Cross-border Health Services (England/Wales)

13:27:00

Mr. Mark Harper (Forest of Dean) (Con)
It is a great pleasure to serve under your chairmanship, Mr. Hood. The purpose of the debate, which I have been fortunate to secure, is to raise ongoing concerns about the quality of health service provision for my constituents who live in Gloucestershire, in England—that is important—but who have general practitioners who are registered in Wales. The primary care trust has estimated that about 8,000 people in my constituency—a significant number—are affected by this issue. Devolution has created differences in the health care available in England and Wales. I shall not go into issues of devolution itself, but I shall argue that the Government have failed to think through how to implement devolution properly and the effect of that on constituents such as mine regarding health care.

As a result of devolution, there is no national health service any more. We have health services in England, Wales, Scotland and Northern Ireland that have different policies, which, in the English and Welsh services, are decided by English and Welsh Health Ministers. The 8,000 constituents whom I have mentioned are effectively forced to use health services over which they have no democratic control because they cannot influence the policies of the Welsh Assembly Government and they have no vote in Wales. I do not think it is right that they are forced to use some of those services, and that is primarily what I want to address.

The Department of Health—I think that the Minister himself has said this—has stated:

“The border between England and Wales does not represent a barrier to the provision of health care”.

That is true, but it went on to say:

“Patients will not be disadvantaged as a result of any of the differences in the two systems”.

My contention is that that is not true, and that there are disadvantages for my constituents, who do not have the sort of access that they should.

Let me give an example. A constituent recently wrote to me about his case. He had been in hospital, and had received excellent care, and the hospital had expected to discharge him into the care of community nurses working under the direction of his GP. He lives in Gloucestershire, but his local surgery is part of a practice that is registered in Wales, and there is no available funding. His GP could not get funding, so he is having to go all the way into Gloucester—25 miles from his home—two or three times a week to have some basic dressings changed and things done that should, frankly, be done by his GP. That is a direct result of the differences and the lack of a joined-up service health service in England and Wales.

Following devolution, the legislation did not make it entirely clear who was responsible for providing health care for people who live in England but who have a GP registered in Wales. A statutory instrument passed in 2003 made it clear that primary care trusts in England are responsible for delivering care for everyone who lives in England. However, that proved too complex to implement straight away in border areas, where lots of people live in one country but have GPs registered in another. I understand that that was complicated by the different funding arrangements in England, where there is a payment by results system, compared with Wales, where there is a block contract system.

In 2005, a supposedly temporary protocol was put in place to address the issue. The protocol slightly altered the residence-based criteria and meant that commissioning was based on GP registration, rather than residence. The protocol applies only to primary care trusts along the England-Wales border, which, in England, includes Gloucestershire, Herefordshire, Shropshire and West Cheshire. As I said, the protocol was introduced in 2005 and was supposed to be temporary while the details were ironed out. Ministers have just announced that the protocol will be rolled forward to 2011, which is past the date of the next general election.

I have been raising this issue with Ministers since I was first elected. In 2006, the then Health Minister, Lord Warner, said that officials in the Department were working together with their colleagues in Wales to ensure that appropriate arrangements were in place when the interim protocol expired in March 2007. As recently as January this year, the Government said:

“It is anticipated that a more permanent and sustainable protocol will be agreed shortly”.

In a recent answer to a parliamentary question, the Minister stated that

“the Government expects to agree a protocol with the Welsh Assembly Government as part of the finalisation of NHS business plans for 2009-10”.—[Official Report, 23 February 2009; Vol. 488, c. 218W.]

Time and again the Government have promised to sort the issue out.

The recent report of the Select Committee on Welsh Affairs on cross-border services states:

“We are very disappointed that a permanent protocol on cross-border health services has not been agreed between the Department of Health and the Welsh Assembly Government.”

The Committee also states that it was

“disturbed by the fact that this has not even been published in draft for consultation”

and that its

“interim report concluded that this was a critical issue in need of urgent consideration. The lack of a permanent protocol leaves clinicians and administrators in a strained position and risks adversely affecting patients as a result of cross-border commissioning and funding problems.”

