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Cross-border Health Care (England and Wales)

Volume 565: debated on Tuesday 25 June 2013

Motion made, and Question proposed, That this House do now adjourn.—(Mr Evennett.)

I start by thanking Mr Speaker for kindly granting this debate on a topic of great importance to many of my constituents and to many others living in English counties on the border with Wales.

I am grateful to two of my colleagues, my hon. Friend the Member for Monmouth (David T. C. Davies) and the Minister for Immigration, my hon. Friend the Member for Forest of Dean (Mr Harper), who have both worked with enormous diligence on behalf of constituents of theirs who have been similarly affected. I pay tribute to my constituent the indefatigable Patti Fender for bringing this issue to my attention, and to Action4Our Care, the action group which has pressed the matter so hard in Gloucestershire.

The basic problem can be simply stated. There are more than 20,000 NHS patients who are resident in England, yet registered with a Welsh general practitioner. Of these, some 3,500 are resident in my county of Herefordshire. Many of these people, like my constituents in the village of Welsh Newton—a Welsh name, but an English village—have no choice but to register with a Welsh GP because no English practice covers their location.

These people live in England, but they are being denied access to hospital services in England. That is grossly unfair, especially as for many, if not all, of them Hereford hospital is the closest and the best place to be treated. The situation also has the damaging knock-on effect of depriving Hereford hospital of revenue from patients who are being treated in Wales. The result is a double whammy: the patients cannot receive the health care that they want and need, and Hereford hospital, already undermined by the deeply iniquitous NHS funding formula, must suffer an unexpected additional financial burden. This burden is already becoming evident. Outpatient treatments for patients living in England but registered with a Welsh GP fell by 10% to 11% in March, April and May this year compared with the same period in 2012, and the hospital expects them to fall further in the months to come.

Is my hon. Friend aware of the situation in Chester, where the Countess of Chester hospital serves large numbers of people who live in north Wales? One third of the people presenting at accident and emergency at the Countess of Chester live in north Wales. There is no funding available for them so people in Cheshire are losing out. Does my hon. Friend think that is fair?

It is interesting to have the parallel case, and I thank my hon. Friend for bringing it to the attention of the House.

Let us look at the issues in more detail. The relevant NHS regulations state that legal responsibility for these patients remains with the relevant clinical commissioning groups in England, but that local health boards in Wales take day-to-day responsibility for their care. The English and Welsh NHS take their guidance from the protocol for cross-border health care services, the latest version of which was agreed by Welsh and English Ministers in April this year. However, it appears that the protocol does not give full effect to the law. Specifically, point 14 of the current protocol implies that patients from England who are treated in Wales are to be seen and treated within the maximum waiting time targets of the NHS in Wales, which are of course rather different from those of the NHS in England. Why does this matter? It matters for three particular reasons.

First, as we have seen, these South Herefordshire patients struggle to get referred to the hospital of their choice. The Welsh Assembly Government Minister for Health and Social Services has openly stated that choice is not the basis of the health system in Wales.

The hon. Gentleman will be well aware of the land border between the Republic of Ireland and the United Kingdom of Great Britain and Northern Ireland. There is co-operation, although it is not full blooded, between the health service in Northern Ireland and the health service in the Republic. Perhaps the Minister should look at that to see how it can work for the situation on the border between England and Wales.

I am grateful to the hon. Gentleman for that intervention. There is co-operation at the moment between England and Wales, but I think that it would absolutely benefit from further examination of the situation he describes between Northern Ireland and Eire.

The fact that the Welsh Assembly Government Minister for Health and Social Services does not believe that choice is the basis of the health system in Wales means that my constituents do not have the choice of health care, hospitals or consultants that is their proper legal right.

Secondly, the Welsh NHS’s performance in meeting its own waiting time targets continues to deteriorate. In England the waiting time target is 18 weeks, but in Wales it is 26 weeks, and that is regularly missed. Some patients are not even treated within 36 weeks. For example, some 4% of patients are not treated within 36 weeks at Cardiff and Vale hospital, according to recent Welsh Government statistics for April this year.

Thirdly, the current set-up is giving rise to serious clinical concerns. Earlier this year, in evidence to the Silk commission on devolution in Wales, the Royal College of Surgeons, the British Medical Association and the Royal College of Nursing made the following submission:

“The Panel... acknowledged that increasing policy divergence between health services in Wales and England was a challenge, especially in regards to cross-border services. The Panel added that there was a need to strengthen commissioning arrangements to improve current delays for processing individual cases... It was also agreed that it made sense for some specialist facilities to be shared by both England and Wales; and to work together to deliver economies of scale and efficiency savings, including cross border sharing of procurement and use of high-tech equipment.”

