Transport for health and social care

Prepared for the Auditor General for Scotland and the Accounts Commission
August 2011

Auditor General for Scotland
The Auditor General for Scotland is the Parliament’s watchdog for helping to ensure propriety and value for money in the spending of public funds. 
He is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management. 
He is independent and not subject to the control of any member of the Scottish Government or the Parliament. 
The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General: 
•	directorates of the Scottish Government
•	government agencies, eg the Scottish Prison Service, Historic Scotland 
•	NHS bodies 
•	further education colleges 
•	Scottish Water 
•	NDPBs and others, eg Scottish Enterprise. 

The Accounts Commission
The Accounts Commission is a statutory, independent body which, through the audit process, requests local authorities in Scotland to achieve the highest standards of financial stewardship and the economic, efficient and effective use of their resources. The Commission has four main responsibilities:
•	securing the external audit, including the audit of Best Value and Community Planning
•	following up issues of concern identified through the audit, to ensure satisfactory resolutions
•	carrying out national performance studies to improve economy, efficiency and effectiveness in local government
•	issuing an annual direction to local authorities which sets out the range of performance information they are required to publish.

The Commission secures the audit of 32 councils and 45 joint boards and committees (including police and fire and rescue services).
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Summary
Good transport services can help the whole health and social care system to work efficiently. 
Background
1. Older people, those with long-term health or social care needs and people who live in remote and rural areas may need support to get to a hospital appointment or to access services such as their local day centre. This includes help with paying for transport or getting to their appointment in transport provided by the ambulance service, councils, NHS boards or the voluntary sector. If transport is not well planned it can result in unnecessary journeys, missed or late appointments, people staying in hospital longer than they need to and reliance on unplanned options such as taxis.
2. There is limited national data on the number of people receiving help with transport to health and social care services. In 2009/10, there were 4.6 million outpatient attendances in Scotland and 1.6 million people were discharged from hospital.1 At 31 March 2007, there were 23,011 people attending day centres in Scotland.2 Many of these people need help getting to and from these services but this information is not separately recorded.
3. For the purpose of this audit, our definition of transport for health and social care is transport arranged by the ambulance service, NHS boards and councils to take people to and from health appointments and social care services such as day centres. Our definition excludes public transport such as regular bus services, regular school buses and general community transport to support independent living, such as taking people shopping.3 Our audit does not cover emergency healthcare transport. 
4. Transport for health and social care generally covers three main groups of people:
•	People with a medical need who are eligible to access the Patient Transport Service (PTS) provided by the Scottish Ambulance Service.
•	People who are not eligible for PTS but need help with transport including people who are on low incomes, those who live in remote and rural areas and those who have ongoing health or social care needs. This group is the main focus of our audit.
•	People who have their own means of accessing services, for example those who have their own or family transport or can easily access public transport.
About the audit 
5. The overall aim of our audit was to assess the efficiency and effectiveness of transport for health and social care in Scotland. We assessed how well agencies work together to plan and deliver transport for health and social care to meet local needs. Where possible we have identified potential savings and good practice examples.
