The following amendment has been selected: amendment 1 in the name of Caroline Jones.

We now turn to the Welsh Conservatives debate. I call on Angela Burns to move the motion.

Motion NDM6177 Paul Davies

To propose that the National Assembly for Wales:

1. Believes that promoting the innovative use of cross-border healthcare can offer improved patient outcomes for people in Wales and England.

2. Notes the findings of the Silk Commission, which made recommendations to improve cross-border health delivery, particularly to promote closer working in relation to specialist services.

3. Calls on the Welsh Government to reflect on the findings of the Welsh Affairs Select Committee report on cross-border health arrangements between England and Wales, which reflects concerns about the difficulties and delays in accessing secondary and specialist services on a cross-border basis.

Motion moved.

Thank you, Deputy Presiding Officer. I wish to move the motion before us today, tabled by the Welsh Conservative group, and, by doing so, highlight the innovations that cross-border healthcare can offer in improving the outcomes for patients on both sides of the border. We would also wish the Assembly to note the very sound recommendations made by the Silk commission, which are reflected also in the Welsh Affairs Select Committee report on cross-border health arrangements. We ask the Welsh Government to recognise the challenges that cross-border working brings.

Our motion today, Deputy Presiding Officer, will look at ways of improving patient outcomes for patients based on both sides of the border, will consider the recommendations made on this issue by the Silk commission, and will also use the evidence taken by the Welsh Affairs Select Committee to highlight a number of concerns raised by patients and other health organisations. We will also seek to make constructive suggestions for improving cross-border healthcare. The challenges of cross-border healthcare are unlikely to prey upon the minds of most of us, and yet it is an issue that impacts on every one of us living in Wales. It doesn’t matter whether you are one of the 50 per cent of Wales that lives within 25 miles of the English border, or any other user of the NHS, because we rely on being able to access services, from GPs to specialist care, from the English NHS. Yet many patients and organisations find that the system is often mired with confusion and uncertainty because they are not really aware of where they are getting their services from.

Over the years, very clear differences in health policy between Wales and England have developed. Devolution has enabled the respective Governments to promote policies that they see fit to reflect the needs of their own populations. However, it does mean that we need to be more alive to problems that this may generate, and find a more robust and constructive solution. These problems are not insignificant, given that some 56,000 Welsh patients are admitted to English hospitals every year. The Welsh Affairs Select Committee report says that there’s no practical or realistic prospect of diverting these well-established cross-border flows, nor would it be desirable to do so. So, we say that, whilst there is no way of altering this pattern, there must be ways that we can improve the situation so that patients on both sides of the border get fair access to health treatments.

Geography is not the only challenge that we face. The sparsity of our population gives us problems in equity of access to health services, and so it is a real positive that many rural communities in Wales are able to access health services by crossing the border to a centre closer to them rather than having to travel miles within Wales, particularly if they’re relying upon public transport.

Now, to try and address some of the challenges faced by the respective services, a cross-border protocol was introduced by both Governments, with the latest iteration being in 2013. This protocol sets out who is responsible for providing which services and to whom. However, the seven Welsh LHBs do remain responsible for Welsh patients. In turn, the English clinical commissioning groups remain responsible for English patients. Now, this can and does cause tensions, which can arise when different policies come into play on either side of the border, and we have a situation where one set of rules can apply to different patients at the same surgery, depending on where they live, or different rules even apply to neighbours, depending on which GP surgery they are registered at. Another tension comes over disparate policies between Wales and England concerning patients choosing their own location for treatment. If they’re in the English system, they can choose which hospital to go to. However, this freedom is frowned upon by the Welsh Government, who state that providing patients with more of a voice is important. Now, this debate isn’t about looking at that policy. The challenge of patient’s voice against patient’s choice means that those English patients receiving their treatment in Wales lose the rights that their countrymen have across the border. So, we’re seeking equity across the whole piece.

Waiting list targets are another issue that causes tension. Ninety-five per cent of English patients have a legal right to start treatment within 18 weeks of referral, and no-one is expected to wait over 36 weeks. However, in Wales, our ambitions are not set so high, with a 26-week target for starting treatment, but there is no legal right. According to figures from last month, almost 5 per cent of patients in Wales waited longer than 36 weeks from referral to treatment. Figures show that, even for routine procedures, waiting times can be as much as two and a half times longer in Wales as in England. This is a very confusing situation for those who live around the borders of our country. Worryingly, the Welsh Affairs Select Committee highlighted that many clinical commissioning groups operating along the English side of the border operate two waiting lists within the same surgery—a Welsh list and an English list. Now, can I and my colleagues here echo the views of the committee that the Welsh Government and the Department of Health need to resolve this problem, and as a matter of urgency? So, Cabinet Secretary, could you provide assurances that this will happen, and that you will address this as a matter of urgency? It seems to be highly unfair for one surgery to operate such a difference between whether you’re a Welsh or an English person.

The Welsh Affairs Select Committee report, which was published in March 2015, also stated that the then Welsh Minister had said he would move to amend the necessary regulations in Wales to remove barriers to GPs providing services on either side of the border. I think that’s a very welcome step forward.

