Good afternoon, everyone, and welcome to this oral evidence session of the Welsh Affairs Committee. My name is Ruth Jones and I am Chair of the Committee. I am delighted that, as well as our witnesses, we will be joined by Russell George, who is Chair of the Senedd Health and Social Care Committee. We are pleased to be working with our Senedd colleagues on this and we are very grateful to Russell for coming along in person today—thank you. Healthcare is very important to the lives of all our constituents, and accessing healthcare across the border with England is a reality for many people in Wales. Today’s session will focus on what works well but also on how cross-border healthcare could work better for patients across Wales and for communities on both sides of the border. On our first panel we are joined by Rachel Power, Dr David Bailey and Dr Stephen Kelly. On behalf of the Committee, I thank you so much for coming in person to be with us. We are really delighted to have you with us. We have three quarters of an hour and we have a lot to get through. I make a plea for short questions and short and to-the-point answers. Before I ask the witnesses to introduce themselves, I will check for Members’ declarations of interest. Lovely, there are none. I ask the witnesses to introduce yourselves very briefly, starting with Rachel Power, please.

Thank you for inviting me today. My name is Rachel. I am the Chief Executive of the Patients Association, a very small national charity that works directly with patients. We are non-disease and non-condition specific, and we hear from patients through our free phone helpline, our focus group and our survey work.

My name is Stephen Kelly. I am a respiratory consultant in Wrexham Maelor Hospital. I am also chair of the Welsh consultants committee.

I am David Bailey. I am a recently retired GP and the immediate past chair of the Welsh council of the British Medical Association.

Thank you very much. I will begin with a general question to Rachel Power. Do the current cross-border healthcare arrangements work for patients? If they do not, how could we improve that experience?

That is quite a big question. In our experience, we hear from patients that once they get to their healthcare professional, the relationship is really good and there is trust and confidence. It is everything around that that can cause a level of frustration—the impact that waiting, not knowing what is happening and the lack of communication can have on patients’ ability to get on with their lives, to go to work, and the mental health impact it has when you are waiting for something and not knowing what is happening. For me, there are areas that really need addressing. The first one that we hear quite often is the lack of integration of electronic healthcare records, with patients having to repeat themselves and go for different tests in different parts of Wales and England, and the impact that has. The unnecessary repetitive tests can have a real impact on your mental health if you are worried about something quite serious. For the country—both Wales and England—that has a cost in respect of the co-ordination and continuity of care that can happen across borders. The other thing I would like to raise now—I will not go on for too long—is the impact that can have on patients, especially if you think of areas where there is no district hospital and a reliance on English facilities. Patients are left with complex journeys. We just did a piece of work on health inequalities in cancer and blood disorders. We spoke to one person who talked about paying £150 to get to a hospital appointment and the impact of that. That was a choice between food and going to a hospital appointment. Also the location of centres in areas that are accessible to public transport is really important, because you can have accessible healthcare but it may not be accessible. One patient described being able to get to the appointment, but the bus would get them home two days later, given the time of the appointment, so we need to think about that as well. We are very grateful to Llais—which I hope I am pronouncing properly—and to the RCGP in Wales. We heard a lot about the impact on first language Welsh speakers and what happens when they are receiving treatment and not getting interpreters. The interpretation that they need for Welsh is not available. There is the impact that can have, especially on people with mental health illnesses and dementia, if they are not culturally in their area. I am coming to the end. For me—this is true of integrated care systems in England as well as cross-border care—the truth is that the communication is not great between services about patients, and in terms of involving patients in communication and keeping patients up to date with what is happening. When things go wrong—we hear this through our helpline quite a lot—there are different systems for complaints management. In certain cases, we have to remember and think about inequalities and think of English as a second language. A lot of people, especially on the borders and in some of the new housing developments, are not sure whether they are in Wales or England when they are receiving treatment, so when something goes wrong they find themselves stuck between the complexity of two different systems. Those are the issues that we are hearing from patients at the moment.

Thank you. You have articulated the issues very clearly. I will bring in my colleague Claire Hughes.

This question is also to Rachel Power. Obviously, Wales and England have quite different populations and different healthcare policies. What impact would you say the differences have on patients who are accessing services across the border?

The Patients Association is all about patient partnership, design and delivery of services, and shared decision making in the way that we undertake individual consultations. The impact, especially for Welsh residents coming into England, is sometimes a lack of knowledge about the services, how the services work and how they are commissioned. Probably since the pandemic the BBC news has seemingly got better at explaining in Wales that something is an English development, not a Welsh development. Sometimes there is confusion about where funding will happen, especially for more specialised care, and where the funding will come from, even though there are protocols. There are funding protocols and partnerships but, like everything, sometimes those fall in the middle and the patient is left trying to find their way around it. The main thing for me is that the patients who are coming across the border are often not involved in the design, delivery and feedback loop about what will work for them as patients.

How do you think these problems could be best improved? What could be done?

It is about each system recognising the patients that they are working with and where the patients are coming from, because I think this comes across the whole inequalities lens as well. We need to work with patients to understand what services will work well for them. We have done a lot around patient partnership and there is a lot about commissioning for outcomes. Rather than commissioning for activities, I think there is something about saying, “We are commissioning this for outcomes. We are going to get patient experience and we will work with that patient experience.” It is about getting patients’ experience when it is good and bad and making sure that there is real interconnectivity between systems across Wales and England.

Welcome all. This is to Dr David Bailey. We are seeing big challenges with staffing shortages across the NHS in the whole of the UK, including with GPs. We have two performance lists. Would having one list across Wales and England, rather than separate ones, make a difference to medical professionals hovering between Wales and England? Would that help to simplify the cross-border complexities that we see and improve delivery?

Up to a point. About a million people live along the border, so there are a lot of doctors—particularly peripatetic doctors—who would like to practise on both sides. At the moment we have two separate lists. They both do the same thing and English GPs and Welsh GPs would be quite happy to combine them. There is a small difficulty in that the English list allows non-specialist GPs on to the list, which Wales does not. A lot of the governance issues that were a problem maybe 10 years ago, where Wales was uncomfortable with actually joining up, have gone with national provision. Yes, we would absolutely like to see that, particularly for out of hours care. A lot of out of hours care in Wales is provided by Shropdoc. A lot of people work on both sides of the border. It would be very helpful if at the very least, even if we kept separate lists, the same criteria applied, and you could just apply to two lists with one set of data. At the moment you have to go through a whole rigmarole twice, which is a barrier to people being flexible.

