There has been renewed interest in the arrangements for cross-border healthcare between England and Wales following the Countess of Chester Hospital NHS Foundation Trust’s recent decision to stop accepting new referrals for elective (planned) treatment for Welsh patients.
The Trust said this decision was due to ‘unresolved funding issues’, but that it was working in partnership with Betsi Cadwaladr Health Board to resolve the matter.
Earlier this month, the First Minister told an Assembly Committee:
“Over the period of devolution, there have been regular suggestions from English providers that, somehow, Wales doesn't pay our bills. And every time that has been looked at, that has turned out not to be true. We always pay our bills, and we will, of course, pay our bill in relation to north Wales patients in the Countess of Chester.”
In all areas of healthcare, there is significant cross-border flow of patients between Wales and England.
For hospital services, lack of provision in the patient’s locality is a key factor. Some areas may not have the population base necessary to support a large hospital or specialist centre, and patients from these areas may need to travel further – including across the border – for treatment. In 2017-18, around 60,000 Welsh residents were admitted to hospitals in England. In the same period, Welsh hospitals treated 11,000 English residents.
In primary care, patients living in border areas may choose to register with a GP as close to their home as possible, even if this isn’t in their actual country of residence. In January 2019, approximately 13,500 Welsh residents were registered with a GP in England, and more than 21,000 English residents were registered with a GP in Wales.
For the patients involved there may be uncertainty about their position where there is a policy divergence between the Welsh and English NHS. Frequently asked questions include: are they able to choose the hospital they’ll go to for treatment? How long should they be waiting to start treatment? Does Wales’ free prescriptions policy apply to them?
Cross-border principles
In England, patients have the right to choose which hospital they’re referred to by their GP. This also applies to Welsh residents in border areas who are registered with an English GP. This legal right lets patients choose from any English hospital offering a suitable treatment that meets NHS standards and costs.
The Welsh NHS does not operate a system of patient choice but looks to provide services close to a patient’s home where possible. Under a previous protocol, English residents with a Welsh GP would automatically be referred for treatment in Wales. The new Statement of values and principles (November 2018) allows English residents who are registered with a Welsh GP to choose whether to be treated in Wales, or to receive their treatment at an English hospital of their choice. The new arrangements aim to address concerns that English patients were being denied rights under the NHS England constitution, such as patient choice of hospital, and to have their treatment delivered within NHS England’s target waiting times. For Welsh residents with a GP in Wales, the situation remains unchanged and they do not have a statutory right to choose which hospital they are referred to.
The following table summarises what patients should be able to expect in terms of standards for access to healthcare depending on residency, GP location and provider. (As well as waiting time targets this includes clinical thresholds for treatment and other referral criteria specified by the Local Health Board or Clinical Commissioning Group).
Free prescriptions
All patients registered with a Welsh GP are entitled to free prescriptions, including English residents with a GP in Wales. However, prescriptions are only dispensed free of charge at pharmacies in Wales. Patients who have their prescriptions dispensed outside Wales will be charged at the rates that apply in that country.
Welsh patients who have an English GP are also eligible for free prescriptions, but would need to apply to their Health Board for an ‘entitlement card’.
Welsh patients who are treated at hospitals or out of hours services in England, and are charged for prescriptions at the English rate, are able to claim a refund.
Funding arrangements
Emergency care
Health Boards in Wales and Clinical Commissioning Groups in England are responsible for commissioning accident and emergency services for anyone present in their geographic area, regardless of the patient’s residency or GP location.
Primary care
For primary care services provided across the border, including GP services, dentistry, and ophthalmic services, there is also no funding flow between England and Wales. Any costs fall where they lie, in what’s been described as a ‘knock for knock’ arrangement that broadly balances itself out. Wales’ then Health Minister told the Welsh Affairs Committee’s follow up inquiry into cross-border health arrangements:
“At primary care, we essentially operate on a knock-for-knock basis. The Welsh NHS picks up the costs of primary care for some patients who live in England and the English NHS picks up the primary care costs for some patients who live in Wales.”
Secondary care
In relation to patients registered with a cross-border GP, the aim of the Statement of values and principles is that there will be no financial shortfall on the part of a Welsh Health Board or Clinical Commissioning Group in England in providing healthcare services to the other country's residents.
The Welsh Government receives an annual payment from the UK Department of Health in recognition of the additional secondary care costs that fall on the Welsh NHS as a result of the net import of patients into Welsh primary care (ie there is a greater number of English border residents registered with a Welsh GP). The current settlement figure is £5.8 million.
Where English residents with an English GP receive secondary/tertiary care services in Wales, payment for their treatment is agreed locally between the Welsh provider and English commissioner. There is no standard tariff used within NHS Wales. The rate of payment should reflect the cost to the Welsh provider of undertaking the activity.
For Welsh patients (with a Welsh GP) receiving treatment in England, Welsh commissioners (Local Health Boards and the Welsh Health Specialised Services Committee) pay English providers, either under contractual or non-contractual arrangements, as per national tariff prices.
In reference to the ongoing situation between Countess of Chester Hospital and Betsi Cadwaladr Health Board, the First Minister told Assembly Members:
“Welsh patients are part of their bottom line in the way that the English system is run, and, if they choose not to provide those services, then they will have to face up to the fact that the income stream that they rely on that comes from Wales is not going to flow to them in future. So, there are very good reasons why the Countess of Chester needs to come to the table in a constructive way of resolving these things, as we will too.”
On 11 April, the Health Minister issued a statement outlining the action taken by Welsh Government.
“My priorities are to urgently resolve this local issue and ensure we have robust and fair cross border payment arrangements agreed that has patient care at its forefront.
Officials have been actively engaging with Betsi Cadwaladr University Health Board (BCUHB) to ensure that discussion and communication is taking place with partners and information and support is being provided to patients. BCUHB are putting in place interim systems and processes to ensure that patients receive the care they need.”
Article by Philippa Watkins, Senedd Research, National Assembly for Wales