Cabinet Secretary, I would be interested to know whether any progress has been made on this subject, and whether, in fact, this is an ambition that you would want to see happen. I understand that the protocol is subject to a three-year review. As I’ve already established, the last protocol was drawn up in 2013, so I believe I’d be correct in saying that we must be due another review before the end of this year. Cabinet Secretary, will you provide an update as to whether this review has taken place, and, if not, do you intend to review, and when might we see such a review?

The Silk commission, which reported in March 2014, goes further than the provisions of the 2013 protocol and argues that current arrangements should be strengthened by developing individual protocols between each border local health board in Wales and the neighbouring NHS Trust in England. I wonder if you’ve got any views on whether or not that should be moved forward.

Additionally, Silk called for English and Welsh health services to work more closely together to develop better joint strategies to maximise joint efficiency savings, but there’s a lack of clarity as to how far that has been moved forward. We need to make the cross-border situation more of a level playing field when compared to services other people in Wales can access. So, can I ask, Cabinet Secretary, that, when policies are introduced in health in this Assembly, they are automatically assured or looked at to ensure that they are suitably border-proofed so that Welsh people are not disadvantaged overly if they are going to an English GP? I appreciate it may only affect a relatively small number of people, but this needs to be done to provide greater consistency in healthcare and also fits into some of our discussions yesterday emanating from the chief medical officer’s report surrounding reducing health inequalities.

I know my colleagues will wish to speak more about individual areas on the border, but it’s worth touching on some of the key issues. Due to the free-prescription policy, patients from Wales being discharged from an English hospital sometimes are asked to pay for their own medicines and then have to try and claim back. Also, the policies pertaining to discharge to social care are different between the two countries, leading, quite often, to patients routinely facing delayed transfers of care. May I just add a quick rider here? This is not just stuff I’ve dug out of nowhere. This has come from the Silk commission report, from the Welsh Affairs Select Committee report, and from the NHS Confederation. So, these are all verifiable instances that are happening out there today.

Finally, the lack of co-ordination between IT systems on either side of the border is fast becoming a problem. Although I know there’s currently a study going on surrounding establishing an electronics referral system between Welsh GPs and English hospitals, I would like to know how this pilot is progressing and when we will learn of its outcome. I really feel the issue of IT services is important. If we can get this right, it may really help to streamline services and outcomes.

Evidence was given to the Welsh Affairs Select Committee from a doctor based at the Countess of Chester Hospital in England who deals with diabetes. He described how blood samples taken by Welsh GPs are sent to Wrexham Maelor, even though the patient is under him. Due to a lack of cross-border compatibility, he is unable to access the results and provide a full consultation. The Royal College of Physicians backed up this view and gave evidence as to how it was often easier to repeat blood tests rather than find results from across the border. This has just got to be a shocking waste of time and money. We need to be able to resolve this. The committee went on to detail how there is currently no joint programme of work between the English NHS and the Welsh Government around central IT arrangements.

I do recognise there’s a divergence of approach here, with England looking at improving interoperability for local IT services in England, and we want to develop a single national system. But I’m sure, Cabinet Secretary, you will agree about the importance of patient information being transferred effectively between primary, secondary and tertiary services, no matter which side of the border they’re on, and across the border. So, I wonder if you can tell us or give us some guarantees that this issue will be addressed as soon as possible. Would you also consider a short-term fix that may be given that would enable patients who are receiving cross-border care to have a hard copy or an electronic copy of their records to take with them to their appointments? I believe we can trust patients to take care of their own medical data.

The OECD report into the quality of the UK’s health service raised concerns over the whole area of cross-border and, whilst they found that there were good joint-working arrangements, they did propose that collaborations could help health boards deliver meaningful change by a range of initiatives, such as mentoring partnerships between health boards, staff exchanges and ensuring open comparison of results. I would be interested to learn from you, Cabinet Secretary, if you intend to take any of those OECD recommendations forward.

Cabinet Secretary, the Welsh Conservatives would like to see both national health services, and the relevant commissioning groups, and the Governments of the two countries, working together in a consensual way to ensure that patients on both sides of Offa’s Dyke get the best possible deal. With more cross-border co-operation, we may be able to better address the concerns that have been raised by many of the witnesses to the various committees. We may also find ourselves in a better position to tackle some of the staffing issues that currently face the Welsh NHS and reduce the ever-increasing reliance on bank and agency staff. And with the workforce pressures in mind, I would confirm that the Welsh Conservatives will be supporting the amendment put forward by UKIP. I trust, Cabinet Secretary, that you’ll take our observations forward, and I look forward to your answers to the questions I’ve raised.

I have selected the amendment to the motion, and I call on Caroline Jones to move amendment 1 tabled in her name—Caroline.

Amendment 1—Caroline Jones

Add as new point at end of motion:

Notes the problems in recruiting GPs in rural cross-border areas and calls on the Welsh Government to work with the UK Government’s Department of Health to establish a single performers list for GPs which will enable GPs to operate on both sides of the border.

Amendment 1 moved.

