UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 401-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

WELSH AFFAIRS COMMITTEE

THE PROVISION OF CROSS-BORDER PUBLIC services FOR WALES

TUESday 4 MARCH 2008

RT REVEREND ANTHONY PRIDDIS, REVEREND NICK READ,

RT REVEREND DOMINIC WALKER and REVEREND ROBIN MORRISON

Evidence heard in Public Questions 1-51

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Welsh Affairs Committee

on Tuesday 4 March 2008

Members present

Dr Hywel Francis, in the Chair

Mrs Siān C. James

Mr David Jones

Mr Martyn Jones

Alun Michael

Mark Pritchard

Hywel Williams

Mark Williams

________________

Memoranda submitted by Rt Reverend Anthony Priddis

and Rt Reverend Dominic Walker

Examination of Witnesses

Witnesses: Rt Reverend Anthony Priddis, Bishop of Hereford, and Reverend Nick Read, OBE, Chaplain for Agriculture and Rural Life, Diocese of Hereford, and Rt Reverend Dominic Walker, OGS, Bishop of Monmouth, and Reverend Robin Morrison, Provincial Church and Society Officer, Diocese of Monmouth, gave evidence.

Q1 Chairman: Good afternoon; a very warm welcome to you all to the Welsh Affairs Committee. The acoustics in this room are very poor and there is a lot of background noise, so our Members will be very keen to raise their voices, and I hope that you will be very happy to do so as well so that we can hear one another clearly. For the record, would you please introduce yourselves?

Reverend Morrison: Robin Morrison: I am children Church and Society Officer for the Church in Wales.

Rt Reverend Walker: Dominic Walker, Bishop of Monmouth in the Church in Wales.

Rt Reverend Priddis: I am Anthony Priddis: I am Bishop of Hereford.

Reverend Read: Nick Read, the Agricultural Chaplain for Hereford, and I chair the Cross-Border Officers' Group.

Q2 Chairman: Can I, as Chair, ask you to very simply outline your work? Originally we thought of asking both of you, Bishop Anthony and Bishop Dominic, but all four of you perhaps could say a little bit about the work you undertake in relation to cross-border issues.

Rt Reverend Priddis: I think we made clear in the written statements to you - speaking for myself and also for Dominic as a Bishop -the nature of our dioceses. In my case that encompasses the whole of Herefordshire plus south Shropshire, with about twenty parishes that are in Wales that are also part of our diocese. By virtue of being a Bishop and by virtue of having presence, as we do as Church of England in most of the communities, therefore I travel around a great deal in the diocese talking a great deal and listening, and I am therefore acutely conscious of a lot of areas where they speak about the cross-border issues. We have referred to those in terms of health, but also, as we have intimated, there are other issues in other areas. Nick has done a lot, as our rural officer, to highlight these issues, and also his work in the West Midlands.

Reverend Read: I chair the West Midlands Rural Affairs Forum, which is the rural stakeholders group for the West Midlands. That forum established a cross-border working party in 2003 because we were concerned about a whole range of English/Welsh issues where the borders interfered. As a result of that, the memorandum of understanding, which you have been sent, was drawn up by that group and signed last year, and we established a core officers' group. It is about forty people from organisations from both sides of the border, including the Welsh Assembly Government and the Regional Assembly. I currently chair the Core Officers' Group. Under that group, thematic groups have been set up, and Health and Social Care will meet for the first time later this month, so there will now be an established group looking at health and social care issues. I also chair the Borders Institute of Rural Health, which has made a separate submission to this Committee - but it is concerned again with health issues across the UK though again looking at border issues.

Rt Reverend Walker: Similarly, my diocese borders the English border, and the River Wye forms its natural boundary, although in some of our parishes in the north some of the farms go over into England, but people inevitably worship one side of the border or worship on the other side, and we are in constant contact with people who encounter difficulties, particularly in terms of health and where it comes to health provision, where they have perhaps a GP one side of the border or they are referred to a hospital on the other side. They encounter the difficulties we have outlined.

Reverend Morrison: My perspective and context is that I am responsible for the specialist work of the clergy and people in the Church in Wales - for example, social responsibility officers throughout Wales and rural life advisors throughout Wales, and working with the social, economic, environmental policy changes of the Welsh Assembly Government, to some degree on behalf of parishioners as well as other organisations. As a broader, bigger picture, I used to chair a health trust and I used to be on a health authority, but that was in England, so I do not have current experience in Wales on those issues.

Q3 Chairman: Can I place on record our appreciation of the written evidence you have given to us; it was most helpful in preparing for this session and indeed for this inquiry. It occurs to me that I need to ask a further question: even though you may not have been doing your present work perhaps ten years ago pre democratic devolution, it occurs to me that many of the issues you are raising have become more challenging since devolution. That is not to make a judgment of devolution, but would that be the case?

Rt Reverend Priddis: I think that would be our perception.

Rt Reverend Walker: And it continually develops because as changes are made one side of the border they do not necessarily change the other side of the border. For instance, if GPs in England are required to have extended opening hours, it will not apply to GPs in Wales; therefore someone living in England with a GP in Wales will not have the same access to their GP. On the other hand, free parking is going to be introduced in Wales, so those visiting patients in Wales will be able to park free of charge but might have to pay in England.

Rt Reverend Priddis: What would bother me about it is that when you have two systems that begin at source with the same rules and same regulations, then the longer the time is of slight divergence here and slight divergence there, the more it spreads and the more, therefore, the systems become complicated for everybody. They then have to think, "Which bit, which used to be the same, is now different?" Increasingly, that is more and more and more of it. Some changes may be slight. For prescription charges, at one level you may say that is slight, but it changes the culture, it changes the attitude and the mentality. It has been said that committees will spend a long time deciding how to spend £10 and it will go through on the nod if you spend £100,000! It is the small detail that affects people more.

Q4 Chairman: Of all the issues, I take it from what you have said and from what you have written for us that of all the issues that we are facing, health is by far the most challenging. Is that accurate to say?

