Oral evidence: Cross-border health arrangements between England and Wales, HC 404

Oral evidence, 18 November 2014.

Witnesses

Jesse Norman, MP for Hereford and South Herefordshire, and Pamela Plummer, Action4OurCare, gave evidence.

Chair

Thank you both for coming along this morning. As you know, we are a bit short of time, so I will dive straight in and ask some questions. You do not both need to answer every one. Jesse, could you tell me why so many patients living in Herefordshire and Gloucestershire are registered with Welsh GPs?

Jesse Norman

I thank the Committee for taking this testimony. I come at this very much from a constituency representative position. I do not have a political agenda about it, but I do have a serious issue. I have a lot of constituents—about 3,500 in Herefordshire overall—who live along the border and are registered with Welsh GPs. In almost all cases, they do not have a choice about that; it is because their nearest GP is in Wales, and very often other local GPs will not accept them on their rolls. The difficulty with that has come because in some cases those people are not being given the rights they are entitled to as English residents under the English NHS. The classic example would be one of my constituents who was pregnant and was looking for a nuchal scan. She lives in Herefordshire and wanted to have her baby in Hereford hospital, which has a very good maternity unit, as do other hospitals. It is one of those things where you have a narrow time to get the scan; you have to have it between 11 weeks and two days and 14 weeks and one day. Essentially, what happened was that she missed her scan. That is just one example among many.

Chair

Others will forgive me, but I am jumping ahead a little. We saw a letter in our pack from the Health Minister saying that she had given an instruction that in future English patients registered with Welsh GPs would have by guarantee whatever standards apply in England. As far as I can tell, that is officially Government policy, as of a few weeks ago. Am I right or wrong in saying that?

Pamela Plummer

You are absolutely right, yes.

Jesse Norman

If I may follow that up for a second, before Pam speaks, in her letter it looks as though that applies to primary care. A lot of the concerns that we have relate to secondary care—different waiting times between the Welsh NHS and the English NHS and access to the cancer drugs fund. There is a whole suite of rights to which people are entitled as English residents. The question is, should they get them? There is a worry from the Government’s standpoint. If they do not honour the rights in full, they are potentially open to legal challenge, judicial review and criticism. I think they want to avoid that.

Pamela Plummer

To go back to the original question, the reason that so many of our residents in Gloucestershire are registered with Welsh-registered GPs is historic. When they registered with them years ago—lots of people have lived in their village for decades—there was a UK national health service. Secondly, it is about accessibility, because we live in a rural area; it is about the local GP. Thirdly, as Jesse said, there is absolutely no choice. There are no English GP surgeries that will take you, because of home visits, although that has eased very recently because of what Aneurin Bevan health has done. Uniquely in Gloucester, there are seven GP practices affected. Three of those surgeries are physically in England. For example, I moved to Gloucestershire from Monmouthshire. I registered with my local GP in 2002, when there was a UK national health service. I lived in England and my surgery was in England. Why would I bang on the door and ask them whether they are Welsh? You do not do that. You just do not think that is the case.

Chair

I didn’t know you were a constituent at some point.

Pamela Plummer

Didn’t you?

Nia Griffith

Essentially, your patients are resident in England but are registered with a Welsh GP. When it comes to secondary services, it is the Welsh NHS that pays. Do you think it would be easier if it were the English NHS that paid? That might circumvent some of the delays that you have experienced.

Pamela Plummer

We would like to see the money for secondary care channelled through to Gloucestershire clinical commissioning group, because that would solve a lot of the issues around representation, consultation and our legal rights. If Gloucester CCG were able to commission for the whole of Gloucestershire—which they should as it stands, because their own constitution says they commission for the whole of Gloucestershire, but in fact they don’t; they commission for most of it—we would be able to hold Gloucester clinical commissioning group to account for all the decisions they make, through our democratic representatives. The way it is organised at the moment, Aneurin Bevan health board do our commissioning and are absolutely unaccountable for their actions through any democratic process. We have no representation whatsoever in Wales. The community health council is not allowed to represent us because we live in England. Healthwatch has no powers because we are treated as if we live in Wales. Gloucester CCG are sympathetic but powerless. We have no means of complaining or objecting to anything that Aneurin Bevan health do, which is why we ended up in a mess over a year ago, when they introduced their out-of-area referral policy, which prevented us from accessing secondary care in England.

