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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

WELSH AFFAIRS COMMITTEE

The provision of cross-border public services for Wales

Tuesday 13 May 2008

MR JOHN HOWARD and MR BRYN WILLIAMS

MS JUDITH PAGET and MS REBECCA RICHARDS

Evidence heard in Public Questions 368 - 467

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Welsh Affairs Committee

on Tuesday 13 May 2008

Members present

Dr Hywel Francis, in the Chair

Nia Griffith

Mr David Jones

Alun Michael

Albert Owen

Mark Pritchard

Hywel Williams

Mark Williams

________________

Memoranda submitted by Montgomery and

Brecknock & Radnor Community Health Councils

Examination of Witnesses

Witnesses: Mr John Howard, Chief Officer, Montgomery Community Health Council, and Mr Bryn Williams, Chief Officer, Brecknock & Radnor Community Health Council, gave evidence.

Q368 Chairman: Good morning, welcome to the Welsh Affairs Committee. The acoustics in this room are not brilliant, so please do not be afraid to raise your voice so that everyone all around can hear you. For the record, could I invite you to introduce yourselves, please?

Mr Howard: My name is John Howard; I am the Chief Officer of Montgomery Community Health Council.

Mr Williams: My name is Bryn Williams, I am the Chief Officer of Brecknock & Radnor Community Health Council.

Q369 Chairman: Thank you, also, for your memorandum, which was very helpful in preparing for this session. Could I begin by asking a very straightforward question about the impact of devolution on the quality of services accessed by Welsh patients in your area?

Mr Howard: Certainly. It is a little bit like the curate's egg: it is good in parts. It initially started off with large hopes for having local input, influence and able to be heard and things, and I think that started and evolved very well, and there is a basic one, of course, and that is that we would not be here if there had not been devolution, inasmuch as the Community Health Councils were disbanded in England but have been retained in Wales and, therefore, are there for the benefit of patients. We think there is - and we would say that, wouldn't we - a considerable benefit because patients are represented through the Community Health Councils, either through its strategy or, in fact, through the complaints process, and so on. So there is a benefit in that. Obviously, as things have progressed and as the health services (how shall I say it) have diverged in with England, there is a degree of conflict and there are issues where because (and both Bryn and I represent Powys) Powys is, geographically, a third of Wales with a very small population but it has no district general hospital, it has to access secondary care services from outside of Powys. Therefore, especially when the population that I serve actually is about 12% of the Royal Shrewsbury's business, both financially and in services, we see the difference between the Welsh provision and the English provision, and we often see issues around patients being told: "If you were English you could be treated a lot better". These are issues that are often put right at the forefront and almost stamped on the forehead of Welsh patients, who feel, in many respects, from where they are, second-class citizens.

Q370 Chairman: Mr Howard, you have anticipated my second question, which is at the very heart of the question, namely the divergence. How do Welsh patients view that divergence of policy between England and Wales?

Mr Williams: There is certainly a two-edged sword to the whole question. Generally, there is a positive feeling about having health services in Wales. Having said that, from the population perspective, the major problem that we have is one about waiting lists, as an example. When we have reports from our complaints officers, whereas the rest of Wales, perhaps, have got different problems in relation to where the complaints come from, ours are basically around this concept about waiting lists and how they can access those waiting lists across the border that are better. From the Welsh perspective of service, we feel it is a bit of a two-edged sword anyway because whilst John said: "At least we have still got CFCs in Wales and it is democratic", it is still very much a political football. As a result, whilst it is useful to have the democracy and having the means by which we can get at the levels of power in health services, including through the AMs and MPs, etc, it has also got its downside because often you will engage in discussion about future services, whereby you would think in terms of how can we improve services, how can we make it a better service, but then, of course, if something happens, like we discuss perhaps the closure of some facilities, then those MPs or AMs are stood on the picket lines, and it is a bit naughty, if you can put it that way. On the one hand, you are participating in the discussion of making the service a better service, more economically viable, more effective and more efficient, but at the same time you have got this whole situation of running with both sides of the fence. I must come back to the point that, really, if we talk in terms of democracy and health there is participation of the masses. I find it absolutely a benefit, because it becomes their service, in essence, and where things go wrong then they participate in those discussions. Both John and I have also got what we call health focus groups, which will be of interest to others, that we run in communities where we feed information to communities and the communities feed back information to us about perceptions of health.

Q371 Mark Pritchard: Mr Howard mentioned 12% feeding into the Royal Shrewsbury Hospital. Did I hear you correctly - 12%?

Mr Howard: Twelve per cent of our business, yes.

Q372 Mark Pritchard: Are any of those paediatric patients at all?

Mr Howard: Yes, because there is very little paediatric service in Powys. Part of the problem we have is that there are, in some respects (because, I suppose, of the way the funding works) certain services that are what I would class as "fragile" in Wales. Some of them are paediatric services, some of them are, for example, mental health and things like that. They are just very thin on the ground. We do not have a district general hospital so we do have to access them through Shrewsbury.

Q373 Mark Pritchard: What about any accident and emergency admissions at all to the Royal Shrewsbury Hospital from Powys?

Mr Howard: A&E? We are dependent upon the A&E services in Shrewsbury.

Q374 Mark Pritchard: Are you aware of a proposal going to the Telford & Wrekin Primary Care Trust, the Shropshire Primary Care Trust, and, indeed, the Royal Shrewsbury and Telford NHS Hospital Trust this very week that proposes downgrading paediatrics and accident and emergency at the Royal Shrewsbury Hospital and building a specialist, purpose-built site halfway in the county, therefore removing the accessibility to those services eastward? Would it cause you problems?

Mr Howard: It would cause us problems. We have been involved with the Shropshire PCT and the Telford & Wrekin PCT in looking at the services in Shropshire. I was at a meeting last week looking at the review of their services for the future. There were issues in there about, specifically, maternity and neo-natal. A&E I was not aware of; I thought that was safe. I did not think there were proposals to change that. Obviously, as a stakeholder we would expect to have been consulted on that by Tom Taylor and his board at Shrewsbury before any kind of advances or changes were made.

Q375 Hywel Williams: Can I ask a very brief supplementary to Mr Howard on your initial reply? If I heard you rightly, you said that Welsh people who have been treated in hospital were told by staff that if you were English you would be treated better.

Mr Howard: Faster.

