MEMORANDUM SUBMITTED BY

THE MINISTER FOR HEALTH AND SOCIAL SERVICES,

WELSH ASSEMBLY GOVERNMENT. (CBPS 70)

General points

1. Since devolution in 1999, Wales has developed its own health policies, to suit Welsh needs and circumstances.

2. There is recognition that, because of its population size, Wales cannot safely and efficiently be entirely self-sufficient and provide all services within its borders. That said, the precise balance between services provided within and outside its boundaries will change over time. Most of the healthcare needs for the people of Wales can be provided in Wales. This may mean people having to travel for some specialised services. In reality, we are likely to always have a mixed picture of health service provision in Wales, and there will be areas where it is sensible to continue with arrangements for Welsh patients to be treated in English hospitals.

3. It is the responsibility of healthcare commissioners, that is the Local Health Boards and Health Commission Wales (for specialist treatment), to decide whether to enter into agreements with Trusts in England. The policy has not changed. Nor does it impact on very large numbers of patients. 6.3% of all elective/emergency admissions of Welsh residents go across the border into England

4. Although there are differences in some areas of policy and practice between England and Wales - such as structures, the role of markets, targets - the basic position on both sides is that patients should not suffer detriment as a result of these. Any issues should be resolved in ways invisible to the public.

a. Cross-border public services currently provided for and accessed by the Welsh population

5. For decades, there have been arrangements in place to ensure that patients and social services clients receive services promptly and efficiently, though the detail has changed over the years. The current context for service development and delivery is a commitment to creating world-class health and social care services for the people of Wales, with safe, effective services provided as locally as possible.

6. Cross border services will be needed particularly for certain groups. These will include patients who reside close to the Wales/England border, and those who need services not routinely provided in Wales. Cross-Border patient flows to England have been a significant aspect of NHS treatment for Welsh residents from North and Mid Wales, less so for those from South Wales. Transport and access issues matter, for example with east-west links often easier than travel north or south.

7. In respect of primary care (GPs, dentists, pharmacists and optometrists), cross border flows of patients are common and routine the length of the border. Patients gravitate to their nearest convenient GP practice. Welsh residents can be registered with a GP in England; equally English residents can be registered with a GP in Wales. At 1^st April 2007, 15,093 Welsh residents had an English GP.

8. Use by Welsh residents of hospital services in England varies, depending on population distribution, hospital location, ease of access and distribution of services. Admissions have risen - from 32,000 in 1999/00, to 41,000 in 2005/06, to around 43,000 in 2006/07, including both emergency and elective patients.

9. Emergency admissions generally are unforeseen. In these cases, speed of access, and therefore geography, are crucial, and the decision as to which hospital to access is made purely on grounds of accessibility, though patients are generally taken to the nearest hospital. In 2006/07 there were 17,413 emergency admissions of Welsh residents to English trusts included in a total of around 43,000 admissions.

10. Elective admissions are planned and scheduled, In 2006/07 there were 25,196 non-emergency admissions of Welsh residents at English trusts.

11. The English hospitals which are the main focus for Welsh secondary care elective referrals are in Liverpool, Chester, Gobowen (Oswestry), Shrewsbury, and Hereford. To a lesser extent St Helens, Knowsley, Gloucester and Bristol are used.

12. Powys has never had a District General Hospital within its boundaries, its population being relatively small and sparse. The population of Powys is around 126,000. In terms of travel time, Assembly Government officials have estimated that some 45,000 lie in the catchment area for Shrewsbury, 11,000 in that for Hereford and the balance in those for using Welsh hospitals.

13. Flintshire's population looks three ways for hospital services - to Glan Clwyd Hospital, to Wrexham Maelor Hospital, and to the Countess of Chester Hospital. Usage broadly reflects geographical proximity.

14. Some highly specialised services are not available within Welsh borders, especially with regard to cancer, high secure mental health and transplantation. The North West of England continues to provide important specialised services for the population of North Wales. In particular, Cardiothoracic Centre Liverpool for Cardiac Services, Royal Liverpool Children's Hospital for specialist children's services, Walton for neurosciences. All of these services have continued to attract increasing investment in capacity and quality.

15. Wales continues to access national specialised services for highly specialised children's services and transplantation at centres such as Great Ormond Street Hospital and Royal Brompton/Harefield. Investment in all centres has been significant over the passed 5 years.

16. Different issues arise in relation to social services. The biggest groups using cross border services are Looked After Children and children requiring specialist placements reflecting their need for complex care particularly specialist disability needs. Although figures on cross local authority boundary and cross border placements are not compiled centrally, there are known to be significant cross border flows of Looked After Children from England into Wales and a probably smaller number in reverse. They are primarily placements with Independent Foster Care Agencies or independent children's homes, with a smaller number in residential special schools, mainly in the more rural areas. The Chief Inspector has drawn attention to this and the increased numbers of children placed out of area. Such arrangements make difficulty in maintaining contact for family and services.

17. Policy in England and Wales is for children to be placed close to home (family, friends and school) and usually within their own authority area. Welsh Assembly Government Regulations, which came into force from 1^st July 2007, strengthened arrangements for placements out of authority area. The Children and Young Person's Bill, currently before Parliament, will further strengthen arrangements by requiring local authorities to develop sufficient provision their area to meet need.

