Elements of a Regional Transport Services Strategy

Transcription

1 Access to Health and Social Services DRAFT REGIONAL TRANSPORT SERVICES STRATEGY A CONSULTATION PAPER March 2005

2 Index Page Index 1 Executive Summary 2 Glossary 5 1. Introduction 6 2. Present Law and Policy 8 3. Transport Services Today Strategic Context and Drivers for Change Objectives and Principles Strategic Issues Arising Eligibility Equality 42 Summary of Consultation Points 43 Annexes Annexe 1 Annexe 2 Annexe 3 Steering Group Membership and Terms of Reference Bibliography Proposed Social Services Transport Request Form 1

3 Executive Summary Developing a Regional Transport Services Strategy Background and Current Policy This Draft Regional Transport Services Strategy sets out proposals, and invites comment on specific issues, for the development of a comprehensive regional management framework for the provision of transport services, which will meet the needs of nonemergency health service patients and social services clients. Emergency Ambulance Services are not covered. The Department has a statutory duty to provide transport to enable eligible people to receive health and personal social services where it is considered necessary and when such transport is reasonably required. Non-emergency transport services cost an estimated 30 million each year. This is clearly a very important field of activity yet it has not yet to date been governed by a management strategy. Currently, eligibility for health service patient transport is based on medical need as determined by a medical practitioner. Good practice guidance on non-emergency health service patient transport was issued in No similar guidance has issued for social services clients and eligibility for transport is assessed as part of an overall assessment of need for day care services. The final Strategy, which will be developed after the consultation period, will need to have the flexibility to be implemented regardless of the future structures of health and social services organisations flowing from the Review of Public Administration. Other strategies and policy initiatives will also have an impact on the way health and social services are delivered and might change the demand for transport services. These include a new Regional Strategy, which is being developed and which places increased focus on a shift from treatment in hospital to outpatient, home and community settings. Also, a new General Medical Services (GMS) contract came into effect in April Some elements of the contract might have an effect on future transport requirements. The new contract will allow Health and Social Services Boards to commission enhanced services from the primary care system. These include minor surgery and certain specialised services, which opens up the possibility that more services may be delivered closer to patients homes. The full implications for transport of the new GMS contract cannot be identified with certainty at this stage. However, its impact will need to be carefully monitored as patterns evolve. 2

4 Objectives Chapter 5 outlines the policy objectives and underpinning principles for the future planning and provision of transport services. One of the purposes of transport services is to support users and hospitals by ensuring patients can attend appointments in comfort and on time. This helps reduce the number of appointments missed due to a lack of appropriate transport. Strategic Issues The Steering Group examined a range of options for the future planning and delivery of transport services (Chapter 6). The Group recommended that the current mixed economy of transport provision should continue because it provides the most cost-effective and efficient model of transport services, and has the flexibility to meet the needs of the user. Currently the Northern Ireland Ambulance Service provides most health services transport, while social services transport is provided mostly by Trusts own transport fleets. Trusts have however the flexibility to commission transport services from a range of other providers, including taxis, voluntary and community services and private ambulance operators. The Steering Group found that there was a lack of comprehensive management information on transport services. The Draft Strategy has set out a number of proposals to introduce management, monitoring and reporting measures to ensure that public funds are used efficiently and effectively. The Department has a permissive power to charge for transport services but in practice has not enforced that power. Paragraphs cover charging policy and propose that we do not introduce charging for transport but to provide transport only where the agreed eligibility criteria are satisfied. Eligibility People who have difficulty accessing health service facilities services because of transport difficulties have a range of options other than transport provided by the health and social services. The main categories of need are: medical need; mobility difficulties; rural isolation/lack of public transport; and financial hardship. Currently people with a medical need receive free transport. People with mobility difficulties might be eligible for Disability Living Allowance, which if awarded at the higher of two rates, can be exchanged for a car under the Motability scheme. The Department for Regional Development (DRD) assists older people and people with disabilities through its concessionary fares scheme. DRD also sponsors 15 Rural Community Transport Partnerships, whose purpose is to develop and co-ordinate local transport services for people in rural areas, and a Transport Programme for People with Disabilities, which provides a similar service in urban areas. 3

5 People with financial hardship, if on a low income or in receipt of qualifying social security benefits, can have their hospital travel costs reimbursed through the Hospital Travel Costs Scheme. The Steering Group recommended that eligibility for health service transport should continue to be based on an assessment of medical need as determined by a medical practitioner. There is no current guidance on eligibility to social services transport and transport tends to be provided as part of an overall assessment of need for day care. The Steering Group recommended that the need for social services transport should be subject to a separate assessment and that social services clients should be encouraged to use other forms of transport where available and appropriate to the individual s care needs. Chapter 7 deals with eligibility issues and a suggested pro-forma for assessing eligibility to social services transport has been produced at Annexe 3. Proposals For ease of reference the proposals, and issues on which we would welcome comment, are included at the end of the paper. 4

