In 2018/2019 during the Mobility and Access Committee for Scotland’s (MACS) engagements with disabled people and Disabled People Organisations (DPOs), as part of our information gathering and advocacy remit, we were hearing more frequently about the transport difficulties disabled people and older people were facing when trying to access health and social care services.
We decided to look into this further and formed a sub group from MACS, with members who had the following experience: lived experience of using our NHS, career expertise from their current and previous roles within the Scottish Ambulance Service (SAS), NHS Scotland, Public Health Scotland, the Third Sector, from working in Local Authorities (LAs), with the Community Transport Association (CTA) in Scotland and with employment and engagements with Regional Transport Partnerships (RTPs).
We focused our 2019/2020 phase one work around 3 themes – Availability, Accessibility and Affordability of transport, which we call the MACS Triple A check. The report from our phase one work shows the feedback under each area that informed our initial 27 recommendations. This report is available on MACS website.
A strong message that came through, which instigated this work, was that this issue had raised its head again as the SAS had changed their Patient Needs Assessment (PNA), their Escort Criteria, abolished their volunteer Ambulance Car Service and introduced demand capping without any impact assessment. As a result of these service changes many people were no longer eligible for ambulance transport, could no longer travel with much needed escorts and didn’t know where to turn.
It should be noted that the SAS only transports a small amount of the trips generated and the eligibility criteria includes where an individual has a medical need for transport such as; needs care on route to hospital from a care assistant, requires oxygen during the journey, has an unstable but non-emergency medical condition, to give a few examples of eligibility.
Looking at public transport provision - Some bus services had been withdrawn, did not connect (particularly in rural areas), buses were not accessible with bus stops not close enough to home and people could no longer use or rely on this mode of public transport.
In addition, it was reported that routes didn’t align with accessing healthcare facilities i.e., a journey required more than one bus (trip chaining, which many were unable to do due to health and mobility), timetables were not compatible with appointments and treatment times, journey times were too long for those unwell. We heard that the nearest bus stop left too much of a walking/wheeling distance to get to the treatment centres by foot or wheel be it hospitals, health centres or GP practices. It was reported that people were taking taxis from the bus stop, under a mile, to reach their destination and this was costly but necessary.
In short there was a gap between the intentions of our public transport system to deliver door-to-door journeys and the reality. Some individuals turned to the Community Transport (CT) schemes. Most CT schemes (surveyed as part of the phase one work) were becoming overwhelmed by demand for transport to medical appointments. Patients also had to pay a rate per mile making CT unaffordable as they could not use or benefit from their National Entitlement Card (bus pass for concessionary travel) and this was highlighting an inequality.
People were skipping meals to afford transport.
People were just not going to appointments with some instances of withdrawing from palliative or life extending care.
In further desktop research it came to light that the Local Authorities, Local Outcomes Improvement Plans were light on transport strategy if included at all.
Again, through desk top research and case studies it came to light that NHS and other website and apps were difficult to navigate, not helpful as they didn’t have the information they needed, and NHS reimbursement schemes were over bureaucratic and didn’t work. Suggestions being that app development needed to include distance from bus stop to modal connection/destination, gradients, drop kerb placement, accessibility of bus stops for waiting/sitting and boarding etcetera.
Onto the roundtables
The first roundtable cumulated in 27 mutually agreed recommendations with implications for Scottish Government, SAS, NHS Boards, hospital sites, Integration Joint Boards, Local Authorities and Regional Transport Partnerships. It was also suggested that the CTA needed to be more visible at transport planning “tables”, given the lifeline service they were providing.
Our second roundtable brought stakeholders back together and we spend the day looking at themes and prioritising these into 9 recommendations.
The summary report from the second roundtable in March 2020 is attached as Appendix One for background information.
These recommendations were then agreed in principle by Scottish Ministers (cross portfolio i.e., health, transport, equalities) with a commitment to develop a “task force” to implement the recommendation. This was then delegated to the SG Primary Care Team, who in 2021 facilitated a further workshop with the main delivery partners and wider stakeholders.
The result of the above is the evolving “draft Transport to Healthcare Delivery Plan”, with actions and owners identified and areas embedded into the NHS Recovery Plan.
Observations and Conclusions
Not much new came up in MACS phase one work over and above what the National Audit Office (NAO) found in their review of Transport to Health and Social Care in 2011 - unfortunately these recommendations appeared not to have been progressed in over a decade.
Transport to health is a major trip generator but seems to fall through the gaps with transport planners and providers with those needing transport finding the landscape very difficult to navigate. This has an impact on the level of missed appointments as well as people not being able to access the treatment they need, where and when they need it.
There is a financial implication in terms of the inefficient use of clinician time and the impact on people’s health (deterioration) and longer-term reliance on NHS to recover this health deterioration whilst awaiting a new appointment.
There is a ministerial appetite, a genuine and evidenced need and a renewed focus to “lift the lid” and working to make progress in improving transport to healthcare. This work needs to cross regional planning, health board and local authority planning areas. The work will have greatest impact if it also works across transport providers and looks for opportunities, benefits, and efficiencies from sharing resources to populate transport options.
