Memorandum submitted by

The North East Wales Institute of Higher Education (NEWI) (CBPS 37)

Provision of Cross-Border Public Services for Wales

The North East Wales Institute of Higher Education (NEWI) is an expanding Higher Education Institution (HEI) with approaching 8,000 students, that is in the final stages of its application for taught degree awarding powers and university title. NEWI has been a full member of the University of Wales since 2004 and is based in Wrexham. With that comes an essentially Welsh ethos. The Institute has close collaborative links with HEIs and Further Education Colleges (FECs) and with businesses in both Wales and England. Given its location less than ten miles from the border with England, NEWI is uniquely qualified to comment on cross-border provision of public services following devolution, informed by both consultancy work and practical experience.

NEWI welcomes the call for evidence and provides below, from its unique perspective, a report on the cross-border provision of:

- further and higher education;

- health and social care; and

- transport.

The Senior Executive at NEWI would be supportive of any further work on cross-border issues, both by entering into debate with the Committee and by taking forward research into these issues.

Further and Higher Education

The perspective of NEWI, as the HEI in Wales closest to the border, is of particular relevance. NEWI, in common with other Welsh HEIs, collaborates with many HEIs in other regions of the UK, in a variety of ways. Institutions appoint external examiners, and honorary research and teaching staff from HEIs from any area of the UK. There is cross-border working in staff development, such as a senior management developmental activity that NEWI has organized with Keele University, Staffordshire.

There is cross-border collaboration on research and development projects. The Research Councils and the Technology Strategy Board have a UK wide brief and invite collaborative proposals from multiple partners. NEWI has collaborated with English institutions in several bids for research funding and has benefited from the availability of cross border expertise in conducting such research. Our partners in current or recent collaborative research include the University of Bath, the University of Durham, University College London, and Surrey University. Through the OpTIC (Opto-electronics Technology and Incubation Centre) Technium in St Asaph, NEWI collaborates with Cambridge University and Cranfield University. Such partnerships enable complementary knowledge and facilities to be brought together in solving complex research problems. The outcome from such research benefits the research community generally as well as industry and students in Wales.

Collaborative arrangements for educational provision in further and higher education also cross the border. NEWI collaborates with a number of English FECs, for example, in validating Foundation Degree programmes and other sub-degree awards at Shrewsbury College of Arts and Technology and developing a partnership with Wirral Metropolitan College. NEWI works also with Reaseheath College by out-reach delivery of HE programmes at the college's premises, and is pleased to provide staff development for academic staff at Reaseheath a Nantwich based college which was awarded the title of 'Most Outstanding Commitment to Education and Training' in 2007 in respect of its horticulture provision. NEWI has been exploring the possibility of developing provision in animal health in collaboration with the University of Liverpool, which has one of its Veterinary Science campuses less than 20 miles from NEWI.

Increasingly NEWI's cross-border educational collaboration includes not only HE or FE institutions, but also corporate training organizations and companies (e.g. SACCS Limited, Shrewsbury; Scalchemy Training and Development Ltd, Worcester).

There are a number of cross-border issues around educational provision. Normally, student places funded by the Higher Education Funding Council for Wales cannot be taken up by Welsh institutions delivering or validating programmes at partner institutions in England. For institutions near the Welsh-English border this can be a significant issue. There may be a market for a Welsh institution's programmes in a neighbouring district of England, and a partner English institution wishing to collaborate on provision; however, the current HE funding regime does not support such delivery. The demand for the provision remains unmet, and a market opportunity is lost for both institutions.

There is concern about reports that English HE institutions have been permitted to buy facilities in Wales and to run courses from them, such as the University of Central Lancashire purchasing Tyn Dwr Hall at Llangollen. There is a perception that a Welsh institution would not be permitted to purchase facilities in England in order to grow its academic base; if this is the case, Welsh HEIs are disadvantaged by unfair competition and restrictions.

The differential HE fees regime between Wales and England means that English students studying qualifications validated by Welsh HEIs at FECs in England have a financial disincentive compared to their Welsh counterparts to proceed to top up degree studies at the partner Welsh HEI. Care is needed in the implementation of policies intended to benefit Welsh students, that students studying close to the border are not inadvertently disadvantaged. Welsh students may find that the closest higher education provision in their subject of choice is over the border in England, but that this choice of institution means that they are subsequently prevented from practising professionally in Wales because of curricula and policy differences.

