There has been ongoing interest – and some continuing uncertainty – about the circumstances in which patients cross the Wales‑England border for NHS treatment. This has been heightened by sustained pressure on waiting times and wider debates about collaboration between the Welsh Government and the UK Government.
While political attention has focused on whether cross‑border working could help manage NHS capacity pressures, the underlying framework governing cross‑border healthcare between Wales and England remains largely unchanged.
This article explains how cross‑border healthcare operates in practice, and what this means for patients where there is a policy divergence between the Welsh and English NHS.
Why do patients cross the border for healthcare?
Patients cross the Wales-England boundary for several reasons:
Lack of provision in the patient’s locality is a key factor. Some areas, particularly rural regions like Powys, do not have the population base necessary to support large hospitals or specialist centres. Patients from these areas may need to travel further – including across the border – for treatment. For many patients in border areas, it may be much more convenient to access services in their neighbouring country. For example, many Powys residents receive hospital care in English cities like Shrewsbury or Chester.
In 2024-25, around 64,000 Welsh residents were admitted to hospitals in England. During the same period, 9,600 English residents received hospital care in Wales.
In primary care, patients living in border areas may choose to register with a GP as close to their home as possible, even if this isn’t in their actual country of residence.
In April 2025, 13,200 Welsh residents were registered with a GP in England, and around 21,000 English residents were registered with a GP in Wales.
What are patients entitled to?
The rights and standards patients can expect differ depending on their residency, GP location and where they receive treatment.
Patient choice in hospital referrals
In England, patients have the right to choose which hospital they’re referred to by their GP. This also applies to Welsh residents in border areas who are registered with an English GP. This legal right lets patients choose from any English hospital offering a suitable treatment that meets NHS standards and costs.
The Welsh NHS does not operate a system of patient choice but looks to provide services close to a patient’s home where possible. Under a previous protocol, English residents with a Welsh GP would automatically be referred for treatment in Wales. English residents with Welsh GPs can now choose to be referred into either the Welsh or the English system.
Cross border principles
The 2018 Statement of values and principles clarified standards for cross-border care and has continued to provide the framework for current arrangements. The statement aimed to address concerns that English patients were being denied rights under the NHS England Constitution, such as patient choice of hospital, and to have their treatment delivered within NHS England’s target waiting times. The situation remained unchanged for Welsh residents with a GP in Wales: they do not have a statutory right to choose which hospital they are referred to.
The following table summarises what patients in border areas should normally be able to expect in terms of standards for access to non-specialised and specialised healthcare depending on residency, GP location and provider. (‘Standards’ includes clinical thresholds for treatment and other referral criteria specified by the Local Health Board or Integrated Care Board).
|
Residency |
GP location |
English provider to meet |
Welsh provider to meet |
|
Wales |
Wales |
NHS Wales standards |
NHS Wales standards |
|
Wales |
England |
NHS England Constitution |
NHS Wales standards |
|
England |
England |
NHS England Constitution |
NHS Wales standards |
|
England |
Wales |
NHS England Constitution |
NHS Wales standards |
In recent years, media reports highlighted that Welsh residents treated in English hospitals would be subject to Welsh waiting time standards. While this was widely perceived as a policy change, it in fact reflected clearer application and communication of long‑standing cross‑border commissioning rules, under which responsibility for organising and paying for care - and the waiting time standards that apply - follow residency and GP registration rather than the location of treatment.
Free prescriptions
All patients registered with a Welsh GP are entitled to free prescriptions, including English residents with a GP in Wales. However, prescriptions are only dispensed free of charge at pharmacies in Wales. Patients who have their prescriptions dispensed outside Wales will be charged at the rates that apply in that country.
Welsh patients who have an English GP are also eligible for free prescriptions, but would need to apply to their Health Board for an ‘entitlement card’.
Welsh patients who are treated at hospitals or out of hours services in England, and are charged for prescriptions at the English rate, are able to claim a refund.
Who pays? Understanding funding arrangements
Health Boards in Wales and Integrated Care Boards in England are responsible for commissioning accident and emergency services for anyone present in their geographic area, regardless of the patient’s residency or GP location.
For primary care services provided across the border, including GP services, dentistry, and ophthalmic services, there is also no funding flow between England and Wales. Any costs fall where they lie, in what’s been described as a ‘knock for knock’ arrangement that broadly balances itself out.
In relation to patients registered with a cross-border GP, the aim of the Statement of values and principles is that there will be no financial shortfall on the part of a Welsh Health Board or Integrated Care Board in England in providing healthcare services to the other country's residents.
The Welsh Government receives an annual payment from the UK Department of Health in recognition of the additional secondary care costs that fall on the Welsh NHS as a result of the net import of patients into Welsh primary care (i.e. the greater number of English border residents registered with a Welsh GP). The annual settlement figure is around £6 million.
For Welsh patients (with a Welsh GP) receiving treatment in England, Welsh commissioners (Local Health Boards and the NHS Wales Joint Commissioning Committee) pay English providers, either under contractual or non-contractual arrangements, as per NHS Payment Scheme prices.
Where English residents with an English GP receive secondary/tertiary care services in Wales, payment for their treatment is agreed locally between the Welsh provider and English commissioner. There is no standard tariff used within NHS Wales. The rate of payment should reflect the cost to the Welsh provider of undertaking the activity.
Cross-border healthcare between Wales and England is not a new phenomenon but a key aspect of ensuring patients in both nations receive the care they need. While differences in policy and funding create complexity, these arrangements provide flexibility for rural and border communities. As waiting lists and patient rights remain in the spotlight, cross‑border healthcare is likely to remain an area of interest for both the Welsh and UK Governments,.
The UK Parliament Welsh Affairs Committee is currently carrying out an inquiry into the cross-border healthcare arrangements between England and Wales.
Article by Philippa Watkins, Senedd Research, Welsh Parliament
