1.1 Hereford Hospitals NHS Trust provides the full range of District General Hospital services to the population of Herefordshire, mid Powys (Radnorshire), southern Powys (Brecknockshire) and northern Gwent (Monmouthshire).


1.2 The size of Powys’ population and the distribution of that population preclude the development of a dedicated District General Hospital.  An analysis of drive times suggests that it would not be practicable to insist that Powys residents access alternatives to NHS England District General Hospitals.


1.3 Activity provided to the Powys Local Health Board is critical to the clinical and financial viability of Hereford Hospitals NHS Trust.


1.4 NHS England and NHS Wales employ different systems for funding hospital care.  This is not sustainable.


1.5 Powys Local Health Board seeks to manage the referral process between GP and the Trust.  This is not sustainable.


1.6 There is confusion about the eligibility for treatment in NHS England hospitals of patients resident in Wales and registered with an English GP.


1.7 There is considerable potential for the increased local provision of outpatient, day surgery and diagnostic services in Powys by Hereford Hospitals NHS Trust which is frustrated by a range of problems currently inherent in cross border working.


1.8  With technology enabling hitherto centralised services such as chemotherapy   to be devolved to local hospitals such as Hereford, there are benefits in terms of convenience and access for Welsh patients crossing the border


1.9  Recommendations are as follows








2.1 Hereford Hospitals NHS Trust (HHT) provides a full range of District General

      Hospital (DGH) services i.e.



2.2 The Trust’s catchment area covers Herefordshire and mid Powys

      (Radnorshire).  A smaller number of patients from southern Powys

      (Brecknockshire) and Gwent (Monmouthshire) also access their DGH

       services from the Trust.




3.1 Powys residents access their DGH care from a number of hospitals in Wales

      and England.  The size of the Powys population base and the distribution of

      that population do not permit the development of a local DGH.  The map at

      appendix 1 sets out an analysis of travel times from Llandrindod Wells to

      NHS DGHs in Wales and England. It should be noted that Nevill Hall Hospital

      in Abergavenny is scheduled to be downgraded within the next five years

      with services being concentrated to a greater degree in the

      Cwmbran/Newport area. It would not be a practicable proposition to require

      Powys residents who have traditionally accessed HHT to use an alternative

      Welsh provider. 


3.2 Activity undertaken for Local Health Boards accounts for in excess of 10% of

      HHT’s overall activity and budgeted income.  Activity for LHBs and the

      income this represents are integral to the continuing clinical and financial

      viability of HHT.


3.3 Increasingly, English NHS Trusts are remunerated on the basis of a

      predetermined national tariff for each patient under the Payment by Results

      system.  The tariff includes an element for service development, replacement

      of capital and cover for contingencies.  As the tariff system has been

      expanded, NHS England Trusts increasingly have no access to other sources

      of income.  The PbR system formally does not apply in Wales-instead cross

      border contracts between LHBs and English providers continue to be based

      on locally negotiated prices. The consequences for English providers

      adjacent to the border are differential pricing and cross subsidy between

      contracts. For HHT the position is even more stark: the contract with Powys

      LHB is £1m lower than would be the case if the national tariff were applied

      which effectively means that English commissioners (primarily Herefordshire

      PCT) are subsidising Welsh patients. This is not sustainable as an equitable



3.4 The maximum waiting time targets set for commissioners in England by the

      Department of Health and in Wales by the Welsh Assembly Government are

      now very different-the 18 week target to be achieved in England by

      December 2008 is significantly lower than its Welsh equivalent. For a Welsh

      resident living close to the English border this is particularly emotive because

      of the close proximity of patients in England who have quicker access to

      hospital services as a consequence.


3.5 For English providers close to the border, such as HHT, this divergence of

      policy on access increasingly means running differential waiting times and

      separate waiting lists for English and Welsh residents. This represents a

      significant administrative burden and an inefficient use of limited capacity.

      Indeed Powys LHB as a commissioner has taken this arrangement further as

      a commissioner by controlling referrals to HHT (in effect intervening between

      the referring GP and the consultant) in order to ensure that the maximum wait

      is achieved and no better, within the agreed contract financial value. This

      “drip feed” referral mechanism does not make efficient use of provider



3.6 The divergence of policy also extends to patient choice which is more fully

      developed in the English healthcare system, to the extent that “free choice”

      will be available to all English patients through the Choose and Book system

      from 1st April. The same opportunity is not available to Welsh residents and

      any restriction of well established patient flows into England would be in stark

      contrast to the English choice agenda.


3.7 LHB catchment populations are based on district of residence whilst English

      Primary Care Trusts catchment populations are based on registration with

      GP practices.  This can result in confusion about the eligibility for treatment in

      NHS England hospitals of patients resident in Wales and registered with an

      English GP. 


3.8 HHT believes that a greater volume of care can be provided by its clinicians

      to mid Powys (i.e. Radnorshire) residents through the decentralisation of

      outpatient, day surgery and diagnostic services and their provision on an

      outreach basis in  community hospitals (particularly  Llandrindod Wells).  This

      would have a number of benefits:-

·        Powys patients would have improved local access to services with a reduced requirement to travel to a DGH

·        Patients would have the safety net of a referral to see the same clinician at their catchment DGH in Hereford in the event that more complex treatment were required

·        The future viability and cost effectiveness of Powys community hospitals  (an important subject for local residents) would be enhanced

·        Services would be better underpinned in terms of clinical governance arrangements


However these benefits for patients in mid Powys can only be achieved if there is an acceptance in policy terms that English providers have a legitimate role in providing services on an in-reach basis in Wales and if appropriately incentivised financial arrangements are developed in support. There will also need to be a collective cross border commitment to overcome practical difficulties e.g. those associated with establishing IT links.


3.9 The NHS in England recognises that continuing technological advances

      enable certain services hitherto provided at specialist centres to be devolved

      to a local setting, thereby improving access for patients. This is particularly

      pertinent to HHT: for example 90% of chemotherapy services for local

      residents are now provided at the County Hospital whereas historically

      patients had to travel to Cheltenham or further to a tertiary centre. HHT is

      embracing such advances and developing services to meet needs with

      support from visiting specialist clinicians providing services locally. This

      decentralised model equally benefits Welsh residents from mid Powys

      whereas centralisation of services would reduce both choice and access


3.9  In the same vein, the new national Cancer Reform Strategy for England focuses on travel times to access radiotherapy services, recommending a maximum of 45 minutes journey time for treatment. On this basis, the Trust in conjunction with the local PCT is exploring the option of satellite radiotherapy at the County Hospital which would again improve access for Welsh residents.





The following recommendations for action are respectfully submitted for consideration by the Committee:


4.1   That Welsh patients are encouraged and enabled to access NHS England hospitals where this is in line with ease of access and their clinical needs


4.2   That LHBs remunerate NHS England hospitals using PbR tariff payments


4.3   That LHBs do not manage NHS England provider waiting lists


4.4   That Welsh patients accessing NHS England hospitals benefit from NHS England waiting time targets


4.5   That appropriate cross border arrangements for delivery of care in Wales by NHS England providers are encouraged, incentivised and enabled.


March 2008



Appendix 1- Travel Times from Llandrindod Wells, Powys (30, 60, 90 min)