Memorandum submitted by The Right Reverend Dominic Walker, Bishop of Monmouth (CBPS 8)

A. Executive Summary

1. This submission is restricted to the subject of health and cross border issues. It recognises the difficulties faced by people living near the Welsh English border as well as wider ideological issues concerning health care in England and Wales.

2. It attempts to avoid repeating issues which are being raised by the Bishop of Hereford although the writer shares his concerns.

3. It recognises the particular circumstances in Wales which are brought about as a result of poor health and social deprivation.

4. It provides examples of some of the practical problems that result from different political approaches and values regarding the NHS.

5. It accepts that there will be differences in approaches to health care between England and Wales (because there are differing health needs and political principles), but recognises a need for a pragmatic approach to serve the needs of people and to share the common goal in providing the best possible patient care.

6. It seeks to offer some suggestions as to a way forward to solve the cross border difficulties.

B. The Writer

1. I was elected Bishop of Monmouth in the Church in Wales in December 2002 and succeeded Dr Rowan Williams five years ago. Before that I was the Bishop of Reading for 6 years and I have been a parish priest for most of my ministry.

2. Some of my post graduate work was in Religion and Mental Health. I am a member of the Spiritual Interest Group of the Royal College of Psychiatrists.

3. I was a member of the working group of theologians and doctors that produced A Time to Heal, a major report on the ministry of healing produced for the Church of England in 2000. I am a patron of the Guild of Health.

4. My diocese is the old county of Monmouthshire and includes the eastern valleys, part of Cardiff, the city of Newport (where I live) and rural Monmouthshire. To the east it borders onto the English dioceses of Bristol, Hereford and Gloucester.

5. Along with the other Bishops of the (Anglican) Church in Wales, I support devolution, take seriously the implications of the Government of Wales Act and value being consulted on matters that concern the well being of the people of Wales.

C. Factual Information

1. Cross border issues are not confined to those living relatively near the Wales/England border. For example, a patient in West Wales requiring heart transplantation would need to travel to England for surgery. The same is true for specialist paediatric care. Nevertheless, there are particular issues that are regularly encountered by people living near the Welsh English border.

2. Studies show that the general health of people in Wales is worse than in England. Wales has a higher incidence of people with asthma, hypertension, coronary heart disease, insulin dependent diabetes in males and non insulin dependent diabetes in males and females, stomach, colorectal, breast and prostrate cancers with subsequently higher age-related morbidity rates from cancer, respiratory disease, and cerebral infarctions. Life expectancy is lower; child obesity and infant mortality are higher. The suicide rate for males under 25 is 35% higher than England. (Sources: Health in Wales & UK (Chapter 2), Mental Health Wales, Office of National Statistics).

3. There are different philosophies, values and political approaches to health care in England and Wales. The document The Structure of NHS Wales states, 'Although the NHS in Wales has had slightly different policy and structural arrangements from England for most of its existence, these have diverged more markedly since devolution in an attempt to find distinctively Welsh solutions for specifically Welsh problems. Wales has some of the highest rates of cancer, heart disease and deprivation, whilst part of its population suffers the worst health status in Europe'.

4. One study goes further. In Developing Policy, Diverging Values? which examines the NHS in the UK, the authors write, 'different systems make different choices because policymakers differ in their meaning and priorities they assign to different values. Devolution is about not just different means but different ends'.

5. The differences in philosophies, values and political approaches between England and Wales are inevitable given that there are particular health care issues in Wales which the Welsh Assembly Government wishes to address, but this can lead to confusion and to the detriment of vulnerable patients when they are caught up in cross border health care. For example, my 88 year old mother lives in Monmouth and has macular degeneration. She was referred to a specialist in Hereford who said he would need to write to Cardiff to discover what treatment might be available to her there. Although she has been given plenty of literature to read, she feels she is caught between two systems and nothing is happening.

6. Those living near the border can find that some care packages are not open to them and that they are caught in a postcode lottery. If you are living in England but registered with a GP in Wales, you only get the Wales package (even if referred to a hospital in England) - the targets are different; choice is different. When English/Welsh policies kick in, hospitals can find themselves operating two different waiting lists and funding approaches for patients with the same problems. Patients in the same hospital with the same clinical needs can be on different waiting lists because of which side of the border they live. Even clinicians get confused.

7. In Wales the target is to reduce waiting time for primary care treatment to 26 weeks by 2009; in England it is 18 weeks.

8. The WAG policy to provide all services from within Wales can run counter to its policy of putting patients first. For example, a patient in North Wales requiring neurological treatment is likely to be sent to Swansea whereas Walton Hospital in Liverpool is much nearer. It might require a journey of five hours or more to reach Swansea whilst being less than an hour to Walton. Being such a distance from home, the patient is less likely to have regular visitors and in any holistic approach to health care the proximity and support of family and friends is considered significant.

9. Another example of where policy appears to come before patients' interests is that clergy and their families in Wales can no longer use St Luke's Hospital for the Clergy in London because Wales will not pay for any tests that need to be carried out in London but only for tests carried out in Wales. St Luke's is a charity hospital that does not charge fees and the consultants give their services free of charge. The use of St Luke's Hospital would save Wales about £300,000 a year and free up beds because St Luke's would not charge Wales for consultations, surgery or hospitalisation but only for tests.

10. Wales seeks to be independent and self-sufficient in all clinical areas but with a population of less than 3 million, there are bound to be certain medical conditions for which there is an insufficient critical mass to make it possible. In attempting to make it work, patients are required to travel from north east to south west Wales rather than be referred to an English hospital nearer to them.

11. In cases where it has been arranged for patients resident from one side of the border to be taken to a hospital on the other side, ambulances have only been able to take them one way.

D. Recommendations for Action

1. There needs to be a simple, pragmatic approach with the well-being of the patient as paramount. Patients should have access to centres of excellence with consideration being given to geographical proximity. A system is needed to ensure equality of treatment for patients with the same clinical needs.

2. Hospitals should not be required to operate two systems regarding waiting lists. A reciprocal agreement needs to be reached about funding patients who receive treatment across the border so that the funding follows the patient.

3. I would make a particular recommendation regarding St Luke's Hospital for the Clergy (and there may be other charity hospitals in similar situations) so that Wales follows England and benefits from the financial and bed savings.

4. There needs to be a dialogue that can lead to a Memorandum of Understanding or an Agreement to remove the present cross border anomalies.

February 2008