Oral evidence: Cross-border health arrangements between England and Wales, HC 404
Oral evidence, 2 December 2014.
Witnesses
Councillor Darren Mayor, Portfolio Holder for Adult Social Services, Powys County Council, and Frederick Geoffrey Davies, Vice-Chair of the Visiting, Monitoring and Scrutiny Committee, Brecknock and Radnor Community Health Council, gave evidence.
Chair
Mr Davies and Councillor Mayor, thank you very much for coming along this morning. We have already had a bit of an answer to this, but could you briefly explain the nature of the cross-border health flows that take place from Powys to England?
Geoffrey Davies
I hope you do not mind if I refer to my notes. Because we represent both parts of the county, we have prepared a brief in compliance with the questions. In terms of the cross-border flows, approximately 80% of the area of Montgomeryshire looks to acute services in England, principally the Royal Shrewsbury and the Princess Royal at Telford. The western half of Montgomeryshire looks to Bronglais. Specialist orthopaedic services are at the Robert Jones and Agnes Hunt. For the eastern side of Brecknock and Radnor, from Hay to Hereford county hospital, Hereford is the principal one. Hospitals in Shropshire and Hereford provide out-patient, day care and in-patient services for approximately 45% to 50% of the population of Powys. In 2013-14, Powys teaching health board spent £45 million with English NHS acute providers and £44 million with Welsh NHS acute providers. The exact number of Powys patients treated in a year by NHS England can be obtained via Powys THB, but we are talking of several thousand in total.
Councillor Mayor
You are well aware of the fact that in Powys there is no general hospital. Basically, all our acute care has to go out of county, so there is a massive outflow from Powys—either west, east, north or south—and hence the high figures.
Chair
Does either of you know of any patients—or have you heard anecdotally of any—registering with English GPs deliberately in order to get access to the lower waiting times?
Councillor Mayor
Last week, when I was with you in Newtown, we had a number of people who were giving their personal experience; we can forward you the name of one, rather than name that person. It was to do with cancer treatment. As they live in Montgomery, it was very clear that it warranted them to move their practice from Montgomery over to Shropshire and to register with a GP there in order to receive the drugs that would prolong their life, which were not available, and to receive the eventual operation, which might have been delayed if they had remained in Powys.
Chair
Conversely, have you heard of patients from England wanting to register in Wales to get access to free prescriptions?
Councillor Mayor
Personally, no. The majority of people on the borders are very much aware that if you are in need not of emergency care—as we heard earlier, at the point of access, emergency care is provided regardless—but of any kind of operation, it does not seem productive, for the sake of saving a few pounds a month on prescription charges, to be registered in Wales. You are far better remaining within the Shropshire footprint, rather than coming across to Powys. Personally, I have not heard of it.
Geoffrey Davies
As the CHC, we do not have numbers or people’s reasons for moving, but recently we asked the Powys teaching health board for those numbers. Of course, we are very much aware of the difficulty of attracting GPs to the mid-Powys area, which is causing problems.
Chair
We shall come to that later.
Nia Griffith
I simply want to pick up the point about waiting times, which you will have heard from the previous witnesses. How do you think this needs to be resolved? You are acutely aware that Welsh patients have different waiting times. They are very aware of that situation when they go to English hospitals.
Councillor Mayor
It is interesting that we remark on the difference in waiting times of 18 weeks in England and 26 weeks in Wales, but we also have to be mindful of the 36-week waiting time that is normally given for more complex cases. In my experience from talking to residents, it is also often used as the limit, rather than the 26 weeks. When they go across the border and it is identified that they come from Wales, not the 26-week waiting list but the 36-week one is used. I just wanted to throw that in at this point. In terms of resolving that, again it needs to be a political decision. I cannot see it changing in any other way, despite all the great intentions of the clinicians who want to treat people at the point of need, put them on the waiting list and go through that. Because of their targets, if they see a Welsh patient who needs treatment, they just get bumped. That is not anecdotal—that is everybody’s experience. There needs to be a political decision to change the waiting list.
