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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

WELSH AFFAIRS COMMITTEE

THE PROVISION OF CROSS-BORDER PUBLIC SERVICES FOR WALES

Tuesday 3 June 2008

MR BEN BRADSHAW MP and MR DAVID FLORY

Evidence heard in Public Questions 468 - 522

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Welsh Affairs Committee

on Tuesday 6 June 2008

Members present

Dr Hywel Francis, in the Chair

Mr Martyn Jones

Alun Michael

Albert Owen

Mark Pritchard

Hywel Williams

________________

Memorandum submitted by the Department of Health

Examination of Witnesses

Witnesses: Mr Ben Bradshaw MP, Minister of State for Health Services, and Mr David Flory, Director General, NHS Finance, Performance and Operations, Department of Health, gave evidence.

Q468 Chairman: Good morning, bora da, and welcome to the Welsh Affairs Committee. Minister, could you introduce yourself and your colleague for the record please.

Mr Bradshaw: Mr Bradshaw, Minister of State for Health Services and on my left is David Flory, who is the Department's Director General of NHS Finance, Performance and Operations.

Q469 Chairman: Could I begin with a simple question: what has been the impact of devolution on the National Health Service?

Mr Bradshaw: Well, I think the impact has been the same as it has in other areas where policy is devolved in that the administrations in the devolved countries have set their own priorities within a national framework. If you are asking me to analyse what I think the main divergences are, in sort of broad terms on health, I think we could say that in England the direction is to more decentralisation, commissioning by primary care trusts, by GP practices in some cases, patient choice, moving towards now individual health budgets for people and an independent regulator. In Wales, the direction of travel has been in the other direction. It is more of a centralising direction, a reduction in the number of health boards, and I think those decisions are the legitimate decisions of different administrations, reflecting the needs and priorities in those areas. I think it is very important to emphasise, however, that in both Wales and England there has been an immeasurable improvement in both the delivery and outcomes of healthcare over the last 11 years.

Q470 Chairman: You referred to the divergence. Is it too early to tell yet, with democratic devolution only being in place for barely a decade, whether or not there has been a change in the quality of service between England and Wales?

Mr Bradshaw: Well, I can only really speak for England, but certainly as far as England is concerned, I do not think there is any doubt, if you look at the reports of the independent regulator, the Healthcare Commission, that are now showing significant improvements both in capacity and quality of healthcare and all of the independent international surveys, one of which most recently showed that the UK healthcare system was improving more rapidly than any healthcare system in any countries of the developed world, and these are independent studies, not government studies, they certainly support our own assessment as well, and I would expect that similar improvements have occurred in Wales too.

Q471 Chairman: To what extent can we still it call a 'National Health Service' or is it the case that we now have four separate health services?

Mr Bradshaw: Well, there are a number of practical matters that are still dealt with on a UK-wide basis, and pay is an obvious example, the GP contract, international matters, public health protection, and planning for pandemic flu, for example. The principle of a healthcare system free at the point of need for people, not based on the ability to pay, is still the principle that defines the healthcare systems in all of the United Kingdom and the systems have far more in common with each other than, for example, any of them do with any other healthcare system in any other country, so I think the differences can be exaggerated, but I think it is perfectly right, if you accept devolution as a principle, which I think everybody in this room does, that you allow for some flexibility in the different countries to reflect the different characteristics, the different needs and, therefore, the different priorities, so you inevitably get a level of divergence.

Q472 Hywel Williams: Good morning, Minister. On the two variables, centralisation and accountability, we are not of course comparing like with like. Centralisation in a country of three million people with 22 health boards is no different from, say, a large conurbation in England having 22 health boards commissioning in that particular context, and of course Wales has retained the community health councils which some people might see as being independent and retaining a level of accountability, so you would agree that we are not comparing like with like here on those two variables when you compare England and Wales?

Mr Bradshaw: I entirely accept that, yes.

Q473 Mark Pritchard: Minister, it is nice to speak about something apart from the environment when we last met, but on the point just raised on the community health councils, we had some witnesses before us some weeks ago and I just wondered whether you could help us here. Are you aware of any meetings between Welsh Assembly Ministers and commissioners in Wales where the commissioners have been told to try and reduce the number of patients crossing the border from Wales and visiting English acute trusts?

Mr Bradshaw: Well, I do not think it is within my remit to comment on what meetings have taken place in Wales and we would not be informed of that.

Q474 Mark Pritchard: Perhaps I can put it simpler. Are you aware of any meetings that have taken place that have had that content in those meetings?

Mr Bradshaw: I am not aware and I would not expect to be aware or to be made aware. These are matters for the Welsh Assembly.

Q475 Mark Pritchard: On the issue then of foundation trusts, I am a Shropshire MP, as you know, and we have the Telford and Shrewsbury NHS Hospital Trust, an acute Trust, which is very reliant on Welsh patients crossing the border into Shropshire and particularly reliant for the future of the Trust in relation to its possible foundation trust application. Given the different financial regimes and indeed different health targets between Wales and England, how do you think that will impact upon the foundation trust process?