6. We reviewed key documents including relevant policies, financial and performance information about the ambulance service, and regional transport strategies. We also carried out a data survey of all councils and NHS boards, collecting information on activity, costs and joint working.4 However, councils and NHS boards were only able to supply limited data on activity and costs, making it difficult to fully assess the scope for efficiency savings. Although we have not reviewed all transport for health and social care (for example, costs of transport for staff, records and samples), the recommendations about potential efficiencies in this report also have wider implications for these services.
7. We interviewed staff in the Scottish Government, Transport Scotland, Regional Transport Partnerships, councils, NHS boards, the Scottish Ambulance Service, and the Community Transport Association.5 We also met with the Association of Transport Coordinating Officers (ATCO), user representatives including Mobility Access Committee Scotland (MACS) and community transport providers in the voluntary sector.6, 7 We have published a supplementary report on the views of community transport providers in the voluntary sector. This is available on our website: www.audit-scotland.gov.uk. 
8. Appendix 1 provides further details on our methodology and Appendix 2 outlines the membership of our Project Advisory Group. We have highlighted specific issues for partners to consider, which will also help to improve the efficiency and effectiveness of these services (Appendix 3). This report is structured into three main parts:
•	setting the scene (Part 1)
•	spending and improving efficiency (Part 2)
•	working together to meet need (Part 3).
Key messages 	
•	Transport services for health and social care are fragmented and there is a lack of leadership, ownership and monitoring of the services provided. The Scottish Government, Regional Transport Partnerships, councils, NHS boards and the ambulance service are not working together effectively to deliver transport for health and social care or making best use of available resources. 
•	From the limited information available we have identified that over £93 million was spent in 2009/10 on providing transport to health and social care services. This is a considerable underestimate as data on costs, activity and quality is poor. The public sector will find it difficult to make efficient and effective use of available resources without this basic information.
•	Joint working across the public sector and with voluntary and private providers is crucial for the successful and sustainable development of transport for health and social care. Improved joint planning could lead to more efficient services. There is scope to save money by better planning and management of transport for health and social care without affecting quality. Pilot projects show scope for efficiencies but these lessons have not been applied across Scotland.
•	Reducing or removing funding from transport services can have a significant impact on people on low incomes, older people and people with ongoing health and social care needs. But the potential effect of changes to services is not often assessed or monitored and alternative provision is not put in place. The public sector needs better information on individual needs and on the quality of the transport services they provide.
Key recommendations 
The short-life working group on healthcare transport led by the Scottish Government should:
•	take account of the findings and recommendations of this report in its work.
The Scottish Government and partners should:
•	work together to clarify responsibilities for planning and delivering transport for health and social care and how these link together.
Partners (councils, NHS boards, Regional Transport Partnerships and the ambulance service) should:
•	collect routine and accurate data on the activity, cost (including unit costs) and quality of services they provide and routinely benchmark performance and costs to ensure resources are used efficiently
•	assess the impact of proposed service changes on users and other providers of transport
•	ensure that staff have up-to-date information about all transport options in their area and provide better information to the public about available transport options, eligibility criteria and charges 
•	integrate or share services where this represents more efficient use of resources and better services for users, including considering an integrated scheduling system
•	ensure that transport for health and social care services is based on an assessment of need and that it is regularly monitored and evaluated to ensure value for money 
•	use the Audit Scotland checklist detailed in Appendix 3 of the full report to help improve planning, delivery and impact of transport for health and social care through a joined-up, consistent approach.