Thank you for your answer, Dr Bailey. I think what you are saying is that it would be preferable to have one performance list for both England and Wales or a UK-wide list. What are the barriers to either Government doing that, and how do you overcome that barrier?

As I say, originally the barrier was that Wales had a more centralised one that we were all fairly comfortable with and England was much more fragmented. That has largely been solved now. The only problem that I think both sides still have is the people who are admitted on—and doctors who are not GP qualified, who are represented by the SAS Committee of the BMA, are also not comfortable with this. They just want a medical performance list that has GPs on it.

What are the practical steps that both Governments need to take to overcome that?

I am not sure that there are many practical steps. All they have to do is agree that the criteria that you submit to the Welsh health board or to the English regions will be accepted by both medical performance lists. “Bang. Thank you very much indeed.” It is not that hard.

That is food for thought. Thank you very much. I will move on to David Chadwick, please.

I have another question for Dr David Bailey. The Committee’s 2015 report noted that having different IT systems in Wales and England has a real impact on patient care. In your written submission you tell us that problems remain today, and I see that a lot in my inbox. Just this week I had a constituent contact me to tell me about her late husband’s experience of receiving cancer treatment at Hereford Hospital. He was receiving treatment there and then he needed urgent emergency end of life care and was admitted to Nevill Hall Hospital in Abergavenny, but the team in Nevill Hall were unable to access his English hospital notes. What has been the main barrier to developing a joined-up IT system, given that this Committee recommended it 10 years ago? What do you believe could be done to solve it? Does it simply come down to a lack of political will?

Some of it is lack of will, but some of it is technical. Given that England is much larger, it makes sense for everybody to go on to the same spine to use that. At the moment, GPs can communicate with hospitals electronically in Wales. They can do exactly the same in England, but if one of you is in Bristol and one of you is in Cardiff, it is hopeless. That is because they just do not talk to each other and the Welsh DHCW—I can never remember the acronym, but the Welsh IT committee—is trying to work towards joining up to the English spine, which would certainly assist with the transfer of records. There are 30,000 people who actually live in England and have a GP in Wales and vice versa, but probably three times that number that move every year—10% of people transfer every year in a GP practice—so it is likely that there may be 50,000 to 100,000 people. If they go across the border in either direction you cannot transfer, and I think we have to accept that Wales piggybacks on to England for that. I know there are technical issues about doing that. The systems are identical. I use exactly the same system as GPs all over England. There are no incompatibilities there. The incompatibilities are the central spines. It needs Government action. It probably needs Welsh action for this, but there are also issues with getting records back down from hospitals and pushing them straight into the GP record, and being able to access records quickly. Again, you can do that in England and in Wales perfectly well at local hospitals. If you are in Hereford and you live in Ross-on-Wye, or whatever, all of a sudden you cannot do it. We really do need to get some joined-up thinking there. The two hospital systems have to start talking together. We have a fairly consistent national one in Wales, but until we do that, and until we have a spine so that all GPs can talk to each other, it will be an issue. It is not just about England and Wales. Of course, that is probably the biggest issue, but it is equally important in Scotland and Northern Ireland. You cannot transfer from Scotland to Northern Ireland to Wales to England either, and we have to be able to. We can do it in a day in each individual nation, but it can take eight to 10 weeks to go from country to country, and that is an unacceptable clinical risk.

I want to turn to the issue of specialised treatment. As a consultant, Stephen, can you set out the steps you would take if a patient needed to be referred for specialist treatment in England, whether that is to do with veterans’ orthopaedics or eyes in Bristol?

It very much depends on the specialty. We have some links that are very well set up and extremely straightforward. In north Wales, for example, we have cardiothoracic consultants who do clinics with us and then operate in England. For some services, the set-up is good; for others, it becomes more difficult. The majority of the time it is relatively straightforward. You have knowledge of specialist services, and you refer. If you come across a need to refer to a service where there are no links, if you get to point where you need to do the dreaded IPFR—the individual patient funding request—and they are my nightmare. They literally take a day. They take hours and hours and hours to do, and that is very frustrating. You may have some examples where IPFRs have had to come into play and there are then difficulties with trying to access services. That said, for the majority where the paths are clear, they can be okay. What is not so clear is that if you have patients who are on a waiting list in England, there seems to be a lack of transparency about whether the waiting list is the same as for the English patients. Is it different? Are they treated differently? Transparency is needed. We hear that there are differences. I lack evidence to present here, but I think transparency in that would be useful. Does Wales commission the same waiting list times as England, for example? That remains unclear. Clarity for patients on that would be good. Going back to the original answer, I think it is very specific. It depends on the service, but it can work quite well. Trying to get information back works less well. It tends to be paper based, which is not the way forward.

Do you know why it would work well in certain circumstances and not in others?

There are established pathways. There are routes that patients go on regularly, so we have relationships with those specialties. They know us and we know them.

Does that vary across different health boards?

Probably, is the answer. Some health boards will be more selective than others so yes, I suspect it does.

Rachel, on patient experience, I think you referenced the dreaded IPFR. I have had constituents who have had real issues in Pembrokeshire with going through that process. Could you speak to the patient experience?

What I know from patients about the funding is that we hear about different health boards and what can be funded and what is not funded in those health boards. One of our recommendations is that there need to be clear cross-border protocols and patient pathways. I heard this morning of a family with a baby with very specialist needs having to travel quite a lot of distance to have a test done, then finding out where they were going to find their results, who was going to fund it and where that funding was going to sit. It adds a lot of pressure to patients to try to work that out, especially if they are moving between health boards.

Finally, Stephen, are patients at a disadvantage? Is there a disadvantage if you live in Wales and are going to England, or if you live in England and are going to Wales?

The answer to that is, again, that it depends on your specialty. For thoracic surgery, I would say no. If you are going for other more elective-type care, possibly yes.

Can I phrase it slightly differently? We talked about the variations between health boards. Is it the same in respect of English trusts? Do you get those variations between the trust referring it over to Wales and the same—

The answer is that I do not know, but I suspect there could be variation, because it is not transparent. It would be useful to have clarity on that so that as clinicians we can see it and the patients can see it. Then there is that question—it should just be open knowledge, but it is not clear. It is hidden, which makes you suspicious that it is different.

