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Patient Transport Contracting
The Larrey Society
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Contents
CONTENTS ... 0
INTRODUCTION ... 1
DIRECTION OF THE SOCIETY ... 1
PRIORITY ISSUES ... 2
IMPORTANCE AND CONSEQUENCES OF ISSUES - COMMISSIONING
... 3
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Introduction
The Larrey Society was established in March 2015 as the first cross sector “think tank” to help shape the policies for an ambulance service fit for purpose in the
21st century. Membership is open to individuals who are currently or have been
previously directly involved in public, independent or voluntary ambulance services and wish to collaborate, share ideas and views under The Chatham House Rule on confidentiality.
In April the Society commissioned DJS Research, an independent market research company, to carry out a survey with its members. DJS worked with the Larrey Society panel of advisers to develop a short questionnaire to canvass member views on the direction of the society and what issues members believe are important.
The questionnaire was set up as an online survey, and seventy members were invited by email to respond. The online survey took place in May 2015 and a total of 35 members responded. This report provides a summary of the findings.
Direction of the Society
Members were asked to indicate their level of agreement with a series of statements about the potential future role of the Larrey Society (see fig. 1 below):
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Agreement was highest for the statement ‘the Larrey Society should address matters of concern with other national bodies’, with 97% of members agreeing with this statement (54% strongly agreeing). There was also widespread support for the society concentrating on providing national guidance (80% agree) and undertaking/publishing research (94% agree).
Priority Issues
Members were asked to choose, in rank order, the top three issues that they think the Larrey Society should focus on (see fig. 2 below):
Fig. 2
The highest priority issue according to members is education and training with 42% in total ranking it amongst one of their top three issues. This was followed by commissioning, burnout and communication across parties.
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Importance
and
Consequences
of
issues
-
Commissioning
Introduction
A patient’s first experience of a hospital or clinic visit is often the transport provider who picks them up and takes them to their appointment. This element of the care package is increasingly being contracted out by the NHS to the private sector and has not been strongly regulated in terms of the quality of the service the patient can expect to receive. The Care Quality Commission (CQC) now inspects private sector providers however there is no standard specification or key performance indicators used to define the level of service which the patient should expect.
Getting a patient to or from hospital can be a complex process. This paper will talk through the process from the original booking to the completion of the journey and highlight the issues which can be experienced. A number of recommendations will then be suggested to improve the service both in terms of quality and cost.
Transport Booking Process
When the patient is contacted about a hospital appointment they are often advised to contact a transport bureau or call centre. This call centre will often be staffed by administrators who follow a predefined script to determine whether or not the patient is eligible for transport. The first complexity along the booking process is to understand whether or not the bureau can afford for the patient to be transported to hospital.
Non-Emergency Patient Transport Services (NEPTS) are currently commissioned in a disjointed manner. Since the establishment of the Care Commissioning Groups (CCGs) there has been some interest from these organisations to be involved in the commissioning of NEPTS services but in other areas the CCG does not get involved. The cost for patient transport is often passed to the CCG through a pass-through agreement with the NHS Trust and this separation between commissioner and payer of the services is adding to the poor levels of service that the patient is experiencing.
Where the NEPTS service is commissioned by the CCG there can be issues when the activity increases beyond that which was stated within the contract. Activity increases can be linked to an increase in patient numbers but can also be linked to incorrect activity information being provided when the contract was established. If the patient does not fit the planned activity level the NHS Trust
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can find that the CCG refuses transportation leaving the NHS Trust to either book NEPTS outside of the contract or not treat the patient within nationally agreed treatment timescales.
Where the NEPTS service is commissioned by the NHS Trust there can be issues around the pass-through cost and to what extent the CCG are monitoring the costs which are being passed to them.
Increasingly the CCGs are looking to commission NEPTS and during September 2015 a number of CCGs wrote to NHS trusts advising them that should a NHS Trust not use their contracted transport provider then the CCG will not cover the cost. Some NHS trusts service in excess of 100 CCGs and as such will need to be able to track each patient, their CCG and the contracted NEPTS provider to ensure they are not financially penalised. This will add a significant administrative burden to the Trust and arguably will reduce the quality of the service which is provided to the patient.
If the patient is deemed within the activity profile that was established at the start of the contract the administrator within the transport bureau/ call centre will then assess their eligibility to ensure the right transport is provided.
In 2007 the Department of Health issued guidance on patient eligibility to identify which patients were and were not eligible to receive free patient transport to hospital. This guidance has not been updated since it was issued any many NHS trusts have now modified this guidance to meet their local requirements. In some cases this local modification is undertaken with the objective of restricting access and reducing cost.
