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

4  Cross-border problems

43. During our inquiry, witnesses identified three issues in particular that have significant impact on cross-border healthcare: access to services; the lack of IT compatibility between England and Wales; and the difficulties surrounding GP Performers Lists. We examine all of these areas in more detail in turn.

Access to Services

44. Many of the people we met in Newtown and Hereford expressed concern about difficulties and delays accessing secondary and specialist services on a cross-border basis. They were particularly concerned by a perceived move towards 'in country' commissioning on the part of the Welsh Government with the ultimate aim of treating all Welsh patients within the country, and felt that on some occasions this was not in the patient's interest. This issue also dominated the comments we received on the webforum. Box 1 below includes some of the submissions we received on this issue.
Comment 1

    … at the end of 2013 we were told that the Aneurin Bevan University Health Board was no longer willing to fund her treatment in Hereford and she would have to return to the Wales NHS as they wished to keep expenditure within Wales […] I believe they chose not to treat to save on expenses. We are treated as 2nd class citizens of the UK compared to England.

Comment 2

    My wife, who was undergoing ongoing treatment for a life threatening condition in Bristol, had her cross border funding withdrawn by the Aneurin Bevan University Health Board. Her consultant himself telephoned to say that he could not see her the following week as was planned. To see a 'new' consultant in Wales would have meant a delay of many weeks.

Comment 3

    It is not at all easy for a Welsh resident to access NHS care in England. My GP is registered with Wales NHS but the surgery I attend is in England. I have had to fight to see a specialist in England because of long waiting times in Wales. My GP applied for "out of area funding" from Wales in November 2013. This was refused. An appeal in December 2013 was refused the following January. […] It's monstrous for patients on the border because we cannot access the right people all in the same area. We are a UNITED Kingdom but not when it comes to Health. I feel that Wales NHS has been deliberately obstructive.

45. We found that many of the concerns related to a policy introduced by Aneurin Bevan University Health Board (ABUHB) in September 2012. At this time, ABUHB had introduced a policy aimed at minimising referrals out of the LHB's area or outside Wales. It described the aim of the policy as being that:

    … the Health Board is the primary provider of secondary care services for the registered/resident population of Gwent […]

    Where this cannot be provided by the Health Board's own services for reasons such as resources, expertise or capacity, then the Health Board will look to plan and secure the necessary services with other NHS Providers in Wales through its agreed care pathways. Where the services cannot be provided by the Health Board or with other Welsh providers, the Health Board will plan and secure services from other appropriate providers.[39]

46. This policy caused concern to patients and medical practitioners. The policy affected Welsh residents seeking to have treatment in England and English residents with Welsh-registered GPs—even when, for a small number of patients, that GP surgery was physically situated in England.

47. ABUHB explained that the policy was introduced immediately following the establishment of LHBs. It had been introduced in recognition that there were Welsh residents going out of area for services that could be more centralised. It acknowledged that the policy had particularly affected English residents with Welsh-registered GPs who had "normal and historic[al] flows" to English hospitals:

    The error that we made was, I think for our English residents on the border registered with Welsh GPs, when we asked them to seek prior approval. We had a lot of appeals as part of that process.[40]

48. Following its own review, ABUHB changed its policy and agreed that from 1 September 2013 English residents with a Welsh GP did not require prior approval to be referred for routine secondary care to a small number of English providers.[41]

49. While we welcome this decision, which has made it easier for English residents to access secondary care closer to their home, there is currently no change for Welsh residents. For a referral to any English providers as a Welsh resident prior approval continues to be required. We therefore sought assurances that there was not a deliberate policy in place to stop cross-border health movement of Welsh patients wishing to access services in England.

50. Mr Drakeford told us that the Welsh Government was focused on providing the best care to all those needed it, whether that was in Wales or across the border in England:

    Our aim is to make sure that people get the treatment they need in the best place for them. Sometimes, that will mean that we are able to move treatments closer to people's homes and to bring services back across the border. But sometimes, services across the border will still be the best for Welsh patients. So I do not have a principle that says, 'Treatments for Welsh patients should be provided in Wales.' That is not my starting point.[42]

51. Cross-border movements have been a fact of life for many years, and this is no less the case for health services. For those residing in immediate border areas, the nearest health provider may not be in their country of residence. There is no practical or realistic prospect of diverting these well-established cross-border flows, nor would it be desirable to do so.

52. We welcome the commitment from the Welsh Government's Health Minister on patient needs and his commitment not to allow the border to become a barrier. We recognise that Welsh GPs will be mindful of a need to maintain investment and capacity in Wales. Healthcare providers in England and Wales need to maintain close links to ensure that patients receive the treatment they need regardless of their country of residence, particularly given the policy divergence that has emerged as a result of devolution.