I have a follow-up question on specialism for Dr Kelly. A constituent of mine was sent to a Bristol clinic—not the eye hospital—in 2021. He had a cataract operation that went terribly wrong, resulting in inoperable damage to his cornea, retina and iris, and he lost the sight in one eye. My point is that if we send patients over the border to clinics rather than to hospitals, there has to be a system where they have access to emergency treatment if something goes wrong in the clinic. His emergency treatment was to go home, a two-and-a-half-hour drive back to west Wales, and come back the following morning, another two-and-a-half hours, or to go to a hotel for the evening, which did not give him any emergency medical treatment. What are your thoughts on this?

I guess that is the difficulty of commissioning services outside of your area. When it goes well, it can be slick and it can be good. When it does not go well, where do you go? They are far away. If you go somewhere local, they may not have access to what has been done and that is the basic problem of contracting out services in other areas. I guess the answer is: try not to do that as much you can and, if you do, you need very clear routes of where people can go to. The difficulty is the distance. You need to be able to set up something locally, which tends not to happen because you have commissioned the service elsewhere. By definition, the distance will always be there and if you have to go back, you have to go back. The only real way around it is not to commission services too far away.

But my point is that if you use clinics, there should be immediate access to hospitals should there be that need.

You would hope so.

To any of you, is there an identifiable trend, let’s say over the last 10 years or so, of referring patients to English providers? If the trend is upwards, does that show an unwillingness of clinicians to practise in Wales, or an antipathy towards geographical specialisms rather than trying to be generalists across the piece?

By and large, the referral rules are different in England and Wales. Health boards commission a service for cardiology, hepatology or whatever from a particular hospital and, by and large, you have to refer into that hospital, whereas in England, of course, you have choice. The fact is that 95% of patients want to go to their closest hospital, so that does not cause a huge problem. It is much more difficult to refer elsewhere, if you have any particular reason, from where the health board in Wales actually commissions a given service. They can commission from different hospitals, but they tend to commission for that particular health board, so your level of choice is significantly reduced.

What about from the patient perspective?

I do not think we have seen or have the evidence to say that there has been a bigger impact, but I think you are completely right in the sense that in England there is more choice and patient choice. We would have to look into that in a lot more detail to make that a firm indication, but we will look and see if we—

Are you able to write to the Committee on that?

I will have a look and see what we can find for you, yes.

That would be helpful. Thank you. Dr Kelly, do you have an observation on that?

I do not think there has been that much change. There are some services that are not across the border. One I can think of in my region is specialist services for premature babies. Having been in that situation a good while ago now, that must be extremely difficult for patients where their young baby is a long way away, especially if they have other children. It might make sense on paper to commission services because you struggle to have the staff or the specialists, but the impact on patients and families can be enormous.

I think we have seen that in a lot of care in both England and Wales. Especially if you look at the “getting it right first time” principles, for more specialist care you may have to commission further away because it is more of an expert place. We did work around health inequalities around cancers and blood disorders, and there needs to be something about schemes for helping people to travel and allow their loved ones to be with them. That is part of wellbeing and the holistic approach of looking at a young child or an elderly person who is travelling and waiting for treatment. They need to know that their loved ones can be close to them, and that has to be brought into the equation around outcomes.

Ms Power, you mentioned in your opening comments that Welsh patients receiving care in England may be Welsh speakers. Is there more that can be done to look after their linguistic needs, especially, as you mentioned, for people who have dementia or perhaps young children as well? We realise that the Welsh Language Act does not apply to England, but the matter of equality and the Equality Act apply everywhere. What are your thoughts on that?

When I think about shared decision making and working with patients and healthcare professionals, we have people beyond our conditions and our diseases. We need to know how to work with that person and what matters most to them. If it is a first language Welsh speaker, hospitals being commissioned or patients coming in for treatment in England have to ensure that there is clear interpretation, and we should not be relying on families. There need to be professional interpretation and translation services available. I think there is something more about the cultural thing. If we think about dementia, it is about being able to get radio and TV—things like that—and that has to become part of the equation as well when we are working cross-border.

I will add one thing on the Welsh language. Looking at provision for learning the Welsh language is also an issue. I did many years of Welsh learning and my wife became fluent doing the same classes. I should have done my homework and been better, but I do understand a lot. My course was not quite next to the hospital and I had to fund it myself, whereas I was at the same time with people who worked for local councils who were released and given time to do that. I think more serious consideration needs to be provided for people who properly want to become Welsh learners and fluent speakers. There are too many sort of “Meet and greet and have a few words of Welsh”-type courses, which are not helpful. It is much better for the small number of people who really want to learn Welsh to be able to do that. We have things in north Wales like the Bangor Medical School, which will probably get more people to stay locally and you hope will help Welsh language as well. I would like to see more serious attention given to properly supporting Welsh people who want to learn Welsh in hospitals, because I think it is lacking.

That is fantastic to hear. Thank you.

Thank you. I will move on to Russell George, our Senedd guest.

Thank you, Chair. To pick up on an earlier point, there was quite a bit of discussion about the independent patient funding request. It is quite astonishing that in the English system you wait a day or in the Welsh system you wait a day, but across the border a request could take several weeks. I think you said that it was an unacceptable clinical risk. I want to be clear: in your opinion, how can that be overcome? In a nutshell, how do you overcome that?

It is about better access to IT. I had a patient contact me this week who had been seen in England, but I had no correspondence. I had to chase that and the patient had to chase that. That is not right. The lack of knowledge and the lack of sharing of IT is a problem. Another patient I had was breathless and the problem was not respiratory but cardiac. They have a cardiologist across the border in Chester but they cannot remember their name, I cannot find out who they are and I have to contact their GP to ask. There is the lack of access to systems. I think in secondary care we may have different systems. In primary care I understand you want to align, but even if the system is different, access to the different systems of local hospitals would be incredibly helpful. IPFRs are more patient specific, so that is difficult. I do not have an easy answer to that.

Does anybody else have an answer to that?

Not on the IFPRs, but I agree completely. On the digital interfaces, most patients tell us that they want to have a single healthcare record. We should have a single healthcare record that is digital for those that it will work for—we need to think about rural areas where maybe wi-fi is not as good, and patients talk about having to carry their information around with them. That is where a lot of the information gets lost and you have healthcare professionals trying to chase down information. Strengthening the digital infrastructure between England and Wales will allow requests to come through quicker, but it is also about having clear protocols and not just partnerships. It is about being quite clear about what those protocols look like.

There needs to be a clear political drive to make this happen. It is a clinical risk to every individual patient if you cannot get hold of results conveniently and quickly.