I move amendment 1 in my name. Diolch, Ddirprwy Lywydd. I would like to thank the Welsh Conservatives for bringing forward this debate today. As the Welsh Affairs Committee discovered, the increasing divergence between the healthcare systems over the border not only causes confusion for patients who rely on cross-border services, but also difficulty in accessing services. As others will no doubt mention, witnesses to the Welsh Affairs Committee identified problems due to in-country commissioning and a lack of compatibility between healthcare infrastructure on either side of the border. But I want to focus my contribution on the third area, namely GP performers lists.

The maintenance of separate performers lists in England and Wales not only affects the ability of GPs to operate freely on either side of the border, but, as the Welsh Affairs Committee discovered, acts as a barrier to GP recruitment. According to both the British Medical Association and the Welsh NHS Confederation, many GPs will not go through the process of applying separately for inclusion on the list in the neighbouring country, and this has prevented GPs on the English performers list from taking up vacancies on this side of the border. The BMA also highlighted the fact that separate performers lists were preventing locums from operating across the border. This is adversely affecting care, particularly in rural areas close to the border. It has always been difficult recruiting GPs in rural areas, and with an ageing population of GPs, we are starting to see more and more rural practices close. However, if those practices were able to rely on support from neighbouring practices on the other side of the border, we would be able to offer primary care in those areas.

The people of Wales expect a national health service—a service that delivers first-class healthcare, regardless of where you live or where you receive treatment. The inability of GPs and locums to operate cross-border is adversely affecting healthcare in rural Wales. I am not opposed to increased divergence in the healthcare systems in England and Wales, but that divergence should not impact on the level and quality of treatment for patients. UKIP believes there should be a single performers list for England and Wales, and calls upon the Cabinet Secretary to work with the Department of Health to achieve that aim. Bureaucracy and processes should never get in the way of patient care. I urge Members to support the amendment tabled in my name. Diolch yn fawr. Thank you very much.

I’d like to thank Angela Burns for introducing our debate and the issue so well today. Matters of healthcare have dominated my inbox and my postbag since becoming an AM, but I suspect that’s the case for Members across the Chamber. But, because of the cross-border elements in my own constituency, the issue is all the more dominant, and in my contribution today, I would like to highlight some of the issues that my constituents face in accessing cross-border health services.

Now, of course, the county of Powys is the most sparsely populated and the largest geographical county in Wales. And of course, that brings us unique challenges. Powys has no district general hospital. Residents are served generally by the Royal Shrewsbury Hospital, the Princess Royal Hospital in Telford, or by Gobowen. Residents in the west of Montgomeryshire are served by Bronglais, but 80 per cent of my constituents are served by hospital services over the border, and this means, of course, for my constituents, they have to travel huge distances to access healthcare services. The differences in policy between England and Wales have a direct impact on the access to, the consistency of and the quality of care for patients in my constituency. Many patients suffer from a postcode lottery when it comes to waiting times, funding decisions and different treatment priorities. This means that mid-Wales patients often fall between the administrative cracks when accessing care. This is an issue that is the biggest in my postbag, perhaps more so than other AMs. I’m dealing with those administration issues of people falling between two different systems.

I’ll give a few examples here. One of my constituents—I’ll call him Mr L—requires a transcatheter aortic valve implantation—I hope I’ve pronounced that correctly—at Stoke university hospital, but funding has been declined twice. If Mr L was a resident in England, he would have had the operation without even the need for a funding request in the first place. Mr L, of course, is informed by consultants of the situation, because they are frustrated as well; consultants are frustrated that they have to operate a two-tier system; they’re frustrated that they have to give less of a service, as they see it, to Welsh patients.

Mrs E and Mr M need a total knee operation and a complete left hip respectively. Both are waiting 26 weeks for an operation in Gobowen, instead of 18 weeks if they were resident in England. The different waiting times, also—. The different targets, I suppose, that both hospitals have to work with in regards to two sets of targets is, of course, an issue here. Hospitals are facilitating a two-tier system when it comes to supporting Welsh and English patients. I’m forever getting this issue raised with me, where a patient will be told, ‘Ah, Mrs Jones, you’re going to have to wait 18 weeks’, and then as the consultation continues, ‘Oh, hang on, I notice you’re from Wales, it’s 26 weeks’. That’s a regular occurrence. That perhaps wouldn’t happen if a patient lived in Wales and went to hospital in Wales. The consultants are normally used to seeing English patients, so this is one of the issues that comes about.

A number of constituents have also expressed a big concern about PET scans, where normally only one PET scan would be allowed. But, of course, in England, two PET scans are allowed—usually one before the operation and one post-operation. So, the confusion regarding waiting times, funding arrangements and treatment priorities is rife, and my message to the Welsh Government, and the UK Government for that matter, is: work together to break down these barriers and provide clarity for patients and clinicians.