6 Glossary When we use these terms this is what we mean: Admission Appointment Carer Client Day Case Discharge Medical Practitioner Patient Social Worker Transport Services User Where an individual is admitted to hospital for treatment that will involve at least one overnight stay. Where an individual attends a hospital clinic to see a consultant, or another health professional. Carers are individuals who, without payment, provide help and support to a family member or friend who may not be able to manage at home without this help because of frailty, illness or disability. Carers can be adults caring for other adults, parents caring for ill or disabled children, or young people, under 18, who care for another family member. The term excludes paid care workers and volunteers from voluntary organisations. Clients are individuals who use social services. Where an individual is admitted to hospital for treatment that does not involve an overnight stay. Where an individual is discharged from hospital following at least one overnight stay. In the context of eligibility for access to non-emergency transport, Medical Practitioner means a General Practitioner, Hospital Consultant, or any associated health professional authorised by the GP or Consultant. Patients are individuals who use health services. In the context of eligibility to social services transport Social Worker means the Social Worker responsible for assessing an individual s social care needs, or another Social Worker delegated to undertake this specific task. Transport Services means transport provided or arranged by the health and social services for non-emergency health service patients and social services clients. Users are individuals who use transport services. 5

7 Chapter 1: Introduction 1.1 This Draft Regional Transport Services Strategy, being issued for public consultation, outlines the Government s proposals for the development of a strategy for the future provision of transport services for non-emergency health service patients and social services clients in Northern Ireland. It does not cover emergency ambulance services. 1.2 Many people in Northern Ireland benefit every year from transport provided or paid for by the health and social services, at an estimated cost of some 30 million. This is clearly an important field of activity, yet it has not to date been governed by any comprehensive regional management strategy. The arrangements for regional nonemergency transport services will be influenced by a number of drivers for change and the strategic context for the development of health and personal social services as set out in Chapter 4. Other factors include: The Department s Regional Strategy document A Healthier Future: A Twenty Year Vision for Health and Wellbeing in Northern Ireland which was recently issued for consultation and whose themes include responsive combined services; teams that deliver; and improving quality; Developing Better Services the model for future hospital services, where the current configuration of 15 acute hospitals is to be replaced by a network of ten acute hospitals supported by local hospitals, with better access for all to the appropriate level of service 1.3 The proposals in this paper fit into the Government's wider agenda for improving the delivery of public services, which commits it to: set clear standards for all public services; devolve decision-making to the front line wherever possible; increase flexibility so that public services are more responsive to people s needs; and, ensure that the public benefits from consistently high standards of service, flexibility and choice, which, in turn, help to deliver better value for money. 1.4 The paper embodies the Department s overarching commitment to improving the health and social well-being of everyone in Northern Ireland in a way which: is fair and equitable, targeting resources towards people, groups and areas with greatest health and social need and reducing inequalities; listens to the views of service users, carers, the public and stakeholder organisations and takes their views into account in planning and developing services; continuously improves the quality of health, social services and public safety; stimulates and supports the formation of partnerships across all sectors to promote and improve health and social well-being. 6

8 1.5 Chapter 2 outlines the present law and policy. Chapter 3 summarises available information on current provision, costs and patterns of uptake. It also describes the present commissioning arrangements and eligibility criteria for accessing transport services. Chapter 4 sets the wider policy context and identifies drivers for change. 1.6 Chapter 5 outlines the policy objectives and the principles, which should underpin them. It takes into account the lessons of good practice here and elsewhere. Chapter 6 identifies a number of important strategic issues and possible options for change, on which we would particularly welcome views. It includes an assessment of future demands and associated costs. Chapter 7 deals with eligibility criteria for access to transport services, and makes proposals for a revised eligibility criteria framework. 1.7 Chapter 8 refers to the statutory equality duty and invites views and any evidence that might suggest possible adverse impacts of this strategy on equality. 1.8 For convenience, we have repeated at the end of the paper the proposals and specific issues on which we would particularly welcome your views. 1.9 This paper has been produced by the Department of Health, Social Services and Public Safety, with the help and advice of a joint Steering Group drawn from Boards, Trusts and voluntary organisations. The remit and membership of the Group are attached at Annexe 1. The Department is grateful to the members of the Group, and to others who have contributed to this work Comments on the proposals, responses to the questions and general observations can be sent to the address shown below. Unless otherwise requested, it will be assumed that responses may be used and published This paper is being widely circulated. Additional copies, and accessible versions in large print, Braille and audiotape may be obtained by contacting the address, address or telephone number below. It is also available on the Department s website at The closing date for responses is Monday 6 June Contact details: Gary McClurg Public Safety Directorate Annexe 4 Castle Buildings Stormont Belfast BT4 3SF publicsafetyunit@dhsspsni.gov.uk 7

