Uncorrected Evidence 401

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Oral Evidence

Taken before the Welsh Affairs Committee

on Monday 31 March 2008

Members present

Dr Hywel Francis, in the Chair

Mr David Jones

Mr Martyn Jones

Albert Owen

Mark Pritchard

Hywel Williams

________________

Memorandum submitted by Dr Peter Enevoldson, Medical Director,

Walton Centre for Neurology and Neurosurgery, Liverpool

Examination of Witnesses

Witnesses: Dr Peter Enevoldson, Medical Director, Mr Christopher Harrop, Director of Finance, Mr Ken Hoskisson, Chairman, and Ms Mel Pickup, Chief Executive, Walton Centre for Neurology and Neurosurgery NHS Trust, gave evidence.

Q137 Chairman: Good morning. Welcome to the Welsh Affairs Committee. I could not say, "Welcome to Liverpool", because we are visiting! For the record could you introduce yourselves, please?

Mr Hoskisson: I am Ken Hoskisson and I am the Chairman of the Walton Centre.

Ms Pickup: I am Mel Pickup and I am the Chief Executive of the Walton Centre.

Mr Harrop: I am Chris Harrop, Director of Finance at the Walton Centre.

Dr Enevoldson: I am Peter Enevoldson, consultant neurologist and Medical Director at the Walton Centre.

Q138 Chairman: I am not sure whether you can hear us very clearly but do not be afraid to raise your voices, we will not be offended. Could I begin by asking you the question, what impact has devolution had on medical services and do you consider them to be opportunities or challenges or problems?

Ms Pickup: From a medical perspective Peter can answer that.

Dr Enevoldson: I think that it has not altered the way medicine is practised at all. It has obviously altered the system within which medicine has to be practised and most of that, I think, is from the clinical point of view around the differential waiting times that have grown up with the system not parting company but diverging. The commissioning priorities in Wales are obviously different from those in England and, as English waiting times have come down more than Welsh waiting times, the gap has grown between them.

Q139 Hywel Williams: Could I ask a supplementary. You said there was a divergence between England and Wales. Is England uniform in its commissioning? We have specialised commissioning from Wales and is there a similar body in England?

Mr Harrop: There are very specialised commissioning teams across England, all with a consistent commissioning agenda, so in terms of the standards of performance within each contract they would be uniform across England. We only deal with one specialised commissioning body which acts on behalf of the North West of England so, in a sense, we only have two main commissions. We have the Health Commission in Wales which commissions the services for the whole of Wales which accesses our services at Walton and the North West specialised commissioning team.

Q140 Hywel Williams: It is just that I noticed in the submission from Health Commission Wales they say here that "each specialised commissioning group have their own commissioning strategy for a certain procedure". Might there be some divergence within England for the emphasis placed on treating one particular condition as compared with another?

Mr Harrop: It is possible, but that is not our experience because we only really deal with one commissioning body.

Q141 Hywel Williams: It is difficult to generalise that there is a Welsh system and an English system which diverge, there might be divergences within the English system as well?

Mr Harrop: I think probably the comment that Peter was trying to make was about the waiting times in particular, because obviously with regards to a commissioning body we are working to consistent waiting times for the whole of England and they differ from those in Wales. I think that is the issue.

Dr Enevoldson: Those waiting times are common within the four regions of England.

Q142 Mark Pritchard: You mentioned the gap has grown. How have you identified that gap, in what way, and, geographically, where precisely?

Dr Enevoldson: As I understand it, if it is a Welsh patient registered with an English GP, then it is English waiting time targets; if it is an English patient registered with a Welsh GP, it is Welsh targets and obviously it goes with wherever the patient is registered.

Q143 Mark Pritchard: As a provider, have you identified particular areas in Wales that are worse than other areas?

Dr Enevoldson: I do not think we would say that within our patch of North Wales, they are fairly uniform. I think I am right in saying that.

Mr Harrop: That is right. Again, we only deal with one commission for the whole of Wales. Although the majority of patients who are accessing our services are from North Wales, we provide a service to the whole of Wales and our contract is for the whole of Wales, so there is no differentiation between different parts of Wales as far as that is concerned.

Q144 Albert Owen: Which actual services does your Trust provide for Welsh patients and what proportion of your care is given to Welsh patients?

Dr Enevoldson: The services we provide are neurosurgery, both elective and non-elective emergency; neurology, elective and non-elective, and some of neurology is provided within the centre and some out in the district general hospitals of North Wales. We provide some neuroradiology and the diagnostic backup services to those two core services. We provide a very, very small amount of neurorehabilitation, but the neurorehabilitation that we provide is just a very small amount commissioned by Health Commission Wales whereas most neurorehabilitation in North Wales is commissioned by the local health boards so commissioned separately and we do not provide that. In percentage terms I think about 20% of our patient activity derives from Wales and about 16% of our patient-related income comes from North Wales.

Q145 Albert Owen: You have got a very large area that you cover. I notice in your submission you have the Isle of Man and other large areas, so it is 20% of the total area that you cover?

Dr Enevoldson: It is about 20%, yes, and we do some pain services, chronic pain relief services as well for North Wales.

Q146 Albert Owen: Does anybody else want to comment on that point? No. The other one is you mentioned that you organise satellite across North Wales. Could you explain how the whole mechanism works and co-ordinates? Importantly, you mentioned a figure of 16% of the income, how is that organised?

Dr Enevoldson: I will leave the finances up to Chris, if I may, but from the point of view of the services, the services are organised in the same way as for our neurology patients throughout all our area, namely the neurologists are employed by the Walton Centre and they spend two or three days each out in a district general hospital. They go there, they do their clinic, they do their administration and then they spend a session doing ward referral work, namely if a patient with a neurological problem has been admitted to that hospital and the local physician wishes a further opinion, a specialist neurology opinion, then the neurologist will see the patient. Sometimes just the provision of the opinion is sufficient; sometimes the patient will need to be transferred to the Walton Centre. That is if the severity of the condition is such or that the patient needs the extra expertise that is available at Walton in terms of the other personnel there, whether it be medical, nursing, diagnostic or if there are certain treatments which are only available at the Walton Centre and those are a number of medical treatments but in particular the neurosurgery which can only be practised safely in a centre like the Walton Centre.

Q147 Albert Owen: For our constituents in North West Wales you go to Bangor, how frequently would your staff be at Bangor?

Dr Enevoldson: I think in Bangor it is three days a week, in Wrexham it is three days a week and in Glan Clwyd it is four days a week, so there is very good provision there. In our English hospitals it is three or four days a week.

Q148 Albert Owen: Do you see the viability of having an all-Wales for the treatment of Welsh patients?

Dr Enevoldson: For what, neurosurgery?

Q149 Albert Owen: Yes.

Dr Enevoldson: For neurosurgery it is absolutely impossible unless you are going to employ a huge number of neurosurgeons, such as the subspecialisation within neurosurgery now. Gone are the days anywhere in this country where anyone would ever contemplate having a centre, I would have thought, starting up with four or five neurosurgeons. You need a critical mass for neurosurgery. For neurology it is possible to provide some basic neurological care in the neurology centre covering a smaller population, but they always need to be able to plug into a much bigger centre because there are certain things which one cannot provide. You just do not have the critical mass in terms of the diagnostics or other skills to provide those facilities for some patients who still need to plug into a bigger centre.

Q150 Albert Owen: The critical mass is obviously important. What about the number that would be in your team?

Dr Enevoldson: I think for a population like North Wales you would need, I would guess, to cover for leave and everything else, according to the ABN guidelines, probably about six or seven full-time neurologists and at the present time there are ten days a week going into North Wales. We do not think it is sufficient, but that is what we commission to provide. There are also the facilities available at the Walton Centre and some patients come to the Walton Centre for their care and the other thing which one has to realise is there is - for want of a better term - a large leakage across the border from, in particular, Flintshire and Denbighshire to the Countess of Chester Hospital. We have five neurologists who go to the Countess of Chester and a lot of their clinic, probably 20%, are dealing with the Welsh population.

Q151 Albert Owen: My final point is when you said it is absolutely impossible to have an all-Wales, would you say at the risk of being controversial that is it impossible for the people of North West Wales to travel down to South Wales?

Dr Enevoldson: My clinical view is that it would be detrimental to their clinical care for elective care. For non-elective care it is just a no-brainer, absolutely impossible.

Q152 Hywel Williams: I am wondering about an all-Wales what. The Minister in her statement was fairly precise. I think she said in the case of the adults and neurosurgery the approach that she intends to take is an all-Wales one. I am a complete layman in these matters. What proportion of your work is neurosurgery and what about the other work that you do? We did hear by explanation a very interesting presentation from Herefordshire last week or the week before, where they said that services which were commonly hospital-based at one time were now being provided out in the community and increasingly so.

Dr Enevoldson: I think one has to realise that neurosurgery can never be done in the community, can never be done in district general hospitals, it can only be done in big centres. The outcomes are so much better. Neurosurgery has to be centre-based. In terms of neurology, we are keen to keep those bits of neurology that can be done close to home and that is why we run what we call "the satellite model" of providing neurological care to DGHs. That care is not only outpatients but inpatients, ward referral work. We are keen to keep that as close to home as possible. We are keen to provide as much as we are commissioned to provide and with that it is not just the consultant time but also we have been trying to get some specialist nurses, MS nurses, epilepsy nurses to help back up the local services.

Q153 Hywel Williams: I am interested in whether you can disentangle the stuff that you must provide in hospital from the stuff you must provide in the community. Must there be a link between the two? It is common sense, I guess, I suppose there must be.

Dr Enevoldson: I think there should be a link and I should also say that one of the points about neurosciences is that to get the best care one needs integrated care. Neurosurgery cannot survive without neurology; some of neurology can do without neurosurgery, but you get the best care when everything is integrated. That integration comes about because you both need the same diagnostics, the same nursing care and the same physios and things like that, but also there is that integration between the neurologist and the neurosurgeon. If I need a neurosurgical opinion I can wander down the corridor with the scan in my hand and say, "Paul, what do you think of that? How should we manage this?" It is at a human level that you can integrate your care and you can pick your neurosurgeon for the right patient. It is the sort of thing that if you are working together, you can provide proper integrated care; if you are working in different hospitals, then that breaks down. That is why neuroscience in this country, and I think in every other country, is becoming increasingly centre-based.

Q154 Mr David Jones: Just to pursue that point further, please, Dr Enevoldson. You referred to the question of integration of care. What in your opinion could be the potential impact upon a patient having that integration, if you like, fractured as a result of requiring that patient to go to Swansea or Cardiff for elective neurosurgery?