Mr Bradshaw: It should not have any impact at all. I may ask David Flory to comment on this in some detail because this is one of his areas of deep expertise, but, if you look at what has happened in Chester, for example, a very successful FT hospital, there have been issues, which you will be aware of, I am sure, from the evidence you have taken, about tariff payments, but these have been resolved quite successfully. One of the reasons I think we would like to see a permanent protocol is to make sure that that is put on a sustainable footing. You will also see from the memorandum that it is fairly clear, the system at the moment, in that you can expect a healthcare system, depending on where you are registered with your GP, so for argument's sake, with your hospital in your constituency, a patient registered with a GP in Wales would generally expect the provision of care to be provided by the Welsh Assembly, and the same would be the case for England. In practice, what happens in Chester is that Welsh residents registered with GPs in Wales who are referred to Chester do not enjoy, do not get a second-tier service, they do not operate separate lists and they get treated just as quickly as an English patient would, so I think in all of these areas it is perfectly possible, and indeed happens in practice, for the two healthcare systems to manage these. Do you want to comment a bit more on the details of the FT application, David?

Mr Flory: Yes, Minister. The process for Trusts to become NHS Foundation Trusts is one of assessment and then authorisation by an independent regulator, a foundation trust monitor. There are now 96 Foundation Trusts in England and what we have learnt from the process is that on the financial side it is a very risk-based assessment that is undertaken and this plays out in many different ways in many different Trusts. The sources of income are varied, not only for the resident-based population, but there are separate flows of income beyond the tariff payments that the Trust receives from income, and what the regulator looks for is a financial projection from the Trust that shows its income and expenditure over a number of years ahead and it assesses how that Trust plans to deal with fluctuations in either income or expenditure and how they formulate their assumptions about it and manage the risks around it, so, in that sense, there is no fundamental reason at all in the scenario for Shropshire and Telford why a successful application could not be progressed if the Trust meets all the financial criteria and other factors which are taken into account.

Q476 Mark Pritchard: Is there not a perverse incentive? The Minister says he is responsible for England, but of course it is the Westminster Government that is responsible for the financial settlement for Wales and that includes health, but if, for example, Welsh Ministers were inclined to lobby for greater funding for Wales which, in turn, would mean a greater health provision within Wales, then that would cause a difficulty, would it not, given your comments, Director, for an English hospital trust, whether foundation or not, because of course, as we see the Welsh health services improve, increase and expand within Wales, that will have a direct financial impact on those hospitals in Hereford and Shrewsbury, Telford and Chester, into cross-border areas, which may very much affect their financial output?

Mr Flory: The system that operates in England now is one in which, structured around payment by results, income comes into Trusts as patients are referred there or choose to go there and for hospital service providers there is a volatility in that now. They cannot be secured or guaranteed patient flows for a period ahead. They have to, by demonstrating the necessary quality standards and by the way in which they deliver their service, attract the patient. Therefore, in any forward-looking scenario, there is an element of risk that the existing patient flows might change, they might increase or they might decrease, and all of that needs to be modelled, built into and thought about in the risk assessment that the Trust produces for consideration by the regulator.

Mr Bradshaw: If I may add to that, free choice of course in England means that hospitals are in practice competing for patients anyway within England, and the implication of your question would seem to be that either Welsh Health Boards are going to stop commissioning or stop sending patients to these hospitals. I think that would be highly unlikely. There are long traditions and there are very strong geographical reasons for residents in these border areas of Wales to want to be treated in Chester or at your hospital and, given the advantages in terms of waiting times, I think it would be politically very difficult for suddenly a decision to be made that would stop that flow.

Q477 Mark Pritchard: Director, you used the word "volatility" and, to me, that would concern my constituents. They look to their Acute Hospital Trust and indeed Private Care Trust and they want to see, as the Minister started off his introductory remarks, free healthcare at the point of need, but when you start talking about volatility and risk, to me, that does suggest that in the medium to long term, if the models are wrong, if the calculations are wrong, and if the financial director of a particular Trust or the chief executive happens to have got it wrong, and we have had a few across both England and Wales that have got it wrong, then, to me, that sends out a very worrying message that basically the future of healthcare of my constituents and indeed over the border in Wales is based on financial models which, as you imply, are volatile.

Mr Bradshaw: I would argue that, if anything, the opposite would be the case because, if the Welsh keep their form of commissioning which is by Health Boards and they purchase the services, in a way, that flow of patients across the border to England is more secure than the flows of patients from within England who have free choice and who can go anywhere, so I think the opposite of the argument you are making is actually the case.

Q478 Mark Pritchard: Does that not indicate that the future of Wales having been part of a national health service and having all the things that England has is actually not a bright one? The future is not bright because, as I said earlier, there is a perverse incentive for the Government here in Westminster to ensure that those new Foundation Trusts are flying financially and they never will be if Wales begins to stand up on its own two feet and have its own national health service?

Mr Bradshaw: No, I do not accept the premise of the question or the analysis.

Q479 Mr Jones: How often does the Welsh Health Minister meet UK Health Ministers?

Mr Bradshaw: There is no set frequency to such meetings. They will happen as and when it is felt that they are necessary.

Q480 Mr Jones: Do you agree with the Secretary of State for Wales, who agreed with us, that it would be helpful if those meetings with the Welsh Health Minister were announced and it was broadly outlined what was going on in the meetings? Would that not help with transparency?

