2 Literature Review

Overview

2.1 There are many benefits associated with CT provision. While some of these are relatively easily quantified, such as the number of journeys, many of the core elements which contribute to the overall value of CT such as improved health and well-being and higher levels of social interaction are more difficult to measure. In particular, these social outcomes are often difficult to quantify and are not easily assessed using conventional transport analysis methods.

2.2 This chapter provides a review of existing literature on the topic, identifying the key evidenced benefits which will form the basis of this research. It is worth noting however, that the available literature on the benefits of CT is limited and often focussed on individual providers or small geographic areas. A bibliography of the literature consulted is included in Appendix A.

Accessibility and Social Exclusion

2.3 There is much discussion in the literature as to the ability of CT to improve accessibility and consequently reduce social exclusion (Farrington and Farrington, 2005). Accessibility can be defined as "the ease with which individuals can reach destinations" whilst social exclusion can be understood broadly as the inability to participate fully in society (Velaga et al, 2012).

2.4 Accessibility is a multi-dimensional concept, with accessibility barriers or gaps existing across a number of domains. These include, for example, a lack of service (spatial gap), inaccessible vehicles (physical gap), services being too expensive (economic gap), a lack of service at the required time or too long a journey (time gap), a lack of information (knowledge gap), and cultural/attitudinal issues (cultural/attitudinal gap) (Mulley and Nelson, 2012).

2.5 Problems of accessibility and social exclusion can be particularly acute amongst members of vulnerable groups, most of whom do not have access to private transport and are therefore reliant on public transport to access key services. These groups may include:

Older and disabled people - who may experience problems using conventional public transport as a result of a lack of accessible vehicles or the requirement to walk to conventional public transport pick-up and drop-off points;
Unemployed people and those with low incomes - who may experience difficulties in accessing conventional public transport because of the cost associated with travel; and
People in communities with limited public transport provision (e.g. rural areas) - who may not be able to access conventional public transport as a result of lack of the required provision within their area.

2.6 The provision of suitable transport for older people is a significant issue, with growing numbers of people living into their eighties and the specific accessibility requirements of this segment of the population often not accommodated through traditional public transport services. These include lower incomes, an increased number of physical limitations and changes in trip purpose (Alsnih and Hensher, 2003).

2.7 The problem of providing accessible public transport in rural areas is also discussed widely in the literature. As a result of low population densities, it is often difficult to provide conventional public transport services in rural locations. This situation is further exacerbated by high levels of private transport ownership and declining funding for rural services (Alsnih and Hensher, 2003).

2.8 Through overcoming gaps in accessibility, CT services can provide access, particularly amongst vulnerable groups, to key destinations including employment, education, and health services.

Social Interaction and Social Capital

2.9 While generally less well understood than the economic impacts, a lack of accessible transport can also result in significant social impacts at both the individual and community level (Lucas, 2010). Individuals who are socially isolated as a result of distance, infirmity or poverty can experience feelings of loneliness and isolation. By providing a means to access key destinations such as employment, education and leisure facilities, CT provides users with the opportunity to get 'out and about' and interact socially within their community.

2.10 The social benefits of transport are examined by Lucas et al (2008) in their analysis of the benefits of transport services in deprived areas. The study examined a number of different transport schemes, including demand responsive services, and surveyed both professionals and local residents. They found that, in contrast with the professionals interviewed, local residents talked of the social amenity value of the transport in the first instance over and above employment benefits. The social benefits discussed included the opportunities the services provided to "go out and meet people" as well as social interaction undertaken during the journey itself (Lucas, 2010).

2.11 The importance of the CT journey in providing an opportunity for social interaction is highlighted in a number of studies. For example, while not focused on CT directly, in their analysis of the role of free bus travel on the well-being of older people in London, Green et al (2014) note that the bus journey itself provided a "therapeutic space" and a "source of potential events, social encounters and opportunities for engagement" which were "fundamental to the well-being" of participants (Green et al, 2014). Similarly, in their submission to the Scottish Parliament Infrastructure and Capital Investment Committee Report, the Dumfries and Galloway Accessible Transport Forum noted that when the driver is known to users the journey itself is transformed into "something of a social occasion (especially for those living on their own) or a chance of social contact conversation" (Scottish Parliament Infrastructure & Capital Investment Committee, 2013). This sentiment is echoed by Martikke and Jeffs (2009) in their research on CT providers in Manchester. They note that "low-key interactions" with the driver can become "very significant and something to look forward to" for those whose opportunities for social interaction are limited (Martikke and Jeffs, 2009).