Q376 Hywel Williams: Is that globally or is it specifically to do with the waiting lists? Are you alleging a general attitude while you were at the back of the queue, or is it on the specific issue?

Mr Howard: It is specifically to do with waiting times for elective surgery, and it is very much geared - and there are a number of consultants - so that you almost know when you get a complaint from a patient where they come from. We have tried to minimise that, and some of the information that has got out into the public domain, in some respects, is, for lack of a word, scurrilous. It is basically untrue. Arguments that Powys does not pay its bills, for example, and things like that, we have tried to downplay, but there are still issues and huge issues around the different ways of funding now between the English system and the Welsh system that causes the problems and, therefore, it is this idea of commissioning services with different lengths of waiting times that actually cause the problem. I think it is really a result of the consultants not knowing how to handle it, from their point of view, and how to manage that situation. In some respects they often seem more intent on raising the issue than actually getting on and treating the person's problems.

Q377 Hywel Williams: Thank you for that explanation. We have heard in evidence to this Committee a difference between the Welsh and the English approach, which has been characterised as being "patient's choice" in England and "patient's voice" in Wales. What does that mean in practice, as far as you are concerned? If you can make a distinction (and we would be very glad if you could) could you tell us if one approach is better than the other?

Mr Williams: Yes, if I can respond to the choice thing. If Welsh patients have a choice, the most important thing to Welsh patients is that they are on a common waiting list with the English patients and, therefore, they would automatically be going across the borders. There would be no borders if their choice was available to Welsh patients because they would automatically be going over the border and getting the service. It is perceived to be a very much first and second-class service to many Welsh people; that they cannot access those services in the same timescales as they do in England. We can put all sorts of issues forward, like: "We have got free prescriptions", or "We have got free parking", but they are miniscule compared to the need to have common waiting lists across a bigger border.

Mr Howard: Choice and voice. Almost by definition in Wales there is very little choice because you have one supplier, and therefore if you, in some respects, fall out with your GP you have very few places to go. As far as a district general hospital is concerned, you have one and you go there and you are used to going there. So you have a choice: you either have it or you do not. The voice issue is dependent upon how much you are listened to, because many a voice can be spoken but it is not always heard. Therefore it would be interesting to actually plot the difference about when the public voice is used what changes happen or what the outcomes are and what the process is. There is often a danger and there is a feeling sometimes that going through a consultation process is sometimes a tick-the-box exercise; "We have consulted". There are issues that have to be considered in the delivery of health service, like access, that really are only looked at, in some respects, from the health service's perspective, not necessarily from the patient's point of view. The clinical aspect: it is clinicians who say that, and in many respects there is a debate and a debate could be had as to whether in fact there are outcomes that come out of that which are definitely there, and are prima facie from the patient's point of view. Finance issues, actually, go into that and therefore they become complex, and then there is the public's perception, or the public voice. In some respects the public voice is often the last one, if they were weighted. I think they are very low-scale because there is a fear sometimes that the way in which, for example, the Community Health Councils are asked to contribute to public consultation is, one, we help organise the public consultation sessions, and from that we then have to submit a response. If we are submitting something that is at variance with the proposals we have to put up a full business plan and so on, which we do not have the resources to do. So, in some respects, it is actually quite difficult to submit a public perspective.

Chairman: You are anticipating lots of the questions on which I want to give an opportunity for the Committee to cross-examine you more fully. I am not being disrespectful, but could you shorten your answers a little?

Q378 Hywel Williams: Can I ask you: the Local Involvement Networks has been set up in England - the LINks. Do you think that that will have an impact on the way that the patient's voice is heard in England comparable to the function that you have in Wales as Community Health Councils?

Mr Howard: I hope so.

Q379 Nia Griffith: Can I just raise this issue about the waiting times that we have been discussing. Presumably, the reason for the waiting times being as they are in Wales is because certain specialities and so forth may be difficult to obtain within the given time. Would you see the solution being that we need to switch immediately in Wales to exactly the same waiting times in England, or would you see that there could be agreements made about certain types of elective surgery? Which would you see as a possible way forward?

Mr Williams: Can I just say, Chairman, in answer to that, that the system that is operated in England is one of tariff for whatever service is available, so there is a standard charge for a service. As an example, an particular operation, say, would be in X-amount of days. In Wales they have got a broad contract system, and it does not matter whether a patient is in two days or 20 days, it does not cost any different. It does not matter if the throughput of those hospital beds is two or 20, it still does not matter. So you are in a whole situation where it is ineffective, inefficient and uneconomic. So you get difficulty then in actually auditing that sort of situation because it is an ineffective and inefficient sort of system. So you must alter your systems, otherwise the waiting lists are not likely to change very much in the future, unless the system is altered. I like the tariff system because at least you know what you are getting and what you get for that money; in Wales there is nothing like that.

Q380 Mr Jones: Mr Howard, I listened very carefully to the answer that you gave to Mr Hywel Williams's first question just then. Given your view as to the priority that the patient has in all this process, would you say that patient voice means anything at all or is it simply meaningless sloganising?

Mr Howard: I think it is important for people who ostensibly speak with the patient voice to actually be able to demonstrate where their church is or where their constituency is. I think that is important. I am a little bit fearful of the way that things are developing whereby people can almost say: "Ah well, we'll have you to speak on behalf of the public" without them necessarily having an identified kind of constituency or church or body where they, kind of, can keep their views. The danger is always that the person who speaks loudest gets heard most.

Q381 Mr Jones: So does it mean anything?

Mr Howard: It depends on who is hearing and what effect they have.

Mr Williams: It adds to this whole perception of whether there should be a big change in health services or whether there should be incremental change. One of the good things in the Welsh situation is that incremental change is a necessary part of the process. The difficulty is, of course, suddenly somebody will get a wonderful idea and there will be a dramatic change throughout Wales, and then we have to live with that for a few years before the incremental changes are coming through. A particular example is all the LHBs that we have got in Wales at the present moment, and the change that is perceived in that regard. If there was good thought about it in advance then certainly there would not have been that sort of activity. One thing that we are finding - John and I - from a Powys-wide perspective, is that we are able to offer (and I am sure Judith and our colleagues behind will comment on this) an influence over the policy, the strategy and the implementation direction of health services in Powys. I think that is vitally important. We are also able (you asked the question about whether the patient's voice is necessary or worthwhile) to offer quite ----

Q382 Mr Jones: Forgive me, I did not ask that. What I asked you was whether the expression "people's voice" actually means anything.