Geoffrey Davies
Absolutely. This has caused immense frustration and dissatisfaction. It is the root cause of why there are so many complaints. With the odd extension of waiting times, the good will of a patient towards the NHS will prevail, but the strain on them is such because of these political decisions about funding, that that is highlighting the cross-border issue, which is the subject of this review, and the issue of health provision in central Wales, which is the subject of another review. It all relates back to the basic dissatisfaction of the average Welsh patient, especially in a county such as Powys, where funding is such a problem.
Nia Griffith
The previous witnesses suggested that to clear that backlog would be a major challenge.
Councillor Mayor
It is. In the world we live in today, with the financial pressure that there is, that is the reality of it. It is not a hidden agenda; it is a very obvious agenda. Basically, we just do not have the money to do it. There may be the will to do it, but not the financial means. However, that is a big fundamental question about what we value most. We need to put in our funding according to what we think is valuable, but it is a political decision.
Geoffrey Davies
From the patient’s point of view, obviously one appreciates what my colleague has just said, but the patient is desperate to have someone explain what Councillor Mayor has just said: “You can’t have it, and this is why, but you will have it.” Then you take away the frustration. In business, if you are going to be late delivering to the customer, you ring him an hour before the time to say, “Don’t come at 5. We won’t be ready for you until tomorrow because there has been a hitch.” If that policy is adopted, the patient can be made aware. It is all about the business of communication. That is where it falls down.
Jessica Morden
Councillor Mayor, earlier you mentioned cancer treatment and the person who came to the session we were at who had moved to an English GP to get drugs that they could not get in Wales. Would you like to see a single system across England and Wales for treatments that are not approved by NICE?
Councillor Mayor
Very much so. It was very interesting listening to the first session. We were encountering the fact that we have this national health service, but we do not have a national health service. We have an English national health service and a Welsh national health service, and they are different. Particularly on the borders, you see acutely the difference in the treatments that you receive. We need to have equalisation of policy in terms of what drugs are available and an equal funding system to do it. It was very ironic listening in. My personal view is that we do not have a national health system any more, because there is a two-tier system. If we want to have a national health service again, we need to have correct funding and policies that are equal across the border.
Jonathan Edwards
That leads me to the next question: how can that equal situation be achieved in a devolved context? We have a Welsh health service, an English health service, a Scottish health service and a Northern Irish health service. How can it possibly be achieved in a devolved context?
Councillor Mayor
I hope that you do not mind my referring back to a question to the previous panel about “your wish”. It is not going to happen. Basically, if we could reverse the devolution of the health service to the Welsh Government, it would be fantastic, but we understand that that is not going to happen. Or is it; who knows? That is the only answer. I do not know how else to do it. There needs to be the political will to do something about this.
Geoffrey Davies
That is the basic concern of the average patient, especially in Powys. If you were to ask one of your constituents about a particular health matter, they would refer to what was in the Daily Mail the day before, believing that it belonged to them. People do not appreciate the fact that there are two health services. When we were devolved, we were promised consensus politics. If we could have that and the NHS could cease to be a political football, that would be the wish. That is what we want—a cross-party investigation, root and branch. We could get somewhere then. For as long as it remains a political football, it is frightfully frustrating for everybody—most of all for the patient.
Mr Williams
We all agree on the political football point; that is very regrettable. Jonathan did not respond to the comments that you made about repatriation of health back to Whitehall. The question that I asked before was about the need to get the protocols right, which manifestly has not happened so far, because we have these problems. It is the responsibility of both the Assembly Government and the UK Government to work at those. I want to return to one very practical issue, which we touched on in the earlier session. In many ways, it is a manifestation of a lot of the problems we have talked about, to do with incompatible systems, particularly incompatible IT systems. The Welsh NHS Confederation reported, “The delay in information sharing” between both health services “could potentially put Wales’s patients post-discharge at a higher risk than English patients from the same hospital,” as files may have gone missing and there is not that compatibility. In your experience, is that a real problem that people have been experiencing? We can talk about big political goals and aspirations, but that is something very practical that needs to be addressed.
