It is in this context that we are making this submission to the consultation on the recent proposals for the Scottish Ambulance Service Strategy.

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1 Scottish Ambulance Service Strategy: Discussion with partners A submission by WRVS September 2009 About WRVS WRVS is a charity registered in Scotland (SC ) and in England and Wales ( ). It is also a limited company registered at Companies House ( ). WRVR operates across the UK. WRVS wants every older person to have the opportunity and choice to get more out of life. We enable older people to do so by delivering practical support through the power of volunteering and working to publicise and address the issues that affect older people. We also provide in the field support to the emergency services. Our many services are entirely reliant on our 55,000 volunteers, 11,000 of whom are in Scotland. These dedicated Scots, men and women of all ages and backgrounds, deliver hundreds of community based projects including meals on wheels services, good neighbour befriending schemes and community transport initiatives (further details of which can be provided if required). We have, in Scotland alone, over 200 emergency services teams involving more than 2300 people and well over 50 established hospital operations supporting visitors, patients and staff. It is in this context that we are making this submission to the consultation on the recent proposals for the Scottish Ambulance Service Strategy. Introduction WRVS has chosen to respond to the Scottish Ambulance Service (SAS) document entitled Discussion with partners as opposed to that entitled Discussion with patients and the public. This is because we are responding in our capacity as a provider of volunteer led community transport services, that is, a potential partner. It is clear from the consultation document Discussion with partners that the SAS wishes to align itself with the thrust of the Shifting the Balance of Care (STBOC) initiative and ensure that health care and patient experience is improved by making the best possible use of SAS vehicles and personnel. In terms of the STBOC Improvement Framework WRVS believes community transport can assist in various ways with: Maximising flexible and responsive care at home with support for carers 1

2 Integrating health and social care and support for people in need and at risk Improving access to care for remote and rural populations WRVS believes community transport has a significant part to play in helping the SAS realise its other aims as well. We note that reference is made to linking with other parts of the NHS and Local Authority Social Care but we feel adding the third sector to that list is a prerequisite for success. We will deal with the areas raised in the consultation that we are in a position to comment upon and then make some further points. Accessing the right help in an emergency The development of a robust shared system for assessing need between NHS 24 and the 999 service appears a sensible move. But if such a system truly has the capacity to diagnose need the resultant service should not merely mean a straight choice between getting an ambulance or getting advice. It should be sophisticated enough to hold local transport information including community transport services and be able to identify the options available to callers, recommend the most suitable and even, if necessary, liaise with the transport providers themselves to accommodate the needs of individual patients. A similar type of approach has recently been adopted by Greater Glasgow and Clyde NHS in partnership with Strathclyde Partnership for Transport (SPT) and Traveline Scotland in the form of a journey planning service for those with hospital appointments (see: If they are not already doing so we suggest the SAS and NHS 24 should explore how this scheme might inform the transport element of any shared system for assessing need. Delivering for remote and rural healthcare The consultation paper focuses on emergency healthcare in rural and remote areas and it rightly highlights the opportunities for the SAS and others to undertake healthcare in situ without the need for a journey of any kind. Presumably however, if the statistics on patient visits to hospital trips given on page 11 are taken at face value, there is the same issue with non emergency use of ambulances in remote and rural areas as there is elsewhere. If ambulances are being used in cases where alternative modes of transport would be perfectly adequate there is an obvious opportunity to make sure patients in these cases can access these alternative modes of transport instead of an ambulance. We expand on this point below. Getting patients to and from hospital The SAS research noted on p.11 states that 80% of (SAS) patients are able to travel around on other transport when not attending hospital. If our reading is correct the SAS is implying that 80% of patients are requesting (and getting) transport by ambulance unnecessarily and that this is unsustainable. The SAS were kind enough to provide WRVS with a copy of the eligibility criteria applicable to their Patient Transport Service, which are or at least should be used to determine whether an individual qualifies to be carried in an ambulance for non emergency purposes. 2

3 For the benefit of those other than SAS personnel who will read this document these criteria are provided as an appendix. It is clear from the criteria that there is considerable scope for interpretation as to who is or is not eligible. In some instances it will be a fine judgement as to whether or not someone requires PTS staff support; whether mobility is limited by a medical condition so as to prevent access to healthcare or whether travel by alternate means would be detrimental. It is also unclear why provided there is enough room inside the ambulance one relative or friend should ever be prevented from accompanying a patient. The consultation paper notes (p.11) that the SAS has recently conducted another consultation with patients and asked Should those who have no medical need for the service continue to be included in the eligibility criteria under social or geographical need? It is unclear from this question what the current situation actually is but the use of the word continue suggests that currently people who have no medical need may access an ambulance if they have a social or geographic need. Alternatively we can see that the question should be taken to mean Should those who have no medical need for the service but have been accessing it anyway when they shouldn t have been; be decriminalised by being explicitly included in revised eligibility criteria using the new categories of social need and geographical need? In either case, since the responses to this question are not included in the consultation paper it is difficult to gauge what patients think about the eligibility criteria, which is a shame, as this information would be helpful in responding to the Strategy consultation. However, even taking the above points into account, we submit that the fine definition of who does and doesn t qualify for an ambulance should not be the starting point for finding a solution to the issue of inappropriate ambulance use. If the existing eligibility criteria are not consistently applied (as it says on p.12) re writing them, even in the most liberal terms, is unlikely to help. Instead what we would like to see is the intelligent inclusion of transport information in any shared system for assessing need as noted above. If the person who wishes to book a journey to hospital (whether a patient or someone acting on a patient s behalf, such as a social worker or a member of NHS staff) is routed through this system, the appropriate transport can be easily identified and no one will be left without transport whatever type of transport an assessment of their needs determines that they require. This will inevitably relieve pressure on the SAS and it will no longer matter whether those requesting transport know about (or can remember) the eligibility criteria as the shared system for assessing need will identify the best transport option based on the information exchanged at the time of booking. If poor awareness of reimbursement schemes is currently a problem an obvious way round it is to ensure people are told about the reimbursement scheme when they book via the shared system for assessing need. They could be directed to a website to fill in a claim form or, for those without internet access, sent a form by post with an offer of telephone assistance to fill it in if need be. It would be essential to agree in advance the different rates 3