Given those commitments, I had expected that we would have a permanent solution in place by this financial year, which started a couple of weeks ago. I was disappointed to see the letter from the Welsh Assembly Government Health Minister that was sent to Welsh local boards on 1 April. The letter states that

“the principles set out in the revised protocol remain unchanged from the previous interim agreements.”

This morning, I received a timely answer to a parliamentary question, which stated that a “revised protocol” is now in effect to replace the interim one. I am at a loss to see any significant differences between the new protocol and the previous one. As far as I can tell, the revised protocol is the previous one rolled over, with the one difference that it is now a two-year interim temporary protocol that runs through to March 2011. That is not a permanent solution, but it does take us past the next general election. Only a Labour Government could think that “revised” and “unchanged” are the same things. The Government have flunked dealing with the issue again.

Will the Minister explain why the interim protocol has been rolled over yet again despite everyone, including the Government, agreeing that it is not sustainable? Why have the Government not put in place a permanent solution and why, in the words of the Select Committee, does the issue appear to be “too hard” for Ministers to tackle. The Government have effectively said that they will not tackle the issue until 2011, so it will be the next Government, which I hope will be Conservative, who will have to sort this out.

The real issue is that a significant number of my constituents are forced to use health services in a system that they have no ability to influence. Health policies are set by Ministers in the Welsh Assembly Government and Edwina Hart, the Welsh Assembly Government Minister, has said:

“The Welsh Assembly government is responsible for securing health services for the people of Wales…Responsibility for English patients sits with the Department of Health in London.”

If someone lives in England, they can vote on and influence only English health service policies, as my constituents can. However, a number of them are forced—they do not have any choice about it because they have no ability to use a GP registered in England—to use and are dependent on services provided by the Welsh Assembly Government.

A further twist to the problem is the issue of screening services, for example, in relation to bowel cancer. That is an appropriate example because April is bowel cancer awareness month. The issue was raised with me by a local GP, Dr. Alasdair Jacks of the Vauxhall practice, who is concerned about the risk to which his patients are exposed. Bowel cancer is one of the most common forms of cancer and it develops over a number of years but, if it is caught early, it can be cured.

In England, screening for bowel cancer is carried out according to someone’s GP registration, but in Wales, it is done by residence. So if someone is one of the 8,000 people who live in Gloucestershire but have a GP registered in Wales, they do not get screened in England and they do not get screened in Wales. That means such people fall through the system and that their lives are effectively put at risk because they are not called in for screening. In a recent letter to me, the Welsh Health Minister Edwina Hart said that my constituents were not entitled to the Welsh service, that the Government in England were aware of the problem and that she thought they were dealing with it. I would be grateful if the Minister could say what Ministers will do urgently to make sure that my constituents have access to that screening service.

I understand that the same problem occurs in relation to the cervical cancer screening service, which works in the same way. Hon. Members will have seen the publicity surrounding the tragic death of Jade Goody and her attempt to secure a review of cervical cancer screening in England. That will be of little comfort to the thousands of my constituents who do not get any cancer screening at all based on the current system because they fall between England and Wales. What do Ministers plan to do to resolve that problem?

Another specific example is provided by a local case. A local care home based close to the border requested an ambulance and was given a number by its GP. The care home ended up speaking to the Rhondda Cynon Taf booking centre via the Welsh local health board. The booking was passed to the Welsh ambulance service, but because the care home is in England, which is outside the contractual area, no booking number was created and no booking made. As a result, a number of my constituents from that care home missed hospital appointments and the care home had to book taxis at its own cost. Again, my constituents were put at a significant disadvantage.

A further issue is that performance management also fails because in Wales it is based on residency, but in England it is based on the commissioner. That means that the treatment of around 8,000 people will not be monitored by any of the organisations that monitor the quality and performance of health services. The obvious response to all this is to say to my constituents, “You can choose a GP registered in England if you want to.” Indeed, when the Minister wrote to me on 16 January, he told me:

“Patients are free to approach any GP practice and ask to join its list of patients.”

