Health and Social Care Committee

Oh, that's fine. You don't have to press the microphone either, it's fine. It's all right. It will just come on naturally. You're fine.

Bore da. Good morning. Thank you for inviting us here today. The joint commissioning committee is a committee of the seven health boards, and we report into those health boards. We commission a variety of services on behalf of the health boards, mainly, for the purpose of this committee, specialised services. [Inaudible.]—the variety of the illnesses are such that we don't have huge numbers, but they do need to access, obviously, high-quality care and have a smooth path into those. So, the health boards come together and ask us to organise the commissioning of that on their behalf. We do also commission other services such as Welsh ambulance services and transport, but that's probably not so relevant for this discussion. That does cover both physical health and mental health. So, for mental health, for example, the vast majority of mental health care, which most people would access locally, is commissioned by health boards, but that very specialist high-end, medium-secure and high-secure mental health would be commissioned by us. Because of the nature of those types of treatment and those illnesses and the few numbers of people, there are some conditions in Wales where we just don't have the number of people who need that care to provide it locally within Wales. We will obviously commission care locally whenever we can. And so, therefore, we end up having contracts with a whole variety of providers in the English health system.

Brilliant. Thank you. And what aspects of the UK's Health Bill are most likely to affect the JCC's role and the services that you commission on behalf of NHS Wales?

So, I think from my perspective, there are probably three key things. If I just give those in headlines and then my colleagues will be able to give more details as well. The first is that, obviously, the English Health Bill changes how specialist care is commissioned across England. It's currently done mainly centrally and it's going to be partly centrally and partly devolved. So, at the moment we do rely on England sometimes for the commissioning—we run it through the central service if we have very few numbers, but also, importantly, just to get the clinical expertise and the knowledge. By the very nature of the fact that these are small specialties, there aren't many people who work in them, so we may not have all the expertise in Wales, or certainly you'd want to bounce the ideas around and talk. So, we need to make sure that we've still got access to some of that. In many ways, the model they're moving to is how we already work in Wales. They're developing these regional committees, offices of pan-integrated care board commissioning, for their commissioning, on behalf of local integrated care boards, which is how we operate. So, the Bill doesn't set out the detail between how they work, but that would be important and we can delve into that one.

I think the second part is that it's explicit in the Bill that it puts a duty on local health boards to consider Welsh patients, or border issues—not just Welsh ones, but, obviously, other countries as well—if they are making changes to services. So, I think that's a good thing. We have many services, as we've said, that use hospitals in England, particularly Bristol and Liverpool, and they now, if they want to change something, have to talk to us and they have to work with us to see what the impact would be on Welsh patients. And we can give some examples of how that, actually, we think, is a good thing.

The third area you may want to explore is the data. So, within that, it now creates a national data set and the linking up of data systems, which, for good clinical care is, I personally think, a good thing—that people will be able to write records. Two things with that for us. One is that Welsh patients would need to be aware that if they go to an English hospital, their data will go into this and their records will be available. The second is that it gives us an opportunity to look at interoperability between Wales and England, and that could be improved, and, hopefully, this would provide an opportunity to look at how that could be improved.

Brilliant. Thank you. We've got some questions now from Nigel Williams.

Hello. I represent Fflint Wrecsam constituency, and lots of people in that area obviously travel cross-border all the time, completely. If I had my own way, it would be 'NHS Great Britain', really, but it isn't, so we do have cross-border commissioning. Lots of people tell me all the time that they're off to the Walton Centre or they're off to the Clatterbridge Cancer Centre, perhaps, for cancer services. And their main concern, really, is a speedy service, making sure there are no waiting times—things like that. So, my question is about the role of the JCC in terms of commissioning services from providers in England, and how this differs from the cross-border commissioning responsibilities of local health boards. Can you tell me about that, please?

Yes, we can. I don't know, Helen, did you want to—?

So, a number of years ago—and Stacey will probably remember how many years ago—there was actually an agreement that, where there was that cross-border commissioning, most of that would actually be brought through our contracts, and that is still the case at the moment. So, whilst we commission specialised services, we also commission on behalf of the health boards, and it is their governance responsibility, so it's flowing through our contracts, for some of that secondary care work. As you say, I also live in north Wales and see that flow happening back and to, to places like the Countess of Chester Hospital for that secondary care.

We work very closely with Betsi on those sorts of contracts. We were in a conversation just last week with Alder Hey Children's Hospital, where we very much come together—ourselves and Betsi and Alder Hey—in those contract meetings, and it's a three-way partnership at that point. Because we have to recognise that there are probably, in some places, greater volumes of those patients than specialised—. As Juliet said, the specialised patients—they are fewer in number by their nature.

And how does that affect—? Everyone I speak to out there just talks about waiting times: 'I've been waiting so many months', blah, blah, blah. So, how does that affect waiting times—the reality of it on the ground? What would you say to somebody saying, 'Look, I've waited so many months, I don't want to wait that time. I could die during that time'? So, how would you defend that?

Our contracts are set up in such a way that they meet the Welsh waiting times targets. However, we do have that discussion regularly with English providers where, for them operationally on the ground, it is incredibly difficult to manage two separate waiting lists, so they don't, in effect. And they do actually manage just to that English waiting time, which we know is lower. So, there is potential for differential there between somebody going to Glan Clwyd Hospital, for instance, and somebody going to the Countess of Chester. And that is noted, you know. As you say, your constituents talk to each other, don't they?

They do, absolutely, yes.

It's one thing that we'd like to see, those waiting times reduced over time.

Yes. Can I ask another question here? Is that all right? So, if a serious incident occurred between England and Wales, how's that dealt with in terms of your commissioning processes?

Do you want me to take that?

Yes, go on.

Sorry. All the questions are to you now.

That's okay. No problem. We have a dedicated quality team and their details are obviously within our contracts, and our quality team know those providers in England, their quality teams as well. So, the first thing that happens is the escalation happens between that English provider, and it happens directly into our quality team. We then talk with the relevant health board, as obviously the population is their responsibility. We follow the English quality processes and the English investigation processes, and we work on the output of those as we go as well, but we always make sure that we follow everything through on those as we go, and they're brought back into our contract meetings as well.

Okay. Do you want me to ask another question?

If you've got one more.

Yes, I have.

I think we can fit one more in.

So, talking about the challenges, basically, faced between English and Welsh commissioning and funding arrangements for cross-border healthcare: what are the challenges you face?

Sorry, could you repeat that?

Yes, I can. So, I'm talking about, basically, the commissioning arrangements between England and Wales. Essentially, what are the challenges right now? If you could give a succinct answer to that, I'd appreciate that.

I think, in summary, it's picking up on, really, I guess what Helen's already said. We have different waiting time policies in Wales and England, and England's are shorter than Wales's, so negotiating that and working that through is one.

Probably the second thing I would highlight would be the data and the data flows across. Stacey, you can talk in more detail about how border GPs work, and we've got frameworks in place, and there are certain implications—. For GPs and patients who live on the border, there are arrangements in place, but of course our patients for specialists come from all over Wales.

Yes, sure.

And we have got examples where data—. Because England is so much more digitally enabled than Wales, probably, they assume the data has flown back.

I don't think the word's 'probably'. [Laughter.]

And so I think that, for me, would be the two things that I would pick out are the challenges we currently work with.

Okay. Thank you.

Thanks, Nigel. And just another point around the significance, really, of the Bill's requirements for English integrated care boards to consider the impact of commissioning decisions on people living in Wales near the border, and how that duty is expected to operate in practice.

I think part of the issue is we don't know how it's going to operate in practice, and as the details work through the Bill, it would do. My assumption is that whenever there are service changes in England or Wales, we have a duty to engage both with the public and with other health bodies who would be implicated. What the Bill states that it will do is it will make that a legal duty to consider the impact on Wales and those patient flows. So, I would expect, therefore, that if things are being talked about and being planned, that they would come to us.

I think one of the risks is that currently, with specialist services being more centralised, that informal arrangement and knowing who's in charge and who you go to when you've got something to talk to is quite clear. Helen was saying earlier to me that we're already seeing the implications of the redundancy programme in England, that people that we used to link in with aren't there any more. Now if that's devolved to all the ICBs, there will be a lot more relationships that we need to develop, both informally, but also formally when we're negotiating and talking through our contracts and commissioning. So, we'll need to navigate through that.

Brilliant, thank you. I've got some questions now from Safa Elhassan.

So, I'm going to ask questions around fair access to care. So, how do you assess whether patients across Wales have fair and timely access to the specialist services, regardless of their postcode or background, and where you identify differences, what actions follow?

Shall I kick off or do you want to?

So, that is mainly through our commissioning processes at the moment. We do recognise that, within all health systems, there is inequity of access in places, and that's something that through our planning systems that we want to root out and to minimise as much as we can. Within Wales, we have very varied populations, don't we? We have very rural populations and then we have some more isolated populations, and we've got those travel distances to think about as well. So, all of that comes into our planning.

There are probably some examples that might be useful. So, if we look at complex neurosurgery, perhaps, and I know that Nigel's already mentioned the Walton Centre. So, if you live in Anglesey, there isn't a neurosurgical site in north Wales. There isn't that population there that requires that, but it's then about making sure that that access through to the Walton Centre for somebody who does live in Holyhead, say, is available to them and that we do everything we can to make sure the patient access is the same as it would be in south Wales.

There are things that we can do through this Bill that may help us as well. So, yes, a patient may need to travel to the Walton for their actual surgical care, but through some of the digital innovations, they may be able to be treated much more locally. Digitally, virtually, there are all different types of monitoring now that can happen at home, and obviously then you've got e-consults and things as well, so it's making sure we keep up with that. We do look at the population health base as we work through our commissioning processes, but there is always more to do.

Okay, good. And then in terms of waiting times, outcomes, and unmet needs, could you break these down in terms of geography or deprivation, and protected characteristics as well?

I don't know, Stacey, do you want to pick it up?

Yes, I think you've hit the nail on the head—it's a very good question. I think it's something, in all honesty, that we need to work on collectively. I think we are constantly considering all of the characteristics that we need to be considering as part of our assessments when considering services and what we commission within Wales and over the border. Obviously, providing care closer to home is the foremost optimum solution for patients, particularly those who have to travel or have conditions that make them very vulnerable. So, we've always got that in mind when we're considering deprivation, population outcomes, and where they're accessing their services for the best patient experience.

I think overall, though, the organisation is really committed to making sure that patients are receiving the care in the best place for that patient. And I think, when you talk about systematic commissioning, bringing in the patient outcomes, how we're managing, monitoring those, using those to be able to make decisions for future commissioning is going to become really important. And as we grow as a JCC, that is definitely something that the organisation will be focused on. And hopefully, through things like this Health Bill, we'll be able to contact more locally those organisations that are set up and commissioned more regionally to be able to factor those into some of the data transfers that will be required going forward.