4 which different operators would need to charge patients (which would have to account for the true cost of operating the service as opposed to simply covering the fuel costs) and that patients qualified for reimbursement whatever the rate they had been charged. For example, if an older person who doesn t qualify for an ambulance but who lives nowhere near a scheduled bus route has to use local community transport for their journey to hospital there should be no quibbling about the fare they are charged on the part of whoever is administering the reimbursement scheme. If the SAS is serious about making the best use of its resources and creating a system fit for purpose for NHS patients it needs to be prepared to direct an element of its resources to supporting community transport partners like WRVS to deliver efficient and effective services that can replace unnecessary and costly ambulance use. We understand from a presentation made by Stephanie Phillips of the SAS on 3 August at a meeting hosted by NHS Greater Glasgow and Clyde that the SAS is open to directing resources in this way. The diversity of need in Scotland means that the SAS should expect to create different working relationships with different transport providers in different parts of Scotland but working with these providers remains the best way to get a great service and save money. In doing so the SAS must bear in mind the following: Volunteer led community transport services have a legitimate cost attached to them which has to be met somehow. If such services, with all their social advantages and efficient use of resources, are to be best used to support patients, pushing them into untenable financial circumstances by failing to acknowledge or meet these legitimate costs will contribute to their demise and will put the problem right back where it already sits: with the SAS The individual user of a service may have multiple needs and want to use the community transport service to meet them all. In this context while it is inappropriate for a transport provider to bill a contractual partner for journeys made for a purpose other than the purpose contracted for it is equally inappropriate for a contractual partner to: o attempt to forbid stops en route that do not affect the overall journey cost (e.g. stopping at the shops) o attempt to prevent the transport provider from undertaking other journeys for which they are not billing their contractual partner or prevent the use of vehicles for other journeys on the premise that because the vehicle itself benefits from monies provided by the contractual partner it should therefore be kept exclusively for use under that single contract. This is particularly important in a situation where a vehicle has been wholly purchased via a single contract. While levels of user demand under that contract must be accounted for, contractual partners must be open to the need to make best use of resources as opposed to being wedded to a short sighted view that says no one can use our bus but us and let vehicles sit uselessly idle. o expect income from other sources or other contracts (e.g. donations from the public or a contract with a local authority) to cover costs associated with their contract. Unless contracts can be agreed which represent the true cost of providing a service, third sector community transport providers (or any other 4

5 transport providers for that matter) will be unable to afford to tender for them. Other points If the National Concessionary Travel Scheme (NCTS) was extended to community transport, older people in Scotland would be able to access much more flexible transport services, using their free bus pass, than is currently the case. This would also remove funding pressure from the SAS/NHS itself as reimbursement to community transport providers would come via the NCTS (i.e. straight from the Scottish Government) and would not involve the passenger claiming under an SAS/NHS reimbursement scheme. The recent review of the NCTS did not recommend such an extension but it did not explicitly reject it. WRVS is currently seeking further clarity from the Scottish Government on its position in light of the review. Conclusion If community transport provision can be properly integrated into the shared system for assessing need and if the SAS can release the resources to enable creative partnerships with third sector community transport providers that will meet that need; WRVS believes that there is a real chance to definitively establish an affordable, flexible and effective patient transport provision for Scotland which will serve the country well for many years to come. For more information contact: Andrew Jackson Media and Public Affairs Manager WRVS in Scotland andrew.jackson@wrvs.org.uk

6 Appendix: Eligibility Criteria for Scottish Ambulance Service Patient Transport Service PTS Eligibility The non emergency transport of patients with a medical need for ambulance transport is provided through the Scottish Ambulance Service Patient Transport Service. Patients eligible for PTS transport are those: o Where their medical condition is such that they require the skills or support of PTS staff on/after the journey and/or where it would be detrimental to the patient s condition or recovery if they were to travel by other means. o Where the patient s medical condition impacts on their mobility to such an extent that they would be unable to access health care and/or it would be detrimental to the patient s condition or recovery to travel by other means. Relative/Carer Eligibility A relative escort/carer will be acceptable if the following criteria are indicated: o Patient is a child or if the patient s clinical condition is such that they require constant attention. Consistency of criteria throughout Scotland The Service strives to ensure that eligibility criteria are consistently applied across the whole of Scotland to ensure equity of access for patients to transport services. In the vast majority of areas first appointments are be booked by the clinic of attendance based on an electronic assessment of need from the GP along with the referral. The ambulance journey should then be booked by the clinic using the online booking facility, based on the medical needs assessment. Some patients in the North Division are required to contact the Service directly to book transport following a GP opt out of providing this service. 6