53. The way in which Welsh health providers commissions specialised healthcare from English providers was also raised as an issue. Specialised services are commissioned on a national basis by the Welsh Health Specialised Services Committee (WHSSC), a joint committee of the seven Local Health boards in Wales. The majority of specialised care commissioned from English providers (between 95% and 99%) is done through service level agreements, where contracts are already in place to treat Welsh patients. This is provided directly on the basis of a direct clinical referral, usually from a secondary/tertiary care clinician in Wales, to one of the designated centres in England. In total, WHSSC currently manages 34 healthcare contracts with NHS England providers to the value of £100 million.[43]

54. WHSSC told us that these contracts represented a "very positive set of relationships" between Wales and England.[44] However, it expressed concern that it was not always possible to formalise service level agreements (SLAs) and sign contracts due to key differences in the contract documents. It cited issues such as the fact Wales did not operate the patient choice scheme, differences in access criteria and waiting time targets. WHSSC told us that a review was needed of SLAs.[45]

55. There are some conditions and treatments which fall outside of the contracts that WHSCC already has in place with specialist centres in England, either because they are excluded from the payment by results mechanism or they are not normally commissioned. In these circumstances clinicians apply on the behalf of patients either for prior approval (for a limited number of conditions due to their rarity or high cost treatment) or through Individual Patient Funding Requests (for service not normally commissioned) where patients must apply through the "exceptionality" criteria. WHSSC told us that they managed Individual Patient Funding requests (IPFR) and non-contracted activity to the value of £6 million per annum.[46]

56. Witnesses expressed concerns about these two processes, and told us there was a lack of knowledge amongst clinicians of the referral processes. Genetic Alliance UK told the Committee that both systems required the same application form to be used, which led to "great confusion for the responsible clinician".[47] The Royal College of Physicians said that the forms were "laborious and an administrative waste of time".[48]

57. We also heard concerns about the length of time it took to get approval for a referral to a specialist in England. Genetic Alliance UK told us that some patients had waited "a few years" to have their application processed, and such delays led to "negative consequences" for patients with a delay in diagnosis and inability to access targeted treatments.[49]

58. When we questioned WHSCC about delays in the process, they told us that they aimed to be "very timely" in their approval process. They told us that there was a two-day turnaround for prior approvals, while there were monthly panels for requests done via IPFR process, with "virtual panels" organised for urgent situations. They cited a recent example where they had held a virtual panel to expedite cancer treatment involving HIPEC heated chemotherapy.[50]

59. However, they told us that a lack of knowledge about the process and the forms amongst clinicians in Wales did cause delays. For example, many of the delays that occurred were as a result of not receiving the correct clinical information from referring clinicians. This would involve the panel going back to the clinician for further information: "if we have challenged back […] we need two or three weeks to get the right diagnostics done, to get the right preparation of the case brought forward, so when we do make a decision it is the right decision for the patient".[51]

60. Witnesses agreed that there was a need for further education regarding the process of patient referral for specialised services.[52]

61. Specialised services are accessed by patients from all across Wales. It is unacceptable that administrative issues lead to delays to patients seeking specialised services. We recommend that Welsh Local Health Boards must provide improved training for clinicians on how to refer patients for tertiary care.

62. The divergence in policy since devolution can cause difficulties in cross-border contracts. There must be improvements to service level agreements (SLAs) between LHBs and CCGs. We recommend that the Department of Health and the Welsh Government work together to carry out a review of cross-border SLAs.

63. Uncertainty in the referral process can cause unnecessary worry to patients and their families, particularly when they are their most vulnerable. Decisions must be made in a timely manner. We recommend that a 30-day limit be placed on decisions on referrals by WHSSC.

Information technology compatibility

64. There are different IT systems in use in the healthcare systems in Wales and in England, and indeed, systems vary even within the English system. During our inquiry, we heard that this made it difficult for primary and secondary/tertiary systems in England and Wales to communicate with each other.

65. Healthcare professionals told us that the current lack of compatibility of IT systems was affecting patient care, causing delay to results and potentially putting patients at risk. Dr Frank Joseph from the Royal College of Physicians described how his inability to access blood tests taken in Wales had an impact on patient care when diabetes sufferers visited him at the Countess of Chester Hospital in England:

    When patients are referred to me I see them. We try to do a shared case management strategy. I see them maybe every six months or a year, and in the interim the GP would look after them for intermediate visits, but all the blood samples taken at the Welsh practices are sent to the Wrexham Maelor. Therefore, when a patient comes to me at the Countess for review I am at a loss because I am unable to access those results. […] If I am unable to get those results, I have an incomplete consultation.[53]

The Royal College of Physicians told us that many of their members repeated tests as this was often faster than waiting for the original results to be made available, leading to a "wasteful duplication".[54]

66. The Welsh NHS Confederation also explained that the lack of IT compatibility had an impact on continuity of care, once patients were discharged from hospital:

