Memorandum submitted by The Right Reverend Anthony Priddis,

Bishop of Hereford (CBPS 7)

Section A Executive Summary

1. The submission considers issues to do with the ability of Welsh residents to access health services, especially, in England.

2. It considers the funding needs of English hospitals, and the medical needs of patients, not least to do with their safety and the way that that is itself affected by "distance decay". Other issues like transport and Welsh language are also considered, as are the particular needs of patients with cancer.

3. Time-critical conditions are also considered together with the needs of the elderly, and those with mental health problems.

4. Particular issues relating to prescriptions and dentistry are referred to.

5. The lack of cross-border issues being considered in Strategic Health Planning is especially highlighted.

6. Transport issues are referred to next.

7. The absence of higher education institutions in Herefordshire and South Shropshire is referred to, as are some of the other educational issues, particularly relating to parental choice for schools.

8. Finally, the submission observes that farming, planning and schools are not included in the 6 areas that the Select Committee is considering, and assumes that they are dealt with elsewhere since they, too, are crucial.

9. The submission concludes by encouraging the Select Committee to put its weight behind the need for cross-border dialogue and for mechanisms that enable both discussion to take place and solutions to be found, as well as the political will for that to happen.

Section B The Writer

1. I have been Bishop of Hereford for nearly 4 years and Bishop of Warwick for 8 years before that. My initial training was as a biochemist (M.A. Cantab.) followed by a Diploma in Theology at Oxford. I was ordained in 1972 and worked as a parish priest, (with the exception of being Chaplain at Christ Church, Oxford for 5 years), until being made Bishop of Warwick.

2. Among other things, I am a Fellow of the College of Emergency Medicine, having been the lay member of their Board for nearly 6 years.

3. The Diocese of Hereford which I serve covers all of the County of Herefordshire, South Shropshire, and about 20 parishes in Wales including Presteigne, and a small part of Worcestershire.

4. One of the roles I hold nationally is to chair the Rural Bishops' Panel of the Church of England. I am very conscious of cross-border issues for farmers, in addition to the 6 items which the Select Committee is particularly considering. Indeed, it was the farming issues which contributed to our Agricultural and Rural Life Chaplain, in his regional role, to work for the "Memorandum of Understanding" which was signed a year ago. That document is enclosed and you will know that it is part of our Diocesan attempt, in partnership with others, to address some of the cross-border issues.

Section C Factual Information Included With This Submission

1. Memorandum of Understanding. Signed on 5^th March 2007 by the Minister for Environment Planning and the Countryside, Carwyn Jones AM, on behalf of the Welsh Assembly Government, and by Cllr David Smith, Chair of the West Midlands Regional Assembly

Section D My Submission

1. When first contacted about making a submission to the Welsh Affairs Committee, I was told that you would be considering your 6 areas sequentially beginning with Health. Subsequently, I have been told that you are in fact considering all 6 areas together but I had already worked on the information I was first given and so the bulk of what follows will be about health issues.

2. Health Issues

One of the main problems for those who live in proximity to the English Welsh Border is the ability to access services which are on the "other side" of the border. This is particularly important with respect to health care since the provision of specialist services generates a high incidence of cross-border traffic. Hereford and Shrewsbury Hospitals, in particular, draw a large number of patients from mid-Wales and those which require cancer treatment may have to travel into Gloucestershire. It should be recognized as well that Primary Care Trusts in England operate to different targets from those of the Local Health Boards in Wales, for example waiting time targets for operations, prescription charges etc., are different. There has been discussion for some years about which branch of healthcare (English or Welsh) pays for the treatment when a patient has to cross the border to access the service.

3. Currently, Herefordshire receives funding for 10% of its patients who come from Powys. Those living nearer to the English border than to hospitals in Cardiff, Swansea or West Wales are naturally the ones who are most drawn both to the County Hospital in Hereford and in Shrewsbury. The needs of patients on the eastern border of Wales to be able to continue to access hospital care in England are vital, not only for them but also for the English hospitals.

