6 Social & Health Benefits of CT

Summary

CT helps to tackle problems with transport accessibility - 50% of survey respondents noted that their trip could not or would not be made without CT.
CT provides a means for isolated individuals to interact - eg 68% of all respondents indicated that the CT service they used was very important 'just to get out'.
89% of respondents explained that CT was either "Fairly" or "Very Important" in supporting personal independence.
CT offers a range of health benefits, including improved access to health services, fewer missed appointments and the continued ability to live at home.

Overview

6.1 In addition to the economic benefits, CT offers significant social and health benefits. Whilst many of these benefits are difficult to quantify, let alone monetise, they are critically important across a range of policy areas including transport, health, social care, rural sustainability and general well-being. This chapter reviews the findings from the different areas of our research and identifies the main social and health benefits of CT.

Accessibility & Social Inclusion

6.2 Transport accessibility, both in terms of physical accessibility and services, timetables etc, is a key issue in Scotland, even in urban areas. CT plays an important role in tackling this by providing transport services in certain geographic areas or at certain times of the day when conventional public transport is financially unviable.

6.3 The user survey elicited responses on the importance of community transport services in accessing services/activities such as medical appointments, shopping, work/education and social interactions with friends/family and days out. It also considered the physical accessibility benefits that the community transport services provide.

6.4 Looking at aggregate results across all case study areas as shown in Figure 6.1, we see that the use of community transport to access shopping is reported to be important by most respondents, followed by access to medical appointments and day trips. Although not relating to accessibility, the importance of CT to 'just get out' is also very high, highlighting the social inclusion benefits of CT.

Figure 6.1: Importance of CT Services to Access Everyday Tasks (Aggregate Results Across Case Studies)

6.5 Considering the case studies on an individual basis, Figure 6.2 highlights the following:

Access to shopping is deemed to be important by the largest number of respondents in three case studies: Badenoch & Strathspey, Buchan and Order of Malta. Day trips are thought to be important by most respondents for Annandale and medical appointments for CT Glasgow.
Use of CT for work and education related journeys is thought to be important by the least number of respondents across all case studies - this is probably due to the predominantly elderly respondents to the survey.
It is interesting to note that respondents in the most rural case study area (Badenoch & Strathspey) are most likely to use multiple different CT services for a range of trip purposes while the most densely populated case study area (CT Glasgow) are most likely to only use a single CT service for a specific purpose. This emphasises the importance of CT providers in remote rural areas where they act as a lifeline provider for all access needs as opposed to a more specialist service evident in more populated areas where more transport alternatives for different trip purposes are likely to exist.

Figure 6.2: Proportion of Survey Responses Indicating use of CT Service to be "Very important" or "Fairly Important" by Trip Purpose for each Case Study

Proportion of Survey Responses Indicating use of CT Service to be Very important or Fairly Important by Trip Purpose for each Case Study

6.6 Respondents were asked how they would access activities if the community transport service they currently use did not exist. Across all case studies, at least 50% of responses indicated that the trip could not be made or would be made much less often. For essential activities such as medical appointments respondents were more prepared to find a way of making the trip.

In the CT Glasgow case study, for accessing medical appointments over 50% of responses identified taxi as an alternative, 25% identified service bus, and 15% would need to cancel their appointment. For other trip purposes, 70% of responses claimed they would simply not be able to make the trip or would travel less if the CTG services were not available.
Half of those using OOM to access medical appointments (20 respondents) would need to use a taxi while five would rely on family members for a lift if possible and a further six would need to cancel their appointment. Two respondents would require a home visit. For accessing services and shopping, some respondents would consider a taxi but for most respondents they would travel less often or not travel. Lifts from family was only an option for some respondents at some times.
In Buchan half of those using BDACB to access medical appointments would not be able to travel and would need to cancel appointments, while the other half would need to ask family members for a lift or get a taxi. For those accessing shopping, five respondents stated they would get the bus, although this was not a good option for them. The same number would just not go. Overall, 13 respondents would not be able to access the activity, eight would need to rely on family members for a lift, five would have to use a local bus but stated it was not a good option and only two respondents felt taxis were an alternative option.
In Annandale over 50% of respondents indicated they would not be able to travel or would need to travel less. Almost a third would rely on a lift from family or friends. Very few would be able to make the trip by taxi (10%) or service bus (5%).
In Badenoch and Strathspey the majority of respondents would struggle to afford taxi fares or get lifts from family/friends for the trips provided by BSCTC. One respondent indicated that they would consider taxis for essential activities. For non-essential services such as visiting family/friends and day trips the user would forgo the trip.

