Memorandum submitted by the United Bristol Healthcare Trust (CBPS 19)

Thank you for inviting the Trust to respond to the House of Commons Welsh Affairs Select Committee's Call for Evidence.

UBHT treats significant numbers of Welsh patients across a variety of specialties. Emergency treatment is provided as per Department of Health (DH) Cross Border Emergency Treatment, Gateway Ref 7057. Activity and income is summarised in the table below and a detailed summary is attached as an Appendix.

1. Financial Issues

There are continuing issues with payment of invoices for cross border activity outside of contracts. Disputed invoices total:

Local Health Boards

£128k outstanding from 05/06

£356k outstanding from 06/07

£212k outstanding from 07/08 YTD

Health Commission Wales

Outstanding debt for 2007/08 is £395k, though agreement has been reached and UBHT is expecting payment before the end of the financial year.

05/06 - 07/08 YTD this totals £1,091,000

When payment is received from HCW the revised total will be £696,000

There is a lack of consistency between HCW and the LHBs over which services HCW is responsible for, with HCW claiming that they were not resource mapped for all the services outlined in Welsh Circular 63 (2003). Providers get caught in the middle of these intra-Wales disputes over funding, with payment being severely delayed or invoices remaining unpaid. There is also a lack of clarity around the PbR tariff, with English trusts adopting tariff as per English national guidance, the Welsh Assembly guidance stating 'do not recognise English Tariff', but then also stating 'do not pay more than English Tariff', and neither offering any further guidance on the matter.

2. Prior Approval Schemes

2.1 Local Health Boards

An increasing number of LHBs are moving to cost per case/NCA and away from contracts. This appears to be both because neither the Welsh nor the English model contracts are appropriate for cross border commissioning, and because it is easier to dispute billing. This places a huge administrative burden on the trust and causes delays in the patient pathway. Whilst UBHT is supportive of the drive to repatriate referrals where appropriate, the prior approval requirements do not appear to be built around improving patient care, rather a desire to save money. Guidance issued by the Welsh Assembly and the Department of Health on treatment of NCAs is contradictory.

The trust is reluctant to reject all Welsh referrals before clinical triage in order to ensure urgent cases where delays in treatment could be critical are identified. This further increases the burden on the trust.

Not all LHBs require prior approval, and UBHT has good working relationships with these organisations.

2.2 Health Commission Wales

In 2007/08, UBHT was asked to implement two different referral management schemes for HCW patients: prior approval for adult routine elective patients, whereby referrals must be authorised in advance by HCW, and Tertiary Referral Management, whereby paediatric routine elective referrals must be accompanied by authorisation from a gatekeeper. It appears that neither scheme has been implemented within Wales, with the trust receiving only a handful of referrals accompanied by either form of approval, and, it is understood, there is limited clinical support within Wales for these schemes, with no Welsh gatekeepers identified for key areas such as Paediatric T&O. Again, clinical triage of referrals is necessary to minimise clinical risk.

3 Summary

To summarise, the ability of Welsh patients to access cross-border services is dependent on the policies of the organisation funding the referral rather than clinical need. UBHT would welcome the development of cross border care pathways for Welsh patients, and is hopeful that this Welshcom review will result in improved partnership working.

Appendix

Activity and income for 2005/06, 2006/07 and Q1-3 2007/08.

14 March 2008