There is current a heavy reliance on private car trips to access health and social care facilities due to the inadequacy of public transport and the limited capacity of other transport providers such as the SAS and CTA. Improving the public transport provision to health and social care facilities lends itself to encouraging behavioural change and switching modes to reduce car kilometres by 20% by 2030, supporting the climate change agenda and promoting a just transition to net zero.
- People can access the healthcare they need, where they need it when they need it and with less stress and anxiety.
- We can reduce the “did not attend” and reduce inefficiency linked to this.
- Reducing did not attends will reduce waiting lists as those who miss appointments go back onto these long waiting lists.
- We can embrace collaborative working to deliver joined up, person-centred approach to service delivery and discharge legislative duties under the Public Sector Equality Duty.
- Nothing is done and the current unacceptable position remains the same.
- That the SG Primary Care Team (leads) and the other delegated leads lack ambition in their approach and lack the appetite to change and do things differently.
- That improvements are expected without the initial funding required to stimulate the much-needed change, which would undoubtedly deliver longer terms benefits.
- In concluding, since March 2020, MACS have been pushing the importance of:
“Transport should be built in as an integral part of the care pathway. There needs to be better joined up care planning and working with NHS, Local Authorities and SAS, with CTA recognised as key partners in the planning and care pathway.”
Briefing/Discussion Paper prepared by: Linda Bamford - SEStrans Non-Council Board Member and MACS National Convener
Date: 21 September 2023
Mobility and Access Committee for Scotland (MACS) - March 2020 Development Day @ Edinburgh Corn Exchange
Theme: Transport to Health - Working Together to Deliver Improvements
Background: The aim of this event was to engage key stakeholders on the recommendations of MACS phase one work on Transport to Health and Social Care.
- To hear directly from lived experiences (in person or through representatives)
- To review, focus and prioritise recommendations
- To understand/model how to best frame the conversation
- To agree next steps
MACS report from their phase one work was circulated to all attendees in advance.
The event attracted a valued mixture of people from Community Transport, Scottish Ambulance Service, NHS, Third Sector, Disabled People Organisations, Disability Organisations, and those with lived experience of transport to health.
Linda Bamford, MACS Convener, introduced the day and set out the challenge. She reminded all of us that there was little change since the Audit Scotland review, report and recommendation on Transport to Health and Social Care in 2011. Meantime things had worsened, not least since the change in the Scottish Ambulance Service’s (SAS) patient needs assessment (PNA), which changed the qualifying conditions, the escort criteria and the introduction of a demand capping system resulting in many people seeking support elsewhere. The above actions by the SAS having significantly reduced the number of people the transport on a daily basis.
Karen Armstrong, Team Leader, Accessible Travel Policy @ Transport Scotland gave an overview of the key discussions and outcomes from MACS winter session of Ministerial meetings.
The morning session was focused on input from a range of people involved in the transport and transport to health sector. This was to improve the audience’s knowledge of the current context, alongside the previous briefings and reports produced by MACS.
The first to present was Sam Richie, Head of Scheduled Care Services @ SAS. She presented on their current context and confirmed they planned to review their service provision model soon.
Sam faced several questions. Many that illustrated the gap between policy (the SAS service model) and lived/direct experiences. There was a strong recommendation of the need for meaningful involvement from those who used the service in the redesign. It was voiced that several people did not experience the service as person centered. The ability of carers to travel with patients to appointments was an issue for many and they identified that the psychological impact of attending health services was not fully appreciated.
The booking process was also an issue with some people finding it inconsistent, often oversubscribed and that they were more likely to get ambulance transport when their clinician or healthcare professional “stepped in”, although people only tended to ask for this intervention as a last resort.
Bernard Anderson had travelled from the Western Isles (Barra) to tell the group about the challenge attending healthcare appointments for those on the islands. Bernard gave an overview of the opportunities for using a remote link like NHS Attend Anywhere, coordinating appointments with travel (and not going to the back of the waiting list if travel problems affect appointments) and joining journeys with others when possible. Attendees from the mainland were really struck by the impact and the complexity of accessing healthcare for island patients.
Andrew Stewart from NHS Grampian (Health and Transport Action Plan Project Manager) described best practice in a service, which is jointly funded by NHS Grampian and NESTRANS, a unique and impressive example of partnership working. The programme has been developed to co-ordinate partnership working between agencies in the areas of promoting active travel, improving the links between transport and public health and access to healthcare. He highlighted the benefits of the THInC project, which helped people access health and social care services.
Emer Murphy, Deputy Director of Community Transport Association (CTA) in Scotland, introduced the research she had done on the role and experience of the CTAs regarding transport to health. Her survey was completed by 67% of the audience.
A return that was excellent and showed the level of interest in this issue.
The full report is not yet available but there were several themes already emerging. There is an inequality of access across the country and clients are often surprised that there was a payment. They felt there was an important need and opportunity to work with other partners to join up the service.
A snapshot of the findings from Emer’s survey is available within MACS report on Transport to Health and Social Care (page 9).
The afternoon was structured to work at tables to identify what people noticed most and thought were underlying causes of these issues and then time was taken to discuss, review and prioritise the recommendations.