When you talk about political will, what is your message to both Governments to make this happen?

Both Governments must make GP systems talk to hospital systems and hospital systems talk to GP systems. Ideally, it all must be done in what they call a push way, so that the information automatically downloads from the hospital on discharge to the GP. The GP referrals already go up automatically online, but that must happen seamlessly. There simply has not been sufficient political will to do that, and every patient in that situation is at clinical risk.

So it is clear it is about political will, which leads on to my next question quite well. In September the Secretary of State for Wales announced a new partnership between the UK Government and the Welsh Government to drive down waiting times. How do you analyse that statement and what difference have you seen, if any, since that statement was made in September?

I have not seen a lot of difference.

No, I cannot say I have.

Okay, so you have seen no correspondence or a statement from both Governments saying, “We want to work more proactively together to drive down waiting times”? No correspondence or information has passed your desks about that?

No.

Not particularly.

On lessons that could be learned either way, are there lessons that the UK Government can learn from what is happening in Wales or the Welsh Government can learn from what is happening over the border? What are the best examples from each?

I think it is fair to say that waiting lists are shorter in England. In Wales, we would argue that that is partly because of the Barnett formula, but the fact is that they are shorter, and in a United Kingdom surely that cannot be right. We must learn and the two Governments must talk together, and hopefully now that they are the same political colour they will do that more. Currently, Welsh patients are disadvantaged. I think the services you get in primary care are broadly similar even though the contracts are different. The individual consultations are much the same. There is no doubt that waiting lists for hips, gall bladders, hernias or whatever are longer in Wales. They are not as long as in Northern Ireland, but they are a lot longer in Wales than in England. We must learn from what is being done there. I, and I suspect many in Wales, would argue that part of that is purely about funding—about buying in sufficient capacity in hospitals, and sufficient clinicians to provide that and drive it down—but there are probably efficiencies as well.

What are the efficiencies?

Choice helps. We do not have much choice currently for referral, and if that were the case there might be something. It is about capacity. We often argue that we do not have a waiting list problem: we have a capacity problem. We must put more capacity in to be able to treat people quicker, and currently we are not doing that.

You talked about choice. There is choice in England, not in Wales; why is that? What do you envisage is the thought process of the Welsh Government? There must be an unintended consequence of that so there must be a reason why the Welsh Government are—

I think the Welsh Government feel it is more efficient to do that and it depends on your view of competition. If you think that competition improves the breed, you may find that having a number of choices will shorten waiting lists. If you think that doing the same thing three or four different times makes the whole service less efficient, you may well feel that directing referrals to a particular spot may work better. All of that is entirely predicated on whether, given the populations you serve, the funding is identical. I suspect that is too big a question for us here. But if it were, that would be the thing.

There is a lot to unpick. I will bring in Llinos Medi.

I just wanted confirmation: you have seen nothing following the announcements of the Secretary of State for Wales about cross-border working and how that can improve the experience for the patients and yourself as a service. Also, you touched on the Barnett formula and the need for fairer funding to mitigate the issues that our demography faces with poverty and all the health implications that come with that. There are two parts to my question: the funding part, and the announcement that we thought could mean better cross-border working but that might not be a fact.

It creates a problem in that the funding models in Wales and England are different. In England we have patients who cross the border, go to a hospital, they have out-patients and procedures and they come at a cost. I think England is very good at billing Wales for the cost. It is not so cost driven when patients come from England into Wales because we are a provider and commissioner. Some services are good at recovering those costs, but the suspicion is that others are not, so there may be income going one way but not the other due to the funding models. Also, the difference in funding models creates problems. I was speaking to a colleague recently who does sleep medicine. With some of the newer tests you do not buy the kit; you buy the test. That works well if you have a model in England where it is per test, but it does not work well in Wales because you have to try to get the kit and the companies do not want to do that. It makes it more difficult and may inhibit access to different tests. The funding model causes a problem. On the waiting list question, hopefully it is coming but we just have not noticed it on the ground yet. We hear announcements but we have not noticed practically much difference. I am not in a waiting list-heavy specialty but maybe there is just a bit of a lag.

It has always been my belief that when most people have a medical need they are not that precious about where that need is diagnosed, treated and cured. They just want to have it done as quickly as possible. I think most people would also have an expectation of the cross-border sharing of best practice, and sharing where somebody has tried something innovative and it has not landed properly, and the lessons learned to avoid duplication. I happen to serve also on the Northern Ireland Affairs Select Committee, and we heard this morning from Fleur Anderson, the Parliamentary Under-Secretary of State, who heartened our Committee. Yes, of course health is devolved, but she was talking about a real determination being driven equally from Belfast and Westminster to share best practice in health, to drive up standards, to improve the patient experience and to improve patient outcomes. The impression she gave as far as the Westminster Government are concerned was that that was a vision that they saw being operational in all parts of the kingdom, because it is a national health service and people have, as several of you have mentioned, an equal expectation. I am slightly worried, if I have heard you correctly—please correct me if I have misheard you—that there does not seem to be that drive towards sharing best practice, learnings and repeated mistakes made between England and Wales, notwithstanding the point that Dr Bailey made about the commonality of colour in both Administrations now.

I think the desire to drive up standards is absolutely common across the four countries of the UK. I do not think there is any question about that or any barrier to sharing best practice. I probably take issue with the idea that people are prepared to travel anywhere for slightly quicker care. If it was much quicker, that might be different, but an awful lot of people do not like going away. Wales is a more constrained country in many ways—

I am a Welshman.

We prefer to stay local. If you want to have your gall bladder done, you do not want to have it done 100 miles away where none of your family can see you. I agree with you that if you could have a hip done in six weeks somewhere away and it was a year in Wales—there are degrees of magnitude to that and I think that most people prefer to stay local if that is reasonable. That is a big driver. Commonality of standards is a professional issue and we absolutely must do that. I think we do and we do that quite well. On whether people would be prepared to travel more, it depends on the condition and on the variations. Unfortunately, currently we are seeing some significant variations, although if you have served on the Northern Ireland Committee you will know that the variations between Northern Ireland and the rest of the UK are massively greater than they are anywhere else.

Yes, indeed.

People are always keen to share good practice, especially when it is successful. If you go to professional conferences, you will hear, “We did this. This is what worked.”

It was more about things at the political level, at the commissioning level, at the design level rather than, “Have you tried this new type of bandage because it is much better than the last one?”