1	Inpatient and Outpatient Activity – by NHS Board of Treatment, Information Services Division (ISD) Scotland, December 2010.
2	Day Care Services Scotland, Scottish Government, 2007 (web-only publication http://www.scotland.gov.uk/Publications/2007/11/27110719/0).  This is the latest available national data. Information based on responses from 531 day care services in Scotland, which were registered with the  Scottish Commission for the Regulation of Care (the Care Commission).
3	Community transport means any transport provided by the voluntary sector but not necessarily using volunteers, for example, local dial-a-bus schemes or car schemes.
4	Throughout this report where we say NHS boards, we mean the 14 territorial NHS boards. When we mean the Scottish Ambulance Service, we refer to it directly.
5	The Community Transport Association is the national representative body of voluntary sector transport operators.
6	The Association of Transport Coordinating Officers (ATCO) brings together council officers involved in transport planning. 
7	Mobility Access Committee Scotland (MACS) was established by Scottish ministers under the Mobility and Access Committee for Scotland Regulations Order 2002. It is responsible for advising Scottish ministers on the transport needs of people with disabilities in Scotland.

Part 1. Setting the scene
A number of organisations are involved in planning and delivering transport for health and social care. 

Transport is an important part of ensuring health and social care services work efficiently
9. The availability of transport is an essential part of making health and social care services work efficiently. Transport is often the first part of a person’s contact with health and social care services and if this is poor, difficult or stressful, their experience can be undermined. Well-organised transport can have a big impact on people’s lives. As well as helping people get to the services they  need, transport can also enhance people’s independence. 
10. Considering transport needs when planning and delivering services can help make services more efficient by getting people to the right place at the right time. This can contribute to fewer cancelled appointments, less disruption to services as people arrive on time for their appointment, shorter journeys and people getting the most out of the care and support being provided for them. Organisations that arrange or provide transport services to and from health and social care services need to work together to make best use of available resources. 
11. Using public transport to get to health appointments or social care provision is not an option for some people. This may be because it is too expensive, it is only available at times which do not suit their needs or they may not be able to access it because of a physical or mental health problem and need door-to-door transport. In some areas, there is no public transport provision at all. This affects people in urban as well as remote and rural areas. 
12. In Scotland, 60 per cent of households with a net income of up to £10,000 do not have access to a car, compared to a national average of 31 per cent and only two per cent of households with an annual net income of over £40,000.8 Forty-one per cent of Scottish households in large urban areas do not have access to a car compared to 15 per cent of households in remote and rural areas.9 In the UK, nearly two-thirds of people claiming income support or jobseeker’s allowance do not have access to a car or have a driving licence.10 People with mobility difficulties are more than twice as likely as those without to live in a household with no car.11
13. Thirteen per cent of older people living in rural areas report poor access to a range of basic services, including GPs, dentists and hospitals. Those on low income and those aged over 80 are significantly more likely to report poor access.12 Two-thirds of public transport journeys are made by bus, and for many people buses are the only way they can travel to a health or social care appointment.13 In many rural areas, although bus services are often less frequent, there are rarely any alternative transport options for people who are not mobile or do not have access to a car. 
A number of organisations are involved in planning and delivering transport for health and social care
14. Transport for health and social care is provided by a number of public, voluntary and private sector bodies (Exhibit 1). Services are either provided directly by the ambulance service, councils and NHS boards or commissioned from voluntary and private sector providers (Exhibit 2). The transport available ranges from specialised transport for people with a medical need to community buses and private taxis. 

Exhibit 2
Summary of the public sector role in delivering transport for health and social care services
Public sector bodies provide a range of transport for health and social care.

	Background	Delivery	
Regional Transport Partnerships (RTPs)	The Transport (Scotland) Act 2005 established seven Regional Transport Partnerships (RTPs).1 RTPs are independent bodies which work like joint partnership boards, bringing councils and other stakeholders together to take a strategic approach to all transport in each region of Scotland.2 Transport Scotland, the national transport agency for Scotland, is responsible for liaising with RTPs, including monitoring of funding. 	There are two types of RTPs in operation – most only have a strategic remit, but three RTPs also deliver services.3, 4 Each RTP has a statutory duty to prepare a regional transport strategy to address the transport needs of people in the area, including health and social care transport needs. RTPs have a broad remit and transport for health and social care is only a part of this. Strathclyde Partnership for Transport (SPT) has developed differently to other RTPs. SPT received a capital grant of £25 million from the Scottish Government in 2009/10 and covers more councils than other RTPs.5	
Councils	Councils provide transport to take people to social care services, such as day centres, and transport to schools, for example for pupils with special educational needs. They may also provide transport such as dial-a-ride services for people who cannot access regular public transport.6 	All 32 councils operate their own fleet, 28 commission services from the private sector and 19 have contracts or service level agreements with the voluntary sector for health and social care transport. 	
Scottish Ambulance Service 	The ambulance service has a statutory duty to provide transport for people with a medical need to get to and from hospital. This service is known as the Patient Transport Service (PTS). Only patients with a medical need are eligible to access the PTS, for example if their condition needs to be monitored or they are not mobile enough to travel any other way.	The PTS undertakes 1.5 million journeys to and from NHS appointments each year. There are 601 patient transport vehicles, including ambulances, specialist vehicles and cars based throughout Scotland. Specially trained ambulance care assistants and volunteer drivers deliver the service.	
NHS boards	NHS boards provide transport for healthcare, for example for people who are not eligible for the PTS or when a patient is not able to get to their appointment or to get home from hospital.	Four NHS boards use owned or leased vehicles, 14 commission services from the private sector such as taxi companies, seven contract with the voluntary sector and seven have volunteer drivers. 	

