3 Funding and Commissioning |
17. Health services in England and Wales are subject
to different funding and commissioning arrangements, which can
result in confusion and misunderstanding by patients, and indeed
sometimes by staff. We have sought to shed light on the arrangements
for funding of cross-border healthcare.
18. In England, 211 Clinical Commissioning Groups
(CCGs), overseen by NHS England, are legally responsible for the
commissioning of health services. CCGs are clinician-led groups
that include all of the GP groups in their geographical area.
The aim of this is to give GPs and other clinicians the power
to influence commissioning decisions for their patients.
Clinical commissioning groups work with patients and healthcare
professionals and in partnership with local communities and local
authorities. CCGs operate by commissioning healthcare services
including: elective hospital care; rehabilitation care; urgent
and emergency care; most community health services; and mental
health and learning disability services.
19. In Wales, seven Local Health Boards (LHBs) are
responsible for planning and delivering medical services, and
aim to integrate specialist, secondary, community and primary
care and health improvements. In general, this means that LHBs
are largely responsible for commissioning all primary and secondary
care. Tertiary and highly specialised services are commissioned
in Wales through a joint committee: the Welsh Health Specialised
Services Committee (WHSSC). A diagram showing the structure of
NHS England and NHS Wales is below.
Structure of the NHS in England
Source: House of Commons Library
Structure of NHS in Wales
Source: Wales Audit Office
20. The Protocol for Cross-border Healthcare Services
sets out which body is responsible for commissioning care for
people who live on one side of the border, but are registered
with a GP on the other.
The protocol provides that the operational responsibility for
commissioning services for a patient is determined by GP registration,
rather than residency. Under the protocol, Welsh residents who
are registered with an English GP or English-registered GP are
'English' patients. Likewise English residents who are registered
with a Welsh GP or a Welsh-registered GP are considered 'Welsh'
21. Paragraph 11 of the protocol summarises the commissioning
and healthcare planning responsibilities and legally responsible
||Commissioning/healthcare planning responsibility
||Legally Responsible Body
22. Paragraph 16 of the protocol summarises what
patients should be able to expect in terms of standards for access
to health care dependency on residency, GP location and provider:
||English Provider to meet:
||Welsh Provider to meet:
||WG standards||WG standards
||WG standards||WG standards
||NHS Constitution||WG standards
||NHS Constitution||WG standards
Compatibility of the Cross-border Protocol
and NHS Constitution
23. In England, the Health and Social Care Act 2012
and the NHS Constitution gives certain rights to English residents,
including the right to choose their hospital, and sets maximum
waiting times targets.
However, as we have set out earlier in this Chapter, English residents
who have a Welsh GP or a Welsh-registered GP are considered 'Welsh'
patients and therefore treated to Welsh Government standards.
24. Witnesses told us that English law and the cross-border
protocol were incompatible, and had led to English residents being
denied their legal rights. Action4OurCare
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 Government. You should make sure that, whatever you
do with devolution, you do not deny English residents their rights.
25. Witnesses told us that this particularly affected
residents in Hereford and Gloucestershire. Jesse Norman MP explained
that over 3,500 patients in Hereford had no choice but to register
with a Welsh surgery as they lived in a location not served by
an English practice.
In Gloucestershire, approximately 10,000 patients are affected,
while residents in Gloucestershire also face the situation that
a number of GP surgeries, while physically based in England, are
registered in Wales.
At our public sessions, some attendees resident in England told
us that when they had requested a transfer to a GP's surgery in
England, they had been turned away.
26. In oral evidence, Mr Norman called for English
rights under the NHS Constitution to be recognised under the protocol:
I am just insisting on the very obvious [
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.
27. Shropshire Clinical Commissioning Group commented
that currently Welsh providers did not offer a dual service for
the English-responsible patient and treated them with the Welsh
targets "even though we would pay for it".
It told us that: "it is only a matter of time before an English
resident who is registered with a Welsh GP challenges that".