6.7 When considering physical access, the door-to-door nature of the CT services and the understanding and assistance offered by drivers were consistently viewed as being important by over 75% of respondents across all case studies (see Figure 6.3).

Figure 6.3: Accessibility Benefits of CT Services (Aggregate Results Across all Five Case Studies)

6.8 By utilising the scoring system indicated in Table 6.1, we can determine an overall score at each site for each statement in Figure 6.3. This is presented in the spider chart of Figure 6.4. The centre of the chart/web represents a neutral view on the statement, a value of 4 (the inner ring on the web) represents slight agreement and a value of 5 (the outer ring on the web) represents a strong agreement with the statement. This chart allows easy visual comparison of the five case study sites.

Table 6.1: System to Score Statements Based on User Responses
Designation	Score
Strongly agree	5
Slightly agree	4
Neither agree/disagree	3
Slightly disagree	2
Strongly disagree	1

Figure 6.4: Site Specific Ratings for Accessibility Benefits of CT Services

6.9 Improving accessibility and social inclusion were seen as key benefits by the staff and volunteers at each case study. Staff and volunteers emphasised that they offered a higher quality of service compared to commercial bus and taxi services, with drivers (and where relevant passenger assistants) providing users with additional assistance where required including help on and off the vehicle, assistance with shopping bags, and help into their home. This was felt to make a huge difference to those with disabilities who may not be able to get out without such support:

"The shopping bus is a typical example and because we have an escort on the bus….they get picked up at the door, the escort is there to help them to and from the bus, they are also there to help with their shopping and on and off the bus and in the supermarket" (Staff Member, BDACB)

"if you were to book a taxi... the guy is going to turn up, he's going to sit there and say 'come on hurry up I've got another fare' where as Dial-a-Bus will come along and they'll make sure the patient is looked after…if they are in a wheelchair they'll take you to the bus, get you strapped in… there's no time limit on it… most taxis can't do that" (Staff Member, BDACB)

6.10 The financial benefits for users were also highlighted. For example, BDACB noted that the cost of transport to healthcare can be particularly prohibitive with a return trip to Aberdeen Hospital costing between £70 and £80. It was noted that many of the clients using the service cannot afford these costs, especially if the trips are regular:

"One lady who contacted us... she wanted [us to transport her] to Aberdeen to pawn her jewellery to pay her gas bill because she used all her pension to pay to get to hospital" (Manager, BDACB)

6.11 It was noted that the NHS currently provide a non-emergency patient transport service. However, a large number of users are not eligible. In addition, for this service, users are picked up and transported together and as a result they have to travel long distances and wait for each individual to finish their appointments before returning. This, it was felt, was not appropriate for some users who would be unable to undertake such long trips.

Social Interaction & Social Capital

6.12 At three case study sites (OOM, BDACB and BSCTC), over half of the respondents live on their own. At CTG the figure is a third and just over a quarter for ATI. This emphasises the isolation of large numbers of CT users if they cannot get out of their homes. The CT services provide one of the few means for many isolated members of their communities to interact socially.

68% of responses indicated the CT service they used was very important to them 'just to get out' with a further 17% viewing this as fairly important.
70% of respondents strongly agreed and 14% slightly agreed that they liked to socialise with other passengers and/or driver during the journey.

6.13 In terms of social capital, across the five case study sites, there were 11 respondents who 'strongly agreed' and three who 'slightly agreed' that the CT service helped them volunteer in the community. These were spread fairly evenly across the sites. One volunteer from Annandale stated:

'Our group has been operating for the last twelve years, last year we had fourteen members in our group, without ATI I do not think we would exist.'

6.14 Providing opportunities for social interaction was seen by staff and volunteers as a key benefit of CT. It was noted that many users live alone and that the services provide the only means for them to get out and about and interact with others.

"People are often widowed, living alone and they want human contact. Often they have family but their family are too far away and they don't have that contact" (Volunteer, ATI)

6.15 The driver's role in facilitating interaction with and amongst users was seen as particularly important and a fundamental element of the services provided:

"The organisation receives a lot of positive feedback about their drivers. When we do an induction there are certain things which we say that they have to have. A good sense of humour is essential…A lot of the people we are carrying are socially isolated and [the driver] is the one person who they see that week.