I strongly agree with the Welsh NHS Confederation, which has said that there needs to be greater cross-border citizen engagement to raise awareness of devolution and the differences in treatment availability. Again, this is one that fills my postbag. I’m forever replying to constituents saying, ‘This is my advice for how you deal with your particular request, and I’ll make representation on your behalf’. Then I’m going on to give them a lesson in devolution, because often one of the issues that is raised is, ‘I’m a taxpayer, we’re supposed to have a national health service, what’s gone wrong here?’ And, of course, then I’m answering, ‘Well, actually, you’re wrong; we have no longer got a national health service, we’ve got two different Governments with different priorities’. I’m forever answering that, perhaps on a weekly basis.

The Welsh Affairs Select Committee—

Are you coming to a conclusion, please?

I will come to an end in that case. I would just say in that case, Deputy Presiding Officer, that when we are making policies, we should be making sure that they are border-proofed to provide consistency of healthcare.

When you have a country where 50 per cent of the population live within 25 miles of the English border, the matter of cross-border healthcare is an essential one. We can’t draw a neat line and insist that the population living on the border must trot off to be seen just by the Welsh NHS staff. It’s unrealistic, it’s impractical, but most of all, it simply wouldn’t suit many members of the public who live on the border. So, having a constructive and healthy relationship between health boards on both sides of Offa’s Dyke is imperative, and this week’s publication of the report on the sustainability and transformation plans for Shropshire and Herefordshire are critical to healthcare delivery in Powys—an area that I, like the Member opposite, represent.

Now, whilst we in Wales recognise the importance of cross-border working, I think it’s worth noting that, in the guidance to English trusts, the Tory Westminster Government made no reference to cross-border working arrangements nor the care that should be provided to Welsh patients. I therefore welcome the fact that this omission is recognised by the Shropshire, Telford and Wrekin partnership board and that there is a specific reference by the English health boards that their hospitals are the main providers of acute care for communities in Powys and that they understand that within those transformation plans.

But let’s be clear, whilst it’s true that Wales needs our border patients to be treated in Shropshire and Herefordshire, their services would not be sustainable without Welsh patients—without the money given to them by the Powys teaching health board. For many people living in Powys, the majority of their hospital care is provided in England.

The recently published strategic commissioning framework sets out how the Powys teaching health board works with providers in Wales and England to deliver the standards of quality and access that they expect on behalf of Welsh patients in line with Welsh and UK arrangements for cross-border healthcare. It also helps to deliver the recommendations set out in the Welsh Affairs Committee report on cross-border health arrangements.

Now, I’ve met with health campaigners in Powys who have real concerns, in particular about access to primary care. GP recruitment is not just a problem on the border; it’s a problem that we encounter across most of Wales and I do hope that the Government recruitment drive on this issue will go some way to resolving this problem. I think it’s worth underlining that for patients and providers in Powys, the added difficulties of working across two governments, differing structures and political direction, does mean that there is an issue in terms of accountability. But I don’t think it’s impossible for health providers, even at primary level, to come together to do what’s right for patients and to provide a seamless service. There’s an example of this where GPs on the Powys-Shropshire border are working closely together for the communities in Knighton and in Clun. Now, the two current practices have worked alongside the health board to overcome the challenges of rural healthcare across that border and they therefore are meeting the expectations of the Welsh Labour Government’s programme for government.

This morning, the Future Fit programme board met and recommended a set of preferred options for the delivery of healthcare that will impact patients in Powys and in particular patients in Montgomery. These recommendations end years of uncertainty about where services should be delivered. So, whilst I welcome the return of a consultant-led women and children’s centre to the Royal Shrewsbury Hospital, I’m keen to explore further the impact of moving the majority of day-case surgery to Telford. I’ll be meeting with Powys teaching health board in the new year, seeking to establish if more day-care surgery can take place this side of the border, reducing travel time for Welsh patients. In many ways, the border between England and Wales might seem bigger than ever, but in terms of healthcare, as we’ve seen just today, through collaboration, positive engagement and respect for the NHS on both sides, progress can be made to resolve those problems that are felt on both sides of the border.

Speaking in the Welsh Conservative debate on cross-border issues here in May 2009, I stated:

‘Cross-border movements in health…services are a long-established fact of life, reflecting geographic and demographic realities.’

I referred to the Welsh Affairs Committee report on cross-border services then, which concluded that there was a lack of effective communication between the Welsh Government and the Department of Health in England, and called for the two to work together to ensure that Welsh residents’ rights to access English services are protected and vice versa. They considered that an improved Government-level protocol was essential to standardise and clarify funding arrangements and accountability mechanisms, stating that the result should be seamless care for patients based on clinical need.

The Flintshire governors on the board of the Countess of Chester Hospital had stated that their hospitals of first choice are the Countess of Chester and the teaching hospitals of Liverpool, and orthopaedic patients had expressed their need for continued access to Gobowen hospital. They referred to the Welsh Affairs Select Committee’s statement that citizen engagement should not stop at the border, and to Flintshire local health board’s annual report the previous year, which said that more Flintshire patients were treated as out-patients, day cases or emergency cases at the Countess of Chester Hospital than at either Wrexham Maelor or Glan Clwyd hospitals.