4. Hereford Hospital NHS Trust is in the advanced stage of seeking Foundation Trust status. As I understand it, there is no model for Foundation Trusts in Wales. The success of a Foundation Trust for Hereford Hospital will be dependent upon the funding arrangements which will include the need for there to be funding from a network of patients, including those in Wales who use the Hospital.

5. If, for example, elective services were discontinued for Welsh patients and only emergency services from Hereford Hospital funded, then this might be enough to tip the balance of financial viability for the Hereford Hospitals NHS Trust in terms of it receiving Foundation Trust status. Were that to happen, then not only would the reduction of income for Hereford Hospital be disastrous but that in itself would impact on the provision of healthcare in Herefordshire. The total population of Herefordshire is less than 170,000 (some of whom live nearer to Worcester or Gloucester than they do to Hereford) and if the number of people being served by Hereford Hospital no longer included those from Wales, then I understand that there might be a risk that some of the provision of healthcare currently provided by Hereford Hospital could be transferred to Worcester or Gloucester. Others will be able to give you factual information about this.

6. The Royal Shrewsbury Hospital serves a catchment area of over 300,000, many or indeed most of whom live in rural areas. There is anecdotal evidence that people are less inclined to either go for treatment initially or follow it up subsequently when they have large distances to travel. This is borne out by the factual experience of the Emergency Department (A & E) of the Royal Shrewsbury which sees 1 in 9 of the population in a year, as compared to the more urban proportion in the rests of the country of 1 in 5. This causes a "double whammy" in that not only is the hospital, because of its rural context, serving a smaller total number of other people than nearly every other County town hospital, but also a smaller proportion of that smaller total number are attending it.

7. The Emergency Department needs to be staffed at a level which provides cover 24/7, which is costly but necessary.

8. The phenomenon known as "distance decay" is of concern. This is where there is a proven reduction in the rate of service use as the distance from the source of health care increases; put another way, the closer the service the more likely it will be used (see 6 above). Rural and remote populations are affected by distance decay anyway, but it is more acute across a border where the transport networks may not be harmonized because they operate across two or three different counties, and where free social transport rarely applies (e.g. hospital car schemes) because of the distances and resources involved. Most funding streams for transport operate either in England or Wales, but not in both (see also 10 below).

9. Efficient ambulance services are difficult to provide: to cover the border catchment areas needs more vehicles, if not, then the response-time is compromised. Each vehicle will travel further with a patient than the urban counterpart and the crews will see smaller numbers of cases each shift. Crews have to provide care for longer with each case. There are not enough staff on board to provide effective resuscitative care en route (only one paramedic with the patient which is not enough to both ventilate a patient, defibrillate and administer drugs). Without an additional first responder scheme there may be delay to defibrillation and other immediate care which compromises survival. Without pre-hospital thrombolysis, given the travel times involved, there can be delays in achieving national target time response (call to needle time less than an hour in England).

10. Another aspect of the transport problems is that patients, brought from Wales to an English hospital as an emergency, may then have major difficulties accessing transport back home. This problem is now being addressed in Shropshire through the Care Co-ordination Centre run by the Shropdoc organization.

11. While reconfiguration of hospital services has been mooted in North Wales, it is hard to see how that could ever be achieved, given the rural geography and population distribution served by Wrexham District General Hospital, along with the other hospitals along the border.

12. Probably less acute in mid-Wales, but of importance in the north, are cultural barriers to accessing health care. Welsh language speakers, especially those in emotional distress, may prefer Welsh language consultants and doctors, rarely found in English hospitals. (More common as a language barrier is in fact Polish in our areas.)

13. There is documentary evidence of the effect of distance decay on rural health: for example, mortality rates for asthma and cancer are worse than in urban areas, cancer is diagnosed at a later stage and intervention rates for coronary disease are lower. Breast screening uptake is lower, especially for women aged over 65. Anecdotally, I know of people with cancer who have begun treatment but, as a result of the travelling distances involved, have decided not to continue with chemotherapy. A study published in 2005 looking at referrals from Montgomeryshire to cancer genetics services concluded that distance, time, travelling and accessibility by car and public transport were all perceived to have an impact on a patient's decision to attend a clinic appointment. Some of these patients were referred to services in England (compare 6 above).