I think just to add to that, again, it comes back to the data, and can we use this Bill as a catalyst to improve the data we receive? Helen and I were talking before and we've both worked in the English system and, as commissioners there, you had a lot of data that enabled you to see those health outcomes and look at protected characteristics, and it just flowed to you weekly, automatically. It doesn't flow to us in Wales in the same way, so it's hard. We want to do this—it's absolutely what we're committed to in commissioning—but getting the data can be a barrier to that. So, is there something, as England starts working differently, where we can use it as an opportunity to sort that out for our patients?

Okay. When patients receive specialist treatment outside of their local health board, and including in England or through the independent providers, how can you ensure that there's clear clinical responsibility throughout their care, particularly for follow-ups, and if there are complications as well?

Helen, this might be more appropriate for you.

So, what we try and do with a specialised piece of care that may be sitting in England is make sure that it's part of a whole pathway. So, a good example would be cardiac care in north Wales, where your cardiology will be done much more locally to you, but then you may need to go to Liverpool Heart and Chest Hospital for your cardiac surgery and then back again. The interoperability issues at the moment do cause us challenges in terms of reporting responsibilities. And it's the clinical relationship and the pathways and protocols underneath that keeps that safe. What I would like to see is that we become much more interoperable and then we can actually access that scan easily, so that it flows in a much more cohesive manner.

So, I'm not going to say it's perfect at the moment, but the pathways on the ground and pieces within our contract try to keep us as safe as we can, and try and keep our patients as safe as we can. And we have very few incidences of issues happening, but they do happen from time to time.

We have examples, I think, of really good practice across the border, where our clinicians work really closely together. We've got examples where English hospitals provide all services in Welsh for us and translate, but that takes quite a lot of time from Helen's team, and effort, to get that in place. So, what we hope to work towards is that that becomes a more natural way of doing things. And again, as we use technology and as we focus on getting things closer to home, and maybe by looking across that whole pathway, it will just flow more naturally.

I think we'll go back to Nigel now.

The question I want to ask is about the impact of losing NHS England as a single co-ordinating body for cross-border healthcare and specialised commissioning. What will be the impact?

Do you want to pick that up from a contracting perspective to start with?

Yes, I think it's a really good point. Nationally, we get greater economies of scale if we're able to do it on a national basis. And having to devolve that and speak to more organisations, by its very nature, may introduce a level of variation that perhaps didn't exist before. So, we've really got to consider, as part of our commissioning processes, how we manage some of those things.

We have contracting arrangements with all of our providers in NHS England who provide specialised services and for those pathways of care that we contract on behalf of health boards. We need to be thinking about, under the new arrangements, what that contract now looks like. So, traditionally, that's been in the form of more of a heads of terms or a memorandum of understanding, due to the legal differences between the NHS England contract and what we're able to sign up to from an NHS Wales perspective. Going forward, when we get the final Bill and we understand more of what those changes look like, there will potentially be an opportunity for us to make a really robust contracting mechanism with NHS England providers, to allow us to maybe be more integrated into their local commissioning arrangements and, if you like, have more holding to account arrangements with the providers. That's not to say that that doesn't happen now, because it does, but at the moment, a lot of it is based on heads of terms and our relationships with the providers.

In terms of taking away NHS England, there are two things for me. We've got our highly specialised services that are very, very small in number in terms of patient access. So, we really need to be working with NHS England or its new way of commissioning those services, either through the Department of Health and Social Care or through its offices of pan-integrated care board commissioning to be able to manage access to those services for the very small number of patients that we will have. And that's not just for the border patients, that's for everybody across all of Wales. And then, obviously, we need to keep a really close eye on what is deemed a specialised service going forward and what isn't. I know there's some deviation in some of our frameworks currently, but having a more robust framework, and thinking about how we do or do not align with the NHS England framework, would be really important as part of our strategic planning rounds going forward.

Yes, and in terms of patient safety, because obviously that's a real concern, what are your concerns over patient safety with this reform going on right now? Will there be concerns? And if so, what are they?

I'd better pass over to the commissioners in terms of the individual patient safety concerns, but just to say that they are included as part of the monitoring, as part of the contracting arrangements. We see the Care Quality Commission reports and we do have regular contact and quality conversations through our quality commissioning with the providers in England. But I will hand over to—.

I think there are probably a couple of things on a macro level. The Bill currently says that NHS England or the department of health, as that centralised body, will keep responsibility for developing service specifications, and that sets out what outcomes should be expected and those safety things. So, it ingrains it right from the start. I think that that's really important because it gets to some of the equity of the service. If we can look at it and everyone can expect this standard of service, then that's really important. I'd be really interested in ensuring that that stays in the Bill and how that develops because, that way, although specialist commissioning will be devolved in England, everyone will be expected to commission to that set service standard.

We're not legally obliged to do that same service specification, but in reality, we do look at them and we try and ensure that we are—why wouldn't we want to if it's best practice? And we input to them and we work with the central team to help develop them. That, to me, is the overarching way that quality right from the start before we even get to contracting is there. So, we really want to see that continue. I think the second point would be that it is devolved to local areas. One of the advantages of that is that they should understand the local service better. If we've got the right relationship with that local integrated care board or OPIC who is commissioning that, then we should be able to have visibility of that quality, arguably more so than if it's at national—

One question I want to ask is about the established relationships you have already and how will they be continued, maintained and ensured for the smooth operation of what goes on on the cross-border aspect.

Helen, do you want to take that one?

Let me give you a couple of examples of where I've seen that already starting to happen. Within contract meetings of the north-west this last week, we were talking about the quality governance boards that sit on that regional scale at the moment and them being brought more locally, and Adele within our team is already ingrained within that process and has definitely been brought through, and it's making sure that we don't get dropped off anywhere, isn't it, in those relationships.

Another example is we sit within the south-west on their regional planning board for specialised services, which—it's the start of the OPIC, isn't it—brings those ICBs and those current specialised commissioners together. And because some of our services do flow, or some of our patients do flow, into services in the south-west, we are sat around that table and we continue to do so. We also then, on top of that, have a—. It comes from within NHS England and ourselves. We have a cross-border meeting that happens every couple of months as well, where we tackle any of those border issues as we go as well. So, the issue, as Juliet has raised, is losing some of those key contacts. We've got to make sure we don't allow that to happen and I'm already seeing that we're not allowing that to happen. We're actively out there and saying, 'Come on, we still need to be here in this discussion.'

Just to get it straight in my head—. I mean, I don't know any of this right now. In terms of NHS England, if you could say it as a succinct statement, what is replacing NHS England right now and who will you be talking to?

What the Bill lays out is—. Currently there is a team centrally in NHS England that commissions all the specialist services. The arrangements suggested are that the very, very highly specialist services will stay central. They haven't, in the Bill, as far as I'm aware yet, declared or stated what specific services, and I know there are some worries about that, so we need to keep an eye on that and input into that, hopefully.

But the vast majority of specialist services will be devolved to the ICBs. What the ICBs are then doing is coming together in groups. They're regional groups, and they're embedding regional teams into an ICB on behalf of everybody else, which is how we operate in Wales, sort of. I mean, it's coming at it from a different direction but the end result is the same. So, that is how it will commission. Those teams are yet to be established. Dependent on how they are set up, that does give us—

What's the time frame you're looking at for that?

Well, it will depend on the Bill going through and what's set through—

Yes, I realise that, but in your head, I'm thinking now, to sort this out, what are you looking at? Because you must have had plans for this at some stage.

It's impacted by the process that England is getting to to get there, and the question is who are those people going to be, because of course at the same time as devolving it, they're reducing by 50 per cent the staff. So, I think that's probably more of an implication we're experiencing at the moment. It's not the structural reform; it's more the reduction in headcount. I guess our concern would be that these are highly complex services that absolutely need focus, and because we've got the JCC working on behalf the health boards in Wales, we can give it that focus. Whereas actually, in numbers, it's dwarfed by the rest of health board activity. I guess that could be our concern in this arrangement, particularly as they reduce headcount and they've got to focus where their resources are, that all the focus goes onto the non-specialised and it's harder to have those conversations, because of the focus. But I guess that's how it's enacted, and if we're aware of that risk then we can start having these conversations now to set it up.

Great. We're going to move on now to Claire Archibald.

England is proposing the single patient record. What would this mean for Welsh patients receiving their treatment in England and what needs to happen to ensure that the information flows across the border?

It's a good thing, isn't it, to have that single patient record, so that your GP can see the same as your consultant can see, and you can also—you will be able to within England—see that as well, which is quite different to what we have in Wales at the moment. What we need to make sure in Wales is that we have that interoperability with that, so that, again, a consultant in Glan Clwyd could actually see what was going on in Liverpool Heart and Chest Hospital for that patient, and the GP could also see the same, for instance. I think we've got a way to go on that, but I think, through some of the Bill's suggested enactments of having to work closer together and to consider our needs—it will be coming from that English side to do that—we need to make sure that we then engage and do the same.

Yes, that's what I was going to say: aren't are we at risk of creating two digital systems, with the patients still having to bridge the gap, which is something that, for the patient, obviously, having the treatment is quite—? So, at the moment, it's still in an early phase, is it? You're not quite sure whether it's going to be two systems or—?

I couldn't comment on what the Welsh plans are. Stacey, do you want to—?

Thinking about it from a commissioning perspective, the single patient data pathway access is really very much a provider issue. When we're thinking about continuity of care, from a commissioning perspective, what we need to be really clear of is that our providers are thinking about that at every step of the way through commissioning that care. I think that interoperability is a question, probably, for Digital Health and Care Wales, thinking about how we are developing our own patient apps, and how that works across the border, together and collectively, because that's when you'll get the best—. And also, what is the Welsh patient population voice in that as well, because, at the moment, we aren't as advanced.

We're going to come on to some questions now from Natasha Asghar.

Thank you so much, Chair. I've been listening intently to all of your answers to my colleagues, and the one subject or topic that's been kind of resonating in all the questions—. I know the Chair asked a question, and you mentioned data. Safa asked a question, you mentioned data. Nigel, I'm sure data was in one of your answers as well. So, my focus is going to be primarily on data, because it is a big concern for a lot of people. So, from your perspective, as it stands, what are some of the current issues, barriers, hurdles that you're encountering when it comes to data sharing between NHS organisations in Wales and England at present?

I think, fundamentally, we have different data systems. This English Bill puts that mandatory legal—that they will all be joined up in England and have that interoperability, which is fabulous. I know there have been concerns, and patients are rightly concerned about data protection, and I get that. But, particularly for us in specialist services, where we are reliant on those cross-border flows, the fact that somebody could access your health records, and you don't as a patient have to go through everything again, and you don't have to travel to England to have the test because they can see the test you had with your GP down the road, has to be brilliant. I think the time frames laid out are quite aggressive in England, to get there, because they understand the importance of it, which is great. So, the challenge for us is how do we get some of the building blocks in place really quickly to be able to have that conversation that will enable it.