Although the Welsh Government health Minister, during the third Assembly, stated that her overriding aim was to secure as many services as could be safely provided within Wales’s boundaries, and although the impartial Assembly Research Service told me in 2013 that they’d spoken to a Welsh Government official who confirmed that it was Welsh Government policy to repatriate Welsh patients presently served in English in-patient settings, the last Welsh health Minister wrote to me stating that this information is incorrect—there is no hidden policy to repatriate Welsh patients. However, in a meeting with the Countess of Chester Hospital in September 2013, I was told that Betsi Cadwaladr University Local Health Board was reducing or cancelling referrals and pulling activity back across the border, despite not having the capacity. As they said, the focus should be the patient and they wanted to contribute to the provision of quicker, better and more economic cross-border care.

Early last year, the Welsh Government announced that it was commissioning pain management clinics from England, after waiting lists in Wales reached 78 weeks. I’ve been contacted by constituents in pain who’d always received their treatments at the Countess of Chester, but were now instead being added to long waiting lists in Wales. When I took this up with the health board, they acknowledged that there was a waiting time for this service, but said that they had not been able to secure additional NHS capacity in north-west England. So, I contacted the chief executive of the Countess of Chester who replied that Wales withdrew from their pain service two years previously, and as a consequence, they could no longer accept Welsh referrals. But he added:

‘maybe this is something that you might discuss with the Welsh Government to see if there’s a political will for us to be seen as part of the North Wales acute healthcare solution.’

When I did this, however, the then health Minister simply passed the buck back to the health board.

Although the Wales-England protocol for cross-border healthcare services was implemented in April 2013 to improve communication, the Welsh NHS Confederation states now that the decision-making process on each side of the border needs to be more co-ordinated, coherent and transparent. The 2016 Welsh Affairs Committee report on cross-border health arrangements between England and Wales expressed concern that there’s a lack of communication regarding changes to healthcare services, which could have an impact across the border, and recommended that formal protocols are put in place to ensure consultation between Welsh local health boards and English clinical commissioning groups, when changes to services impact on populations across the border.

As Dr Dai Lloyd said here in 2009:

‘Mature nations work together across boundaries in historical time-honoured fashion for the better health provision of all of their people.’

Excellently put. As I then said, we must avoid at all costs a slate curtain in services between these two British nations. Our long and porous border should be a cause for celebration and co-operation, rather than an obstacle to efficiency and effectiveness.

Plaid Cymru will be supporting this motion and the amendment. The recommendations made by the Welsh Affairs Committee are sensible ones, and I hope that Governments on both sides of the border consider them. A cross-border flow of patients is, of course, one of the facts of life across Europe, and certainly worldwide. I’m sure it often makes sense for a patient to cross a border to receive the appropriate treatment. I could draw your attention to several examples of collaboration, for example the sharing of health facilities in that low-population area on the border between France and Spain in the Pyrenees; insurance brokers in the Netherlands contracting with hospitals in Belgium for specialist services; and French women choosing to give birth in Belgium because the hospitals there are closer to them and because of a perception of a better standard of care. So, this is nothing new and it benefits everyone that we get things right, and to organise the kind of collaboration that takes place.

There are a couple of matters that I’d like to raise. The first is that there are several proposals on the table to centralise emergency services in England, and it would appear that many more are in the pipeline. These will inevitably affect people in parts of Powys and north Wales especially, who will face even longer journeys in emergency situations and a corresponding increase in risk as a result. I do ask the Welsh Government to acknowledge this and to consider what arrangements can be made to mitigate the effects of these changes. This isn’t an argument against cross-border services. Remember what I said earlier—cross-border travel does happen when it makes geographical sense. But in a situation where people have to travel over three hours in north Wales for services across the border, then that’s not the same thing. It’s unacceptable. Distances of that kind suggest to me the need to plan a health service that’s more appropriate for a rural area.

The second point is that changes to services could benefit Wales if we have the right mindset here. Too often, I think, in the past, specialist services have been seen as something that the people of Wales must travel to England to receive, perhaps because we don’t have the population levels to justify such services. But do remember that more people from England come to see a GP in Wales than go the other way for primary care. But if we consider people in England who live on the border as prospective users of specialist services in Wales, then we could justify establishing, or developing or strengthening these kinds of services here, and bring funds into the service located here, as well as—and this is an important point—increasing the attractiveness of the NHS in Wales for prospective staff and so on. I would therefore ask the Government and the Cabinet Secretary to keep an eye on changes to services in England to see whether changes there give us scope to extend our services here. After all, as we heard from Eluned Morgan, our population here does add to the critical mass to help support and maintain services in England, and we could overturn that by offering more services to our neighbours.

Finally, I want to discuss those cross-border issues that don’t affect Wales and England but affect Wales and the rest of Europe. I’m talking about the rights that Welsh citizens have to access medical treatment in Europe by carrying a European health insurance card, and, of course, the reciprocal rights that European citizens have when they visit Wales. Even though I’m sure I can leave one party in this Chamber out of that consensus that’s developing on cross-border treatment, the rest of us, hopefully, continue to be supportive of cross-border Wales-European health services of this kind. So, I would seek that assurance that this kind of cross-border healthcare is not going to be left off the table in Government discussions.