9 Chapter 2: Present Law and Policy 2.1 This chapter summarises current legislation and policy guidance on transport services for non-emergency health services patients and social services clients. To avoid repetition of this lengthy description the services will be referred to collectively as transport services, and those who use the services as users hereafter except where it is necessary to distinguish between health service patients and social services clients 1. Definitions Non-emergency patient transport and social services transport provide access to public services, promoting social inclusion. Their users include some of the most vulnerable people in society. Non-emergency patient transport helps to increase the efficiency with which the NHS uses resources by helping to ensure that people attend appointments. Effective transport can also help to prevent delays in patient discharges, thus helping to release beds more quickly for use by other patients. Social services transport helps to bring people together for social and other activities. This helps to combat low morale and depression, which, if unchecked, can place extra demands on social services and the NHS. Going Places, Audit Commission The health and social services in Northern Ireland offer non-emergency transport services to patients for a wide variety of purposes. These include hospital admissions for inpatient treatment; attendance for treatments such as renal dialysis, chemotherapy, radiotherapy and physiotherapy; outpatient attendances at clinics and day hospitals; appointments for x-rays and other tests; day surgery; and hospital discharges. This transport is provided on the basis that the patient has a medical need as defined by a medical practitioner (see para. 2.8). 2.3 Social services, based on the need for a care package, assessed by a social worker, offer clients transport for a wide variety of purposes. These include travel to and from day care facilities; family contact visits; community clinics, mental health and community dental appointments; vocational and independence promoting programmes; social and therapeutic activities; and home from hospital visits for people with mental health problems or with learning difficulties. Social services transport is also used to support voluntary groups and for a range of therapeutic social activities in the evenings and at weekends. 1 See Glossary 8

10 Legislation 2.4 The Department has a statutory duty 2 to make arrangements, to such an extent as it considers necessary, for providing or securing the provision of ambulances and other means of transport for the conveyance of persons suffering from illness, expectant or nursing mothers or others persons for whom such transport is reasonably required in order to avail themselves of any service under this Order. 2.5 The Department must, therefore, in relation to the latter category of users, make arrangements to provide transport services to such extent as it considers necessary and where it is reasonably required. The Department also has a specific duty 3 to provide such assistance, to such extent as it considers necessary, to social services clients. Furthermore the Department has a specific duty 4 to provide transport to social services facilities for people assessed as having a qualifying disability The Department also has an obligation to determine the terms and conditions on which transport services shall be provided. 2.7 These powers are exercised on behalf of the Department by the four Health and Social Services Boards and 19 Health and Social Services Trusts, including the Northern Ireland Ambulance Service Trust. Although the legislation empowers the Department to set charges for transport, in practice all service users who satisfy the existing eligibility criteria receive free transport. Access Guidance 2.8 In December 1992, the Department issued good practice guidance 6 on transport services. The guidance covered health service patients but not social services clients. This still provides the definitive statement of policy on transport to and from hospital. It states that Non-emergency patient transport services should be provided free of charge to those patients with a medical need defined by a medical practitioner. The guidance makes it clear that the clinical need for treatment does not of itself imply a medical need for transport, and that transport should not be provided free of charge for patients who are able to travel by public or private transport. 2.9 There is no comparable guidance on access to transport services for social services clients. 2 Health and Personal Social Services (Northern Ireland) Order 1972 Article 10 3 Health and Personal Social Services (Northern Ireland) Order 1972 Article 15 4 Chronically Sick and Disabled Persons (Northern Ireland) Act 1978 Section 2(d) 5 Chronically Sick and Disabled Persons (Northern Ireland) Act 1978 Section 1(1) 6 Circular HSS (OP1) 6/92 9

11 2.10 The guidance advises that health service patients with a social rather than medical need for transport may be provided with it, but are expected to pay for it unless they are in receipt of a qualifying Social Security benefit 7. Patient Travelling Expenses 2.11 The Department has a permissive power 8 to provide for the reimbursement of travelling expenses incurred by users of health and social services. This power is exercised under subordinate legislation 9. The regulations provide for reimbursement of travelling expenses for patients attending hospitals or consultant clinics, people accompanying them, and relatives visiting them if they are transferred to a hospital in Great Britain or the Republic of Ireland for treatment. The Department issued guidance on the Hospital Travel Costs Scheme (HTCS) in December To qualify for reimbursement of travel costs, patients must be in receipt of a qualifying Social Security benefit, such as Income Support, Income-based Jobseekers Allowance, and Working Tax Credit. Patients can also qualify if on a low income, the assessment for which is the responsibility of Social Security Offices Further information on the HTCS can be obtained from the Department s Secondary Care Directorate on Mobility Allowances 2.14 Disability Living Allowance (DLA) is a benefit for adults and children with disabilities. It is for people who need help looking after themselves (the care component) and those who find it difficult to walk or get around (the mobility component). The mobility component is paid at either a lower or a higher rate DLA is tax-free, not means tested and non-contributory. It is paid on top of any earnings or other income people have, and it is almost always paid in addition to other Social Security benefits People in receipt of the higher rate mobility component can use their benefit to obtain a car for mobility purposes under the Motability 11 scheme. The car may also be obtained for carers or family members to provide the recipient with transport. 7 Article 3 Health and Medicines (Northern Ireland) Order Health and Personal Social Services (Northern Ireland) Order 1972 Article 45 9 Travelling Expenses and Remission of Charges Regulations (Northern Ireland) Circular HSSE (SCB) 4/96 11 Motability is a charity that provides cars, powered wheelchairs and scooters to disabled people in receipt of qualifying benefits 10