Of course, he knows that the matter is not that simple. First, many people have been with their GPs for years and do not see why they should have to leave their family GP, with whom they are familiar. The family GP knows their health care and their family, and people do not see why they should be forced to leave them just because of devolution.

Secondly—I have been in correspondence with Ministers about this—a number of my constituents have tried to change their GP and have been refused. In the southern part of my constituency, there are no GPs registered in England. If people try to register with the closest GP registered in England, they find that the GP refuses to take them because they say that they are unable to look after them due to the distance they are from their home. The PCT does not appear to have any responsibility to ensure that people can register with a GP based in England. That is wrong, and I would like the Minister to deal with it. Does he agree that if someone lives in England, they should have the right to register with a GP based and registered in England, and that the GP or the primary care trust should have the responsibility to make sure that people can be registered in that way?

I am coming to the end of my remarks. I am not raising a new issue; this has been going on for a number of years. It was supposedly a transitional matter that occurred after devolution while the administrative and operational details were being sorted out as we moved from one system to another. However, the problem has not been tackled, and each year, an interim protocol is rolled forward. The Welsh Assembly Government and the Department of Health agree that such protocols do not provide a permanent solution, but they do not seem able to agree a permanent solution. That is causing real, demonstrable difficulties for thousands of my constituents. That is not good enough. Will the Minister answer my questions and set out why dealing with the matter is so difficult?

If someone lives in England, the PCT should be responsible for their health care. It should ensure that they have the ability to register with a GP registered in England. The health service that they vote for, that they pay taxes to and that they have influence over should be the one that looks after their health care needs. It should not matter that they live close to an internal border in the United Kingdom, but, at the moment, it does matter, and that has a real and potentially damaging effect on the health of my constituents. What I really want to hear from the Minister is what the Government plan to do about the situation, preferably quite soon.

13:40:00

The Minister of State, Department of Health (Mr. Ben Bradshaw)
I congratulate the hon. Member for Forest of Dean (Mr. Harper) on securing this debate. Before I address in detail the concerns that he raised, I would like to recognise the good work that is being done in his local NHS. It is delivering a better-quality health service than ever before, on both sides of the border, thereby benefiting his constituents and those of other hon. Members.

As the hon. Gentleman acknowledged, the Government introduced devolution in 1999 to push power closer to the people of Britain. Prior to that, there was a single NHS across all the nations of Great Britain. Patients living along the border between England and Wales would register with their local GP practice and receive the health care they needed accordingly.

As the hon. Gentleman also acknowledged, the border between England and Wales has never been a barrier to health care. People resident in Wales have always accessed health services in England and those living in England have done the same in Wales. For many people in border areas, the GP practice nearest to their home might well be on the other side of the border. That is the case for a number of his constituents. There are 20,000 English residents who have a GP in Wales and 15,000 Welsh residents who have a GP in England. Some 8,000 people in the Gloucestershire primary care trust area, many of whom are represented by the hon. Gentleman, have a GP in Wales.

However, with devolution, the Welsh Assembly Government became responsible for health policy and the delivery of health services in Wales. This presented an administrative challenge for the NHS on both sides of the border. With responsibility for patients determined by residence, there was confusion among health care providers and commissioners when they were dealing with patients who were registered with GPs across the border. That inevitably led to tensions as health authorities tried to work out who should pay for a patient’s treatment. There was also the problem of members of the public registered with the same GP receiving a different quality of service based on their residence.

Therefore, in 2005, the Governments of England and Wales agreed an interim protocol whereby responsibility for a patient would be determined by GP registration rather than by residence. Therefore, if a person’s GP was in Wales, they would be the operational responsibility of the NHS in Wales, even if they lived in England, and vice versa. That arrangement was convenient for patients and more practical for both health services. It meant that, despite devolution, patients were still able to register with the GP who was closest to them.

Patients retain the ability to choose, which we believe is vital if they are to receive high-quality care. I will happily look into the examples that the hon. Gentleman gave, if he would like to furnish me with more details after the debate of people who have tried to register with a GP in England because that is their preference but have been told by the PCT that there is not the capacity or that places are not available.

