Memorandum submitted by The Institute of Rural Health (CBPS 5)

Specialist Health Services

Executive Summary

The IRH has built up a wide range of knowledge and expertise in rural health and wellbeing. Access to services is the key issue for rural populations and proximity to the England/Wales border has brought additional challenges to patients, commissioners and providers of care on both sides of the border since devolution. Traditional care pathways for rural patients do not follow political boundaries but are determined by geography and its influence on transport systems. The IRH supports access to cross-border specialist services for Welsh patients and believes that this should continue. Health planning should take into account the needs of border populations and how they access care in order to avoid duplication of services and destabilisation of existing services. Evolving health policies should take into account the need for compatible electronic communications, mutually recognised education and training qualifications, the impact of longer referral distances on patient outcomes and appropriate resourcing of commissioners in order to respond to the different funding regimes. Devolution has provided the opportunity to do things differently but has also provided a chance for the NHS in both England and Wales to learn from each other and as a result offer better and equitable services. Close contact should be established and maintained between the providers and commissioners of care on both sides of the border in order to address the needs of the border population of Wales.

1 The Institute of Rural Health

1.1 The Institute of Rural Health (IRH) is a UK-wide independent organisation that is working to inform, develop and promote the health and wellbeing of rural people and their communities through its three main programme areas:

o research and projects (contributing to the evidence base),

o education and training (developing a workforce fit for purpose), and

o policy analysis (including rural proofing).

1.2 The IRH was established in 1997 and has built up a wide range of knowledge and expertise in rural health and wellbeing. More information is available on the web site at www.irh.ac.uk

2 Rural health

2.1 Rural populations are frequently peripheral populations. In rural areas the population is dispersed, and sparsely populated areas may not be taken fully into account in public services planning. The concept of rural proofing is well established in England but has not been similarly taken up and

applied in Wales. Border populations in Shropshire, Herefordshire and Powys have many similarities but access to public services is vastly different.

2.2 People cross the England / Wales border in both directions along its full length to access specialist health services. In the central region, there is no district general hospital in Powys and patients cross the border to access specialist health services in Shrewsbury, Telford and Hereford (and possibly further afield in the West Midlands).

2.3 Health policy has changed on both sides of the border since devolution in 1999 and continues to do so. This is not only an opportunity but also a challenge for border populations who have traditionally crossed the border and continue to do so to access services.

3 The issues

The IRH would like to make the following points with regard to the provision of cross-border specialist health services for Wales:

3.1 Care pathways

Patients follow traditional care pathways that are influenced by geography, ease of access and availability of public transport. Patients, and clinicians, have strong links and referral patterns with the DGHs (District General Hospitals) across the border that have been built up over many years. Patients in Montgomeryshire, for example, who may be as little as half an hour from the Royal Shrewsbury Hospital, choose to be referred there rather than attend a Welsh DGH at Wrexham or Aberystwyth which incur much greater travelling times and challenges of access. Transport infrastructure is such that it is also much easier to travel to Shrewsbury than west through the mountains to Aberystwyth. It is similar in South Powys.

3.2 Travel

Patients will travel when they need access to highly technical and specialised care such as neuro-surgery or specialist burns treatment (but would prefer ongoing care to be managed more locally). For other procedures patients prefer to be as close to home as possible. Main routes in Powys are generally east west, and public transport routes (rail and bus) facilitate access to services in England. Travel to Welsh DGHs could involve substantial journey times for patients living on the border and without the availability of direct public transport links. Specialist dental services are an example here: patients in north Powys have traditionally been referred to the Royal Shrewsbury Hospital but are now also being referred as far away as to the Prince Charles Hospital in Merthyr. This can mean a minimum 2.5 hour journey for patients, even using their own transport, as no direct public transport is available.

3.3 Duplication of care

3.3.1 As stated in point 3.2 patients are prepared to travel when they need access to highly technical and specialised care. Current examples are neuro-surgery for north Wales populations, specialist

paediatrics for Powys, orthopaedics for Welsh patients. In all these cases there is expert care available in England that is accessible to Welsh patients: Liverpool for neuro-surgery (as opposed to Swansea), Liverpool and Birmingham for Paediatrics (as opposed to Cardiff), Stoke-on-Trent for Cardiac Surgery (as opposed to Cardiff) and Oswestry for orthopaedics (as opposed to Cardiff, and dentistry (as above).

3.3.2 Powys does not have a DGH and its patients access other specialist services in other parts of Wales and for east Powys across the border in Hereford and Shrewsbury. The need for a DGH in Powys has been considered on many occasions (although there is not the population to support a Powys DGH) and would need to be carefully considered as existing care pathways are well established and the creation of a new DGH could impact on existing services. Health planning should include peripheral (rural) populations and consider the provision of cross border services as duplication is both costly and could destabilise existing services.

3.4 Time limited conditions

3.4.1 Medical and surgical emergencies should be dealt with as soon as possible but certain conditions are time limited, that is, when a specific treatment must be given within a specified time frame in order to optimise patient outcome. For critical life threatening conditions each additional 1 km travelled leads to a 1% increase in mortality. An example is Acute Myocardial Infarction requiring defibrillation or Thrombolysis. Referral pathways are crucial for rural patients and changing pathways could have a serious impact on outcomes for patients. Innovative approaches would need to be taken to ensure that the appropriate therapies can be given within the right time limit.

3.4.2 Rural ambulance services in Powys are already stretched to the limit and do not have good performance in terms of targets. If ambulances had to travel further to Welsh DGHs this would have a knock on effect on the ambulance service.