2.12 A number of commentators also note that by providing an arena for social interaction, the provision of CT can support social capital, particularly in rural areas (Gray et al, 2006). Social capital can be defined as "the connections and relationships among and between individuals" (Gray et al, 2006). Communities with high levels of social capital generally have greater access to resources, skills and influence and research indicates social capital is positively associated with a range of positive social and economic indicators. The concept of social capital is difficult to quantify, with typical measures including perceptions of trust and participation in organisations (Spinney et al, 2009).

Well-Being, Quality of Life and Mental Health

2.13 Transport mobility, social interaction and the ability to engage more fully in community life are also important pre-conditions for well-being and quality of life. There is no standard definition of well-being but it is typically represented by notions of "happiness, life satisfaction, fulfilment and human flourishing" (Vella-Brodrick and Stanley, 2013). While the link between CT and well-being has not been explored in detail, a number of researchers have examined the relationship between transport mobility and well-being more generally.

2.14 Bannister and Bowling (2004) examined the relationship between mobility and quality of life amongst people over the age of 65 in Britain (Banister and Bowling, 2004). The research used data from interviews undertaken as part of the British Office for National Statistics Omnibus Surveys which included a number of self-reported measures of quality of life. The study found a clear relationship between quality of life, and both the availability of facilities such as health services and shops and the number of social activities undertaken in the last month, with the authors concluding that transport is important as it provides the means to access local services and facilitates engagement in social activities.

2.15 A similar study was undertaken examining the impact of transport mobility on the quality of life for non-working individuals in Canada (Spinney et al, 2009). The research used time-use data from Statistics Canada's General Social Survey (GSS) to understand how improved transport mobility correlated with quality of life (as measured against a series of quality of life indicators). The research found that improved access to transport options was positively associated with a variety of related quality of life domains. For example, they found that individuals who were very satisfied with their life as a whole spent almost 2.5 hours per day outside of the home engaged in a range of leisure activities compared to only 1.5 hours per day for those who were very dissatisfied (Spinney et al, 2009).

2.16 The relationship between transport mobility and well-being has also been examined by Vella-Brodrick and Stanley (2013). Using survey responses from adults in Melbourne, Australia, they assess how transport mobility helps to satisfy inherent psychological needs which are deemed necessary for well-being. These include relatedness needs i.e. having supportive and satisfying relationships, competence needs i.e. the belief that one has the resources to achieve desired outcomes and autonomy needs i.e. the perception of undertaking activities based on choice, volition and self-determination. The study found that transport mobility successfully predicted psychological well-being which in turn predicted subjective well-being, with mobility providing the means to "interact with the world" and generate "feelings of connectedness, self-worth and competency" (Vella-Brodrick and Stanley, (2013). The authors concluded that the fulfilment of these psychological needs "is vital to many other positive outcomes such as improved health, vitality and motivation as well as decreased anxiety" and thus improving transport mobility "could provide lasting benefits to individual well-being and reduce the health care costs associated with mental illness" (Vella-Brodrick and Stanley, (2013).

Supporting Independence

2.17 CT can also support independent living and mental and physical health. In their analysis of CT providers, TAS and DHC (2011) found that many of the users of the organisations they assessed would not be able to live independently without support from CT and would therefore need to move house or into residential care services (DHC and TAS, 2011). Such a move would result in significant additional costs with the authors estimating that for just one of the CT organisations they examined, the additional costs if the service were not provided could be as much as £25k per person per year, with a potential total annual cost for social care of over £1.25m (DHC and TAS, 2011).