Reverend Read: I think the finding of the Cross-Border Group - we commissioned some research - was that there is a whole range of issues. Health is certainly challenging, but transport is another area. In almost every field environmental, social and economic development is affected by the border, usually to the detriment of those living on both sides. Although health is an issue, it is not by any means the only issue that needs to be addressed.

Reverend Morrison: It has got related issues around it, but as a focus for this concern it is probably, in my view the most difficult one to address. One can look at many other issues and see borders disappearing and becoming invisible - for instance in the private sector the Institute of Directors in South Wales: one is conscious that their view of administrative borders is very different from the public sector's view. I think the health one brings to the fore all that you hinted, Mr Chairman, about the dilemma around unintended consequences of devolution.

Q5 Alun Michael: Can I commend the papers that you have both submitted, particularly the paper from the Bishop of Monmouth, which we ought to use as a model for future requests for evidence, partly because it starts off by referring to the facts. In that factual information you referred to the divergence of statistics between England and Wales in terms of Welsh health being worse than in England, which is something that is generally known and understood. I was not quite clear, though, whether you were suggesting that that divergence applies not just to the generality of England and the generality of Wales but to the communities in your two respective dioceses.

Rt Reverend Walker: It certainly applies to the valley communities within my own diocese and also people in Newport itself, where I live, where some of our estates have children - 80% of the children are below the poverty level, and a third of those are at least because of poor diets. Of course, we have a very high suicide rate - not as high as other parts of Wales, but one of my priests told me recently he had taken the seventh funeral for a teenage suicide in the last year, and that was in a small valley community. We do have particular problems caused by poverty and deprivation. I can understand why the Welsh Assembly Government therefore says these are Welsh problems and we need to have Welsh solutions. The problems arise with border issues when sometimes the ideology seems to get in the way of the practicalities. That not only affects patients, but also affects clinicians. They sometimes find it very difficult to know what the rules are. I was speaking to a doctor the other day who said: "I can see one patient with a particular problem and put them on one waiting list, and the next patient has exactly the same problem, but I have to look where they live and then I put them on a different waiting list; so one patient would be treated weeks ahead of the other." Somehow there seems to be a problem in which people perceive there being a lack of justice, and there needs to be some sort of pragmatic solution.

Rt Reverend Priddis: I would endorse that entirely. From where we are it is entirely unreasonable that there should be that difference of treatment according to where people live and waiting lists. We would want to see much greater quality and treatment for people, whichever side of the border they live. The issue of rural poverty is dear to your heart, I know, and as I have referred to earlier, South Shropshire district is, on Defra's figures, the most deprived rural district in England. Part of the consequence always for rural poverty is that so much of it is hidden. In sparsely populated areas, even if the proportion is significant, it is still diffuse. As Dr Stuart Burgess was saying just the other day, as rural advocate: if you have 2 million people in England who are deprived in rural areas, put them together and that is the size of Birmingham; but in fact they are spread around and it does not show up. It is those people also who suffer most with these cross-border issues.

Q6 Alun Michael: That is why it is so important that we get to the facts in order to make the difference.

Reverend Read: It is difficult to distinguish as a consequence of rurality and being a peripheral area and what is the consequence of being on the border; but our approach is that the difficulties of living in a rural area are compounded by the cross-border issues, understanding that distance decay and that people often give up on treatment rather than travelling for miles for treatment happens in rural areas anyway; but when you have a transport scheme that goes across the border to get access to healthcare it is even more difficult. You can easily distinguish between the two, but it makes rural issues far more difficult.

Reverend Morrison: It is important to point out that those facts were the same more or less in the 1930s, and in one sense the economic and social causation of those facts in Wales has nothing to do with devolved systems and so on. It is quite evident that certain ministers of health in Wales post 1999, post devolution, have gone for collectivist values that put, for example, public health policy at the centre of the solution to those facts; but I am not sure that the way of tackling those and reducing those per se is internal health systems alone.

Q7 Alun Michael: That takes us quite nicely from the facts, which may diverge, to the practicalities and then to the divergence of philosophies, values and political approaches, as you said in your paper. Divergence is obviously something to celebrate. I notice in the paper you refer, for instance, to the impact of the policy in providing your services within your paragraph 8 and then to the example of St Luke's Hospital in paragraph 9. I wonder whether each of you could comment on the impact of divergence of policy on both sides of the border?

Rt Reverend Priddis: The divergence, we have both referred to in quite a lot of examples, but part of the problem about divergence is divergence of some of the philosophy. I think it is spreading further rather than closer. That is the feeling in terms of the difference and the implications of that. Part of it, therefore, is what we have just been saying about targets, waiting lists and different treatments, and those implications; and part of it as well is that both Shrewsbury and Telford Hospitals and Hereford Hospital are looking for foundation trust status, and where is the funding to be for that? Is it going to be reliable and secure for people across the Welsh border, and what will be the implications of that for future planning? If there are decisions made in Wales over which a foundation trust has no control, will they be devastating for the finances of that foundation trust? Where is the dialogue? Who asks the questions? Who accepts the implications of the decision-making in one area that is totally legitimately within their philosophy and structure but which actually has un-thought-out consequences, because nobody is speaking up for them? These are real, real issues, and they could be extremely damaging. As I have said, if you withdraw 10% of the funding because a philosophy goes more and more to look in Wales towards Swansea and Cardiff - if the implication of that is that a foundation trust hospital serves a whole county, it is financially no longer viable and that would carry vast implications for another 170,000 people. It may not be the responsibility of the Welsh governing body, but nevertheless that is part of the implication. There is all that raft of questions that concerns us greatly if decisions can be made without that being connected and joined up, and without a structure that ensures that the implications are thought through and ensures that there is not the potential to cause, frankly, financial chaos and therefore health chaos - and the same would be true in other areas - with a decision one side, taken in good faith, serving those people, which has undiscussed and un-thought-out consequences.

Rt Reverend Walker: Often people perceive that they are caught between two systems and they tend to compare the two systems of course and feel, "If I lived the other side of the border I would be better off because ..." It is usually, "If I lived in Scotland I would be even better off"!

Q8 Alun Michael: Presumably without noticing the reverse!