3.5 Continuity of care / communication

3.5.1 Rural areas often have a network of community hospitals and Powys is a good example of this. Continuity of care is recognised as being extremely important to patient outcomes and satisfaction and it is essential that there are cross border links as patients are referred back in to their communities from specialist services for ongoing management and care. Different IT systems have not facilitated communication between England and Wales. The differences are apparent at the diagnostic (see 3.6 below) and referral stages, for example, "Choose and Book" is being introduced in England but not in Wales which poses additional challenges as the border DGHs will receive referrals in different ways.

3.5.2 Communication in an emergency situation is obviously critical. The e-patient record is still some way off but it will be essential that patient e-records can be read wherever the patient presents for care.

3.6 Diagnostics

3.6.1 Many diagnostic procedures can be undertaken in community hospitals, which improves patient access considerably. If results are interpreted at a Welsh DGH, eg for x rays, but the patient is referred to an English DGH, tests may have to be repeated as there is no access to the original results by the consultant. This can result in additional trips for the patient.

3.5.1 In 2002 the IRH reported on the use of cancer genetic services by general practitioners. The research had been commissioned as there was a lack of uptake of services available in Cardiff by Powys GPs. There was a lack of recognition of the border - or edge effect , patients / clinicians were found to be accessing the equivalent cancer genetics services in England.

3.7 GP choice and confidence

The systems in England and Wales have diversified considerably in recent years and it is appreciated that this is one of the opportunities of devolution. Unfortunately for border communities this has also created challenges and problems, not least for the general practitioners who have both English and Welsh patients on their lists and will be referring both English and Welsh patients for specialist care. Welsh patients do not have the Choice agenda or Choose and Book and the NHS in Wales is not subject to Performance by Results. GPs need to have the freedom to refer patients to the most appropriate hospital, which may or may not be the nearest, but (as has been referred to in paragraph 3.1) there are well established care pathways from Welsh GPs to English specialist hospitals and consultants. Good working relationships have been built up and the English consultants engage locally with the CPD (continuing professional development) programme. It would be unrealistic to bring consultants from Cardiff, Swansea or North Wales to CPD events on a regular basis, particularly evening meetings, which are extremely popular and beneficial to local healthcare professionals.

3.8 Destabilisation of GP practices

There is anecdotal evidence that English patients, registered with Welsh GPs, are changing practices to register with English general practitioners in order to benefit from the (substantially ) shorter waiting times in the English NHS for specialist health services.

3.9 Recruitment of community specialists

3.9.1 Rural communities are ageing communities. Service demand is going to increase. The drive to provide services as close to home as possible is to be welcomed but quality community care involving the essential specialities will be vital. Seamless care will be important for the patient and good communications between the health professionals involved will be essential. Currently much community specialist provision for the border populations of Powys comes as advice only from England and is provided by a local community nurse. For example there is no respiratory rehabilitation in Powys and Welsh patients are not able to access services available tin Shropshire. The same is true for patient diagnosed for Chronic Fatigue syndrome. These are significant issues.

3.9.2 In-house specialist care can be developed in Powys but the professional support required and the maintenance of clinical skills must be addressed and provided on a pragmatic basis.

Anecdotal evidence indicates a lack of mutual recognition for training, particularly for nurses, where Welsh nurses may attend a course in England but this may not be accredited by a Welsh NHS employer. Training on both sides of the border should be respected and acknowledged or it could lead to future recruitment issues as well as duplication of effort and funding.

3.10 Patient Choice

Patients in Wales should have the same degree of choice as English patients. For the border communities it is fundamental that they retain the choice to use the most appropriate hospital for

their condition (in terms of clinical care and taking access into account), even if in some cases this is in England.

3.11 Inequity within the National Health Service

People living in Wales pay tax and national insurance to the same level as in England and the benefit system is the same. There is inequity for Welsh patients in the quality of care that is provided as a consequence of devolution, and because of the proximity of the border there is much greater awareness than in other parts of Wales. The post code lottery has not been removed as a consequence of devolution. Welsh GPs who have both English and Welsh patients are in the uncomfortable (and inequitable) position of no longer being able to offer all their patients the same quality of care.

3.12 Funding issues

Payment for specialist services is on a different bases in England and Wales. Where commissioning of services in England for Wales patients is unavoidable the Welsh Commissioner should be funded at a level to support the commissioning process. Underfunding the Welsh commissioner puts additional restrictions on the availability of services to Welsh patients.

4 Recommendations for action

The IRH welcomes the opportunity to contribute to the Inquiry and would like to make some key recommendations:

4.1 Cross-border access to specialist services for Welsh patients should continue.

4.2 Health planning should take into account what is available and accessible to patients on either side of the border in order to avoid duplication of services and destabilisation of existing services. As health policy continues to change and evolve in both England and Wales the challenges for people living along the border and the service providers should be addressed. A "Border Health Commission" could be set up.

4.3 Electronic communications should be compatible in order to facilitate communication between clinicians, particularly in emergency situations.

4.4 Education and training qualifications and skills should be mutually recognised or will again lead to duplication but also impact on recruitment.

4.5 More research is needed to examine the impact of longer referral distances on patient outcomes.

4.6 Different funding regimes should be addressed and commissioners should be resourced to the appropriate level.

4.7 The opportunity should be seized for the NHS in both England and Wales to learn from each other and as a result offer better services. Close contact should be established between the providers and commissioners of care on both sides of the border.

15 February 2008