Notes: 
1. The seven RTPs are Highlands and Islands Transport Partnership (HITRANS), North-East of Scotland Transport Partnership (Nestrans), Shetland Transport Partnership (ZetTrans), South-East of Scotland Transport Partnership (SESTRANS), South-West of Scotland Transport Partnership (SWESTRANS), Strathclyde Partnership for Transport (SPT) and Tayside and Central Scotland Transport Partnership (TACTRAN). 
2.  RTPs provide copies of their business plans and annual report to Scottish ministers, though there is no formal approval requirement.
3.  The Transport (Scotland) Act 2005 made provision for three different models of RTPs but only two are in use (types one and three). Type one is a strategic model and type three is a strategic and service delivery model. The type two model would give a Regional Transport Partnership limited authority to deliver transport services for specific reasons identified in its regional transport strategy, but this model has never been used.
4.  Strathclyde Partnership for Transport (SPT), Shetland Transport Partnership (ZetTrans), and South-West of Scotland Transport Partnership (SWESTRANS) deliver services.
5.  The councils in the SPT area are Argyll and Bute, East Ayrshire, East Dunbartonshire, East Renfrewshire, Glasgow City, Inverclyde, North Ayrshire, North Lanarkshire, Renfrewshire, South Ayrshire, South Lanarkshire and West Dunbartonshire.
6.  Destinations and journey purposes on these services vary according to the user’s needs, but may include trips to health and social care services.

Source: Audit Scotland, 2011

The voluntary sector has an important role in providing transport
15. The voluntary sector is a significant provider of community transport in many areas of Scotland. Community transport organisations range from small volunteer driver car schemes, to large social enterprises which compete with the private sector to win contracts from councils and NHS boards. The availability of different types of community transport varies across Scotland. The Community Transport Association estimates that around 100,000 people use community transport in Scotland and a survey conducted in July 2007 indicated that community transport provided 2.6 million passenger journeys in the previous year. This includes all community transport journeys, not exclusively health and social care related journeys.14 In areas where public transport services are limited or not available, voluntary sector providers often provide a vital service which enables people who are not able to use or access public transport and are not eligible for PTS to get to their healthcare appointment or social care service. 
There are some significant challenges ahead
Financial pressures
16. Given current financial pressures there is a risk that public bodies will reduce services which they do not have a statutory duty to provide. This makes it more important that organisations work together to make the best use of transport resources in the local area and ensure that services are available for everyone who needs them. This is particularly important for transport for health and social care, as services are fragmented across a number of bodies and there is a risk that people are left without support. For example, in some areas the local community may need a bus service but the service would not be commercially viable. The local council may provide this bus service but it is not a statutory duty for it to do so. 
17. Research shows that people who live in rural areas can spend between 20 and 30 per cent more on transport (including motoring costs, public transport and taxis) than those living in urban areas, for example because of distance travelled, specialist support needed or not being able to use public transport.15 There is a risk that these people will need to pay more for their transport as councils reduce the amount they spend on community transport schemes. 
18. Fuel costs are increasing and this is having an impact on services. The Local Government Association reports that councils in England have had to spend an additional £20 million on fuel in the last financial year.16 Increasing fuel prices are a pressure for both service providers and users, particularly in more remote and rural areas and for people who use their own vehicle to get to regular health and social care appointments.
Changing policy context and rising demand
19. Scottish Government health and social care policy over the last decade has focused on providing services nearer to people’s homes and a move to services which are tailored to individual needs. These changes have implications for the way people access services and the type of transport they need. The shift to caring and supporting people in the community may increase the number of people who need help with transport, for example to get to day centres or to attend a hospital appointment.
20. Across Great Britain, 16 per cent of people aged 70 and over report difficulty with travel to a doctor or hospital.17 The number of older people in Scotland is projected to rise by 12 per cent between 2010 and 2015 (from 881,000 in 2010 to 991,000 in 2015), with an 18 per cent increase in the number of people aged 85 and over (from 106,000 to 125,000). By 2031, the number of people aged over 50 is projected to rise by 28 per cent and the number aged over 75 is projected to increase by 76 per cent.18 This is likely to have a significant effect on the demand for transport for health and social care and highlights the need for effective joint working among organisations involved in planning and delivering services. It has not been possible to project future levels of demand due to a lack of information about the number of people who need help with transport for health and social care.
8	Household Transport in 2009, Scottish Household Survey, Scottish Government, 2010.
9	Ibid.
10	Transport, social equality and welfare to work, Campaign for Better Transport and Citizens Advice Bureau, October 2010.
11	National Travel Survey 2009, Department for Transport, 2010. 
12	Building a society for all ages, HM Government, July 2009.
13	Public Transport Statistics Bulletin GB: 2009 Edition, Department for Transport, 2009.
14	Consultation on Scotland-wide Free Bus Travel Scheme for Older and Disabled People: Three Year Review – Response to the Scottish Government Transport Directorate, Community Transport Association (Scotland), 2008.
15	The Forgotten Age: Understanding poverty and exclusion in older life, The Centre for Social Justice, 2010.
16	Media release, Local Government Association, 7 March 2011. This includes all fuel, not only fuel used for transport for health and social care journeys. No equivalent figure is available for Scotland.
17	National Travel Survey 2009, Department for Transport, 2010.
18	2008-based National Population Projections, Office of National Statistics, 2009.