However, as I have mentioned, that ban on hospital access for those patients is not merely grossly unfair to them but places further financial pressure on Hereford hospital.

My hon. Friend and neighbour is making an important and powerful speech and should be congratulated on securing the debate. Does he agree that when one has a national border next to one’s county, it should be treated like a coastline, because it is not the Minister’s responsibility to control the health service in Wales? But if we do not have proper funding we will suffer as a result of not only our rurality but our sparsity, and once again people living in the marches will be at a disadvantage. We have the Barnett formula, but should we not have something similar for people on the Welsh border?

I am grateful to my hon. Friend and neighbour for that kind intervention. I share his view that the situation needs to be addressed, and it needs to be addressed in the spirit of amity and co-operation between the two sides.

In 2009-10 I commissioned an independent study of the funding of public services in Herefordshire relative to other suitable comparators across the country. I was only a parliamentary candidate at the time and such a study had never before been undertaken, but it seemed obvious to me that Herefordshire suffered from a serious shortfall in public funding and I was determined to get to the bottom of the matter. The results were astounding—even frightening. The study found that Herefordshire had been underfunded by no less than £175 million over the previous five years across all public services. In health care, the underfunding was £44 million, or roughly £9 million a year. It is no coincidence, I suggest, that Hereford hospital is currently running a deficit of almost exactly that amount. It is that deficit that is being worsened by the denial of choice to cross-border patients in my constituency and elsewhere.

Why did that funding shortfall occur? The reason is that the NHS funding formula is systematically skewed against areas that are highly rural and have a large population of older people, and systematically favours urban areas with younger populations. The formula does not recognise the relatively high cost of delivering services in sparsely populated areas, as my hon. Friend the Member for North Herefordshire (Bill Wiggin) indicated, and it does not adequately recognise the special costs imposed by caring for older people—particularly the over-85s, the very oldest in our society. Research by Professor Sheena Asthana at the university of Plymouth indicates that the areas of greatest health care need are those with the highest proportion of over-75s. However, the current funding formula is focused on deprivation rather than on need for health care. That means that less funding is available to treat older people with chronic diseases.

Nationally, 17% of people are aged 65 or over. In Herefordshire, the figure is already 22% and pensioners will make up a third of the population by 2030. In 2010-11, Herefordshire had the highest proportion of over-75s in the west midlands, and the most patients per 100,000 on the cancer register.  It also had the lowest cancer spend per cancer patient per year—a little over £5,000—and was in the lower half of the per capita allocations.

By contrast, the Heart of Birmingham PCT had the lowest proportion of over-75s in the region, and the fewest patients per 100,000 on the cancer register.  However, the spend per cancer patient per year there was not £5,000 but more than £10,000—nearly double that in Herefordshire. Thus the effect of the funding formula is that Heart of Birmingham has twice as much funding per cancer patient as Herefordshire, for a much lower incidence of cancer. That is not merely unfair; it is a monstrous injustice.

I conclude by asking the Minister three questions. First, will her Department amend the cross-border protocol and reintroduce patient choice for English residents registered with GPs in Wales? Secondly, will she acknowledge the strain that the protocol places on hospitals such as Hereford hospital? Thirdly, will she press her Department to make the case to NHS England for a fairer funding settlement, which will give older people—not merely in Herefordshire, but up and down the land—the funding for cancer and for other health care that they so richly deserve?

I congratulate my hon. Friend the Member for Hereford and South Herefordshire (Jesse Norman) on securing this debate. He has raised a number of important topics—notably, the difficulties of people resident in England who are registered with a local GP whose service is deemed to be in Wales, even though the surgery may be in England. I am fully aware of my hon. Friend’s keen interest in local health matters affecting his constituents and his tireless work to support Hereford hospital. The whole House will agree that we would all expect good quality patient care, regardless of which part of the country we live in.

As my hon. Friend knows, I am very sympathetic to the concerns he has raised about English residents who are unable to access English hospital care because they are technically registered with a Welsh GP practice—even when, as I said, for a small number of patients, that GP surgery is physically situated in England.

I am told by my officials that the NHS services that any patient can access, and their NHS rights, are determined by their GP’s country of registration. As we have heard, that is formulated through protocol between NHS England and the Welsh Assembly; it means that, legally, a person has to be registered with an English GP practice to access English NHS services.