Yes. There is less of that and there is certainly a lot less of, “This did not work,” because people do not trumpet that very often.

They do not like sharing failure.

I do not think people share that quite so much, so I think that is much less well done. From a professional point of view, you find out what people have done and you will share best practice. It happens for the successes but probably not for, “Don’t do it this way.”

Yes, that is always the problem.

One of the things that the healthcare system at every level could do an awful lot better is learning from innovation and from where things have worked well and have not worked so well. Where things have not gone well, how do we learn if we have different systems for the management of complaints? Because that is how we learn: we learn by mistakes. A lot of the recommendations that have come out of inquiries where things have gone wrong repeat themselves. We have to have a system where England and Wales, through the different parliamentary ombudsmen, come together and look at those themes—especially when the percentage of people going from Wales into England is much higher than the other way—so that we are able to do that learning at a place level. That is important from an inequalities point of view and then at a strategic, Government level.

A very brief question from Andrew Ranger to finish, please.

I seek a bit of clarification on a technical point. We talked about the choose and book system in England. If you have a Welsh patient being referred into England secondary care, either from a Welsh GP or a Welsh residential patient, do they get access to that choose and book element? Or is that more restricted by whether the GP has a relationship with a certain hospital or service?

From a primary care referral point of view, it depends on the commissioning body. If it is a Welsh GP, they must follow the Welsh rules. If it is an English resident, they are still entitled to choose and book. If it is a Welsh resident, they must follow the same rules. If it is a Welsh person going to England, I think I am correct in saying that the English GP can still access choose and book, but it does not work the other way around. I am trying to get my head straight on this. It is technically more difficult. The GP is controlled by the health board. If your patient is in England and you are a GP in Wales, you must work to the Welsh rules, but the English patient is still entitled to be referred for secondary care under choose and book. That is my understanding. There is a clear difference between where you reside. If you are in England and you are a Welsh patient, I think you can still be referred. It only works one way, is my understanding, which is unfortunate.

Can you write to the Committee to clarify that for us? We are not as technical as you and it would be really helpful if you could write to the Committee on that point.

I can certainly do that.

Thank you very much. I want to bring the first session to an end now. Thank you to all three of our witnesses for being so helpful and sharing your experience and being so open. It has been very helpful and we have lots of notes. Thank you so much for your time. I will bring the first session to a close. Witnesses: Stacey Taylor, Carol Shillabeer and Simon Whitehouse.

Good afternoon and welcome to the second session this afternoon looking at cross-border healthcare. It is great to have our three witnesses online with us. My name is Ruth Jones. I am still Chair of the Welsh Affairs Select Committee. We welcome Carol Shillabeer, Simon Whitehouse and Stacey Taylor. I thank you on behalf of the Committee for joining us this afternoon. We have a lot to get through and we have only 45 minutes. I know your time is precious so I am making a request that we have brief questions from the Committee and similarly brief and precise answers from the witnesses. I will start with Gill German.

Thank you for letting me join online; I am grateful. The first thing to say is that the NHS, whether in Wales or in England, has worked together forever and for very many communities across Wales it is absolutely normal for them to access their healthcare in England and vice versa. I wanted to start with that because the sense of having new relationships for me is an extension of relationships that already exist, and that is important. Clearly there has been some divergence in health policy over time and we are all dealing with the same challenges, but the way we deal with them will be different in our respective nations. As a health service chief executive in Powys and now more latterly in Betsi Cadwaladr, I have always looked across the border. At times I have felt that I have had a foot in England and worked in England anyway, with colleagues such as Simon and others, so this further strengthening of the collaboration is welcome. We have had a ministerial advisory group established, and just this week they visited us in north Wales. That was very helpful. That panel or group is made up of 50% of people from Wales and 50% from England. The strength of the discussion led me to believe that we were going to learn from each other. There was clearly some feedback about the things that we can do perhaps differently that England have learned. I am happy to give a bit more detail on that. While we do not necessarily have the full detail of the new partnership on the ground, the ministerial advisory group is a strong start in sharing best practice.

That is definitely true. Like Carol, I thank you for being able to join virtually today. Since 1 April 2024 we have set up a new organisation, the Joint Commissioning Committee, on behalf of all of Wales, commissioning care for the patients of Wales. In some cases that will be for specialist cases that need to go over the border, but also where the flows or access to services need to be over the border into England for Welsh patients for various reasons, particularly in respect of London providers. We also have a financial arrangement where patients can access those services seamlessly through a contract arrangement with us. We do that with the Joint Commissioning Committee as well. We have around 37,000 patient contracts with NHS England. A little bit more will go through our IPFR panels for the highly specialist services. We spend around £170 million collectively across the border for the arrangements that go through the JCC books. The health boards will spend more for patients that go through their services locally into English provider organisations. Broadly, where access to specialist services is not available in Wales because of the economies of scale or the sustainability of services, or where there are rare diseases or highly specialised services, we are the conduit to allow patients to access those services seamlessly in England.

It is a complex question. On commissioning more broadly, the thing that we constantly look at from a public health perspective is what is the need of the population. Our arrangements in Wales look at that more broadly, and we have a national public health organisation that looks at that for us. Patients can access those services seamlessly. They are getting through to English providers and those who need access to that care are receiving that treatment. By and large, the arrangements within the current systems are effective.

We have just taken evidence from Dr Stephen Kelly on this specific issue. He raised concerns about the variations between health boards and also in respect of the type of specialist treatment that is available. There are established pathways for certain treatments but perhaps it is more complicated for others. The first panel talked about the dreaded IPFR. Why is there such a difference between the evidence you are giving to this Committee compared with the evidence we just heard from Dr Stephen Kelly?

Perhaps it is helpful to put a bit of perspective around it. We said that there are around 37,000 patient counts that go across the border. A lot of those will be for out-patients, as well as individual patients accessing some expensive medical treatment and drugs for their care. If we put it into context, that means from an IPFR perspective, on specialist services, we are probably receiving about 2,500 applications as a proportion, and around 200 that come through the IPFR route. If you think about how many of those are particularly on the border, in context we are talking about individual cases that are very individual, very complex in need, are specific in requirements that need a bit of a look at. We need to make sure that the care and provision that they want or require fits within policy. We are acting on guidance that is provided by Welsh Government to us as health boards, and specialist services commission as well. Carol, I do not know whether there is anything to add from a health board perspective on that.