In conclusion, as I say, Plaid Cymru will be supporting the motion today, and I note, in my final words, that if the rest of Europe can agree on the practicalities of cross-border healthcare, then certainly issues between Wales and England on a cross-border basis can also be resolved, for the benefit of people on both sides of the border.

Healthcare pathways for patients have always crossed the Welsh and English borders. Before devolution, this was not a problem as there was a single NHS. The NHS Act of 1946 provided for the establishment of a comprehensive health service for England and Wales. The United Kingdom Government was responsible for services in both countries, although from 1969 the NHS in Wales became the responsibility of the Secretary of State for Wales. Now, with the advent of devolution, responsibility lies with the Welsh Government. However, since half of the Welsh population live within a 15-minute drive by bus, car or ambulance to the border, movement across it to access health care is routine. Around 55,000, as Angela just said, Welsh residents are admitted to hospitals in England each year. Welsh hospitals admit some 10,500 people resident in England. There are just under 21,000 English residents registered with GP practices in contract with the Welsh NHS. The figure for Welsh residents registered with GPs in England is somewhere between 15,000 and 16,000.

We all want to see people get the treatment they need in the best place for them. Clearly, sometimes those services will be across the border. The Welsh Affairs Committee, in their report, found concern about difficulties and delays accessing secondary and specialist services on a cross-border basis. In particular, patients were worried about a perceived move towards in-country commissioning on the part of the Welsh Government. They believed the ultimate aim was to treat all Welsh patients within Wales irrespective of whether it was in their best interests. In some cases, patients living in south-east Wales receiving treatment at Hereford or Bristol were told that Aneurin Bevan Local Health Board would no longer fund their treatment. Aneurin Bevan Local Health Board introduced a policy in September 2012 of minimising referrals outside of Wales. They said, and their quote is:

‘the Health Board is the primary provider of secondary care services for the resident population of…Gwent…Where this cannot be provided by the Health Board’s own services…then the Health Board will look to plan and secure the necessary services with other NHS Providers in Wales through its agreed care pathways.’

Quote closed. Only if a Welsh health board could not provide the appropriate services would Aneurin Bevan health board look across the border. Although they changed this policy in 2013 for English residents with a Welsh GP, they did not do so for Welsh residents. As a result, prior approval is still required before a Welsh patient in Gwent can be referred to an English provider for treatment.

Many specialist services are simply not available in Wales, Deputy Presiding Officer. Specialised services are commissioned on a national basis by the Welsh Health Specialised Services Committee. Concerns have been expressed that it is not always possible to formalise service level agreements between Wales and England due to key differences in the contract documents. Key differences cited include differences in access criteria, waiting time targets and the fact that Wales does not operate a patient choice scheme. Different IT programmes in use in the healthcare services in Wales and England also make it difficult for primary, secondary and tertiary systems to communicate with each other across the border. Deputy Presiding Officer, cross-border movements to access healthcare have existed for many years. For many residents of border areas the nearest health provider may not be in their country of residence. It is vital, therefore, that the border does not become a barrier to accessing the best healthcare. If we promote the innovative use of cross-border healthcare, we can deliver the improved patient outcomes we all wish to see in Wales.

Finally, I would like to ask, Minister: the waiting list and the cancellation of patients in Wales are really, really at crisis point. I know that, for some of my own constituents, at least half a dozen times, their operation was cancelled after waiting two and a half years. And after that—the sixth time—the operation was cancelled. What a disaster in the NHS. We should use our own family to operate, within not only an 18-month wait but before an 18-month wait, and let these waiting lists be shortened as soon as possible in Wales. Thank you.

As an Assembly Member serving constituents for whom accessing specific services across the border is the norm, I welcome this debate and the opportunity to be able to briefly contribute. I have already raised many times in this Chamber how the north-east of Wales is economically and culturally connected to the north-west of England, and the border assists as a two-way path to prosperity, as opposed to a somewhat artificial barrier. Indeed, there should also be no such barrier when it comes to accessing specialist secondary services. For those living in parts of north Wales, accessing specialist services in the north-west is a standard practice that predates devolution. I, like many of those living in Delyn and across north-east Wales, have experienced this at first hand and seek the same as everyone else for my nearest and dearest, that is, ensuring the best possible specialist treatment as close to home as possible, whether that be heart surgery at Broadgreen Hospital in Liverpool, or cancer treatment at Clatterbridge hospital on the Wirral. I welcome the cross-border protocols put in place by the Welsh Government for the treatment of patients who have been referred across the border, but the challenge is actually how they are followed and implemented to best effect on the ground, on a day-in, day-out basis, and of course to make sure that any Wales-domiciled patients receiving treatment in the NHS in England are treated no less favourably than their England-dwelling counterparts.

From the correspondence and conversations that I have had with constituents, it seems that better communication with users of cross-border health services at a primary care level is key, even at the basic level of people understanding why they are being referred for specific treatment across the border. By taking steps to build on the work of the Welsh Government in respect of cross-border healthcare, and by actually working together at all levels, we can and must ensure the provision of the best possible high-quality care for patients who access cross-border health services.

Thank you very much. I call on the Cabinet Secretary for Health, Well-being and Sport, Vaughan Gething.

