Ein cyf / Our ref:     

Eich cyf / Your ref:

(: 01248 385336

Gofynnwch am / Ask for: Grace Lewis-Parry

E-bost / Email:




Dyddiad / Date:        29 July 2013


Daniel Collier

Deputy Committee Clerk

Committee Service

National Assembly for Wales



Ysbyty Gwynedd, Penrhosgarnedd

Bangor, LL57 2PW












Dear Mr Collier


Public Accounts Committee 18th July 2013

Requests for further information


Thank you for your email of the 19th July requesting additional information following the Health Board’s attendance at the PAC on the 18th July.


Please find below the information requested:-


Further information on the categories and amount of re-charging made to cross-border Health Authorities.


Cross border activity and recharges are governed and regulated by the Cross Border Protocol agreed between the Welsh Government and the Department of Health.


This Protocol sets out the agreed procedure for:


·           Securing NHS healthcare for residents in England who are registered with a GP in Wales.

·           Commissioning NHS healthcare for residents in Wales who are registered with a GP in England.


Specific rules apply to the following border counties:


Areas of Wales bordering England

Clinical Commissioning Groups

bordering Wales






NHS South Cheshire

NHS West Cheshire

NHS Wirral

NHS Herefordshire

NHS Shropshire

NHS Telford and Wrekin

NHS Gloucestershire

NHS South Gloucestershire


For these specific border counties, the following rules apply:



GP Location

Funding Responsibility








None / (unknown)










For patients resident elsewhere in England or Wales who are registered with a GP on the other side of the border, responsibility for commissioning or for  planning and securing their healthcare will remain with the PCT or LHB area where the patient defines his or her usual place of residence.


Patients from across the UK are entitled to use the services provided by the Health Board, and the income arising from caring for patients from outside the Health Board’s borders is subject to standard processes, including tariffs and contractual arrangements where appropriate.



For areas from which there is a longstanding relationship, such as patients from Western Cheshire, Shropshire and North Powys, formal contracts are held which ensure that the costs of caring for patients are reimbursed in a regular and timely manner. These contracts provide long-term planning stability to both the provider and the commissioner of care.


In addition to the cross border counties, as a result of travel and tourism into North Wales, the Health Board also treats patients from across the wider UK regions. Income is collected for these patients based upon admitted patient care (inpatient or outpatient treatment), and is charged at National Cost Tariffs.


It is important to note however that Cross Border Recharges cannot be made for an Attendance at A&E as A&E Services are paid for by the local LHB / Trust irrespective of patient residency or GP registration. If a non-BCU resident attends A&E and is then admitted to a ward they then become an A&E Admission in which case the LHB is able to recharge for the cost of their treatment.


There are a number of challenges to collecting the income due to the Health Board for treating non-BCU patients:


·      Residency status between Welsh Health Boards is dependent on the patient’s postcode, and between English PCTs residency is dependent on the patient’s GP. Cross border arrangements determine residency on the patient’s GPs but only between certain English PCTs and certain administrative areas with BCUHB, otherwise “local” rules then apply. This can be very complex.


·      Charging requires the prompt and accurate coding of activity.


·      Overseas Visitors’ entitlement to free NHS care is subject to complex rules, and staff do not always feel confident to challenge patients in respect of their residency and entitlements. The Health Board is able to charge the Welsh Government for patients from Countries where the UK has reciprocal agreements, otherwise we will charge individual patients our local “private patient” prices.


·      There are approximately 7,000 Residents of Shropshire and Western Cheshire with a registered GP in North Wales, for which the Healthcare responsibility lies with BCUHB.


·      There are approximately 8,500 residents of North Wales (Flintshire, Wrexham, Denbighshire) registered with Shropshire, Wirral or Western Cheshire GPs for which the Healthcare responsibility lies with the relevant English CCG.


·      For patients registered with a BCUHB GP and resident elsewhere in England, the CCG of “usual residence” is the responsible commissioner, however identifying the “usual residence” can be challenging.


·      For patients with no registered GP, the home address as given by the patient determines the responsible LHB / CCG. It is difficult to challenge a patient on their declared home address.



The Health Board has a range of controls and measures in place to ensure that it captures all external income due to it, and regularly uses Internal Audit to test these controls and assurances.


During 2012/13 the Health Board recovered £15.633 million of external healthcare income, which represents 1.3% of its total £1.2 billion resource allocation

Further information on the number of patients affected by the delay in elective procedures caused by the emergency expenditure controls in the final weeks of the 2012-13 financial year.

The number of patients affected by the decisions made December 2012 for the final quarter of 2012/13 was approximately a combined 1250 inpatient and day case and 1600 follow up outpatient reviews.

A note on when the Board and Quality and Safety Committee first became aware of concerns with the C Difficile outbreak.

On the 7th March 2013 the Quality and Safety Committee of the Board met.  This Committee received the minutes of the Infection Control meeting held in January 2013 which had been chaired by Mrs J Galvani, the Executive Nurse Director at that time.  C Difficile rates were reported to the committee at this meeting, as is routine. What was reported is as follows:-

“December 2012 data indicates a 10% improvement overall with a 30% improvement at Wrexham Maelor Hospital.”

On the 22nd March 2013 a C Difficile major outbreak was declared on the Ysbyty Glan Clwyd hospital site and the Acting Chief Executive was notified immediately.   Comprehensive arrangements were urgently put in place in line with the Major Infection Outbreak Control Plan.

The Quality and Safety Committee next met on the 4th April 2013 and at this meeting the C Difficile outbreak was discussed.

A copy of the Health Board’s risk register.

Further information on actions undertaken by the Health Board to address Risk Adjusted Mortality Index (RAMI) figures.

The Health Board has been aware of a month on month increase in RAMI in Ysbyty Gwynedd for the last 7 months of validated data (now up to April 2013). In the last few months, the RAMI in Ysbyty Glan Clwyd has also increased and the RAMI in Wrexham Maelor is higher than that seen in the other two hospitals but has been relatively stable over the same time period.  This matter is being thoroughly investigated and regular written updates are being provided directly to the Chief Medical Officer for Wales. Further detailed information in relation to all aspects of the mortality reviews and methodology and further investigations into the RAMI data are detailed in the attached correspondence.




Yours sincerely


Grace Lewis- Parry

Director of Governance and Communications