NEWI is aware that data appear to show a "funding gap" between Welsh HEIs and English or Scottish HEIs. Given that all HEIs are in competition, the comparatively lower level of funding given to Welsh HEIs disadvantages them in the market place. Welsh institutions are able to provide fewer resources per student, possibly resulting in equipment and buildings being of a lower standard. Press releases indicate that there have been substantial investments in individual English HEIs and FECs in recent years far in excess of sums invested in any individual Welsh HEI.

The Higher Education Funding Council for Wales provides funding to support collaboration and reconfiguration amongst Welsh institutions. Whilst such a fund is welcomed, it is generally less valuable to those institutions close to the border with England, for which collaboration would be more appropriate with English institutions because of geographical proximity. There are 12 English HEIs which are geographically closer to NEWI than the nearest Welsh HEI. Chester University, for example, is approximately 13 miles from NEWI whereas the nearest Welsh HEI (Bangor University) is approximately 72 miles away. NEWI believes that support for cross-border collaboration would be beneficial to Welsh HEIs and to the Welsh people.

It appears that there are currently no Welsh-based representatives on the Councils of several of the Research Councils including MRC, NERC, AHRC or BBRSC and so there may be an issue concerning the lack of a Welsh voice steering the work of these organizations which fund a large proportion of the fundamental research undertaken in the UK. This may be reflected in concern that Welsh HEIs receive significantly less from the Research Councils per FTE academic staff member than English HEIs, with consequent implications for the outcome of the last Research Assessment Exercise (2001) and external, including international, perceptions of the quality of higher education in Wales.

It is the case that there is excellent higher education in Wales. The appointment of Welsh graduates to senior posts on either side of the border can only enhance the reputation of Wales. Similarly, if Wales is to be fully recognised for its excellence in higher education, Welsh HEIs need to be supported in offering programmes and undertaking research that can attract students, employers and research partners that are both within and outwith of Wales. Where engagement with HE in Wales has a positive impact on a person's career, or in the case of consultancy and research, the competitiveness of a business or enterprise, then Wales naturally creates a network of ambassadors who testify to the high quality service they received. The success of Scotland in creating a "quality brand" in HE demonstrates the effectiveness and importance of ensuring that HE is recognised beyond regional, national, European and international borders

Health and Social Care Issues

The first few years of devolution have been relatively easy years because governments at the Assembly and Westminster have been of similar political persuasions (Jackson-Read & Watkins Young 2005). With the Conservative party making inroads into the long standing Labour majority at Westminster however, the prospect of two different parties being in power at Cardiff and London becomes more likely. This brings with it the possibility that differences in health and social care provision between UK nations, already emerging, may become increasingly evident, with implications for choice and cross border and, perhaps in particular, near border experiences.

Despite Labour Governments being in place at Westminster and Cardiff (until 2007) differences have developed in relation to health and social care services. Bogdanor (1999) suggests that a "different standard of social welfare" (p.169) has come to exist in Wales and England. Keating (2005) suggests Labour Governments in Scotland and Wales face more electoral competition from left facing nationalist parties and hence have stuck more to traditional social democratic philosophies of public service delivery. The First Minister, Rhodri Morgan refers to his philosophy as "21^st century socialism" that establishes "clear red water" between Westminster and Cardiff.

Accordingly, the emphasis in Wales in health and social care has been on public services working together to deliver improved "universalist" services to all people. The emphasis in England has been on driving up standards through competition and privatisation with increased targeting of health and social care funding in particular. As an example of how this translates in practice in social care, whilst in England some of the money given to the Children's Fund was ring-fenced for services to children and young people who had offended, the Welsh Assembly Government delegated the money to local authorities without any ring fencing conditions. Giving evidence to the Richard's Commission, the head of the Youth Justice Board perceived this as creating very different experiences for children and young people caught up in the youth justice system in England and in Wales. Giving evidence to the same commission the "Disability Wales" group recorded their view that the Assembly had used its powers to the advantage of disabled people in Wales with charging policies for social care services being significantly less stringent than in England.

According to Davies (2003), in the health field Welsh Labour has made limited use of the private finance initiative, has rejected foundation hospitals and the use of private diagnostic and treatment centres. Rhodri Morgan objects to foundation hospitals because, 'the experiment will end not with patients choosing hospitals, but with hospitals choosing patients'. His preference is for hospitals to 'develop specialisms through collaboration rather than competition between trusts'.