Dr Enevoldson: I do not want to be shroud waving here or anything like that, but to me I know the value of that integration of care, as a neurologist, knowing my neurosurgeon and the neurosurgeons I deal with. If I was referring a patient who had presented to me, as a neurologist, to a neurosurgeon that was 150, 200 miles away who I only ever speak to occasionally on the telephone, I do not bump into in the corridor, I do not think that I could send that patient to the right neurosurgeon at the right time, so from the point of view of the referral I think it is more difficult. The patients themselves obviously have to do the travelling down to South Wales which, I think everybody would agree, is quite a journey. I think it is quite a journey also if you are 75 and you already have a bit of a disability and you need to be driven down there by the neighbour because your spouse does not drive or they themselves have a disability or you have to somehow try to get public transport. These are real practical difficulties. To subject patients and their carers, neighbours and extended family, it is not just the patient, it is everybody having to make that trek to Swansea, have your outpatient appointment, come all the way back, go down then for your operation, the people who are your nearest and dearest to visit you and then to come back and go back again for your follow-up appointment, to me it seems almost inhumane. I think there would be a huge impact on the patients themselves. Lastly, one would have to say what would happen if, for example, there was a post-operative complication a week or two weeks after the surgery took place in South Wales and the patient is in North Wales? Sometimes they can be dealt with at leisure but at other times they may be more acute. Where would that patient go? Would they travel back down to South Wales again as an emergency or would they go to Walton, in which case you then have a neurosurgeon having to deal with that patient when he did not do that original operation. That is difficult, more difficult anyhow, not impossible but more difficult.

Q155 Mr David Jones: A question, I guess, for Mr Harrop. Could you explain how payments for treatment of Welsh patients is calculated?

Mr Harrop: Yes, it is very similar to the English system. We agreed with Health Commission Wales quite a long time ago that we would try and mirror the payment by results process, even though Health Commission Wales do not formally recognise payment by results. The mechanism by which we contract with Health Commission Wales is exactly the same as it is for the English counterpart with one exception and that is, unfortunately, the contract we have with Health Commission Wales does not reimburse us for overperformance. We negotiated a certain level for the current financial year, I appreciate we are in the last day of that financial year, but for the current year we negotiated a settlement of �7.2 million and we do not receive a penny more for overperformance. That is not typical of the system in England because obviously payment by results by definition means we get paid for every additional patient we see and that is on an agreed tariff basis. We have been negotiating very keenly with colleagues in Health Commission Wales for the coming financial year to make sure that level of performance is recognised in the future.

Q156 Mr David Jones: For the financial year commencing tomorrow?

Mr Harrop: Absolutely.

Q157 Mr David Jones: Is it as profitable to treat a Welsh patient as it is to treat an English patient?

Mr Harrop: At the moment it is exactly the same pricing structure both for English and Welsh patients. Obviously the big difference is when we reach that level by which there are not any additional payments for Welsh patients, we are in effect reducing the unit price for everybody who we see within that total contract.

Q158 Mr David Jones: On a per capita basis, it is potentially more profitable to treat an English patient?

Mr Harrop: Potentially, but I would not put too much emphasis on that because the level of significance is fairly low.

Q159 Hywel Williams: How much is the overall performance worth? Just to explain, when we had the Herefordshire people over they said the dispute was about two million which within a global spend of however many billions that is it is inconsequential? How much is it worth to you? How much of a loss are you making do you reckon?

Mr Harrop: For us it is about half a million for the current financial year which is about 1% of our total turnover.

Q160 Mark Pritchard: Perhaps I misunderstood the commissioning and the financing process, but I thought that for English patients there would be per patient as an agreed tariff whereas for Welsh patients it is an agreement for a block tariff, so I am intrigued by your earlier reply that basically they bring in the same amount of money.

Mr Harrop: The decision we took about 18 months ago was to try and mirror the English payment by results system so although the contract, as you say, is a block contract, we said, "Well, if we look to going to payment by results by shadow form, what would that look like?" The value of the contract was not that dissimilar to what we had been working with previously, so we thought this is an ideal time to implement the same kind of tariff system, the same pricing system, for our Welsh patients as well as our English patients and it was within the financial envelope that Health Commission Wales had at the time. Although, on the one hand, you can say, "This is a block contract and thereby it is a different system to the English system", we are actually using the same currencies and the same contract mechanism, so in other words we identify it by speciality level and by point of delivery so we classify it as outpatient, inpatient, critical care and rehabilitation. We are able to provide a very high level of detail to our commissioners and they can then make choices on that basis. If within their envelope they can only afford a certain level of rehabilitation input, for example, or outpatient follow-up activity, then they are able to make those choices based on the information we give them. You are right in saying it is a block contract and that makes it very different in terms of how we manage the service each year, but it is done on the same currency basis.

Q161 Mr Martyn Jones: It is interesting to hear that, because we have heard from other trusts that they believe they are subsidising Welsh patients out of English patients. In fact, Christine Russell, one of our colleagues, said publicly, and I quote: "[There is] some truth in the argument that English patients [are] actually subsidising Welsh patients", and another of our witnesses said that English patients are subsidising Welsh commissioners. Do you agree with either of those statements to any great extent?

Mr Harrop: This is a personal view, I suppose, and, based on what I just said, I do not believe that to be true to any great extent for the Walton Centre. Obviously you have heard there is a half a million pound level of overperformance that we are not currently being reimbursed for. I think you can form your own view about whether or not that constitutes subsidisation for the English commissioners. Whatever your view, it is not that significant for the Walton Centre.

Q162 Mr Martyn Jones: That is interesting because I think probably other trusts would like to talk to you about how you are dealing with it.

Dr Enevoldson: One of the points is if we are dealing with Health Commission Wales in a very specialised subject we can provide across a relatively restricted number of service lines whereas I think if you are dealing with a local health board providing care over a huge number of lines, then that would be more difficult. We have only basically got three services and two of them have opened into elective and non-elective. I think that might explain some of the differences, I am not sure but, having read that evidence which was given to you and knowing our situation, I think that might explain something. It might do, I do not know.

Q163 Mr Martyn Jones: It probably does, it certainly seems to. The next question I was going to ask you was how do you get out of it, but I think you have got out of the impasse because you have the specialised service provision.

Dr Enevoldson: I think so and perhaps there have been quite good relationships with Health Commission Wales and both realise that we are in it together.

Q164 Hywel Williams: I did read out the quote from the Minister earlier on. I wondered has the apparent uncertainty had any effect on your forward planning, financially or whatever?

Ms Pickup: Yes, it has. Whilst clearly the Welsh Assembly does not recognise as a policy the concept of foundation trusts, we are pursuing an application to become one of those and, as a requirement of that, we have to outline our forward plans for the next five years. Inevitably, the announcement from the Minister last July essentially gave us a financial risk. To be able to forward-plan on the basis of that and mitigate against it is a particular challenge. That level of uncertainty exists until the outcome of the independent review about that.

Q165 Hywel Williams: Could I ask you, have you heard anything directly from Cardiff or the Minister herself about this or is it something you have read in the press?

Ms Pickup: We were informed about it through a press inquiry and that is how it was brought to our attention and I went on the website and read the transcripts of the Minister's speech. Aside from that, we did not have any communication and it was just at a point at which we were finalising for a July submission our integrated business plan so that threw up a particular challenge. We had been invited to give evidence to Mr James Steer, who is chairing the review panel. Dr Enevoldson went down to Cardiff to do that and subsequently Mr Steer visited the unit quite recently to see it for himself and understand the issues.

Q166 Hywel Williams: The subsequent communication has been through Mr Steer rather than directly?

Ms Pickup: Yes, but the Chairman and myself did write a joint letter to the Minister, once we became aware of the announcement and the subsequent process, offering our support for the independent review and offering to give any assistance that we could. We got a reply back saying, "No decisions have been made", and we will await the outcome of the review.

Q167 Hywel Williams: Could I turn to some broader issues about waiting times. Clearly, there is a divergence between Wales and England. How does that impact on your Trust?

Ms Pickup: I think it is something that has existed for some considerable time.
Dr Enevoldson has alluded to some of the clinical considerations that are brought about as a consequence of that. I think from a managerial and operational perspective we have to be very cognisant of managing in administrative terms these patients quite differently because we have to differentiate between the waiting times for English and Welsh patients, so at an operational level it does carry with it some additional administrative burdens to do that. Aside from all those things, Dr Enevoldson would always make the point, and indeed it is the case, that if it is a clinically urgent case, then they will be treated as a clinical urgency and that is irrespective of whether they are English, Welsh, from the Isle of Man or wherever. At a level beyond clinical urgency where patients are just waiting in a queue for treatment, then inevitably patients are frustrated and what we have to deal with at a face-to-face level with a patient is "Why can't I come in sooner because I have been sat in the waiting room next to an English patient and they have only been waiting six weeks and I've been waiting considerably longer than that". We have to be cognisant of that, be very aware not to inflame or exaggerate that situation and when people do come armed with a full and certain knowledge that there are two different waiting times we have to deal with their frustrations around that.

Q168 Hywel Williams: This is a question of a matter of opinion I suppose, but do you think that there should be uniform or perhaps comparable waiting times throughout the UK?

Ms Pickup: Purely on a personal level and this is my opinion, if I were Welsh I would prefer to wait the same amount of time as an English patient.

Q169 Hywel Williams: There is an interesting question here and that is the Health Minister in London has said that the divergence is because of devolution, and devolution in its current form has been in since 1999. I do not know if historically you can tell me whether there was divergence in waiting times previous to the establishment of the Assembly or is it subsequent to the Assembly being established? Perhaps you are not in a position to say that.

Ms Pickup: I could not answer that.

Dr Enevoldson: I think there was always a longer waiting time in Wales because traditionally there has been more difficulty in getting commissioners to sign up to more resources being put into the neurology clinics in particular in North Wales. There did not used to be a difference between the waiting times for surgery once a decision to operate had been made. Everything was absolutely one waiting list until recently, but certainly in terms of the waiting times for an outpatient appointment for neurology it has always been longer in Wales. Those waiting times have tumbled in England, they have come down a fair amount in Wales but tumbled in England, because extra resources and extra neurologists have been put in. If we had the same sort of resources put in in North Wales, in fact I am sure we could have reduced those waiting times far more, but I would like to put on record the fact that if a Welsh patient requires treatment urgently or semi-urgently, they are treated under the same waiting lists as an English patient. There is no question any clinician would allow where somebody lives or which GP they are registered with, whether they be English or Welsh, to influence their clinical decision about an urgent or semi-urgent patient.

Q170 Hywel Williams: One more question, Chairman. Are you a public body in respect of the Welsh Language Act 1993? Do you have a Welsh language scheme and do you have any contact with the Welsh Language Board? Do you have any statistics on the numbers of patients who speak Welsh and the number of staff who are able to provide nursing services, for example, through the medium of Welsh? Do you have any of that which you might be able to let the Committee have?

