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MEMORANDUM SUBMITTED BY THE BRITISH MEDICAL ASSOCIATION (WALES) (CBPS 2)
About the BMA The BMA is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.
Defining specialist healthcare In order to understand the issues around cross-border healthcare, it is important to define what is meant by 'specialist healthcare'.
Secondary medical care - usually provided in a District General Hospital (DGH) setting - is medical care provided by a physician who acts as a consultant at the request of a primary physician. With the exception of large parts of Mid Wales most Welsh patients access this level of care at their 'local' DGH.
As a consequence, there is a widespread acceptance that Welsh patients are able to access uniformly high quality of care in their community. This care is provided as close to the patient's home as is compatible with high quality, safe and effective treatment.
In contrast, tertiary healthcare is specialised consultative care, usually on referral from primary or secondary personnel, by specialists working in a center that has personnel and facilities for special investigation and treatment. Specialist cancer care, neurosurgery, burns care and plastic surgery are all examples of tertiary care services.
Research and patient satisfaction surveys consistently find that patients are willing to travel to access specialist care. Patients are willing to travel for expert services for which the quality of care and the expected outcome would be better than if treated locally where they may not be the appropriate resources or expertise to deal with the situation.
Cross border regions Welsh life, our social network and communications infrastructure do not stop at the English border - the same is also true of our health services.
Wales can be broadly divided into three main cross border regions. North Wales with its close links with Merseyside and Greater Manchester; Mid Wales with its close links to the English Midlands; and South Wales with its much denser population, but close links to the South West of England.
Cross-border secondary care Secondary medical care for many Welsh patients is provided in English health settings. In 2001-02, there were some 21,000 elective operations for Welsh residents in England and 2,800 elective operations for English residents in Wales. In 2002-03, there were 20,000 elective operations for Welsh residents in England and 2,800 elective operations for English residents in Wales.
In 2000-01 over 25,000 elective patients from Wales were treated at hospitals in England, mainly in Chester, Shrewsbury, Oswestry (Gobowen), Hereford, Liverpool, Walton, Manchester, Gloucestershire and Bristol. To give some idea of the over reliance of Welsh patients in North Wales on English health services, there were 19,500 Flintshire residents treated in English hospitals in 2002-03.
As a consequence, the importance of these cross-border ties has resulted in effective and co-ordinated secondary care health system. Health service commissioners on both sides of the border have worked together relatively successfully to ensure health services are available to Welsh patients in areas where there is insufficient critical mass in the population.
The Royal College of Surgeons of England (and Wales) in a recent consultation on reconfiguration of services, Delivering High-quality surgical services for the future, maintain that for an acute or district general hospital providing the full range of facilities, specialist staff and expertise for both elective and emergency medical and surgical care requires a population of between 450,000 - 500,000[1] residents.
This partly explains (in addition to lack of sufficient transport infrastructure) why North and Mid Wales residents are referred to English providers in much greater numbers than in Welsh health settings: the population is not sufficiently large to merit its own secondary services.
Devolution - equality of access to secondary health services? Devolution has provided Wales with an opportunity to develop policies that respond to differing circumstances and political priorities from other parts of the UK.
Wales has already seen significant divergence in health policies. Most significantly, Wales has not witnessed the same use of the private sector and policy has focused on long-term health issues, which has been broadly welcomed by the medical profession.
The new Labour/Plaid Cymru One-Wales Government has also signalled a continued divergence in health policy. Free prescriptions will continue, there is a commitment to end the internal market and eliminate the use of private hospitals by 2011. A ruling out of the use of private finance and the ending of compulsory competitive tendering for cleaning contracts. These are all policies that differ from those pursued over the border in England.
However, devolution has not been a complete success nor has it meant a positive experience for all Welsh patients. The length of time that Welsh patients have to wait for specialist treatment remains a concern.
The One Wales Government has a policy commitment to reduce waiting times to a maximum of 26 weeks from referral to treatment, including all or any waits for therapies and diagnostic tests in Wales. This is in contrast to England's waiting time target. In England, a maximum wait of 18 weeks from the time of referral to a hospital consultant, to the start of treatment has been established.
