the use of healthcare services on the other side of the border; Patient awareness 29. Patients remain generally unaware of the existence of different policy arrangements, such as waiting time targets between England and Wales, until they are undergoing treatment. Patients generally remain unaware of the potential implications of their decision to register with a GP in either England or Wales, should they need a referral to a secondary provider. 30. The health service, due to the differences in structures and policy direction, can be somewhat confusing for patients living on the border and there remains a lack of awareness and understanding around devolution. Polls conducted recently by the BBC iii highlighted that fewer than half of people in Wales realise the NHS is the responsibility of the Welsh Government. The poll showed that 48% of people knew Welsh ministers are in charge of health, while 43% thought it is the UK Government. As the Silk Commission Part II highlighted: Parts of the border region between Wales and England are densely populated and all along the border people work and obtain services in Wales or in England with little concern for the administrative boundary. iv 31. This lack of engagement and awareness at a practical level means that it is quite possible to have two people living next door to each other in either Wales or England registered as patients with two different practices and subject to two different health policies. Patients who live close to the border and choose to register with a GP outside their home country usually do so for reasons of convenience. They are unlikely to consider any implications in terms of increased or decreased waiting times should they require hospital treatment at a later stage. 32. We would recommend that much more information about the differences in health services should be made available to patients at the time of registration with a GP so that patients are fully aware and engaged with the healthcare service that they are accessing. The tables within the protocol for cross-border healthcare services should be made more readily available to the public to increase their understanding of the arrangements. Paragraph 11 of the protocol summarises the commissioning and healthcare planning responsibilities and legally responsible bodies. Paragraph 16 summarises what patients should be able to expect in terms of standards for access to healthcare depending on residency, GP location and provider. 5 Submission by the Welsh NHS Confederation to the inquiry into

6 Residency GP Location Commissioning/healthcare planning responsibility Legally Responsible Body Wales Wales LHB LHB England England CCG CCG Wales England CCG LHB England Wales LHB CCG Residency as below GP Location as below English Provider to meet: Welsh Provider to meet: Wales Wales WG standards WG standards England Wales WG standards WG standards England England NHS Constitution WG standards Wales England NHS Constitution WG standards Patient engagement in healthcare development 33. One of the key criteria for cross-border health policy should be to ensure that patients and the public are able and encouraged to engage effectively in health policy development. It is vital to establish a degree of citizen ownership of healthcare provision in order to maintain the focus of services on the patient. In Wales, Community Health Councils (CHCs) serve patients needing information, or wishing to make a complaint. In England Patient Advice and Liaison Services provide information, advice and support to help patients, families and carers on a health Trust by Trust basis. 34. In addition to the Patient Advice and Liaison Service in England, patient forums of the Clinical Commissioning Groups patient forums and Healthwatch, the national consumer champion in health and care in England, need to engage further with LHBs in Wales to ensure information is shared about the needs of cross-border patients. It is important that patients are effectively engaging with the healthcare system and that they have a voice which can be heard by those who commission, deliver and regulate health and care services. Patient choice 35. A major policy divergence since devolution relates to patient choice in booking elective hospital treatment. In England, as part of the commitment to use an internal market and competition as a means of improving quality and efficiency, patients are able to choose which hospital they are referred to by their GP. This legal right lets patients choose any English hospital offering a suitable treatment that meets NHS standards and costs. Patient choice of hospital also applies to those Welsh residents registered with a GP in England. 36. In contrast, the Welsh Government One Wales agreement in 2007 committed the Welsh Government to eliminating the internal market and giving patients a greater say in how NHS services are run a focus on patient voice rather than patient choice. Patients registered with a GP in Wales do not have a statutory right to choose at which hospital they receive treatment. This difference causes patients confusion and sometimes frustration. 6 Submission by the Welsh NHS Confederation to the inquiry into

7 37. There is a difficulty in relation to patient choice because English residents who register with GPs in Wales should expect to receive their community services in Wales wherever possible, but there have been instances where some English residents expect LHBs to commission these from English Community Healthcare. Waiting Times 38. The implementation of different waiting time targets has also had an impact both on the management arrangements for meeting these targets and on managing the population s expectation of services provided in England and Wales. Similarly, the English providers who have continued to operate different waiting times targets between English and Welsh commissioners have had additional administrative burden placed upon them. 39. Health Boards in Wales have to manage both patient and clinician perceptions of different waiting time targets between England and Wales. This has resulted in letters of complaint due to the confusion over the differences. Although English waiting times are shorter, the principle of treatment based on clinical need and order are consistent with Wales. Car Parking 40. In general there are no car parking charges in Wales (except for those subject to private contracts) but they continue to be in place in England. Patients feel disadvantaged when attending an English Hospital as no refund arrangement exists as they do with prescriptions. Complaints received about Cross-Border Provider Services 41. When a patient makes a complaint about a cross-border provider service, there can be a lack of transparency and information sharing between Trusts in England and LHBs in Wales. 42. Welsh GPs who refer English residents to English providers are not generally informed of any complaints or issues of concerns raised by the patient. This issue was recently highlighted within the Silk II Commission report: it has been suggested to us that there is a need to ensure that complaints are swiftly and effectively dealt with We agree and believe that a sub-committee should be established under the new Welsh Intergovernmental Committee to consider and resolve cross-border issues when they are not resolved through normal channels. v 43. It is important that national regulators and inspectors in England ensure information around any concerns or complaints raised by Welsh residents are communicated with the LHB. As it stands, health and care regulators in England do not inform Welsh commissioners (LHBs) of any complaints or concerns. This is important to ensure that LHBs are commissioning safe and quality assured services. Medical Performers List 44. The Medical Performers List operating in England and Wales, the list upon which the name of a practitioner must appear if they are to be permitted to provide primary care services in any given area, causes administration and practical issues for GPs. For example, if a GP is on a Medical 7 Submission by the Welsh NHS Confederation to the inquiry into