It is a duty of PCTs in England to ensure that GP services are available to serve communities. If, as the hon. Gentleman suggested, many people in his constituency would rather be registered with a GP in England, that is something that he and I can help them to take up with the PCT.

Mr. Harper
Can the Minister clarify exactly what PCTs are responsible for doing? My understanding is that they think that they are responsible for making sure that there is a GP available to the patient, but not for making sure that a GP registered in England is available. That has been the issue. I will remind him of the details of a specific case about which I have been in correspondence with the Department—I forget whether it was with him or another Minister—but we did not come to a very satisfactory solution as far as the PCT was concerned.

Mr. Bradshaw
I will happily look into that case and write to the hon. Gentleman with clarification, if I may. He says that he has constituents who live in Gloucestershire who want to be registered with a GP in Gloucestershire and do not mind making a long journey. There may be a problem, as he indicated, with the duty for GPs to do home visits, if the distance is very long. That is one of the reasons for geographical boundaries to GPs’ lists. That may be a problem, but I do not know the details of the local area well enough. However, I promise to look into the matter and get back to him with more detail on it.

The implication of what the hon. Gentleman suggests could mean people being forced to register with a GP in their own country. If we were to base the system on residence rather than on GP registration, I suspect that many of his constituents would object to having to register with a GP in England if it meant that they had to travel much further or, indeed, had to deregister from a GP who happens to be in Wales with whom they are very happy. The current system also works much better for GPs who have to serve only one health organisation—the local health board or the primary care trust where they are based—and not deal with two separate and increasingly different bodies.

As the hon. Gentleman acknowledged, as of April this year, the English and Welsh Governments agreed a new protocol that will run until the end of March 2011. It will then be renewed in line with the three-year planning cycle and the comprehensive spending review.

The hon. Gentleman asked why there is no permanent protocol. The reason is that health policy on both sides of the border is dynamic—it changes over time. Therefore, we do not believe that a permanent protocol set in stone is sensible. The principles in the protocol are clear—I have spelled out some of them and will spell out a few more in a moment—but, as the English and Welsh systems diverge, it will become increasingly important to clarify the implications for cross-border patients, and to ensure that funding reflects patient flows. It is more important to have a framework in place that allows both sides the flexibility to respond to each other’s policy changes rather than to have something rigid that would prevent us from making exactly the kind of changes that the hon. Gentleman would like us to make, to make life easier for his constituents.

The new protocol is much broader in scope than the original interim one. It provides greater clarity on commissioning and funding arrangements and will lead to further improvements for patients who live along the border. It allows both Governments to respond to changing health policies in the other country. It establishes a financial framework to take account of cross-border flows, which will continue to be negotiated annually.

The new protocol agrees the principles and the basis for the funding of secondary care. As there are more people living in England who have a Welsh GP than there are people living in Wales who have an English GP, my Department pays the net difference for secondary care to the Welsh Assembly Government. In 2008-09, it amounted to £5.8 million.

We have also agreed in the new protocol that my Department will provide Welsh commissioners with up to £12 million for 2009-10 to pay English providers’ tariff prices under payment by results. We believe that that will help to reduce some of the tensions that there have been between commissioners and providers across the border over that issue. For example, the Countess of Chester hospital estimated that 20 per cent. of its activity comes from Wales. It said that it had received insufficient funding from Wales for that treatment, thereby creating an additional financial burden on the hospital. The revised protocol will address that issue in line with the commitment that I gave to the Welsh Affairs Committee last year.

The new protocol also clarifies standards of access for patients. It sets out what patients are entitled to, depending on where their GP is located. Officials from my Department will work with colleagues in the Welsh Assembly Government and the NHS to improve patient awareness of the implications of their GP registration. In England, at least—I cannot speak for Wales on this—PCTs in the border areas will provide information directly to patients in their annual guide to local health care services.