12 2.17 The Social Security Agency (SSA) of the Department for Social Development administers DLA. Further details may be obtained from the SSA Benefit Shop on

13 Chapter 3: Transport Services Today Information base 3.1 The Steering Group asked Trusts to provide a range of information on their transport arrangements for the two years 2001/02 and 2002/03, including: what categories of transport they used; what types of vehicles they owned, leased or hired; how many drivers they employed; how many patients/clients were carried; the number of miles travelled; capital costs, i.e. purchase/lease; revenue costs, including commissioning costs, e.g. other Trusts vehicles, private operators, voluntary and community sectors, taxis, mileage allowances for voluntary drivers etc. 3.2 Trusts were asked to identify costs and patterns of activity by category of transport and by Programme of Care (POC). POCs are categories of health and social care, into which activity and finance data are assigned so as to provide a common management framework. They are used to plan and monitor health and social care service, by allowing performance to be measured, targets set and services managed on a comparative basis. In total there are 9 POCs, as set out in Table 1 below. Table 1 POC 1 POC 2 POC 3 POC 4 POC 5 POC 6 POC 7 POC 8 POC 9 Programmes of Care Acute Services Maternity and Child Health Family and Child Care Elderly Care Mental Health Learning Disability Physical and Sensory Disability Health Promotion and Disease Prevention Primary Health and Adult Community 3.3 The responses received by the Steering Group indicated that Trusts do not collect such information in a consistent format. Information on cost and activity was not always available either by category of transport or by POC. While some Trusts provided comprehensive detail, as requested, others were able only to provide overall costs, but little or no supporting information, such as patterns of usage. 3.4 For the purposes of this analysis, the information that is available is presented by category of Trust as set out in Table 2 below. The Northern Ireland Ambulance Service Trust (NIAS) is not included in the table, as it is a provider, rather than user, of transport services. 12

14 Table 2 Acute Mixed Community Altnagelvin Area Hospital Belfast City Hospital Craigavon Area Hospital Mater Infirmorum Royal Group of Hospitals United Hospitals Armagh & Dungannon Causeway Down Lisburn Green Park Newry & Mourne Sperrin Lakeland Ulster Community & Hospitals Craigavon & Banbridge Foyle Homefirst North & West Belfast South & East Belfast Transport Provision 3.5 The Steering Group examined the existing arrangements for planning and provision of transport services. 3.6 Currently, transport services for non-emergency health service patients are provided mainly by the Northern Ireland Ambulance Service (NIAS) Patient Care Service (PCS). A Volunteer Care Service (VCS), also managed by NIAS, supports the PCS. In a small number of cases NIAS uses private hire taxis for patient transport. 3.7 Acute 12 Trusts use the PCS almost exclusively, but have the flexibility to use a range of other providers to meet local priorities, e.g. the private and voluntary sectors, and taxis. Acute Trusts do not own vehicle fleets for patient transport although a small number of vehicles are maintained for on-site patient transfers. 3.8 Both mixed 13 and community 14 Trusts can provide social services. Most of the transport services are provided by these Trusts own transport fleets, but like acute Trusts they have the flexibility to use other transport providers. 3.9 The Trusts listed in Table 2 use a wide variety of transport services, including: The Northern Ireland Ambulance Service (NIAS) non-emergency Patient Care Service (PCS), supported by the Volunteer Car Service (VCS); Vehicles owned by Trusts; Private ambulances; Transport services provided by voluntary and community organisations; Volunteer Driver Schemes (apart from the NIAS VCS); Taxis Numbers of Trusts vehicles and drivers are set out in Table 3. Acute Trusts have been excluded from this analysis, as they run only a small number of vehicles used for on-site transfers and other duties. 12 Acute indicates that the Trusts provides acute hospital services but not social services 13 Mixed indicates that the Trust provides both acute hospital and community health and social services 14 Community Trusts do not provide any acute hospital services 13