And how are you going to do that?

As Stacey was saying, we believe it is really important and we are entering into all the discussions. I was with all the chief execs in Wales just on Tuesday, when we were talking about the importance of this, so I know the drive is there. The responsibility for that sits with DHCW, who manage the data and the IT that sits behind healthcare in Wales. So, we're influencing rather than having direct control over that.

Okay. I'm a huge supporter of data sharing; I think it will make people's lives a lot easier, personally. But there are a lot of people out there who are going to be concerned about where their data is going. It's a genuine reason. I can completely understand that there will be people who will be thinking to themselves, 'Well, is my data actually going to be safe, and is it actually going to be secure?' So, from your perspective, how are you going to reassure people that their data is going to be safe, even if it is shared?

I was reading through the Bill, and looking at the—. To be honest, I'm not a technical person, and there was far more in that Bill that just blew my mind. But, clearly, there is a lot of thought that is going into it, and I think, absolutely, those questions should be asked by people who understand it, not just for primary reasons, but secondary reasons.

Personally, I was a patient in the English service just last week and the fact that I have got it all on my phone and I had my discharge letter the minute I walked out of the hospital and I could see it and I could take that to my optician and to my GP was brilliant. They asked me personally there—I could tick 'Do you want to be involved in research?' So it gave me that feeling of control. So I can talk about it from a patient perspective, which I think is really important, because we all work in the service, but we are all also patients, and we need to keep that view on it. That patient involvement and community involvement and conversation around it that Stacey was talking about, I think, is going to be really important as we develop this.

Just to add, I think it's really important that we do work with DHCW to look at what the information governance rules need to look like to make sure people are kept safe and their data is kept safe and is used for all of the right reasons. And we're happy to be a voice in that and make sure that the commissioning perspective is well heard.

I'm glad you mentioned governance, because that was going to be my final question now, because I know we are going to be short for time otherwise. Do you think the current governance arrangements that have been proposed by the Bill provide sufficient clarity and assurance regarding the sharing and use of patient information at present?

My take on it was that it was good to see that it is talked about and is referenced in there. I think there are huge questions to be asked for it. I don't think I have the technical knowledge, and we probably don't within the JCC because it's just not our area of focus. So, I guess, in summary, it's good that it's referenced and it's good that it appears that conversations are being had, because these will be the same questions that different regions and people in England will be asking, but absolutely, it's essential, it's got to be a focus of it.

Thank you, Chair.

Matthew Jones.

Diolch. Dwi'n mynd i'ch holi chi yn y Gymraeg, os ydych chi eisiau gwisgo eich offer cyfieithu. Jest cyn i fi holi fy ngwestiwn, dwi jest eisiau nodi yn rili gyflym y byddwn i wedi licio gofyn i chi am bethau cyffredinol sy'n digwydd gyda'r NWJCC ar hyn o bryd—pethau fel Gwasanaeth Rhywedd Cymru. Dwi'n gwybod gallwn ni ddim ffocysu ar hynny heddiw, mae'n rhaid i ni ffocysu ar y LCM a'r Bil iechyd yn Lloegr, ac mae amser yn rili brin, ond dwi'n gobeithio gallem ni eich croesawu chi yn ôl rhywbryd i fynd i mewn i fanylder ar hwnna, a dwi'n edrych ymlaen at hynny.

Ond i godi llywodraethiant ac atebolrwydd ynglyn â'r Bil yma, ydych chi'n credu bod y Bil yn rhoi digon o eglurder ynghylch pa sefydliadau sy'n gyfrifol ac yn atebol am wasanaethau trawsffiniol?

Diolch. I think a lot of the technicalities in the Bill aren't laid out in a lot of detail as of yet, so I guess the easy answer is 'no'. I don't think that's an intention of it, though. I think that needs to be worked through as they take it forward. The advantage that it puts that statutory accountability on ICBs to talk and take cross-border into consideration is the first time that that direct accountability has been put into law. We have a framework at the moment, but it doesn't sit as a legal requirement. So, arguably, it is being tightened up with this Bill and it is clear that that is an ICB's responsibility, but, as ever, it will come down to how it is implemented as it goes forward.

Just to add, there's the Bill and then there's the ways of working. We currently have the statement of values and principles, and in Wales we have the Welsh health circulars, which help us define how to manage those rules for those cross-border patients, particularly when it comes to payment and responsible legal entities and bodies. So, I think it will be really important that we keep abreast of that and make sure that those guidances and ways of working are also kept up to date at the same time as the Bill is going through and that becomes clearer, as Juliet's trying to describe.

Diolch. Ydych chi'n credu, felly, ar hyn o bryd, bod y Bil yn dangos bod prosesau effeithiol ar gyfer codi a datrys materion gweithredol, comisiynu a chytundebol trawsffiniol? Ydyn nhw'n ddigonol ar hyn o bryd, neu ydych chi'n credu bydd hwnna'n mynd yn ôl at y ffyrdd o weithio hynny yr oeddech chi'n sôn amdanynt?

I'm going to take these off to speak, if you don't mind—

That's fine. You don't have to reply in Welsh.

Good. Thank you. Diolch. First and foremost, the guidance, principles and legislation all point to making sure that patients access seamless care whatever the environment is, whoever's paying for it at the time that they need the care. And I don't think the principles of any of those changes in any new legislation, new guidance, principles or frameworks. But the current contracting environment that we work in, as we say, is less legally binding, because the way that we operate. So, we're a hosted organisation and we contract with NHS England providers, so we have a heads of terms in relation to how we work together to be able to access those care pathways seamlessly.

So, in terms of escalation, I suppose it depends very much on relationships. At the highest level, we are able to escalate things Minister to Minister, and there have been circumstances very many moons ago where that may have happened. But as it currently stands, and I think as part of the new Bill, we will still have to maintain very robust relationships with NHS England providers and with ICBs, OPICs and the department of health in order to be able to escalate any issues.

But in the principle of what we're trying to do, which is to make sure that patients are accessing care seamlessly, we would like to think that we work together really effectively to enable those pathways, and to make sure that those things are not always escalated at the first port of issue, really.

Thank you. We'll go on now to Sara Crowley.

Thank you. Croeso. I've got two questions. I'm going to ask them together just in the interests of time. I'm talking to you about consultation and engagement. So, does the Bill provide sufficient robust mechanisms for consultation and engagement where decisions taken in England affect people in Wales?

And then my follow-up question to that was going to be—and I'll declare an interest; I worked for 10 years in transitional care—so I was going to ask: what impact, if any, will the commissioning arrangement have on adolescents and young adults transitioning between children and adult care? And how have their needs been taken into consideration in developing these arrangements?

There's quite a lot there, but I just wanted to get the two questions in so I can pass that over.

On your first question, it comes back to probably what we've already highlighted, which is that this duty to consult and getting that enshrined in law has to be a good thing for Welsh patients. Again, it'll be how it's implemented and looking at how that works, but it does make the framework that we have in place more robust because it makes it a legal requirement.

On transitional care—a really, really important area for all of us—I don't think, for me, and this is just my understanding of the Bill, that there's very much in there that makes a difference. It's much more about how the commissioning arrangements are and their physical structure within the Health Bill. I think how care is provided within that isn't so much a topic of it, and therefore I don't see it being particularly influenced one way or the other. I don't know if you've taken a different take on it.

I think there is, possibly, opportunity, isn't there, because there are differences at times now in ages between different services, and there is possibly an opportunity to realign some of that. So, I know that there are sometimes times when a service in England may wish to keep hold of a patient longer and that transition piece into adult services here, or vice versa—maybe they discharge slightly younger. I think we've got an opportunity there, through that closer working at ministerial level and all the way down, to make sure that we align that better.

My final ask would be that when you're able to influence, that that is taken into consideration, because I think it's very much overlooked. So, that would be an ask of mine to move forward. Diolch yn fawr.

And final questions from Becca Martin.

Diolch. I'm looking at futureproofing, so probably going over a little bit of what's already been said today, but going into the future. So, what I really want to know is: what opportunities have you identified so far in terms of strengthening and formalising those cross-border arrangements through the proposed reforms? But equally on the other side, are there any implications that haven't been fully considered yet?

Thank you. Stacey, on the formal contracting side, do you want to come in?

Yes, and maybe it's something that we can come back to the committee on as and when it develops over the next months or so, when it gets to the final stage. For me, just my initial thought there was around that the Bill brings in the cross-border patients, but obviously a lot of what we commission from NHS England relates to a highly specialised service, which may be for cross-border patients, but is for all patients across all of Wales. So, I think there is an opportunity looking into the future that, through consultation and so on, those cross-border voices are taken into account. Maybe we need to be thinking about, if you're a specialist hospital providing highly specialised care, how you would consider it all more broadly.

But, in all fairness, I think we have got examples where we commission specialised services where good practice has happened so far anyway. But it's just with any change, and with any sort of disaggregation of a national body, you lose some of the economies of scale sometimes, and therefore those single points of contact. So, it's just to make sure, really, that going forward we maintain contact with those relationships and make sure that the futureproofing is thought about at every level, even if things get devolved more regionally in NHS England more broadly.

I think the challenge for us is making sure the benefits that are there in keeping some of it national are absolutely there. So, I talked about the service specification and I think that's really important for us, that those things are maintained and go through. And those highly specialist services, we’ll need to be aware of which ones they are declaring are highly specialised, because we rely on clinical conversations informing what we do at that level.

One of the advantages of local devolvement though is we'll be able to get into that more sort of micro conversation about how we get a service to work across border, and therefore how we can contract effectively. So, for example, we offer a thrombectomy service, which is the highly specialised end of stroke care, which is provided in Cardiff at the moment and in Bristol. There aren't very many doctors who work in that area, nursing staff and others. Now if, because there's this more local focus on it, we can get into a different conversation, which is how can we work effectively together and have a more networked service that crosses border, that would be a real advantage for patients and residents of Wales. So, I think it's exploiting some of those opportunities that may arise whilst also ensuring that that governance is there at a national level.

Thank you. And just how do we embed that, so that it continues going forward, so that it's not really good now, but then sort of years down the line we're looking and it's not as good? So, how are we going to really effectively embed this within the future commissioning and governance and that planning?

Helen, did you want to—?

I think there are a couple of different things there, aren’t there? There's the how we interact day to day, and making sure that we have those right governance meetings in there, that we pick up the right things through those and that we're embedded there. There's also then, which Stacey's alluded to, making sure that our contracts embed them as well. So, it's those two things together, I think, that will bring it and make sure that we continue, no matter if any of us moved on, that it would go into the next managers who came through.

Thank you.

Thank you. And that's the end of the session today. Thank you for providing us that evidence for our look at the Bill. We really appreciate that, and you will be sent a transcript to check for factual accuracy as well. But diolch yn fawr, thank you for joining us.