Geoffrey Davies
You know the operative word only too well—“communication”. That is the root cause of the problem. In our written evidence, at paragraph 3.3, we refer to the incompatibility of the IT systems. If I may read from my notes, the CHCs do have details of individual cases where a delay in receiving, for example, a test result is part of a complaint being handled by the CHC, but we do not have the individual patient’s permission at this stage to divulge the details. From regular meetings that our chief officer—the CHC chief officer—has had with senior officials from the NHS Wales information service, we know what progress has been made in NHS Wales to unify IT systems so that GP practices and hospitals can talk to one another using digital technology to make referrals, receive test results and receive patient discharge letters. Within NHS England, the policy structure focuses on individual autonomous NHS trusts. Fortunately for Powys patients, through the commissioning discussions that Powys THB has had with NHS trusts in England, information service IT staff have been having discussions about digital links between Powys GPs and hospitals in England that serve Powys. We understand that trials are proceeding at some GP practices in the north of Powys. The CHC supports that work. Indeed, we are very pleased that it is being done. Mentioning the north of Powys, I am charged by my colleagues on the CHC to say how much better, as far as Powys is concerned, the links are in the north than in the south, where I am. The link there is much better. For example, in May, Ann Mathias, the chairman of South Powys CHC, and I made a monitoring group visit to Hereford hospital. I take it that you are all familiar with visitor monitoring groups; they are the part of the committee that goes in and looks. The area of prime concern to us was the transfer of stroke patients from Hereford back to Powys and the delays that are occurring. You may know that we transferred the stroke rehabilitation unit from Bronllys to Brecon. Discussions with the two sisters on the ward at Hereford revealed horrendous bed blocking. Having discussed it with them in the third week of May, I said, “Wouldn’t it be possible for us, during the month of June, to chart exactly the progress of patients from Powys through Hereford and back into the community, either to Brecon for rehabilitation or to home care facilities?” I was told, “Fine; no problem,” but we are still waiting. That was deemed to be a perfectly simple one. When I talk about communication, this is the basis of the problem. We heard our clinical colleagues say earlier that they are not really interested in who comes from where, but rather that the patient is treated. Here we were saying, “This is a perfectly simple operation.” At the moment, this communication between Hereford and us has got to CHC chairman level, with each person writing individually and saying, “It will be the Minister next stop if we don’t get an answer.”
Mr Williams
Is that problem compounded by the border? I have the problem within a health board between hospitals and social services on the ground in the delivery of community services, so it is a problem within Wales as well. You are saying that it is exacerbated by cross-border issues.
Geoffrey Davies
Yes, it is exacerbated by cross-border issues.
Simon Hart
I return to what you said a few minutes ago about political footballs. As long as you have two different health services administered by two Parliaments—irrespective of who might be in office—isn’t there always going to be an element of political football about the service? Secondly, is that not also entirely healthy? Is that not precisely what we should be doing as politicians or parties—highlighting successes and failures in individual health services, if that warrants it?
Councillor Mayor
You are right in the sense that it is very important that we highlight the problems, but do we address those problems and actually do something about them? What we are talking about here is not a new problem. It has not happened in the last couple of weeks or months, or even the last couple of years. It has been known for a long, long time. In essence, what has happened? What are we doing about it? It comes back to the fact that when Mr Joe Public or whoever turns to the NHS, they expect the same service that their colleagues, friends or relatives are receiving in Gloucestershire, Hertfordshire or wherever it may be, but that is not the case. We are part of this United Kingdom. We pay all our taxes in exactly the same way, but we are receiving a different service. You are right—it is always going to be a political issue. The challenge is: what are the politicians doing to address this kind of issue to make sure that the service we pay for is the same as the one our neighbours pay for?