Part 2. Spending and improving efficiency 
There is scope to make more efficient use of existing resources.
Key messages
•	In 2009/10, over £93 million was spent on providing transport to help people access health and social care services. This is a significant underestimate as not all agencies were able to supply this information. The public sector will find it difficult to make efficient and effective use of available resources without basic information about cost, activity and quality of services.
•	Spending on transport for health and social care is fragmented across several different organisations. Funding arrangements are complex which makes it difficult to plan and deliver services in a joined-up way. The voluntary sector provides vital transport services but the risk of reductions to their funding and the impact this may have on their capacity is not being properly assessed by councils and NHS boards.
•	Spending on transport for health and social care varies across Scotland. The ambulance service and some councils and NHS boards have some information on activity, cost and impact. Because this information is not collected on a consistent basis it is not possible to compare the cost-effectiveness of different services.
•	There is scope to save money by improving how transport for health and social care is managed, including the potential for sharing resources. Pilot projects show that there is scope for efficiencies but these lessons have not been applied across Scotland. 
At least £93 million was spent on transport in 2009/10 but cost information is poor
21. A number of organisations spend money on providing transport for health and social care. Funding for these services can come from a range of sources including councils and NHS boards, and specific funding from central government schemes. 
22. From the information available we have identified that the public sector spent at least £93 million on transport for health and social care in 2009/1019 (Exhibit 3). However, this is likely to be a significant underestimate since the quality of data available from NHS boards and councils is poor. Not all councils and NHS boards were able to supply us with basic financial information, for example how much they spend on staff, vehicles and maintenance. There is more detailed information on the costs of the PTS run by the Scottish Ambulance Service, including information on the costs of staffing and fleet.
23. Understanding activity and costs is essential to making informed decisions about how resources are allocated, to identify efficiency savings and deliver better services for users. NHS boards and councils cannot specify how much they spent on transport for health and social care as transport costs are often part of service budgets and not separately identified. For example, an NHS board may be able to provide an overall figure for spend on taxis, but this may include costs of staff transport, and transporting patient notes and specimens. 
Regional Transport Partnerships
24. Regional Transport Partnerships (RTPs) receive funding from the Scottish Government, their constituent councils, Europe and other partners. RTPs spent a total of £85 million in 2009/10, but it is not possible to identify how much was received for or spent on health and social care transport. Prior to 2007, a capital grant was paid directly to all RTPs but Strathclyde Partnership for Transport is currently the only RTP which continues to receive this. Since 2007, this grant is paid to councils as part of their block grant, and not all councils pass this money on to their RTP. All councils have to contribute to the revenue costs of running RTPs.
Ambulance service
25. The ambulance service spent £201 million in 2009/10.20 This money is not allocated as separate funding for emergency transport and the PTS, and the ambulance service decides how much to allocate to each service. In 2009/10, the total cost of delivering the PTS was just over £34 million.21 This equates to an average of £20 per patient journey. The cost of providing the PTS is more expensive in the north of Scotland – in 2009/10, the cost per patient journey ranged from £14 in the East Central division to £36 in the North division.22, 23 The ambulance service also received additional income of £1 million from NHS boards in 2009/10, of which £552,000 related to service developments or changes within NHS boards. It is not possible to identify how much of this relates to the PTS. If the NHS board requires more journeys than planned, for example as a result of significant change to services such as the introduction of a specialist clinic, the ambulance service may charge it a fee. The ambulance service has not been able to provide information on how much it charged each NHS board for additional journeys in 2009/10.
NHS boards
26. In 2009/10, NHS boards spent over £4.5 million on transport for patients. This represents 0.05 per cent of their total operating costs in 2009/10. This includes reimbursement of £2.5 million for the Healthcare Travel Costs Scheme (paragraph 31). In addition, NHS boards claimed £9.2 million from the Highlands and Islands Patient Travel Reimbursement Scheme (HITS) over the same period (paragraph 29). Although transport represents a small percentage of overall NHS funding, there is scope for efficiency savings. 
Councils
27. From the information available we have identified that councils spent around £45.2 million on transport for health and social care in 2009/10, but this is likely to be a significant underestimate. It is difficult to determine actual spend on these services as they are often not centrally coordinated, funding is not ring-fenced and these costs are not necessarily separately identified in larger service budgets. 
28. The amount of money spent on transport for health and social care varies across Scotland. Poor-quality data, along with differences in how services are organised, makes it difficult to determine the reasons for such variation in costs (Exhibit 4). 
Exhibit 4
Spend on transport for health and social care by public sector organisations
Spend on transport for health and social care varies across Scotland but most expenditure is by councils.