Rt Reverend Walker: That is right - the grass is always greener on the other side, I suppose. It does sometimes become - vulnerable people seem to be given lots of information but seem to know less the more bits of paper they are given. My mother has macular degeneration and she is given an amount of paper to read as her eyesight becomes worse and worse. Her doctor is saying, "If you lived in Scotland, I could treat you. I will write to Cardiff and see if they can treat you" - and you discover they have the same policy as England, so she is not being treated at all! We are getting the feeling, as Bishops, that people feel they have nowhere else to turn so they turn to the Church to see whether we can bring justice for them.

Q9 Alun Michael: MPs more or less feel the same!

Reverend Morrison: The pieces of paper thing is pertinent, is it not? One of the things we have said in Wales is that if you have got divergent philosophies leading to divergent provision of care, systems and so on, then one way to solve that problem is to give more information so that GPs, primary care and local health boards and so on will ensure individuals understand their choices and the alternatives offered. I think that is slightly naive because I do not think information solves the problem. I think there are many vulnerable people who cannot manage that information in the way that one would assume. It is interesting that, obviously, in looking at divergence, you have got to say it is entirely appropriate within devolution for the people of Wales to have elected members and to come up with their own systems, and there will be systems that do not impact at all on this cross-border issue. I think one must be careful not to put all this together in one single focal point. If we go back to Bevan, one of Bevan's points was to erode differences, so there is a huge irony in this in Wales where the direction of travel chosen is increasing differences. I remember Brian Gibbons, when he was in the role, saying, "We want voice, not choice in Wales". That clever little turn of the words symbolised a whole divergent philosophy of values. Values in Wales are conflicting about this; it is not that there is one simple system; but our starting point is pragmatic and we would say you start with the patient on the hospital ward, not the civil servants writing the policies and not even the boards of the acute sector trusts and so on. You start with the patients and what matters to them. It ought not to be beyond us to re-jig the system to follow patient leads, but clearly that is not happening.

Reverend Read: It is important to determine where policy is being made in the sense that we now have a regional health board. We used to have three in the West Midlands, but we have a single regional health board developing regional health strategy. We rural-proofed that. We also rural-proofed - forgive the jargon - the health promotion strategy in the West Midlands. The health promotion strategy took account of cross-border issues and dealt very much with people. The regional health strategy dealt with provision of acute NHS services. That was the strategy that was quite a surprise, to understand that Hereford Hospital, for example, wanted an oncology unit. It did not feel that we were justified in having specialist cancer treatment because of the number of people that hospital served, but had not cottoned on to the fact that people travel from Powys to access healthcare there. So policy is also being made at a regional level, not just in Richmond House and the Welsh Assembly Government; and how that policy is interpreted and applied across the border needs to be carefully thought through.

Q10 Mr David Jones: Bishop Dominic, there is one paragraph in your submission which startled me, frankly, and I would like to ask you about it, on this issue of divergence. In paragraph 4 of section C you quote the author of a work Developing Policy-Divergent Values: Examining the NHS in the UK: "Different systems make different choices because policy-makers differ in their meaning and the priorities they attach to different values." Then there is this astonishing sentence, in my view: "Devolution is not just about different means but different ends." I can fully understand how devolution can be about different means, but I would have thought that in the case of healthcare the ends must surely be uniform - keeping people as healthy as possible and, if they are ill, treating them as effectively and speedily as possible. I am just wondering why you quoted that extract in your submission to the Committee.

Rt Reverend Walker: I think it was to try and emphasise that there are different philosophies - and I quite understand why there are. We fully support the idea that Wales has particular health needs that need to be addressed in a particular way but yet it seems that while they are saying, "we put the welfare of the patient first", in practical reality often the patient does not feel that or that does not appear to be the case. For instance, quoting the case of someone living in the north-east of Wales who has a neurological problem; they get sent to Swansea when they could go to Liverpool. That appears to be putting the philosophy and ideology before the care of the patient, when presumably the care of the patient is what matters.

Q11 Mr David Jones: It is not a question of means, which I quite understand; it is different "ends": what do you understand by that expression?

Rt Reverend Walker: I think I understand the means lead to the end; therefore, if you have different means that you will in the end achieve different ends. Sometimes I think the philosophy is not thought through far enough to see what the end product is going to be. I used the St Luke's Hospital example, not because I want to lobby for St Luke's, although I have benefited after heart surgery from their care, but I think it shows how, if you have a rigid philosophy that says "Wales will meet all Welsh needs within Wales" - and in fact it cannot of course - but if you say that that is the ideology, even though a patient could be treated free of charge in London and that frees up a bed and saves Wales £300,000 a year, somehow it seems that they are putting the ideology before the practicality. I can understand why they do not want private healthcare, but then I could argue that St Luke's is not providing private healthcare because no-one is paying for it; it is all being given free.

Reverend Morrison: Could I add to that, Mr Chairman? This is a quote from the Nuffield Trust Report, which you may know. In the same report the Director of the European Region of the World Health Organisation who had written a substantial piece of work on the value of values, says: "In practice the difference between policy statements and policy outcomes affects the difference between the means and ends." But if you look at policy outcomes as well as studying policy statements about direction of travel and values, et cetera, you can see that ends can be warped very easily where a gap develops between that difference.

Q12 Hywel Williams: Bishop Dominic, I am slightly troubled by the statement in your submission - and the comment that you have just made - at (a) on page 3 where you say: "A patient in North Wales requiring neurological treatment is likely to be sent to Swansea." It is the "likely" that worries me because I am not aware that large numbers of people from North Wales have been sent to Swansea at present. It might be the case later on, but that is an open policy debate at the moment. I am concerned that we are jumping the gun here slightly.

Rt Reverend Walker: The Bishop of St Asaph tells me that that is already the case, but being in south-east Wales I am not sure what happens in north-east Wales.

Q13 Hywel Williams: That is your source; that is what the Bishop of St Asaph says.

Rt Reverend Walker: Yes.