Jesse Norman

To be fair to Aneurin Bevan health board, there has been lobbying on that; they have listened to it and put in place a temporary arrangement, but no one thinks it is a durable long-term arrangement. It applies only to certain trusts that they work with. There is another anomaly, which is that Welsh patients who are registered with English GPs have all the rights that they get under the English NHS. There is parallel unfairness the other way as well.

Chair

Who pays for them? Is their secondary treatment paid for by the Welsh health board or by the English commissioning group?

Jesse Norman

I do not know what the financial arrangements are, but the principle is clear: the money should follow the rights. That would mean that people on both sides would have to be sorted out either way.

Chair

We will have to find out—

Jesse Norman

What I am focusing on is the rights, if you see what I mean.

Nia Griffith

You have covered most of it. As you say, initially Aneurin Bevan said, “No, we have to look at every single one.” Then they said that there were four you could go to. How much communication was there with patients and GPs about the new arrangements—that you could go to specific hospitals but not to others? Do you think there is more that ought to be done in that respect?

Pamela Plummer

Do you mean as it is now or what happened a year ago?

Nia Griffith

Initially, in 2012, they said that you could not go. Then, in September 2013, they said that there were specific, named hospitals that—

Pamela Plummer

In 2012, we wrote to Aneurin Bevan health board and had two letters back, one on 18 April and one on 20 June. In those letters they defended their consultation process and said that it was extensive. It was extensive, but not for Gloucestershire. There were no adverts in the local press, only in the Welsh press. One person from Gloucester PCT, Sarah Hughes, attended one meeting. Gloucester PCT was in the middle of being unravelled because of the reorganisations in England, so really there was no consultation whatsoever in Gloucestershire. In terms of how people found out that they could not access services, I personally found out because my friend rang me up and said, “I can’t go to England for my hearing treatment any more.” When I asked why, he said, “Because Wales won’t allow us to refer to England any more.” In my naivety 18 months ago, I said, “What has it got to do with Wales?” I had no knowledge of the system or how it worked. They changed their policy partly because of a public outcry. It was not just a rethink. We had a public meeting, and 270 people came. We had 800 people sign a petition. We personally delivered over 2,000 leaflets. Our MP and Jesse Norman helped as well. Parish councils and district councillors also got involved. There was a public outcry about what was happening because people’s care was being jeopardised to such a degree. That has been sorted out now, but it does not represent a permanent solution. On paper, as things stand, Aneurin Bevan could change their mind at any time they like, and we could go back to that in five years’ time. It also denies us our legal rights under the NHS constitution and the Health and Social Care Act. We always believed that to be the case, but Ms Ellison and the Department of Health have now confirmed it. We are now in a situation where we feel that we are not being treated lawfully.

Jesse Norman

Pam has explained it very well. Could I add a very quick grace note? In Herefordshire, where we had a similar outcry, three of the cases that I cited, which relate to eye care denied, an MRI scan and antenatal scans, occurred after the change in policy. Not only was it evidently not particularly well communicated, but it was not clear that they were following the policy even within the system after the change had been announced and supposedly promulgated.

Geraint Davies

Mr Norman, we have heard from you that you have constituents who live in England but have no option of registering with an English GP. They are required to register with a Welsh GP, but even though they live in England the money for their treatment is paid by Wales. Do you think that it would be better if their treatment were paid for by the English NHS, in order that they could make the demands and representations that you want where they are treated—namely, in the Welsh NHS?