28. In response, Jane Ellison MP, Parliamentary Under-Secretary
of State for Public Health, told us that she had established that
there was an inconsistency between the protocol and the legislative
position. She had written to Mark Drakeford AM, Minister for Health
and Social Services in the Welsh Government, to raise the issue
with him. She told us that there were three scenarios:
As part of the work that we are taking forward
with the Welsh Government, we want to resolve the problem around
the rights of English residents. I can see three theoretical scenarios
here. The first is that one attempts to close the border and accepts
that the two systems are totally separate. It seems to me that
that runs contrary to the whole spirit of the conversation that
we have been having here this morning and to putting the interest
of patients and communities paramount, so I do not think that
is the right solution.
The second approach is simply to recognise that
English patients who are registered with Welsh practices do not
receive their NHS constitution rights in relation to either a
legal entitlement to choice or maximum waiting times. Clearly,
that is very problematic and is not something that we can duck.
We need to find a way of addressing that.
The third option is that those patients who are
registered with Welsh practices receive English standards and
entitlements. That contrasts with policies of the Welsh Government
as to the equal treatment of Welsh-resident and English-resident
patients on a GP's list. We are working with the Welsh Government
to try to resolve that conundrum.
29. During our evidence session with Mr Drakeford,
we asked whether the Welsh Government was prepared to recognise
the rights that English residents are afforded under the Health
and Social Care Act 2012. He told us that
The system we have [
] is that if you sign
up with a Welsh GP you get the package that goes with that, and
if you sign up with an English GP you get the package that goes
with that. I understand that in England the Department of Health
believes that this causes some difficulties to them in terms of
English law. It causes no difficulties to us in Wales; but we
are having discussions. [
] I am happy to be as helpful as
I can, but the problem is not mine, and the solution is not mine
30. There is
an unresolved tension between the cross-border healthcare protocol
and the Health and Social Care Act 2012. English patients registered
with Welsh GPs or Welsh-registered GPs do not receive the same
services as if they were registered with an English GP, and for
the majority of people concerned, they will not have a choice
of registering with an English GP.
31. The Department of Health should investigate
the problem of why some patients living in England, currently
being treated in the Welsh healthcare system and wishing to be
treated in the English healthcare system, have been turned away
by GP practices in England. This should be considered in light
of the legal rights of these residents under the Health and Social
Care Act 2012.
32. We recommend that the Welsh and UK Governments
continue to work together to clarify what an English patient registered
with a Welsh GP and a Welsh-registered GP, and a Welsh patient
registered with an English GP and an English-registered GP, can
33. In the case of primary services provided across
the border, which include GP services, dentistry, and ophthalmic
services, there is no funding flow between England and Wales.
The Department of Health told us that:
no transfers have ever been made between
the English NHS and the NHSs in other parts of the UK to reflect
the use residents of one part of the UK make of primary care services
provided in another part of the UK.
Any costs lie where they fall. This was described
to us as a 'knock for knock' arrangement based on historical funding
34. Mr Drakeford told us that this was a sensible
way to do things. He explained:
The alternative is to bill one another for all
the different treatments that go on. My view is that that would
create a big industry of accountants following bits of activity
and we would end up paying more to create the system than we would
save in other ways. On the whole, the system is satisfactory to
both sides as it is. We pick up costs in Wales for some people
who live in England, and the English system picks up some costs
in England for people who live in Wales. Those costs are not sufficiently
significant to erect an industry around them to pursue them in
an accountancy way. The system broadly balances itself out.
SECONDARY AND TERTIARY SERVICES
35. In the case of secondary care services provided
to patients with a GP 'across the border', a net funding transfer
is agreed annually between the Department of Health and the Welsh
Government, in recognition of the additional secondary care costs
that fall on the Welsh NHS. This is set out in the cross-border
protocol, which confirms that there will be no financial shortfall
on the part of any LHB or CCG in providing secondary healthcare
services to the other country's residents.