Reverend Morrison: He was unable to be here today, but has sent us his own comments, which we have not passed on directly to you. That issue reflects the previous dilemma as well because it is an open-ended question to some degree, but we know that in policy terms the intention is to make Wales self-sufficient in terms of critical mass, and therefore have specialist centres that will enable that critical mass of volume of patients to be achieved as much as possible in order to attract the doctors to those specialist centres, so it is a bit of a loop. That is the direction of travel and one could describe it as an end, but it would have consequences if implemented.

Q14 Hywel Williams: I refer to point 10 on page where you state that Wales seeks independence and to be self-sufficient in all clinical areas. I have to say I do not recognise that as a stated aim of the Assembly Government at present. I am not here to defend them as such, but I thought they were more pragmatic in their view of provision of health services and that they would provide them wherever they were available rather than saying they are seeking independent answers in all clinical areas. I wondered if you could source that contention of yours on page 4!

Rt Reverend Walker: "All" may be wrong; it may be most clinical areas. Certainly there are areas in which they cannot be, as I highlighted earlier, with things like heart transplantation.

Q15 Mr Martyn Jones: Can we see the papers from the Bishop of St Asaph? If you have not got them today, would you be kind enough to send us his views on the situation - or should we write to him directly?

Rt Reverend Walker: We had an e-mail from him. We could ask him.

Q16 Mark Pritchard: Gentlemen, welcome. Thank you for your work and remarks to the Committee, which have been very helpful. Bishop Anthony, your memorandum notes: "The needs of patients on the eastern border of Wales to be able to continue to access hospital care in England are vital not only for them but also for English hospitals." On the issue of mutual dependence, could you flesh out some detail of your understanding?

Rt Reverend Priddis: It was partly the point that I was mentioning a few minutes ago about the funding for the elective medicine at the hospitals, and partly the fact that in Hereford Hospital 10% of the funding comes from Powys at the moment. Shrewsbury and Telford - I do not know the proportion, but they serve a rather bigger catchment area in total, and I imagine that probably a similar proportion, maybe even higher given the geography there, may well come from cross-border funding. Part of the issue is about that. I think that the issues I referred to in, for example, Shrewsbury Hospital with the proportion of people who use accident and emergency being lower in rural areas anyway - what then happens is that you need the critical mass, and it goes back to the question you were asking just now, Mr Williams. Certainly in terms of accident and emergency, if you are going to have an accident and emergency department in a hospital, it needs that hospital to be big enough and serving enough people to have enough other departments. There are four critical other departments, preferably ten, that a hospital needs if it is going to be able to provide the best possible provision for A&E. Therefore, if the numbers are withdrawn because a specialism has developed in Swansea that the Welsh Assembly then wants doctors to refer people to - and if the consequence of that is that some of the departments get weaker, then the provision of A&E gets weaker. That, therefore, puts people more at risk. Those are part of the implications for us over these kinds of issues.

Q17 Mark Pritchard: Would you see the cross-border arrangements that Shrewsbury and Telford NHS Hospital Trust has, one where Welsh people are needing access to English healthcare and the English hospital trust whether Hereford or Shrewsbury or even in Cheshire is requiring access to funding from Welsh patients, whether that funding is 100% funding of the actual healthcare or not?

Rt Reverend Priddis: They mutually need one another. It would be a nightmare for people just across a Welsh border not to be able to go to Shrewsbury Hospital which was five miles away, or to Hereford Hospital which was twelve miles away, and certainly Shrewsbury because there is nothing else anywhere near in terms of a Welsh hospital. The same would be true of Wrexham, the opposite direction; that people on the English side can be a mile or two miles from Wrexham Hospital. If there was a clear demarcation, clearly that would be absurd because we would be back to the issue about what is best for the patient. Presumably, what is best for the patient is partly geography and closeness, shortness of travelling time, optimum speed of care therefore; and if the end really is patient care rather than trying to build on the best department down in Swansea so that that can get stronger, for example, or possibly the best department Liverpool and take everybody in that direction - if patient care really is the end, then geography is going to be key to that because closeness of provision of the best care that is nearest is clearly in the patient's interest. It is not just in the patient's interest in terms of best and speediest medical care; it is also in the patient's interest in terms of the support networks. This is an issue that I suspect we, as clergy, see rather more acutely than hospitals themselves see because we see a great deal through our congregations and through our villages and towns the relationships and networks of the family and friends visiting. We know that health and wholeness is not just to do in a restricted narrow way with immediate physical treatment at a hospital; it is also to do with not worrying about your wife or your husband or your children having to get to visit you or how they are being supported elsewhere, and all the pressures on them. Equally, it is about the wider family and friends support for people to have the health and wholeness of their whole relationships and all the other dimensions of their life. This does not figure on the statistics; it does not figure in budget, but it does figure in how people recover and in how the communities respond. The geography affects that, if people have to go five hours down to Swansea rather a half-hour journey. The implications are not just there for the medical treatment in the restricted more physical way; it is also there for the wider support and the wider sense of good, the recovery rates and the support that people are given afterwards.

Q18 Mark Pritchard: If you look at a very large county like Herefordshire, do you think the drive for foundation status in Hereford Hospital and Shrewsbury Hospital Trust as well is likely to tempt both trusts to continually look towards Wales and perhaps to look to Wales more so in the future seeing Wales as a helpful revenue stream - payment by results, et cetera? If that is the case and if you agree with that, do you share my concerns that there are patient needs in the other parts of those counties, for example in Shropshire, the eastern side, and Ross on Wye in Herefordshire and that those patient needs may well be forgotten or downgraded as a result of the foundation trust hospitals looking towards Wales and focusing their attention mostly on their western side rather than thinking of the county as a whole? The primary function, surely, of an English hospital trust, however helpful you want to be to Wales, is to service the needs of the English patients?