Ms Pickup: We do have some. We are always very cognisant of the provision of services that we give to North Wales and certainly in our major publications like our consultation document for foundation trust status, we had two versions, one was a Welsh version and one was an English version. We are in the process of having proofread by one of the Welsh Assembly departments signage because we are having dual signage, English and Welsh, at the centre. As far as I am aware, we did elicit recently that we do not employ any Welsh-speaking staff, but we do avail ourselves of translation services for Welsh patients and very often we use Language Live, not just for Welsh patients but for any patients who do not speak English.

Q171 Hywel Williams: One of the considerations we have is quality issues and I did notice that one of the things that Mr Steer is looking at as well is quality. I am less concerned about the sign outside and more concerned about the recovering patient who has had brain surgery perhaps and, because of the surgery, has lost the ability in English, for example, which I know from personal experience does happen. It is the quality of the nursing service and any psychotherapeutic services that you might provide following, say, the removal of a tumour or whatever.

Dr Enevoldson: I think there are some nurses who are bilingual within the centre, not many but I think there are one or two. What I would say is for the outpatient services in North Wales the clinic nurse with the neurologist is always bilingual and that, I understand, is very helpful on occasions. It is very helpful particularly with the more elderly patient.

Q172 Hywel Williams: Do you have any plans for the inpatient nursing care to see if it is possible to do something about this question?

Ms Pickup: I cannot say that we have got any documentary plans around this. We have policies around diversity and equal access, et cetera, and we have, as I say, patients who do not speak English because they are from any number of different places. We are able to identify that fairly quickly and get the right kind of translation services. I am sure if a member of staff came to a job interview who had those skills, then that would be considered to be advantageous.

Q173 Mr David Jones: Of course, there was a review prior to Mr Steer's current review, as I understand it, conducted by Health Commission Wales. To what extent, if at all, do the recommendations of that review impact upon the Walton Centre?

Ms Pickup: That predates my time in my current role but I think - and I will hand over to my colleagues - my understanding is that the report was published in December 2005.

Mr Harrop: Around that time. You referred to Design for Life.

Ms Pickup: Yes, and, as far as I am aware, I do not think any of those recommendations were implemented so as to affect the Walton Centre before the subsequent announcement around this repatriation of elective work.

Dr Enevoldson: I think that review found that the provision of neuroscience services for the North Wales population should continue to be provided by the Walton Centre and that there should be one centre to provide for the population of South Wales. I think it also found that centre should most properly be in Cardiff.

Q174 Mr David Jones: Which would of necessity have led to the closure of the Swansea centre?

Dr Enevoldson: Yes.

Q175 Mr David Jones: Did you take the recommendations of that review into account when making your own forward planning for the Walton Centre?

Dr Enevoldson: I think one would say that we felt assured that we would continue to be the provider of neuroscience services for North Wales and when the news came through the press that it was being considered otherwise I think it would be fair say we were rather surprised.

Q176 Albert Owen: Dr Enevoldson, you partly answered when you mentioned that if there was any serious or semi-serious treatment needed by a Welsh patient that clinical need would override everything, but is that clear right the way along from GPs to people in the general hospital services to your administrators at the centre because the anecdotal evidence we get from constituents is that they are phoning up a unit and being told, "No, you're from Wales. You will be treated differently". It is clear all the way through?

Dr Enevoldson: It is clear for the Walton Centre. It is clear for everybody employed by the Walton Centre, they know what their position is. I think the people who work out in Wales would always through their local contacts be saying, "If something needs doing, it will be done whatever". Of course, how that then is played back within the media and to the patients can be ---

Q177 Albert Owen: It is not just the evidence we are getting, which again is anecdotal, it is somebody phoning up the Walton Centre and being told, "Oh, yes, you're from Wales. You'll have to wait longer", these are the things we are being told. There are things I want to take the opportunity to clear up and put on record the excellent service that you do, but this is the feedback we get from constituents and patients, that they are led to believe they are second class in treatment. You said you have to manage this when people come into your waiting room so it is obviously an issue and an issue I want to ask about.

Ms Pickup: From a patient perspective, what they would deem to be of themselves if they are suffering an illness would be they are an urgency or an emergency or it is important they are seen quickly. The clinical definition of that might be different. I think if it were the case, and it is the case, that the clinical view is that is urgent, then that patient's appointment and treatment will be expedited in line with every other member of our catchment population. If it is the case that they believe themselves to be urgent but the clinical view is that they are not necessarily that urgent, then if they are phoning up the centre and they are pressing the staff and saying, "Why can't I have my appointment? I know that I am waiting longer than English patients. Why am I waiting?", then there is only one answer and the answer is the Welsh waiting times, as we are commissioned to provide, are different and they are longer. This is the difficulty I alluded to in answer to a previous question about how our staff feel. Sometimes they are in a very difficult situation playing out the decisions of the Assembly to people who are clearly frustrated and anxious about their treatment. The fact of the matter is that there are differential waiting times.

Mr Harrop: To add to what Mel said, we are slightly different to some of the hospitals you have spoken to and obviously the type of treatment that we provide means we are able to see inpatients much more quickly than perhaps some of the other district generals you have spoken to. At the moment we have very few inpatients who are waiting longer than their English counterparts, purely by definition because the type of service we provide is a very urgent service, so from an inpatient point of view you are not likely to find many patients waiting that long. I think the issue we are talking about really relates to the non-urgent - if you can call it non-urgent - neurology outpatients we see who obviously do wait longer than their English counterparts, but we need to make the point that from an inpatient perspective we do provide a very quick service.

Q178 Mark Pritchard: Dr Enevoldson, you said that ten days is not enough for Wales. How many days would be enough?

Dr Enevoldson: I would have thought - this is just off the top of my head, I would have to sit down with the figures - probably 50% more, 15 days. You might need a bit more than that to bring the times down initially but then after that you could hold it. I would guess something like that. That would be for neurology. I do not think there is any additional neurosurgery required.

Q179 Mark Pritchard: On the English/Welsh health protocol, what sort of input have you had to that? Have you been involved in any consultations and also do you think it would be helpful, perhaps for the Chief Executive, to have an English/Welsh health protocol?

Ms Pickup: I am not clear what the protocol is.

Q180 Mark Pritchard: Let me ask you another question. English strategic health authorities, what sort of input do you have with them with regard to commissioning Welsh health services?

Ms Pickup: Clearly, as a centre, we sit in the North West NHS region and by definition, therefore, we are answerable to the executive of that body and we have dialogue. I have dialogue with the Chief Executive, there are other groups, the Director of Finance, et cetera, and more recently in terms of the strategic health authority's response to the Darzi Review we have been asked to participate, comment on, be consulted on the North West's response to that about defining the clinical model for the future. Those discussions do not take place around Welsh, we do not have any dialogue.

Q181 Mark Pritchard: You have had no input at all with regard to the protocol between England and Wales on the delivery of health services?

Ms Pickup: No.

Q182 Mark Pritchard: Would you like to have input into the decisions that are being made at strategic level?

Ms Pickup: I think it would be very beneficial and, in part, that was the reason that we wrote to the Minister, to offer up our services in assistance. Clearly, that was not appropriate at the time, but I think going forward then certainly, given that it is 20% of the population we serve and would want to continue to serve, I think that would be helpful, yes.

Q183 Mark Pritchard: Am I going too far in saying perhaps, as a senior management team, you might feel a little bit frustrated that you do not have input into an organisation that is expecting you to deliver the outputs from a strategy they agreed?

Ms Pickup: I think it is safe to say that the level at which we have dialogue we are very happy with. We have a good relationship with Health Commission Wales, but ultimately in terms of the chain of events that lead to decisions, that dialogue with the commissioner at that point is quite a long way down the track. It is not about determining the decisions, it is about how we engage with them to deliver the decisions, not really influencing their commissioning decisions. We can do it at a fairly local level on the basis of our experiences and what we did last year and certainly the dialogue going forward will all be about clearly whatever the contract was last year in terms of the block payment, we have overperformed on that, so what are we going to do about this coming year. In terms of overarching health strategy, there is not the opportunity to do that and that would probably be helpful.

Q184 Chairman: Thank you very much for your evidence this morning. Could I also place on record our thanks for the written memorandum that you provided for us, it was very helpful to us in preparing for today's session. We look forward also to visiting you at your centre this afternoon. Thank you very much.

Dr Enevoldson: Can I say in answer to your question about the waiting times and how long people do wait, we do have some statistics which you might find helpful, illustrating how few patients are waiting more than the English waiting times, in practice there are very few.

Chairman: We would be very grateful to have that. Could you send those on to us. Thank you very much.

Memorandum submitted by Flintshire and Wrexham Local Health Boards

Examination of Witnesses

Witnesses: Mr Geoff Lang, Chief Executive, Wrexham Local Health Board, and
Mr Andrew Gunnion, Chief Executive, Flintshire Local Health Board, gave evidence.

Q185 Chairman: Good morning and welcome to the Welsh Affairs Committee. For the record could you introduce yourselves, please?

Mr Gunnion: Andrew Gunnion, Chief Executive, Flintshire Local Health Board.

Mr Lang: Geoff Lang, Chief Executive of Wrexham Local Health Board.

Q186 Chairman: Could I begin by asking you what proportion of the care you commission is carried out in England and how has this changed in recent times?

Mr Gunnion: The majority of the care that we commission is within Wales, a significant proportion for Flintshire residents is within England and a significant provider of secondary care services is commissioned through Countess of Chester Hospital in particular. I think we account for around 18% of their total activity. It is about a third of our district general hospital activity for the county of Flintshire. As with all other local health boards, we commission secondary care services, we do not commission specialist services. We do have a number of other contracts across North Wales, Geoff will probably talk for Wrexham in a second. We have given information to the Committee which gives a figure in terms of the quantum of the activity we commission from a range of providers, mainly historically-based, for services which are not provided within North Wales itself. There are some specialist services in hospitals such as Aintree Hospital, Royal Liverpool Children's Hospital, Alder Hey, et cetera, which are still classed as our responsibility to commission and we have contracts with those as set out in the evidence given to the Committee.

Q187 Chairman: In general terms what impact has devolution had on the services you provide?

Mr Gunnion: I would not say a significant impact to be honest, because what has happened is that the clinical and cultural links between the North West of England and North Wales are strong and, therefore, have been maintained through devolution. Those links are clear I think and are well respected and well used. The main, significant part of our local population sees, for example, in Deeside the Countess of Chester as their natural, local hospital so, therefore, what we try to do is to ensure that we commission services as best we can to meet those local needs as locally as we can and to work with those local hospitals wherever possible.

Q188 Chairman: How would you describe the opportunities and challenges that are before you now as a consequence of devolution?