We'll now take a short break just to bring the next set of witnesses in.

Geoff Ryall-Harvey. I'm the regional director for north Wales.

Brilliant. Diolch. And Members have a number of questions to ask you about the Bill this morning, so we'll go straight into that, and we'll start with Safa Elhassan.

I'd just like to declare that I sponsored a Llais event this week, and I had a meeting with Angela last week as well regarding the event.

Regarding patients' experiences, from patients and families, what do they tell you in terms of the greatest difficulties that they face when it comes to care across Wales and England's border? Who is affected the most? And what does this mean for their care and well-being?

I think some of the biggest barriers to the cross-border care is information flowing with the patient. We hear through our complaints advocacy and our open engagement that people have to repeat their story several times. Things like test results don't flow with the patient, so that means that they have to have blood tests again in England, as well as in Wales. I think also, sometimes in the converse, on the discharge processes in England and Wales, they can sometimes not flow as well as they could do. So, I think those are some of the barriers that we hear about the most.

In terms of who it affects the most, I think, obviously, the border communities who use those services—quite often, it affects them. And I think particularly rural communities, or people who have to travel long distances, so potentially, someone using a specialised service in England who is travelling from, maybe, west Wales. That travel and the kind of challenges in the processes moving forward are more acutely felt by those communities.

And just on that, could you give us an anonymised example of the difficulties that patients are describing in terms of travel, or communication of that follow-up that you've mentioned?

Yes, sure. We supported one individual with a complaint and we supported their family as well. It was an elderly lady who was 80 years old and she was having treatment in England. She was medically fit to be discharged, but it took four weeks from that point to her going home, and that family were travelling—. I think they added up the miles and it was getting close to 8,000 miles that they'd travelled in those four weeks, trying to support that individual to be discharged back into their home.

It can work very well. Betsi Cadwaladr commissioned prostatectomy at a London hospital and we've heard very positive things about that. The preparation is very good, the experience at the London hospital is very good, and aftercare works really well. A lot of thought and effort has been put into that. The only negative comment we had on that was a guy who rang me up and said, 'I've been referred to a London hospital. I see it's the best in Europe. What are they not telling me? Am I more seriously ill than I've been told?' So, it can work very well, but conversely, for some of the more routine treatments, we hear the things that Ben has said, and we regularly hear from people that they have tests, imaging done in north Wales, they arrive in the Liverpool or the Manchester hospital and they say, 'Well, we're going to do those again because they never come over.' And so your first appointment is about imaging and diagnostics and it's not until the second appointment that you get to see the consultant.

Okay. And what are the two most important practical changes you would ask this committee to recommend to improve patients' experiences that they receive across the border?

I would say that it's around the information, accountability upfront, making sure that those responsible who are providing that care understand who's leading, who's responsible, and for the person who's having that care in England, they understand what it means for them. Where are they going to be going? How do they get there? What's going to happen when they get there? Are they going to have to repeat their story? We hear from people who take their patient medical records with them, because it's easier for them to take them rather than starting again and, like my colleagues have said, repeating those tests. So, I think that information upfront is really important, and accountability is also really important, and clear governance, to make sure that that works really seamlessly.

Would a named contact help patients navigate their care and make it more meaningful? Would that be something that—?

I think, at the beginning, it's important that they know who to contact if their care goes wrong. And that should be clear to them at the very start, when they're referred, and that can be a contact telephone number for somebody and who they contact.

Llais is a statutory independent organisation that is there to support people. Our details are often added to information so that they can contact us and we can help navigate that. What people tell us is that they don't always understand where they need to go and who to contact. So, that front information for the patient, if they have that, 'Where do I go when things go wrong?' or 'What does it mean to me?', they naturally feel more comfortable going into that appointment, and if things do go wrong, they know exactly where to go then. So, it's having that clear information; people want to be and need to be informed.

Thank you.

Okay. Brilliant. Thank you. Questions now from Sara Crowley.

Helo a chroeso.

I'll declare an interest: I worked in transitional care for the past decade before being elected. So, whilst I'm keen to hear your broad assessment, I'd also be keen to hear whether there are particular issues affecting adolescents and young adults, especially when they may be transitioning from children to adult services, within some of your answers, if that's appropriate.

Where do current information and support arrangements fall short, particularly at key stages of the patient journey at the moment? I think you've touched on quite a lot of the question that I was going to ask in terms of information and support there, so—.

I think it's around that information just not being clear for people. They don't always get that information. So, for people, it's just their care, the boundaries almost don't exist for them. When they're referred, they need to know where they're going. How are they going to get there and is there support for them? We see people travelling from west Wales to England for specialised services. If they aren't able to get there themselves, if they haven't got a loved one who can take them, that can be really costly. So, can they have support with that transport as well? It's around making sure that the information is really clear for people.

In relation to children transitioning to be adults, we hear from people a lot that they almost have to start again. It's not seamless. With children who are accessing services, they're on a journey, aren't they? It's really difficult, and going into adulthood is a scary enough situation by itself. So, it's having to start again, 'I've been waiting for an assessment, but now suddenly I'm an adult. Am I going to go to the bottom of the list? What does that mean for me now as an adult? How am I going to be treated differently?' I think what we would like to see the Bill achieve is much clearer information for the patient. Ultimately, that will help clinicians who are there supporting the patient as well.

I'd add to that that, sometimes, the different entitlements or the different approaches to treatment, screening, things like that can add more complexity in terms of ages for treatment, ages for transitioning to adult services, and those differences confuse things a little bit more as well. So, having that one point of contact to supply that information and support would be really useful for people.

For mental health services, for example, there's a sliding scale that can go as high as 25, depending on the needs of the individual patient. It's not as clear-cut as it would be, say, for medical things. But that might suit others as well, to have that. It depends on maturity, it depends on your individual situation.

So, there's an inequality there, isn't there? Mental health has more flexibility.

It does, I agree.

Just to follow up, then, how well do people understand the NHS rules, waiting time standards and entitlements that apply to cross-border care?

I think there is confusion. People just see it as their NHS care, they don't understand it. If they do recognise there's a difference, there's complete confusion then. There are different governance arrangements, different accountability, different waiting times. What does this mean for me? So, I think for those who do understand that there's a difference, there's complete confusion. For those that don't, they just don't understand what that means for them. If you have an English patient who's got to wait three months for treatment, but a Welsh resident who has to wait two years for an appointment, it creates huge inequity for the people of Wales.

It's very difficult when you have patients in, I don't know, Gobowen. You've got an English patient and a Welsh patient sitting next to each other, they share information, and it appears to be very, very different. You would naturally be concerned if you're waiting two or three times as long.

Absolutely.

We've got some questions now from Natasha Asghar.

Good morning. I've been listening attentively to all of the answers you've been providing my colleagues, and you've mentioned tests, imaging, discharge levels. So, aside from the ones that you've mentioned so far, are there any particular points within a patient's journey where people are most likely to experience delays, duplication and disruption to their care?

Other than what we've mentioned—well, I did mention it, but I'd stress the discharge. I think that is a particular challenge for people, especially if they need a care package put into place to return home. Other than that, I think it's definitely the things that we've already highlighted.

The start, the middle, the end. They have these delays because imaging, tests and records are not available. They might need to be done again. So, that takes longer than it really needs to. And then at the end, the discharge. We have seen arrangements where it works really well, really smoothly, but too often we hear that people have difficulty getting into the service, and then we have examples of people who struggle on discharge. You live 100 miles away and you're discharged late at night. It doesn't work for Welsh residents.

Yes, we supported someone with a complaint, an elderly lady who was discharged late at night, and because she didn't have any family or carers, she ended up having to pay for a taxi to take her home, into the hundreds of pounds, just because that's when she got discharged.

So, from your experience, what do you think could improve the effectiveness of such care that's required?

I think, as Angela said, in terms of having those clear points of responsibility and accountability on that journey—. Patients see the journey, they don't see the different services. So, behind the scenes, services need to work together better. The information, the process needs to follow the person through the pathway. Otherwise, they're just left, or families and carers are left trying to piece that together before things can move forward.

Okay.

I think it would be quite easy to specify this in the commissioning, that there are no late night discharges and that discharges generally take place in the morning, that pharmacy needs are attended to as part of discharge, and that there are really clear arrangements around patient transport.

Okay, fantastic. Thank you so much for that. Final question: what do you think are some of the risks and opportunities that the reforms may present for seamless patient care going forward?

I think the Bill provides lots of benefits for patients and Welsh residents who are living in England, but we do believe it does need to go further. I mean, if you think about the single patient record—that would be such a benefit for people; if you think about those people who are carrying their pack of information around with them, because they go to see the clinician and they have to spend time talking about what allergies they have, what medication they're on.

So, we do see clear benefits in the Bill, but we do believe it does need to go further to protect Welsh residents to make sure they have seamless care. And we just need to remember that with all these systems, there's a patient at the end of each one of them, and I think we just need to—. When the Bill moves forward, the proof will be in patients' experience, and that's where those providers need to listen to people and understand whether it's making a real difference for them, in that single point of access, because a single record can make a huge difference.

Thank you, Chair.

Thank you. I've got some questions now from Nigel Williams.

I just want to declare some sort of interest, really. Geoff, we probably worked together a long time ago. I worked in performance management with Peter Higson.

Oh, yes.

You'll have seen e-mails from me and various things at various times over that time. And I'm also in a constituency, Fflint Wrecsam, which is a border and a rural community as well. In fact, I live in a very small village, actually.

So, in terms of that, what are the particular challenges you think that are faced by people living in an area like Flint and Wrexham, where they've got a border, in terms of what goes on across the border?

In terms of challenges, people who live particularly in that Flint corridor, if you ask them, 'Where's your local hospital?', they will not say, 'Wrexham'. They will say, 'The Countess of Chester Hospital'.

Yes.

And these patient flows have been happening for a very long time. Twenty-five per cent of the patients in the Countess of Chester are from Wales. That hospital couldn't exist in its present form without Welsh patients. And those English providers need to understand that, that Welsh patients are an integral part of their business plan, of the viability of their business.

I think this Bill gives an opportunity to think again about how patients flow across the border, and it gives an opportunity to address some of the issues that make that problematical. But as you know, Nigel, people in north Wales, in all parts of north Wales, when they're seriously ill, expect to go to Liverpool or Manchester.

Yes, they do.

And very often they have family in those areas, so that helps them. The transport links are very good and that helps them.

You mentioned issues. What do you perceive as the issues right now?

It's again getting there in terms of tests, imaging, preparation. We hear too many times that people with serious illnesses become their own care co-ordinators, and they have to ring the consultant's secretary, they have to make sure that test results are there, they have to make sure the record's there. They even have to make sure that people know that they're coming. So, all of those, I think, need to be taken into account, and some of those preparations are there already. They need to be improved, they need to be built in, and everybody needs to know that these patient flows are not an add-on, they're an integral—

And are they listening to you? That's the question. Because patients out there think, 'Oh, my waiting time is so and so.' We've all got personal experience of waiting for 12 months and more and that sort of thing, and with the serious issues that people have got, health issues, and they're still waiting a long, long time.