15 Table 3 Sector Vehicles Drivers/ Comments Ambulance Staff Mixed Mixed Trusts own a variety of vehicles used almost exclusively for the transport of patients and clients. These vehicle fleets comprise cars/people carriers, minibuses and larger coaches of varying seat numbers. All include wheelchair-accessible vehicles. Community Community Trusts own a variety of vehicles used exclusively for the transport of patients and clients. As with mixed Trusts, these vehicle fleets comprise cars/people carriers, minibuses and larger coaches of varying seat numbers. All include wheelchairaccessible vehicles. Ambulance Service The NIAS PCS fleet comprises van conversions capable of carrying patients sitting, on wheelchairs and on stretchers. They are manned in a combination of single or double crews with staff trained to provide levels of care appropriate for the user. The VCS service is provided through volunteers using their own cars. An average of 70 voluntary drivers provide the VCS across Northern Ireland. TOTAL Transport Costs 3.11 Trusts were asked for information on capital, revenue and commissioning costs for 2001/02 and 2002/03. Table 4 shows the annual revenue costs averaged over the two years. The figures include transport commissioned from other sources. Table 4 Sector Capital Revenue Comments ( 000 s) ( 000 s) Acute 0 1,230 Largely made up of commissioning from other providers, e.g. private ambulance operators. Mixed 784 5,654 Revenue costs include: staff salaries, insurance; fuel; Community 1,179 6,577 maintenance; and related estates costs and consumables. Ambulance 488 3,620 TOTAL 2,451 17, Capital costs should be treated with caution, as some Trusts were not able to provide figures and the information sought was for a two-year period only, which means that any vehicles purchased outside that period were not included. The true annual capital cost may be greater In addition to the above costs, there is an estimated annual total cost of taxi contracts for Trusts in Northern Ireland of over 2,374, The contracts are negotiated through the Central Services Agency (CSA) Regional Supplies Service (RSS). Trusts were unable to provide details on patterns of taxi usage. It cannot be assumed that all of the costs were exclusively for transport of service users. Other 15 This is the Regional Supplies Service estimate for 2002/03. This figure excluded Newry and Mourne as that Trust, until September 2003, negotiated taxi contacts directly. It now uses RSS. 14

16 reasons for taxi bookings include transporting blood and other urgent medical supplies and transporting hospital staff under special circumstances. Hospital Travel Costs Scheme (HTCS) 3.14 The HTCS makes provision for Trusts to reimburse travel expenses for people in receipt of a qualifying Social Security benefit, or on low income. Costs for 2001/02 and 2002/03, as reported to DHSSPS, are set out in Table 5 below. Table 5 HOSPITAL TRAVEL COSTS SCHEME TRUST 2001/ /03 Altnagelvin Area Hospital 111, ,002 Belfast City Hospital 517, ,916 Craigavon Area Hospital 38,338 37,868 Mater Infirmorum 14,057 17,617 Royal Group of Hospitals 158, ,721 United Hospitals 55,207 61,716 Acute Total 894,971 1,007,840 Armagh & Dungannon 311, ,303 Causeway 17,522 19,503 Down Lisburn 344, ,878 Green Park 50,212 49,655 Newry & Mourne 58,544 42,859 Sperrin Lakeland 70,685 68,623 Ulster Community & Hospitals 83,068 90,257 Mixed Total 935,635 1,026,078 Craigavon & Banbridge 15,808 14,036 Foyle 73,436 72,421 Homefirst 89,587 82,270 North & West Belfast 379, ,660 South & East Belfast 231, ,090 Community Total 789, ,477 TOTAL SPEND 2,620,230 2,914, There are significant variations in take-up across Boards and Trusts, even after allowing for differences in their size and type. These variations need to be researched and explained, in particular the significant spend on hospital travel costs by mixed and community Trusts. Total Costs 3.16 Based on the limited information currently available, the total annual cost of transport services is estimated at 27.5 million. There are however gaps in the information, e.g. not all taxi usage is for patient and client transport and there is a need to examine more closely the costs attributed to the HTCS. The capital value of vehicles would also need to be taken into account. It seems reasonable therefore as 15

17 an indicative guide, for the purposes of this paper, to estimate the annual cost of transport services at approximately 30 million. Patterns of Uptake 3.17 Trusts do not all collect information on user journeys by POC. This makes it impossible, without further research, to provide a meaningful analysis of activity by user group, and from identified trends, to predict future demand and associated costs. Review 3.18 In view of the information gaps identified in this chapter, the Department intends to review transport services management information collected by Boards and Trusts, (including NIAS) covering service provision, cost and patterns of uptake. The Review will assess the adequacy of the information currently collected, and make recommendations on the information that should in future be collected, and made available to the Department, to enable more effective management and monitoring of transport services. Application of guidance on eligibility 3.19 In accordance with current policy guidance 16, non-emergency patient transport services are provided free of charge to patients with a medical need. Although the guidance states patients with a social need may also be provided with transport services, but should be charged unless they receive a qualifying Social Security benefit, or are on low benefit, the Steering Group found no evidence that patients were being assessed as having a social need The Steering Group found some evidence that the guidance is not being applied consistently. Authorisation for transport is often delegated to clerical or administrative staff No guidance has been issued specifically on eligibility to social services transport and the Steering Group found that clients are usually provided with transport as part of their overall care package, which is provided based on an assessment of need The Group found that no Trust currently operates a charging system for users of health or social services transport. The Department has not to date, as permitted under current legislation, set in place a charging policy for transport services. Commissioning Arrangements 3.23 Trusts in the Eastern Board area commission non-emergency Patient Care Services (PCS) transport services directly from NIAS. In the other three Board areas it is the 16 Strategic Objectives and Good Practice Guidance, DHSS