Mr Williams: Fine. The people's voice means a lot because we act with the people and through the people to the process of policy-making at government level. Your MPs in Wales, I am sure, would reflect that. So we are able to influence at all those sorts of levels as well as a voice.

Q383 Alun Michael: Can we look at the actual flow of patients across this long, porous border of ours. Has the patient choice agenda affected the flow of patients across the border? Have you seen patients registering in England in order to access services not available in Wales, or registering in Wales from the other side of the border for particular reasons?

Mr Howard: There are patients who, because of where they live, can only access the services through their GP. Remember, the GP is the gate-holder, basically, so therefore they will go to where they think their closest GP is. There was a - whether it is apocryphal or not - discussion recently up in Cheshire of a small village there talking about aspiring to become Welsh so that it could have free prescriptions. Whether it is real or not is a different thing. I am not sure that there is choice coming back into Wales. There are some things - waiting times for, say, cataracts - that you can get done faster in Wales than you could in England, and therefore there is a choice sometimes but not much of it.

Q384 Alun Michael: With respect, I think what we are trying, as a Committee, to get to is what is really happening rather than what may be apocryphal. Is there any evidence of how patient choice has affected the flows across the border?

Mr Howard: Not from my perspective.

Mr Williams: Certainly from Brecknock & Radnor's perspective, I get all sorts of comments from the population to say that they find it very confusing in relation to the whole set-up and why one system should be different to another when you pay into a national income tax.

Q385 Alun Michael: With respect, my question was about evidence of flows across the border. Is there any evidence?

Mr Howard: I can only say there are 800 English patients registered with Welsh GPs in Montgomeryshire.

Q386 Alun Michael: Compared to?

Mr Howard: Compared to 55,000 in Montgomeryshire as a whole.

Q387 Alun Michael: Compared to ten years ago?

Mr Howard: I have not got a change. I do not know whether that has altered in the last 12 months.

Q388 Alun Michael: I think I have to take that as "no evidence", with respect. You have talked about confusion, but there is nothing you can point to. One of the points about the changes on the two sides of the border is that, obviously, there are developments of foundation trusts on the English side of the border. Are the interests of Welsh patients being dealt with adequately within those new arrangements?

Mr Williams: From a Hereford perspective to South Powys, the catchment area for Hereford also embraces South Powys. As a consequence, they have taken that into account when they have put their business plan forward. The difficulty is, of course, when we get this thing about pulling people back into Wales, and there is strong evidence that that is happening. I think it will be to the detriment of Hereford, the provider, and it will be to the detriment of the Welsh people who have been receiving treatment at Hereford if they have to go somewhere else in South Wales, as an example.

Q389 Alun Michael: Would you explain that sentence? Who is pulling people, and how?

Mr Williams: The information I get from the Commissioners and from others is that there is a definitive directive to them to pull people back into Wales that are getting services outside at the present time. I have got some correspondence that, perhaps, would interest you in that regard as well - of individual cases.

Mr Howard: As far as Shrewsbury is concerned, they were guidelines for the foundation trust - not in specific numbers - that increased those. They are doing their best to actually get representatives from Wales into their trust and going about safeguarding the statutory rights that we have as Community Health Councils with their foundation trust status.

Q390 Mark Pritchard: Mr Williams, you mentioned the word "directive". Of course, if the Hereford and Shrewsbury & Telford NHS Hospital Trusts are going for foundation status (certainly the latter) then, obviously, payment by results and their financial projections in the future are based on existing patient flows and projected patient flows. If you are saying there is a directive from somebody (and perhaps you can say who it is from - I am sure with such an important document you, no doubt, will have in your mind who it is from if not necessarily the date) then, clearly, there is an impact for those English hospital trusts going to foundation status and, indeed, if they did not get foundation status an impact on their, if you like, balance sheet for today and in the interim. Also, it has implications for the Welsh Government and, indeed, the national Government and the financial settlement for Wales and the part that deals with the National Health Service for the health service in Wales. On the first part, who actually set this directive or this letter that you mentioned?

Mr Williams: From what I understand, and I have seen nothing on it and other people also make the same comment - they have seen nothing specific in writing - it is from the Welsh Assembly Government and from the Health Commission Wales. Whether that is a fact or not I do not know, but certainly that is the impression that has been given throughout the service and is an impression that I am getting from leaders of the service and, indeed, from patients who actually have been receiving treatment outside of Wales, who are being told by their consultants that they have to go back into Wales for the service.

Q391 Mark Pritchard: Mr Williams, I am confused. A few moments ago you mentioned about correspondence and a directive. Now you are saying it is rumour and innuendo, and it is what people are saying. Which is it? I am sorry, I am confused.

Mr Williams: I am sorry if I confused you. I am probably confusing myself just as bad. Certainly the reflection that I get, and as I said earlier ----

Q392 Mark Pritchard: I am sorry, Mr Williams. So we are absolutely clear, have you received correspondence or not on the issue of patients returning to Wales from English trusts?

Mr Williams: I have not seen any correspondence from any particular body, but the overall impression is as I have indicated. I have the minutes of a meeting that I had with the Commissioner who said that that is the directive that they have had.

Q393 Mark Williams: Just to reiterate what you have said: are you aware of an increase in appeals to the Health Commission Wales for precisely the reason my colleagues have been talking about? I have my own constituency examples of people who have been having neurosurgery treatment in Frenchay Hospital, Bristol and who have been told that they have got to go to Swansea. Are you aware of any information on that point?

Mr Williams: I am not aware of that particular situation, but at the same time there is some correspondence that I have that would indicate that from Birmingham, as an example, they have been told to come back into Wales for the service. You can have that correspondence.

Mark Williams: That would be helpful. It would be very interesting if you could get any figures on the increase in appeals from patients.

Q394 Mr Jones: Mr Williams, forgive me, I am still confused, and I think other members of this Committee are confused too. Do you have correspondence in your possession that indicates that a direction has been given to return Welsh patients who were having treatment in England back to Wales? Is there correspondence in your possession?

Mr Williams: I have individual correspondence in that direction, yes, about individual patients. However, I have not seen any general correspondence from the Welsh Assembly Government or anywhere else, other than the minutes I have taken at a meeting with one of the Commissioners (a Commissioner who is local to us) who has indicated that that is the instruction she has had from the Welsh Assembly Government.