Mr Bradshaw: I certainly agree that I think it would be useful to have more formal, regular meetings at ministerial level, and we have suggested, for our part, setting up a ministerial group to oversee the whole issue of cross-border matters and, within the normal constraints of the need for free and frank exchange inside government, I am always in favour of transparency and openness as to what is being discussed and when those meetings are being held.

Q481 Mr Jones: It would be nice to have a free and frank exchange with the Welsh Health Minister. Are you satisfied that the joint ministerial meetings are satisfactory or could they be improved?

Mr Bradshaw: I think the discussions that we have are satisfactory and they are had when we need to have them, but I think, by implication, what I say in terms of our feeling that it would be helpful to have a formal ministerial group, I think they could be improved by doing that. I think that would be very helpful and I think that would help us develop a permanent protocol which is where I think we need to be sooner rather than later.

Q482 Hywel Williams: I just want to ask a supplementary, Chairman, to Mark Pritchard's previous question. Just on your role as Minister for Health in England, were a group of patients from, say, the south-west of England to be referred consistently to a hospital, say, in the South East, that would be a matter for those patients and those medical practitioners, so you would not feel it necessary to intervene even if that might endanger a hospital somewhere in the South West. Is that the case, Minister? Essentially it is tough, but, if that is the way the market operates, that is the way the market operates.

Mr Bradshaw: Well, we have only had free choice in England since the beginning of April, so it is early days and, whilst we think it is an important mechanism to drive up the quality of care and to give people a choice which I think they are entitled to, I think the jury is still out as to how much people will use their new choice. If you look at opinion polling, for example, most people still put proximity as one of the most, if not the most, important issues when it comes to choosing where they have their healthcare, but it is perfectly possible, for example, now that people can compare infection rates at hospitals, mortality rates at hospitals and all those sorts of things, that they might decide, "Well, I'd rather not go to my local hospital". It is very difficult to imagine the flows of patients being so strong that that would threaten the existence of a whole hospital and I think that is probably inconceivable, and David is nodding here. However, it is not inconceivable, for example, that, if hospitals begin to lose patients because they are providing a sub-standard service, yes, they either have to improve that service or they may have to face the possibility of that service no longer being viable. That is a natural consequence of patient choice and I think it is a positive thing because the experience in England shows that it helps drive up quality and standards.

Q483 Albert Owen: Can I just pick up on your point in response, Minister, to Mr Martyn Jones with regards to ministers from different parts of the United Kingdom meeting. Are they with Scotland and Northern Ireland as well and do you discuss best practice in the four nations?

Mr Bradshaw: David may be able to comment on this. There do not seem to be so many cross-border issues with Scotland, I think, because of the geography, because of the population, because of the fact that traditionally a significant number of people in England have been registered with GPs in Wales and a significant number of people in Wales have had their hospital treatment in England ----

Q484 Albert Owen: I understand that, but there are differences between the four nations in the many ways in which they provide healthcare, and the reason I asked that is that they all pay the same level of National Insurance and taxes and people in the component parts expect the same level of service from the National Health Service. If there are issues across the border, are you aware of them at the central level and is there then a sharing out of best practice?

Mr Bradshaw: If you are asking as to whether we exchange views and whether we exchange information about what we intend to do in terms of policy, yes, I think that is generally good practice. I think the need for discussions with Scottish counterparts, for example, I am not aware I have had a discussion with my Scottish counterpart because I am not aware that that has been necessary on a particular cross-border issue in contrast with Wales where, for example, I have spoken to Mrs Hart about the Chester issue and the Secretary of State has spoken to her about other issues as well, so I think we will have those discussions on a case-by-case basis. I think it is basic commonsense and courtesy to inform colleagues in the devolved administrations if we are intending in England, for example, to take a particular policy decision which they might not be taking or thinking of taking and vice versa. I think that is general good governance and we would expect, and hope, to be informed about decisions that they are taking.

Mr Flory: If I could add, Minister, certainly those discussions take place very regularly at permanent-secretary level between the different administrations.

Q485 Albert Owen: Minister, I think it would be very good if we had courtesy and we heard things on an agreed level rather than having ministers in one part of the United Kingdom saying one thing and another, but that is for another day perhaps. Moving on to some of the issues that you mentioned to Mr Pritchard regarding the two separate commissioning and funding levels in England and Wales, and also Mr Flory talked about the mechanism by results, do English providers become more expensive than Welsh providers and is this an issue?

Mr Bradshaw: Again David may want to comment on some of the detail of this, but the tariff that is charged in English hospitals is set at an average level, so it may be that for some procedures it is more expensive and for some procedures it is less in an individual case, but the implication of your question, "Does payment by results make operations and procedures in hospitals more expensive?", no, I would argue that the opposite is the case. The whole point of payment by results is to increase, and improve, efficiency and, if you look at the overall spend on health in England compared with Wales, spending per head in England per year is £1,547 and in Wales it is £1,639, so it is less than a £100 difference, but a little bit more in Wales. I am not aware of any evidence to suggest that that results in higher volumes of activity in the Welsh hospitals.

Q486 Albert Owen: The point I am making is: with two separate commissioning and funding regimes, are the Welsh providers under-funded?