No, I don’t think so. You have covered that, but there are new and emergent rare diseases almost all the time. We are very grateful to NICE—the National Institute for Health and Care Excellence—which evaluates those, and we seek to implement those guidelines. There are times when we implement them a little later due to set-up. I hope that helps.

Stacey, you think that the IPFR is fit for purpose, and Carol, you disagree with the evidence provided by Dr Kelly that there are not discrepancies between health boards in how it is delivered and accessing specialist treatment across the border.

The all-Wales IPFR policy is under constant review. Like I said, it is a guidance that is provided to us that we must enact through the direction of Welsh Government. The majority of cases, if not all of them, are being considered individually because of the individual nature of the cases that are coming through. They are highly complex and it is under constant review. It is a process, albeit a very complex one.

On the treatment—

Henry, I will stop you there because the witnesses here have not had the opportunity to hear the evidence that was given. Thank you very much for that. I will move on to Steve Witherden.

I would like to hear from the panel as a whole, starting with Carol. What do you hope to see from the UK and Welsh Governments’ new partnership to drive down NHS waiting lists on both sides of the border, announced by the Secretary of State in September?

Thank you very much for the question. Simply put, I am hoping to see that we learn from each other what is working well, what not to try because it does not work, and then for all patients, whether they are in Wales or in England, that we can reduce the waiting times for treatment. How long people are waiting is a big focus at the moment but there are some wider elements that I think we can learn from as well. I know the urgent and emergency care system has been very pressured over the winter. It is about what we are doing in Wales that colleagues in England can learn from and vice versa. That is the main thrust of it: what practice is being brought forward, what innovation, what creative solutions are being tested and how we share that with one another.

Carol summarised it quite fairly there. This is all about where we can learn and share best practice, how we can learn from each other and how we can collaborate more effectively, particularly where those services are scarcer in Wales, and think about making the patient journey as seamless as we possibly can. There is something around data and for us in Wales learning about some of the one nation data dictionary that is available in England. Having some of those opportunities to benchmark, to share some of that, is important to us.

Thank you to colleagues for allowing me to join virtually, as both Carol and Stacey have said. I concur with the comments made by Carol and Stacey. The elective reform plan has been published recently, where the Department of Health and Social Care has set out its four main strands for that. We can perhaps share the learning from that and the work that is preparing to focus on bringing down the waiting lists across the themes of how we empower our patients; how we support the reform of delivery and of the way care is delivered; how we make sure that care is delivered in the right place; and how we make sure we have the funding performance and quality of delivery standards aligned. There is absolutely some commonality in that space. It would be remiss of me not to say that we need to get better at how we share information and how often the systems talk to each other and share that information. In the urgent and emergency care system, if we have an ambulance waiting, how do we ensure that we understand properly the clinical need and the time, whether that is a Wales ambulance or a West Midlands ambulance, if it is outside one of our urgent and emergency care departments? I am confident with the way the clinicians are working that the patients are treated absolutely appropriately at the time, but having the data and sharing that information better will enable us to ensure that we plan in a more robust way for that demand and capacity piece.

Thank you. I had planned to ask what you feel the English NHS can learn from Wales and vice versa, but you touched on that in some of the answers, so I will leap straight to my most important question for my constituents. Do you think that greater cross-border working has the potential to cut waiting lists for Welsh patients?

My starting point is that we have good relationships and the principle of how we do any work is the basis of relationships and the individuals and people having those relationships. Whether that is with Carol, Stacey or other colleagues, there is the basis of the relationship there. There are challenges with funding, capacity and some of the differential policies and Government mandates that drive the different waiting times. I am clear that our clinical community want to deliver the right care to the right patients in the right time. We need to bring waiting lists down across the board and we need to do that in a way that is clinically based and managed well.

This is quite a complex one. We have talked about the learning and we have made the points about if we are offering patients to go elsewhere, most patients would like to have as much care close to home as they can, but some will certainly travel. We have been looking to offer those opportunities to people in north Wales—not only NHS but also non-NHS provider opportunities. We have good, strong long-term agreements in place between NHS bodies, and I have certainly been an advocate of looking to the NHS partners to see whether they have additional capacity to treat more patients should patients choose that. I will give the example of Robert Jones and Agnes Hunt Orthopaedic Hospital, which is very well used by the people of mid-Wales but also by the people of Wrexham and Flintshire and even further afield in north Wales. That is an English system—an NHS body that we work very closely with. We have these conversations about whether another provider has more capacity so that we can make an offer to our residents. That is not always straightforward, because colleagues are trying to meet the needs of patients in their own area, but we have a collaboration that where an organisation can help, I have found it usually does. They want to help. That is good. There is no problem with will. There is probably more of a challenge around capacity and that is a more difficult point to fully address.

I do not think there is much to add to what Carol has already suggested, but our relationships are strong. We have strong contracting relationships with NHS England. Definitely where we lack capacity for certain specialties we look to all providers to help us to manage some of the ministerial targets and waiting lists. I have nothing much more to add to what has already been said but definitely a collective approach is always a step in the right direction.

I think we all recognise that data is king in all this. Most normal people out there would put their heads in their hands if they thought that such a very core and basic thing about the ability of institutions to share data to improve outcomes is not readily done and available, but we are where we are. That is understood. Can you share with the Committee the sense of urgency that drives that agenda, the timetable of delivery to which you are working, who takes the lead in that and who effectively holds the pen or holds people’s feet to the fire to ensure the delivery of that integrated data sharing leading not of itself but playing a very key and pivotal part in improving outcomes for patients?

Who do you want to speak?

I do not mind. They can toss a coin if they like but I am interested to hear, maybe from our commissioner first.

I am sure you are aware that in NHS Wales we have the organisation Digital Health and Care Wales, which leads and is undertaking a huge task in our data integration at the moment. It is working with NHS England and colleagues to try to integrate the data and patient records to make some of the seamless transactions that we have talked about earlier in the session. The timetable to delivery is always a bit of a challenge. It is incredibly difficult. Our data architecture in both countries looks different. Data architecture for governance changes quite regularly and we need to think about the infrastructure that supports all of that more broadly.

I am sorry to interject, Ms Taylor. Those are hurdles but they are not insurmountable hurdles. My genuine experience is that it may be missed but unless some sort of deadline and a pathway that can be tracked is set, things often go into the slightly tricky in-tray and never get the resolute attention that they require. Your answer hitherto is encouraging, but I would not say it was confidence-giving.