14. Another study giving clear evidence that mortality increases with distance travelled is that in Emergence Medicine Journal 2007(24,665-668) from Nicholl et al, showing a 1% increase in mortality for each 10km travelled.

15. One of the clergy in our Diocese, who lives in Wales,was diagnosed with cancer a few years ago but treated in Hereford and Birmingham, thank goodness successfully. The experience of the clergy in parishes near the border is, by and large, that cross-border emergency and urgent provision is generally excellent but inevitably takes longer, and that those just over the Herefordshire border into Wales are mostly seen in Hereford for emergencies, but less urgent or chronic conditions requiring hospitalization are often seen in Cardiff or Swansea. These are a great deal further for most of them to travel and such a requirement therefore has major consequences for families and friends visiting them. The anecdotal evidence is that it is often the elderly who seem to be sent to Swansea. One suggestion made to me as well is that this seems to happen more often at the end of the financial year when budgets are running out, but I would not know whether that is true or not.

16. There is also an issue for the treatment of acute time-critical conditions. Medical and surgical emergencies are all time-constrained, in the sense that speed of treatment improves the patient outcome. Therefore the provision of emergency services in rural areas is of concern, and again the ability to cross the border is an issue. In rural areas the local GP is often the first on the scene for heart conditions, for example, but the closest GP may live across the border. Clinically it would make sense for ambulances to cross the border: administratively it is problematic.

17. The rural areas in both England and Wales, and especially the counties along the border, face a growing demographic challenge as the proportion of elderly within the population continues to grow. The rising cost of social and health care is one of the drivers that prompted Herefordshire PCT and Herefordshire Council to examine ways of sharing administrative costs and engage in a more rational approach. It is sometimes difficult to ascertain whether looking after older people is a "medical" or a "social" issue. The provision of specialist care for the elderly and the higher costs of providing residential and sheltered homes in rural areas applies in both locations. Of particular importance is the ability to provide care close to existing family networks. Even where care is provided, there is a recognized shortage of homes that can cater for people with dementia where secure accommodation and specialized nursing services are required.

18. I am told that cutbacks in Wales mean that there is now no psychotherapy available to a woman in Powys who moved to Wales 8 years ago but had lived in England prior to that where she had received psychotherapy. This particular woman has certainly experienced deterioration in not only the healthcare provision but also her own health as a consequence by moving across the border. In her case, she was admitted to Hereford Hospital recently when she attempted suicide yet again but it would seem that only in extremis, like that, is she able to come to England for treatment.

19. There are difficulties about prescriptions as well. As you will know, there is currently no prescription charge in Wales but if someone living in Wales receives a prescription written by a doctor or dentist working in England then they do have to pay at a Welsh (or English) pharmacy.

20. This situation can result in Welsh patients who are seen in the Emergency (A & E) Department of an English hospital decline a prescription that it then written for them because they want it written by their own Welsh GP so as to avoid a prescription charge. This clearly adds to everyone's time and other costs.

21. Even more strangely, I understand that for some in Wales, their emergency dentist will be in England so that if they need to see that dentist and she or he needs to write a prescription, they will then be charged for it.

22. While on the subject of dentists, the shortage of NHS dentists on both sides of the border continues to be a major concern. I know of people in Presteigne who wanted to sign up with an NHS dentist in Leominster but were told they were not eligible to do so because they live in Wales. It would seem that a Welsh resident can be treated for cancer in England on the NHS but not get a tooth filled.

23. Of general concern to the Rural Affairs Forum of the West Midlands, and one of the reasons that prompted the development of the cross-border "Memorandum of Understanding", was the lack of recognition that seemed to occur in strategic health planning of the cross-border traffic in people, and of the significance of District General Hospitals in remote rural areas to a constituency that was much wider than the county boundaries. Regional NHS strategists expressed some surprise that Herefordshire had a campaign for a specialist cancer unit and felt that we would never justify the degree of specialism required given our perceived catchment area.