Mr Bradshaw: I would not say so, no, because the implication of your question is that the procedures in England are more expensive and I do not accept that and, as I think I have just indicated from the overall spending figures, in Wales slightly more is spent, but I am not aware that more volume is delivered. If anything, I suspect the contrary is the case because payment by results has increased the volume of activity in English hospitals and made English hospitals more efficient. There is a separate issue about the money that is actually paid by Welsh Health Boards to English hospitals for procedures, which has been an area in some cases of difference which we have managed to resolve. The reason that that figure is lower in general terms, I think I am right in saying, is because it is based on an historic figure, so it is somewhat out of date. You should not take the inference from that that it means that current costs of providing procedures in Wales is lower.

Q487 Albert Owen: You are aware of the tensions and you mentioned them in your memorandum. Just to move on, and again you have touched on it, with regards to the Health Boards in Wales commissioning, there is talk, you may know, and proposals that there may be a National Health Service Board in Wales. Do you think things would improve or would that cancel out then this historic arrangement and things would be fairer, in your opinion?

Mr Bradshaw: I would not expect that to have any material impact. In a way, there is always going to be an element of tension between commissioners and providers and that is why you have commissioning and provision. Obviously in Wales, they think it would be helpful, otherwise, they would not be moving in that direction. David, do you want to say whether you think it would have any impact one way or another on that?

Mr Flory: I think we have seen through commissioner-provider interaction in terms of negotiating contracts for health delivery both pre- and during PBR ----

Mr Bradshaw: Payment by results.

Mr Flory: ---- that efficiency improves, productivity improves and the cost per procedure in many, many examples across the countries come down. There is that tension that the Minister refers to between the commissioner and the provider. Where the patients' interests are put absolutely first and foremost in that, we see fantastic examples of how services for those patients, which better meet patients' needs, have been developed as a result of that commissioner-provider interchange.

Q488 Albert Owen: The reason I raised the local health board issue is that between local Health Boards there is friction. We have had evidence anecdotally from constituents, but also evidence during this inquiry that they are getting different answers from hospitals in England across the border, so I would suggest that, if Wales had a Board, that would be eliminated. Would you see that as a benefit to Welsh patients?

Mr Bradshaw: Well, I have resisted assiduously commenting on the merits or otherwise of internal Welsh policy and, if you will forgive me, I do not intend to do so. I suggest that you direct those questions to the Welsh Minister when she appears before you.

Q489 Albert Owen: The First Minister has recently stated that the Welsh Assembly Government requested funds from the Department of Health, and this is the Department of Health, not the Welsh internally, but they wanted extra money for the providers' tariff prices for the treatment of Welsh patients and that request was made. Was that request rejected by your Department?

Mr Bradshaw: Not as such. First of all, there is not currently a requirement, and we are not making it a requirement, that Welsh Boards pay the tariff rate for procedures carried out in English hospitals. I think this is an issue that needs to be resolved. I think it is best resolved in the form of a proper formal and sustainable protocol.

Q490 Albert Owen: But can you confirm that a request was made and one was rejected as it stands now and may change in the future?

Mr Bradshaw: Not exactly. I was going on to explain exactly what did happen. I think I am right in saying, and David will correct me if I am wrong, that the suggestion was made that, if we were to require Welsh Boards to pay the full tariff cost, the up-to-date tariff cost of operations carried out by English providers, a figure was suggested by the Minister in Wales as to how much she thought that would cost in terms of extra revenue. We were not confident that that figure was robust, but we certainly were not rejecting either the principle or the idea that this is something that needs to be resolved, but I think it is something that needs to be resolved properly and seriously in the form of a properly worked-out protocol to end the uncertainty. I certainly think the principle is right and we need to have discussions about the costs. We did not think the figures that were provided were necessarily robust.

Mr Flory: That is right.

Q491 Albert Owen: So this is work in progress then?

Mr Bradshaw: Exactly.

Albert Owen: Developing as we speak.

Q492 Mark Pritchard: Minister, coming back to the National Health Service Board, earlier you mentioned the importance of a cross-border relationship in health provision. Given the importance of that, if there is no material difference in establishing Boards, which is what you have just mentioned, which is stating an opinion rather than not having an opinion on the National Health Service Board, why should it go ahead if it is going to have no material difference on something which Wales hopes will have a material difference on something which you yourself have said is very important, and that is improving cross-border relationships?

Mr Bradshaw: No, the point I was trying to make is that, as far as the English providers are concerned, I am not aware of their having made any representations to us one way or another. Clearly, if the Welsh Assembly Government thinks for the reasons that have just been outlined by Mr Owen that it would help create a better coherence in Wales about commissioning policy, for example, from English providers, then I am sure that they would have their own good reasons for pursuing that, but we are not aware that English providers have complained to us that the existence at the moment of the large number of health boards in Wales is causing problems to them. Are we?

Mr Flory: I am not aware of that at all.

Q493 Mark Pritchard: Given the community health councils, and one of the things we have heard in this inquiry repeatedly from many witnesses is of patient confusion, given that you did state that it would make no material difference to have a National Health Service Board in Wales, do you think it would just unnecessarily create another layer of bureaucracy and indeed add to that confusion?