    While hospitals in England can pass discharge information electronically to GP practices managed by English primary care organisations, they cannot do so to Welsh practices. GPs in Wales do not get patients' results or reports electronically from English hospitals therefore causing delay in accessing information in a timely manner. The delay in information sharing could potentially put Welsh patients, post-discharge, at a higher risk than English patients from the same hospital. […] The reverse may also be true if an English patient receives treatment in a Welsh hospital which can otherwise access and transfer information back out electronically.[55]

67. There is currently no joint programme of work between NHS England and the Welsh Government around central IT arrangements,[56] despite the Department of Health and the Welsh Government agreeing that patient safety and care require effective integration of IT systems.[57] However, we do note that the two Governments are looking to achieve this in different ways. The Department of Health told us that it was focused on developing standards to improve the inter-operability for local IT systems in England, "rather than putting all of one's eggs in one basket and thereby relying on a single national IT system".[58] In contrast, the Welsh Government told us that it was looking to develop a "single national system" that would allow patient information to follow the patient.[59]

68. The Welsh Government told us that it was currently working on establishing electronic referrals between Welsh GPs and English hospitals "so that everything is more automated and speedier for patients".[60] A number of pilots had taken place between GPs in Powys and English hospitals and these would be extended to additional practices in Powys.

69. It is essential that patient information is transferred between primary and secondary and tertiary services as well as across borders in a timely and consistent manner. It is clear that the existence of different IT systems in England and Wales is having a detrimental impact on patient care in both countries. While we welcome the efforts being made to introduce consistent systems within each country, there must be a commitment to work towards a solution to accommodate the flow of patients across the Wales-England border. We welcome the pilot project currently being run by the Welsh Government in Powys.

70. We recommend that the UK Government and the Welsh Government work together to examine how improvements can be made in the electronic transfer of information between Wales and England.

GP Performers Lists

71. All GPs who perform primary medical services must appear on a Performers List. The list provides an extra layer of reassurance for the public that GPs practising in the NHS are suitably qualified, have up to date training and have passed all relevant checks. Currently each constituent part of the United Kingdom has different Performers Lists.

72. Witnesses told us that separate Performers Lists in England and Wales had a detrimental impact on recruitment to GP practices in Wales and "affected work force movement both ways across the border".[61] The Welsh NHS Confederation told us that many GPs chose not to go through the process of applying separately for inclusion on the Welsh list.[62] The British Medical Association (BMA) explained that GPs on the English Performers List were unable to take up immediately vacancies that existed in practices in Wales.[63]

73. The BMA also said that separate lists had an impact on the availability of locums for border practices, as locums on the English Performers Lists were unable to undertake work in Welsh practices and vice versa. This therefore impacted the choice of locums available to border practices.[64]

74. When we raised the issue with the Health Minister in the Welsh Government, he acknowledged that it was not acceptable that a separate Performers List could prevent people from working either side of the border. He told us that he would move to amend the necessary regulation in Wales[65] to remove barriers to GPs providing services on either side of the border.[66]

75. Wales is currently facing recruitment challenges in relation to GPs. It is unacceptable that the need for separate Performers Lists is acting as a deterrent to GP recruitment and affecting the freedom of GPs to work cross-border. We welcome the Welsh Government Minister's recognition of this problem during our evidence session, and his commitment to finding a solution.

76. We recommend that the Department of Health works with its counterparts in the devolved administrations to establish a single Performers List for GPs across the UK.

39   Taken from page 6 of the Policy for Out of Area Referrals for Secondary Care, issued by the Aneurin Bevan University Health Board, May 2012. Back

40   Q30 Back

41   Hereford Hospital (Wye Valley NHS Trust), Frenchay & Southmead Hospitals (North Bristol NHS Trust), United Bristol NHS Trust Hospitals and Lydney & the Dilke Hospitals (Gloucestershire Care Services) Back

42   Q357 Back

43   Welsh Health Specialised Services Committee (CBH0040)  Back

44   Q297 Back

45   Q321 Back

46   Welsh Health Specialised Services Committee (CBH0040) Back

47   Genetic Alliance UK (CHB0020) Back

48   Q180 Back

49   Genetic Alliance UK (CHB0020) Back

50   Q309 Back

51   Q310 Back

52   Q315 Back

53   Q165 Back

54   Royal College of Physicians (CBH0021) Back

55   Welsh NHS Confederation (CBH0016) Back

56   Q287 Back

57   Welsh Government oral evidence (CBH0051), Q289 Back

58   Q288 Back

59   Q356 Back

60   Ibid Back

61   Q157 Back

62   Q29 Back

63   British Medical Association (CBH0042)  Back

64   Ibid Back

65   The National Health Service (Performers Lists) (Wales) Regulation 2004 Back

66   Q339 Back

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© Parliamentary copyright 2015
Prepared 12 March 2015