Political philosophies aside, Wanless (2003) argues that health and social care demands in Wales are very different from those in England and hence on purely pragmatic grounds there has been the need for different policies in Wales. Wales has a greater proportion of elderly people and an ageing population that experiences greater the impact of socio-economic factors on general health and well being (with lower than UK average life expectancy). Equally it is a country with a dispersed rural population. His report recommended a series of reforms, with an emphasis on prevention rather than cure.

A particular issue in relation to cross border Health and Social care provision relates to language and culture. In Wales, Welsh speakers make up around 20.8% of the population. Welsh speakers required to access services in England may not be afforded the equality of access to services in the language of their choice as they might do under the provisions of the Welsh Language Act in Wales. Research suggests that Welsh speakers, who do not receive services in the language of their choice, feel that the service they receive is inferior (Misell 2000, Cwmni Iaith 2002, Irvine et al 2006)

1. The extent to which cross-border public services are currently provided for and accessed by the Welsh population.

Being primarily home based, concerns about cross border social care provision have primarily arisen in respect of a perceived post code lottery in terms of charging policies within Wales and between England and Wales. There is published evidence of lack of capacity in terms of in-patient health service provision in Wales however. This relates to specific conditions, including patients with heart disease, patients requiring haemodialysis and those suffering from muscle disease. The British Cardiology Society set up a working group to investigate variations in services and clinical activity and to explore their origins. The report discloses compelling evidence of major differences in service provision, activity and aspirations between the developed nations. Wales and Scotland fare badly in terms of access to coronary angiography and Wales has the lowest overall rates of revascularisation (Brooks 2005).

Most haemodialysis patients are elderly and dependent, and therefore require centralised dialysis units rather than home treatment. As White et al. (2006) points out, a small number of Welsh residents obtain treatment across the border in Shrewsbury, Hereford, Liverpool and Chester, and a few English residents receive treatment in Wales. Only one centre in Wales (Cardiff) undertakes renal transplants, but patients from North Wales are transplanted in Liverpool. Dialysis capacity in Wales is overwhelmed with areas of relative under-provision and over 20% of the population living more than a 30 minute drive from a dialysis unit (White et al. 2006). Philip Butcher, chief executive, said: 'People with rare illnesses are living longer thanks to medical advances and yet NHS services in Wales are failing to meet this demand' (Lister 2008). Moreover, as the Welsh Secretary Paul Murphy has admitted, patients in Wales with muscular dystrophy are also not getting the service they are entitled to.

Cardiff MP Jon Owen Jones attacked the assembly government's lack of enthusiasm for Private Finance Initiatives and warns that rejecting foundation hospitals will mean there is a danger that English foundation hospitals do not have an obligation to treat Welsh patients from over the border (Davies 2003).

In addition to the above published information, further evidence from Flintshire LHB revealed that approximately 36% of Flintshire patients have NHS secondary care services provided by English NHS Hospitals due to the County bordering England.  This will be the same for Powys and other counties bordering England.

Figures for secondary care activity for 2006/7 were:

North Wales' patients also receive specialist tertiary services from English Trusts (such as Neurology, Cardiothoracic, specialist Cancer Treatment, Orthopaedics (Gobowen) etc).  No contract activity is available (see section on funding below).

2. The arrangements currently in place to co-ordinate cross-border public services provision

Cross-border health care provision between England and Wales is provided for by the Welsh Health Circular WHC (2007), which states that where patients are resident in an area of a specified Primary Care Trust (PCT) in England, but registered with a GP in a specified Local Health Board (LHB) in Wales, the LHB in the border area is responsible for the operational commissioning of services. Likewise, if patients reside in an area of a specified LHB but are registered with a specified PCT in England, the PCT in the border area is responsible for operational commissioning. This applies specifically to Shropshire County, West Cheshire, Herefordshire, Wirral and Gloucestershire PCTs.

Despite this arrangement, however, there is published evidence of lack of co-ordination of cross-border health care provision. For example, a report from the Muscular Dystrophy Campaign indicated that despite treatment being available on the border at a unit in Oswestry in Shropshire a Welsh health board said funding constraints meant it could not commission services (Lister 2008). This is recognised by Tory MP for Clywd West, Tony Jones, as a flaw in cross-border health care, which particularly affects patients in north-east Wales who often travel to Chester, Liverpool and Manchester for specialist treatment. This means that although patients in Wales pay the same taxes as those in England, they do not get health services of equal quality, thus resulting in a postcode lottery within the NHS (Lister 2008). We therefore need 'a policy across the NHS that the prescription of drugs for serious conditions and the treatment of serious conditions should be determined on a UK-wide basis, and such a policy should be agreed by the Labour party in all parts of the UK' (Lister 2008).