Mr Bradshaw: No, I think again you are slightly misquoting what I said. I was answering the question in response to what the impact on English providers would be and I made it quite clear that it was not my job, and it is not my intention, to comment on the advantages or otherwise of decisions that are quite rightly made by the Welsh Assembly Government in terms of the configuration of health services commissioning their own ----

Q494 Mark Pritchard: But it is obviously seen as part of Westminster Government with the Financial Settlement in Wales giving you day-to-day responsibilities dealing with cross-border issues across Wales and more so in Scotland and other devolved areas. Do you have a view that this is going to impact on you and your office?

Mr Bradshaw: We do not have any reason to suppose that there would be any negative impacts on those areas for which I am responsible of this development at all and, as I have said a number of times, it is entirely up to the Welsh Assembly Government what structure they would like to see in their country.

Q495 Albert Owen: There is just one interesting point you raised there. You said that you have had no complaints from English providers. I would put it to you that during our evidence one of the English providers said that they received 20% of their patients from Wales and they were unhappy that they only got 16% funding, so there is disquiet amongst some of the English providers, I put it to you.

Mr Bradshaw: This is an issue that I have already touched on. I imagine you are talking about the Chester Hospital.

Q496 Albert Owen: No.

Mr Bradshaw: Well, anyway the Chester Hospital is in a similar situation, and that is why I think we need to resolve the issue about the payment of tariff. That is quite a separate issue, I would argue, and that does not depend on the structure of healthcare commissioning from Wales. It is an issue that we need to resolve, however many Health Boards there are in Wales, and it is not really relevant ----

Albert Owen: It was the Walton Centre, for the record, which is very controversial in north Wales.

Q497 Hywel Williams: You will be aware, Minister, that these questions about cross-border treatments have been hugely controversial in Wales for various reasons. You did say that the Health Minister for Wales has suggested a figure as to the cost of tariff prices which would then equalise matters. Can you tell us and the people of Wales actually who might be listening how much are we talking about in real money, if you can reveal your cards, as it were?

Mr Bradshaw: I think the figure that she used was £16 million.

Mr Flory: Yes.

Mr Bradshaw: So, if we look at the overall spend in health terms, we are talking about really quite small figures of a £110 billion budget, so I think that is a good indication of how I think these issues are perfectly resolvable and why it should not be too difficult or too challenging for us to resolve them through the process which I have already described.

Q498 Hywel Williams: If she is asking for £16 million and you are prepared to concede a certain amount between nought and £16 million, the actual difference between you might be even smaller than £16 million.

Mr Bradshaw: Well, until we have had a chance to sit down and really thrash out the figures, I think it would be wrong to speculate on what the figure might be, but I think the fact that she put a figure of £16 million on it, and we are not quite sure if that was based on robust data, indicates that the differences that we are talking about are really fairly small here, and the impact is also pretty minor.

Q499 Hywel Williams: There has been a great deal of heat around this and that actually throws some light on it as well. Thank you.

Mr Bradshaw: Well, I do not see why there should have been any heat around it. My impression is that the public heat is around other issues which you may want to come on to ask me about or discuss later.

Q500 Hywel Williams: If I can just continue with a further line of questioning around waiting times, can limits in waiting times or in fact in any other significant variation in performance between England and Wales be justified? Should they not be the same, which carries on from the question that the Chair asked you initially, I think? Can you justify those sorts of variations?

Mr Bradshaw: Well, as I think I have indicated in my answers to previous questions, this is a consequence of devolution and in England we have taken a conscious decision to make driving down waiting times our number one priority. In Scotland and Wales they have also been very successful at bringing waiting times down, but they have also had other slightly different priorities that they have put emphasis on, so it is a consequence of devolution, but I do not think we should lose sight of the fact that waits in both Scotland, Wales and in England have come down substantially.

Q501 Hywel Williams: I suspect your answer to this next question will be similar maybe, which is about free prescriptions and free hospital parking in Wales. I am not asking you to comment on decisions that the Assembly have made in this respect, but is it sensible for Wales to be able to provide that sort of service, whilst patients in England complain that they cannot, or at least not the ones that are not registered in Wales of course?

Mr Bradshaw: You will forgive me, but you said you would not ask me to comment on the decisions which have been taken by Wales and then you invite me to say whether I think it is sensible. As I have already said, I think these are matters entirely for the Welsh Assembly Government. What I have said, and I will say again, is that, as far as England is concerned, given that 88% of all prescriptions in England are free anyway, given that there are concessions in place for the people who need to use hospital car parks regularly, they may have a long-term condition or something like that, we have made a different decision and that is that the funding should be prioritised to minimise waiting, and that is a decision I am very happy to stand by and defend.

Q502 Hywel Williams: In your written evidence you say that "it is difficult to make direct comparisons on hospital waiting times between Wales and England due to the differences in recording information, and different targets and timings". Now, is that acceptable for patients accessing a national health service, that there should be different ways of counting?

