Memorandum submitted by

North Bristol NHS Trust and health care for residents of Wales

(CBPS 50)

1. North Bristol NHS Trust (NBT) is a large teaching trust based on two main sites in north Bristol. We provide a comprehensive range of services to the local population and some specialist services on a wider regional basis, across the South West of England. Our total income is £420 million.

2. We have service level agreements (SLAs) with all the primary care trusts (PCTs) in the South West of England who pay on a mainly cost per case basis in line with the NHS national operating framework. We also treat some patients from further afield in England under the non contract agreement rules, which require PCTs to pay for all treatment, with prior approval (from the PCT) only required for treatments that will cost over £10000.

3. Whilst parts of Wales are closer geographically we only have an SLA with Monmouthshire Local Health Board (LHB) incorporating GP practices identified as 'cross border'. Only 5 of the 14 practices within the contract allow referrals across the border. For all other activity, either within the Monmouthshire LHB SLA or for Non-contracted Activity (NCA) elsewhere in Wales there is a requirement to obtain prior authorisation (from the LHBs or HCW) for each elective episode of care.

4. Health Commission Wales (HCW) purchases on a cost per case basis all specialist activity for Welsh patients defined by resident postcode or by registered GP practice for the cross border practices. The Welsh specialist definition set has not been updated since its production (2003), although HCW has set out to implement changes to the definitions based on historic resource mappings which are either difficult for an acute Trust to implement or have been challenged by the Local Health Boards expected to pick up the financial impact of these changes.

5. In total the Trust receives about £2 million in income from Wales. This is invoiced at the same tariffs as for English PCTs.

6. Welsh patients attending the Trust are mainly treated within English waiting time standards, although the longer Welsh waiting times may be deployed if this helps the Trust where there are capacity constraints. Shorter English wait times may be an incentive for Welsh GPs to continue to refer, despite the Welsh Assembly and LHB's requirement for Welsh patients to be treated within Wales under existing block contracts.

7. Welsh GPs continue to refer (some 500 patients per annum), as do consultants from Welsh tertiary centres, without obtaining prior authorisation from the commissioning body. Seeking prior approval or returning referrals to GPs (some 20% are rejected for approval) causes delay and uncertainty for the patient and is contra to the Choice and Access agendas operated in England.

8. In addition the Trust has to carry out additional administrative work to gain such approval, often for minor financial values. The financial risk is entirely with the Trust to monitor access to the hospital. Even in cases where authorisation is requested and received, the final invoice will often be challenged if the patient's care exceeds the estimated cost of the funding requested, e.g. if the patient requires ITU/HDU which was not factored into the original request. Queries on invoices are slow and significant patient detail is requested to support invoices for both emergency and elective work. Emergency activity is not settled if there are queries on elective activity within the same invoice.

9. Undertaking care for unauthorised welsh patients represents a financial risk to the Trust under the current arrangements.

25 March 2008