Mr Gunnion: I think the challenges are the fact we are moving to different systems, in particular in terms of waiting times and also in terms of the financial allocation of resources and different systems of paying for hospital care. That is causing challenges which I would class as more administrative and bureaucratic rather than actual clinical services.

Mr Lang: Could I add also to that in terms of challenges. I think there is also the increasing divergence in philosophy regarding the market system for England and a Welsh system which is far more built upon partnerships and strategic links between commissioners and providers. That does manifest itself in some of the system changes that Andrew referred to, but clearly in terms of issues such as patient choice, the use of the private sector as a provider for NHS care the government policy in Wales is different from England and, therefore, there is a divergence. That does not, in my experience, present particular problems because we have not been great users of the private sector and in terms of patient choices Andrew said the referral patterns which have existed over many years still exist. In practical terms that is not impacting at this point but potentially, as we move forward, that could have a greater impact.

Q189 Chairman: Do you get a sense that a Welsh patient or an English patient has a better deal whether they are registered in England or Wales with a GP?

Mr Gunnion: I think that would be difficult for us to answer. What we can say is the fact that we work with the local trusts to ensure that the patients get their care based on their clinical need. I think there is clearly at the margin a small number of patients who get treated within the maximum waiting time where there is a differential between England and Wales in terms of the clinical need, the clinical care. It is consistent and there should be no difference between English and Welsh residents apart from, as Geoff said, some system changes which give patient choice which creates a degree of flexibility for English residents in Wales.

Q190 Mr David Jones: You have noted in your memorandum that a significant number of Welsh patients from your catchment area are registered with English GPs and vice versa. Do you know why this should be?

Mr Gunnion: It is partly due to geography, particularly in certain areas because there is movement around the boundary, patients will often retain their GP when they move house. It is through patient choice, geography, a whole range of issues why a patient will wish to retain the link with their GP.

Mr Lang: Certainly from a Wrexham perspective, many of those areas are rural areas and it is about the location of GP practices and they are quite far apart and, therefore, the border between England and Wales from a patient perspective does not exist. They use their local GP, whether that be a Welsh resident moving to a GP in England or an English resident registering with a Welsh GP, that is their local practice.

Q191 Mr David Jones: Have you done any studies, for example, into the extent to which free prescriptions in Wales or shorter waiting times in England impact upon a patient's choice of GP?

Mr Gunnion: There is nothing to suggest in terms of the information we have that has had any impact at all in terms of patients moving. We have not noticed anything.

Q192 Mr David Jones: Have you conducted any research?

Mr Gunnion: We have not specifically looked at it, no, but in terms of the historical numbers and the distribution of numbers, it has not changed.

Q193 Mr David Jones: Does this phenomenon impact at all on your planning and commissioning arrangements?

Mr Lang: The cross-border registration? From our perspective, no. In terms of what we plan to deliver for our residents, no. Wherever people who are registered with our GPs are resident, they have access to the same services and in terms of the standards that we offer in terms of waiting times and other things, those are common, whether those be patients who access the services in England or access them in Wales. In terms of our commissioning, we provide for access to the traditional referral route so, for example, if you are registered with a GP in Wrexham but may be on the border with England and traditionally you have been referred into England perhaps to Shrewsbury, perhaps to Oswestry, that will still carry on and our commissioning reflects that. We do take into account those patterns in natural clinical links and also links in terms of access for patients. If it is a more local hospital in England then we do commission for those hospitals to secure that access.

Q194 Mark Pritchard: English NHS reforms, are there any particular reforms past, present or looking forward that you think will affect your ability to commission services?

Mr Lang: I do not think there are particular ones that affect our ability at this point and I do not feel that hitherto there have been problems. I think what we do not know is the degree to which the reforms that respective governments bring in will increasingly be divergent and, therefore, cause greater problems. There have always been difficulties even before devolution in terms of things like strategic planning and the relationship perhaps between North Wales and the former health authority in North Wales which related to providers in England. There were always difficulties in terms of ensuring that North Wales and Welsh residents had an important influence on strategic development of services over the border which would be their provider. That has always been a challenge, but we have managed to do that. I think as the systems change and become increasingly different, that introduces more tension into that relationship. For example, if you have a foundation trust that has a particular agenda and a particular means of transacting its business and a strategic approach on which trusts have been established with a very clear focus, that may not sit quite so comfortably with the relationship and planning structures in Wales. They are potential areas of greater tension.

Q195 Mark Pritchard: Being precise then, if you have an English trust on one of the border counties, it goes for foundation status, payments by results and says, "Actually the tariff we are currently getting from the Welsh patients" - because the tariff is being bought en masse as a block rather than following per patient - "has got to end. We are going to phase it out over 12 months". Is that what you are talking about having a real impact?

Mr Gunnion: That is not currently the policy in Wales. Obviously it could have an impact if that were to happen. I think Geoff is right, what we have tended to do is have quite good links at a local and strategic planning level. I think they are getting potentially increasingly difficult to maintain as the systems begin to differentiate. The challenge for us is to continue to ensure that when we are strategically planning services, such as cancer, cardiac services, those links that exist are maintained. I think the issues around how services are paid for evolve and constantly change. Wales is looking at a similar version, a limited version of the PBR-type approach. It is constantly changing and that is something we have to manage and make sure that does not get in the way of patient care.

Mr Lang: I think the issue for me in terms of whether or not it is increasing a problematic relationship is partly the way the two parties see the relationship and certainly to date we have had a very positive relationship with providers over the border, we are seen as key partners in their development. At the moment I think that is okay. What I would be unsure of is if the systems increasingly become more different whether we would still be viewed as key partners and, therefore, have influence for the benefit of people in North Wales. If we lose that influence because we are not seen as key partners for the future, I think that is a concern.

Q196 Mark Pritchard: I am glad you have mentioned patients. I wonder what research you have undertaken which identifies the impact of that diverging health policy either side of the border, what impact it has on patients?

Mr Lang: Certainly in Wrexham I have not undertaken any specific research on that. There has been a significant amount of work that the NHS Confederation, which I understand has given evidence to the Committee, has undertaken on the impact of cross-border policies and we fed into that work and had the opportunity to influence things like the cross-border protocol in terms of finance and resourcing. We were part of those discussions and a part of the discussions about the emerging potential impact of the policy positions, but then the discussions have been taken forward between the Welsh Assembly Government and the Department of Health.

Q197 Hywel Williams: Going on that influence issue, we did hear from the Walton Centre that 600,000 of their catchment is in Wales out of three and a half million-odd. Last time we heard from Herefordshire I think it was �15 million of their �215million funding comes from Wales. In that respect of fundamentals, surely the needs of Welsh patients and the ability of Wales to pay ensure that there is going to be influence, do you not think?

Mr Gunnion: Yes. I think depending on where we are, obviously Welsh payments, Welsh residents and commissioners have a significant role to play; in certain other areas it would be less. I think what Geoff was saying was that where it would become more marginalised it might well be more difficult to maintain that communication and that influence if we start to consume less capacity of a particular provider where there is a clear link between such as Walton, Countess of Chester, Robert Jones and Agnes Hunt. I think that is going to be given as a fact of life because we will need to ensure that we have effective planning and commissioning links with those providers because it is in their interest, our interest and the local patients' interest most importantly.

Q198 Hywel Williams: What I am concerned about here is the impression which has been given to my constituents across North Wales, that there is some sort of threat that, to put it at its most crude, somebody from Saltney will have to go down to Swansea to have their ingrown toenail cured. We are not talking about that sort of thing at all, are we, gentlemen?

Mr Lang: Absolutely not. As Andrew has mentioned, the relationships that exist are built upon the natural clinical relationships between GPs and their local hospitals and between consultants in our district general hospitals in North Wales and the specialist centres. Certainly we are not engaged in discussions to try and change those clinical patterns and links and I am not aware that those discussions are ongoing, so from that perspective those strategic links are still maintained. I think even if there were a view that certain services could potentially be transferred to other centres that needs to be reflective of the fact that the clinical relationship between the secondary care hospital and the tertiary care is often an ongoing one. Individual patients rarely have one-off encounters for very specialised services, they have an ongoing relationship and that needs to be maintained and kept. From that perspective I think we will have an ongoing relationship and I do not sense that there is anything particularly undermining that at the moment.

Q199 Hywel Williams: That is very reassuring to hear. The more interesting questions, I suppose, are around the different uses of IT, the different systems of commissioning, but those are matters that people like yourselves sort out and I am just concerned that the impact on the actual care that the patient gets is minimised or even does not occur at all.

Mr Lang: There are challenges in terms of financial systems that we talked about, but those are manageable and they are manageable through agreements at a local level and a national level. There are challenges with things like information strategy and information systems where some of the national policy is common in principle but different in its deployment and both of the strategy teams working on them are working together to try and ensure they connect up. Certainly from a North Wales perspective we have long established links, for example, with the Walton Neurosurgery and Neuroscience Centre in terms of things like transferring scanning images electronically and so on and having the infrastructure there to do that to allow the best clinical care for patients so those problems are tackled as we move along and are there to support patient care.

Q200 Hywel Williams: What I am concerned about here is getting a sense of proportion about this, we heard earlier on this morning that it is about half a million pounds. We heard a couple of weeks ago it was �2 million's worth difference. However, the NHS Confederation did tell us that commissioning of services across the border lacked clarity. Would you agree with that and how can you address that lack of clarity without impacting on patient care if it exists?

Mr Lang: I would say there is a lack of consistency in terms of methodologies, systems and approaches. It depends on what one means by "clarity". Clarity of responsibility, I think there is clarity of responsibility, it may not be ideal but there is clarity there. I think there is clarity of relationships in terms of who is commissioning services from whom and there is clarity at the moment around the principles and rules that surround that engagement. There is inconsistency in that some of those rules and principles in England are different to ones being applied across the border and differences that we would apply with a Welsh provider. My experience of relationships with providers in England is there is clarity about our role, there is clarity about the services we commission and by and large those relationships are very positive in delivering for patients.

Q201 Mr Martyn Jones: Do current funding allocations take account of cross-border payments for Welsh patients being treated in England?

Mr Gunnion: In the main, yes, but there have been some technical adjustments, if you like, over periods which have not been made so it is not totally in sync, but in the main, yes.

Q202 Mr Martyn Jones: Are there arrangements for the reciprocal of that, English patients being treated in Wales?

Mr Gunnion: Yes.

Mr Lang: Yes.

Q203 Mr Martyn Jones: What are they?