Mr Bradshaw: Well, it is difficult to make comparisons, but it is not impossible. If you start, for example, with targets, and these are publicly published targets, they are different. In England, we have a target of a maximum wait from GP referral to treatment of 18 weeks by the end of this year, which we are on target to meet. In Wales, I believe the target is 26 weeks by the end of next year. With accident and emergency, there is also a difference in targets, and in Wales you do not have the 24/40-hour standard in terms of GP access and you are not getting extended GP opening hours, so there are different targets and I think it is inevitable that, where you have different targets, you do in some cases have different outcomes. You are right to say that some of these are measured in different ways. For example, I believe I am right in saying that the waiting times in Wales include referrals from consultant to consultant, whereas in England we are only talking about GP referrals, but the vast majority of referrals are from GPs. In terms of outcomes, I think where we can be quite clear, and these are published data, in England in terms of actual waits for outpatients, for example, the latest figures we have available are that 109 outpatients waited for more than 13 weeks for their first appointment compared with 25,042 in Wales. Inpatient maximum waits are broadly similar, we think, at the moment. Diagnostic waits in England, the latest figures are six weeks and in Wales 14 weeks. A&E, we have the 98% target for all A&E, whereas Wales has the 95% target only for the major A&E. We are meeting that at just 0.1% below our target, from the latest figures, 97.9 per cent, and I believe the latest figures for Wales are 93.8. It is difficult always to make accurate comparisons, but I think there are comparisons that can be made. In terms of your supplementary question, I would very much welcome a more formal agreement on data and comparability of data and I would welcome, for example, the involvement of an independent organisation like the King's Fund in helping us get through some of these because I think the implication of your question is absolutely right, that people, the public, in a democracy have a right to know, they have a right to accurate and comparable information, that is their basic democratic right and I think we need to do more work in order to deliver that to people.

Q503 Hywel Williams: I would say that there is a difference between targets and outcomes of course, and we did have some evidence from the Health Service in north-east Wales, that in effect these targets might be 26 weeks in practice and most people had their service on the same basis almost as people over in England, so I think you would agree that it is important that we bear that in mind.

Mr Bradshaw: You are absolutely right and I think it is also very, very important, when we talk about waiting time targets in terms of maximum waits, to emphasise that, although our maximum wait target is 18 weeks, the vast majority of people will get their treatment much more quickly than that and I think that, as far as England is concerned, at the moment the current average is down to eight weeks. Of course what you say about north-east Wales is quite right because, as I said earlier, although, in theory, people registered with a GP in Wales who access an English hospital can only expect Welsh waiting times, in practice, they are getting English waiting times, so you are absolutely right and they are not having to wait longer, in practice, any longer because English hospitals are not operating separate lists.

Q504 Hywel Williams: If I can just ask you one very broad question, therefore, about health inequalities, historically health inequalities have been marked in Wales as compared to England by people dying younger, life expectancy being shorter, and also the sorts of diseases that people die of in that they are nastier in some ways with some of them being related to heavy industry. However, there is a perception that devolution in some way has accentuated the health inequalities, particularly in respect of, as we were discussing, waiting times. You did in fact say in an interview in the Health Service JournaleaHealH that patients have to wait longer than patients in England, but that is as a result of devolution. Would you agree with me that actually devolution has been the answer to some of those health inequalities by providing for more localised planning, better delivery, et cetera?

Mr Bradshaw: Yes, I think you are absolutely right, and one of the great strengths of devolution is that it enables the sort of flexibility that we have discussed earlier to deal with the particular problems that you outline in different parts of the United Kingdom. One example I would say is that Wales has been quicker and more focused on the whole issue of public health than we have in England for the reasons that you suggest, that lifestyle diseases and life expectancy in parts of Wales were more serious issues than they have been, so Wales has set a priority on public health. I think it is probably too early to see, but my Welsh colleague, when she comes before you, may be able to help you with this, whether that has had a quantifiable impact, whereas in England the big public issue for us in 1997 was long waits. You could argue that our current big priority, because this is what the public tell us matters to them most, is being able to see their GP at a time that is more convenient for them and being able to get to see a GP quickly and make an appointment ahead, so we have been very much in England responding to the concerns of the English public, whereas I am sure my colleagues in Wales have been responding to the concerns of the Welsh public.

Chairman: I am sure the Health Minister in Wales will be very pleased to hear the praise that you have just attributed to her concerning the virtues of the Health Service in Wales.

Q505 Alun Michael: Indeed, the same as we look forward to discussing it with her. You talked about how the Service is seen by the public. Have you undertaken any research to establish how patients on the two sides of the border perceive the difference in health service provision between England and Wales and how it affects them?

Mr Bradshaw: I am not aware of any research that we have done specifically on the perception of cross-border issues. We do measure in England, and again I cannot comment on Wales, but we do measure patient satisfaction rates through the GP Survey and the Healthcare Commission also measures patient satisfaction, and patient satisfaction is a very important part of the Healthcare Commission's annual health check, the league tables that it publishes, for example. There is the British Social Attitude Survey, I think, which is British-wide and surveys people's attitudes to the quality of healthcare and their latest figures show that satisfaction in both England and Wales is increasing strongly in general terms. In England, between 1996 and 1997 general satisfaction rose from 36% to 49% and in Wales it rose from 41% to 47% in the same period, so a slightly faster rise in England, but I would not say that that was statistically of significance there.