Probably the challenges are real challenges, and leading into the part around the timescales is giving us some delay in how quickly we get digital programmes such as Once for Wales up and running. Probably you would be better off posing the question to somebody from DHCW and getting an answer from them directly. Obviously the Welsh Government have a part to play in that too, as part of their policy position. The other thing is that just because that is not happening does not mean that we are not trying on an individual level, and we will wherever possible try, to look at the data that is readily available to push for better integration to deliver patient outcomes. Carol, from a delivery perspective, shall I bring you in?

Carol is itching to come in. She is almost leaping out of the screen at us.

I am delighted you asked the question because it gives me a chance to talk about what we are doing here.

Briefly.

I will start with when I was in Powys. We had cross-border challenges with the transfer of information between us as a provider and a commissioner into our colleagues’ providers and commissioners across the border. We had that challenge and we found ways to work around it—not ideal, but we did. There was a lot of hard work and not very much automation, I’m afraid. Where I am now in Betsi Cadwaladr I am absolutely determined that we drive forward an electronic health record that helps the pathways of care, and helps clinicians and others to do their job more effectively. I have had some discussions with colleagues in the north-west—where, of course, very many of our patients go for parts of their pathway of care—about the potential for joining up. That is a technology challenge as well as an information-governance challenge, but we are bringing forward an outline business case for an electronic health record. The Welsh Government have already invested, I am delighted to say, in a mental health electronic health record, and we are busy procuring that and then we will be implementing it. We will have gained a lot of experience but it is one of the board’s priorities to improve data and the management of care through better records.

Thank you very much. I will move on to Russell George, who I am sure is very familiar to some of you, as the Chair of the Senedd Health and Social Care Committee.

In your earlier answers to the question about the Secretary of State’s announcement in September of a closer partnership between the UK and Welsh Governments to drive down waiting times, you talked about your hopes for what that means. Have either of you received any correspondence or had any meetings or correspondence with the Secretary of State, Welsh Government Ministers or the chief executive of NHS Wales about what that means, what will follow and what arrangements might change?

I am happy to start by saying I have not had any direct correspondence from the Secretary of State, Welsh Government Ministers or the director general in the Welsh Government. However, there have been conversations and discussions in several meetings about the potential for the ministerial advisory group, as I mentioned earlier, being the start of a relationship where we learn more about each other’s practice. Certainly I am very keen to take practice from anywhere, to be quite frank—whether that is England or internationally, I do not mind—that will help to deliver better care for patients. I have not had formal correspondence on the detail of the partnership.

Was that sharing of good practice between the Welsh NHS and NHS England not happening before?

I will mention something called GIRFT. I do not know if people know what that is. It is Getting It Right First Time. We have had colleagues from GIRFT. It is a fantastic initiative. I am a big fan of GIRFT. There is a host of clinical practice guidelines, new pathways and so on, and we have worked very closely with the GIRFT team in Wales. Some of that has happened already. This is about taking that to the next level. The lead for GIRFT, Professor Tim Briggs, was with us here in north Wales on Monday. He is a regular feature of some of our discussions on how we can improve our practice and where we can learn. For example, the Llandudno surgical hub is under development in north Wales. Some of that is modelled on and we took learning from developments in Devon and London. We look beyond our own borders for innovative practice, and I know that colleagues on the MAG were looking at us on integrated health boards and the benefit of having everything under one roof. There is that exchange but no formal partnership paperwork as far as I am aware.

Thank you. I will make a plea for very brief questions and answers.

Simon, I believe the area of Wales that I represent is the only one that straddles two trusts. Around 65% of the constituency is covered by Powys Teaching Health Board. I have spoken before about how Powys is in a unique position with no full service hospital. What arrangements for joint working does NHS Shropshire, Telford and Wrekin have with Powys Teaching Health Board to reflect this, and are they fit for purpose?

That is a fair and valid question. I think we need to look at this on a number of levels. If we are looking at urgent and emergency care, there are clear arrangements in place between the Shrewsbury and Telford Hospital NHS Trust and the Powys Teaching Health Board for the management of urgent and emergency care demand, and that is agreed directly with the provider in that space. Carol has already touched on the arrangements with Robert Jones and Agnes Hunt Orthopaedic Hospital, where we talk about elective care and the management of elective demand and elective referrals through that. We have already touched on and you have previously heard evidence on the challenges of some of the different governmental policies that sit behind, which drive some of that variation in waiting list times and some of the capacity challenges that we have there. From an integrated care board perspective, from a commissioner’s perspective in England, we are clear that we work closely with our provider trusts to map and consider the demand and the capacity required from Welsh residents so that we understand the impact of that on any profiling of work and plans that we put in place for the providers within the England health system. I think the final part of your question was about whether these are fit for purpose. I have not heard anybody say anything other than that the clinical drive to deliver the best care in the right place is just a continued commitment to do the right thing by patients as and when they need to access healthcare. We have touched on the fact that there is more to do to ensure that patients are treated fairly and equitably in waiting times for elective care.

I have another question for Simon about Powys Teaching Health Board. In your view, do proposals by Powys Teaching Health Board to extend the treatment time of Welsh patients being treated in hospitals in Shropshire and Herefordshire break the statement of values and principles that govern cross-border treatment, particularly where it lays out that different financial regimes on both sides of the border will not create barriers to patient care?

I think it is not appropriate for me to comment on whether it breaches the guidelines or not. I think what is appropriate for me to comment on is that we are in active dialogue with colleagues and the board about the impact of any decisions that are taken. We have met with providers as well so that we have had one conversation about the impact of any decisions that are taken by the health board. We need to ensure that we have a collective responsibility to use taxpayers’ money in the most appropriate way to benefit the residents that we serve and have responsibility for. One of the points that our providers articulated in those conversations was that trying to run and manage a clinical service where you have different rules and responsibilities has created an administrative burden and is challenging when we want to ensure that we are treating people as quickly as possible.

Do you think it would be helpful for that statement of values to be transformed into a proper legal document to guarantee patient care for those living on the borders?

I repeat, and I am not avoiding the question at all, that I think we have a responsibility as a health commissioner to ensure that we are commissioning for the right outcomes for the population that we serve. We require Government colleagues to be able to work with us to ensure that we have the right policies around that to get the right outcomes in place for all the residents in the population we serve.

I will follow on with a question to Simon. Does the fact that Wales and England measure things differently—waiting lists, waiting times, targets and performance targets are measured differently—result in Welsh patients in England being on a separate waiting list to the English patients?