Jesse Norman

If I may, I will not get drawn on that, only because the financial arrangements between the Welsh NHS and the English NHS are so complicated and cross so many different areas—secondary care, primary care and the ambulance service. An equitable settlement needs to be drawn up between the two. I am just insisting on the very obvious and boring point that if people live in England and have no choice but to use a Welsh GP, they should maintain their rights under the English NHS. They are owed that duty of care. There is a parallel case for Welsh patients who are in the other situation.

Geraint Davies

We heard from the previous witnesses that there are various commissioning arrangements between England and Wales where a health trust in Wales will pay England, or vice versa, according to where they send their patients. That seems to work. It seems to follow from that, in principle, that, if you are a person coming from England into Wales, the money should follow the patient—and it does not. Surely that would be part of the solution. Why aren’t you pressing for that?

Jesse Norman

As far as I understand it, that is the general principle. Of course, often the tariff arrangements do not work at all well. At Hereford hospital, we have always served Welsh patients, all the way up to Rhayader and Llandod. Often the tariff is inadequate for the work that is done, and paid late. There is a range of issues. I would like a consolidated solution to have the overall issues addressed.

Chair

In fairness to Geraint, he has a point, hasn’t he? Shouldn’t English residents who have registered with Welsh GPs pay their own prescription charges if they want to have English standards—English waiting times? Aren’t people getting their cake and eating it at the moment? They are getting the free prescriptions, but they are demanding English standards on waiting times.

Jesse Norman

I see the force of the argument. I just do not know enough about the financial arrangements to comment. I would say that they are people who are forced to use those GPs. They are not people who are doing it as a matter of choice in order to avail themselves of free prescriptions.

Jessica Morden

Could you explain a bit more about why GPs will not take those patients?

Pamela Plummer

It is because of practice boundaries and locality. They have to do home visits. They will not cross the line to do home visits because it costs them money. Until very recently, we could access only Welsh GPs. After the public outcry, one GP practice in Lydney extended its boundary to take 500 more people, but that is not going to help the 6,000 people if they want to get to an English GP. We are locked into a situation where there is an absolute monopoly on us. There is nowhere else to go.

Nia Griffith

There is no patient choice.

Pamela Plummer

Absolutely—not even at the level of the GP. That goes against the NHS constitution as well, because you are supposed to be able to choose your GP. We are stuck, and there is nothing we can do about it. When the out-of-area referral policy came in, that was recognised by Aneurin Bevan health board in their board minutes; they actually commented that we could not move and, therefore, their GP practices were at a low risk of being destabilised.

Jessica Morden

You mentioned that there had been some changes to the boundaries. How have you achieved those?

Pamela Plummer

Sir David Nicholson wrote to the English GPs locally, apparently. He confirmed to us that that GP had extended its boundaries, but again it has not been communicated particularly well to English patients if they need to move. Most people do not even know about Lydney. We are doing leaflet drops on behalf of the NHS to tell people what is going on.

Nia Griffith

Are you lobbying NHS England to do that?

Pamela Plummer

Yes. We had meetings with NHS England in July and we have been exchanging e-mails ever since. In fairness to Mr Stevens, he asked us to be involved in the proposal communicated to us, but we are having quite a job trying to get NHS England to tell us what our legal rights are. We asked our MP, Mark Harper, to go to the Department of Health to get a statement because NHS England would not tell us. They kept telling us that they did not know and that it was complicated. The last e-mail said, “We will tell you when we have implemented it.” We were about to say, “Sorry, but we would really like to know anyway,” when we got the letter from Jane Ellison, which solved the problem.

Jesse Norman

I do not share Pam’s view that it has solved the problem, because it only addresses the issue of primary care and does not reflect a settled agreement between the two NHSs, Welsh and English. That is what we want. I have also lobbied the English NHS on this issue. Let me give you an example. Patti Fender, a local campaigner who is well known to Pam and me and who lives in Welsh Newton, applied to be supported by Much Birch surgery and the one in Ross-on-Wye. Both said no. The result is that she has no primary care. She was with a Monmouth GP, but she is asserting her rights under the English NHS, and I think that she is perfectly entitled to do that.