Question: What did you notice most from the report and today’s contributions and what may be the underlying causes to take account of as well?
Several themes arose
- There needs to be a review of the Scottish Ambulance Service scheduled care service and this review should be done by an organisation independent to the SAS.
- A joined-up service is needed, as a disconnected service is inefficient and confusing and stressful for users. A single point of contact is needed to avoid people being treated differently.
- There are many small local initiatives, but they need to link up to offer the service as one.
- Communication is poor between those who offer different parts of transport to health. Silo working was acknowledged. There is also a need to listen to hear properly what is being communicated and not to defend when challenged.
- Budgeting issues are part of the lack of joined care. One organisation should be the lead and accountable for progressing and maintaining this work and ensure the focus us to meet people’s needs appropriately.
- Inequalities are deepened by the lack of prioritisation, a stretched budget, and a need for clarity of what a good service looks like.
- The cost of missed appointments was identified as a significant issue and that a system that worked better would save a budget that could be transferred to improve it more.
- Appointments could be linked better to people’s situations looking at both geography and travel times with transport or not giving early appointments to older people.
- It was suggested that other initiatives might not help this issue i.e., the Accessible Travel Framework does not focus on this issue, and it should.
- It was voiced that Active travel can disenfranchise older and disabled people and again not link up to this agenda even given the recent large investment through Programme for Government.
- Redesign of healthcare is needed to include how the person gets to appointments in primary, community, and secondary care. Transport needs to be part of the care pathway. Also are all appointments necessary or could they be delivered differently example; by a local member of the care team or by tele-care, email, what’s app or SKYPE/Zoom for digital consultations.
Question: What recommendations are right (from the MACS report from the earlier round table) and are there gaps?
The recommendations were well-received, and the gaps identified were:
- The Accessible Travel Framework is good but doesn’t fit with healthcare policy. This should be explored and reviewed by Transport Scotland’s Accessible Travel Policy Team.
- There is a need to state clearly that patients and users of the service MUST be part of design, planning and any changes to services.
- There needs to be more recognition of different health care settings, as so far, it’s tended to focus on simply acute services.
- Claiming back travel costs is difficult and hard to identify. The system assumes people have the spare money to pay travel up front.
- There would be a benefit to widening up concessionary travel to include a Plus One to cover the cost of people travelling to health appointments with a carer or friend to support them (when this is the only option as they do not meet the criteria for ambulance transport or have been refused an escort).
Each person was asked to identify his or her three top priorities. There was some overlap as well, so the following are the summarised and merged priorities in order of preference.
Transport should be built in as an integral part of the care pathway. There needs to be better joined up care planning and working with NHS, Local Authorities and SAS, with CTA recognised as key partners in the planning and care pathway.
Missed appointments should be seen as a priority for this work. Missed appointments that have resulted from transport barriers have a cost to the health service as well as to the individuals and their carers (including being detrimental to their condition through delayed treatment). Ideally this would be quantified to identify financial implications, health and wellbeing complications and the potential for the patient’s condition to deteriorate while waiting longer for treatment.
Transport should be designed around access to health and social care. Organisations must engage with getting disabled and older people to their services. Transport resources and budgets should be shared between the NHS, Local Authorities, SAS, and CTA’s (with those budgets ring-fenced).
One organisation needs to take the strategic lead for planning of the cross-sector transport to health service. This must ensure that ambulance, hospital, community, and public transport provision meets demand and is accessible, available and affordable to all. Local transport providers should be involved in the planning of transport particularly in rural areas.
Disabled and older people should be given more influence on transport to health services and the planning and design of buses, bus routes, bus stops, information points and public toilets to ensure they are geared towards disabled people and older people accessing health services. Transport Scotland should consider including plus one on bus passes for those on PIP.
Online booking of patient transport services should be explored by SAS. A booking system like passenger assist of public services, which is a needs-based and person-centred process.
The SAS, hospitals and GPs need to take responsibility for proactively giving information on what is available locally for transport to health including what’s available should the person not qualify for patient transport. Information should be in accessible forms and suitable to the population it serves. This would include both online and printed form.
People report issues with accessible parking at healthcare, especially hospitals. Blue badge holders report insufficient blue badge spaces and those available being used by non-blue badge holders. This also results in missed appointments and there are situations when people are asking for patient transport because they cannot park even when they have transport. This needs to be addressed and prioritised to ensure enough spaces and that these spaces are monitored to eliminate misuse.
All local authorities should have an accessible transport strategy that encourages and facilitates more disabled people and older people being able to access public transport.
Improve discharge or waiting hubs to be more like a social and shared space to improve social connection and reduce loneliness. NHS providers should involve patient groups in the design of these.
In conclusion, Linda thanked all the contributors, the facilitator, and the attendees. She noted that MACS would retain a focus on and an interest in this area. MACS will continue to engage with Ministers and key stakeholders to advocate the need to move things forward.
Audrey had conveyed her hope that the coronavirus would encourage changes in how we work and communicate and in the words of one of the attendees ‘there should be a culture of challenge and critique to help raise the bar and deliver constructive improvement.’