8 Performers List in a Health Board in Wales, there is a degree of flexibility across all the Welsh Health Board areas. However, the same does not apply to England. 45. If a GP is on a Medical Performers List in England and they wish to work in Wales, or vice-versa, they must also apply separately for inclusion on a Welsh Medical Performers List. Faced with the inconvenience of going through a second application process, those already in England are often put-off applying to the Welsh Medical Performers List and therefore do not make themselves available for work in Wales. iii) The case for greater sharing of resources and facilities between the English and Welsh healthcare systems, for example in relation to procurement and use of high-tech equipment. 46. The Welsh NHS Confederation, in our response to the recent National Assembly inquiry into medical technology, highlighted the practical difficulties for health professionals supporting people on the border. 47. In our response we highlighted that the current lack of integration of primary and secondary care systems in both Wales and England is causing difficulty. It is important that there is further development in integrating IT systems because currently hospital systems are often bespoke and do not fit well with GP systems. 48. While hospitals in England can pass discharge information electronically to GP practices managed by English primary care organisations, they cannot do so to Welsh practices. GPs in Wales do not get patients results or reports electronically from English hospitals therefore causing delay in accessing information in a timely manner. The delay in information sharing could potentially put Welsh patients, post-discharge, at a higher risk than English patients from the same hospital. Extracting information for medicine reconciliation in hospital is also affected, potentially increasing safety risks for Welsh patients. The reverse may also be true if an English patient receives treatment in a Welsh hospital which can otherwise access and transfer information back out electronically. iv) The impact of the Protocol for Cross-border Healthcare Services agreed by NHS Wales and NHS CB England, implemented in April 2013, and whether it is meeting its objectives; 49. Since the introduction of the protocol there has been improved clarification for arrangements and further developments to improve cross-border healthcare in England and Wales. 50. The protocol has supported the development of key principles that have ensured that patients in border areas receive more consistent services. The Ministers have agreed principles on a range of areas as part of the protocol - information sharing, regard for the financial implications for providers, emergency care available for all, access to a GP across the border, clear rules on responsible bodies, recognition of NHS bodies, services and qualifications and changes to NHS services should all consider cross-border impact. 51. The protocol has led to border healthcare providers working more collaboratively with each other, including through the Cross-Border Health and Social Care Task Group. The Task Group was 8 Submission by the Welsh NHS Confederation to the inquiry into

9 established to develop and promote closer cross-border working and collaboration specific to health and social care between partners and organisations operating along and across the border between England and Wales. The Task Group considers health and social care policy developments across the border area and the potential impact that these could have on patients. The Task Group also provides reports and recommendations on working group activity and resolves issues where appropriate. 52. While the protocol is positive in the areas it is explicit about the responsibilities of each country, when new health guidance, or policy, is developed in England or Wales the needs of cross-border patients and services must be considered. Clarification is also required over the hosted service arrangements, for example sexual health services and the impact Better Care Fund will have on cross-border patients with the direction in England being a transfer of healthcare funding from the NHS to Local Authorities. 53. The Welsh and UK Governments must work closely together to ensure that the needs of people and organisations on both sides of the border are taken into account in the development and delivery of policies. v) The Silk Commission Part II recommendations on cross-border health, particularly the proposal to develop individual protocols between each border Local Health Board in Wales and neighbouring NHS Trust in England; 54. As highlighted previously, arrangements between LHBs in Wales and Trusts in England can be different depending on their needs. For example, the cross-border flow in Betsi Cadwaladr University Health Board and Powys teaching Health Board predominately relates to residents in Wales going to England for secondary or tertiary care. Meanwhile in Aneurin Bevan University Health Board, it predominately relates to English residents who are registered with Welsh GPs. Due to the different needs of patients there would be some scope in developing individual protocols or better coordination between each LHB in Wales and NHS Trusts in England. vi) Any lessons that can be learned from other cross-border health arrangements, such as between England and Scotland or Northern Ireland and the Republic of Ireland. 55. Due to the fact that devolution has been established longer in other nations than in Wales, the cross-border health arrangements are more established and understood in other nations. This underlines the need for increased awareness by the public in both Wales and England in relation to devolution and the difference in healthcare systems. Conclusion 56. Healthcare providers in England and Wales need to maintain close links to ensure that patients receive the treatment they need regardless of their country of residence. While the numbers of cross-border patients are small, any divergent policies must be implemented in a way which accommodates the continuing flow of patients across the Wales-England border to ensure that patients receive treatment where it is most clinically appropriate. 9 Submission by the Welsh NHS Confederation to the inquiry into

10 i Public Health Wales Observatory, March 2014, Demography profile: Registered population. ii Welsh Government, October 2013, Patient Episode Database for Wales Annual Report. iii BBC Wales, 9 June 2014, Fewer than half the population know who runs Welsh NHS, says poll iv Commission on Devolution in Wales, March 2014, Empowerment and Responsibility: Legislative Powers to Strengthen Wales, page v Commission on Devolution in Wales, March 2014, Empowerment and Responsibility: Legislative Powers to Strengthen Wales, page 10 Submission by the Welsh NHS Confederation to the inquiry into