Cross-border health arrangements between England and Wales - Welsh Affairs Contents

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.


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.


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.


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'.


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]


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]


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  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 Back

14   Q308 Back

15   Department of Health (CBH0055) Back

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© Parliamentary copyright 2015
Prepared 12 March 2015