I am very concerned that despite an English border patient’s right to register with a GP practice on either side of the border, that is not always possible in practice. I recognise that, in rural communities, patients often do not feel a choice is available, given that the most accessible practice is a Welsh one. I also recognise that many people are registered with a local GP in England but the main practice is over the border in Wales. Those people may not want to change their GP practice. Why indeed should they? We could understand why they might, because in Wales people unfortunately do not get some of the excellent access to services that we enjoy in England. I am very concerned about this. I am told by NHS England that it has asked its legal advisers to review their earlier advice on the protocol signed between it and the Welsh Government with reference to the specific concerns that Ministers—that is, me—and the Welsh Secretary have raised.

It is very kind of the Minister to take an intervention at this stage. Will she kindly confirm that when she invites her officials to look at this issue they will take up the suggestion made by the hon. Member for Strangford (Jim Shannon) and look at the valuable lessons that have been learned in Northern Ireland about the useful co-operation across a land frontier with the Republic of Ireland and a key, integral part of the United Kingdom—Northern Ireland?

I am grateful for that intervention and for the wise words of the hon. Member for Strangford (Jim Shannon), who, as ever, brings a great depth of experience to these matters. Yes, we will certainly take that on board.

All this came about because of a meeting between me and my officials, the Welsh Secretary and my hon. Friend the Member for Forest of Dean (Mr Harper). As a result of that meeting, I have asked NHS England to work locally with GP practices in the border counties to review their practice boundaries with the aim of providing additional choice of GPs to those who do not currently have it. I am keen that all English patients are able to access an English GP if they wish or that they can register with a Welsh GP if that is their choice and they are aware of the impact of that decision. I have also asked NHS England to review the protocol as it currently stands.

I have asked the Welsh Government to review their policy on out-of-area treatments to consider an exception for English residents—specifically, that GPs operating from branch surgeries in England should be exempt from the requirement to seek prior approval for English resident patients to be referred to hospitals in England. These are all matters of concern not only to constituents of my hon. Friend the Member for Hereford and South Herefordshire but to others. We have heard about that from my hon. Friend the Member for City of Chester (Stephen Mosley) and my hon. Friend the Member for North Herefordshire (Bill Wiggin), and of course I know of the concerns of my hon. Friend the Member for Forest of Dean.

I am informed that since the meeting with the Welsh Secretary and my hon. Friend the Member for Forest of Dean, NHS England has had several further meetings with colleagues in the Welsh Government and local health boards based in Wales to discuss these concerns so that they can be addressed. There have been constructive discussions with Aneurin Bevan local health board, which has confirmed that it will undertake a review of the application of its policy on out-of-area treatment. I understand from NHS England that work will continue on this review over the next few months, and I will of course keep everybody fully informed and up to date on any progress.

I am most grateful to my hon. Friend. I am really heartened by the positive things she has said, and I congratulate her on the work she has done. Will she also look at the impact of cross-border patient numbers on hospitals, which also badly affects us in Herefordshire?

Indeed. I will come to the effect on Hereford hospital, but I am more than happy to write to my hon. Friend about his specific point. The usual rules apply: if there are questions that I have not answered I will of course write to any hon. Member.

We have asked the Welsh Government to request that other local health boards along the border in Wales should similarly review the application of their own policies for out-of-area treatment affecting patients in the same circumstances. In many of those areas patient numbers are much smaller, but that does not matter; these are important issues for these individuals.

In the light of the further legal advice that NHS England is seeking, I am advised that it will review the protocol with the Welsh Government in view of my concerns and those of other hon. Members, the updated legal advice, the outcome of the local health boards’ reviews of the application of their policies on out-of-area treatment, and feedback that we have received from local NHS bodies on the operation of the protocol. The review will be undertaken in the autumn following completion of the reviews by the local health boards.

My hon. Friend the Member for Hereford and South Herefordshire is concerned that the policy of the Welsh Government that those who are registered with a Welsh GP must use Welsh NHS services will have a direct impact on the viability of Hereford hospital. I share his concern, but I understand that a number of other factors affect the viability of the hospital and the Wye Valley NHS Trust.

I was a bit concerned when I read the next part of my brief, because it has been worded in an interesting way by my very able officials. It states that those factors include

“the drop in the numbers of young people locally leading to a lack of activity in maternity services”.

I am not sure what “lack of activity” young people have been guilty of. I think that what is meant is that there are not as many young people in the area, because there is undoubtedly a higher proportion of retired elderly people in the population. It is obvious that if there are fewer young people, people are less likely to be having babies and are therefore less likely to use maternity services. I am sure that activity remains at a high level.