Geraint Davies

Are you saying—I would agree with this—that someone living in England should have the right to register with an English GP, because they live in England, and, secondly, that if they are to be registered in Wales, they should have the money follow them from England to Wales to pay for that service and deliver the expectations that they have from living in England?

Pamela Plummer

In theory, yes. I think we have the right to have an English GP and that NHS England should be providing that. All I can say is that, when we held our public meeting and 270 people came to it, people said to us that they really like their Welsh GPs. The issue is not their GPs; their GPs are great. They are happy to stay with their Welsh GPs. They just want their rights to secondary health care under the NHS constitution.

Geraint Davies

But it should be paid for by England. That is the point I am trying to make—the money should follow them.

Pamela Plummer

I am not an expert on the money. Logically, I would have thought yes, because it makes sense.

Jesse Norman

These areas are very large. Even if the GPs were to open up their lists, in many cases it is not realistic to ask people to move.

Geraint Davies

I understand that.

Nia Griffith

But if the money followed the patient—

Jesse Norman

If the money followed the patient, it would be absolutely different.

Pamela Plummer

The situation in my area is that you could stay with a GP you know; they treat you well, they know your family and background and there is a good relationship. Then they just access NHS England secondary health care. The commissioning is done in Gloucester, so it is safe and protected, and it is all as clear as a bell. Gloucester commissions for 620,000 people. Another 6,000 would not make any difference.

Chair

Just to be clear about this, you both agree that the money should follow the patient around, broadly speaking.

Pamela Plummer

Yes, that makes sense.

Chair

It is complicated, but that is your position in simple terms.

Jesse Norman

I am not contesting that, but that general principle, which is the one the NHS adopts, has to be weighed against issues of fairness in the overall balance. We have a system that is not fair on both sides of the border. That needs a consolidated discussion.

Geraint Davies

Basically, the money should follow the patient.

Chair

There is almost some consensus. On that happy note, let us move on.

Simon Hart

We will soon put a stop to that. What would your constituents and your friends and neighbours think if they were listening to this debate now? Devolution is all the rage. Do they think that devolution has been for the benefit of health care in the border counties?

Jesse Norman

Are you asking me as a Member of Parliament?

Simon Hart

I am asking both of you.

Jesse Norman

From a constituency standpoint, as I think has been testified, they often do not understand the difference, and they do not care about the difference. What they want is good local health care and the rights they believe they are entitled to by virtue of where they live to be observed.

Simon Hart

Okay. I will come back to Pamela and ask the same question in a different way. Assuming that they now know, because they are watching this, or they read the transcript or you inform them of it, and with much discussion about further powers for the Welsh Assembly coming down the line—that seems to be a subject that never goes away—how do you think they would react to that?

Jesse Norman

Let us be clear—

Simon Hart

I will tell you why I am saying this. There is a real sense of frustration emerging.

Jesse Norman

Let us be clear. There is huge frustration and a great sense of injustice. I am taking the view that the Committee understands that, and therefore I am not going on about it now. Because of that, they may well have criticisms of the arrangements that were reached as a result of devolution, but that is not really the basis on which I am making my argument. I am making an argument about the unintended consequences of a specific set of circumstances, rather than the in principle question of whether it was right to have that.

Simon Hart

Fine. I suppose that what I am saying—I am talking to Pamela here—is that we have opportunities on the political horizon possibly to rectify some of this. If so, how would we do it? From everything you have told us so far, if I were just waiting for my care and were living in the border counties, I would be thinking the sort of things that Hansard don’t want me to think. I would really be wondering. It would confirm all of my worst views about—

Jesse Norman

If you wanted to get really angry about it, you would look at the difference in ambulance crossings. There are 186 English ambulances going into Wales and 16 going from Wales to England. If you wanted to get angry about things, you might get angry about that.

Simon Hart

Absolutely.