They are. That's a commissioning issue and Betsi Cadwaladr have been appraised on that many times in our representations to them. Because you're on the border, you might have somebody who lives a couple of miles away. Between the centre of Chester and Wales, it's less than 1 mile. So, people talk to their neighbours and hear, 'I'm having my hip replacement in three months'; 'I've been waiting two years'. There are reasons for that, and people need to understand what they are, but also there need to be efforts to improve that.

And how often do you meet with all the representatives of healthcare in north Wales to discuss these issues?

Constantly.

What does that mean?

That would mean that, on a daily basis, I'm speaking to people about clients' needs. But also I would be involved with—. I have a place on the quality, safety and experience committee; I'm currently on the reference group for the well-led review. So, we speak on a daily basis and we make them well aware of the issues that we raise. We have, in any one year, about 500 complaints about services in Betsi. Many of them are about waiting times, many of them are about quality. We deal with complaints across the border as well.

And how well are they actually resolved, those complaints? Because it's a real issue for people in my area. They talk to me every day about it.

I just want to make sure we're sticking to the purpose of the Bill. I'm just keen that we don't get—

I'm sure Nigel and I could talk about Betsi forever.

We've also got Betsi coming in after this session. I'm just really conscious that we've got a very short amount of time to focus on this.

I'm quite happy to speak to Nigel another time.

Yes, absolutely. Do you want me to go straight on to NHS England now?

Yes, absolutely. Thanks, Nigel.

Going on from that, we're going to talk about the opportunities and risks that are arising from the abolition of NHS England and the wider reforms to the English NHS for people who rely on cross-border healthcare. You mentioned at some stage some of the aspects, but what are the opportunities and risks from this? It's going to be a whole new world for you, I think, isn't it?

The commissioners have the opportunity to address all those issues around tests, around information transfer, around public awareness. Within north Wales, people can find easily the information that when things go wrong, they need to speak to Llais for assistance and help through the complaints procedure. That needs to be included in the letters that come from the English health boards, because people don't know how to complain.

We recently had a Public Services Ombudsman for Wales decision around private services commissioned by Betsi in the north-west of England. Betsi Cadwaladr declined to deal with it through the complaints procedure. We reminded them that they had to. It eventually went to the PSOW. The PSOW also reminded them that, in addition to the financial aspects of any contract, they needed to also be looking at the quality. They didn't lose their responsibilities because it was in England. Any legislation needs to strengthen that on both sides.

I think one of the risks as we transition to this is that the responsibilities, as they lie now—and even some of that is through goodwill and established relationships—need to be mapped across and all taken into account as this transition happens. Otherwise, Welsh residents could drop between the cracks and there could be some gaps there that could have an effect on people's safety and their experience. But I think there's also the opportunity to revisit the cross-border statement on values and principles and to make sure that that's the opportunity to look at that and make sure that that's working.

And just one last question, if I could—you just mentioned it—in terms of visibility of Welsh patients. We don't want them to become invisible. Is there a risk that patients in Flint and Wrexham and cross-border areas might become not as visible as they were before with what's going on?

If that process is not done and those responsibilities are not mapped out, there would be a risk that that could happen. I think that really needs to be taken seriously to make sure that all of those responsibilities happen in the new landscape, as it were.

I think the other thing we need to recognise is that Welsh patients are very important to these providers in the north-west of England. They're a huge part of their business and they need to maintain really good relationships with Betsi Cadwaladr and to provide the service that the Welsh patients need.

Can I just put on record as well that Llais do a really good job? Thank you very much.

Thank you. We'll move on to questions from Matthew Jones.

Mae fy nghwestiynau yn Gymraeg, os yw hwnna'n iawn, os ydych chi eisiau rhoi eich offer cyfieithu ymlaen. Pa risgiau sy'n bodoli i gleifion gyda'r newid sefydliadol a allai ddigwydd o ganlyniad i'r Bil yma?

Generally, in terms of the risks, I think I just touched on some of them. If the responsibilities are not mapped out, Welsh residents could drop between the cracks. I would also highlight a big benefit but also a risk to the single patient record, because if that process happens in England and it's built for England and then Welsh residents and Welsh connectivity is not considered upfront, there could be a big risk that we're going to put in a bigger digital divide than exists at the moment. As you've heard from us, information flowing, test results flowing with the patient is really important, so there's a big opportunity with the Bill but there's also a risk.

The other risk is—. We welcome the duty on the ICBs to have consideration of Welsh residents in their commissioning, but at the moment that's focused on border communities. As you would have heard this morning, for specialised services there are residents across the whole of Wales, be it west Wales, north Wales, that are using those. So, we think that's a bit of a risk and we'd like to see that extended to any Welsh resident who's using services in England.

Ydy'r diwygiadau sy'n cael eu cynnig yn rhoi digon o eglurder i gleifion ynghylch cyfrifoldeb, atebolrwydd a llwybrau i godi pryderon neu gwynion?

As I mentioned at the beginning, it needs to go further. That information at the front door when the patient is being referred needs to be really clear. They need to know who's responsible for their care. Patients can very often have a Welsh GP and then they're seen across the border by their clinician. So that information needs to be really clear. And for clinicians and providers, they need to know who's responsible, who's accountable. When care goes wrong and people are making complaints, the person needs to know who they make that complaint to, but the providers involved need to know who's going to lead on that. There needs to be clarity. So that accountability and that governance is really important. But I go back to the information for the patient at the point of referral—that needs to be really clear.

I would also suggest that there needs to be consideration of how a wider investigation into bigger failings, systemic failings, would be made. Who would deal with that? Would it be Healthcare Inspectorate Wales? Would it be the Care Quality Commission? Who would lead on it? Would it be the commissioning agent in the English area? Would it be the health board in Wales? That needs to be, I think, written down and made clear, because these things happen from time to time.

Mae'r problemau hyn yn bodoli eisoes. Ydy'r newid yn y Bil yn mynd i waethygu'r sefyllfa neu wella'r sefyllfa, neu gadw'r un fath o broblemau sy'n bodoli?

I think that that would be down to how the governance around that is. You've touched on a good point—it could get worse. They do exist at the moment. There is confusion.

I would say that the Bill is neutral at the moment—

It is, yes.

—but this could be an opportunity to improve that.

Thank you, Matthew. Now, questioning goes back to Natasha Asghar.

Thank you very much, Chair. What do you feel is the impact of existing barriers to data sharing and interoperability on patients receiving cross-border care?

What's the impact on them? I think you've heard quite a lot of the different examples. There's a patient safety risk if the right information, allergies, medicines don't travel with the individual and that information is not shared. That's a problem. I think it affects people's experiences of care: it's start-stop, cancelled, 'I've turned up, you weren't expecting me.' All those kinds of things happen. So, I think it's a really big impact on people, actually. And also then for people, as we've said, who travel long distances, that's just magnified. In some rural communities as well, it takes longer to get to the appointment. I think that's a big impact on people.

We've got some examples. We supported someone who was taken off a waiting list because they had the NHS Wales app and the NHS England app. They lived in Wales, were registered with a Welsh GP, and couldn't access the NHS England information because of that. They had the NHS England app but couldn't register because they were registered in Wales. Eventually, this confusion led to them being taken off the waiting list. That's a practical example of what happens when information doesn't flow.

I was going to ask my second question on the single patient record, but I believe you answered it to my colleague earlier, which is absolutely fine. But there's something that I'd like—. I hope, through the Chair, I can ask this question. In relation to this Bill—. Obviously, that's going to be the focal point of this session today. With regard to—. And I should have probably asked the previous group that were here earlier, and I will ask the following that comes after you. With regard to the nitty-gritty, the devil's ultimately going to be in the detail of this Bill, let's be honest with each other. So, from my perspective, who has briefed you on the nitty-gritty so far on the Bill? Do you have a legal team that's advising you? Have you gone through it yourselves? What is the process for you to understand more about the Bill? Because we're obviously very fortunate in our position. We've got great researchers, we've got a legal team, we can go through different channels for this. But what about you?

At this stage, it has been us going through it. We are working with our legal team as well to think about what that means for people and to highlight some of the big risks as well. We get a lot of intelligence from people who come to us to share these practical things, and I think that's where we can really stress things. We've got people's experience shared with us, so that when we do get down to the nitty-gritty and the details, we can talk about the practical issues that are going to happen. The Bill lays some good foundations, if done well. The opportunity and risks lie in the things that are going to surround it—so, the principles and values of cross-border, how the plan for the single patient record is going to be set out, and an England and Wales agreement on all those things. That's going to be the devil in the detail to make the benefits realised, I'd say.

We also deal with very large numbers of complaints. When we quote examples, those have been through the complaints procedure. The outcome is known and provable. So, when we give those examples of where the system has let people down, they are real examples. They're not speculation. They're actually agreed with the health board who responds to the complaint.

And just to add, when people make complaints and the care they received has gone wrong, we want to see action following through from that and learning for the organisation. As you'll see in our evidence, we're calling for Llais to be recognised in the Bill as well. We're a statutory organisation. We want the Welsh voice to be heard, and Llais is the best fit to represent that voice.

How is that working out for you so far?

It's done on goodwill at the moment, so that's why we're asking for us to be recognised in the Bill. We've got established relationships. Even though Llais is quite new, the previous organisation was there for some time. Geoff has got established relationships and other colleagues have established relationships. But the Bill is the opportunity to take that further and put it into strong governance terms.

Thanks. Thank you, Chair.

Great. Questions now from Claire Archibald.

I'm really sorry, because my question has just gone off the screen. Voices, obviously, patients—are they being listened to when you make decisions about transporting back and forth? I'm sorry because my question has literally just gone off my screen. That's just great.

In terms of listening to patient voices, one of the things that concerns me slightly in this Bill is that it includes the abolition of Healthwatch and the transfer of those engagement responsibilities to the commissioning board. I think Llais needs to be included in that. There needs to be a recognition that Welsh patients also need to be consulted. Llais would be a good mechanism through which to do that, in addition to all the other things, Civica, or whatever feedback they use, all those engagement things.

I'm concerned also about the vast experience of Healthwatch being lost. And I'm just trying to get in touch with my Healthwatch colleagues on the Wirral to speak about what is happening to that. Are they somehow being brought into the commissioning bodies to carry on the work that they've been doing, or is that just all being lost? I think that's really important.239

Commissioning bodies don't always have the best track record in engaging patients and listening to them. Some of them do, not all of them. Independence, I think, is really important in that. We've found that over the years, for Llais, and for community health councils before them.

