Somerset County Council
Health Scrutiny Sub-Committee
– 10 March 2008
Paper
A
Item No. 5
Non-Emergency Transport for Health Patients in Somerset
Lead Officer: Keith Wiggins, Scrutiny ManagerAuthor: Gemma Waugh, Scrutiny Researcher
Contact Details: gwaugh@somerset.gov.uk 01823 356859
1.
Summary/link to the Annual Plan
1.1. Patients travel to and from hospitals in Somerset in a variety of ways. These include the 999 Emergency Ambulance (not covered within this report), their own transport, taxis, public bus & rail transport, “demand responsive” and community transport, plus two different non-emergency patient transport schemes. Equitable access to transport to health services is a national concern to help address health inequalities and particularly important to the rural nature of Somerset. 1.2. The Patient Transport Service (PTS) takes NHS patients with a non-emergency
medical need or mobility problems to and from treatments. In Somerset it is commissioned by Somerset PCT and provided by South Western Ambulance Trust (SWAST). In 2006/07 it provided 25,470 patient journeys.
The NHS Hospital Travel Costs Scheme (HTCS) provides financial assistance to those patients who do not have a medical need for ambulance transport, but who require assistance with their travel costs. This in effect means free or reduced cost travel for those on benefits.
In Somerset, the Voluntary Ambulance Car Service (VACS) provides the majority of the transport for those who benefit from HTCS and is operated and
co-ordinated by SWAST. In 2006/07 it provided 108,765 patient journeys. However SWAST have given notice on the VACS contracts with the PCT and acute trusts, which it has decided does not form part of its core role.
During the later part of 2007 a Commissioning Manager was appointed to the Dorset and Somerset Procurement Federation to review NHS contracts for transport across the Trusts and PCTs. This seems a perfect opportunity to review the commissioning of PTS and VACS within the wider scope of Somerset’s Local Transport Plan and other public and community transport.
1.3. The work on patient transport could go some way towards addressing the following points in the County Council’s Annual Plan.
Aim 1: Priority 2 - Work with our partners to promote equality of opportunity, reduce any inequality for and between groups.
Aim 3: Priority 8 - Invest in traffic management, highway and transport
2.
Issues for consideration
2.1. Are the differing eligibility criteria used across the County consistently satisfying the Department of Health guidance published in 2007? Are any areas of
Somerset getting a poorer level of provision than suggested by the guidance? 2.2. Now that South Western Ambulance Service Trust does not consider the
Voluntary Ambulance Car Service core business there is an opportunity for joined up commissioning. There is potential for utilising spare capacity in public and community transport as a part of implementing Somerset’s Local Transport Plan.
2.3. The following areas of partnership working are recommended by SCC Transport: 1. Reestablishment of a Transport Partnership for Health in Somerset
2. Development of a Joint Eligibility Criteria for Patient Transport Services 3. Better Utilisation of Existing Resources
4. Better Strategic Development
5. Engagement with the Accessibility Planning process and Joint Consultation
3.
Background
3.1. What is non emergency ambulance patient transport? 3.1.1. What is the Patient Transport Service (PTS)?
The PTS takes NHS patients with a non-emergency medical need or mobility problem to and from treatments. These include bringing people to and from treatments such as renal dialysis, radiotherapy and physiotherapy; for
attendance at mental health units; for other outpatient attendance at clinics and day hospitals; for x-rays and for day surgery. It is also used to take people home following discharge from inpatient care.
There are 14 PTS ambulances available on a normal working day in Somerset and this includes one discharge vehicle
The last 3 years including projected for this year are; 2005-06 2006-07 2007-08 Average
26,773 25,470 27,788 26,677 Patient Journeys per year including escorts and aborts
The 2007-08 figures are based on 9 months actual and 3 months projected. 3.1.2. What is the Volunteer Ambulance Car Service (VACS)?
The NHS Hospital Travel Costs Scheme (HTCS) provides financial assistance to those patients who do not have a medical need for ambulance transport, but who require assistance with their travel costs. This in effect means free or reduced cost travel for those on benefits.
In Somerset, the Voluntary Ambulance Car Service (VACS) provides the majority of the transport for those who benefit from HTCS and is operated and
co-ordinated by SWAST. They provide transport for patients who are able to walk with minimal assistance and are able to get in and out of a car without any
significant assistance. The patient is charged at nominal rates in Dorset and Devon but the service is free for those eligible in Somerset.