Rt Reverend Priddis: The first bit of your question I think I can say "yes" to; that the foundation trust status is going to strengthen, if anything, what already exists anyway - I think the primary care trusts. I think it will make people more concerned who run those hospitals to make sure the funding stream is there for people across the Welsh border if it is an English hospital - so I think you are right about that. I am not sure I would necessarily go with you quite so much about the other issues for two reasons. One is that whether or not, in terms of Shrewsbury and Telford or Hereford Hospitals, including people from Wales would then mean there has to be greater attention given to Wales, I do not see that that is the case. I would have hoped that if a hospital is serving people on a western region, it will have no greater need to give them a higher priority than the people on the south or the east of their region. I do not see that if it operates properly, once they are aboard as it were in terms of system and decision-making and policy so that they can come and funding will follow it, they need be given a higher priority or higher treatment from any other people. I do not actually see that the consequence need be that any people in England would suffer; rather it seems to me that the reverse is true, for the reason I was saying earlier: if you withdraw funding and you get below the critical mass level, then some of the specialisms cannot be supplied because the budget does not stack up for a 24/7 provision in this particular department; and then everybody suffers. The English patients would suffer with withdrawal of specialism if the funding were not there to provide the doctor care seven days a week. Actually, not looking after the Welsh part, in terms of your question, would actually make the English suffer.

Q19 Mark Pritchard: If I may, I will give you the example of Shrewsbury and Telford NHS Hospital Trust, who have one trust on two hospital sites. One is a hospital in my constituency and one is in Shrewsbury. If the focus is going to be revenue from Wales, then it makes sense for the trust to pour more investment into the site that is nearest to the Welsh border. That was my point.

Rt Reverend Priddis: I see.

Q20 Mark Pritchard: Clearly, that disenfranchises constituents of both mine and centrally in Shropshire and in Shropshire that I represent as well. The point is not about English versus Welsh or not helping the Welsh patients or the Welsh not prepared to go - it is not about that. As a Member of this Committee it is about Welsh taxpayers being able to access the Welsh health services that they have paid for. It is not a party political point. If the direction of travel of the Welsh Assembly as a whole is to provide as many health services as they possibly can in the coming years, then clearly there is a divergence of policy in relation to foundation trusts in England because they will be pulling against one another.

Reverend Read: I am not clear from your question. There seems to be an assumption that all hospitals offer the same degree of service. A lot of the cross-border traffic is to a degree of specialism that does not exist in very many hospitals: Liverpool for neuro-surgery; Liverpool and Birmingham for paediatrics; Stoke-on-Trent for cardiac surgery, and Oswestry for orthopaedics. They would not be part of a normal district general hospital set-up. In order to maintain that degree of specialism in a sense you have to cast the net as widely as possible, and pragmatically the east-west transport routes across much of the border are just so much more straightforward than north-south. In terms of patient care it must make sense.

Q21 Mr David Jones: If I may come back on that point, you may be aware of the controversy at the moment over Walton. You say it is clearly much more convenient for north-east Welsh patients to go to Walton, but we have now a Welsh Health Minister who has said on the floor of the Welsh Assembly that she intends to aim at what she called an "in-country" solution, which would require North Wales patients to travel to South Wales. Clearly, your point about convenience is absolutely right, but that is not apparently what is happening in the Assembly.

Reverend Read: It is not a policy that we would support for that reason.

Rt Reverend Priddis: It is precisely what concerns us and precisely what we are referring to in terms of divergence of philosophy; and it is precisely what is behind the point you picked up on earlier about ends. What you have just articulated surely is an end that is intended, and it has a consequence that we would say is not for the patients' best interests. I think you have put very clearly why that reference was there in paragraph 4 that Bishop Dominic wrote.

Q22 Mrs James: Forgive me gentlemen because some of what I was going to ask you about you have covered already and I want to tease out a bit more on the particular issue of the experience of people living on the border. Bishop Dominic, in your written evidence you state: "Although cross-border issues are regularly faced by those living near the Welsh/English border, they are not confined to them alone." Can you illustrate how those cross-border issues, particularly health issues, differ from those living on the border as opposed to in other parts of Wales?

Rt Reverend Walker: What I meant was someone in Aberystwyth, for instance might need a heart transplant and would have to travel to England for it. It is not just something that affects twenty miles outside the English/Welsh border; it is a bigger issue than that. Bishop Anthony said that there is not the critical mass in Wales in order to provide specialist services and therefore inevitably people from Wales have to travel to England for some treatment. That is particularly so for some paediatric problems as well as heart transplantation, because by-pass surgery and everything else can be done in Cardiff.

Q23 Mrs James: Those are the specialisms that Bishop Anthony referred to; because of critical mass you need larger centres of population. Bishop Anthony, this is related to the question: you say in your memorandum that there is a reduction in the rate of service use as the distance from the source of healthcare increases. Can you tell us a little more on that?

Rt Reverend Priddis: Are you meaning the academic sources for that?

Q24 Mrs James: Yes. You stated it in your submission.

Rt Reverend Priddis: I referred in one of my paragraphs to the College for Emergency Medicine Journals about uptake. That was more about mortality, a 1% increase per 10 kilometre of travel. I think it was more of an issue you were referring to, Nick. I do not know whether you have got the more detailed factual papers that that came from.

Reverend Read: I do not have them on me but I can certainly send you details.

Q25 Mrs James: It related to the time. For example, if you were in an accident would you need to get within a window of opportunity?

Reverend Read: There is that, and also the distance decay. A number of studies have shown that people in a way do not access health services in the first place, unless there is an acute situation where there has been a road traffic accident or something, but of course they go and see a GP, and the GP refers them to the specialist hospital, which is X miles away, and they decide that they are not going to take it any further because of the sheer hassle involved in getting there and the effect on the family. There have been a number of studies done in Wales. I can get you the details.

Q26 Mrs James: That relates to cross-border transport services that you mentioned earlier on. Are there particular problems with the ambulance services?

Rt Reverend Priddis: There are. I think the A&E departments reckon that people need to be there within 45 minutes for more acute treatment - cardiac arrest problems; and if they are not, then the mortality rates change quite significantly. Part of what I have already said is that there is then a difficulty if it is longer routes; if you only have one paramedic, then they cannot necessarily provide the treatment that is needed to sustain a patient in a critical condition because you might need two people. In paragraph 9 I have referred to some of those areas. Longer travelling time ought, I think, in the best interests of the patient, means that at times you can have two paramedics present rather than one; but clearly that has cost implications, and that is part of the difficulty.