Thank you, Deputy Presiding Officer. I would like to thank Members for tabling a debate on this topic, so we can discuss the reality of cross-border treatment for patients between England and Wales. The Welsh Government, of course, has been keen to ensure that the approach to cross-border patient flows is sensible and pragmatic and to focus on providing the best care for all of those who need it. That has been the primary focus of the cross-border protocol.

The Welsh Government’s aim is to ensure that all patients receive high-quality healthcare at the right time and in the right place. Sometimes, services provided across the border in England will be what is best for Welsh patients. There have, as has been discussed today, long-established patient flows into England for hospital-based care. Local health boards have the flexibility to refer patients out of their area for treatment, where a patient’s clinical need and circumstances justify it, or where services are not provided in Wales.

There is, though, the reality of the party political approach that has been taken to describing NHS Wales, which has unfortunately got in the way of some of the debate. The Offa’s Dyke comment was not particularly helpful, and has still not really been undone. But, to be fair, and to Angela Burns’s credit, she has not taken that partisan approach to talking about cross-border healthcare and what we actually need to do about it. [Interruption.] Suggestions that NHS Wales don’t pay on time were previously made in the past by English organisations in suggesting that NHS services in Wales weren’t paying upfront for Welsh patients. That simply isn’t true. That was really disappointing and actually damaged relations at one point in time between different organisations that were having to treat Welsh patients. Indeed, it is right—and many people in this Chamber have made this comment before—that those services over the border do rely on Welsh patient flows to make those services sustainable. So, there is a need to have a genuine and sensible conversation about how patients get treatment and where they get it.

And, of course, it isn’t just the standard secondary care treatment because, of course, there are specialist services, where people do need to go over into England. Hannah Blythyn described some of those in her comments. Of course, north Wales has a link to the trauma centre in Stoke. Now, that has actually improved outcomes. People travelling further geographically to go to the right centre in England has actually made a real difference for them in improving outcomes. That’s a good example of commissioning the right care, at the right time and in the right place to the benefit of patients in north Wales.

But of course, there are not just patient flows out of Wales and into England because Morriston Hospital in Swansea serves as a specialist burns centre for Wales and south-west England, and Velindre Cancer Centre in Cardiff provides specialist cancer services for Wales as well as treating a number of patients who are referred in from England. We do know that there are challenges in some settings in England where Welsh health boards commission care normally—Powys and Betsi in particular. Services in the Wye valley, Gloucester and Shropshire clinical commissioning group, for example, have been—or still are—in special measures. It is a matter that I discuss regularly when I meet people from Powys Teaching Local Health Board—how they are safeguarding their own assurance about not just the quality of care, but the timeliness of that care, and to make sure, as has been suggested in some of the comments, that Welsh patients aren’t treated in a less favourable manner, and that they’re getting the care that they’re actually commissioning. So, it is a regular part of the conversation at a performance level as well as at a more strategic one.

We also know, unfortunately, that some of the specialist gender identity service in Charing Cross clinic will be discontinued, and that brings us back to the challenge, I guess, at the start of this—how do we ensure that the right care is delivered at the right time and in the right place for the public that we are here to serve?

I note the findings of the Silk Commission, and I’m happy to inform Members that the Welsh Government is in ongoing discussions with NHS England concerning healthcare provision along our border. These discussions more recently focused on GP referral arrangements, and we will be taking account of the wider needs of border patients who will benefit from a more formal agreement being put in place. Because as has been recognised, there is more cross-border flow of primary care patients into Wales than out. Over 20,800 English residents are registered with a Welsh GP, compared to 14,700 Welsh residents registered with an English GP.

As a Government, we would not look to instigate or prevent individual protocols between local health boards and clinical commissioning groups, as any formal arrangements between those organisations are best undertaken at a local level, by those organisations that are best placed to assess and deliver on individual patient need.

I have looked at the findings of the Welsh Affairs Committee inquiry into cross-border healthcare, and I recognise that many of the conclusions and recommendations highlighted within their report were already being actioned at the time of the report’s publication. Since the committee’s inquiry, the Welsh Government continues to work with the Department of Health in England, and to an even greater extent with NHS England, to help the Department of Health address its issues with non-compliance with its legislation—the legislation in respect of English residents registered with a Welsh GP who require secondary care. This does highlight that some of the challenges here are about different systems, and about the way that NHS England now sets out in an apparent constitution apparent legal rights, so it’s difficult to see how those are enforced. But it doesn’t have a practical impact, I think, on performance, which you know is a real challenge, and meeting some of their waiting time targets. The language in the legislation hasn’t changed that. But there is that real practical conversation to be had about how we get through some of those challenges.

Of course there are real challenges about how some treatments are provided to English residents who see Welsh residents getting a better service. Many of the examples given in the debate today have been the other way around, with people saying, ‘Actually, we’d like to have what England has’, but on a range of issues, for example, Sativex, we understand that that’s a challenge in England, where it hasn’t been available at the same period of time. Ironing out the wrinkles is a two-way process in the way that we talk to each other.