The service transports patients to health related appointments in hospitals and other treatment centres and also undertakes patient admissions, transfers and discharges.
Patients who frequently undergo renal dialysis, oncology, or mental health treatments are the highest users of the service. Patients are often elderly and frail and are very appreciative of the service provided.
The number of VACS journeys for the last 3 years, including projected for this year, are;
2005-06 2006-07 2007-08 Average
123,097 108,765 106,069 112,644 Patient Journeys per year including escorts and aborts
The 2007-08 figures are based on 9 months actual and 3 months projected. The Voluntary Ambulance Car Service relies on volunteers who give up their time to transport walking patients to and from health facilities in their own cars. The following table indicates the number of available drivers by geographical area. It should be noted however that some of them only work half days or for short periods of the day.
Area Total on books Average available per day
North/East Devon 66 25
Somerset 86 33
Dorset 83 35
Total 235 93
It is challenging to recruit and retain Voluntary Car Drivers. The following table indicates the number of driver’s lost/recruited in the last 12 months by
geographical area.
Area Drivers Left Drivers Recruited
North/East Devon 8 0 – Due to planned end
Somerset 2 6
Dorset 42 12
Total 52 18
There is an increasing reliance on taxis as driver numbers are falling, this
increases the cost of operating the service and this is subsequently passed on to the commissioners.
3.2. Policy Background
In November 2001 the Audit Commission published ‘Going Places’, a National review of how Local Authorities and health agencies are involved in improving access to services. The report cited poor availability of transport to a number of services including health and social care.
The Social Exclusion Unit report ‘Making the Connections’ requires Local
Authorities and other agencies, including Health Trusts, to work in partnership to achieve integrated, joined up solutions thus improving access to services. In 2005 ‘Our Health, Our Care, Our Say’ white paper set out a vision to provide people with good quality social care and NHS services in the communities in which they live. The paper made a commitment to extend eligibility for the Hospital Travel Cost Scheme (HTCS) and Patient Transport Services (PTS) to include procedures that were traditionally provided in hospitals but are now available in a community setting.
Somerset’s Local Transport Plan 2 identified access to Health care as a major concern for Somerset’s residents. The Accessibility Strategy stated that:
28% of rural residents have to travel (by public transport) for longer that 30 minutes or have no bus service at all to their nearest GP.
43% of Somerset residents have to travel longer than 1 hour or have no bus service at all to their nearest General Hospital (51% from rural areas and 37% from urban areas).
24% of rural residents have to travel longer that 1 hour or have no bus service at all to their nearest Community Hospital.
The plot in Appendix 1 shows General and Community Hospital accessibility in Somerset between the hours of 07:00 and 10:00 by public bus transport – white showing no access at all. Worth noting this plot does not include access to any community transport or demand responsive transport. It shows a large
proportion of rural locations have no public transport access to General or Community Hospitals between the hours of 07:00 and 10:00, with only those living alongside main roads and arteries managing a reasonable journey (less than 2 hours).
The Department of Transport have introduced free off-peak local bus travel for older and disabled people in England. From April 2008, a national concessionary fare scheme will be introduced to offer these groups free off-peak travel on buses anywhere in the country.
3.3. Who provides patient transport in Somerset?
In Somerset, the South Western Ambulance Trust (SWAST) delivers the majority of non-emergency health transport.
3.3.1. Providers of PTS
South Western Ambulance Trust (SWAST) delivers the majority of PTS in Somerset. This is done through service level agreements (SLA) with the acute trusts and the PCT.
Providers usually use a mix of multi-seat ambulances and cars to meet demand. These vehicles are often similar to the minibuses used by local authorities to carry social services clients and those with special educational needs, containing both seats for people who are able to walk and space to carry wheelchairs.
3.3.2. Providers of VACS
South Western Ambulance Trust (SWAST) delivers the majority of VACS in Somerset. This is done through service level agreements (SLA) with the acute trusts and the PCT. Private providers are sometimes used by acute trusts. The Ambulance Trust has given notice on the VACS contracts side. Although the SLA expires at the end of March 2008 the Ambulance Trust have agreed to cover this service for another year or until such time that the Trusts can either re-tender the contract or work with the local authority to provide the service under an SLA.