Even where the CCG commission the NEPTS contract GP’s are reluctant to undertake the first eligibility screening of the patient as they do not like to challenge the patient or inform them that they are not eligible for transportation. This is often left to the administrator following the local version of the Department of Health guidance. These administrators are not always clinically trained and will therefore be relying upon the answer which is provided by the computer based on the patient’s response to a number of questions.
Defining patient mobility is also undertaken in a disjointed manner. In a recent survey of London NHS trusts, 72 ways of categorising patient mobility were identified. This adds complexity to the eligibility process and confusion to the contractor who is asked to undertake the work.
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Having completed the eligibility check the transport bureau will signpost the patient to a vehicle which meets their requirements. The patient may not be eligible for NEPTS and may be signposted towards other transport options not all of which are coordinated by the transport bureau. Across the Country there is not a coordinated approach between social care transportation and NEPTS. In London there are a number of transport options available to patients ranging from fully funded non-emergency patient transport to subsidised Dial-a-Ride, to non-funded public transport services. The uncoordinated booking processes between these services mean that patients are often unaware what options are available to them.
Discharging patients from hospital is often an unplanned activity with an increase in requirements at the end of the day or towards the end of a week. This is partly due to the availability of drugs for the patient to take home with them but also poor coordination between all parties involved in the discharge process and a need to empty beds before the weekend when some support services do not work. The peaks and troughs this approach to booking transportation makes the planning of resourcing almost impossible and leads to additional cost to the contract.
The discharge process can also be complicated where a patient is admitted to hospital under one mobility but due to changes in their health whilst in hospital require a different mobility to return home. Bookings can often be copied from the most recent journey without a reassessment being undertaken. This can lead to the transport not being fit for purpose and the patient having to spend additional days in hospital.
Many NHS organisations are reporting poor performance in delivering the 4 hour A&E target and this is often attributed to a lack of beds in the hospital. By improving the NEPTS service and seeing it as an integral part of the overall patient experience a better flow of patients throughout the hospital can be achieved. The separation of duties between the CCG and NHS Trust has across the country has led to various stories of poor patient experiences and NHS Trusts commissioning extra activity outside of an agreed contract to ensure that discharges are managed in a timely manner.
Where issues arise in the transport process NHS trusts will usually review the contract and key performance indicators to see whether service credits can be applied. Poor contract management can lead to reviews of performance only occurring when an issue arises and NHS trusts looking to backdate service credits to the time key performance indicators were first missed. Suppliers will often state that the key performance indicators which were used to establish the
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contract are unachievable. This results in the relationship between buyer and supplier deteriorating.
Conclusions
Those aged 65+ will increase by 34% by 2031 (1.17M people) and those aged 90+ to double to 96K people (Transport for London, Improving Door-to-Door Transport in London, 2015). The requirements on patient transport will only increase over the coming years with a heavier reliance upon higher mobility vehicles.
The disjointed approach to commissioning is not providing a patient focused service and there is a lack of coordination for defining a patient’s mobility. Closer integration is required between NEPTS and social care transport to ensure that the patient is getting the level of service they require at the most cost effective way for the public sector.
There is a lack of standardisation in the commissioning of NEPTS which has led to a range of key performance indicators being used across a number of NHS trusts. This culminates in a patient receiving a different level of service from different hospitals and providers having to resource contracts differently to achieve the stated level of service and not be penalised for poor performance. Improvements in demand need to be achieved by the NHS to smooth the peaks and troughs. There is a reliance on drugs being ready before the patient can be discharged and this can lead to the majority of discharges being undertaken late in the day. Patient mobility and eligibility should also be jointly managed by the NHS Trust and CCG. The patient should not be expected to define their mobility by standardised questions, but should be assessed by clinically trained individuals who can ensure they get the level of service they require.
Recommendations
The Larrey Society suggests the following recommendations are taken on board by commissioners, the Department of Health, NHS England and the Care Quality Commission to improve the level of service the patient receives:
• A joined up approach to commissioning transport (social and healthcare) needs to be established bringing together NHS Providers, NHS Commissioners and Social Care.
• Centralised booking for all social and healthcare transport should be established in each region which recognises changes in requirements and describes patients in the same way. This central booking team does not have to be provided by a transport supplier.
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• Standardisation of eligibility criteria which is fair and transparent should be issued centrally and mandated all NHS organisations adopt.
• Patients should be allowed to manage their own travel budgets so that they can take ownership on the cost of their travel and make the most use of existing transport services.
• Standardised specifications and key performance indicators should be established centrally which should link into the CQC measurements and standards. Any KPIs should be applicable to NHS and non-NHS provider equally and should have a mandatory requirement of CQC registration. • Contract management between all parties, regularly checking activity,
mobility and performance should be undertaken to ensure that the quality of service the patient receives reflects the care which they receive in healthcare facilities.
