Memorandum submitted by

Montgomery Community Health Council (CBPS 78)

Background

Powys has a population of approximately 120,000 people within an area of 2,000 square miles. It is approximately one third of Wales but has no District General Hospital. It accesses these services from adjacent health bodies in England and Wales. Consequently the people of Powys are at the forefront of the stark differences in health provision between England and Wales, and often health professionals are seemingly more concerned in highlighting these differences than treating the patient's condition.

As a very sparsely populated area, perception is that the needs of the area are not fully included in health service planning. The pragmatic assessment of the impact of changes proposed to health communities in cross border areas is not undertaken, consequently continual polarisation of health services causes increased difficulties for the people dependent on cross border access.

Details of Concerns

Care Pathways

Patients have historically followed natural catchment areas not political ones that were influenced by close relationships with GPs, patients and the appropriate hospital, many fund raising initiatives were undertaken to provide added extras for 'their' hospital in other places. Access times and public transport reinforce these close links, Montgomeryshire (part of North Powys) provides the Royal Shrewsbury Hospital with some 12% of its business, and any significant change in commissioning may precipitate a destabilising of service. any change in the site of delivery will impact hugely on the patients concerned, for example a patient in Llanfyllin who used to have a bone density scan at Gobowen in England - 12 miles and one bus journey away, has now been redirected to Aberystwyth 66 miles away, as the crow flies, but four different buses and 90 miles on the road. This patient is an 84 year old female without relatives who can transport her.

Travel in Mid Wales is comparatively slow with little or no dual carriageway and no motorway. It is considered essential that the existing care pathway should continue unless a better service is possible for the patient.

Access

Patients are used to having to travel to access specialist services although how they travel varies. Much of the transport is private and public transport is neither destination nor dignity appropriate. People travelling for dialysis or chemotherapy require a suitable, relaxing mode of transport, not found in the public sector. There is evidence of discharged patients from English A&E hospitals being left to their own means to get home in pyjamas/dressing gown. What appears to be a short distance on a map can be a much longer travel time on the road due to road type, single lane and rural traffic etc. a 26 mile journey from Newtown to Llandrindod Wells - part of the spine of Powys - takes at least 40 minutes whatever the weather. Travelling by rail from Mid Wales requires a trip to Shrewsbury before catching the main line south down to Gwent and Cardiff, or north to Wrexham. Ease of travel is not a concept that people recognise without the use of a private car.

Emergency Ambulance response times with a national standard target of eight minutes have recently recorded response times of 45-60 minutes. An emergency ambulance call resulting in a visit to the A&E department in England can result in the ambulance being off-station for some three hours with the consequential reduction in service.

Patient travel time or access time is often a half-day commitment or more.

Waiting Times

Wales NHS and the English NHS have differing targets for patients awaiting services. As independent observers the CHC are unsure as to what the determining factor is - is it the capacity to provide the service or money?

The CHC's view is that no patients using the same facility/service provider should have a different length of wait; all 'customers' should get the same quality of service. Patients from Wales are regularly used as political footballs being told - "you're Welsh, you will have to wait", or "why not come and live in England and you will be treated better". The difference between the payment by results and the historic method is a major problem. If as seems evident there are only a small percentage of affected people, why shouldn't the WAG pay the going rate rather than commission a reduced service?

The information that the CHC has is that services in English Hospitals are as good as any in Wales and the tariff paid to the English Hospitals is lower than any other reasonable provider alternative in Wales.

The management of waiting times by Powys LHB for the English Hospital providers is far from well received by the patients. There is evidence of patients falling into black holes, being on no waiting list despite being referred some years ago and patients expecting to go to a hospital being redirected to another. There must be added administrative systems and costs by having waiting lists at sites that are apart,

Prescriptions

Wales's patients (residents) are now able to get prescriptions free of charge but only on a Welsh prescription sheet/pad in a Welsh pharmacy/dispensary, however, when a Welsh resident is taken to A&E in an English hospital (no choice) and is given drugs they are expected to pay the English charge, often sent by invoice. If the charge is disputed debt collection agencies become involved. Similarly dentists giving prescriptions are subject to the same rule.

The CHC will be interested to observe the possible introduction of free parking at hospitals when Welsh residents have to access services in English hospitals.

Equity and Equality

With the NHS being driven by finance, equity when dispensed on a per capita basis deprives low populated areas of equality of services. The basic core service takes a higher percentage of the sum total due to minimum core levels that have to be provided, leaving less flexibility or variable money for discretionary services or lower priority services. Consequently rural/sparse communities are disadvantaged in a per capita allocation when the cost of rurality provision is not recognised.

Ambulances

In a relatively large, sparsely populated area without a District General Hospital, having to access services outside the area puts demands on an ambulance service as it cannot be on call until it is back on its patch. This results in individual calls taking up to 3 hours.

Fast access to hospital care can affect recovery rate and thereby reduce cost to the NHS, it is imperative that ambulances can access the nearest A&E.

Transfers of Care

There are often problems with Transfers of Care as there are differing requirements. Powys Local Health Board does not always follow the same rehabilitation course that English patients would follow, sometimes preferring to send patients to Welsh Schemes. There is evidence of Welsh patients attending a rehabilitation course at Royal Shrewsbury Hospital and being told you cannot have a kit because Powys doesn't pay for it. When you are one or two patients in a class of eight or ten this can be very demeaning.

Record Transfer

There is evidence of patient records not being similar/compatible, maternity patients rushed to an English hospital do not have notes that are readily transferable or understandable because they are set out in a different way. It is essential that there are minimum communication problems to avoid patient distress.

Education and Ongoing Personal Development

As England is often the provider of quality health services for Welsh patients it seems logical that there should be strong links between the hospital sites and the community networks that cross the boundaries to reach the communities within the catchment areas. Integrated information systems and databases would improve knowledge around the cross border services and help refine patient pathways.

UK Integrated NHS

The CHC is convinced that specialist services that have relatively low numbers would be better linked covering a safe clinical network embracing the whole of the UK, there may be instances where Wales does not have the critical numbers to maintain safe services.

Partnership

There is now considerable good-will and partnership working at a local level. Powys Local Health Board, English Primary Care Trusts, Hospital Trusts, Patient Bodies etc., are working together to minimise operational problems, the strategic and policy level are often the restriction that causes patients to be confused, bemused or frustrated.

Summary

1. There are ethical problems concerning the provision of differing standards of service to patients using the same hospital - this should not happen.

2. If services are to improve the "managers" must be given the authority to minimise the problems at a local level, the continual ongoing creation of differences does nothing to reduce patient frustration with politics.

3. The increased desire to specialise and strategically place these specialised sites required most patient input to travel costs and the more people have to travel creates a less green environment. Recent changes in the consultant contract have caused reductions in clinics in rural areas.

4. The additional cost of delivering a health service in rural areas is not realistically reflected in the funding formula.

5. From where the CHC sits, no one seems to care about resolving/reducing the differences, it seems that people should accept what they are given and be grateful.

6. There is almost a rule that maximum waiting times are minimum waiting times.

May 2008

Reports/Cross Border Issues plus Summary HOC130508