There are Service Level Agreements for VACS in Somerset with the following Trusts;
Taunton and Somerset NHS Foundation Trust; Yeovil District Hospital NHS Foundation Trust; Somerset Partnership NHS and Social Care Trust; Somerset Primary Care Trust;
Weston Area Healthcare NHS Trust; North Somerset Primary Care Trust.
Cars are be used to provide the services and may include taxi and hired car services (typically used for work outside the patient transport service’s normal weekday hours) and volunteer car services in which volunteers use their own cars to carry people to and from hospital (mileage allowances paid covering additional motoring costs).
3.4. Who commissions patient transport in Somerset?
The key Commissioners on behalf of Cornwall, Isles of Scilly, Devon, Dorset and Somerset Trusts are the ‘Dorset and Somerset Procurement Confederation’ and the ‘Peninsula Purchasing Alliance’. The PCTs are ultimately responsible for the cost of PTS, as it remains within the relevant tariffs of Payment by Results. Where it is decided the acute trust should not be responsible for providing PTS then the tariff should be adjusted to allow the PCT to contract for PTS directly with the providers. Provider units (e.g. hospitals) are responsible for the administration of Hospital Travel Costs Scheme (including VACS) and the
provision of payments to patients. PCTs are responsible for reimbursing provider units for the payments made under the scheme for all patients resident within their districts, also through the Payment by Results tariff with the exception of mental health where other reimbursement must be made.
3.5. Who is eligible? 3.5.1. Eligibility for PTS
In response to the 2006 white paper in September 2007 the Department of Health reissues its guidance on the eligibility criteria for patient transport services. The guidance states that eligible patients are those:
where the medical condition requires the skills or support of PTS staff or where use of other means of transport would be detrimental to the patients condition.
where the medical condition impacts on their mobility to such an extent that healthcare would not be accessed otherwise or the use of other transport would be detrimental to the patients’ recovery.
Parent or guardian of an eligible child being transported.
It also states that judgment on what is reasonable will need to be defined locally due to varying circumstances.
The new guidance suggests that a patient’s eligibility for PTS should be determined either by a healthcare professional or by non-clinically qualified staff who are both:
clinically supervised and/or working within locally agreed protocols or guidelines, and
employed by the NHS or working under contract for the NHS
In Somerset all GP referred hospital PTS transport is booked through the Patient Referral Centre (Choose and Book) at Bridgwater Express Park. The referral centre, along with Musgrove Park and Provider Services (community hospitals), uses the 1999 Health Authorities eligibility criteria, while it is believed that Yeovil District Hospital and Somerset Partnership use different eligibility criteria.
At the request of the Somerset Transport Partnership (officers from the then four Primary Care Trusts, Acute Hospital Trusts, Patient Referral Service and Somerset County Council) a sub-group was formed in 2006 to review the existing eligibility criteria and produce a report with recommendations for change in line with central government guidance on eligibility issues.
To date none of these recommendations have been adopted consistently as the latest changes to the health structure has brought about changes in personnel and a period of ‘bedding down’ has meant it has not been possible to move forward with these recommendations through the partnership.
3.5.2. Eligibility for VACS and other transport
Where patients are not eligible for PTS, they may be eligible for the Hospital Costs Travel Scheme. This allows free or reduced transport by a variety of methods, public transport, taxi, or community transport, private motor vehicles or voluntary car schemes. This is what the VACS is covering. The Hospital Costs Travel Scheme guidance states the following people are entitled to help with their transport, where:
the journey is made under the care of a consultant (not a GP).
the journey is made for a traditional hospital diagnostic test or treatment, paid for by the NHS.
the patient is claiming benefits
o Some benefits allow full help with travel costs, e.g. Income Support, Job Seekers Allowance (Income Based) and either Working Tax Credit or Child Tax Credit with either the disability element or proof of an income of or less that £15,050,
o Other benefits, including those on the NHS Low Income Scheme, are allowed help with transport costs but are expected to pay some (means tested).
There are some exceptions to being covered by the Hospital Costs Travel Scheme:
those already covered by PTS.
those transferred between treatment centres (is a cost of their care and therefore PCT funded).
those who discharge themselves against advice.
visitors to patients (although they may qualify for a Social Fund Loan). private patients.