Local evidence from Flintshire LHB, suggests that cross-border arrangements/ commissioning for secondary care services in terms of Long Term Agreements are the responsibility of the individual LHB, albeit the process is managed on a North Wales Consortium basis.  In terms of tertiary services, these are commissioned by Health Commission Wales. The arrangements include the monitoring against Welsh Assembly set targets, so there are some issues about two patients from Wales and England waiting for the same treatment that may have different waiting times due to the different access targets.

3. The funding of cross-border public services

A DoH (2007) protocol for cross-border issues for NHS-funded nursing care in care homes in England and Wales provides guidance on funding of care homes. This states that where cross-border placements are made from England to Wales, and vice versa, and the resident is entitled to NHS funded nursing care, the council and the health body in the country that the resident is moving from should inform the council and the health body in the country that the resident is moving to. Furthermore, the level of funding will be that in operation in the destination PCT/LHB.

More specifically, the protocol distinguishes between those already in care homes at 1.4.2004 and those admitted after this date. For those already in a care home at 1.4.04, who previously lived in Wales, but are now in an English care home, assessment and funding is the responsibility of England, whilst for those previously living in England, but now residing in a Welsh care home, assessment and funding is the responsibility of Wales.

In relation to residents moving into a care home after 1.4.04; for those who previously lived in Wales, but entered an English home, assessment and funding is provided by England before admission, but if this is not possible, the LHB will assess and then inform the destination PCT. For those who previously lived in England, but entered a Welsh home, assessment and funding is provided by Wales before admission. Again, if this is not possible, the PCT will assess and then inform the destination LHB.

Local Authority funding arrangements are also provided in the same protocol. In relation to residents in LA care homes at 1.4.04, those living in English care homes, but funded by a Welsh LA are assessed by the PCT, which then informs the Welsh LA who then fund the place. In contrast, those living in a Welsh care home funded by an English LA, are assessed by the LHB, which then informs the English LA who then pay for the place.

Different arrangements apply for residents entering a care home providing nursing care after 1.4.04. Those living in England and planning to move to a Welsh care home are assessed by the PCT, which informs the LHB of needs. The Welsh LHB then funds the place. Those living in Wales who plan to move to an English care home are assessed by the LHB which then informs the PCT of needs. The PCT then funds the place.

The protocol also makes provision for payment and contractual arrangements where cross border relationships exist, in which partnership arrangements involving lead commissioning and or/pooled budgets should be developed.

Local evidence from Flintshire LHB outlines arrangements for LHB funding of treatment for secondary care.  The agreement is for LHBs to pay on a historical contract process basis and not Payment by Results (PbR) which is the English Tariff. Health Commission Wales commissions tertiary services, some of which will be provided in England.  They have an annual budget, some of which will be spent with Wales' specialist providers (usually South Wales) and some with English Trusts for North Wales' patients. Their commissioning plan for 2007/8 is attached via the link below (this is a public document)

http://wales.gov.uk/dhss/publications/healthcommission/2011176/hcwcommissionplane.pdf?lang=en

Some other issues, as they apply in Flintshire, are that England has PALS (Patient Liaison Officers who replaced Community Health Councils some time ago) and the Choice initiative whereby a patient can choose which hospital they are treated by. Wales still has Community Health Councils and some Welsh Trusts have implemented a slightly different version of PALS but we do not have Choice.

In relation to Primary Care, there will be some patients who live in Wales and who are registered with an English GP and their care is the responsibility of the PCT and is funded by them (Saltney, Saughall etc).  There will also be some patients living in England and registered with a Welsh GP. The relevant local health board would be responsible for the commissioning and funding for those patients.

The references for this section on Health and Social Care issues appear at the end of this written evidence.

Transport

NEWI's location close to the border between England and Wales means that the provision of public transport, and the development and implementation of public policy in relation to public transport, are of particular significance to the Institute and its stakeholders. NEWI students will often seek jobs and placements in the Chester, North Shropshire and Wirral areas, for example as well as in NE Wales and Mid Wales.

NEWI is relatively well served by road links with England, but less well served by public transport. An example of the impact of poor public transport links is the recent decision of the Skills for Health organisation to reverse its decision to hold its national conference in Wrexham, citing poor accessibility as one of the reasons.

