Mutual dependence

44.  The mutual dependence of Welsh patients and English providers on one another is clearly identified in the evidence we have received. We agree with First Minister Rhodri Morgan AM that Welsh and English health services are "very closely integrated" and would further note that one of our greatest assets in Wales is our proximity to England.[20]

45.  The reliance of many English providers on Welsh activity for the viability of their services was highlighted in evidence to the Committee. With hospitals such as The Robert Jones and Agnes Hunt Orthopaedic and District Hospital receiving 30% of its income from Welsh commissioners, services are highly dependent on continued flows of Welsh patients to English providers. A key criterion for the success of future heath policy decisions will be to ensure that policy developed within one jurisdiction does not have unintended consequences for patients or providers in another. The continued viability of English hospitals located along the border, and hospitals providing specialist services for Welsh patients, should not be adversely affected by the decisions of policy makers who fail to consider long-standing cross-border flows of patients.

All-Wales provision

46.  In December 2005, the then Welsh Assembly Government Minister, Dr Brian Gibbons AM confirmed that it was the Welsh government's objective that patients needing tertiary and specialist services, wherever possible and clinically appropriate, should be seen and treated in Wales.[21] On 4 July 2007, the Welsh Assembly Government Health Minister Edwina Hart AM stated that her:

… overriding aim is to secure as many services as can be safely provided within Wales's boundaries. Of course, there will always be rare conditions and highly specialist services that can only be supported by populations greater than the population of Wales. This means that, in order to get the best possible treatment, there will always be some patients who must travel outside Wales for the services that they require. However, where the Welsh population base is sufficient to support an in-country service, that is the way in which I wish to proceed. Therefore, in the case of adult neurosurgery, the approach that I now intend to adopt is one in which we will look as actively as possible at redirecting additional elective work generated inside Wales to the two centres at Swansea and Cardiff.[22]

The suggestion that North Wales patients may have to travel to the South as opposed to crossing the border in future has caused great concern.

47.  During the course of our inquiry we visited The Walton Centre for Neurology and Neurosurgery NHS Trust at Fazakerley, Liverpool and the Royal Liverpool Children's NHS Trust, Alder Hey. This gave us the opportunity to see at first-hand how cross-border health services are provided for Welsh patients in England and how patients, clinicians, and administrators perceive the arrangements currently in place to provide and co-ordinate such services. We are grateful to the dedicated staff at both hospitals who took the time to introduce us to the valuable work that they undertake, and we commend the services that they provide for patients, particularly those from North and Mid Wales.

48.  Statements made by the Welsh Health Minister, and individual patient cases outlined to us in evidence, do little to quell fears amongst the Welsh population, particularly in Mid and North Wales, that they will be unable to access neurosciences or other health services on a cross-border basis in the future. We acknowledge the First Minister's assertion that the modernisation of medical care means that, from time to time, specialist services become mainstream and can be repatriated where clinically safe and geographically convenient for patients and their families.[23] We are reassured that he agreed with us that decisions on the repatriation of services will be informed by pragmatic and practical considerations.[24] For that reason, we also agree with him that the dependency of North Wales "on Manchester, Liverpool, maybe Chester and Shrewsbury, et cetera, is much more likely to last for a much wider range of services".[25]

49.  We await the findings of Mr James Steers's review of neurosciences services for Welsh patients and will comment on its implications for cross-border health services in our full report in the autumn.

Inter-governmental co-ordination

50.  Much written evidence submitted to the Committee called for greater inter-governmental co-ordination of cross-border health services. Acknowledgement is given of the success of initiatives and agreements at the local and regional level, such as the Memoranda of Understanding signed between the Welsh Assembly Government and the West Midlands Regional Assembly.

51.  Evidence also suggests that cross-border health services would be better served by a permanent protocol between the Westminster and Cardiff governments to address funding and commissioning tensions. Areas identified by our inquiry as causing greatest concern to patients, managers and clinicians are divergence in performance and payment regimes. Establishing a permanent protocol on the commissioning and funding of cross-border health services would provide greater assurance and clarity to patients, commissioners and providers of health services as to the arrangements in place for accessing and providing health services on a cross-border basis. A key criterion for the success of any future protocol is that it provides clarity and sustainable solutions, and should be subject to extensive consultation with key stakeholders. The permanent protocol between the Department of Health and the Welsh Assembly Government should be agreed and published in draft form, for consultation, as soon as possible. We also believe that bilateral ministerial meetings between the Department of Health and the Welsh Assembly Government should be announced and that the nature of all discussions should be made public and transparent.

The impact on the patient

52.  Patient representation on a cross-border basis is complicated and unclear. The plethora of patient representative bodies available to citizens accessing cross-border health services creates a complex web for patients to understand. Those citizens wishing to understand local policy and express their views on service structures find that they have to navigate amongst the local Community Health Council (CHC), Local Health Board (LHB), Patient Advice and Liaison Services (PALS), Local Involvement Networks (LINks), and Foundation Trust Membership. Little information exists as to how this multiplicity of bodies liaise with one another when patients cross jurisdictions, and little evidence was presented to show how patient representative bodies formally contribute to dialogue relating to cross-border health issues. Similarly, the phasing in of certain patient bodies, such as LINks, alongside the phasing out of others, such as Patients' Forums, yields a very unclear picture of how cross-border patients are represented within governmental policies to increase patient and public involvement.

53.  We expect further clarification from the Department of Health and the Welsh Assembly Government on the role undertaken by each of these patient representative bodies in relation to cross-border health services. We also urge both administrations to consider carefully how future arrangements for the development of patient and public involvement will impact on cross-border patients and to include these in a formal public agreement.

21   Memorandum submitted by the Minister for Health and Social Services, Welsh Assembly Government, para 26 http://www.publications.parliament.uk/pa/cm200708/cmselect/cmwelaf/ucprovision/ucm7002.htm  Back

22   National Assembly for Wales, Official Record, 4 July 2007 Back

23   Uncorrected transcript of oral evidence taken before the Welsh Affairs Committee on 12 June 2008 (HC 401-vii, Session 2007-08) Q 530 Back

24   Ibid, Q 531 Back

25   Ibid, Q 530 Back