3.6. What is currently happening in Somerset?
During the later part of 2007 a Commissioning Manager was appointed to the Dorset and Somerset Procurement Federation to co-ordinating the contract negotiations for PTS and VACS across the Trusts and PCTs.
Somerset County Council officers have begun to work with this Manager (Angie Mortley) to review the recommendations and move forward on commissioning services and utilisation of resources to ensure patients and service user’s needs are met.
In Somerset all GP referred hospital non-emergency transport is assessed and booked through the Patient Referral Centre (Choose and Book) at Bridgwater Express Park. The referral centre also organises many of the follow-up
appointments particularly for Musgrove Park Hospital and the community hospitals. The referral centre, using a set criteria, decides if a patient is eligible for free transport and if so will forward the details to the transport provider. Between January 2007 and December 2007, 72,423 patients were referred to the Choose and Book system, of those 12,176 (17%) were booked onto PTS (and information about other voluntary transport services is provided where PTS cannot be offered leaving the patient to book this themselves). There is no data collected of how many people are eligible compared to how many of those book transport.
Where an appointment is made by one of the general hospitals (such as a follow up appointment) it is arranged directly with the transport provider. This is also the case where non-emergency medical transport is required to transfer or to
discharge a patient.
The Ambulance Trust Board have concluded that VACS is no longer a financially viable service and is subsequently not core business. The Trust are now in the process of divesting its self from this segment of the business. VACS ceased in Cornwall in June 2006 and South/West Devon in June 2007. The Trust
continues to provide the VACS in North/East Devon, Somerset and Dorset until discussions are concluded with Commissioners and a smooth transfer can be achieved to an alternative provider.
In line with commissioner views and that of national PTS guidelines a letter has been sent to the Dorset & Somerset Trusts to cease the SWAST VACS service in Dorset & Somerset from 1st April 2008 with the view to transfer the service in its entirety to another provider. SWAST will continue to work with commissioners to provide support where required to ensure a smooth transition of services. The service will continue as long as commissioners are prepared to pay for the ongoing service and until an alternative provider can be found.
A review is under way within Dorset & Somerset headed by Angie Mortley of the Dorset & Somerset procurement Confederation to secure a single three year SLA across all Trusts in line with the Devon & Cornwall approach. SWAST is working closely with Angela to focus on the medical tier PTS rather than VACS. Work is currently being undertaken with the Peninsula Alliance and Dorset & Somerset Procurement Confederation to develop a joined up approach and Service Level Agreement for PTS across all SWAST Commissioning Trusts.
4.
Consultations undertaken
4.1. South Western Ambulance Service Trust, Somerset PCT and Somerset County Council’s Transport teams have kindly provided information.
5.
Implications
5.1. Working together in partnership could have the following positive implications. Improved Utilisation of Joint Resources
Somerset County Council has a fleet of approximately 100 minibuses, 150 volunteer drivers and many contracts with external transport providers. Some SCC’s vehicles are under utilised during the middle of the day, weekends and evenings and therefore could be available to get patients to hospital for
appointments or to enable discharges from hospital during the evenings. Improved Service for Somerset Residents
Both the PCT and SCC have a call centre already in operation. Various
engagement with Health personal has established that many are in agreement of a ‘one stop shop’ which would allow patients to ring one number to obtain
medical or social need transport providing a seamless service for patients and SCC transport users.
Reducing Social Exclusion and Improving Accessibility
Poor access to health services may result in costly missed appointments or patient not accessing services at all. By working in partnership to identify the barriers when accessing healthcare solutions can then be identified and joint action plans developed to reduce inequality of accessing services.
Delivery of Strategic Policy Guidance
Working effectively in partnership can help to deliver the aims of several strategic policies that include:
• Our Health, Our Care, Our Say • Somerset’s Local Area Agreement • LTP2’s Accessibility Strategy
5.2. Failure to work effectively in partnership could result in the disjointed and poor value for money transport to health services, increased social exclusion and poor accessibility and the non delivery of key strategic policies.
6.
Background papers
6.1. South Western Ambulance Service NHS Trust (2007) Changes to the
Voluntary Ambulance Car Service (VACS). [attached]
6.2. Department of Health (2007) Hospital Travel Costs Scheme. Guidance for NHS organisations
6.3. Department of Health (2007) Eligibility Criteria for Patient Transport Services
(PTS).
6.4. Somerset County Council (2006) Local Transport Plan 2
