A borderline debate

Reports that Welsh residents were crossing borders to use English health services unfolded into a spat between the Daily Mail and the Welsh Government. Ian Blunt looks at the evidence.

Blog post

Published: 24/11/2014

Cross-border health arrangements between England and Wales are, by most peoples’ standards, a relatively niche administrative issue. Yet such is the level of debate about the NHS in the run up to the general election that the number of patients who are resident in Wales but use English health services recently blew up into a front page spat between the Daily Mail and the Welsh Government.

With the House of Commons Welsh Affairs Select Committee currently considering evidence in a short inquiry on the matter, it could be about to launch back into the headlines. But what can data about hospital admissions tell us about how useage has changed since the National Assembly for Wales was handed control of the Welsh NHS in July 1999?

Then and now: A look at Welsh hospital admissions in English hospitals

In 2013/14, there were just shy of 60,000 inpatient admissions to English hospitals for patients resident in Wales, while between 8,000 and 10,000 patients went the other way*.  While this seems like a large disparity, it’s worth noting that around half the population of Wales lives within 25 miles of the border with England. For many in this group, the nearest hospital may be in England.

In both nations, these cross-border admissions represent a tiny fraction of the total: 0.36% in England and between 1.08% and 1.39% in Wales*.

These numbers have not shifted much since devolution. Analysis of Hospital Episode Statistics shows that there were just under 42,000 admissions for Welsh patients in England in 1999/00. That number had grown by 42 per cent by 2013/14.

While that seems like a big increase, hospital use has increased dramatically in England over that period. In fact, inpatient treatment for English patients rose by 41 percent between 99/00 and 13/14; almost exactly the same increase as for Welsh patients (see figure below). The proportion of all admissions in England is exactly the same  today (0.36%) as it was in 99/00.

There has been no disproportionate increase in the treatment of Welsh patients in English hospitals. In fact, the number of admissions for Welsh patients has fallen slightly since 2009/10, when it hit a record high of more than 62,000 patients. These trends are not-mirrored for English patients.

Different policies, different trends

Similar to most western countries, there is a clear long-term trend for increasing use of hospital services in both England and Wales. But the chart does show some interesting variation across the countries associated with the introduction of new policies by both governments.

In 2001, the English NHS started a significant push to reduce waiting times, which directly led to more hospital admissions. This included a strong emphasis on meeting performance targets, but these targets didn't necessarily apply to Welsh patients in English hospitals, which may explain why we don’t see a similar increase in English admissions for this group.  

However, Welsh admissions did increase from 2004 onwards, which reflects a growing focus on waiting times in Wales during that period – for example the 2005 announcement that, by the end of 2009, no patient in Wales would wait more than 26 weeks from referral to treatment.

The fall in inpatient admissions in 2010/11 happens at around the same time the Welsh Government started to reduce NHS funding in real terms (although it later increased again). Perhaps the most surprising message is that despite the range of different choices made in both systems the overall growth in activity has been so similar

The state of the debate

A deeper dive into the numbers suggests that there's not much change in hospital admissions rates since devolution of the Welsh NHS. So what does this episode tell us about the state of debate on NHS quality?

There's intense public interest in understanding which of the four systems performs 'best' – as can be seen in the response to Nuffield Trust’s reports comparing the four countries health performance in 2010 and again in 2014. Each of the four NHS systems in the UK have made different choices since devolution, and for the public and health services managers it's an opportunity to understand and reflect on variations in performance and outcome of the four systems. 

As the election debate becomes increasingly pugnacious, it’s perhaps natural that any differences between the performances of the health systems can be highlighted as having political significance. But we need to be wary about taking any of these figures at face value, and think about what they tell us in context. Fortunately there’s good research available to help us do this.

* Estimates based on 2012/13 data.

Suggested citation

Blunt I (2014) 'A borderline debate' Nuffield Trust comment, 24 November 2014. https://www.nuffieldtrust.org.uk/news-item/a-borderline-debate