Indeed, I’ve heard the conversation—again, Eluned Morgan’s point—about cross-border healthcare and the way it’s planned. We were previously concerned that conversations were taking place on NHS Future Fit across our border that weren’t properly taking account of the patient flows from Wales in making that choice. Now, we’re encouraged that a choice has been made today, but it does clearly need to go to clinical commissioning groups in England, so we still need to make sure. Those conversations are not yet complete, the decision isn’t yet finalised, and we need to be part of the conversation. Actually, since the start of that, Powys health board are now engaged properly as part of the programme board to understand what is happening in the way those decisions are being made.

We recognise that collaborative working does continue at a local level on the cross-border network. Healthcare commissioners and providers, including GPs, do come together on a quarterly basis to discuss local issues affecting cross-border healthcare. I want to address here the issue of the single performers list, because we won’t be supporting the amendment. We would be happy to see a single performers list, but the Department of Health in England are the issue. They’re not keen to see that happen. We’ve done all we can do to make sure that GPs can be performers on both lists in Wales and in England. We’ve done all that we could do to make that an easier and simpler process. It really does matter in areas across the border. But we want the Department of Health to come and talk to us and actually agree a way forward. We’re not in a position to require them to act in the way that we would wish them to, and that I know Members in this Chamber would wish today. It’s been a helpful discussion on that point, actually, because I simply can’t give guarantees for the English system.

We will continue to make changes that improve NHS Wales, but we can’t be held back by a UK Government refusal to do the same thing either at the same pace or in the same direction. There’s the reality of having differing systems between the borders. I’m keen, though, to do what we could do and should do, and including on the point raised by Angela Burns on sharing patient information. There’s an issue there about the quality of care that people receive.

The challenge isn’t what we do now. The challenge is what we can do to further improve on what we have. I’m happy to work with NHS England to improve outcomes, but it does, of course, require a willing partner and a level of trust. I’m happy to work in that manner now and in the future for the benefit of patients in Wales and England.

Thank you very much. I call on Darren Millar to reply to the debate.

Thank you, Deputy Llywydd, and thank you to everyone who’s taken part in this debate. I think it’s been a good-natured debate and there have been some very important points that have been raised about some of the challenges that are presented as a result of having two different health systems on both sides of the border, and the consequences that many of our constituents face as a result of that, particularly in mid Wales, as Russ George has said, and indeed in parts of north Wales, as has been identified by Mark Isherwood and Janet, and of course we mustn’t forget either, Oscar, your comments in relation to some of your constituents down in Gwent.

These are really serious issues and they do boil down to poor planning, sometimes on the English side and sometimes on the Welsh side, a lack of communication between health organisations on either side of the border when they’re trying to plan for the needs of their population, and a lack of recognition sometimes as well about the differences in terms of the aspirations of the Welsh Government on targets and treatments. It’s all very well, Cabinet Secretary, you saying that every health board has the right to refer across the border—that’s absolutely right—but very often there’s a commissioning process that you have to go through in order to commission those services across the border, or those treatments, or referrals, in a way that there aren’t barriers to English patients having referrals to some of those specialist hospitals.

Very often, my postbag is filled up with reports from individuals saying they’re having problems in accessing some of those services that they need to access. I do recognise that this Welsh Government has given a commitment to maintaining those cross-border health service relationships and that’s very important. We certainly didn’t have it when there was a coalition arrangement with Plaid Cymru in the third Assembly, where there was a deliberate policy decision that was taken to repatriate services across the Welsh border and bring all of those patients back. It was a great disservice to patients in many parts of Wales, that particular policy, but I’m pleased that that situation has now been reversed and that the importance of maintaining these health service relationships is absolutely recognised.

The Cabinet Secretary said another important phrase: he said that Welsh patients shouldn’t be treated in a ‘less favourable manner’ as a result of being referred to a hospital over the border in England. But the reality is, they are. In north Wales, if there’s a patient who is referred from the Betsi Cadwaladr health board for orthopaedic surgery to a hospital over the border in England, even if that hospital is able to treat them within the 18-week target that the English NHS has upon it in terms of waiting-time targets, they are very often having to wait for 52 weeks because the Betsi Cadwaladr health board is saying, ‘You’re not allowed to treat them in any time less than 52 weeks because that’s a disservice’—[Interruption.] That’s absolutely the case. I’ve got copies of letters, Cabinet Secretary, which I’m happy to share with you, if that’s what you would like to see.

Are you winding up, please?

We need to make sure—. I fully agree with your aspiration that there shouldn’t be disadvantage, but we have to begin to realise some of these things and we’re not going to be able to realise those things if you remain ignorant of the facts—[Interruption.]

Thank you. You’re out of time. You had far more time and there were no interventions, so I was generous.

The proposal is to agree the motion without amendment. Does any Member object? [Interruption.] Sorry? No? Sorry, but can you all concentrate? The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Thank you. It’s only because it’s nearly Christmas I’m being generous. Okay then, we’ll defer voting under this item until voting time.

Voting deferred until voting time.

It has been agreed that voting time will take place before the short debate. So, unless three Members wish for the bell to be rung, I will proceed directly to the voting time. Fine, okay.