Jesse Norman

Okay, but I do not think that is absolutely germane to what we are trying to talk about now, with respect.

Simon Hart

I am trying to change the subject; I am trying to make it germane and to shine a light on this bit. We keep highlighting problems. Let us pass the ball to Pamela a little bit. How do we rectify this? It is nonsense.

Pamela Plummer

Devolution is a fact of life. The Welsh Government are going to make their own decisions about their health care, and they absolutely should, through their democratic representatives. What they should not do is entangle English residents in your decisions. The Health and Social Care Act is really clear. It applies to absolutely everybody who lives in England. The cross-border protocol has overwritten that, but it has no authority or mandate to do so. The legislation should stand for the English and for the Welsh Governments. You should make sure that, whatever you do with devolution, you do not deny English residents their rights. What has happened to a lot of people in Gloucester is awful. I have goodness knows how many case studies of really poor care and appalling decisions. I can give you examples in generic terms of what has gone wrong. English residents who are registered with a Welsh GP and are being seen by a Welsh consultant have to jump to an English GP, through a GP fix, because nobody will take them. When we met him, the GP told us personally that he was absolutely livid that he had lost a patient of 20-odd years, who is now with an English GP, seeing the same Welsh consultant, so that he can get access to rare cancer drugs. Some of the machinations—

Chair

He is getting access to rare cancer drugs in Wales.

Pamela Plummer

In England, through his English GP, but still seeing the same Welsh consultant, who could not get him the drugs in Wales. People are leaping through all sorts of hoops.

Simon Hart

Can you illustrate that? What sort of delays have been built into the system that would not have been there if we had not—

Jesse Norman

I have a constituent who desperately needed an MRI scan, was not able to get it because of arguments about these things, and then discovered that she had a cyst on her spine. She very rationally and rightly takes the view that if the MRI scan had been forthcoming when originally requested, under her perfectly fair rights as an English patient, it might have had a meaningful impact on the diagnosis and treatment of her condition. These things get very angry very quickly, once you go into detail.

Chair

Mrs Plummer, I know you have an organisation that represents English patients who are looking to have their treatment in England or, at least, to English waiting time standards. As far as you are aware, are there patients in England who are opting to go to Wales or who are quite happy with the service in Wales?

Pamela Plummer

Some people want to go to Wales, as that is where they have gone in the past—they had their baby at Nevill Hall, they want to cross the border and they are quite happy to go to Wales. That could be accommodated, if you recognised the English rights. If Gloucester’s clinical commissioning group commissions, they can commission contracts in Wales for those people, to maintain that flow. It is a no-lose situation if you do it that way.

Chair

Are there any particular services that people prefer to have in Wales, or where the standards are obviously higher? We are getting a sense that there are differences in different areas. Obviously people will always want to have their prescriptions for free, if they can. What else sends people to Wales?

Pamela Plummer

The main problem with Wales is the waiting times. If you had the option of going to England in four months’ time for an operation, or to Wales in four months’ time for an operation—as you are actually entitled to—and somebody said, “Wait six months,” which one would you choose?

Chair

Yes, but are there some things for which you would wait a shorter time in Wales?

Pamela Plummer

Yes. Where we live, we are much closer to centres of excellence in Bristol than to centres of excellence in Wales. For example, one person wanted to go to Frenchay because his son had hurt his hand. He was sent to Swansea, 75 miles away, when they would not allow us to refer to England. Instead of being able to jump out of bed and see his son when he woke up from the anaesthetic, he was told that he would have to book a hotel in Swansea. He was told he would have to wait much longer—

Chair

That is more of a distance issue than a standards issue.

Pamela Plummer

But you also have good centres of excellence in Frenchay and at Southmead.

Jesse Norman

We have the cancer drugs fund, which we talked about. The eye hospital in Hereford is national if not world-class quality, but people are not able to use it.

Chair

But there must be some things we are better at in Wales. We are the Welsh Affairs Select Committee. What are we good at in Wales?