They've got to have the confidence to talk to the passengers. The passengers have to feel comfortable with the driver" (Operations Manager, CTG)

6.16 Staff and volunteers at each organisation noted that individuals often make friends through their use of the services and this helps build confidence:

"As they build the friendships they feel more confident in going out… you know what it's like when you walk into a room and you don't know anyone. It's better when there are familiar faces" (Manager, ATI)

6.17 The links between greater levels of social interaction and improved mental health were also emphasised:

"Keeping people mentally healthy and physically healthy. It's preventative care. It's as valuable to the healthcare service as the medicines … if you cure the loneliness you create a healthier person" (General Manager, BDACB).

Supporting Independence

6.18 When asked how important the CT services were to their current level of independence, 70% (n=109) of responses indicated them to be 'very important' and 19% (n=30) to be 'fairly important'. The results by case study site, presented in Figure 6.5, show all sites with the exception of Annandale to align with these aggregate results. Responses from Annandale show that a much lower proportion of respondents view the CT services as being important to their independence, probably explained by the far higher levels of access to private cars (75%) compared to the other sites (ranging from 17% to 36%).

Figure 6.5: Importance of CT Services to Levels of Independence at Each Site

6.19 Figure 6.6 presents users responses across all five case studies as to reasons why the CT service contributes to levels of independence, whilst Figure 6.7 illustrates variations between case study sites.

Figure 6.6: Reasons why CT service contributes to levels of independence - results from across all five sites

Figure 6.7: Site Specific Ratings for Level of Independence Enabled by CT Services

6.20 It is clear from the above figures that CT supports independence in a variety of almost equally important ways, ranging from allowing people to stay in their own home to reducing dependence on family friends and others for assistance with travel.

Wellbeing, Quality of Life & Mental Health

6.21 Transport mobility, social interaction and the ability to engage more fully in community life are also important requirements for well-being and quality of life. The user surveys demonstrate the value of CT in contributing to this as illustrated in Figure 6.8:

Figure 6.8: Wellbeing and quality of life benefits (aggregate results from all responses across all five case studies)

6.22 It is clear from Figure 6.8 that the CT services act as an enabler to get people out of their houses. Moreover, the act of travelling on the bus is seen as a social experience in its own right by the vast majority of passengers with over two thirds of respondents agreeing that they like to socialise with other passengers and /or the driver during the journey. It is interesting that the CT services are generally viewed as more important for accessing services and activities (shopping, medical appointments) than for accessing destinations where users can then socialise. This emphasises the importance of the CT service itself as an environment for stimulating social interaction.

6.23 The CT services provide more and quicker access to activities and services: more than half of all responses (¾ of applicable responses) agreed that the CT service they used was vital in helping meet friends and family and 65% of all responses (> ¾ applicable responses) agreed that without the service they would find it difficult to access activities. While only a third of all responses agreed that the service reduced the time spent travelling and/or waiting times once at their appointment, the figure was over 75% when only considering respondents who felt the CT service to be important to them in accessing medical appointments. Almost half of all respondents 'strongly agree' that their physical health is better because they use the CT service.

6.24 There was agreement amongst staff and volunteers that by providing a means to get out and meet others/take part in activities, the services improve the quality of life and mental well-being of the clients. The following example was provided of a severely disabled user who is reliant on the organisation's transport to get out:

"There is one client who was involved in a car accident when she was very young and is now severely disabled. The organisation transports her twice a week to the hydrotherapy pool, shopping or the stables. She goes to the stables and she really responds to having access to the animals. You can see it on her face. She actually holds the reigns of the horse now. Gradually her quality of life is getting better. Sometimes the carer forgets the carrot to give to the horse and if that happens the driver will stop to get them beforehand. If we did not transport her she wouldn't get out." (Volunteer ATI)

6.25 CTG made particular reference to the benefits in terms of health and well-being provided by the Hospital Visitor Service:

"With the Hospital Visitor Service, we are transporting family and friends to patients who in the past couldn't get that access. That maybe helps that person to get better quicker because they have something to look forward to because someone is coming to see them," (Operations Manager, CTG)

Healthier Lifestyles

6.26 The user surveys indicate that CT services make an important contribution towards healthier lifestyles and improving the health of its users. The main healthier lifestyles benefit relates to the CT services enabling about half of all respondents to stay more active and get out and about more (see Figure 6.9). This fits with previous sections which highlighted the value of CT services for retaining independence and enabling users to get out of the house. CT services were also found to allow access to a wider range of food and drink options and, to healthier food and drink options for about a third of all respondents. Figure 6.10 illustrates variation in response at the different case study sites using the scoring system previously identified.