Q395 Mr Jones: Have those minutes been agreed with the person?

Mr Williams: Certainly the person has agreed those minutes, yes.

Q396 Mr Jones: Will you provide copies of those minutes to the Committee?

Mr Williams: I will indeed.

Q397 Mr Jones: Will you also, please, provide copies of the individual letters, blanking out if necessary the names of the individual patients?

Mr Williams: Yes.

Mr Jones: Thank you.

Q398 Mark Pritchard: Mr Williams, you said that the Commissioner you had a meeting with had had instructions from the Welsh Assembly Government. Were those instructions in writing or oral instructions?

Mr Williams: I got it from hearsay from that person, but I have not seen any correspondence.

Q399 Mark Pritchard: In the minutes you are kindly going to copy to us, is there a reference to that instruction that was made orally in that meeting? You minuted that yourself.

Mr Williams: Yes.

Q400 Mark Pritchard: Thank you very much. Finally, if I may, we met with the Bishops of Hereford and Monmouth, and they alleged that the divergence in health policy between England and Wales was confusing. I think you have touched on that. You used the term "second-class citizens". What do you think the Government, nationally or in Wales, needs to do in order to equalise or bring equality in patient treatment between Wales and England and vice versa?

Mr Williams: The view that has been expressed by the population - and it is a view that I hold - is that they all pay national income tax into the national Government and, as such, health services should not be divided by borders; there should be freedom across borders in health service provision. That is the impression we are getting. What they are saying, at the moment, it seems, is that because of the differences in waiting times they are getting a second-class service compared to their counterparts in England.

Q401 Mark Pritchard: So a National Health Service means "national" by definition?

Mr Williams: Yes.

Q402 Mark Pritchard: I am not, hopefully, reading too much into what you are saying, but by definition, conversely, you are saying that Wales is not part of the National Health Service.

Mr Williams: No, what I am saying is that it is running a different NHS system than they run throughout the rest of Britain. As such, issues like waiting lists should be common to all; there should not be the creation of artificial boundaries in health service provision. If we go back to the question you asked about choice, if there was choice the people of Wales would access the service across the border, because of the waiting lists.

Mr Howard: Can I come back on that from a Montgomeryshire CHC point of view and say that our view is that if you are buying a service from a hospital, everybody who gets treated at that hospital should get the same service; there should not be a distinction between whether you are Welsh or whether you are English.

Q403 Albert Owen: Can I come in on this patient choice issue? I hear what you say about the theory that everybody should get the same access and they have paid the same contribution, but do you find that some of the patients get different advice from the Local Health Boards, the GP and the hospital, and that that is what is causing the confusion? Are they saying different things to the patients?

Mr Williams: I think that is absolutely right. I have the impression that neither the managers, the directors, the consultants nor the GPs are fully aware of the regulations that bind this whole system together. There is absolute confusion; not just amongst the population but amongst the people within the service as well.

Q404 Nia Griffith: In your evidence you have mentioned the difficulties of travelling a long way to get certain types of treatment. Do you think there is any possibility that Wales could provide more of the health services within the Welsh borders as opposed to funding services across the border? If so, which ones do you think might be possible?

Mr Howard: The answer to that is yes, it would be nice to see that you have consultants coming into Wales to certainly do more services and offer more services. The difficulty is that in many respects where there is an operation required then certainly there are problems and difficulties in Montgomeryshire because we have no facilities for that. There are issues around the changes in the consultant contract that actually have put difficulties on consultants' travelling for out-patient clinics, inasmuch as their time is then lost because of the travel time. The argument is that patients travel and, therefore, you have, say, 10 or 15 patients travelling to prevent one consultant. That is where the equation between travel does not balance out. That is why, on occasion, it seems that things seen from a health service perspective only govern the decisions that are made. Services that could be done in Wales? Anything that does not actually need clinical intervention or a direct operation.

Q405 Nia Griffith: That you would be seeing as a buy-in from consultants who are currently employed in England as opposed to sending people to North or South Wales to consultants who are employed in Wales. So, effectively, what you are describing there, although it would be taking place in Wales, would still be a buy-in from an English service.

Mr Howard: Yes.

Q406 Mark Williams: Returning to Mr Williams' point about access - the need to view access from the patient's perspective, not necessarily one defined by the NHS - can you tell me more about what patients are actually saying about where their care is located, England or Wales, and how much does it matter to them?

Mr Williams: The only occasion it matters to them, as far as my recollections are concerned, is from the maternity perspective - from having children; they like to have their children born in Wales for Welsh parents. However, at the same time, generally, they are quite happy to travel from here to Timbuktu, if necessary, to get the best service. What we must realise as well is that there are only limited facilities available throughout the NHS that people can reasonably access within a fair distance. At the same time, what the speciality is will depend upon how far it would seem to be reasonable for them to travel. It could be seen to be reasonable to travel a long distance for something that is very serious or a short distance for something that is not so serious.

Q407 Mark Williams: But, if you look at the some of the specialisms anecdotally, for someone, say, in Newtown, and I am thinking about this question of the all-Wales service model that we seem to be moving down, the choice between perhaps coming to my constituency to Bronglais Hospital in Aberystwyth or a shorter journey over to Shrewsbury, what do people say?

Mr Howard: In all honesty, they would prefer to go to Shrewsbury. The argument in Powys is they say, "Where do the patients go?" and they say, "They go where the water goes", so everything from the Cambrians goes to Bronglais in Aberystwyth and then everything on this side of the Cambrians, the English side of the Cambrians goes to Shrewsbury, so there is a flow in that direction, and there is a history of that. There are of course the difficulties that there are, and Bronglais serves the needs of the people around Cammaes Road and Machynlleth and so on also into Merrionnyddshire and they are dependent on that. It is the only district general hospital between the north and the south of Wales. If you actually drew a map of Wales and put on it the cities and the hospitals, there is only one dot that is not on the southern corridor or the northern corridor and I think, therefore, that Bronglais is important to the needs of the people of Mid Wales. When you look at the size of the services and the range of services that are offered, Bronglais does not have the catchment to be able to provide the full range of services that you can get in Shrewsbury.