Okay. Do you think they're being consulted, the patients, early enough, or are they being asked for their views on the main decisions after they've already been made?

If we're talking about changes to services in England, I think, too often, it's an afterthought, and the changes happen and maybe even the health board in Wales doesn't know about it, because they've gone through their system and they haven't thought about, 'What about this 10 per cent of our patients who come from Wales?' I think the Bill is an opportunity to formalise that, to make sure that due regard is given to the opinion and to the experience of Welsh patients.

Thank you. That was going to be my next question.

Thank you.

Right, we'll move on to final questions from Becca Martin.

Diolch. I'm looking at futureproofing, so I might go over a little bit of what you've already said. But, just in terms of going forward, I just want to know if the existing cross-border agreements—and that's including the statement of values and principles—remain fit for purpose in light of the current arrangements and future reforms.

And then, in terms of changes to the Bill, what has been identified in terms of—I'm trying to think of how to phrase this now—the changes to the Bill that will provide the best opportunities to improve patient experience and patient care?

So, in relation to cross-border, it is clear, the benefits that the Bill will achieve for people on the border, but, for us, 15 to 20 per cent of people in Wales access services in England for specialist services, specialist cancer services. So, for us, it needs to go much further; it's not just about the border patients. So, we'd like to see that.

Some of the positives we see in the Bill are the single patient record. We think that has huge promise. If the benefits of that are not realised, then people will continue to see the same experience that they're having now, with lost records, having to take their own records, as we've just described. And we think that the values and the principles framework are strong now, but they need to maintained and protected as the change moves forward, and then it will need to be relooked at to look at the new landscape and see what needs to be changed as well.

I would add, in terms of the Bill, strengthening the regard of the ICB to have regard to the border communities to all Welsh residents, I think that's a real opportunity to improve experience, so that Welsh residents are in the forefront of the commissioning in the ICBs.

Yes, and I'll just add that change will be noticed and the benefits will come out for Welsh patients if Welsh patients are considered from the very beginning. Their voice needs to matter, and it needs to be considered from the very beginning.

Great. I'll just bring Matthew in again. Briefly, Matthew.

I'll ask this in English, sorry. Just one quick question: are there any patients from England that come into Wales, and does the Bill propose—? Does it say that the rights of patients in England will be affected if they come into Wales in any way? Is there any kind of other way of working?

I can speak about north Wales. So, in north Wales, there are detox services at the new Adferiad centre, the one that used to be the Blind Veterans centre, and there would be various specialist services. I can't think of any mainstream NHS services where people would come from England, but because of the geography of north Wales, the ability to buy very large properties at a low price, there are many of those services, those separately commissioned services. In terms of primary care, right across England and Wales, there are more English patients registered with Welsh GPs than the other way around. That's principally because of prescription charges.

And just to add to that, if you think about some of the examples we've provided where the information doesn't follow the patient, or the systems don't speak to each other, that will affect English residents who are accessing Welsh services as well, whether that's primary care or secondary care, and that, again, leads to patient safety concerns.

Okay, great. Can we go back to Becca? Becca, did you have any more questions? Did you, Becca? Don't worry if you didn't.

Sorry. I was sort of fighting with the host then, accidentally muting and unmuting.

Fine. Go on.

No, I haven't got any more questions, but I really just want to say 'thank you' to Llais for being that patient voice and that advocate. Because we only see a fraction of what you guys see. We do obviously get e-mails from residents and things, and some of the stories are awful, and you guys are having to deal with that on a daily basis. So, I just want to say 'thank you' for that.

Thank you. Nigel.

I was just interested in the information about English patients being registered with primary care practices. Do we know what the cost of that is to the Welsh NHS and how many patients, in actual figures? You don't have to tell me now.

I don't know, but I could find out.

Well, would you be able to send me that at some point? It would be interesting, actually.

If you would be able to send that through the committee.

Yes. It would be—. Very often, it's on quite false premises. People just think, 'Oh, well, free prescriptions in Wales', and, actually, you know, if you've got a continuing healthcare issue, if you're over a certain age, then you get the free prescriptions anyway. So, I think that's why it's done. I'm sure Katie, our colleague in Powys, could tell us more, but down that marches area, where GP practices are few and far between, it just may be that your nearest one is in Wales. But we will find that out, and I'll get back to you. I'll go through the Chair.

Brilliant. Thank you. I can see there are no further questions, so just to say 'thank you' again for coming to give evidence on the Bill this morning. It's really helped our evidence gathering for our response. You will be sent a copy of the transcript for factual accuracy as well, but diolch yn fawr for coming in.

We'll also take a short break now as well, just to transfer over witnesses. So, diolch. We'll go into private.

Yes, that's fine. Thank you, Clara.

Thank you. So, as you say, I'm the executive medical director at Betsi Cadwaladr, so north Wales. There are several areas they work in, first of all, for the people who live very close to the border and overlap constantly between England and Wales for primary care, and those are fairly well established, and I'll perhaps leave Pete to talk more about the general practice side of the elements. For us in Betsi Cadwaladr, we are very reliant on secondary and tertiary healthcare across, mainly, into the north-west of England, but not entirely, where there are services that we don't provide in the patch. And we have very well-established pathways, actually, across into those and people will remind me about how, until fairly recently, people would be going over there for far more than they would previously.

So, our main relationships are into the Countess of Chester, which, again, is often just secondary care for a population that live without a very solid wall between England and Wales, so they go to their nearest hospital, and then, more broadly, across into Aintree—so, Arrowe Park for some services and then across to Royal Liverpool and then down the road to Robert Jones and Agnes Hunt for orthopaedic services as well. And, of course, they also access care for specialised services not commissioned by ourselves, but from the JCC, but patients shouldn't be expected to be able to differentiate between whether it's commissioned by ourselves or through the JCC. So, very well-established pathways, very well-established clinical relationships, which is what makes it work a lot of the time.

So, that's what happens, mainly, at the moment. We've got—. About 32,000 were treated across the border in that way last year, about £91 million-worth of spend. So, that's just for the services we commission. Obviously, the JCC is on top of that.

Brilliant. Thank you. Was there anything you wanted to add, Pete? I should say, as well, throughout this session, don't both feel that you have to answer individually if you're both saying the same thing. Don't feel the pressure to answer everything, both of you.

That's fine, Chair. If I could just start, what I would say, adding to some of Clara's comments, is that it does work well—communication, links, working together is all really positive. But we do need to recognise that there are two systems—one in England, one in Wales—and they're operating as one together. That can lead to some confusion, particularly for patients, the population, because we do have different funding regimes, we do have different policy, and there are different threshold criteria. So, that dynamic does add an area of challenge within those two systems.

Great. Thank you. I'm just wondering about the extent to which the provisions in the Bill will absolutely try and help address some of the existing cross-border challenges that you've outlined.

So, rather than comment on the potential structure within the Bill, I think the really important thing, and the key No. 1 thing, is that attention to the cross-border requirements for those patients that access services cross-border, and that's both ways—that they're recognised, they're included and that there's no detriment to those arrangements from the new Bill.

Brilliant. Thank you. Did you want to say something, Clara?

Yes. I've come from the English system, actually. I've been in Wales a year, so I'm quite familiar with the English system, and I came from an integrated care board as well. So, from the commissioning structures, I'm quite well versed with it. I don't think there are any particular changes. There's obviously been a huge reduction in staff in some of the ICBs that we would interact with or merger. That's not the case for Cheshire and Mersey, because it hasn't merged, but it has lost a lot of staff, and you then lose relationships and corporate memory associated with that particularly. Because commissioning is quite a skill, and therefore that turnover of staff, I think we're probably getting there and out the other side of, because the Bill has come later than those arrangements. But I don't think that's to be underestimated.

I also think that, at the moment, the commissioning remains within the ICBs, but I know that there are possible arrangements, going forward, where that commissioning is then delegated down to integrated care organisations at a lower level. That, again, for me, feels that you then might lose sight of the fact that the healthcare provision there has to be broader than just for the local population and has to include the ability to be able to provide the care across into that north-west population. So, I think it's just constantly working with people. But I am slightly concerned around loss of established relationships because of those changes.

Brilliant. Thank you. I've got some questions now from Matthew Jones. Matthew.

Diolch. Dwi'n mynd i holi yn Gymraeg. Felly, beth, yn eich tyb chi, yw'r prif risgiau i ddilyniant o ran gofal i gleifion o Gymru sy'n deillio o ddiddymu NHS England a'r diwygiadau ehangach i'r gwasanaeth iechyd yn Lloegr?

So, from my point of view, as I say, at the moment, the secondary care pathways particularly are commissioned through the integrated care boards. The integrated care boards remain with the abolition of NHS England. So, that shouldn't be a huge concern with that.

I think specialised commissioning—and I think you've had the JCC in today—previously, it may well have been that the JCC would've interacted more with regional elements, and then, certainly, where I was in Birmingham, specialised commissioning came out of the region and back into the integrated care boards. So, again, a kind of disruption of pathways that one is used to commissioning down. So, it may be more of an issue in some of those more specialised services than when you're looking at localised service provision, which continues down through the ICBs at the moment. The abolition of NHS England per se, I don't think, should have particular issues, in my opinion.

Oes yna unrhyw risgiau neu, efallai, gyfleoedd penodol sy'n deillio o'r diwygiadau i gymunedau gwledig a chymunedau ar y ffin sy'n dibynnu ar y gwasanaethau o Loegr, ydych chi'n meddwl? Unrhyw gyfleoedd?

I think the single patient record is incredibly interesting, and when it gets to the point where it is there will be helpful within England for the transfer of information between organisations, and, of course, it would be very helpful for it to be able to interact with Welsh systems in a similar way. We don't really have particular digital maturity in that area at the moment, and therefore I'm not sure at this point that it will make an enormous amount of difference, but when we do get to the point—which I'm genuinely hoping is very soon because, from a patient safety point of view, a digital record is really vital—then we've just got to make sure that we've got appropriate interoperability to be able to do that, and then that will be very different.

And it's not only the patient record, it's the administrative records as well that are tricky, because you've got those past systems of who's been referred where. That is just very difficult to manage backwards and forwards across the borders, because they are different healthcare systems. So, hopefully, by joining that single patient record, it will join up not only the clinical aspects, but equally the administrative aspects, because then you can track much more easily where someone is within a pathway, which is much more difficult to do at the moment when you're outwith those elements. So, that I would see as positive, but it requires the digital maturity on the Welsh side equally to be able to interact.

Pete.

There are a couple of comments to add, please. So, any changes that improve decision making and improve service responsiveness will be welcome, because that will benefit our Welsh patients. As I said earlier, the need is just to ensure that that focus is on the cross-border issues.

In terms of Clara's point around interoperability, that is one of the most significant issues. In fact, it would be improved if systems can communicate. If there's the appropriate governance legislation around data sharing, that would dramatically improve decision making, and would help in terms of the provision of healthcare.