The hon. Gentleman asked about screening for bowel cancer. As he said, a cancer screening programme is being rolled out. In Wales, the decision was to issue invitations for screening based on residence rather than GP registration. That means that Welsh residents with an English GP may, theoretically, be called twice for screening, whereas an English resident with a Welsh GP may not be invited at all. The NHS in England is well aware of the issue and assures me that, as it implements its screening programme, it will ensure that nobody falls through the gap, and that everyone who is eligible is invited for screening.

I do not have the answer to the hon. Gentleman’s question about cervical cancer screening, but I will happily write to him about it. That programme has been going for much longer, so I would be surprised if a solution had not been found to the problem, but I will clarify that in writing, if I may. I will also ensure that he gets a reply to the letter that he wrote to the Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen), on bowel cancer screening.

The national health service in England, Wales and Scotland remains and will always remain true to the founding values of the NHS: a tax-funded system, free at the point of delivery. The Department of Health and the Welsh Assembly Government work closely together, and will continue to do so, to identify and resolve any issues that will inevitably arise in a changing policy environment as a result of devolution.

Mr. Harper
I was listening very carefully to what the Minister said about the revised protocol that now runs until 2011. Given what he said, am I right in understanding that effectively it is not the intention of the Government ever to move away from that type of protocol? I ask because when the system was first put in place in 2003, PCTs in England were responsible for everyone who lived in England and it is those few counties that I have highlighted that govern matters on different arrangements. Is it the Government’s policy that effectively that difference for those border areas will continue to exist indefinitely, or do the Government plan at some point to ensure that my constituents are treated in the same way as other people living in England?

Mr. Bradshaw
As I have tried to indicate, it is very important that we maintain the flexibility to respond to concerns. However, it is also important that the hon. Gentleman is clear about what the consequences would be for his constituents if we went back to a system whereby health care was based on residency rather than on GP registration. Far be it from me to raise hypothetical problems for him, but if we were to go back to a system based on residency he might discover that many of his constituents who are registered with a Welsh GP would find themselves either under pressure to register with an English GP or receiving a different level of treatment. For example, they would have to pay for prescriptions, which they do not have to pay for if they are registered with a Welsh GP. If that happened, they might be a lot unhappier about that than they are about some of the inevitable anomalies that arise from having two systems across a border and from having people living in one area while being registered with a GP in another.

What we have tried to do in this new protocol is stick to the principles that ensure that people receive a standard of service that they can be clear about and that is based on where their GP is situated. At the same time, people on both sides of the border are benefiting from improvements in health care in both England and Wales.

However, if the hon. Gentleman thinks that he has a better system or that he can write a better protocol to address some of these issues, I would be very pleased to see such a system or protocol. We have done our best, both in England and in Wales, to try to devise a system that is fair and clear to people. However, we do not want to set things in stone for the very reason that, as policy changes and as the two health systems in England and Wales diverge even more, it would be a mistake to set the systems and processes in place. I believe that the principles that we have are right; he may disagree and he may prefer to see a system based on residency rather than on GP registration. However, I simply suggest to him that such a system would perhaps create more problems and unhappiness among some of his constituents than the current system of health care based on GP registration creates.

Mr. Harper
The one solution to that problem is the one that I referred to in my speech, which is to ensure that patients have a genuine choice about the GP that they are registered with. I think that that would solve the problem. I will raise with the Minister the specific case that I mentioned. However, I think that the key issue is the one that he himself highlighted. GPs are concerned about the geographical distance for home visits, and in the southern part of my constituency there are not any GPs registered in England. Consequently, if people try to register with the closest GP in England to them, those GPs refuse to register them. Effectively, those people have no choice, which means that they are forced to use a Welsh-registered GP. That is the nub of the matter. If people had a genuine choice, some of what he says would be reasonable.

Mr. Bradshaw
One of the things that we are introducing in England, as opposed to Wales of course, is much greater choice for people in registering with GPs, and we are reforming the GP contract to deliver that greater choice for the public. However, I will happily look into the specific geographical problem that the hon. Gentleman has highlighted and discuss it with his PCT, to see whether there is any alternative solution that would satisfy both the principles of the protocol and, as he suggested was the case, the desire of some of his constituents to be registered with a GP in England.

Question put and agreed to.

13:53:00

Sitting adjourned.