Q408 Mark Williams: As you will appreciate, we are currently having a debate on the future of our Trust and the geographic parameters which are being defined from above to us. Obviously, within Powys there are issues as well. I should imagine that in the south of Breckonshire, there is a gravity to the south, but more generally we have got this great jigsaw puzzle and I am not convinced, from listening to your evidence, that, given this move, this drive towards an all-Wales service model, Powys really can fit into that jigsaw puzzle. What is your take on that?

Mr Howard: There is the usual statement when people are asked about the Health Service in Powys and their usual answer is, "Well, Powys is different, isn't it?" and it is right in that way. It is the most odd-shaped piece that you could ever fit into a jigsaw, wherever it was, because, if it is a third of Wales geographically, it has got a very small population, 130,000 population, and in fact, when you talk about the distance from the north to the south, it is the equivalent of Bristol to London, there is a huge area to cover without a district general hospital, so you are dependent upon something like five district hospitals around. In some respects, it would make more sense to actually have the services kind of looked after by whoever the district general hospital was that was providing those services and you bought into the services from that, but we have got a very good GP service. It is probably as good as anywhere else you can get in the UK and I think primary care is important, is imperative, but it is still a gatekeeper in that it opens the door into access for secondary care and for tertiary care, it is like being on an escalator, you go wherever the escalator takes you.

Mark Williams: Hopefully it is a short escalator.

Q409 Albert Owen: You mentioned your involvement in consultation and you felt that you did not have a positive role in that, or that is the way I interpreted your answer, so to what extent do you currently liaise on other matters with the Welsh commissioners and English providers to address the issues cross-border with regards to Welsh patients?

Mr Howard: We are involved in discussions with them very regularly. Both of us are on the local Powys Local Health Board and I can go and attend any meeting at any of the secondary care commissioners and providers.

Q410 Albert Owen: So you are on the steering committees and you can feel involved in the policy development?

Mr Howard: Yes, and we are involved in all discussions and debates about changes and so on. We are fortunate inasmuch as we are involved in that almost to the extent that, because we are dealing with so many hospitals from time to time, you are all over the place.

Q411 Albert Owen: Are those committees speaking with one voice when it comes to cross-border issues?

Mr Howard: No, no. Come on!

Q412 Albert Owen: I expected that answer!

Mr Howard: How well do you know Wales!

Q413 Albert Owen: Another issue that you have raised is that you said that, because of devolution, you are still in existence, so what sort of relationship do you have with other bodies across the border on representing the interests of patients?

Mr Williams: The first thing is that across the border with the advent of foundations trusts, I have got two CHC members who are actually sitting on the working group in relation to Hereford, say as an example, and John has got a similar arrangement actually up north. In addition to that, we interrelate closely with the chief execs of Powys LHB, as an example, not just in a formal manner, but in an informal manner as well and with all the operators within the service, so you build up a relationship in a sense over the years, informal as much as formal, and the informality is a lot better and a lot easier than the formality is.

Q414 Albert Owen: So groups across the border have mutual interests for patients?

Mr Howard: We do have links and primarily the link is around a provider, so, therefore, the provider, say the Royal Shrewsbury, will have meetings with patients forums and with us and discussions and we have meetings for that. There is a special group that has been established to look at cross-border issues which involves a number of primary care trusts in England, the Powys Local Health Board in Wales, representatives from the CHC which represent the five CHCs ----

Q415 Albert Owen: And is that a forum that you see will be able to collate evidence of the movement of people across the border?

Mr Howard: Yes, it is doing that at this moment, it is collecting that information so that it can actually put it into the public domain. The problem they have got is that all these bodies, in all honesty, are working as well as they can to try and solve the problems that kind of bubble up to the surface, but there are some things that bubble up to the surface that are outside their control that they are unable to address and it is those things that they need help with.

Q416 Chairman: Mr Howard, you mentioned this cross-border forum. I wonder whether you could provide us with a short memorandum describing the work of this forum.

Mr Howard: Yes, and I will happily send you some minutes of the work that they have done and the frame of reference that they have got.

Q417 Mr Jones: Mr Howard, could I refer you to one paragraph towards the end of your submission to the Committee. You say, "The CHC is convinced that specialist services that have relatively low numbers would be better linked covering a safe clinical network embracing the whole of the UK. There may be instances where Wales does not have the critical numbers to maintain safe services". We heard similar evidence from the Muscular Dystrophy Campaign. Could you expand on that point and could you also maybe, if you are able, give the Committee some examples of the sorts of problems that you have had in that sort of area?

Mr Howard: I just think that there are issues around catchment areas, that, where there are limited kind of specialist services, so there are few people who need them, therefore, it is best to have all the specialist resources in one place rather than actually spreading them thinly. It is the quality of service that I think is paramount. I cannot give you any specific instances, but it works in a small kind of perspective. For example, in Powys there are issues now around a minor injury service and, because we do not have any A&E in Powys, there is an issue about the quality of minor injury services and, if it works on a clinical basis at that level, then it should work at a higher level. Therefore, it is looking at the UK as a whole network and actually having a network in that respect. The specialist services you can think about are things like the services you get from Alder Hey and so on.

Q418 Mr Jones: How would you suggest that network be funded?

Mr Howard: I just think it is a matter of accessing the services, knowing where they are and accepting that, for the really good-quality, specialist services that are available, you have to access them and you have got to go wherever that service is, and it might be ----

Q419 Mr Jones: I understand that, but how would that network be funded? Would it be funded centrally, by the UK Government?

Mr Howard: I would have thought it would have to be top-sliced.

Q420 Mr Jones: By the UK Government?

Mr Howard: By the UK Government, yes.

Q421 Mark Williams: I think I am returning really to the point made by Mr Williams, my colleague here, and he quoted from your document Why not come to England: you'll be treated better. Are the current arrangements for cross-border provision of services for Welsh patients in England sustainable?

Mr Howard: If you lost those services, if, as Bryn mentioned, the fact that people in Cardiff decided that it was fortress Wales and ring-fenced, then I think that the loss of services from DGHs in England by repatriation to Wales would actually put services at those hospitals in difficulty. If you just go through the equation, if Shrewsbury has 12% of its business in Wales, therefore, it would have to lose 12% of its staff if it lost those services back to Wales and, therefore, the business may not be sustainable. There are issues used in the NHS about a DGH needing half a million population catchment. If you lost 55,000 of the half a million that Shrewsbury and Telford has, it would have to reduce its services, so, therefore, services are not sustainable and it would probably be the smaller services that would be fragile.