Jest un cwestiwn olaf sydyn gen i ar hyn o bryd. Sut rŷch chi'n meddwl ei bod hi'n bosibl i ddiogelu buddiannau cymunedau ar y ffin neu gymunedau gwledig pan fo penderfyniadau yn cael eu gwneud gan sefydliadau gofal iechyd sydd yn fwy o faint yn Lloegr, lle efallai bod cleifion trawsffiniol mewn cymunedau lot llai?

Pete, could I ask you to pick up that one in the first instance, because it's probably slightly more relevant to Powys than to us?

Yes, I think the statement of values and principles on cross-border issues is in place, and that helps to ensure that the right approach and attention is given to all parts of the population, including those in rural areas. We also do have our cross-border committee arrangement in place, so those sorts of issues can be discussed and picked up. So, those mechanisms do help to support that, but it's a really important point, and we do need to make sure that all parts of the population are considered in terms of the service access that they require.

Thank you, Matthew. We've got questions now from Sara Crowley.

Thank you. Croeso. Again, I'm going to declare an interest. For the last 10 years, I was working in transitional care. So, I'm keen to hear, when I ask my questions, your broad assessment, but also whether the reforms could have particular implications for adolescents and young adults transitioning from child to adult care as well, and what that might look like. So, what potential impact could the reforms have on Welsh patients' access to specialised and highly specialised services commissioned from England?

So, again, I'm not the commissioner of highly specialised services—that would be the JCC—but it is important for me that my population are able to access those across, because a lot of the services commence within our services and then, of course, move across into specialised services across the border. I think, per se, as long as the relationships can be maintained with the JCC and the appropriate commissioning bodies, and commissioning is able to continue in the way that it has, I don't see it particularly making much of a difference to how it is now, because the changes are structural around those elements.

I welcome the emphasis on the patient quality discussions more within this than was previously, because one of the things we have to be careful about is that we're not just counting and paying for pathways, but making sure that we are commissioning for high-quality services and have metrics associated with that. Now, that would be commissioning in general, whether that's for us into secondary care or JCC into tertiary. But one of the things that can be really difficult for patients is when something goes wrong and then you're not quite sure which area it is, and that kind of formalisation of where something goes wrong and investigations are done in a more structured way across organisations I think would be welcome in that regard. We do it anyway. We're able to do it anyway. But more focus associated with that does feel welcome for me as a medical director.

I'll just bring Pete in. Did you want to say something, Pete?

Yes, thank you. I really agree with Clara's comments. I think there are two routes to specialist services. It’s either via the joint commissioning committee, as Clara's referenced, and also the tertiary pathway, which may link to the relevant district general hospital providing the secondary care. So, the expectation would be that those pathways remain the same and there's no direct impact from that.

I just wanted to add to the comments Clara made around that learning. It’s really important that that learning improvement area does go cross-border and involves all relevant organisations so we can all improve and move forward.

Brilliant, thank you. Sara.

Yes, just to come back on that, really, do you see any challenge—? How would this affect an adolescent or somebody under 25? Are there any specific implications in the Bill that you can think of? The reason I ask this is because, a lot of the time, when it comes to medical services, I think this is an under-represented age group. So, I just wanted to give you the opportunity to come back on that, to see if there's anything specific that needs to be heard.

I think that transition is a very tricky period of time. I'm a kidney doctor, and therefore that transition from child to adult services is a huge step, and from a kidney point of view we'd often see children who'd been very settled in their environment moving into the completely different area of adult services, and it being a very different world to be seen in, and actually being detrimental to health as well as other aspects. I think it is a particular area of focus for all of us, and as you say, you could quite easily—. It could be in our patch, someone having care in, for instance, Alder Hey, and then transitioning back into secondary care services. Some of that may of course remain, almost, in adult tertiary services across the border, so you may well end up going from, I don't know, Alder Hey to Royal Liverpool University Hospital, for instance, in a particular area, as well as if you would be coming from Alder Hey back to ourselves.

I think it is an area that we need to focus on, full stop. I'm not sure that the Bill per se makes particular differences on it, but it is that transition between having things in England and back in Wales, be that at that particularly vulnerable age or at any other age, that I think is upon all of us to pay due regard to within our pathway arrangements. I'm not sure that the Bill per se would make enormous differences. That's probably how we enact the Bill and make sure that our local commissioning and contracting arrangements are appropriate in that regard.

I appreciate you taking my question. Diolch yn fawr.

Diolch. Safa Elhassan.

Again, just to repeat that I'm a practising clinician, an ophthalmologist. So, this is regarding the NHS England reforms. What assessments have you made of the changes to NHS England that could affect the services used by Welsh patients, and which risks to access and continuity of care need the closest attention?

As as I said, really, the reforms per se I don't feel should make enormous differences, as long as we can continue to commission appropriately through the relevant bodies, and that's in how services interact as opposed to what the Bill does in that regard. As I said, I've got some concern about changes in the commissioning bodies from a personnel point of view, and some concerns, if commissioning comes out of ICBs into more local areas, as to how those more local areas will have due regard to the fact that they are covering more than English patients and need to be making sure that they have provision for the Welsh population as well, and that, if you're not at a kind of strategic commissioning level and very aware of the whole population, as you're more focused on your local population, that is something that needs to be paid heed to. I don't think that that will be an immediate issue for us in the north-west, and I think that other areas of England might pilot that first before it comes down and through. But we rely in two ways, really: (1) we commission through the commissioning elements, but (2) we have very close relationships down those clinical pathways. So, those clinical pathways—. Obviously, from a clinical point of view, your consultant body and your clinical staff are often there for a very long period of time, much longer than the managers and commissioners around it. So, that continuity of relationships would continue and allow us to do things that we felt were the right thing for patients in that regard.

Nigel. Pete, sorry. Did you want to add anything to that?

Just briefly. So, just to totally agree, those relationships, that understanding and that sort of built-up work together are really important. So, any change that has an impact on that may be a concern. There aren't any specific areas of concern. Just, I think, for the committee, it would be important to seek assurance that in any changes the cross-border Welsh patients' needs are fully recognised and considered as part of that process, so that there's no move away from that.

Great. Safa.

I know you've mentioned that you don't really see that these reforms are going to have an impact significantly, but are you already seeing any effects on referrals, wait time or follow-ups, or—? Are there any current anticipated risks and are you preparing for any of them at all?

Well, as I've said, I'm not really terribly concerned about the changes in it. We have commissioning arrangements in place, and those relationships and those contracts are the functional element, if you like, of those changes. So, if we are contracting for a certain number of patients or we're ensuring that waits are the same and treatment is the same, then that element would come up through those areas. But I don't think these changes particularly will make a difference. What, of course, makes a difference is pressure in any particular part of the health service, be it in Wales or in England, and if a provider whom we work with across the north-west has particular issues, then that tends to have an effect, but we should pick that up through standard arrangements that we have in place.

Nigel. Oh, sorry, I keep saying Nigel. Sorry, Pete.

That's okay.

Sorry, Pete. We're missing Nigel here, so—.

Nothing to add, as Clara said. So, we're not seeing anything that suggests there are changes in approach or anything to cause concern. So, as Clara said, we're not anticipating any risk from that change in arrangement and structure. I go back to my point about just needing to ensure that that focus remains on those cross-border relationships and patient pathways.

Great. Safa, did you—?

Yes. How are the Welsh health boards involved before decisions are made in England that could affect their patients? And if there's a proposed change that could worsen access or disrupt care, who's responsible for escalating that concern? And how would you ensure patients are kept informed?

Do you want to start that one, Pete?

Yes. So, if there's a significant service change, there will be a process to follow in terms of consultation. Depending on our role, as a stakeholder or whatever it may be, we will be involved in that process in terms of input, comment, action, and then, pending the decision, we're involved in the arrangements for helping to support any changes to make sure that full public awareness and relevant support, et cetera, are in place.

Great. We've got some questions now from Claire Archibald.

Hi. Thanks for coming today. You did explain about the single patient record earlier on, so that was one of my questions anyway. So, I just want to ask a little bit more. How would you ensure that the changes to the medication or treatment made in England reach the patient's GP and community care team when they return?

So, that's a standard issue at the moment. I think the thing to just remember is that England itself doesn't have a single patient record at the moment. So, any transfer between organisations is almost the same as transferring back to us in Wales anyway. So, the difference, sometimes, is that, if you were in the catchment area, for instance, of a large English hospital with a good digital system, things would go digitally across to general practice. At the moment, it would resort to the writing of letters, as it does in a lot of other areas—sometimes they're going by e-mail, but still fundamentally being letters—and that will continue as it is at the moment.

If we got to the stage where we had a proper, interoperable single patient record that was interoperable between England and Wales then, of course, that would be fantastic because you'd be able to do that more smoothly. But, at the moment, the fact that they are moving towards a single patient record will not mean any changes in the way that the communication goes across into Wales at the moment.

Who would be responsible for checking the handover? Who would be responsible for that, if it's not, obviously, going to be coming off just yet?

So, at the moment, it is the responsibility, obviously of the—. That transfer of care is a responsibility to be done well, so the discharging organisation needs to make sure that they are handing that across to the accepting-back organisation. And it's fairly standard practice that you would—. So, if you'd had care in the north-west, you'd be writing both to the GP and to the secondary care across in north Wales, if felt to be relevant, so that you've got those kinds of elements through. And a lot of the English trusts will write directly to the patients as well, of course, which then gives you the ability for everybody to be able to hold on to it in a particular way.

We do have issues at the moment, there's no doubt. So, somewhere like Wrexham Maelor Hospital, for instance, if patients are within the Welsh system, we can, within the hospital, look up what medication they're on in general practice; if they live across the border, you can't and have to pick up the phone to be able to find out what medication people are on. That is standardised; we're very used to doing that. But to get increased digital maturity would be fantastic.

Thank you.

Natasha Asghar.

Thank you so much, Chair. I want to ask a bit about data. You mentioned about some of the poor ways of communication that currently exist. I just wanted to know, and for the benefit of the committee, are there any other ways that you feel that you could call barriers, in fact, to effective information sharing at present between the health providers in Wales and health providers in England, as it stands?

Well, as I've described, actually, because it's not even—. It's between Wales and England we're concentrating on, but, literally, if you were going from a hospital in Liverpool to a hospital in Manchester, you'd have exactly the same problems about that data transfer backwards and forwards, because there isn't an interoperable system within England either. So, we're used to doing that backwards and forwards.

There are some where we do have access. I was looking at an incident with a patient the other day where our cancer doctors do have access into the digital systems in Mersey for the histology, for instance. So, where you are working together with patients, there are arrangements that can be made when you're working down pathways so that you do have digital access across organisations to be able to do that, and, of course, that's incredibly helpful. So, arrangements can be made at an individual pathway level.

Okay, great.

Pete, did you want to come in?

