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My wife, who was undergoing ongoing treatment for a life threatening condition in Bristol, had her cross border funding withdrawn by the Aneurin Bevan University Health Board.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.
TERTIARY SERVICES
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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