Mr Lang: The Assembly Government and the Department of Health periodically undertake assessments to gather the data relating to the flow of patients across the border and then there is at an all-Wales and England level a calculation of the cost of English patients being treated in Wales and Welsh patients being treated in England. There is a resource adjustment between the Department of Health and Wales, England can pay for services in Wales and Wales can pay for services in England. That is periodic so, as Andrew said, over time it does drift a little bit as activity changes but, for example, within Wrexham Local Health Board's allocation there is a specific sum to relate to the services provided over the border in England. That is not a ring fence in that it cannot be topped up and it cannot be reduced, but it is identifiable and we are able to track that in terms of relationships with hospitals over the border.

Q204 Mr Martyn Jones: You say that is an intra-national thing in the sense that it is between the two countries on a global scale. How does that affect your local health board funding? Is it allocated in headcount?

Mr Lang: Essentially it is built up from a provider by provider and local health board and PCT by PCT analysis, so it is aggregated to the national level to allow the departmental settlement and then through the allocation process the element that it relates to, for example, is English patients being treated in a local hospital in North East Wales or North East Wales Trust is removed from what would have been a settlement in that area which is transferred to England. Likewise, money is removed from England and is given to us so that we can commission our services over the border.

Q205 Mr Martyn Jones: English providers, including the Countess of Chester Foundation Trust, have stated they receive less funding from Welsh commissioners than English commissioners for the same work. What is your perspective?

Mr Gunnion: They receive less than they would get if we were funded and commissioned on the basis of payment by results. I suppose it is a different historical between price and cost. We would argue that when the allocations, as Geoff has just outlined, have been undertaken and the funding identified, we have funded the Countess on that basis as is agreed between England and Wales and, therefore, we are paying them a fair price for the work they are undertaking for local residents. I accept that if we were funded and worked under a different system that would lead to a different cost or price to us, but I think it is about the system as against what is the actual cost. We would argue we are covering the costs to them of providing the services to us.

Q206 Mr Martyn Jones: They are not getting an element of profit. There is some difference here.

Mr Gunnion: Yes, the contracts that we have, a change in activity would be funded at a marginal rate rather than a full cost basis and that can lead to the sort of figures that are bandied around, "We would get �X more if we were funded on that basis". We have not within NHS Wales been funded, nor is there any agreement for NHS Wales to contract with England on that basis. It becomes almost for me an academic exercise which we are not allowing to get in the way of the delivery of services between England and Wales in terms of the Countess of Chester in terms of delivering services on that basis.

Q207 Mr Martyn Jones: Would you say on that basis that we are getting a good deal then?

Mr Gunnion: I would say that we are currently getting a good deal in terms of that particular contract, yes.

Q208 Mark Pritchard: There are some people in the Assembly who want to see NHS Wales expand within Wales. Do you think that is a good idea or not and how would that impact you?

Mr Lang: I think there are some services that one could expand in Wales. If we look at services provided over the border they range from very, very specialist services down to what we might call fairly routine district general hospitals services and, indeed, over time some of the services which we consider to be highly specialised now in a number of years may well be considered appropriate to deliver in a district general hospital. That is part of the natural change of healthcare. For example, cardiac catheterisation, which five or six years ago would only ever have taken place in regional centres such as the cardiac thoracic centre in Liverpool, now takes place in Glan Clwyd Hospital in North Wales and that is an entirely appropriate clinical change.

Q209 Mark Pritchard: If I may briefly interject, forgive me. Whilst that might be right clinically that more and more can be delivered locally in the context of Darzi and scarce resources, is it not the case that, whilst that might or could happen in principle, the reality is that there will not be the resources there and it is counter to national government policy?

Mr Lang: I do not think the picture is black or white on that. I think there are examples where, given that we know - and cardiac intervention is a good example - because of the need of the population and the need to expand capacity throughout the country that there is a need to ensure we have more spots available and more places and you then have options about where you place those. From my perspective, provided that - and this is an important proviso - when you weigh up value for money, clinical outcomes and the issues of access for patients, there is a credible position to provide within North Wales I think that is appropriate to do so. I think there are very difficult issues if you start saying that it is a disproportionate burden on scarce resources to have a unit in North Wales just because we want one. That would be a very different proposition.

Q210 Mark Pritchard: Finally, do you welcome the statement by the Health Secretary yesterday about the possibility of a health voucher scheme being introduced in certain circumstances?

Mr Lang: I am afraid I am not very familiar enough with the detail of that to be able to comment.

Mark Pritchard: A very good response.

Q211 Mr David Jones: Mr Gunnion, if I could please go back to the point you made about the disparity in funding arrangements being effectively an academic exercise. From the perspective of the English NHS trust, it is not an academic exercise, is it, because from that perspective they are actually receiving a shortfall in terms of the income they are receiving from your health board? Is that not correct?

Mr Gunnion: No, because under the system for which we are commissioning we are paying a price that we should be paying. If we were commissioning under a different system they would get more. We are not giving them less than we should be giving them, we are giving them what they need to provide the work on the basis of the agreement between England and Wales to provide services.

Q212 Mr David Jones: I understand that, but if you look at it from their perspective and the disparity in funding arrangements between England and Wales, were you funding them on an English basis they would be receiving more revenue, would they not?

Mr Gunnion: Yes.

Q213 Mr David Jones: On that basis, of course, they would be able to provide superior facilities for patient care, is that not correct?

Mr Gunnion: Possibly, yes, but I would argue that potentially we have only got the power of commissioning that once so if we spend it somewhere else we cannot spend it elsewhere, there will always be choices. I think the issue for us would be to understand how the system will flow through the healthcare system.

Q214 Mr David Jones: Certainly just to reiterate the point, from the perspective of the English provider they are suffering a revenue loss as a result of the disparity between the two funding systems. If in fact you were funding on the same basis as an English commissioner they would have a better income stream?

Mr Gunnion: Yes.

Q215 Albert Owen: Mine is along the same lines really. You say it is an academic exercise, but we have just heard evidence that there is a shortfall in the Walton Centre of half a million pounds and they are looking for five-year planning for foundation status. Obviously the pressure on the Welsh commissioner for the underfunding is going to become more and more as the progress of the foundation status in various hospitals continues. What is the response there? There is underfunding, they will want to maximise their profits and their incomes that they get in so the current situation is not sustainable, is it?

Mr Gunnion: We are merely commissioning within the rules that were set for us by the Welsh Assembly Government and if those rules change then clearly we will have to look at it. My understanding is that where there is a policy initiative which impacts on one nation there will be a revenue transfer to cover that. If we were to move into that scenario we would be funded to commission on that basis, so the money would revolve around the system in that sense because we would get additional funding from the Welsh Assembly Government to pay for that additional price.

Q216 Albert Owen: It is likely to happen, is it not? You are facing that now. It would not be your decision, it would be the Welsh Assembly Government's decision?

Mr Gunnion: It is to do with national policy.

Q217 Albert Owen: On the reviews that are going on within the neurology unit and the review of the Welsh Assembly Government, what kind of input have you put into that?

Mr Gunnion: In terms of the general policy around cross-border issues, certainly I have had officers in my organisation heavily involved in that both, as Geoff said, with the national confederation work and my director of finance has also been working with the Welsh Assembly Government and had meetings with the Department of Health to talk about the technical aspects of the revenue transfers and allocation issues. There is quite a significant input in terms of officers tying into the technical process of resource allocation between England and Wales.

Mr Lang: In terms of the neurosurgery issue specifically, certainly that has been a subject of much local discussion, as one would expect. The views that have been expressed are particularly in relation to the clinical continuity of care and the need to maintain that and the need to maintain the relationships between secondary care clinicians and clinicians in the specialist centre, which are very good in North Wales, and to keep continuity of care over time because often, as I mentioned earlier, episodes are not single and one-off, they are part of an ongoing package of care. Those are important issues and I think there are great difficulties in trying to do that on a North-South Wales basis for issues of geography and access and also the other major issue was one in relation to patient access, particularly visitors and family support in relation to patients who may be having planned procedures. Whilst it is fair to say that patients will often travel for a planned procedure if they believe that to be of the highest quality and the right place to be, the issue is really we have that service on our doorstep almost in terms of the Walton Neurosciences Centre and, therefore, it is a very difficult issue to consider patients travelling perhaps to Swansea or Cardiff.

Q218 Albert Owen: On the Steer Review, are you speaking with one voice for local health policy in North Wales?

Mr Lang: Yes.

Mr Gunnion: Yes.

Q219 Hywel Williams: I am concerned about the whole question of profit and loss and that coarse understanding of the relationship. In the Countess of Chester or Walton Hospital they are not forced in any way to come to an agreement on their cost with the Welsh Assembly Government. I take it it is an agreement voluntarily gone into far as you know?

Mr Gunnion: We basically have regular meetings with, for example, the Countess of Chester where we identify changes in activity and changes in clinical care and agree with them how we should be in essence paying for the service they provide. What is clear on the payment by results is that a lot of the work we undertook was that some of the requests for additional funding were technical coding issues, so the patients would go for an antenatal appointment, be checked, have slightly high blood pressure. On the payment by results they would then be coded, not just for an outpatient attendance but then be coded for a day unit attendance while the blood pressure is monitored for an hour and therefore potentially we would end up paying two sets of payments if we paid through the payment by results system. In terms of Flintshire Health Board that would lead to a potential �300,000 a year. Whether there is an �300,000 additional cost in the system, I think we would argue probably there is not, but in terms of the pure payment by results process where everything is counted separately and costed separately that was how we can ratchet up the costs. What we do in terms of our negotiations is have discussions around the services and in relation to that to identify what we believe are the fair, reasonable and true costs of that, not what is the given cost or given price.

Q220 Hywel Williams: Which is why you are saying we are getting a very good deal.

Mr Gunnion: If you compare it in stark terms, yes, but we think it is a fair deal in terms of the price for the services that are being provided.

Mr Lang: And one the Countess have agreed to with us. Within that there are certain elements of financial allocations which are outstanding at a national level and there is a transfer of issues of superannuation funding between England and Wales and that equates in terms of the Countess, and they understand that it is done at a national level but they are down half a million pounds. These figures can be looked at and are not quite as stark as sometimes presented in the press.

Q221 Hywel Williams: Could I turn to waiting lists. What are the practical implications of the differing waiting list targets for patients, commissioners and providers? What does that mean in real terms?