24. The National Health Service Regional Health Strategy for the West Midlands (which deals with the provision of NHS services) simply fails to address the significance of cross border issues, and is generally unhelpful to a rural context. The Regional Health and Well-Being Strategy (which is about promoting good health in its widest context) expresses some of the rural issues but says very little about our proximity to Wales.

25. The Darzi Report, which is due to be published in July, will be making the points that the NHS needs to be fair, personalized, effective and safe. This is clearly of enormous significance in rural areas. Some of these issues have been touched on above, including that of "distance decay", as well as the personalized needs of those in remoter communities needing to be able to get to whatever GP, dentist or hospital is nearest to them, and providing the services they require, and not having to travel longer, taking more time, and so making them less safe.

26. It is perhaps worth noting that the Darzi Report is based on a model adopted from London with its centralization of major and specialist services, but which could not be replicated in, say, Herefordshire.

27. Transport

Some of the issues touched on above (6) refer to the fact that we are bad at integration within a region, but integration of transport systems across the national boundary is even more problematic. In Herefordshire and Shropshire transport links tends to be north/south rather than east/west, but for some people employment, education, health etc require east/west links more than north/south.

28. Some villages are establishing "dial a bus" facilities but this is extremely patchy, which, as a result, places enormous pressure on even the poorest families in remote areas to have a car. It is worth noting in that connection, that South Shropshire District is the poorest rural district in England. Deprived households are likely not to be grouped together, in the way that they would be in urban areas, and therefore do not figure in quite the same way statistically, and furthermore their needs are, therefore, even more difficult to address.

29. Education

30. You will be aware that Herefordshire has no university or institution of higher education within it. The University of Worcester, formed 18 months ago, looks to make some provision, including providing training for nurses in Hereford Hospital. As a consequence, people are unlikely in the main to come across the Welsh border into Herefordshire or indeed into South Shropshire for higher or further education.

31. The situation with regard to schools is of course quite different and here there is movement in both directions according to where people live and local quality and reputation of primary and indeed secondary schools, together with crucial issues of transport which may well themselves be connected with where parents work if they are taking children to school themselves.

32. Farming and Planning

33. It surprises me that neither farming nor planning, nor indeed schools in themselves, are among the areas of cross-border issues being considered by the Select Committee. I am sure that there must be good reason for this but, if you wanted us to speak to these issues or write more about them in the future, then please do let us know.

34. To provide one slight example of the bureaucracy and difficulties faced by farmers over cross-border issues, consider the situation of a sheep farmer with adjacent fields on different sides of the border. If he or she wishes to move sheep from the English field into the Welsh field they have to pay £4 per animal because of the current different regulations arising from blue-tongue zones.

35. Another example would be that of Single Farm Payments which have to be applied for by a Welsh farmer with land in both countries, to each country separately. The English application is then sent back to Wales for approval. The bureaucracy and complications of the two different systems are a nightmare for small farmers.

Section E Recommendations for Action

1. It would be extremely helpful if the Select Committee would put its weight behind the need for cross-border dialogue (as described in the "Memorandum of Understanding" attached document, the need for which is highlighted again and again above) and for mechanisms that enable not only discussions to take place on the above issues, but also solutions to be found, and the political will to carry them out. The experience of farmers, for example, highlights the difficulties of two different political and bureaucratic systems, but the difficulties are there in all the areas referred to above.

2. The need for proper funding of elective medicine for those in Wales near the border who need to come to Hereford, Shrewsbury or Chester Hospitals, is of paramount importance. Wrexham hospital has the same need from the other direction. This need for proper funding carries with it the inevitable implication, which effects funding on both sides of the border, that in order to provide Emergency Medicine and other care within a "relatively safe" distance, then there will be a higher proportion of posts per patient than in densely populated urban areas.

3. There are equivalents in all the other areas mentioned above.

18 February 2008