Q27 Mrs James: It is not just faced by people cross-border.

Rt Reverend Priddis: No.

Q28 Mrs James: Far West Wales faces similar problems.

Rt Reverend Priddis: I am sure Scotland would say the same to us.

Reverend Read: There is a paper by Iredale et al in 2005, Health and Place. I will reference this to you.

Q29 Hywel Williams: Bishop Dominic, you say in your paper that there are two different funding approaches for patients with the same problems being adopted between Wales and England (paragraph 6, section C). Can you give us some examples of different funding arrangements that you have identified? I am slightly worried at the conversation we are having in regard to the difference between England and Wales, and I am interested to see examples.

Rt Reverend Walker: Robin may know more clearly.

Reverend Morrison: Again, I cannot quote an individual case in, say, a hospital ward; but I think what we are hearing about - and it is anecdotal, clearly - is that because the commissioning arrangements are different - the block and tariff systems, for example - there is a fault line there which some clinicians struggle with. We are hearing that in some hospitals clinicians are doing their best to get round this so that on a ward the care package or the funding package of the commissioning route will not make any difference at all. We are also hearing that that fault line is an irritant, and people are reacting differently to it. I suppose that that is a hugely complicated area because it would depend upon the individual ward staff, teams, boards and off you go. There may of course be very legitimate reasons why two different systems are needed and can work well. If there is a fault line, for example in the same hospital, it does seem, as we said earlier, not only to disadvantage the patient, which is the main concern here, but some processes within the hospital. We mentioned foundation hospitals earlier, and one of the things around that status is to give more flexibility in systems and in governance and autonomies and so on, which presumably might aid the case of cross-border issues because there might be local autonomies that can address the specifics. I guess we are talking throughout the health economy but primarily in the acute sector here, and I suppose if there is no fault line there is no problem; but you are quite right that we must get from generalities to the specifics. I would urge you, as a Committee, to find people who would give you that evidence. We certainly only have it anecdotally.

Q30 Hywel Williams: I would say anecdotal evidence is entirely valid. It is interesting what people think. I am just worried that popular debate has been coloured by anecdote and not sufficiently by statistics.

Rt Reverend Priddis: If I might say, I am pleased to hear you say that. "Anecdotal" means people without any voice. That is literally what "anecdote" is; and therefore it is not to be dismissed. It is rather giving voice, which is part of what we seek to do.

Q31 Hywel Williams: Are the current cross-border funding arrangements impacting on the quality of service provided to patients, the quality within a hospital? Are there quality issues?

Reverend Morrison: That is a suitable question, is it not, because as bishop Anthony earlier said, if you put geography and distance decay and all these other factors alongside quality of provision, which is your question - it is such an important question because, again it might well be that whatever the systems, good local provision and response achieves enormous quality of patient care and outcomes for individuals. The relationship between systems that have glitches in them and local delivery is an interesting debate. Presumably, we are interested in removing the glitches to give the quality as much chance as possible. That is, I know, a controversial way of looking at it because it does start with the patient end. I know how difficult that is, particularly in large-scale organisations and large-scale public service delivery. The interesting thing in Wales for me was the public reaction to Design for Life, which clearly tries to address many of the crucial issues about quality and excellence, centres of excellence, quality of provision and how you link these and focus these in certain places. The implications of that of course is the local reaction against the perceived removal of local access to services, and that was so widespread in Wales that I would have thought that is quite good evidence that the case we have been arguing for in terms of access and geography, and carers as well as patients, is already made for us. It then gets very difficult because you cannot spread the resource too thinly, so there is a tough policy debate to be had alongside the public reaction to that issue. I think you are absolutely right to go for quality. That raises all sorts of other issues about training, standards and values in hospitals and the poor outcomes in hospitals, which I guess is a much larger conversation than the remit of this group. I am totally with you: if we want to raise the bar on quality, let us remove the stupidities in the system that make it more difficult for clinicians to do an excellent job.

Q32 Hywel Williams: Bishop Dominic, you mentioned the apparent policy of the Assembly to provide more services from within Wales: but be that as it may you also say that there are bound to be certain medical conditions where there is an insufficient critical mass to make it possible. Can you expand on those sorts of conditions? You have talked about heart conditions and there have been certain discussions about -----

Rt Reverend Walker: I think some rare illnesses, like NEMO-Pig disease, that kind of thing, where there may only be a small number of people who suffer from that particular illness in Wales and where specialists in that reside in particular English hospitals; and therefore it may be necessary to provide for a child with NEMO-Pig disease to go to Cambridge or Oxford or somewhere where there is a specialist in that particular illness.

Q33 Mark Williams: Bishop Anthony, in your paper you talked at length on cross-border traffic in people. In part, I guess, a solution to this has been development of a memorandum of understanding between central Wales and the West Midlands. Is that addressing some of the concerns you have addressed? Reverend Read, at the start, talked about the work of core officers and the thematic approach to hospitals' more general problems. As a matter of process, what is being done through that memorandum to address some concerns you are hearing and that we agree with you on?

Rt Reverend Priddis: Nick and I have observed before that we feel that the memorandum of understanding perhaps has achieved two things that are significant and important, but it is only in some ways a beginning. One is that it has been a clear acknowledgment that these issues are around and that they are difficulties that need addressing. The second is that it has therefore been a means to conversation taking place and the dialogue happening for people to have some channels and routes by which they can talk more about shared difficulties and shared issues. However, that is nowhere near enough. The discussion needs to take place but it is a starting point. It has got to lead, as we have been saying, to some further actions. It is not just a matter of local people across the border being able to resolve the problems themselves; hence your own agenda and your own roles, because these are not just local issues or not just regional, but also national issues. Nick would be the best one to take that further.

Q34 Mark Williams: Can I reiterate that point and follow up from Mrs James's question on people living further away from the border. Would you agree there is a need for people further afield to have an input into those cross-border issues?

Rt Reverend Priddis: Absolutely.