As my hon. Friend is aware, Wye Valley NHS Trust published a strategic outline case in March this year, setting out the options for its future form to create a clinically sustainable model for local people. I have been advised by the NHS Trust Development Authority that it has been working with the trust to develop a full business case, which it expects to receive for consideration by the end of this month. Again, I make it very clear that I am more than happy to revisit this issue with my hon. Friend and others following the outcome of that process.

Wye Valley NHS Trust has informed me that the policy has cost it between £1 million and £2 million so far. Given that it is running a deficit of £8 million to £10 million, that is a significant sum. The work that is being done pre-supposes the current funding formula. In a way, it therefore pre-supposes the point at question, which is whether the formula is fair. As I have submitted, it clearly is not.

I do not doubt for one moment the veracity of what my hon. Friend has told me about what he, in turn, has been told. That is a substantial amount of money and it would go a long way to explaining part of the deficit. These are terribly important matters.

The funding formula has been raised yet again. The argument advanced by many Members on both sides of the House is that the formula does not take account of the relatively high cost of delivering services in rural areas or reflect the fact that many rural areas such as Herefordshire have relatively older populations. I have had a number of conversations with hon. Members who make exactly the same complaint as my hon. Friend.

I am reliably informed—this point is important—that allocations to individual clinical commissioning groups, which are made up of the GPs and other clinicians who now commission services locally, and the formula that is used to decide what those allocations should be, are the responsibility of NHS England. I am not seeking to pass the buck, but it does bear that responsibility. In making those allocations, NHS England relies on advice from the Advisory Committee on Resource Allocation. ACRA provides advice on the share of available resources provided to each CCG to support equal access for equal need, as specified in the mandate given by the Secretary of State to NHS England.

Therefore, NHS England does not set income for CCGs on an equal cost-per-head basis across the country. Instead, allocations follow an assessment of the expected need for health services in an area, and funds are distributed in line with that, meaning that areas with a high health need should receive more money per head. The calculation is based on the age of the populations, relative morbidity and unavoidable variation in cost. The objective is to ensure a consistent supply of health services across the country. The greater the health need, the more money is received because the more health services are needed.

I know that some hon. Members just do not accept that that is the reality with the allocations to their CCGs and, in effect, to their constituencies. NHS England plans to review the funding formula for 2014-15 and the following years better to reflect the needs of local communities and enable the best outcomes for local people. Perhaps there is hope in that. Obviously, I must say quickly that I cannot make any promises.

If anybody would like to intervene, we do have the time. Hon. Members often want to make a point, but do not feel that they can make a speech.

I thank the Minister for her kindness and I am sorry that I was not here at the start of the contribution from the hon. Member for Hereford and South Herefordshire (Jesse Norman). Hereford hospital is key in delivering medical services to people in my constituency in Wales. If it had not been for the co-operation of my predecessor, Richard Livsey, the rebuilding of Hereford hospital might not have taken place, because it needs patients from the east of Wales too.

I am grateful to my hon. Friend for that intervention. My officials will listen to the debate and read it in Hansard. All the points that have been made about Hereford hospital—equally important points could be raised by others about the effect on other hospitals—must be considered, because they are important. It would not be right or fair if hospitals felt that they were suffering as a result of a system that is basically not fair through no fault of their own.

We have a little time, so I am very grateful to the Minister for giving way again. Will she ask her officials to look more closely at the functioning of ACRA? The formula under which we are labouring was set up in 2002. There is a clear case to be made that, contrary to its desire, it is not delivering funding to the areas of greatest need, but to areas defined by a deprivation formula. The truth is that morbidity and age go together, not deprivation and morbidity.

I might not share my hon. Friend’s final remarks, but we know that NHS England, which is in charge of distributing funds to CCGs, is considering the formula. It will no doubt bear in mind the argument made by him and others who believe that ACRA’s formulation is not delivering in the fair way that we all agree was intended.

In conclusion, I am pleased that NHS England has responded to my concerns, and the concerns of my hon. Friend the Member for Hereford and South Herefordshire and others, most notably my hon. Friend the Member for Forest of Dean, with whom I had a long meeting. As a result, NHS England is doing what we had hoped it would. I am encouraged by the dialogue that has been taking place between NHS England, the Welsh Government and local health boards in Wales, and I hope to see further rapid progress. We must not let anybody drag their heels. I look forward to being able to update my hon. Friend the Member for Hereford and South Herefordshire, and others who represent border communities, in the autumn. I undertake to do that once NHS England has finished its review. I once again congratulate my hon. Friend on securing the debate on this important issue. While it might not affect a huge number of people, it is a very important issue for them and they feel that there is an injustice. It behoves all of us to ensure that we eradicate any injustice.

Question put and agreed to.

House adjourned.