Mr Lang: From our perspective in Wrexham, and I think it is the same for all local health boards, from the commissioning perspective we commission the same maximum waiting list and waiting times for all our residents wherever they are, so whether they are treated in North Wales, England or elsewhere. I was listening to the end of the evidence session with colleagues from the Walton Centre and there are very practical issues about those patients who do wait up to the maximum period of time. As was said earlier, because of clinical urgency if a patient is urgent, whichever hospital you are in and wherever you are from, you are treated in accordance with your clinical need, though if you are a Wrexham patient attending Shrewsbury you may well get treated quicker than a Shrewsbury resident because your clinical need determines that to be the case and all hospitals are working that way. What we have then is those patients who in terms of a classification will be seen as routine, although it is never routine to the individual involved and is very important and a matter of great concern but the routine waiters, those patients are then effectively seen in turn and in accordance with the amount of capacity that is commissioned. If I give an example of our relationship with the Robert Jones and Agnes Hunt Hospital where we commission a lot of orthopaedic surgery there, we commission enough capacity to deliver the Welsh national maximum waiting time guarantee. What that means is that we do not buy enough capacity for all Welsh residents to be treated in turn chronologically because that would mean we would have to buy even more and they would be treated then in line with the English standard. All of the patients categorised as urgent get treated as they need to be. The routine waiters do have a longer period. That period has narrowed over recent years and is less of a contentious issue than it used to be, I would not say it is not contentious but it is less of a contentious issue. In practical terms, what that means is it is very difficult for clinicians at the sharp end in having discussions with patients to explain why one patient would have to wait 26 weeks and another may have to wait 32 weeks for no other reason than area of residence. I think that is where the practicalities hit in terms of the patient-clinician relationship and also the difficulties for the hospital in managing effectively two sets of waiting and booking systems that have to be brought together to use their capacity to best effect.

Q222 Hywel Williams: That is interesting, the way you have unpacked that, and that for people with acute problems, therefore, there is equality of service throughout the UK in fact.

Mr Lang: Yes.

Q223 Hywel Williams: Should there be a uniform waiting list targets throughout the UK for acute and more routine treatment? Is that practical?

Mr Lang: Is it practical? Yes, it is practical to have either exactly the same waiting time or as wide apart as practically you can manage it. Ultimately the decision is one for the Government in terms of what they wish to commission. In practical terms we can commission, provided we have the resource, whatever waiting time standard we are given, whether that be the same as England or it be different. I think the desirability or otherwise is a matter for the Government to determine. We have to implement that policy.

Q224 Hywel Williams: Could I ask you therefore the same question that I asked colleagues earlier. I do not know if you are able to tell us about the situation prior to the establishment of the Assembly, but do you know whether there were different waiting times for people from Wales as compared with England than before the Assembly?

Mr Lang: Yes, there were and at times they had greater divergence than they currently do. Through the greater impetus that the Welsh Assembly Government put on reducing waiting times back in 2005 when its major health strategy, Design for Life, and a pathway towards a 26-week waiting time referral to treatment by 2009 were announced, Wales has increased rapidly its reduction in waiting lists compared with where it was in previous years. Having worked in a former North Wales health authority which commissioned services in England, we often had greater disparity at that point than we currently do now. That is not to say our current disparity is not a difficulty, but it is less than it was.

Mr Gunnion: To add a bit of context, certainly this issue was raised within the Flintshire local scrutiny committee two years ago in terms of access and Flintshire waiting times. We did a piece of work which highlighted that 95% of Flintshire residents were treated within English waiting times. As Geoff says, there is a significant number of patients who have to wait longer but it is probably not as big as we all think it is, but that does lead to problems on an individual basis.

Hywel Williams: We will be questioning the Health Minister, Ben Bradshaw, later on and I hope we will be able to ask him about his statement that waiting lists' divergence has been caused by devolution. It would be interesting to hear what he has to say.

Q225 Mr David Jones: But the earlier divergence in waiting times was not a consequence of deliberate government policy which the current divergence in waiting times is? That is right, is it not?

Mr Lang: Given that we only had one government, yes, it is a matter of implementation.

Q226 Mr David Jones: The divergence we are experiencing is a matter of deliberate government policy, is that not correct?

Mr Lang: I think ---

Chairman: You do not have to answer that question. It may sound as if it is a leading question. Would you like to put it differently?

Q227 Mr David Jones: Is it not correct that current divergence in waiting times is a product of deliberate government policy? That is a straightforward question.

Mr Lang: It is correct to say that, as employers and a commission in the health service in Wales, we commission to a standard set by the Welsh Assembly Government.

Q228 Mr David Jones: Correct. You explained the difficulties that clinicians have in explaining to patients this divergence in waiting times and what a problem it is for them. It is a problem also, is it not, for the patient who, I guess, is wondering why he or she is paying taxes at exactly the same rate as an English patient but is having to wait for longer? Is that not correct?

Mr Lang: It is a problem for the patient, yes.

Q229 Albert Owen: On the waiting lists again, we are comparing England and Wales and Mr Williams asked about historic ones before devolution came in because within Wales there was a huge differential between North West Wales and South. The Gwent area had one of the highest waiting lists in Northern Europe, so it is not just across the border. One of the reasons North Wales had less was because there were good links with cross-border as opposed to Gwent having problems down in the south as well. It is not as straightforward as England versus Wales and never has been and probably never will be. Is that correct?

Mr Gunnion: I would concur with that.

Q230 Chairman: The whole of this session has been an exploration of the relationships between England and Wales across the border. How would you characterise the co-ordination across the border now? Is it ad hoc or is there some degree of coherence?

Mr Gunnion: I suppose if I was being honest it is probably ad hoc. There are some good examples, there are some areas where we could certainly do better. This is not just about foreign devolution, it has always been the way that strategic health authorities have tended to plan within their strategic health authority area. NHS Wales or North Wales have tended to plan in its area and what happens then is about how good the links or the boundaries are. They are often maintained through personal relationships rather than central diktats.

Q231 Chairman: It may be a little late to be opening up this debate and maybe it would be better to ask you to write us. Very briefly, how would you suggest to us that the situation could be improved?

Mr Lang: From my perspective, I think we have got some examples of where things have worked very well and that is as a result of good relationships between the Department of Health and Welsh Assembly Government officials in looking at emerging policy and understanding the practicalities and how it would work. That is the level at which the connection needs to be effective. When it gets to our level then we are effectively implementing the policy as set. Often we are asked to contribute to some of that development and when we are asked we willingly do that, as we did with the cross-border flows work, but essentially the issue is understanding if we are to be given a direction in Wales what are the implications of that across the border, thinking through how that will be managed and is that manageable or not. That has to happen early in the policy process.

Q232 Chairman: We understand that there are discussions currently taking place about developing a health protocol. Are you part of that process and, if not, would you wish to be consulted about it?

Mr Gunnion: We have been involved in the past, as Geoff has said, in terms of the development of the current guidance, both in terms of the work of the Confederation and working with Welsh Assembly Government colleagues linking into strategic health authorities in the North West and West Midlands in terms of how we manage patient flows and resource allocations across. I think that can be improved and we would certainly welcome an opportunity to continue to ensure we can participate and contribute to that process.

Q233 Chairman: Thank you very much for your evidence today and also for the memorandum that you supplied which was helpful in preparing for this session. You mentioned about waiting lists pre-devolution, post-devolution. Could you provide us with some statistics about that or try to?

Mr Lang: We will certainly try to. I am not sure how long back the records are but, yes, we will certainly try to do that for you.

Chairman: Also if you could give some thought to the last question I posed in terms of how cross-border relationships could be improved and provide some more coherent approaches, that too could be helpful to us. Thank you very much.

Witnesses: Mr Jeff Lansdell, Patient Complaints Advocate, Clwyd Community Health Council, Councillor John MacLennan, Chairman, Conwy East Community Health Council, and Ms Gail Roberts, Chief Officer, Clwyd Community Health Council, gave evidence.

Q234 Chairman: Welcome to the Welsh Affairs Committee. For the record, could you please introduce yourselves?

Councillor MacLennan: I am Councillor John MacLennan, Chairman of Conwy East Community Health Council.

Ms Roberts: Gail Roberts, Chief Officer of Clwyd Community Health Council.

Mr Lansdell: I am Jeff Lansdell, Patient Advocate for Clwyd Community Health Council.

Q235 Chairman: Please do not be afraid to raise your voices so that everyone in the room can hear you. Could I begin by asking you, what impact has devolution had on medical services in your area?

Councillor MacLennan: It is hard for us to quantify that, Chairman, really, as CHCs. We measure the services that are provided by the complaints and the incidents that are reported to us. They seem to be at the moment quite low, but from the papers submitted to you, you can see that there are issues surrounding the differences.

Mr Lansdell: I think one of the problems is when members of the public approach us they are usually at the end of their wits trying to get resolution to this and it is usually crisis time for them. It is usually a case whereby either they have been told by a clinician that if they lived over the border they would receive this treatment without any delay whatsoever. In one case where a lady was told she needed the surgery - this surgery was planned - but after discussion with the family it was decided to delay the surgery until she recovered a little bit of strength and the surgery could be carried on nearer to her home, so she could have her friends and family around her and reduce travelling times, et cetera. When she visited the local centre, which in this case was the Walton Centre, she found that they were perfectly willing to go ahead with the procedure and definitely stating she needed it. When they applied for the funding they were told no way would the Welsh Assembly Government fund this treatment. I got involved with the family and I applied to Health Commission Wales and they point-blank refused to fund that situation. The lady is now in the position whereby she is trying to sell her house in order that she can move a few hundred yards over the border to Cheshire, register with a GP there and she will get the operation she needs. It is not as if it is an operation of wish, it is an operation of need and those are the sorts of cases that come to our notice.

Q236 Chairman: That is helpful. You have given one example which may or may not illustrate a more general situation. Could you in more general terms - any of you - explain to us how patients perceive what now seems to be a policy divergence between England and Wales in certain areas?

Mr Lansdell: I deal with an average of 200 clients a year and the perception I see from talking to patients and their relatives is that they get a raw deal on waiting times. They are sitting in a waiting room, waiting to see the consultant, chatting to somebody and saying, "Well, how long have you waited?" "Oh, I have only waited so many weeks." "Why is that?" "I live in Stafford", or, "I live in Chester", or whatever. Or they will be sitting in hospital beds next to each other with a condition that maybe has deteriorated quite considerably and reduces the benefit of treatment maybe and they are chatting to each other and found that they waited six, eight weeks, maybe months longer. That tends to be the general feeling and I think it is a case of people then start to talk, but there is some evidence to support what is happening when people are faced with waiting times which are longer than they would normally have to wait if they were receiving the treatment that was being funded by an English PCT.

Ms Roberts: There is a very strong perception that there is an inequality in accessing services and, as was rightly said before, people see themselves paying the same taxes, making the same contributions and they fail to see why the different governments are allowing this discrepancy to still continue. We have all heard the term "postcode lottery", I do not know how many times we have heard it, that rings true with people. They see it as an inequality in the system when they are paying their taxes at the same rates.

Q237 Mr David Jones: The difference in approach to the provision of health services as between England and Wales is resolved to the rather irritating jargon of "patient choice" in England and "patient voice" in Wales. Cutting through the jargon, what does this mean in practicality for Welsh patients?