2.18 The provision of transport and greater independence can also have positive benefits for the families involved. A number of sources note the reduced reliance and pressure on family and friends to provide transport as a result of the availability of CT (Age Scotland, 2013). This can have wider economic and social benefits as a result of a reduction in days taken off work and can improve the carer-patient relationship by providing carers with much needed respite (Martikke and Jeffs, 2009). Furthermore, Alsnih and Hensher (2003) highlight that, in future, families are less likely to be able to cater for the transport needs of elderly relatives as a result of the growth in life expectancy being above that of the rate of fertility as well as general changes in lifestyle (Alsnih and Hensher, 2003). As a result, they contend that an increasing number of individuals will find it increasingly difficult to meet their transport needs without improved public transport provision which meets accessibility needs (Alsnih and Hensher, 2003).

Earlier Detection and Treatment

2.19 The provision of CT has also been linked to earlier detection and treatment of health conditions, with resultant benefits in terms of quality of life for the individuals involved as well as significant savings for the NHS (Age Scotland, 2013). In part this is likely to be simply a result of improved access to health services, with the greater availability of transport encouraging people to seek medical advice when they might otherwise not have done so. For example, the Countryside Agency (2005) in their review of the Newark and Sherwood Voluntary Scheme identified anecdotal evidence that people were more inclined to visit the GP as a result of the scheme. It was also noted that as a result of CT elderly people no longer needed to wait until family members were available and consequently saw the GP earlier (Countryside Agency, 2004).

2.20 A number of sources also highlighted that involvement with CT organisations can also act to provide an 'early warning system' when health problems arise. In their submission to the Infrastructure and Capital Investment Committee Report, the Highland Council noted that "drivers may suggest to the health professionals that there has been a change in circumstances and a visit may be beneficial for the passenger's wellbeing", with "most health professionals recognising that this is helping to reduce admissions to hospital and care homes and that early intervention enabled by Community Transport gives a net saving" (Scottish Parliament Infrastructure & Capital Investment Committee, 2013). Similar comments were made in the research undertaken by Martikke and Jeffs (2009), with a number of CT providers noting the role of drivers as "early warning systems". One commentator described the situation as such, drivers "know their passengers...know what constitutes an uncharacteristic behaviour pattern and therefore can identify possible emergencies" (Martikke & Jeffs, 2009).

Reductions in Missed Health Appointments and Domiciliary Provision

2.21 The provision of CT and greater access to appropriate transport for health appointments has also been linked to a reduction in the number of health appointment Did Not Attends (DNAs) as well as a reduction in required domiciliary provision (Countryside Agency, 2014). It is not clear to what extent a lack of transport contributes to DNAs as quantitative data on the topic is generally limited. However, reductions in DNAs have been recorded following the introduction of a number of CT schemes.

2.22 In 2008, a pilot research project by Argyll & Bute Health Board found that the introduction of a voluntary car scheme for people over the age of 65 caused a 1% decrease in DNAs in Dumbarton with health professionals involved noting that there was also a reduction in the need for domiciliary visits as a result of the scheme (Scottish Government, 2008). In their analysis Age Scotland, used the results of this study as well as national figures on DNAs, to estimate the impact of CT at the Scotland-wide level. It estimated that, amongst the over 65 age group alone, CT could result in 446 "saved" outpatient DNAs, resulting in a saving of almost £50,000 per annum across Scotland (Age Scotland, 2013).

2.23 The cost savings of CT in terms of reduced domiciliary visits have also been estimated in a number of studies. For example, a CT scheme managed by Honley Surgery in South Huddersfield which provided car transport for patients at the practice as well as two other GPs, resulted in savings of over £30,000 per year in reduced professional time (Countryside Agency, 2004). Similar benefits were also identified in the Newark and Sherwood Voluntary Scheme, with a saving in terms of the number of home visits required for one surgery and an associated reduction in professional time worth £2,450 per year. This equated to a saving of around £18 per trip to the surgery compared to a £9 per trip operating cost for the CT provided (Countryside Agency, 2004).