Q35 Mark Williams: Perhaps not on the scale of people from Powys and the West Midlands, but certainly -----

Rt Reverend Priddis: I would agree, and also north, because this is a West Midlands-driven agenda and therefore that may touch on the middle and south of the border issues, but does not touch Cheshire in the same way.

Reverend Read: In practice, the MOU was a corrective mechanism to ensure cross-border was taken into account. The way it works is that the organisations that have signed up to the MOU have signed up to a commitment to share non-confidential information and to discuss with their partners on the other side of the border when it comes to policy development. The other tool that is being developed is a cross-border toolkit, so the way that we rural-proof policies to see how they impact on rural areas. We want to be able to subject policy development to an analysis that says, "How will this impact on those communities on both sides of the border?" In practice we are looking at policies that are already in existence - the Wales Spatial Strategy, the West Midlands Regional Strategy, and so on. It is asking the question: "How is this going to affect people who live on either side of the Welsh border and how will policy development on the English side impact on policy development on the Welsh side? It is not creating a separate policy, but it is subjecting the existing policies to that mechanism. The toolkits are the cross-border toolkit and the people who apply that, and the thematic working groups that I have mentioned, which are in a sense trying to roll out the issues for each of those specific areas. We identified six areas initially, of which health and social care is one. I am slightly envious of the situation along the Mersey lines where they have a sub-national strategic document. That was economically driven, but each of the partners are buying into that at £5,000 a time each year, so they have a budget to monitor and carry out research. We do not; we are entirely reliant on the volunteers, those who attend the meetings. There is significant buy-in from the Welsh Assembly Government and from the Regional Assembly and the West Midlands, so the major stakeholders are there and we need to progress it. It is early days but it is generating dialogue now that did not happen before - of that we are quite convinced.

Q36 Mark Williams: Bishop Dominic, your memorandum talks about the need for that dialogue. Are you satisfied this is beginning to work and that the people who should be engaged in dialogue are participating? Is there anybody else you would like to add to the list of participants!

Rt Reverend Walker: I do not have any knowledge of the memorandum of understanding and how that is working because that does not cover my area, but I am sure that having clinicians and patient user groups and other community people in dialogue, with, hopefully, Members of Parliament as well as Members of the Welsh Assembly, would lead to a way forward.

Reverend Morrison: This is complicated, though, is it not? If you look at cross-border geography you might well end up with three strategic forums, all quite rightly focusing on their own specific areas. As partnerships and strategic bodies become more mature, not just the cross-border ones but, say, in Wales, one of the issues is how dialogue, co-operation, sharing of information and collaboration at that level gets translated into political policy-making. I think for future policy development this is a very useful first-stage tool, and who would argue against it? As has already been said, more is needed.

Q37 Mark Williams: Would you welcome that? You talk about three strategic bodies. We are going to hear from the Minister from the National Assembly, I am sure, and the Minister for Health here about the dialogue between the UK Government and the Assembly Government on that matter. In terms of practitioners on the ground, would you welcome that?

Reverend Morrison: Subsidiarity is an important principle in this in terms of giving access to local people and local organisations. The issue then is: how do you get the best of perhaps three different approaches to cross-border issues and push them into the present structures rather than just bolt them on? It is really difficult anyway and we have economic forums in Wales. The spatial planning in Wales, which is second to none in Europe in many ways, still has the problem of different zones and areas of Wales feeding back in ways that actually influence political policy-making. It is that little bit of the loop that is tricky.

Chairman: I think we are at the heart of the issue that Mr Williams alluded to there in regard to the ministerial meetings that take place, but the public is not aware of what is being discussed. It may well be that this Committee and your evidence would help in this respect. In the policy process we need to know what they are discussing and what informs those discussions.

Q38 Mr David Jones: I do not know whether someone can assist me with this, but the copy of the memorandum of understanding I have got is labelled "draft": has this been adopted or is it still a draft?

Reverend Read: It was signed twelve months ago tomorrow by Carwyn Jones of the Welsh Assembly and David Smith of the Regional Assembly; but since then another forty or so organisations have signed it. They were the photo opportunity, but, yes, there is a rolling programme of signatures.

Q39 Mr David Jones: This document before the Committee now represents the memorandum of understanding as it now is and it has not been changed or amended in any way, has it?

Reverend Read: I honestly cannot say, but I have a copy of the final document with me.

Q40 Mr David Jones: It might be helpful if a final copy of the document were put before the Committee.

Rt Reverend Priddis: I think it is the same but we will check.

Q41 Mr David Jones: On the assumption that the final document has not changed from the draft we have in front of us, my concern is clause 5 which states: "This memorandum of understanding is a voluntary arrangement rather than a binding agreement or contract, and so does not create any legally enforceable rights, obligations or restrictions." My concern therefore is that if any aggrieved patient who at the end of the day is the person supposed to benefit from this process, decides that he wishes to take the issue to court on, for example, judicial review, he has not got any legally enforceable rights he can point to for taking that step. Is there not a deficit at the end of the process for the aggrieved patient in that he has no recourse if he is dissatisfied with whatever treatment he or she has received?

Reverend Read: That clause was inserted at the request of the Welsh Assembly Government lawyers.

Q42 Mr David Jones: It looked legally drafted!

Reverend Read: They changed very little to the text itself. It was originally a cross-border agreement, which they vetoed; and then it became a concordat, which they vetoed; they accepted MOU and the insertion of that clause because, obviously, they did not want to be contractually bound.

Q43 Mr David Jones: To paraphrase Sam Goldwyn, it might be fair to remark that the non legally-enforceable document is not worth the paper it is written on!

Reverend Read: I do not think that is true because dialogue is happening in a way that it did not happen before.

Q44 Mr David Jones: But unenforceable dialogue!

Reverend Read: Except it is a public document that organisations have signed. The job of the Core Officers' Group that I chair is to monitor and to be able to flag up those who are not honouring the agreement. If they have taken the trouble to sign the agreements, we may not be able to take them to court, but at least we can point up that they are not fulfilling the expectations.

Q45 Mr David Jones: Perhaps that should be said very publicly and very vocally.

