Memorandum submitted by the North East Wales Trust (CBPS 48)

North East Wales Trust (hereafter referred to as NEWT) is pleased to provide evidence on cross border issues as they affect health care provision for our Welsh residents. Our services cover the counties of Wrexham and Flintshire, which border the English counties of Shropshire and Cheshire.

Evidence is presented in narrative form. Quantification in relation to each item can be provided at a later date if required. The evidence is based around the following themes:

a) Tertiary Service Provision

b) Clinical Networks

c) Local cross border collaborative working

d) Impact of policy differences

e) Potential risks arising from cross border issues

A) Tertiary Service Provision

The vast majority of Welsh residents receive care from the Welsh health care providers however where highly skilled and specialist services are needed for the management of specific conditions, patients access English NHS and Foundation Trusts.

North East Wales residents receive a wide range of highly specialised care through tertiary centres of excellence predominantly located in the North of England. The relationships with these specialist centres have developed over a considerable period of time and are supported with technological links, joint clinical working, training links and with the presence within NEWT premises of clinics held by visiting tertiary centre consultants. Whilst surgical care for highly specialised and complex cases is likely to be undertaken in the tertiary centre , the patient experience is supported with good transport links to the North of England, availability of relative accommodation on some sites, and local follow up and after care provision.

Examples of tertiary services provided across the border for NEW residents include:

· Cardiac Surgery

· Specialist Paediatric Surgery

· Neurosurgery

· Transplant surgery

· Specialist Pancreatic and Liver disease management

· Thoracic surgery

· Major cleft lip and palate surgery

· Eating disorders and forensic mental health services

The relationships between clinicians in secondary and tertiary centres are well developed with evidence of good communication and examples of joint clinical management for patients with shared care arrangements.

North East Wales also provides tertiary services in some specialist areas to both Welsh and English residents, the latter commissioned by English PCTs.

For example formal arrangements exist for Upper GI cancer services whereby English and Welsh patients have their surgery at the North East Wales Trust acute hospital based in Wrexham provided by a clinical team of 4 surgeons, (2 from NEWT and 2 from the Countess of Chester Foundation Trust). Referral, discharge and after care are carefully managed between organisations to support patients irrespective of their residency. Other examples of NEWT providing specialist services to English residents include the specialist diabetic foot service managed via the Orthopaedic foot and ankle team.

There are also areas where gaps in care provision within Wales result in patients receiving care outside Wales. Examples would be in the areas of specialist continuing care arrangements.

Whilst every effort is made to optimise the clinical care of patients cross border policy differences and commissioning arrangements do not always support the needs of patients. This can lead to differential management of Welsh residents in English Trusts based on differential access or waiting time targets and contractual arrangements. The development of the Upper GI surgical centre at NEWT demonstrates however that on some occasions these obstacles can be overcome.

B) Clinical Networks

A small number of patients will always need services from highly specialist centres that due to the population in North Wales, cannot be safely provided locally. Clinical networks play a vital role in helping to secure high quality and safe services and to further the development more locally of expertise. Examples include:

· Orthopaedics - consultants on shared contracts between Robert Jones Agnes Hunt (RJAH) and North East Wales Trusts, with RJAH providing significant capacity for both secondary and tertiary orthopaedic care to North Wales residents.

· Vascular surgery - well established clinical network exists to provide 24/7 emergency vascular surgery services between NEWT and Countess of Chester Hospital (COCH)

· Urological services -a well-established clinical network exists for urological emergencies between NEWT and the COCH

· Orthotic services are provided on site at NEWT via a contractual relationship with the Orthotic service at RJAH

· Other complex diagnostics are provided either via shared care arrangements or via contractual arrangements with English providers such as the shared use of the catheter lab for angiography based at the COCH, contractual arrangements for PET scanning for Lung and Upper GI cancer patients at Christies, EMG studies etc.

C) Local cross border collaborative working

Examples of cross border working exist between organisations, health care professionals and teams. Working with Shropshire PCT has enabled NEWT to become a local service provider for Shropshire GPs under Choose and Book. The benefits for patients for patients to choose are self-evident. Any disruption to this system creates risks for the PCT, the GPs involved and for the Trust in terms of services provided for Shropshire patients.

D) Impact of Policy Differences

· Differential Access Targets and Contractual Arrangements

Policy differences have resulted in shorter access time targets for English residents. However as the waiting time targets have become more challenging and contracting arrangements have also differentiated between English and Welsh patients we have seen Welsh patients being treated differentially by English Trusts in accordance with waiting time targets. This means that Welsh patient can wait longer than an English patient for routine treatment by an English provider.

The move to referral to treatment times in both England and Wales looks to narrow the existing access times gaps, but this is not the case. In reality differences in definitions mean that the remaining gap will continue to be larger as the English target of 18 weeks includes tertiary care whereas the Welsh target of 26 weeks excludes tertiary care.

· Choose and Book

As electronic booking of secondary care access from primary care increases through choose and book programmes it will become increasingly challenging to support access for patients who have English GPs and wish to access Welsh hospitals.

It should be noted that some of these patients are Welsh residents. The Trust has explored the provision of choose and book technology to support this patient flow but due to IT contractual issues it has not been possible to achieve full access to this system and so short term work arounds are in place. It is doubtful as to whether these can be sustained once full electronic booking is achieved in England.

· Payment by Results

The existence of payment by results compared to block contract arrangements in Wales has resulted in transitional arrangements between organisations being required to manage financial flows without de-stabilising organisations. With the proposed introduction of Activity Based Costing in Wales it is likely that the 2 systems will move closer together.

· Residency v GP practice registration

The continuity of the different basis for commissioning e.g. residency in Wales and GP registration in England has an impact for some patients on the border. For instance patients resident in Wales registered with an English GP have in theory 2 commissioners - the English PCT and the Welsh Local Health Board (LHB) and their resulting activity, waits etc are reportable to both DOH and WAG.

However patients resident in England with a Welsh GP have no commissioner and are not theoretically reportable from an activity or waiting time to either England or Wales. North East Wales have undertaken some work to quantify these patient numbers. In practical terms patients are managed in accordance with clinical need irrespective of these contractual overlaps or gaps with issues arising not in the care of the patient but with the monitoring and performance management comparators.

E) Potential risks associated with cross border issues

Risks associated with cross border issues arising from policy differences, organisational systems, technological development and process differences between the systems are mitigated through pragmatic approaches to cross border working by clinicians, managers and commissioners. However, concern remains that as targets for delivery become more challenging some of the pragmatism could be lost to the detriment of Welsh patients and financial impact could result in adverse effects on Welsh health care providers.

20 March 2008