Q506 Alun Michael: Would that actually distinguish between attitudes within the cross-border catchment area, in other words, those in places like Shropshire or the North West or on the Welsh side of the border as distinct from broad English and broad Welsh reactions?

Mr Bradshaw: No, not that I am aware of. There may have been some more local surveys done, and I am not sure about the Welsh side of the border, but by Primary Care Trusts or individual hospitals in those areas. I am not aware that they have shown any diversion from the more general trends of rising satisfaction in both England and Wales.

Q507 Alun Michael: Perhaps I could ask you then: would it not be a good idea for her to have some work which was objective and perhaps joint across the border to look at the impact of the cross-border flows on the perception of patients and communities?

Mr Bradshaw: I think that would be something that could very helpfully inform the development of a formal protocol, which we would very much like to see, and help inform the work of the Ministers' group to discuss cross-border issues, which again we are very keen to establish.

Q508 Alun Michael: That was a question about perception. The other element, I suppose, is about patient confusion which sometimes arises because of the different policies which we have already discussed. What is your Department doing, in conjunction with the Assembly, to try to minimise that confusion? Does this take us back to the protocol that you have referred to?

Mr Bradshaw: Yes, and, as you will know from the memorandum, the protocol is based on the principle that your healthcare is dependent on where you are registered with your GP, by and large, and we believe that most patients both sides of the border are aware of this and certainly it is the responsibility of the GPs to make them aware of it, but I think you are right in the implication of your question and I think it would be helpful to have a more formal and settled protocol. I think it would be easier for people to understand and it would end any uncertainty that something might change drastically one way or another in the future. I think it would give people the certainty and the stability that they seek, and of course in cross-border areas you can choose, within certain parameters, where you register with your GP, so one could make the argument that people living in cross-border areas enjoy even more choice because they can choose, in a way, from two different health systems.

Q509 Alun Michael: I think what we are trying to tease out is two things. One is what the perception of people on both sides of the border is and the second is whether there are any confusions or whether in fact people are as clear as we would like them to be. You have referred to the development of a protocol and we heard from the Secretary of State for Wales indeed that he believed that there is a need for an improved protocol on cross-border issues, and I think this is something that you have referred to two or three times in your evidence. I wonder if you could tell us a little bit about the arrangements to establish a new protocol. What is the timescale for its publication, what is its remit and with whom will the Department of Health and the Assembly Government be consulting when drafting it?

Mr Bradshaw: Well, officials have been meeting regularly since the interim protocol was first agreed in 2005 and those meetings have been continuing pretty much monthly, I think. We would like to see an agreement with the Welsh administration by July on a way forward and we believe also that it would be very important to consult fully and publicly on any proper, sustainable, long-term protocol.

Q510 Alun Michael: I think that may point towards the answer to my next question which was: should that protocol not be owned more widely than by officials in Whitehall and Cathays Park, both involving their elected representatives in the Assembly and in the House of Commons and by the wider public? You seem to agree with that.

Mr Bradshaw: Absolutely, and it is not for me to make this comment, it is something that your Committee may wish to comment on, but I certainly sense a level of frustration among parliamentary colleagues on both sides of the border that these issues have not been resolved, and I can understand that frustration.

Q511 Alun Michael: That is helpful. In the memorandum, you state that a group of officials from relevant departments in Whitehall and Cathays Park have been formed to address cross-border issues. Is this the group that has been meeting for the last three years?

Mr Bradshaw: Yes.

Q512 Alun Michael: You are envisaging this going to a public consultation phase before their work is completed?

Mr Bradshaw: I would expect officials, or I would hope that officials, could work up a proposal that Ministers could then agree that would then be consulted on. I think it is very important that there be a proper and full public consultation.

Q513 Alun Michael: And you would see that being in the remaining part of this year?

Mr Bradshaw: I would be very reluctant to renew the interim protocol for another year and I have made that clear.

Q514 Alun Michael: Just two specific points, firstly, that we heard evidence from the Muscular Dystrophy Campaign that there are concerns about the capacity to provide funding and treatment for the super-rare conditions, and we heard about things like very specialised physiotherapy services. In fairness, I think I think it is worth saying that they saw this as not just being a cross-border issue between England and Wales, but an issue of rare services being required in different regions of England as well. Do you think that there is a need for a UK-wide fund and system to deal with those sorts of treatments, which is basically what the Muscular Dystrophy Campaign suggested to us?

Mr Bradshaw: Well, David may like to comment on this in a bit more detail in a moment because I think he actually sits on the group, but there is already an English national commissioning group which involves, and includes, representatives from the devolved administrations specifically to look at these issues of very high specialisms that are best provided on a UK basis. There are even some procedures, I think, where patients are sent overseas for treatment, and one could, for example, think of the Great Ormond Street Children's Hospital in London where certain procedures and specialties are provided, but are not provided anywhere else in the UK, and there is probably a range of others which I cannot think of off the top of my head, but these are dealt with fairly sensibly in this commissioning group.

Mr Flory: I think that what the Minister says reflects that there is a system that deals with this in terms of the national commissioning infrastructure in England which is joined in by colleagues from Wales, Scotland and Northern Ireland. I do not believe it is necessary for that to extend to a single fund, however; I think that different parties and interests can make their own contribution to that system.