Reverend Read: Yes, it is on the Web; who signed it is on the Web, and we have an annual conference at which we will monitor progress. People bought into it, although they are not legally bound to it.

Rt Reverend Priddis: It is a moral force at least and it is a move in the right direction. We sympathise with you entirely.

Mark Pritchard: I was thinking that if we had treaties rather than understandings, paradoxically we might have had fewer wars!

Chairman: Order! Is this a supplementary or not?

Q46 Mark Pritchard: It is a supplementary. Given everything that has been said thus far this morning - and it is not a political question or even a philosophical question but it is pragmatic in terms of delivering more healthcare for the people in Wales - do you think that more devolved power in healthcare to Wales would be a good thing, or perhaps a bad thing?

Rt Reverend Priddis: I do not think that is something I would hold a strong view about one way or the other because my presence here is because I am able to speak from the presence of our 400 and more churches in the diocese, from our congregations, from the people about their needs and, as we have been saying, their desire to be treated in the best possible way, equally, fairly, with fair access, and where geography needs matter. If you, as politicians, think that devolution can achieve that better with more funding or less funding, in a sense that is your question, not my question. We can say what the needs feel like and what needs addressing, but how practically and politically it is addressed I do not think is within my brief.

Q47 Alun Michael: I just want to ask about this business of how binding an agreement is. I accept entirely that an agreement to which people and organisations are committed can be more effective than a legally binding document that means people giving more money to lawyers; but that requires not only those who are signatories but those who provide the funding to be committed as well. At the level of regional government and central government departments, do you think there is sufficient recognition to the binding but not legally binding nature of the agreement to which you have referred?

Reverend Read: I think there is in a sense, that this document has also been signed by the Government Office for West Midlands and Advantage West Midlands; but I am concerned, following the sub-national review at the end of the Regional Assembly, as to who in the West Midlands might take the lead in making sure this happens. At the moment it sits very squarely with the Regional Assembly. When there is no longer an assembly I would hope that they would be able to take it on board, but I think that is an open debate.

Q48 Mr Martyn Jones: As a Committee, we have to find some answers to problems that we have instituted the inquiry for in the first place, and with your spiritual connections we are hoping you might have some answers! Are there sufficient mechanisms in existence within the public services to identify and resolve cross-border issues?

Reverend Read: No. What concerns me is that the thematic group that is being established for health and social care will identify local solutions. The issues are reasonably well known, but they will not necessarily be able to feed that back into policy developments within the Welsh Assembly Government at regional level or national level. I think we will come up with some answers, but I do worry about our ability to see those answers delivered.

Q49 Mr Martyn Jones: Is there a sufficient level of research currently being undertaken on the impact of cross-border issues?

Reverend Read: No.

Rt Reverend Priddis: No.

Reverend Morrison: There is an awareness of the issues, clearly, and different bodies from the NHS Federation, the two different professional bodies, are aware of this and will all have their spin on it. As to independent research, I am not aware of any at all, but I could well be wrong - not that research solves all the problems, of course.

Q50 Mr Martyn Jones: It would be good if it did! Even if we do not know what the problems are, if you do not know of research, that is worrying.

Reverend Morrison: There is a question mark about the kind of research in relationship to patients and hospital functioning and so on, because there are various interests at stake here, and I would be quite careful about the way research is set up.

Q51 Mr Martyn Jones: The $64,000 question: how could cross-border issues best be identified and resolved; and, as part of that, do you know of any examples around the world where this is happening?

Reverend Read: I do not know around the world. There is a very useful local thing: the Shropshire Pathfinder Project, which is about delivering services. Shropshire was the West Midlands pilot project and there was one in each of the English regions. That certainly identified cross-border issues as important and came up with some solutions involving IT for example and access to services, which could equally apply on both sides of the border if funding were there. There are local solutions and people on the whole are quite pragmatic locally about how you make things work; it is whether the structures allow those things to work.

Reverend Morrison: I totally agree with that, and Bishop Dominic's statement in terms of recommendations for action contains a key sentence about the systems needed which makes equality of care possible in whatever provider or care situation - wherever it is, cross-border, immediate geography or elsewhere. We are not saying this is how you do that system; we are saying it is not beyond health authorities and individual hospitals and their governance boards to do that, so long as politically, behind the scenes, there is that recognition that it needs to happen. If that drives the policy-making, the systems can be found. What is needed is a language and clarity about the need. If we do not keep insisting on it, it may be that you need local solutions. Maybe one hospital trust, if it were given the freedom to find its own solution of how it treats English and Welsh patients equitably, could come up with some interesting suggestions. Whether or not that would be acceptable within the hierarchy of what happens to governance boards in hospital trusts is another issue. That is a systemic issue and it needs sorting.

Mark Pritchard: On a point of information, I am not sure whether, gentlemen, you are aware of the new sub-regional working arrangements, with the dialogues going on at the moment between Shropshire and Herefordshire, to work at sub-regional level on a range of issues, health being one of them. I encourage you to find out a little more about that; it is breaking news at the moment.

Chairman: We have almost come to an end. We have started this inquiry with health, and you have largely spoken about health, but at the beginning you alluded to a number of other policy areas where there seems to be a policy divergence. Would you write to us and tell us your experiences of those situations where there is a practical impact of that policy divergence, rather than opening up a discussion with you now? In thanking you for giving evidence and also for your written evidence, could I place on record my personal appreciation and also of this whole Committee for the way in which you have not only represented the views of the people on both sides of the border but also engaged in a very serious and deep way with the policy developments. It was asked of me by a member of the press yesterday: why did we begin with you! It was very clear today that you have very strongly given the answer to that. I was very strongly reminded of the Church's role in recent decades, in my lifetime, and the way the Church has engaged in the big issues of our time. I am reminded of the late Glyn Seimon(?) in the late 1960s involved in large issues, global issues like South Africa, and Aberfan, and then the Church initiative during the miners' strike in 1984/1985, and of course the Bishop of Monmouth in the 1990s and his engagement with steel closures. If I could say, you are in that great tradition, and I thank you for that.