36. The Welsh Government currently receives £5.8
million per annum from the Department of Health. This is based
on 2008-09 calculations, when it was calculated that 20,000 English
residents were registered with Welsh GPs or Welsh-registered GPs
compared to 15,000 Welsh residents registered with English GPs,
giving a net import of 5,000 English residents. This figure is
then multiplied by the Hospital and Community Health Service (HCHS)
spend per resident of £1,145.
37. In oral evidence, the Welsh Government's Health
Minister said that our investigations had helped "expose
the fact" that the formula had not been updated since 2008.
He suggested that the transfer amount "had we increased the
funding by 5% every year, because that is how much the costs have
increased", should now be £9.1 million.
38. We were told that the Welsh Government distributed
these transferred funds to the LHBs that had treated those patients
from across the border: "people who live in England might
receive primary care at Aneurin Bevan, but if they are treated
at a hospital in Cardiff, the funding will go to Cardiff. The
funding goes where the treatment is given".
39. In the case of secondary and tertiary services
commissioned in England for patients resident in Wales with a
GP in Wales, Welsh LHBs and WHSSC make payments for activity undertaken
by English NHS providers, either under contractual or non-contractual
arrangements. This activity is charged by English providers at
English tariff (Payment by Results) rates.
It is less common for English residents registered with GPs in
England to seek treatment in Wales, but where this does occur,
Welsh LHBs and NHS Trust providers charge English CCGs for the
activity based on their local calculated cost.
40. During our public events, we heard concerns among
Welsh patients that they could be refused treatment in English
hospitals because of a shortfall of money from Welsh LHBs. Many
of these statements were based on high-profile events that largely
took place in a particular time frame.
Betsi Cadwaladr University Health Board reassured us that financial
planning had improved, and that Welsh LHBs were developing three-year
plans to allow more integrated planning, which would take into
account population demands and known flows.
We also heard that some English-based providers had failed to
invoice Welsh Local Health Boards within the agreed timeframe.
41. Shropshire Clinical Commissioning Group told
us that relationships between LHB and CCGs had improved and there
was a "lot more dialogue at all levels: in front-line services,
among senior management and at executiveeven Chief Executivelevel".
The Department of Health informed us that greater transparency
would be available from 2014-15 onwards, as the Department would
hold central information on monies owed by Welsh LHBs.
42. We welcome
the good relationship between Local Health Boards in Wales and
the Clinical Commissioning Groups in England. The publication
of the financial accounts of such bodies will enable the public
to see whether value for money is being achieved.
16 Health and Social Care Act 2012, Part 1 and Schedule
Protocol for Cross-border Healthcare Services, April 2013 Back
The protocol has been annually or biannually since 2005. The current
protocol runs from April 2013 until 2016. Back
The National Health Service Commissioning Board and Clinical Commissioning
Groups (Responsibilities and Standing Rules) Regulations 2012 Back
Action4OurCare is a non-party political, not for profit action
group which was set up in March 2013 by a number of Gloucestershire
Jesse Norman MP (CHB0018) Back
There are four practices in contract with the Welsh NHS that
have surgeries in England. In the area of Shropshire CCG, the
Chirk practice has a surgery in Oswestry. In the area of Gloucestershire
CCG (more specifically, in the Forest of Dean) there are 3 practices:
the Wye Valley Practice has a surgery at St Briavels; the Vauxhall
Practice has a surgery at Tutshill; and the Towngate Practice
has a surgery at Sedbury. Back
Department of Health (CBH0049) Back
Welsh Government (CBH0051) Back
The Department of Health publishes national tariffs every year. Back
For example: in 2008, the North Bristol NHS Trust refused to admit
patients from Wales after the Welsh NHS refused to pay the going
rate for treatment; in 2011, the Liverpool Heart and Chest Hospital
banned patients from North Wales from having elective surgery
after Betsi Cadwaladr University Health Board failed to provide
funding for their treatment. Back