18 Board that commissions PCS transport services from NIAS. Trusts also have the flexibility to commission transport services, appropriate to individuals needs, from a variety of other providers. Operational Issues 3.24 Although the scope and remit of this Draft Strategy does not extend to fleet management and operational arrangements, this section is intended to provide helpful background information In 1987 the Department issued guidance 17 on good transport management. This manual was revised and updated in by the Regional Transport Forum (RTF). The Forum was established and facilitated by the Department, and comprises mainly Trust transport managers The manual outlines minimum standards of best practice in relation to procedures for the management and control of the vehicle fleet. The RTF has developed performance indicators, benchmarking practices, and driver training procedures The Northern Ireland Ambulance Service (NIAS) has its own operational procedures and controls The Department s Health Estates Agency (HEA) is producing a Fleet and Transport Management Controls Assurance Standard, in consultation with the Department and Health and Social Services organisations. In developing the standard HEA will consider the Regional Transport Manual and current NIAS procedures with a view to ensuring consistent practice The Standard aims to incorporate all transport issues to reflect the need for total transport management and encompass the following aspects: the safety of drivers, passengers, staff and others; in procurement, give preference to vehicles with reduced emissions to air, and increased fuel economy where they offer value for money over the whole-life cost of the vehicle/contract; the importance of acceptance checks; good maintenance and repair of any fleet or lease hire vehicles; consideration of decontamination issues; the monitoring and replacement policy of vehicles and their equipment; appropriate driver training to include environmental and safety issues; consideration of mileage allowance rates to encourage smaller engine vehicles/cycling rates etc.; produce Transport Plans and encourage staff to adopt healthy transport choices such as walking and cycling (where this is a realistic option); 17 Circular HSS (PRB2) 2/87, Transport Management in the Health and Personal Social Services 18 Regional Transport Procedures Manual

19 to rationalise car parking needs in discussion with local officials where necessary or appropriate which may include consideration of park and ride schemes; the importance of good access, on-site traffic management systems, provision of signs and egress to the healthcare site; the importance of liaising with public transport co-ordinators, both bus and rail, to provide a viable service to the site; negotiate with suppliers for deliveries to be made outside times of peak congestion; pursue opportunities for sharing vehicles or transport - not only for staff but explore innovative solutions to minimise journeys, i.e. partnership approach; consider journey management and distances covered; the application of risk management and incident reporting procedures to reduce accidents and untoward incidents and improve the safety of all users. 18

20 Chapter 4: Strategic Context and Drivers for Change 4.1 This chapter identifies a number of strategies and policy initiatives, in Northern Ireland and elsewhere, which have potential implications for the development of transport services here. Review of Public Administration 4.2 The Review of Public Administration clearly has implications for the future role and status of Boards and Trusts, including the Northern Ireland Ambulance Service. The final DHSSPS Regional Transport Services Strategy will need to have the flexibility to be implemented in the light of whatever changes are agreed to current organisational arrangements. DHSSPS Strategies 4.3 The Department is developing a new Regional Strategy, which will provide an overarching framework for the development of primary and community care and hospital services. Work on the Strategy has already thrown up several emerging factors which might impact on future demand for transport: A shift from treatment in hospital to outpatient, home, and community settings. Self care and chronic condition management, whereby services will be designed to enable users to take a leading role in managing their own health; Integrated networks of health and social care workers, which will co-ordinate activity across settings, organisations and sectors to ensure that smaller community hospitals and treatment units work closely with larger, more specialised centres; Improvements in information and communications technologies, such as telemedicine; 4.4 The Department published for consultation in June 2004 a new draft primary care strategic framework 19. The document sets out a policy framework that will steer and influence future development and delivery of primary health and social care services. Amongst the key attributes identified for primary care is the development of integrated multi-disciplinary primary care centres, with enhanced communication systems linking primary care, community care and hospital sites. This could mean fewer people having to travel long distances to hospitals for diagnosis, treatment or care. 4.5 A new General Medical Services (GMS) contract, governing the provision of services by General Practitioners, came into effect on 1 April Some elements of the contract might have an impact on future transport requirements. The new 19 Caring For People Beyond Tomorrow A Strategic Framework for the development of Primary Health and Social Care for Individuals, Families and Communities in Northern Ireland DHSSPS June