18. In the main social services departments commission or provide services for their own residents who have been assessed as eligible for care. This is particularly so in respect of domiciliary and day care services. Most cross-border placements will be in residential settings and service users have a right of choice in placements within the usual level of funding provided by the authority. Older people may prefer homes across the border or may prefer to be accommodated close to relatives who would visit.

19. Use of cross border hospital services has implications for access to social services. Local authorities (LAs) in which the hospital is located are not empowered to provide services to people not resident in their area unless they have an agreement with the responsible authority. Welsh LAs most affected have arrangements in commonly used facilities either through agreements with the English LAs concerned or for outreach from a Welsh base. This works best for access to locally provided aftercare but it tends to undermine social care input to ongoing treatment for example in specialist surgery where there are family complications and tensions which may impact on recovery. This is as true for out-of-area care within Wales as in England.

20. A problem can arise where self-funded residents from out of area acquire local residence and become the responsibility of the local authority (LA) in which they reside when their resources fall to the threshold for public funding. As with young people there is a problem of people moving to Wales who then require NHS treatment. However younger adults with complex needs usually require LA funding and so remain the responsibility of the placing LA for their care costs.

b. Arrangements currently in place to co-ordinate cross-border public service provision

21. For primary care services, individual patients register with a GP of their choice. However, there is a difference in management arrangements between Wales and England in relation to securing secondary care services, the former based on where people live, the latter initially on where their GP is. In Wales, save for specialised services, which are the commissioning responsibility of Health Commission Wales (HCW - see below), Local Health Boards (LHBs) have both the legal and operational responsibility commissioning medical services on behalf of all persons who are usually resident in their area. As LHBs' commissioning responsibility is based on residency, it complements the role of local authorities, and so assists joint planning and commissioning across the health and social care sector.

22. In England the situation is different. In general terms, the English system operates on GP registration, though if a person is not registered with a GP in a Primary Care Trust (PCT) area (including if they are registered with a Welsh GP) there is a default to the PCT where the patient is usually resident. PCTs have both the legal and operational responsibility for commissioning health services for their resident populations.

23. To deal with the consequences of this divergence, the Department of Health (DH) and the Welsh Assembly Government agreed an interim protocol, which in Wales was published in February 2005 as Welsh Health Circular - WHC(2005)12: Procedure for Cross-Border Healthcare Commissioning between England and Wales (the Interim Protocol). This communication applies only to those patients resident along the England and Wales border, and who live within the following LHB and PCT areas:

· Wales - Flintshire, Wrexham, Powys, Monmouthshire, and Denbighshire;

· England - West Cheshire, Shropshire County, Herefordshire, and Gloucestershire.

24. The Interim Protocol provides that the legal responsibility for providing services to a patient resident in Wales but registered with a GP in England remains with the LHB but the operational responsibility (the commissioning of health services) falls to the PCT. In England, where a patient is resident in England but registered with a Welsh GP, the legal responsibility remains with the PCT, but the operational responsibility falls to the LHB. LHBs are expected to meet Welsh targets, and PCTs English targets. Under (WHC(2006)05 and WHC(2007)036), the Interim Protocol was further extended until 1^st April 2008.

25. Decisions to enter into agreements with Trusts in England regarding mainstream secondary care are made by LHBs. Patient flows to England in secondary care are made within a commissioning framework where decisions to send patients to English NHS Trusts are made for good reasons. Only in the case of Flintshire and Powys are there major flows into England.

26. Tertiary care/highly specialised care is commissioned for Welsh residents by Health Commission Wales (HCW). In 2005 the then Minister, Dr Brian Gibbons, confirmed the objective that patients needing tertiary and specialist services, wherever possible and clinically appropriate, should be seen and treated in Wales. HCW has been pursuing this approach.

27. To assist in planning and managing cross-border activity, a Memorandum of Understanding between Central Wales and the West Midlands was signed in March 2007. The Memorandum is a non-legally binding document, indicating a desire to promote co-operation on policy development and service delivery, in view of the complex pattern of inter-dependence and the need to build stronger cross border collaboration by all public sector organisations. An element of that co-operation will be to consult each other in good time on proposals for change in policy, funding or service delivery that could impact on communities on the opposite side of the border.

28. New arrangements are emerging in social services. In order to enable local authorities to find suitable placements and to plan provision in future, the Welsh Assembly Government has supported the setting up of a Children's Commissioning Support Resource. This comprises a database of provision across Wales, which identifies vacancies and enables placement of children, supported by work with local authorities to develop better commissioning. The database will in future be enhanced to collect information on cross boundary and cross border flows.

29. Most adult placements will reflect an absence of local services in the face of specialist and complex needs, examples being head injuries, mental health and sensory disability, and a complex mix of disability. Local authorities have a duty to provide social services to residents assessed as requiring such care who meet the authority's eligibility criteria for services. This can be residential or welfare services. Since devolution there has been no clear mechanism for resolving ordinary residence disputes between a local authority in England and a local authority in Wales over the responsibility for providing such services, and a handful of cases arise each year. To remedy this, interim arrangements have been agreed, and an amendment to the relevant act is contained in the Health and Social Care Bill currently going through Parliament, allowing arrangements to determine such disputes to be put in place.

c. Funding of cross-border public services

30. LHBs spent £74.5m with non-Welsh NHS bodies in 2006-07. This includes expenditure on non-contracted emergency activity, where Welsh residents need emergency treatment while away from home, as well as expenditure on regular emergency and elective cross border patient flows. HCW spent £71.4m in that year.

April 2008