Figure 6.9: Healthier Lifestyles benefits (aggregate results from all responses across all five case studies)

Figure 6.10: Site specific ratings for healthier lifestyle benefits for CT services

6.27 The benefits from a healthy living perspective seem to be particularly prominent in the CT Glasgow case study, where the CT service helps users to be more active and access a wider range of healthier food and drink options. This is a particularly important benefit in Glasgow, where the resident population's performance against a range of health statistics lags the national average. The benefits are perhaps somewhat less (although still important) in the more rural case study areas. This is likely because the range of services, even within a given geographic distance, are less.

Earlier Detection and Treatment

6.28 The user surveys indicated that 16% of all respondents strongly agreed that they now see the Doctor quicker and/or more often because of the CT service they use. A further 5% slightly agreed with this statement. If considering only those respondents that felt the CT service to be important to them in accessing medical appointments, these proportions increase almost threefold to 46% and 14% respectively.

6.29 Almost 10% of all respondents strongly agreed, and 4% slightly agreed that the CT service makes it much easier for them to get their medication. As before, if we consider only those respondents that felt the CT service to be important to them in accessing medical appointments these proportions increase to 28% and 11% respectively.

6.30 CTG noted that users of the Healthy Journeys Patient Transport Service were more likely to visit medical professionals as a result of the service and that this is likely to have a consequent impact in terms of earlier health interventions:

"the users are more likely to go to the doctors now that they have a way of getting there and they are more likely to go for the things like reviews which might not be a pressing issue because they might think that there is nothing wrong with them but things can be picked up" (Staff Member, CTG)

6.31 It was also noted that without the service individuals sometimes put off going to the doctors as a result of not having transport:

"Some put off going as well…. Some maybe didn't have enough money for a taxi that week so they just couldn't go or they are reliant on family members to take them and they are worried that they are taking too much time off work so they don't like to mention that they have another appointment" (Staff Member, CTG)

6.32 During focus groups and interviews providers recalled a number of instances where drivers had noticed changes in the health of individuals and were able to act accordingly. A number of specific examples were provided:

"We had a lady on the bus and the driver came to see us that night and said she's just not well …there is something wrong. We called her daughter. Her daughter went around and the next thing we knew she was in hospital. She had blood poisoning… We didn't expect to see her again. I happened to be in visiting someone else in hospital and when I went in, she was up and moving around…her son put his arms around me and said 'thank you… thank you so much'… To this day she's still on the bus… so yes not only would some of them not be in their own homes…a couple of them wouldn't be alive". (Manager, BDACB)

"There was one example where we were transporting a lady to the hospital to visit her husband. The driver happened to be an ex nurse and the women was diabetic. The driver noticed something was not right and it turned out that no one had checked that she was eating. She was blind and her husband did all the cooking. That's just one instance but we have had a lot instances like that. Project Manager, RSVP East Renfrewshire)

6.33 The high level of personal care and attention offered on CT services, particularly when compared to conventional transport, offers significant health benefits, sometimes to the extent of saving people's lives as some of the above quotations explain.

Reductions in Missed Health Appointments and Domiciliary Provision

6.34 The user surveys indicate that 23% of all responses (n=172) agreed (15% strongly and 8% slightly) that the CT service they use has reduced the number of medical appointments they have missed. The figure varies by case study from 6% in Annandale where the main purpose of respondents using the CT service was for day trips and group hire to 40% of respondents in Glasgow. An even greater proportion of responses indicated that the CT service used has made it easier to arrange suitable medical appointments with an average across all case studies of 22% strongly agreeing and 6% slightly agreeing (n=174).

6.35 Almost a third of all responses (n=174) strongly agreed that they no longer worry about how they are going to get to their medical appointments due to the existence of the CT service. A further 16% of all responses (n=171) strongly agreed that they have less need for home visits from the GP or nurse and another 7% slightly agreed with this.

6.36 It is worth noting that the proportion of respondents who felt the CT service to be important to them in accessing medical appointments was 72 out of 172 responses or about two fifths of all responses to these questions. So, if we consider healthcare benefits of the CT service to only these passengers who actually use the service for accessing medical appointments then the percentages quoted above increase by a factor of 2.5 for these passengers; e.g. 57% of passengers who use CT to access health appointments agreed that the CT service they use has reduced the number of medical appointments they have missed.

