Introduction

1. Background

Powys Teaching Health Board (PTHB) is responsible for planning and delivering healthcare services in Powys. Due to its low population density, Powys does not have its own district general hospital. Instead, Powys residents receive specialist care in hospitals outside of the county, including hospitals in England. These services are commissioned and paid for by PTHB.

At a meeting on 26 March 2025, PTHB unanimously agreed on the Board’s Annual Plan for 2025/26. The plan requires all commissioned service providers to adhere to NHS Wales waiting times targets, regardless of whether services are delivered by NHS England or NHS Wales. These changes are set to be implemented in July 2025 and will not apply to cancer care, urgent care, or care for those under 18. However, due to the longer waiting times targets set for NHS Wales compared to NHS England, Powys residents treated in English hospitals will face longer waits for planned care than English residents treated at the same hospitals. Powys patients will not, however, be waiting any longer than patients treated at other Welsh health boards.

NHS England Targets

NHS England published an updated set of targets for 2025/26 earlier this year. These targets include:

§    65% of patients waiting no longer than 18 weeks from referral to treatment.

§    72% of patients waiting no longer than 18 weeks for their first appointment.

§    Every NHS Trust in England is expected to deliver a minimum 5% improvement towards these targets by March 2026.

§     NHS England aims to reduce the proportion of people waiting over a year for treatment to less than 1% of the total waiting list by March 2026.

NHS Wales Targets

NHS Wales is working towards different targets as set out in its programme for transforming and modernising planned care published in April 2022. These targets include:

§  No patients waiting longer than a year for their first outpatient appointment.

§  No patients waiting longer than two years in most specialities.

Financial position

The decision to apply NHS Wales waiting times targets to all commissioned service providers was made in response to a financial deficit at PTHB of £38.4 million going into 2025-26.

PTHB claim the cost of commissioned services is a major driver of its deficit, with nearly 40% of the total budget being spent on services outside PTHB’s borders. According to estimates in the Annual Plan for 2025/26, applying NHS Wales waiting times targets to all commissioned service providers will save  £16.4 million. In total, the measures set out in the Annual Plan for 2025/26 are estimated by PTHB to bring savings of £22.4 million. This would reduce the deficit down to £16 million but would still be £4 million short of the £12 million Target Control Total set by the Welsh Government.

The financial position at PTHB has led to an escalation in its status for finance, strategy and planning from Level 3 (enhanced monitoring) to Level 4 (targeted intervention). This escalation was announced by the Cabinet Secretary for Health and Social Care on 5 November 2024. Escalation to Level 4 occurs where “serious concerns have been identified” and targeted support is required from the Welsh Government or other NHS or external review bodies.

2. Welsh Government action

The Welsh Government response to the petition states that it is the responsibility of health boards to plan and deliver healthcare services to meet the needs of their populations and that this may include difficult decisions given available resources. It also emphasises the need for health boards to carefully consider the balance of their statutory duties and deficit position against the need to deliver services in line with Welsh Government targets.

The response mentions that £12.5 million in additional funding has been provided to PTHB by the Welsh Government in 2024-25 in recognition of its financial challenges, with an acknowledgement of the higher costs involved in commissioning services in England. This is in addition to core funding of £400 million provided annually to PTHB.

The Welsh Government has committed to working with PTHB to deliver sustainable improvements following its escalation to Level 4 for finance, strategy, and planning. On 6 May 2025, the Welsh Government agreed to make up to £1 million available to support Level 4 interventions at PTHB (alongside Swansea Bay University Health Board, which has also been escalated to Level 4 for finance, planning and strategy).

3.     Welsh Parliament action

The financial position at PTHB was raised in Plenary by Russell George MS on 11 March 2025. He asked the Cabinet Secretary for Health and Social Care whether the absence of a district general hospital and resulting need to commission services from outside PTHB’s borders made it more difficult for PTHB to manage its deficit. The Cabinet Secretary replied:

I do recognise the point that he makes, that Powys is in a different situation in not having a district general hospital, and commissioning services from elsewhere. However, you could also make the argument that it faces fewer risks in terms of the management of a hospital, which brings its own complexity and exposure. So, it is particular. From a strategy, planning and financial point of view, I think there are advantages and disadvantages to that. The most important thing, of course, is that residents in Powys have access to care on an equal basis with other parts of Wales.

Prior to PTHB’s agreement of the Annual Plan for 2025/26, on 25 March 2025 James Evans MS asked the First Minister what discussions the Welsh Government were having with PTHB to ensure funding was available to prevent the proposed changes from being made. The First Minister replied:

I know that there are ongoing discussions between the health Secretary and Powys health board, to make sure that they are able to not only deliver for the people of Powys, but also deliver within the budget constraints that we've set out. We have bailed out health boards year after year. That time is finished. They need to manage their finances much better because, otherwise, every other department has to bail them out. Enough—that's not happening any longer. And it's really important that Powys takes that seriously.

Russell George MS tabled a written question on 27 May 2025 asking how many patients in Powys were waiting more than two years for treatment in hospitals outside of Powys. The Cabinet Secretary for Health and Social Care replied that 81 patients were on referral to treatment pathways in hospitals outside of Powys at the end of March 2025, of which 40 were in hospitals outside of Wales.