I will need to come back to the Committee for the exact detail of that, if that is okay, but clearly we need to ensure that we are tracking and working to the commissioning rules that are shared, talked about and put in place. That is certainly part of the conversation that we had with Powys Teaching Health Board colleagues about their consideration and the decision making around what that would mean for clinical list management.

Thank you, Simon. It would be really helpful if you could come back on that. I will hand over to Russell George.

My understanding is that there is no separate waiting list, so if a Welsh patient receives treatment over the border with an English provider they are treated on the English waiting time targets. Carol is nodding to that. Of course, the issue here is that the proposal by Powys Teaching Health Board that has been referred to is that that is not the case, because it is effectively asking that a patient being seen in the same hospital by the same health professional could wait longer depending on whether they are a Welsh or English patient. I think the answer, as far as I understand it—I am looking for your confirmation—is that it does not happen now but it would happen if Powys Teaching Health Board’s proposal were brought forward. Do I have that right? Is that your understanding as well?

We will get Carol’s opinion on this as well. Apologies if I was not clear. I was saying that with the proposals that are being put forward we have absolutely talked about the additional burden that would create if we needed to move to a point where that was managed. I did not want to mislead the Committee about whether we are talking elective, urgent and emergency care and across all specialties; want to make sure it is completely robust across all areas.

To be clear, in case anyone is not aware, the standard waiting time in England pre-pandemic—it feels a very long time ago—was 18 weeks, and in Wales 95% of people within 26 weeks. When I was chief executive in Powys we made no differentiation for patients who went across to England for their treatment and that was the approach. Without commenting too much on Powys, because I have not been there for almost two years now, clearly this is quite a tricky issue. Knowing the Powys board, this will have been a very difficult area to explore, given the importance of the English providers to the mid-Wales population in particular. Most people in Powys will have had their treatment much sooner than the larger population of Wales. As we know—it is a matter of record—England is currently looking at around the 65-week wait for the vast majority of their population and Wales is at 104 weeks and above. There is that differentiation to consider as well. It would be bringing something different to the table with a differential here, but remember that most of the Powys population, as far as I can see, wait a much shorter time than people across the rest of Wales.

Prynhawn da, Carol. This question is for you. Do Welsh health boards monitor the timeliness of treatments for their patients once referred to an English provider?

Prynhawn da. Thanks very much. It is lovely to see you. We do and it is very important. I made reference earlier to data sharing across the border, particularly when I was in Powys setting up some systems and processes to ensure that we could track through exactly what part of the pathway people are on. They will go for their first out-patients and then there will be a diagnostic and so on, and we had to get a bit more into the detail of where in the pathway. That was particularly important as well for patients on the cancer pathway because we were trying to drive through earlier access to potential cancer consultations. That is part of what we do. We are strengthening those processes in north Wales. There is quite a bit of room for further development and a bit more transparency on that for the population in our reports, so that people can see what the waiting times are if they are accessing care in England as opposed to directly provided in north Wales.

Thank you all for your attendance today. Ms Taylor, on the contractual arrangements that the Joint Commissioning Committee currently has with English providers who work commissioning tertiary care for Welsh patients, what is your assessment as to how well they work at the moment?

You will appreciate that how strong the interaction or relationship is will depend on where the provider is in England. The further away we go from the Welsh border, the smaller the value of the contracted relationship. We have differential contracting governance arrangements between the two nations, and we know that England has the one contract. Legally we are not bound by that contract so there are some legal differentials between our systems that mean we must work through a different contractor model—through maybe a head of terms or an SLA agreement or an LTA agreement. As I say, the type of relationship we have depends on where the provider is. The closer they are to the border and for some of our specialist services, particularly for Betsi Cadwaladr as a health board and Powys, we will have joint relationships with health boards where we have contractual arrangements, tripartite-type arrangements, and can have some of those conversations together. Into London, we have some single arrangements, through an SLA for example, for smaller values.

That is interesting. You mentioned various ways of operating between different trusts. Is there a reason why it cannot be more standardised and streamlined, or is that a stupid question to ask?

No, it is not. To be fair, it is standardised wherever we can possibly make it so. You will know that English providers are bound by some of their local commissioners as well, so they have a complex arrangement between their local commissioner and arrangements that already exist. There are some things that from a legal perspective Wales cannot sign up to. I know we have had a conversation about waiting lists, so this is not to rehearse that, but there are differentials in approaches. That is probably why we must work similarly for Wales with England and England within itself, but that is why we must work slightly differently.

I understand that, but I suppose that could be a scheme of work that the new co-operation between the two Governments could look at. I think somebody mentioned that the group has met very recently. Could this come under their workstream?

We are very engaged in some of the cross-border activity. We have medical directors that sit on clinical advisory groups, rare disease groups and specialist commissioning groups. We have cross-border contracting groups. We speak very regularly and closely together. It is a piece of work. There is something about the true value that you get out of any economies of scale and about making sure that we start commissioning on a value approach, which I know all nations have shared on, and thinking about commissioning for outcomes broadly going forward. That would be beneficial for us all to work on together.

Thank you. Finally, Ms Shillabeer, we heard from the first panel that there is no standard tariff price for Welsh NHS organisations to charge their English counterparts when English patients receive treatment, particularly secondary care, in Wales. They mentioned that perhaps Welsh organisations are not quite as on it in charging in those circumstances as is true in the reverse case. Are you picking up on that in Betsi Cadwaladr and does it cause a burden for you as a local health board?

I am very conscious that the Chair wants brief answers, so I will do my very best on this because it is quite complex. We do not have the mechanisms that are in the English system, because back in 2009 the reforms in Wales led to the abolition of commissioner-provider splits. We do not have a tariff system or payment by results system that was more familiar in the English system. We have things such as programme budgeting, so we understand all the costs that go into an episode of care and so on. That is not standardised necessarily across Wales. There are different levels of overheads that go in and so on. Stacey mentioned value, and we are looking at value—how much things cost, what the experience is of the individual, the patient and the staff member, and then the outcome, so whether we fixed what we needed to fix. We are moving much more towards a value-based healthcare system rather than a cost-only healthcare system in Wales. I am sure that would be of interest to colleagues in other nations as well. I hope that helps. There is variation between different health boards.

That is very useful.

I thank the three witnesses from the second panel. It has been very helpful. It is a very complex subject matter and you have managed to condense it into 45 minutes, so thank you very much for that. Thank you to Stacey Taylor, Carol Shillabeer and Simon Whitehouse. I must now bring this session to a close.