Chairman: Thank you very much for your evidence and for your earlier memoranda and we look forward to receiving your additional memorandum. Thank you.

Memorandum submitted by the Powys Local Health Board

Examination of Witnesses

Witnesses: Ms Judith Paget, Chief Executive, and Ms Rebecca Richards, Director of Finance, Powys Local Health Board, gave evidence.

Q422 Chairman: Welcome to the Welsh Affairs Committee. Could you, for the record, introduce yourselves please.

Ms Paget: Good morning. I am Judith Paget, the Chief Executive of the Powys Local Health Board.

Ms Richards: I am Rebecca Richards and I am the Director of Finance at the Powys Local Health Board.

Q423 Chairman: Could I begin by asking you what has been the impact of devolution on health services for Welsh patients?

Ms Paget: I think it touches on some of the issues that have been mentioned in the previous evidence really. I think, through the Assembly's policy described in Making the Connections and the Beecham Review, there is a real focus on the citizen voice to drive service change and improvement in Wales. I think that, as a result of that, we have seen a diverging policy agenda in relation to the Health Service and things that have already been mentioned this morning, different waiting times, issues around tariff and payment by results being introduced in England and not Wales, we do not have foundation trusts in Wales, we do have free prescribing and other issues which have been addressed by the Assembly, so I think basically it is around the different policy direction that has been taken now in Wales as different from England.

Q424 Chairman: Those different policy directions or directives are a particular issue for us. We have heard in earlier evidence that there may be a suggestion that the Welsh Assembly Government has sent out a directive requesting you, or directing you, to repatriate Welsh patients. Has that happened?

Ms Paget: No, not at all.

Chairman: Well, that is pretty straightforward.

Q425 Albert Owen: As we are aware and as we have heard from the evidence session previously, the fact is that Powys does not have its own district general hospital and you have to commission services from outside the boundaries of the county, but also in Wales and in England, so what proportion is within Wales and what proportion is in England?

Ms Paget: Rebecca will remind me if I have got the figures wrong, but, of our total secondary care commissioning allocation, 23% of it flows to England and the rest remains in Wales.

Q426 Albert Owen: So what factors determine this care? Is it specialist services available in close proximity across the border?

Ms Paget: Yes, there are a number of factors.

Ms Richards: Obviously the patient flows is the main, predominant factor, so, if a patient is referred to an English DGH, then we pick up the costs for that patient and with an English DGH, if a patient is referred to Wales, we pick up the costs for that DGH because it is part of our contracting arrangements with those organisations.

Q427 Albert Owen: You will be aware of the recent report on the providers of the Powys Local Health Board stated that the county's current network of community hospitals is not providing an adequate service. Do you agree with it?

Ms Paget: I think the position of the Powys Local Health Board actually is to welcome the Clinical Governance Report. We are in the process of going through the detail of it in terms of a programme of action. I think broadly we are very supportive of what the Clinical Governance Support & Development Unit have said.

Q428 Albert Owen: So the current system is not meeting modern-day requirements?

Ms Paget: I think that would be fair, yes.

Q429 Albert Owen: So what is the net effect on the service provision of implementing the report's recommendations?

Ms Paget: I think what we really need to do is to be very clear about what services we can deliver in Powys safely and how we do that, so that will probably mean us having much stronger links with neighbouring NHS Trusts. I think we need to, in many respects, focus some of our services in three main centres in Powys, one in the north, one in the middle and one in the south, and we then need to do some very close working with our communities and our local authority colleagues and the voluntary sector to redesign how health and social care is delivered in the rest of Powys, so I think it is sort of two main emphases really, focusing and centralising our services north, middle and south, where we can and where that is appropriate to do, and working with our communities around redesigning services in other areas.

Q430 Albert Owen: So can cross-border collaboration assist in addressing these alleged problems, and you have given a breakdown of how much is currently across the border and how much is within it, or are we looking at a Welsh solution to this?

Ms Paget: No, I think there are opportunities for both English and Welsh NHS organisations to support Powys and I think that is the way that the Powys LHB will move forward. We know we will need to have, and we already do have, lots of discussions with the Shrewsbury and Telford Hospital NHS Trust and with Hereford, but also we talk to Gwent, we talk to the new Hywel Dda Trust, so we are in active discussions with all those NHS Trusts that sort of circle Powys really because we are very sure that, in order to maintain local access to service in Powys, we will need to develop those very strong relationships.

Q431 Albert Owen: But the reconfiguration that you talked about, does that make travel for certain patients more difficult to English hospitals or within areas of Wales?

Ms Paget: No, I do not think so.

Ms Richards: No. As Judith said, we want to try and provide as many services locally and as safely as possible, so there may be opportunities, I think as somebody previously said, about bringing services into Powys where it is safe to do so, but clearly where it is unsafe to provide those services locally, then patients will need to travel. It is about finding the right fit for Powys that is clinically safe.

Q432 Albert Owen: So satellite services within the county is the priority?

Ms Paget: Yes, and certainly we want, where we can, to arrange for consultants to come into Powys to deliver care where that can be done safely. I think in Powys, as we have heard from the previous evidence, Powys residents are used to travelling outside Powys for a large proportion of their care that is DGH-based. We do provide outreach consultant follow-up clinics locally, we do provide day surgeries locally, and our plan is to continue doing that.

Q433 Albert Owen: When you said they are used to it, they do not have much choice though, do they, if you have admitted that the standard is not very good now and it needs modernising?

Ms Paget: I think that the issue is not so much about the standard, but actually Powys residents need to travel to access DGH care because it is not available in Powys and never has been. I think what the Clinical Governance Report has said is that we really need to relook at the services we are delivering in Powys and actually put in place a clinical governance infrastructure that allows us to continue doing that safely.

Q434 Albert Owen: The reason I push you on that is as somebody who has got a constituency on the periphery and it is condescending to say that they are used to it in many ways. They do not have the choice and, if they are given the choice of services being delivered closer to them, then that is the choice they would go for.

Ms Paget: I think so, but the issue is how you balance access and safety and I think that is the issue that the Clinical Governance Report has tried to uncover really and to try to put forward some proposals about how we actually maintain that balance and deliver as much care locally as we possibly can, recognising that Powys residents, as you say, will always need to travel for some services.

Q435 Alun Michael: In your written evidence, you make the statement that you encounter difficulties with English NHS Trusts over the different healthcare funding regimes in Wales and England. It is perhaps an open-ended question, but what is the solution to that?