21 contract will allow Health and Social Services Boards to commission enhanced services from the primary care system. These include minor surgery and certain specialised services, which opens up the possibility that more services may be delivered closer to patients homes. The full implications for transport of the new GMS contract cannot be identified with certainty at this stage. However, its impact will need to be carefully monitored as patterns evolve. 4.6 In 1998, the Department commissioned a Strategic Review 20 of the Northern Ireland Ambulance Service (NIAS), which was published in February The Department subsequently published in 2001 its response to the Review in the Strategic Review Implementation Plan. The Implementation Plan proposed a phased programme of modernisation, and concluded that the non-emergency Patient Care Service (PCS) should remain as an integral part of the regional Ambulance Service though separated for operational and planning purposes. 4.7 The Department has since made substantial additional financial investments in PCS vehicles and crews. Most significantly, NIAS will be able to access up to 29 million in the coming years through the Government s Strategic Investment Programme. This will enable it to press ahead with the programme of modernisation proposed in the Implementation Plan. Actions already underway include upgrading communications and control systems; preparations for developing and upgrading an ambulance estate strategy; and, introducing a systematic fleet replacement programme. Transport Strategies 4.8 The Regional Transportation Strategy , published by the Department for Regional Development (DRD) provides a framework for the future planning, funding and delivery of land-based transportation throughout Northern Ireland. It was produced to support the Regional Development Strategy (RDS) for Northern Ireland The RDS presented a vision for transportation in Northern Ireland, which is to have a modern, sustainable, safe transportation system which benefits society, the economy, and the environment and which actively contributes to social inclusion and everyone s quality of life. One of the aims of the Strategy is to improve access to healthcare establishments. 4.9 The RTS acknowledged that many people in Northern Ireland are unable to use, or make use of, the transportation system because of the barriers they face. For these reasons, the RTS committed DRD to developing an Accessible Transport Strategy (ATS). DRD published the Draft Accessible Transport Strategy in October The ATS vision is To have as accessible transport system that enables older people and people with disabilities to participate more fully in society, enjoy greater independence and experience a better quality of life. 20 Mapping the Road to Change A Strategic Review of the Northern Ireland Ambulance Service, DHSSPS February

22 4.10 In this context DRD wants to develop an integrated, fully accessible public transport network which will enable older people and people with disabilities to travel by public, private and community transport services in safety and in comfort and move easily between these modes. In doing so DRD wishes to exploit opportunities for better co-ordination of services and utilisation of accessible transport resources that exist in the public, private, community and statutory transport sectors to maximise opportunities to develop accessible transport chains and maintain consistent standards. Audit Commission 4.11 In November 2001 the Audit Commission published a report 21 on the transport arrangements made by local authorities and health bodies in England and Wales to take people to education, social services and hospitals The report confirmed the value of health and social services transport, in helping overcome obstacles to access faced by service users, improving attendance for hospital appointments, helping to reduce bed blocking, and bring people together for social activities. The Commission found a wide variety of arrangements for managing, providing and permitting access to transport services The report made recommendations for action by Government, transport providers, and commissioning bodies. They included measures for: improving patient focus; improving the status of transport services; reviewing funding levels; developing partnership working; improving efficiency; strengthening performance management, benchmarking and monitoring arrangements Key recommendations for Government included: obtaining and responding to users views; clarifying the role of and entitlement for transport services; helping to improve how transport services are commissioned; encouraging co-operation and partnership working This Department has adopted the Audit Commission report and the two handbooks linked with it as examples of Value for Money (VFM) initiatives, and commended the guidance they contain to health and social services managers dealing with transport issues. 21 Going Places taking people to and from education, social services and healthcare, Audit Commission

23 Social Exclusion 4.16 In February 2003 the Social Exclusion Unit (SEU), based in the Cabinet Office, published a report 22 on transport and social exclusion. The report asks key questions about accessibility: can people get to key services at reasonable cost, in reasonable time and with reasonable ease? does transport exist between the people and the service? do people know about the transport, trust its reliability and feel safe using it? are people physically and financially able to access the transport? are the services and activities within a reasonable distance? 4.17 The report stressed the importance of locating and delivering key activities and services in ways that help people reach them. It made a number of recommendations regarding access to healthcare. The Department of Health (DoH) in England is currently taking these forward by: carrying out a review of eligibility for free patient transport 23 ; ensuring that support is available for transport commissioners; examining how the Hospital Travel Costs Scheme (HTCS) might be better integrated with local transport services The Office of the First Minister and Deputy First Minister (OFMDFM) issued a Consultation Paper 24 setting out proposals for the Government s high level policy for tackling poverty and social exclusion. The current statement of policy is defined in New Targeting Social Need (New TSN), which was launched in 1998, to replace Targeting Social Need, first launched in The Consultation Paper recognises that New TSN has been successfully mainstreamed into the planning and implementation of Government programmes and the budgeting process. It proposes that New TSN evolves into a wider antipoverty strategy, to deal with a range of issues linked to poverty and social exclusion, particularly financial exclusion DHSSPS is represented on the National Patient Transport Modernisation Group, a collaborative undertaking, facilitated by the Department of Health, amongst providers, commissioners, and non-profit organisations, which is seeking to improve transport services in response to the SEU Report. 22 Making the Connections Final Report on Transport and Social Exclusion, Social Exclusion Unit It should be noted that social services are not covered 24 towards an anti-poverty strategy, New TSN - the way forward, OFMDFM April