Healthier and More Active Lifestyles

2.24 The provision of CT can contribute to healthier and more active lifestyles. In its analysis, Age Scotland (2013) argues that CT can contribute to healthier eating and reduced levels of malnutrition as a result of the opportunity it provides users to 'shop around' (Age Scotland, 2013). This is echoed by Martikke and Jeffs (2009) who highlight the nutritional benefits of being able to access supermarkets and lunch clubs as a result of CT provision (Martikke and Jeffs, 2009). The nutritional benefits of CT are likely to be particularly important amongst isolated groups on low incomes.

2.25 Age Scotland (2013) also argues that greater use of CT, as with public transport more generally, results in higher levels of physical activity which in turn can lead to reductions in preventable health conditions such as cardiovascular disease, obesity and type 2 diabetes as well as incidences of falls and fractures, all of which carry significant costs for the health service (Age Scotland, 2013). The report notes that CT particularly can be very effective in reducing the incidences of falls and fractures as a result of the specific care provided such as assistance in accessing vehicles and the ability to stay seated while the vehicle is in motion (Age Scotland, 2013).

Employability and Training

2.26 CT organisations are important employers of both staff and volunteers. According to the CTA, the 80 largest CT organisations in Scotland employed around 400 people in 2012, of whom approximately one third were full time employees (CTA, 2012). As well as the direct income provided to those employed by CT providers, there are wider multiplier effects within the local economy. In addition, a 2012 report by the CTA found that at least 2,500 people volunteered their time, providing a total of 278,500 hours over the year period. If one hour of volunteering is valued at the minimum wage rate, this equates to £1.7 million on an annual basis (CTA, 2012).

2.27 In addition, involvement in CT organisations can bring significant benefits for volunteers including greater levels of physical activity, opportunities for social interaction and a sense of purpose with resultant positive impacts on mental health and well-being (CTA, 2014). In addition, the contributions of volunteers mean that there is a great deal of added value in the sector compared to a commercial equivalent. For example, in their analysis of CT in Manchester, Martikke and Jeffs (2009) note that "volunteers who come from within the community being served typically bring with them more familiarity with the issues that community faces" and identify numerous examples of drivers going "above and beyond" what any normal driver would do in order to assist their passengers (Martikke and Jeffs, 2009).

Support for Local Businesses

2.28 The provision of CT can also provide benefits for local businesses through both increased access to employment and increased revenue. The provision of accessible transport to employment through schemes such as Wheels to Work provides businesses with a number of recruitment benefits including a wider recruitment pool; a better match of recruited staff and skills to job roles; improved staff retention; and consequently a reduction in recruitment costs and increase in productivity. This is a key point, as emerging transport appraisal guidance in Scotland and at the wider UK level suggests that there can be a number of economic benefits which accrue from an improved labour supply (Department for Transport, 2005).

2.29 In their evaluation of the transport to employment (T2E) scheme in the rural communities of East Sutherland, Easter Ross, and Southern Caithness, Wright et al (2009) used a social return on investment (SROI) analysis to assess the impacts of the scheme (Wright et al, 2009). A monetary value was established in relation to the social benefits of employment to the individual based on the net increased income (i.e. the individual's wages minus lost welfare benefits and increased taxes) whilst the value to the state was assessed in terms of the reduction in welfare payments and increased tax contributions. The impact on employers was assessed via a series of surveys. They found that employers benefitted from T2E on a number of levels, including: improved staff retention; easier management of staff rotas; and a greater likelihood of appointing staff from the local area. The study found that the combined benefits to individual users and the state were (then) approximately £9,000 per passenger per year, with the measurable social benefits outweighing the investment by a ratio of more than 3:1.

2.30 Local businesses in the retail and service sector can also benefit from enhanced turnover as a result of sales from CT clients. This can be particularly important for shops and other local services in rural communities where provision of such services is more marginal. In their analysis, TAS and DHC estimated the spend in the local retail and service economy enabled by CT using average household expenditure values taken from the Family Expenditure Survey. These were distributed to each CT destination (recreation, leisure and culture, food and other goods), assuming that spending was in proportion to the percentage of trips to that destination by trip purpose. For the schemes assessed, the authors found additional spend in the retail sector of between £5,000 and £100,000 and in leisure and recreation between £500 and £5,000 (DHC and TAS, 2011).