Ambulance division	NHS board	Council	Total costs (£000)	
East Central division			6,419	
	NHS Fife		258	
		Fife Council	1,441*	
	NHS Forth Valley		63*	
		Clackmannanshire Council	1,048*	
		Falkirk Council	234*	
		Stirling Council	129*	
	NHS Tayside		438*	
		Angus Council	INA 	
		Dundee City Council	544*	
		Perth and Kinross Council	532*	
North division			6,590 	
	NHS Grampian		292*	
		Aberdeen City Council	1,526*	
		Aberdeenshire Council	1,905*	
		Moray Council	INA 	
	NHS Highland		2,706*	
		Argyll and Bute Council	418*	
		Highland Council	INA	
	NHS Orkney		1,789*	
		Orkney Islands Council	122*	
	NHS Shetland		2,482*	
		Shetland Islands Council	INA 	
	NHS Western Isles		2,655*	
		Comhairle nan Eilean Siar	368*	
South East division			5,214 	
	NHS Borders		531*	
		Scottish Borders Council	886*	
	NHS Lothian		378*	
		City of Edinburgh Council	5,487 	
		East Lothian Council	792*	
		Midlothian Council	591*	
		West Lothian Council	406*	
South West division			7,596	
	NHS Ayrshire and Arran		420	
		East Ayrshire Council	1,137*	
		North Ayrshire Council	228*	
		South Ayrshire Council	1,317 	
	NHS Dumfries and Galloway		280*	
		Dumfries and Galloway Council	367*	
West Central division			8,329	
	NHS Greater Glasgow and Clyde	1,175*	
		East Dunbartonshire Council	1,217*	
		East Renfrewshire Council	750 	
		Glasgow City Council	10,021*	
		Inverclyde Council	696*	
		Renfrewshire Council	4,881*	
		West Dunbartonshire Council	1,242*	
	NHS Lanarkshire		18**	
		North Lanarkshire Council	1,000*	
		South Lanarkshire Council	5,877*	
	Golden Jubilee National Hospital	270	
Total ambulance costs			34,148	
	Total NHS board costs		13,755*	
		Total council costs	45,162*	