6.37 Figure 6.11 presents the proportion of respondents from a sub-sample of 72 who stated they had used the CT service to access medical appointments.

Figure 6.11: Healthcare benefits (aggregate results from sub-sample across all five case studies)

6.38 There was a general feeling amongst staff and volunteers that CT services provided savings for the NHS. However, there is limited data to prove this. As part of their review of the Healthy Journeys Patient Transport Service prior to the 6 Month Report, CTG asked users whether they had previously missed appointments prior to using the service and found that approximately 37% of users had done so.

6.39 While some providers found the NHS to be supportive others were less positive. BDACB felt that the healthcare service did not take account of the longer term benefits:

"The NHS attitude is 'we treat patients while they are here'. They overbook so if everyone turned up they would have a problem. In many ways they cater for people not being able to get there. They work on percentages so they budget for a certain number not arriving so if people don't arrive, it's expected. But those people will cost them more eventually but they are not seeing the bigger picture" (General Manager BDACB).

6.40 As discussed earlier, ATI is currently trialling a transport to health service from Langholm to Dumfries General Royal Infirmary. However, the numbers using the service are currently low. The volunteers noted that more work needs to be done to ensure that users in Langholm are provided with appointments within specific hours so that they are able to use the bus. The difficulties of working with 2-3 organisations (NHS, local Council, ATI) and getting representatives from all parties around the table at the same time were highlighted.

Rural Sustainability

6.41 While the existence or otherwise of a community bus service in a rural area will have little or no impact on the retention of many local services such as hospitals and care homes, they do contribute to supporting small local businesses such as shops and post offices. It is evident from the user survey responses that the high level of use of community transport for accessing shopping is making a valuable contribution to sustaining such services - especially in rural areas. Figure 6.2 shows that the use of community transport for shopping trips is viewed as important for the largest proportion of respondents in the most rural area (BSCTC) while it is viewed as important for the smallest proportion of respondents in the most urban area (CTG).

6.42 Staff at B&S noted that the organisation provided support for the rural community and enabled people to continue to live within a rural area. Without the service, it was felt that many people would be forced to leave as they would not be able to access basic services. This is backed up by the user survey responses in which over 75% (n=13) of responses stated the BSCTC services helped them continue living in their own home. The figure was slightly lower for the less rural Buchan case study at 63% (n=35). However, in general, the results of the research have shown little in the way of disparity between urban and rural areas.

Support for Families

6.43 Staff and volunteers noted that the services eased the pressure on families and carers and provided them with peace of mind and time off to undertake their own activities. A number of examples were provided whereby the availability of transport to healthcare had resulted in family members no longer needing to take time off work to transport their family members:

"I've got one lady who goes to hospital every month for treatment…she feels really guilty because before we came along it was her son who took her and he was taking time off work. She worried about his job because she felt if there are ever redundancies then he would be the first to go because he's always taking her… so it's given her peace of mind because she's not worrying anymore. That's a reoccurring theme" (Staff Member, CTG)

6.44 A number of the organisations also provide transport for longer term respite care and offer vehicles which can be hired by families for holidays/outings.

Support for Other Organisations

6.45 Through the Group Transport services, the CT organisations provide transport to a range of voluntary groups at a considerably lower cost than the equivalent commercial operators and in so doing help to maintain the sustainability of the groups:

"I was involved with a local mountain rescue team. We have a number of trained individuals who can drive the vehicles and we use them for fundraising activities. That greatly enhanced the viability of the mountain rescue team, being able to replace equipment etc and there will be other groups who will have similar uses and similar benefits. It's a fantastic resource". (Volunteer, ATI)

6.46 In addition, a number of the providers work with other voluntary groups in the area including, in the case of CTG, other smaller CT providers to whom they sometimes subcontract work. Providers also noted that they actively recommend other voluntary organisations to users where they feel they may be able to assist.

"I try to work with other groups such as the Good Morning Service and Food Train, groups who work with Elderly people, so that I can refer them on" (Staff Member CTG)

6.47 Volunteers at ATI discussed the benefits of the services they provide for local schools. As a result of the rural nature of the area, many schools are small in size and the organisation undertakes a lot of work transporting school children during the course of the school day to enable them to access centralised resources. There was general agreement that transport for schools in this way has increased over time. This was thought to partly be a result of schools no longer being able to afford their own minibuses and other smaller CT organisations having lost their minibuses due to lack of funding.