In February 2008, approximately 5,000 enrolled students were studying at NEWI campuses in Wrexham. The majority of NEWI's students have term-time addresses in Wales. Of part-time students, 18% have term-time addresses in England, and 15% of full-time students have term-time addresses in England, concentrated in the Chester, Ellesmere Port, Bebington, Frodsham, Oswestry and Shrewsbury areas.

NEWI's "market share" is significantly less in adjacent areas in England than in the North East Wales area. There is insufficient evidence at the moment to judge the extent to which this is a product of lack of access (for whatever reason) to appropriate public transport services, a product of perception, or a product of a mix of those and other factors.

The high proportion of NEWI students studying through part-time modes of study, and the trend towards full-time students remaining in their family home, suggests that the volume of daily travel to the place of study through means other than walking is likely to grow.

There appears to be a perception amongst some people that the arrangements for the provision of public transport services (by a range of private sector contractors, with a variety of contractual arrangements with different public authorities) tends to constrain effective co-ordination of services across administrative boundaries. However no formal studies have yet been completed to provide definitive evidence.

The decisions of private sector operators can have both helpful and unhelpful effects on provisions. For example, operators' decisions can stifle the attempts of local authorities to co-operate in bus timetabling (and integration with rail services). Pricing policies can have detrimental effects on particular groups. For example, the "Young Person's Rail Card" can be used by young and mature students, but is not valid before 10am. This has an effect on the ability of students to travel to Wrexham by train from such areas as Chester, Wirral, Oswestry and Shrewsbury. On the other hand, benefits can arise through operators' decisions to develop and take advantage of new business opportunities - for example the planned "open access" (not franchise) rail services between Wrexham and London (Euston and Marylebone) increasing opportunities for travel to Wrexham from different parts of England and further afield.

The Wales & Borders rail franchise (a 15 year contract, with more than ten years still to run) was let on a no-growth basis - so the operator has to "manage demand" and ask WAG for extra revenue funding for specific cases when needed (for example, for major events). This is not, in our view, particularly conducive to long term planning of cross-border public transport provision.

Bus services tend to concentrate on offering services for 'workers' at the start and end of the working day. This limited service is not sufficiently flexible for students who live at a distance and may wish to return home during the day, perhaps to work or to undertake family duties (as many of NEWI's students tend to be mature). Other students may wish to stay on and study or take part in social or educational events in the evening. The bus services limit this. There are for example, no bus services from Wrexham to certain North Shropshire rural towns and villages - the service is limited to an infrequent service to Oswestry and to Whitchurch, neither of which service rural villages or small towns as they tend to utilise the main arterial roads.

Services (with linked bus/rail services as in many European Counties) would encourage more people not just from Wales but from surrounding English counties to come to Wrexham, not only for education but to work and shop, thus contributing to the wealth and social development of Wrexham and recognising its position as the largest conurbation in the area. Improved transport links between Wrexham and the surrounding areas of England and Wales would support its further development as a regional centre, as Wrexham moves to achieve its ambition to be a city.

NEWI welcomes the North East Wales West Cheshire Sub-Regional Spatial Strategy which highlights the importance of developing the Wrexham - Bidston railway line as a "key corridor", whilst recognising that the bus will remain the main form of public transport in the sub-region. The Mersey Dee Alliance has a very significant role to play in influencing a range of public bodies in England and Wales to work towards integrated services, and the Alliance, Taith (the North Wales Transport Consortium) and Cheshire County Council are working on initiatives to develop bus services.

Further development of public transport would significantly benefit the development of the West Cheshire/North East Wales sub-region.

Conclusion

Despite its proximity to the border NEWI is firmly rooted in Wales. One advantage of this is the comparatively easy access it has to ministers and civil servants at the Assembly Government. The Institute believes this relationship sometimes allows NEWI's views to be reflected in the policies and strategies emanating from the Assembly Government. An example of this is the Wales Spatial Plan which recognises the geographical influences on North East Wales and advocates further collaboration across the border while at the same time expanding the role of Wrexham (and NEWI) as a major centre within North East Wales.

March 2008

References

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Davies S Devolution stirs policy evolution Health matters issue 54, Winter 2003, pages 12-13

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Welsh Health Circular WHC (2007) 036 - renewed protocol until 31.3.08

White P, James D, Ansell D, Lodhi V and Donovan K L (2006) Equity of access to dialysis facilities in Wales. QJ Medicine, 445-452