Rural Population Decline

2.31 Access to transport, including CT provision, can play a significant role in the continued survival of rural communities. This is highlighted by Skerratt (2010) who argues that the presence or absence of services such as transport directly impact the vibrancy or decline of rural areas (Skerratt, 2010). Drawing on work undertaken by the OECD, she outlines a 'circle of decline' in rural areas whereby low population densities result in smaller potential customer pools and consequently a lower rate of business creation. This, in turn, results in fewer jobs and higher levels of out-migration amongst the economically active which further reduces the population density and the probability of investment.

2.32 Skerratt also notes that the out-migration of the economically active during this process results in an aging population, which not only reduces the likelihood of investment further but also results in a higher requirement for services, particularly in health and social care. This sentiment is echoed in the Infrastructure and Investment Capital Committee Final Report which notes that "in areas of population decline, as families, friends and neighbours move away, it can often mean that individuals can become isolated from traditional support networks, which might otherwise have assisted with transport needs" (Scottish Parliament Infrastructure and Capital Investment Committee, 2013).

Support for Other Services and Groups

2.33 The provision of CT can also impact the operation and sustainability of other voluntary organisations and groups, with the viability of some services often dependent on the provision of CT. This sentiment was reflected in research undertaken by the CTA (2014) on the benefits of CT for older people, with many of the groups involved including day services, lunch clubs, and care clubs, noting that without community transport the services would not be viable and would probably have to close (CTA, 2014). Similarly, in their research with third sector health and social care providers, Martikke and Jeffs (2009) found transport to be a "defining issue", with all of those interviewed reporting that "take-up would be greater if transport problems were eased and/or that take-up would be significantly reduced if the organisation did not sort out its clients' transport issues" (Martikke and Jeffs, 2009).

Contribution to Policy Objectives

2.34 As a result of the wide ranging nature of the benefits of CT, its provision can contribute to the outcomes of both transport and non-transport departments and organisations. In their analysis, TAS and DHC note that CT can contribute to virtually all of the national indicators and targets for Scotland, including those covering transport, health, crime, housing, education, environment, community and other social goals. However, while CT can and does contribute to the achievement of policy outcomes in these areas, often "it is unlikely to be a top priority intervention" (DHC and TAS, 2011).

Summary

2.35 The literature identifies the key benefits of CT as:

Improved accessibility to key destinations including employment, education and health services, particularly for vulnerable groups, and consequent increases in social inclusion;
Support for the development of social capital, particularly in rural areas, through the provision of opportunities for social interaction and networking;
Promotion of social inclusion and reduced isolation and loneliness by providing individuals with opportunities for interaction with others both at their destination and during the CT journey;
Improved quality of life and well-being as a result and enhanced feelings of connectedness, self-worth and competency, with associated benefits for mental health and reduced costs in terms of health care provision;
Support for independent living through improvements in accessibility and consequent benefits in terms of enhanced well-being and care costs;
Earlier detection and treatment of medical conditions as a result of enhanced accessibility and greater interaction with care providers;
A reduction in missed health appointments and domiciliary provision, with resultant NHS savings;
Healthier and more active lifestyles as a result of higher levels of physical activity and greater access to healthier food options;
Cost savings and social capital benefits as a result of the considerable contributions made by volunteers across the CT sector;
Provision of employment and volunteering opportunities within the CT sector itself and associated benefits in terms of training and skills development;
Support for local businesses through increased trade and a more efficient supply of labour with benefits in terms of recruitment and staff retention;
Support for rural communities through the provision of vital travel-to-work and education opportunities helping to tackle outmigration and population decline.

2.36 It is evident that CT provides a large number of benefits which cover a number of different policy areas and as such the provision of CT has the capacity to contribute to a cross section of different policy goals including health, education, environment, community and other social goals. Whilst some of the benefits identified can be relatively easily quantified, many of the core elements which contribute to the overall value of CT such as improved health and well-being as well as higher levels of social interaction are more difficult to measure.

2.37 Having developed our understanding of the benefits of CT, the literature review was used to inform the selection of case studies and the primary data collection exercises.