Mr Lansdell: I think I can give a case. I like to speak on fact. I can give two cases. One was a gentleman who was receiving treatment in a Manchester hospital for a cancer condition and he was prescribed a medication for that condition. He then was discharged from hospital and approached his GP for follow-up prescriptions and was told he could not have it because it was not an approved medication issued in Wales. What this gentleman did in the end was he rented a flat not far from the hospital where he needed to keep going back for treatment and got the prescription by registering with a GP locally. In another case a gentleman has been receiving, again, essential treatment. He has to have an infusion in his medication every four weeks. If he misses, his muscles start to degenerate. He was having this treatment in Hope Hospital. For quality of life issues, he moved from where he was living in Manchester to live in the Wirral area. Then he saw a consultant from the Walton Centre - it was interesting to hear what the Walton Centre was saying earlier - and a consultant from there told him, "Well, the probability is you are going to have to travel to Cardiff for this treatment if Wales are going to fund it". He said, "This is a bit of nonsense. At the moment I can still go to Hope Hospital. I had this course of treatment over a number of years, I can go there in a day and receive my treatment and go home. If I have to go to Cardiff, it means I have to travel the day before, I have to stay overnight, take a day having the infusion and because it is quite a traumatic occurrence, it will mean another night's stay and a day to travel back". You are talking three days every month whereas if he continues to have it in Manchester, it is a case of one day a month and a lot less hassle and strain on him.

Q238 Mr David Jones: Those are interesting examples, but what does "patient voice" mean then? Does it mean anything?

Councillor MacLennan: You cannot quantify it, I do not think, in a sentence like that,
Mr Jones. I think it may be patient choice and clinician's voice in some ways. The patient has to go where the clinician directs them. Is that what you are getting at?

Q239 Mr David Jones: I understand that the Welsh approach to the provision of healthcare is patient voice. I have said previously in these committee sessions I do not wholly understand what "patient voice" means. I am just wondering if any of you witnesses understand what "patient voice" means.

Ms Roberts: From our perspective there is a very, very strong notion in the Welsh Assembly Government about engaging with the citizens and that has been reflected in all sorts of documents, the Beecham Report, which Mike Ponton from the NHS Confederation referred to, and the One Wales Report. There is a very strong message that there should be engagement with the public and, therefore, the public voice be there to shape the services which are going to be provided or are being provided.

Q240 Mr David Jones: That sounds very touchy-feely. What does it mean in practice?

Ms Roberts: If you are asking from a personal point of view?

Q241 Mr David Jones: Yes.

Ms Roberts: My personal view would be that, whilst it is extremely laudable, I see little actual patient voice changing the services.

Q242 Mr David Jones: Does "patient choice" mean anything?

Ms Roberts: I am aware that "patient choice" is the terminology used in England. Apart from that, I do not know, sorry.

Q243 Mr David Jones: Thank you. Is there any evidence as to how patient choice versus patient voice - if these terms do mean anything - have affected the flow of patients across the border? For example, have you seen Welsh resident patients registering in England in order to access English services and English standards of services? You have mentioned some individual examples, but is this a widespread phenomenon?

Ms Roberts: I would not say it is widespread, but we are aware that it does occur and we are aware that, although there is a degree of stability in the cross-border flow of patients, we have anecdotal evidence where we think there are decreased numbers being referred to places such as Robert Jones and Agnes Hunt, particularly from the North West where there was quite a strong flow of patients at one time. That is not to say that is necessarily bad because the patients in theory should be treated in Yspyty Gwynedd rather than being referred over to Oswestry. Generally speaking, we think it is pretty stable in terms of the flow.

Mr Lansdell: Part of the problem that comes from the flow is particularly I have noticed people mentioning when they have an English GP and the expectation of the GP is, say, district nursing services will do X, Y, Z, the reality of it in North Wales is district services will produce A, B, C. It is not within the same timeframe and that sometimes causes false hope for people that they will receive a service. When the reality comes down to it and they get back home and the service is agreed it is not quite what they were expecting. It is those sorts of issues that sometimes deflate people, particularly those who are very poorly and are looking for any light at the end of the tunnel and when they get an expectation which lifts them and then when the reality comes that it does not then develop or the service is not delivered as they expected, it can be quite a deflating blow to somebody who is very poorly or particularly somebody who is looking after somebody who is very poorly.

Q244 Hywel Williams: Could I pursue an answer with Mr Lansdell. I have asked a number of times about the famous patient who is going to be transferred from the Walton to Cardiff and been assured a number of times that has not happened or would not happen in the future, that is the headline case and you have just mentioned one. On what basis was that person transferred? Would it be any different from, say, someone being transferred from Liverpool to Manchester or from Yspyty Gwynedd to London depending on what treatment was available?

Mr Lansdell: He was told that by the consultant neurologist on the basis that there was a change in proceeding taking place. There was a possibility that the Walton Centre would not be providing that service and it would be then provided by Cardiff. That was a consultant's perception at a consultation.

Q245 Hywel Williams: I am concerned that there are a great number of perceptions about any potential change and there is the actuality. Are you saying that actually occurred or was it a perception of the consultant?

Mr Lansdell: The patient was told that.

Q246 Hywel Williams: It was the consultant's perception, telling the patient who was then elaborating to think he might have to spend three days in Cardiff.

Mr Lansdell: What they were saying about the accessibility of Walton, I have dealt with clients who were not complaining about that aspect of it, but when you are taking the history of the story you get somebody who maybe has a major brain haemorrhage and they need brain surgery quite quickly. The consultation and the transfer have taken place within two hours and they are in theatre. I know of one chap who was taken and actually was in the door and in theatre that quick and he survived, went back to work and made a full recovery. I would ask the question, how would he have survived if he had had to travel to Cardiff for that surgery?

Q247 Hywel Williams: Could I ask you, Mr Lansdell, a direct question. Has anyone been transferred to Cardiff? Have they died in an ambulance? Is that happening? Because I am worried, Mr Lansdell, that people reading the evidence from this session will then be encouraged to think they might be transferred to Cardiff, where that, as far as I can see, has not happened and does not seem to be a likely possibility. Perceptions are dangerous sometimes.

Mr Lansdell: I think it is the way that whole matter was dealt with when it was put forward as a proposal, suggestion, whatever it was, it gathered a momentum of its own. When you deal with these people who are very vulnerable and quite poorly they are desperate for treatment which is close to home and which provides comfort. If something goes wrong they are only an hour or two hours down the road.

Hywel Williams: My concern is that they might be worried by this and unnecessarily so.

Q248 Albert Owen: Could I come in on that point. I think it is important what Mr Williams has said there. Are you suggesting that this person was told that and then the complaint was taken up by yourself to the Walton Centre and it was confirmed that was one option or was the advice given?

Mr Lansdell: That is the chap who was told that. What has happened is that the more important part of that complaint for me is to get his treatment sorted out.

Q249 Albert Owen: I appreciate that.

Mr Lansdell: That is what I am doing at the moment. Once I get that sorted, I will then look at historically what happened because it is more important from my perspective.

Q250 Albert Owen: I fully appreciate that. We have lots of constituents with similar concerns and obviously I liaise with the CHC in my area, but if this was brought to my attention, I would certainly take it up with the Walton Centre to confirm that was the case before I made that public. I would obviously find out both sides of it and I think this is an important issue that you have raised and certainly, as part of this inquiry, we need to gather that information which is why we have had all the witnesses. It has not been taken up with the Walton Centre for them to confirm or deny this was an only option?

Mr Lansdell: No.

Q251 Hywel Williams: We had the Bishop of Hereford and the Bishop of Monmouth before us recently saying that the divergence in health service provision between England and Wales is leading to patient confusion. Would you agree with that?

Ms Roberts: Yes, very much so. It is leading to patient confusion. Going back to the previous point I made, it is an inequity in accessing. North Wales patients are historically very good travellers, they are happy to go where the best services can be provided.

Q252 Hywel Williams: Surely they have no option?

Ms Roberts: They do not want all the services in Wales necessarily, they want the best services as close to home as possible.

Q253 Hywel Williams: I take issue with that. People in the far end of my constituency have no option but to travel to Cardiff, Swansea, London, Manchester or Liverpool for that matter. They have no innate extra ability to travel. I find that rather diminishes the problems that they face in travelling to places like Liverpool, Manchester, Cardiff or London.

Ms Roberts: Given the numbers doing that, there is a very small number indeed that have to travel for specialised treatment. We are talking about really specialised treatment. The move within the health service is to provide as locally as possible as much as possible to try and alleviate all the hardship involved with having to travel. We are talking about a tiny number of people in the main. There is a general acceptance, though people do not like it, I agree, but people would rather go somewhere that is a centre of excellence if they really have to because they have a specific condition.

Q254 Hywel Williams: Chairman, I am speculating here, but if I was living in London, and the only treatment available was in Yorkshire I would be an extremely good traveller as well. Can you see the point here? There is a danger of clinicians and perhaps administrators being comforted by the delusion that Welsh people in the West are very good travellers when, in fact, they have no choice, that is the only point I am making.

Ms Roberts: I fully agree with you and I am sure this is the argument that we have all been supporting when it has come to the Minister's recent announcement about neurology. We have all been singing from the same hymn sheet in North Wales.

Q255 Hywel Williams: Going back to the Bishop's assertion about confusion, what can be done to minimise patient confusion about accessing services on the cross-border basis? What can we practically do so people are not unnecessarily concerned and worried, or perhaps necessarily, depending on what your opinion is? Surely confusion cannot be good? What can you do about it?

Councillor MacLennan: Misconceptions come from a variety of sources, they come from the patients themselves who perhaps do not understand what is happening to them, it comes from the doctors who perhaps do not really know where the consultants are going to send the patients, it might come from the hospital which cannot treat that patient for that particular illness and has to refer them somewhere else. There is a number of ways in which patients can become confused about where they go for their treatment. We have put some cases before you. Regarding the one in Sheffield where a patient had to go for treatment in Sheffield and no contract was made with the hospital prior to him going there, that had to be done afterwards. There is confusion all over the place, I think, Mr Williams. It comes from a variety of sources, not just from one. If it was from one it would be so easy to sort it out, but it comes from so many different places that it is very, very difficult to quantify and stop.

Q256 Albert Owen: I want to go back to this equality of service for English and Welsh patients issue, I think it is important. Do you think the gulf there is bigger now with waiting times since devolution or was this an historic thing that happened? Again, the question I put to the LHB with regard to within Wales, there was huge differentials. Again, it is only anecdotal, but I know of constituents of mine who moved from the Gwent area - and that was not the reason they moved - telling me about the excellent service they got in the North West of Wales compared with the South East of Wales. Is equality of service now poorer than it was before the Assembly came into being?

Ms Roberts: It is a slightly difficult one for us. If we put it into the context of the CHCs' role, we have only had an advocacy service and, therefore, only been logging complaints, concerns et cetera, since 2004. Therefore, we have no data going back to 1999 which gives us a little bit of a problem in answering the question. I would say I agree with what has been said by the LHB.