Geoffrey Davies
It may be good for there to be an element of political football, but it should not dominate the whole situation, as it does now. I agree that there should be an element of variance—that is fine—but only an element. It should not be the political football that it is at the moment. The avowed attempt in the early days of AMs was that we would have consensus politics, which we are not getting.
Simon Hart
To follow up on this, is there not a downstream consequence of the two-tier system, if I can call it that, which is recruitment? I will quote a local example. There are some difficulties within the Hywel Dda health board; you might say across NHS Wales, if you wanted to. That is having a negative effect on recruitment. I accept that that can go both ways. It is not a case of money. The money is there, but you cannot get GPs to apply for jobs in parts of west Wales simply because the reputation, rightly or wrongly, is that the service is not as good as the English equivalent. Therefore, the people you are trying to recruit to the area, who may be from away, are not coming because they do not think that the service there is the same as that to which they would be able to refer their patients back in England. That is an ongoing issue in my particular patch. It may not be anywhere else, but it certainly is in mine. I wonder whether this is something you have come across before.
Councillor Mayor
On the GP issue, there is a lot of difficulty attracting GPs to practices in Powys, particularly at the border, because of being on the performance list. Over in England, registration is different from in Wales. That creates another barrier to the ease of GPs becoming locums, because they have to go through another process. That does not help to attract GPs across. They may be living in Wales, but they are registered in England and have gone through that process. It is another barrier if they have to go through the whole process again to be registered in Wales and to go on that list. That is another contributory factor. Because of the borders and the two different health services that we have, it exacerbates the problem of trying to attract and retain GPs to work in Wales.
Simon Hart
The poor recruitment in my part of Wales has already had a consequence, which is yesterday’s rumoured downgrading of A and E in Withybush hospital—and so it goes on.
Councillor Mayor
Yes. It becomes a downward spiral. How do you reverse that?
Simon Hart
You can reverse it only, dare I say it, by politicians getting up, shouting loudly and inflicting a certain amount of pain, but then we are accused of making it a political football—we cannot win.
Geoffrey Davies
That is the acceptable element, but it is not dominant. I believe that when Helen Birtwhistle appeared before you she mentioned the problem of recruiting GPs to mid-Wales. I cannot readily find it in my notes, and I do not want to delay everybody, but if you refer back to what she said, there is something from the GPs’ professional association on how they migrate between the two. English GPs cannot get on to Welsh lists. There is something of that nature.
Nia Griffith
We have a note from them.
Geoffrey Davies
It was good to notice that. Funding is the root cause of the Powys problem. Mr Davies and Ms Morden know from another aspect I have dealt with in the last 10 years—the magistrates service—that any public service in Powys is the most expensive in England and Wales to provide. That was acknowledged in the Williams report. Maybe—not maybe; I certainly believe this—what he suggests is the answer to an awful lot of the problems, to be perfectly honest. If you speak to any of the senior health professionals, they will tell you that while social services and the health service are not operating on the same budget, all that we want is not going to happen, because each is guarding his own patch.
Chair
I have one last question, which is about the redress system. It operates in Wales for Welsh patients and English patients, but there is no equivalent in England for Welsh patients. Is that a particular problem?
Councillor Mayor
That is what I understand to be the case. There is that discrepancy. If you have any cause for redress, it is not available. You have a note there, don’t you?
Geoffrey Davies
I do.
Councillor Mayor
On the extent to which redress is a problem, my personal experience and that of constituents I have talked to in my ward is that when they receive their care across the border that is not an issue. The standard of care has not been a problem. There have been a very small number of official complaints. Between April 2013 and March 2014, only three complaints were received for the Shrewsbury and Telford hospital, which is very insignificant, although not for those people who made a complaint. The need for redress does not relate so much to the service that was received. For many people, the problem was the delay in having that service given to them.
Chair
That probably answers the question, to be honest. Thank you very much for coming along. Oral evidence: Cross-border health arrangements between England and Wales, HC 404 2