Ms Richards: Just by way of background, the way that we fund NHS Trusts in England is based on our historically funded agreements, so in 2003/04 the local health boards were resourced at a level of funding to correspond to those contracts that would have been held by the former health authorities with England. Of course a lot has happened since 2003/04, payment by results has come in and the funding flows regime in England has totally changed, but the funding for NHS organisations in Wales has not and, therefore, we have historical agreements that we uplift for inflation and we address for differences in activity, but we do not recognise payment by results because it is much more expensive for us to commission on that basis than it is against our current contracts. So the simple answer is that, if we were funding to pay for contracts on the basis of payment by results, then of course we would pay it.

Q436 Alun Michael: Well, if we ignore that there is water into, and water out of, the bath, as it were, do you think that really you ought to be paying the English tariff prices for Welsh patients in England?

Ms Richards: The current advice from the Assembly is that we do not because we have not been funded to be able to pay at that level.

Q437 Alun Michael: So, in other words, your answer to the question is a reference to what the Welsh Assembly Government is telling you?

Ms Richards: Yes. We are only funded to pay on the basis of our historic agreements. We have not been funded to reflect the changes in the financial flows as a result of payment by results.

Q438 Alun Michael: But we have heard from previous evidence that that causes problems for the Trust which is receiving patients, does it not?

Ms Richards: Yes.

Q439 Alun Michael: What impact do you expect the Welsh 'financial flows' work, the introduction of a Welsh tariff, will have on cross-border service provision?

Ms Richards: At the moment it has all been put on hold, is the latest advice from the Assembly simply because of the consultation that has now come out about the reconfiguration of the NHS in Wales. For this year we were going to do a pilot where we were going to start trying to commission on an HRG basis within Wales and that would have had impacts on certain organisations and certain NHS organisations in Wales, but, because of the consultation for the proposed changes in Wales, that has been put on hold pending a further review of how funding should flow within Wales.

Q440 Alun Michael: Just as a supplementary question, looking at the situation at the moment and bearing in mind what you have said, we have really had conflicting evidence on whether the way that services are paid for makes a direct difference as far as individual patients are concerned. We have been told, on one hand, that it does make a difference and, on the other hand, that cases are dealt with by the NHS Trust in England purely on the basis of clinical priority, irrespective of which side of the border patients come from. I think it is difficult to reconcile those two statements. What is your experience?

Ms Richards: I will try to explain the differences as I understand them. We have differential waiting times between England and Wales and, putting payments by results to one side, if we were to try and catch up and fund the same level of waiting times in England as we would in Wales, then it would be a one-off hit to Welsh commissioning organisations because we would have to treat the backlog of patients to get down to the same waiting times as they would be in England, so there would be a hit financially to Welsh organisations if they were to commission at the same level as English waiting times. On top of that, the English funding regime is different in England from Wales which would mean that we would have to pay a higher price for those activities as well if we were to change to payment by results.

Q441 Alun Michael: Yes, but does it not follow then that they cannot be taking patients from the list purely on a clinical basis if it is affected by the financial arrangements?

Ms Richards: Yes, sorry. To give assurance, the patients that are assessed as clinically urgent will be treated as clinically urgent. The difference between England and Wales is only on elective, non-urgent cases.

Q442 Mr Jones: To pursue that point further, Hereford Hospitals NHS Trust says that the employment of two different funding systems in England and Wales is ultimately unsustainable, and that is probably right, is it not?

Ms Richards: We have discussed with them the different waiting times that they operate. A lot of organisations in England that we commission from do operate differential waiting times targets for us. Hereford have expressed a difficulty in managing differential waiting times and, as a result of that, we actually manage the waiting lists for patients within Powys to operate to Welsh waiting times targets on their behalf and also for Monmouthshire LHB as well.

Q443 Mr Jones: With respect, it is more than simply expressing a difficulty, it is a positive refusal to operate differential waiting times system, is it not? That is the truth of the matter. It has actually broken down so far as the Hereford Trust is concerned and they refuse to operate it.

Ms Richards: They have refused to operate it. We are having discussions with them at the moment about whether they would be able to reverse that decision and manage a differential waiting times system.

Q444 Mr Jones: But, as we speak, the system has broken down?

Ms Richards: Yes.

Q445 Mr Jones: And you have made it clear in your memo that the local health board has taken on the management of the waiting list because of such refusal.

Ms Richards: Yes.

Q446 Mr Jones: Well, how do you manage the waiting list because you are commissioners, you are not providers? How can you assess the clinical priorities?

Ms Richards: We do not assess the clinical priorities, but we actually get a consultant to do that for us. We just place them on the waiting list at the point that they would need to be to meet Welsh waiting times.

Q447 Mr Jones: Where is that consultant based?

Ms Richards: In Hereford.

Q448 Mr Jones: So you have got a bizarre system whereby you employ a consultant in Hereford to decide which of your patients should be treated first?

Ms Richards: It is their consultant that does the clinical prioritisation.

Q449 Mr Jones: Well, looking at that from the outside, it appears eccentric, if not to say Byzantine. Would you not agree?

Ms Richards: I would say it is a system that is quite difficult to manage.

Q450 Mr Jones: And it is clearly causing you problems.

Ms Richards: Yes, it is a managerial issue that we would rather not have.

Ms Paget: And that is why we are now looking at whether or not Hereford would now work with us to take that back.

Q451 Mr Jones: You would rather just be able to pay them straightforwardly without having to perform this juggling act?

Ms Richards: Yes.

Ms Paget: We would like to have the same relationship with them that we have with other providers, yes.

Q452 Mr Jones: Or, even better, may I suggest, you would rather have the same system that applies in England because that would make your life a lot easier? Surely that must follow?

Ms Richards: I think we would like a consistent system across both England and Wales for all NHS organisations.

Q453 Mr Jones: Do you think that the commissioning of services by a centralised NHS board, as proposed by the Welsh Assembly Government last month, will help address this situation or will it not make any difference?

Ms Paget: I think it will address some of the issues that are of concern in Wales about having 22 LHBs each with their own commissioning role and function, and I am sure that that is why the Minister is now getting comments and consultation on that in terms of making an ultimate decision about whether that will actually improve the system for patients.

Q454 Mr Jones: In your professional opinion, do you think that the consequence of that will be that patients resident in Wales will be treated as quickly as patients resident in England?