Q515 Alun Michael: Could I ask that perhaps you look at the evidence that we were given by the Muscular Dystrophy Campaign which incidentally was reinforced by an event they held for Members, a reception at Journalists' House, which did seem to suggest that it is not seen to be operating as perfectly as you suggest, but I would not like to put you on the spot for any further detail. Could we perhaps have a note in respect of that?

Mr Bradshaw: Yes, I will happily look into that and write to you about it in more detail.

Q516 Alun Michael: That would be very helpful. Just on one final point, the Foundation Trusts based on the English side of the border are quite rightly recruiting members in Wales. Indeed, if I may say so, I welcome the fact that they are engaging people throughout their catchment area. Have you discussed with the Welsh Health Minister how to look objectively at the lessons to be learned from that engagement of the wider community? Obviously it is early days for those Trusts, but perhaps in a year or two's time, the lessons to be learned from that would be looked at both in Whitehall and Cathays Park?

Mr Bradshaw: Well, I have not discussed specifically the lessons to be learned with my Welsh counterpart from the experience of FT membership in cross-border areas, but we certainly, as the Department of Health, monitor the performance of FT membership very closely and we think that, where it works well, it is really a very good model which you may see extended across the Health Service in England when it comes to the next stage review which my colleague, Lord Darzi, is going to publish in July. There are different models, as has already been acknowledged in questioning earlier, of patient involvement in Wales from England, and FT membership is one of the models we have in England, but we also have Links now and there is a debate about the democratic accountability of Primary Care Trusts, so there are different models again going back to the different traditions and priorities in the different areas, but I join with you in welcoming the fact that patients resident in Wales who use English FT hospitals are engaging in that process and I think it would be odd, given that they are receiving care from those hospitals, if they did not.

Q517 Chairman: Could I come back to this issue of the improved protocol. Can this Committee take it as read that the officials drafting this protocol are taking note of the evidence that we are receiving in this Committee?

Mr Bradshaw: Well, I would very much hope that they would, yes, Mr Chairman. If I may say so, I very much welcome your inquiry, I very much welcome the fact that you are focusing on health, I think this is a very important issue, and I am sure that the evidence that you have gathered and any recommendations that you make will be taken very carefully into account, indeed I hope they will be, by officials both in my Department and by Welsh Assembly Government officials in drawing up the recommendations that will be made to Ministers.

Q518 Chairman: I am sure my colleagues would be very reassured by that. In that spirit then and also in the spirit of transparency which you endorsed earlier, would you be able to write us a note informing us of the names of these officials so that we could actually consider inviting them to appear before us before we complete our work?

Mr Bradshaw: I would be very happy to do that; I think that is an excellent idea.

Q519 Mr Jones: Your written evidence states that there is a review underway into arrangements for resolving disagreements between providers and commissioners. Who is conducting the review, who is being consulted and when is it likely to report?

Mr Bradshaw: I cannot quite remember the wording that was used in the official memorandum, but, if I gave the impression that there is some kind of formal review going on, that is not the case. These are matters that are reviewed constantly, if you like, as part of the ongoing work of the group of officials that we have discussed earlier, and I would expect again this to be something that should be resolved by the development of a formal, sustainable protocol.

Q520 Mr Jones: The NHS Constitution proposed in the Government's draft legislative programme, do you know if that offers anything for the provision of cross-border services?

Mr Bradshaw: These are issues that are still under discussion between Westminster and the Welsh Assembly Government and I believe they were the subject of discussions between my Secretary of State and the Welsh Secretary quite recently, but no firm decisions have been made at this stage.

Q521 Chairman: Could I end, Minister, by referring to a letter I have received from one of our colleagues, Ian Lucas, the MP for Wrexham. He is very much, as you know, a border constituency MP and he quotes a letter, and I hope you do not mind my doing this, from you to him in which you say, "I understand that the Assembly is looking into how Welsh patients can increasingly be treated in Wales". Now, when we visited Liverpool, particularly the Walton Centre and Alder Hey Hospital, both clinicians and also patients from north Wales were very disturbed by that kind of statement. In the course of your meetings with the Welsh Health Minister, would it be the case that you actually discussed this?

Mr Bradshaw: I am sure we would discuss it. Again you are slightly inviting me to comment on policy made in Wales, but, as I think I indicated in an answer to a previous question, given the historic patient flows, given the proximity, this is really a political issue for the Welsh Assembly Government to decide on its policy, but I suspect that when they look into it, as I am sure they will, they will find, as you have, that patients are generally going to hospitals in England because they want to and they are their nearest hospitals and the most convenient ones for them. I am not sure if the question as to what the intention of the Welsh Assembly Government is in this regard is much better put to my Welsh colleague.

Q522 Chairman: Well, could I thank you both for the evidence that you have given today and also for the written memorandum you have provided for us which was extremely helpful in preparing for this session. Finally, could I, on behalf of this Committee, thank you for the frank way in which you have answered the questions and your guidance for the way in which we should address our questions to the First Minister and the Welsh Health Minister, thank you.

Mr Bradshaw: Well, it is not really for me to suggest how you address your questions, but I hope I have not been too frank!