24 Scottish Ambulance Service 4.21 The Scottish Ambulance Service in February 2003 published a Strategic Options Paper (SOP) setting out possible options for the development of its Non-Emergency Service The SOP proposed three strategic objectives: to underpin a fully prioritised accident and emergency service, undertaking all non-emergency clinical need; to develop services which are tailored to patient needs and meet national standards; and, to co-ordinate other agencies to provide local transport solutions To meet these objectives the SOP identified three strategic options for change which if implemented would, to varying degrees, realise the vision for the NES. The options were designated provisionally the minimum, medium, and maximum options. They differ with respect to their quality standards, the maximum option being subject to optimum quality standards The main differentiating factor between the options is performance in terms of punctuality for appointment, being the percentage of journeys completed less than 30 minutes prior to appointment. Current punctuality performance was stated as 44%. Minimum improvement would be 60%, Medium 75% and Maximum 90% All three options are based on continuing with the existing mixed range of providers: direct in-house provision; the voluntary sector; and, the private sector. Both wholesale outsourcing to the private sector and switching to exclusively inhouse provision were ruled out mainly due to incompatibility with Government policy, which favours a mixed mode of service delivery whereby publicly funded services mobilise the resources of the voluntary and private sectors, to complement directly provided services In addition to policy considerations, direct in-house provision was ruled out because of resource implications, i.e. it would require substantial investment to enable the existing service to meet all needs without engaging other agencies. It was also acknowledged that it might in certain circumstances be more efficient to utilise other forms of transport, such as taxis, rather than a non-emergency ambulance crewed by professional ambulance staff Wholesale outsourcing was considered to be inappropriate because there was no private sector player currently capable of providing the volume of transport services required. More importantly, essential links to emergency ambulance services would be lost. 23

25 4.28 During the service has been engaging with stakeholders and planning the redevelopment programme in detail. The plan is to commence implementation in Various options for implementation are being considered, including implementing the minimum option and migrating in stages to maximum. It is anticipated that full implementation could take between 5 and 7 years. Common Themes 4.29 There are common themes underpinning these strategies and initiatives which will influence the development of the DHSSPS Regional Transport Services Strategy, including: changes to organisational structures; increased focus on primary and community care; a shift from hospital-based care to the provision of care at home, and in primary and community care settings; patient and client-focused services; development of quality standards, clinical and social care governance arrangements, and controls assurance standards; development of a standard eligibility framework; and increased focus on partnership working. 24

26 Chapter 5: Objectives and Principles 5.1 This chapter outlines the policy objectives and underpinning principles for the future planning and provision of transport services. 5.2 One of the purposes of transport services is to support users and hospitals by ensuring patients can attend appointments in comfort and on time. This helps reduce the number of appointments missed due to a lack of appropriate transport. Over a 12-month period 1.4 million people in England missed, turned down or chose not to seek medical help because of transport problems Greater efficiencies can be achieved through improving the information about the needs of patients eligible to use transport services. Significant changes in personal circumstances can, if not updated, lead to the inappropriate deployment of vehicles, wasted journeys, patient complaints and wasted resources. In an average acute hospital this could be as many as 850 journeys a year at an estimated 10 per person (up to 2% of all Patient Care Service, i.e. non-emergency, journeys). 5.4 Social services clients represent some of the most vulnerable members of our community, and many of them need transport services to take advantage of the support available to them, for example, in day centres. 5.5 We need to make sure that transport services, where needed, provide people, where eligible, with appropriate and timely transport to and from their health or social services facility. 5.6 In particular, we need to make sure that transport services are planned, booked and provided to ensure that people receive the most appropriate and effective service possible. To this end we will explore options to set in place standard booking arrangements, making the best use of information systems for the prioritisation and management of transportation resources. 5.7 The Steering Group identified the following as the broad policy objectives for the future provision of transport services. Assessment: To ensure that those who refer people to transport services undertake an assessment of the transport needs of each individual so as to ensure everyone receives the transport service most appropriate to their needs. Assessments should be reviewed regularly to take account of changes in the individuals condition and transport needs. Safety: To ensure that all transport services are provided in accordance with health and safety regulations, and that staff are appropriately selected and trained about the needs of service users. 25 Making the Connections: Final Report on Transport and Social Exclusion. Social Exclusion Unit February