Ms Paget: It would be difficult for me to comment on that given that the issue that is driving the differential waiting times at the moment is Assembly policy and, therefore, it would be for the Assembly to determine how that might change for the future.

Q455 Nia Griffith: You have obviously hinted at this difficulty of different systems and it must be very confusing for patients as well operating in that sort of situation. What do you think are the main implications for patients who are sort of caught between the two systems and have you done any research to see what could be done or how you could minimise the impact on patients?

Ms Paget: I have been in Powys for nine months now and the thing that has struck me since I have been there is, I think, just the level of confusion really amongst patients about the different systems. When I go to different meetings or meetings in different communities, I often spend some time trying to explain how the systems work because I think there is a level of confusion and I think the community health councils have alluded to that, so yes, I think that is a real issue for patients really.

Q456 Nia Griffith: I think one of the things that has been particularly highlighted to us has been this prior approval service, and patients obviously get very confused about how that works and they may find that they are waiting and then they do not even get a treatment. Can you see any way of dealing with, or improving, that situation?

Ms Richards: Yes, certainly. To echo Judith, I have been in post now for four months and certainly there does appear to be confusion not just by the patients, but by some of the GPs as well who refer patients to different organisations, and the fact that we are managing the waiting lists for two of our organisations means that they need to request our approval before the patient subsequently gets treated. As we said earlier, we are trying to work with those organisations to see how we might improve the system between us so that we do not manage all the waiting times ourselves so that there is a direct referral in, and also we are doing some work with the local GPs to give them information on what they can advise the patients to expect when a referral is made, so there is a whole communication issue that we need to improve as we go forward.

Q457 Mark Williams: We have heard a lot of evidence about the dependence of Trusts on other side of the border on Welsh patients. Generally, do you agree the Hereford Hospitals NHS Trust that Welsh patients ought to be encouraged, and enabled, to access English hospitals where this is in line with ease of access and a patient's clinical need?

Ms Paget: As I have mentioned before, I think that there is a recognition on the part of Powys Local Health Board that patients always will flow into places like Hereford and Shrewsbury and we have not done anything to not support that. I think as I just said, when talking to patients and community groups, I often get asked, "Will Powys LHB stop us going to Hereford?" because they feel that there is some threat over this issue, but, from our point of view, we are working very collaboratively with both Hereford and Shrewsbury around access to services for our residents and that will continue, I am sure.

Q458 Mark Williams: The consultation document published by the Welsh Assembly Government on restructuring proposes that the Powys LHB would no longer offer secondary care services. What is the impact going to be on English and Welsh providers?

Ms Paget: Well, I think that that proposal, in my understanding, relates directly to the proposals in the Clinical Governance Report that said that there were a range of services that Powys LHB was currently providing that perhaps it should not longer do so for the future and, therefore, we will need to work ----

Q459 Mark Williams: Which services? Would you elaborate upon that.

Ms Paget: Things like the management of acutely ill patients in some of our hospitals which we currently undertake, things like maybe mental health services. There is a whole range of services in the report that it suggests that Powys should no longer provide for the future, so that will require us to work with other NHS organisations to actually make sure that we can secure those safe services for Powys residents for the future.

Q460 Mark Williams: Finally, we have alluded to, and I am aware of, the history of Powys. It is unlikely that Powys would ever be in a position to provide all the health services within its borders, but are there areas of specialism that could be developed within Powys as opposed to across the border in England?

Ms Paget: I think that we in Powys need to be very clear about what we can deliver and what we should deliver locally, generalist services. I think there is a real need for us to focus very much on intermediate care, care outside hospital, improving both community health and social care delivery for our communities. I think then, in terms of other services, that that is where the discussion with the neighbouring NHS Trusts come in because we will need to talk to them about what possibilities there are and what opportunities and options there are for more services to be delivered on an outreach basis in Powys.

Q461 Mark Williams: You mentioned at the start your three-centre model. How advanced are you in that work?

Ms Paget: Very early. The report from the clinical governance team came out at the middle of March and we are currently preparing a whole programme of work to go before our Board at the end of May which outlines all the streams of work and there are seven or eight streams of work taking the recommendations forward, so we are at that quite early stage in that process.

Q462 Mr Jones: Has the Board had any involvement in agreeing an English/Welsh protocol for the delivery of services?

Ms Paget: There is a memorandum of understanding that operates across the borders of England and Wales which we have signed up to, and also our Chairman, Chris Mann, is involved in the cross-border working group that was referred to by the previous witnesses and takes an active role in that. I think that group is becoming much more proactive in terms of looking at the cross-border issues and relationships between England and Wales.

Q463 Mr Jones: The memorandum of understanding you refer to is not, I think, a legally enforceable document.

Ms Paget: No, but it sets out the principles of how we might work together and the relationship, and I think some of those things are really important when you are working across boundaries in this way.

Q464 Mr Jones: But it does not contain any element that the patient could rely upon for the purpose of ----

Ms Paget: No, it is more about how the organisations will work together really.

Q465 Mr Jones: Do you think that such a protocol would be best agreed at a national level or are you content with what is happening at the moment?

Ms Paget: I think there has been some work, and Rebecca may know more of this than I do, but there has been some work between the Assembly and the Department of Health looking at the border issues, particularly in relation to financial flows and responsibilities between organisations both sides of the border, and I think some of that work is probably being picked up and pursued and, whether that includes some sort of memorandum of agreement about how we will operate across the border, I think that might be useful.

Q466 Mr Jones: It seems to me that such a memorandum agreed at that level would be of more assistance to you in dealing with, for example, the problem that you have got with the Hereford Trust at the moment.

Ms Paget: Yes, I think there are some things that could be set out at that sort of Department of Health/Assembly level that would be helpful to us in setting the context in which we work together.

Q467 Mr Jones: I think you were present at the earlier evidence session, but I put to the earlier witnesses the suggestion that specialist services that had relatively low numbers would be better dealt with on a UK-wide basis. Do you have any observations on that?

Ms Paget: As you know, the responsibility for commissioning very specialist services rests with the Health Commission (Wales) and it is not the responsibility of local health boards, and I am not close enough to some of the issues that they have been discussing to probably comment on that.

Chairman: Well, thank you very much. Could I place on record our thanks to you both and also to the earlier witnesses for the helpful, open and professional way in which you have answered all our questions.