Put simply, Welsh patients are waiting longer for their specialist treatment compared to those waiting over the border in England. This is not a criticism of devolution per se, rather a criticism of a Welsh Assembly Government that is willing to set a waiting time target that is longer than that in England
Specialist (tertiary) care - the case of neurosurgery To help illustrate the difficulty of providing specialist tertiary services in Wales then we can use the recent example of neurosurgery, especially as it affects North Wales patients.
Services in Chester, Manchester and Liverpool are much closer in travel time than services in South Wales; and there is a complex inter-meshing of medical and clinical links involving clinics, staff and technology with English Centres.
North Wales has an existing and sophisticated arrangement with the North West of England, to supply integrated tertiary services - these can usually be reached by road within less than two hours. Serious head injuries in North Wales currently go to Walton in Liverpool if adult and Alder Hay for Children (as this remains the Children's hospital for North Wales).
These form the bulk of referrals and it would be clinically unsafe to send them any further. In 2004-05 870 patients from Wales were treated at the specialist unit and, in 2005-06, that number had risen to 1,025. In all, there have been 53,000 incidents of north Wales patients crossing the border for treatment.
Considerable concern - especially amongst north Wales patients - was raised by the suggestion that in order to sustain two centres of excellence in South Wales (Cardiff and Swansea) North Wales patients would travel to south Wales for their treatment.
Whilst denied by the Welsh Assembly Government, this caused widespread concern that the well established network of patients from North Wales would be forced to travel to South Wales.
Clinical requirement for specialist services Responsibility for strategic planning and commissioning of services in Wales rest with Local Health Boards (LHBs), with highly specialised services being commissioned by Health Commission Wales (HCW).
A full list of specialist services and Commissioning arrangements by Health Commission Wales in 2007/2008 is available at, http://new.wales.gov.uk/topics/health/hcw/NHSplanning/hcwcommissioningplan?lang=en.
Highly specialised services highlight the need to concentrate workload, expertise and training opportunities in fewer centres. Additional pressures on the centralisation of highly specialised services include shortened hours under the European Working Time Directive (EWTD), the need to provide an appropriate level of training within specialist units and the requirement to ensure surgeons have sufficient volume of surgical activity to avoid de-skilling.
Ensuring patient safety The former Chief Medical Officer for England and Wales, Dr Kenneth Calman, produced a report into specialist cancer services. More commonly referred to as the Calman-Hine report, this report argued that cancer centres are intended to serve populations of one to two million and should be able to offer the full range of specialist cancer services including treatments for rarer cancers.
Such a population base is necessary if the specialists are to see sufficient numbers of patients to ensure that the relevant expertise is built up and maintained. This is purely a patient safety issue. The reality is that so many diseases occur so infrequently that it remains economically unfeasible to support a specialist service, especially when Wales with all typography has just a population of under £3million people.
In addition, staff providing such a service would be unable to maintain their specialisation for that illness if their catchment area did not supply enough cases. Therefore if we apply economies of scale, the population is too small to support a fully comprehensive service in some specialised clinical areas.
Conclusions There are a number of issues that the Committee will need to consider when examining cross border health issues:
· Wales has long and established procedures for patients receiving their specialist services in other parts of the UK.
· Many parts of Wales lack sufficient population and transport infrastructure to sustain all specialist services.
· Wales - and North and Mid Wales patients - rely on specialist services in England. There is little, if any, evidence to suggest that Wales can sustain all specialist services and will continue to rely on Welsh patients travelling to other parts of the UK for their treatment.
· Patients accept where specialist services are not available locally then they are willing to travel for their treatment.
· Waiting times for specialist treatments should be uniform across the NHS. The Welsh Assembly Government needs to question whether it is acceptable that Welsh patients have to wait longer for specialist treatment than patients in other parts of the UK.
· Political dogma should not interfere with delivering specialist services to patients. The location where a patient receives their treatment should be based on what is in the best clinical interest of the patient.
BMA Cymru Wales January 2008 [1] Royal College of Surgeons, Delivering high-quality surgical services for the future |
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