Jesse Norman

Inevitably, I know the ones in my constituency, so I do not know. I cannot comment on the contrast between Nevill Hall and Hereford hospital.

Guto Bebb

I have a brief point of clarification. You mentioned a cancer patient who was registered with a Welsh GP, seeing a consultant based in Wales but not able to access the cancer drugs fund.

Pamela Plummer

That is right.

Guto Bebb

He then transferred to an England-based GP, with the same Welsh consultant, and was able to access the cancer drugs fund.

Pamela Plummer

That is right. People are jumping through hoops to avoid the waiting list. Continuity of care—

Guto Bebb

I just wanted to clarify what I had heard.

Pamela Plummer

That is an absolute case. We had two meetings with GPs in Chepstow. We were told that by the GP himself, so I can say that it is true.

Jesse Norman

Could I add something very quickly, as a grace note? On organ donation, there is a difference of policy between the two. There is deemed donation on the Welsh side and not on the English side. I have lots of constituents who are worried that they may have organs deemed to be donated because they are registered with Welsh GPs, although they live in England. That could be sorted out just by communication and fiat. It is not a financial thing as such.

Geraint Davies

We understand that something like 20,000 people who live in England are registered in Wales and that 15,000 live in Wales and are registered in England. If the people who are resident in England get treated in England, even though they are registered in Wales, the Welsh health service pays for their hospital treatment in England. Do you think that is something that should be changed, because it is a very significant drain on the Welsh health service? These are people living in England, being treated in England and being paid for by Wales because they have chosen to register in Wales, and they are also getting free prescriptions. Do you think that is right?

Pamela Plummer

They are living in England, they are with Welsh GPs—

Geraint Davies

Yes, but they end up being referred to England for treatment Wales pays for. Do you think that should be changed?

Jesse Norman

In many cases, they have not chosen—they have been forced to register with a Welsh GP.

Geraint Davies

Why should Wales pay for that treatment?

Jesse Norman

There is a further question. The general principle in the NHS recently—over the last 10 years—has been that there should be free choice as to where you get treated. I am not sure that it is wise for the Welsh NHS to constrain where people registered under it get treated. It should not be a financial matter, in that sense. They should be treated in the best place they can be treated.

Geraint Davies

That is not the point. These are examples of people who are exercising choice. Who should pay?

Pamela Plummer

The point is that it is not about the money. How NHS England and NHS Wales organise their money is up to the managers within the NHS. Presumably there is a pot of money at Government level, which is spent however they decide. The issue is the legal situation based on residency. That is the bottom line. We are entitled to go to England. We have been entitled to go to England since the Health and Social Care Act in 2012. We are entitled to have access to the cancer drugs fund. We are entitled to choose our GP and to use choose and book. We cannot use choose and book at the moment. We are limited to four trusts where Aneurin Bevan has contracts. We had barely won those rights when there was an argument between Aneurin Bevan and UBHT. They did not pay their bills and a whole lot of people had their operations cancelled again. The current arrangements are not a permanent solution. They are tenuous and unjust. Sorting the money out should not drive the solution. The solution is to decide what is right for us and for the people in Wales and then organise your money. I do not see that we can solve the money problem here.

Chair

You may not know the answer to this, but would a Welsh resident registered with an English GP have access to the cancer drugs fund?

Pamela Plummer

Yes, under the current protocol arrangements. And they get treated in 18 weeks. And they can use choose and book. They have all the five rights under the NHS constitution that we do not have.

Chair

Would the treatment of that Welsh resident registered with an English GP be paid for by the English NHS?

Pamela Plummer

I do not know how the money works.

Chair

I do not see any more questions, so I will call this meeting to a close. Thank you both very much indeed, particularly Mrs Plummer, who has come all the way from the Forest of Dean.

Pamela Plummer

Thank you very much for listening to us. It is really kind of you. International Representation and Promotion of Wales by UK bodies, HC 1206 22