2 Cross-border health services
6. Healthcare pathways for patients have always crossed
the Welsh-English border. Healthcare is divided into primary,
secondary, and tertiary services and cross-border issues are present
in all three categories to some degree.
Primary Care
7. Primary healthcare covers the activities of a
healthcare provider who acts as a first point of consultation
for all patients, such as GP services, dentistry services, ophthalmic
services and pharmacy services. Approximately 20,800 English patients
are registered with Welsh or Welsh-registered GPs.[1]
Approximately 15,000 Welsh residents are registered with English
or English-registered GPs.[2]
There is therefore a net flow of approximately 6,000 patients
into Welsh primary care from England.[3]
We were told that convenience is the main reason behind cross-border
travel for primary healthcare. Patients receiving treatment for
primary care services on the other side of the border generally
live in immediate border areas along the Wales-England border
and choose a GP surgery as close to home as possible, which may
not be in their country of residence.[4]
Secondary Care
8. Secondary healthcare are services which are generally
provided in or by general hospitals. Although the flow is generally
from Wales to England, the cross-border flow does differ from
north to south Wales. For example, the cross-border flow in Betsi
Cadwaladr University Health Board and Powys Teaching Health Board
predominately relates to residents in Wales going into England.
This is partly for reasons of convenience, but also because of
the lack of secondary care in some areas (Powys, for example,
has no District General Hospital).[5]
Meanwhile, in Aneurin Bevan University Health Board, the cross-border
flow predominately relates to English residents who are registered
with Welsh GPs.[6] In 2012-13,
approximately 50,700 Welsh residents travelled to non-Welsh providers
for treatment, including both emergency and elective patients.[7]
In the same year, 10,370 non-Welsh patients were admitted to Welsh
hospitals.[8]
Tertiary Care
9. Tertiary services are provided by specialist hospitals
or regional centres equipped with diagnostic and treatment facilities
not generally available at local hospitals. Referral is generally
from a secondary care specialist. Examples include advanced neonatology,
genetic services, plastic surgery and burns treatment centres,
and organ transplantation. Tertiary care centres are located in
areas of higher population and the relatively small population
size of North and Mid-Wales means there is not the critical mass
of people needed to support more local specialised services.[9]
Cross-border flows for patients for such services are therefore
mostly from Wales into England.[10]
Devolution and policy divergence
10. Since devolution, the NHS in Wales has been a
responsibility of the Welsh Government. Since 1999, the identification
and pursuit of different health policy priorities by the four
nations of the UK has led to the adoption of different models
for the provision and organisation of health services. The healthcare
policies of England and Wales have diverged in some areas. Some
of the ways in which healthcare policies of England and Wales
have diverged are set out below.
INTERNAL MARKET
11. A major policy divergence relates to the differences
in the way services are commissioned and funded. England has a
national tariff system called Payments by Results (PbR) where
each individual treatment is billed to the NHS at a standard rate.
Payment by Results is intended to encourage Clinical Commissioning
Groups to commission only those services they need, and to establish
an incentive for providers to attract more patients and complete
a higher number of procedures at a lower unit cost. Welsh Local
Health Boards do not operate a tariff system and largely rely
on block contracts based on historical data.
FOUNDATION TRUSTS
12. In England, hospitals have the ability to apply
for foundation trust status. Foundation trusts are run by a board
drawn from local organisations and communities. The declared intention
behind this policy is to make hospitals more responsive to the
needs and wishes of their local community.[11]
Foundation trusts do not exist in Wales.
'PATIENT VOICE' AND 'PATIENT CHOICE'
13. England has implemented 'patient choice' in booking
elective treatments. Patients have the right to choose which hospital
they are referred to by their GP. In contrast, in Wales, unlike
in England, there are community health councils whose remit is
to ensure patients' views and needs influence policies and plans.
The Welsh Government has also stated that it will give patients
a greater say in their services, with a focus on 'patient voice'.
WAITING TIME TARGETS
14. Waiting time targets in England and Wales differ.
The maximum waiting time in England is 18 weeks from the time
of referral to a hospital consultant to the beginning of treatment.
Local Health Boards in Wales work to a maximum waiting time target
of 26 weeks from referral to start of treatment.[12]
CANCER DRUGS FUND
15. The UK Government's Cancer Drugs Fund, worth
£280 million in 2014-15 and an estimated £340 million
in 2015-2016, came into effect on 1 April 2011.[13]
The fund is for cancer drugs that are not routinely available
on the NHS. This may include drugs that have not been approved
for funding, are yet to be approved, or that are not approved
for a specific type of cancer. 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 National
Institute for Health and Care Excellence (NICE) guidance and the
All Wales Medicines Strategy Group (AWMSG) for its expert advice
on medications. The Welsh Health Specialised Services Committee
told us that this was meant to ensure that no preference was given
between cancer patients and others.[14]
FREE PRESCRIPTIONS
16. Since 2007, NHS patients in Wales have received
free prescriptions, including all patients registered with a Welsh
GP who collect their prescriptions from Welsh pharmacists and
those patients with an English GP as long as they collect the
prescription from a Welsh pharmacist and present their entitlement
card. In its written evidence, the Department of Health noted
that approximately 90% of prescriptions in England are provided
free of charge, due to various entitlements, so the financial
impact on the public purse of the difference between the two systems
in respect of this policy is not as great as it first might seem.[15]
1 Welsh-registered GPs refers to GP surgeries located
in England which have contracts with NHS Wales. Back
2
English-registered GPs refers to GP surgeries located in Wales
which have contracts with NHS England. There is one practice in
contract with NHS England that has a surgery in Wales: the Meadows
Medical Practice has a surgery at Knighton (in Powys LHB). Back
3
Welsh Government (CBH0051) Back
4
Q14, Q83, Q94 Back
5
Q6 Back
6
Welsh NHS Confederation (CBH0016) Back
7
NHS Wales Annual PEDW data: 2012/13 Provider based headline figures Back
8
NHS Wales Annual PEDW data: 2012/13 Resident based headline figures Back
9
Q297, Q303 Back
10
Q301 Back
11
www.policy-network.net/uploadedFiles/Publications/Publications/Millburn.pdf
Back
12
The targets apply to the majority of referrals to NHS hospitals
for treatment; however, there are a number of exceptions. In addition,
some conditions such as cancer have their own specific target. Back
13
www.england.nhs.uk/2015/01/12/cancer-drug-budget/ Back
14
Q308 Back
15
Department of Health (CBH0055) Back
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