Nothing to add. Clara's covered it. It's the same experience.

Okay, great. What actions do you feel are going to be required to improve inoperable—I can't speak today, my apologies—interoperability and support that is going to be effective for cross-border care as the digital systems evolve, going forward, with this Bill?

Shall we start with Pete? I'm just conscious otherwise—

So, I think, at the risk of repeating ourselves, it's around having a clear understanding in terms of interoperability, clear data standards, clear standards around spec, data sharing and the right framework around it. If we could get to that position cross-border, that would significantly improve that access to information and all the benefits that go with it that Clara's described. And I know that there's the 10-year digital strategy that's being worked on for Wales, and how that can ensure that there's an overlap with England and that interoperability would be a huge benefit.

I think also something about data sharing that's really important here is that most patients would expect that their data is shared between organisations in the NHS to be able to provide seamless care, but even at the moment—. So, general practice are the primary data controllers of their own data, and that's not necessarily shared across into secondary care at the moment for us to be able to see the full data pathway. So, if I wanted to know whether everyone in our patch was controlled appropriately for blood pressure, for instance, we can't do that in a joined-up way at the moment. And I know that we're working together in Wales to try and get to that point.

So, there are the technical aspects, but there's also this philosophical aspect that, actually, we should be all sharing data for the good of patient care, which I think sometimes has been disrupted by some clumsy steps along the way when people are worried about their data being used in ways that they would not be happy about. So, somehow, we've got to work our way through all of those elements as well.

I think one of the areas as well that would be really interesting in this—. We're talking about sharing patient data, but NHS app data for if you're in Wales or you're in England, I genuinely don't know how that works at the moment. So, in England, a lot of it you can get through the NHS app. Presumably, if you're going to get to the stage, which would be lovely, of interoperability around single patient records, you'd have to make sure that the patient access was the same as well, so that you didn't have to have one access in Wales and one access in England, but you could join your patient record together through those means as well. The NHS remains, as we all know, very behind a lot of other organisations to this effect, and it's just so important for us to keep working on that.

Clara, sorry to put your mind not at ease, but the previous members that we had that joined us earlier to give evidence said that that's not working well, the app between England and Wales.

Oh, I'm sure it isn't. I'm sure it isn't.

So, my final question—. I promise, Chair, this is my final one, because I am conscious of time. I'm asking most people who are coming today to give evidence this question. Obviously, the focal point today is the Health Bill. I appreciate, as a committee, we're very fortunate; we've got quite a lot of advice being given to us. We're being fed information from our colleagues who sit on the legislation committee. But, for yourselves, and from your own experience, how are you being guided through the Health Bill? As in, are you being given legal advice, have you been briefed by any particular health organisations coming via England as to how this is going to operate and how it's going to affect you professionally?

I've obviously had briefings ahead of coming in here. The NHS Confed are very helpful for us in that regard, for all of us together. I have the advantage of having come from England and lived through the kind of Health Bill associated with that. So, I understand it to that effect. Having worked our way through it over the last week or so, looking through for this, I come back to the point that, actually, it feels quite enabling. There's quite a lot in there that makes due regard to be able to link across into the devolved healthcare system in Wales if it is helpful to be able to do so. So, I think it's making the most of that for us in Wales to be able to link across. But the key aspects like the single patient record are of less relevance at the moment, and the other bits will be around us continuing to commission locally with our contracts as we work through those other elements, and trying things out like the patient safety elements and things as we go, if that makes sense.

Thank you, Chair.

Brilliant. I've got another question from Matthew.

Diolch yn fawr. Mae fy nghwestiynau i'n ymwneud â llywodraethiant ac atebolrwydd. Felly, ydy'r Bil fel mae'n edrych ar hyn o bryd yn rhoi digon o eglurder ynghylch pa sefydliadau sy'n gyfrifol neu yn atebol am wasanaethau trawsffiniol?

Do you want to start, Pete? Did you want to start, Pete?

Yes, thank you. Apologies, the sound dipped out there, so I didn't quite catch that. So—

I can say it again.

Did you catch the question, Pete?

Sorry, can you hear me okay?

Yes. Did you catch the question?

Yes, it was around accountability. I think that would be one of the questions that we would have. As a result of any changes, we do need to understand which organisation is accountable for the existing arrangements. So, I don't think that is absolutely clear, because it's one of the things that we would seek clarity on.

So, I'd accept that, from a patient point of view, it's usually pretty clear who's accountable for the clinical care that's being delivered—so, if you are providing the care, you are accountable for delivering that care. I suppose the difference would be if there was a shift such that an organisation from which we commission feels that it's not able to provide care any more for the population in Wales. It then becomes slightly more unclear as to how one would need to be able to work through that across into England, because the reason we commission across is because we're not able to provide those elements ourselves. So, how one would work that through might be something, Pete, that needs working through. At the moment, the ICBs would be the ones who start to facilitate that, but if it was something that then had to go across into another ICB, exactly how that works I'm not entirely sure.

Dwi ddim eisiau rhoi geiriau yn eich ceg chi, fel petai, ond rydych chi'n meddwl, felly, bod y trefniadau sydd mewn lle ar hyn o bryd yn gweithio yn effeithiol. Ydy'r Bil o bosib yn mynd i gymhlethu pethau? Beth yw'ch barn chi ar hwnna?

I think the proof of the pudding is always in the eating associated with these elements. At the moment, it doesn't feel terribly challenging, but healthcare rearrangement happens all the time, and so one is used to working through these various rearrangements. What's written on paper and how one works it through is then lived experience that one works their way through. But I come back to the point that we've got established relationships across from the delivery of care in north Wales into the delivery of care in England, and exactly who commissions what around those changes probably every four or five years. Therefore, one has to be able to work with some flexibility associated with the arrangements, making sure, of course, that we keep the patient at the centre of that.

Absolutely. Did Pete want to come back in?

I was nodding because that's been our experience over recent years—that there are changes more frequently in NHS England, and we've got used to responding to that. It does come back to those relationships, which both Clara and I have emphasised a number of times through this session. So, yes, just to agree with Clara, thank you.

Felly mae trefniadau uwchgyfeirio a datrys materion trawsffiniol yn effeithiol ar hyn o bryd.

Pete, can you start on that one for me?

Yes, sure. At the moment, there is no formal mechanism for resolving cross-border disputes. That is probably an area that could be strengthened. I'm not sure if that specifically relates to the Bill, but that is an area of challenge where there could be improvement if we had a formal agreement for cross-border issues.

Diolch. We'll go back to Claire.

You've actually answered quite a lot of the questions on this anyway. When your health board and an organisation in NHS England disagree about changes affecting Welsh patients, how is this disagreement resolved, and who makes the final decision? Could you give an example of how that process has worked in practice?

Pete, could you start on this one, because you're probably more experienced than me in this regard?

In terms of service change, provision of services, they ultimately are worked through in terms of what the new models of care look like, how does that work. I can't think of a direct example, although there will be some. In terms of the dispute resolution, I was more in the contractual, financial element of that in terms of a clear route. So, that may be something that, with the committee's permission, we can look to provide a note on afterwards, if helpful.

Thank you, Pete. Brilliant. We've got a final set of questions from Becca Martin.

Thank you. Just before I ask the questions, I do just want to pop my constituency hat on, and I probably should have come in earlier. Just in terms of that cross-border care between Betsi and Powys, I noticed, Clara, that you said it was more relevant in Powys, but I would just want to point out that that east corridor in Betsi does have really quite substantial cross-border care—primary, secondary and emergency care as well, particularly for those that access the Countess of Chester. So, my plea to you would be to just really consider that when you're making decisions: although in the west there might not be that much, in that east corridor, where I represent, there is quite a bit. So, yes, I know that that's not quite committee—

Shall I just answer that one to start with? Very much so. That was not my intention at all. I'm very aware of that east corridor across into Chester, because, of course, the vast majority of our patient contact is backwards and forwards along there, so I didn't intend that to be the case at all. What I was talking about a little bit there was the complexity of general practice backwards and forwards across the border, which is more in the Powys area than it is up with us, and also because, to be honest, Pete is much more experienced in some of these areas than I am. But I completely recognise that the link across from the Wrexham area into Chester is huge.

Thank you, Clara. Thank you for clarifying that. The questions that I have are mainly about futureproofing. I'm just wondering where you've seen opportunities to really strengthen and formalise the cross-border arrangements within the reforms in England.

Again, from my perspective, as we've said, the reforms at this stage don't really make much difference to us. What we're doing is making sure that we've got appropriate patient pathways in place for when we require them. That happens every day, whether that be through elective care or through emergency care.

I think one of the other areas that we are beginning to focus on, and that has been a particular change over the last few years, is to make sure that our staff can move across a bit as well. For medical training, for instance, we try to keep it in north Wales and the north-west of England, as opposed to them being on training schemes between north Wales and south Wales, because of the distances. So, we've now got very established routes between for training in various areas so that some specialised training can come across into the north-west, if we're not available to do so.

I think that we're beginning to explore the ability again for joint appointments across the border to that effect so that people can have some of the specialised experience in the north-west and then bring it back and take patients backwards and forwards with them across that border. So, those are areas that we are continuing to really explore. But otherwise, at the moment, we would just continue as we are to make sure that we've got those patient pathways in place.

We have also just brought back some of our prostatectomy patients, who are going from Betsi down to London for surgery, and actually were very complimentary about the service and the pathways associated with it. But we've just brought some of that back now to Arrowe Park on the Wirral, to be able to make that a little bit closer, and those relationships. So, we're always reviewing what we're doing and how to make it best for patients in that element.

Thanks. Did you have anything else to add, Pete?

I would say the same. There are no direct additional challenges from the Bill, but the three main issues or challenges for us from a Powys perspective are the complexity—patients are navigating two NHS systems; inconsistency, because we've got different policies, different thresholds and different reporting; and then those practical barriers that relate to travel, discharge and data sharing, which we've all touched on. They remain the same. So, if there's anything that helps improve that from any changes, that will be seen as a huge benefit.

Thank you. That leads on a little bit to my next question, which is how we can more effectively embed those cross-border considerations for the future as well and make that service better, more streamlined, more standardised for people.

At the risk of repeating, I think it goes back to the arrangements for data sharing and that interoperability. I think there's a potential for clarity on cross-border issues—so, some sort of cross-border arrangement or agreement in terms of treatment of waiting times, pathways, and those things that do go across two systems. That would be helpful for that clarity. And then link to that some form of escalation process, a formal one—we do have a process, but there's not a formal part to it. So, that would be helpful.

That's great. Thank you very much.

Great. Thank you so much to both of you for joining us today. It has been really helpful to get your evidence while we're examining this health Bill. So, thank you for your time and the evidence that you've given us this morning. You will be sent a transcript for factual accuracy, just to check over, but diolch yn fawr. Thank you for your time.

Diolch yn fawr.

Diolch; thank you.