Q257 Albert Owen: Is there a trend? You may not have the statistics, but were the complaints similar in nature before devolution? There are other differentials now. Are people more empowered? Are they coming forward a bit stronger now?

Ms Roberts: They are coming forward in terms of making complaints. Going back to the waiting times, I think there always has been a difference in the waiting times. I think Welsh waiting times have, generally speaking, been longer and it depends on where you are as to how long the waiting times are. In Gwent I know that there was a huge orthopaedic waiting list at one point in time and that was creating an awful lot of problems. I suppose part of the reason, perhaps again a personal opinion, we have had longer waiting times in Wales may be the demography but also the chronic disease within Wales which has caused some problems. Yes, I think there always has been a differential. However, I must agree that it has not been improved post-devolution and it is a policy of the Welsh Assembly Government that the waiting lists are the length they are.

Q258 Albert Owen: Of course, you make a very important point that you deal with the complaints and, as the example you gave, there are a real issues and they are very serious, but people who get good treatment do not often register the fact that they have good treatment. That is very difficult. You said about quantifying problems. We do get letters as MPs, I am sure Assembly Members do, for good service, but they are rarer than the ones that are got for bad service.

Mr Lansdell: On that point, quite often you will get patients who are complainants in particular who are very, very keen to highlight the good service they have had within an area. You can have sometimes quite a horrendous story told to you, but within that there will be messages of goodwill and I personally will try and include that in any letters that go in, so that you are giving a balanced view either to the trust or the local health board or whatever. It is very difficult for patients who maybe have experienced it from both sides of the border because there is a lot of movement of people over the border as well. It is those people who are the ones who give you a clearer indication of how it is different, people like the gentleman who moved from the Manchester area to North Wales and found he was having all sorts of hurdles which he did not have to encounter when he was living in Manchester.

Q259 Hywel Williams: Could I check, you are concerned, though, with complaints mainly? Forgive my lack of knowledge, as CHCs, do you have an overall brief to look at quality of services, good bad or indifferent, or is your work inevitably skewed towards dealing with complaints?

Councillor MacLennan: No, we are statutory consultees under the Welsh Health Act, CHC regulations for the Welsh Assembly or any other NHS trust or LHB to consult us regarding patient services or change to patient services and we comment on those. We also lobby the Welsh Assembly Government on matters affecting patients.

Q260 Hywel Williams: You have a specific function to take up complaints?

Councillor MacLennan: It is part of our function, one of the functions.

Q261 Mr Martyn Jones: Do you think it is viable for Wales to provide most or all of its services within the Welsh border or should we carry on commissioning across from England?

Ms Roberts: We understand the critical mass arguments that were well portrayed by the staff from Walton and Wrexham. Though we would all like everything to be as close to home as possible, we accept the argument that cannot always be. I am quoting what the public have said to us in the past rather than my opinion or necessarily my organisation's opinion. Residents of North Wales see the Children's Hospital for Wales in Cardiff and they do not necessarily see it as a children's hospital of Wales. For them their children's hospital of Wales - talking about my catchment area of Denbighshire, Flintshire, Wrexham - is Alder Hey so, no, I do not think it is feasible to have all the services provided in Wales. We understand the critical mass argument. For some specialisms that is three million and that is the whole population of Wales, but having it provided in South Wales or vice versa makes access extremely difficult. Wales has an unusual topography and for that reason I think we could not provide it all within Wales.

Q262 Mr Martyn Jones: Could we provide more services locally?

Ms Roberts: I think things are changing so rapidly within the medical profession, new procedures, new drugs, so much more day case surgery than was ever provided and if we think back 20, 30 years what was happening then and what people are able to do now, yes, things are provided much more locally and this will continue to expand probably far greater than I can start to imagine at this point in time.

Councillor MacLennan: I do take your point regarding financing and commissioning,
Mr Jones. I think part of the problem is are the resources allocated to local health boards and to Health Commission Wales in some parts. It has to depend on how Health Commission Wales manages its budget. That sometimes can be quite frustrating and interesting, shall we say.

Q263 Mr Martyn Jones: Would you say in the areas you represent patients would not be concerned where their care is located so long as it is convenient and high quality?

Councillor MacLennan: Yes, I think that is absolutely right. I also think, as was mentioned here by one of your witnesses regarding patient outcome, if that is measured against money then problems do start there for patients, or clinical outcomes I should say.

Q264 Hywel Williams: A very, very quick one. Apart from the Minister's statement which I quoted earlier, which is now subject to the Steer Review, can you identify anybody at all who says that all services should be provided within Wales?

Councillor MacLennan: Within one part of Wales, Mr Williams?

Q265 Hywel Williams: No, within Wales. The question my colleague asked earlier on, is it feasible to provide all the services within Wales? Can you identify anybody who says that should be the case, that we should be moving in that direction, that we should achieve it? Does anybody say that, can you tell me?

Ms Roberts: Not that I am aware of.

Councillor MacLennan: It might be a political issue there. A political party might say that, but whether the patients will.

Q266 Hywel Williams: We cannot identify anybody who is saying that?

Councillor MacLennan: No.

Q267 Mr David Jones: Further to that point, Ms Roberts, you mentioned the issue of Alder Hey which, in fact, the Committee will be visiting today, I hope. Why did you mention Alder Hey specifically?

Ms Roberts: It was an example in relation to the Children's Hospital of Wales.

Q268 Mr David Jones: Yes, can you expand on that? Why are you concerned that the establishment of Children's Hospital of Wales will impact on Alder Hey?

Ms Roberts: I quoted that as being one of the issues that is quite regularly raised by members of the public who we interact with.

Mr Lansdell: I think the issue with Alder Hey is that many of the children from North Wales who end up in Alder Hey are critically ill and need one or both of their parents or family support and sometimes it is not just the parents, sometimes it is grandparents and uncles and aunts that are needed to support. The issue would be how could they provide that level of support if they had to travel to Cardiff as opposed to travelling to Liverpool which is an hour away.

Q269 Hywel Williams: I am sorry, Chairman, I am puzzled at this. Is anybody saying that children who are currently going to Alder Hey should be going to Cardiff, or are we dealing with speculation here?

Mr Lansdell: No, what I am trying to reinforce is the strength of argument to keep Alder Hey on the frame and what I am trying to explain is the outcome, if it was moved to Cardiff what possibly could be the outcome for the patients.

Ms Roberts: I think Mr Martyn Jones asked the question about all services being provided within Wales and on that basis I said that the some of the public's perception was that a service provided in Wales, such as the Children's Hospital of Wales, if you live in Flintshire they do not see that as being the children's hospital in Wales.

Q270 Mr David Jones: Exactly, it is the title "Children's Hospital of Wales" whereas in fact realistically, would you agree, it can only serve conveniently the children of South Wales?

Mr Lansdell: Yes.

Ms Roberts: South and West, yes.

Councillor MacLennan: That is a perception of the public, yes.

Q271 Mr David Jones: To what extent do you liaise with English patient representative bodies over cross-border issues and how easy do you find it to do so?

Ms Roberts: We do find difficulty in that the community health councils were abolished in England, so it has meant that there is a variety of creations in order to capture the public view. We do, however, liaise quite closely with the Patient Advocacy and Liaison Service, PALS, which exists in centres such as Walton in order to ensure that Welsh patients have access to our services and that issues such as Welsh language, et cetera, are taken on board by the hospital and publications are produced bilingually, et cetera. We have very, very close relationships with the Patient Advocacy and Liaison Service.

Q272 Mr David Jones: How satisfied are you with the independence of PALS?

Ms Roberts: I think from a community health council point of view, we have always had a slight difficulty with the independence. Whilst we embrace the fact that it is wonderful somebody has a first line of contact to hopefully immediately resolve their complaint or concern, from then on we are very concerned that if a person wishes to make a formal complaint they do not have an independent mechanism with which to do so.

Q273 Mr David Jones: Is it fair to say, without being accused by the Chairman of asking a leading question, you do not regard PALS as being sufficiently independent?

Ms Roberts: We find that people who have been through the system do not feel that they are independent, no.

Q274 Mark Pritchard: I want to ask a quick supplementary. Do you think some patients are confused sometimes about the complaints procedures either side of the border, because they are different and, in fact, there is confusion around public information campaigns and oftentimes those information campaigns start at different times in the calendar? Is that something you have come across?

Mr Lansdell: It is very confusing, particularly when you have a complaint which started in Wales but maybe the final treatment has been received in England and you are trying to separate out the two complaints because if they are not happy with the local resolution then it is up to local resolution. The complaints process is similar, you deal with them quite in a similar manner but if local resolutions fail, the Welsh system means you can either apply for an independent review and then take it to the Ombudsman or you can go straight to the Public Service Ombudsman for Wales. In England it goes to the Healthcare Commission which appoints an investigator who looks at it and then a panel looks at it. It is very difficult to try and explain to a patient sometimes why there is such a divergence in the way these matters are dealt with and that then does lead to people becoming a little bit disillusioned and work being very bureaucratic.

Q275 Mark Pritchard: It makes your job more difficult, I should imagine.

Mr Lansdell: Having different systems, certainly, yes.

Q276 Mark Pritchard: Moving swiftly on then, the Institute of Rural Health has suggested the establishment of a Border Commission on Health. Do you think that would be a good idea or just another body adding to, what I think most witnesses have suggested explicitly or at least alluded today, the existing confusion within the health market?

Ms Roberts: Without having some further information about the remit of a border commission, I would not be able to comment.

Mr Lansdell: Part of the problem is when you go out of the remit of something being approved locally and then go somewhere like Health Commission Wales for approval and when a service is readily available to English patients but they will categorically decline it in Wales and give a load of reasons, if this new board is just another tier in this, I think it would just complicate matters for patients. Matters need to be simplified where there is a simple line to obtain.

Q277 Mark Pritchard: National policy is extremely important and has an impact on, if you like, a wider constitutional settlement with the Union and we have seen that with regard to the provision of some health services in Scotland not being provided in England, Berwick-upon-Tweed or wherever. In the context of health and on cross-border issues which we are looking at, if you have a county, let us say Shropshire for example, where you have a single health trust, the Shrewsbury and Salford NHS Hospital Trust, Shropshire being the largest county in England, can you see a situation whereby some patient on the east side of Shropshire begins to get perhaps a little bit resentful that the provision of Shropshire's health is skewed somewhat because more provision is going into East Shropshire because there is a revenue stream coming in from Wales? Can you see the possibility of some upset?

Mr Lansdell: I think for most of the people I deal with all they are after is equality of service and fairness. If they have to wait six months, then everybody will wait for six months. Most people will a