Notes: 
*   Actual costs will be higher as some cost information was unavailable or figures were estimated.
** This only includes reimbursement for the Healthcare Travel Costs Scheme, as NHS Lanarkshire did not provide a response to our data request.
1.  South West Ambulance division also includes the former NHS Argyll and Clyde which is now split between NHS Highland and NHS Greater Glasgow and Clyde.
2. NHS board figures include reimbursement expenditure on the Highlands and Islands Travel Scheme.
3. INA denotes the information was not available.

Source: Audit Scotland, 2011

Central reimbursement schemes could be used more efficiently
Over £9 million was spent on HITS in 2009/10 but this money could be used more efficiently
29. The HITS provides non-means-tested reimbursement to NHS boards for journeys to healthcare for people living in the Highlands and Islands. The scheme covers NHS Highland, the island boards and parts of NHS Grampian. NHS boards administer reimbursements to anyone living within the geographical catchment area for costs over £10.24 NHS boards submit a claim to the Scottish Government for reimbursement of costs under this scheme each year. There is no limit on the amount they are able to claim.
30. In 2009/10, £9.2 million was spent on the HITS. The most recent guidance for HITS dates from 1996. Patients and staff we spoke to as part of our audit reported that the guidance is being interpreted differently in local areas, for example some NHS boards will reimburse patients who have travelled to their appointment using community transport, but others will not. This money could potentially be used more efficiently by public sector bodies to meet the challenging transport needs of people living in remote areas rather than as an individual reimbursement fund. For example, the scheme can currently be used to reimburse several individual journeys in a taxi where there is no alternative public transport but the money available through this scheme cannot be used to fund more planned services, such as community transport buses linking communities to the hospital.
NHS boards spent £2.5 million on the Healthcare Travel Costs Scheme in 2009/10 
31. The second scheme, available to all NHS boards, is the means-tested Healthcare Travel Costs Scheme. NHS boards spent almost £2.5 million on this scheme in 2009/10 and receive money for this as part of their overall budget allocation. To access the scheme patients must be receiving benefits or allowances or be on a low income and must be travelling to receive hospital treatment after being referred by a GP or a dentist.25 Patients who are eligible claim reimbursement from their NHS board.
32. Information on other payments made by NHS boards for transport is not routinely collected. Three NHS boards told us that in 2009/10, they spent a total of just over £121,000 on other discretionary payments for transport not covered by the above schemes, for example when someone is receiving treatment outside their own NHS board area.26 
There are pressures on voluntary sector funding
33. It is not possible to calculate how much the voluntary sector contributes to delivering transport for health and social care as this information is not available centrally. The extent to which councils, the ambulance service and NHS boards contract with voluntary sector providers also varies. We asked public bodies how much they spent on commissioning services from the voluntary sector but they were able to supply limited information only. Twenty-seven councils and nine NHS boards reported that they provide funding to the voluntary sector, either through a grant or through a service level agreement or contract. Based on information from the 11 councils and four NHS boards which could provide it, councils provided funding of £1.7 million and NHS boards provided funding of £285,000 to the voluntary sector in 2009/10.27 In the West of Scotland, Strathclyde Partnership for Transport (SPT) manages the grant funding of community transport projects on behalf of member councils. In 2009/10, SPT provided funding of £455,000 to the voluntary sector. 
34. From 1998 to 2008, community transport providers were able to apply for grant funding from the Scottish Government through the Rural Community Transport Initiative. The total allocation for the scheme during this period was just over £13.5 million. The annual amount available increased from £600,000 in 1998/99 to £2 million in 2005/06. Between 2003 and 2008, additional grant funding was available for community transport in urban areas and for pilot projects in rural areas. The total amount available for these schemes for this period was £5 million.28 In April 2008, this funding was transferred to councils as part of their overall allocations. Councils continue to fund those voluntary sector agencies which were awarded grants, at least until the end of the grant period. Participants in our voluntary sector focus groups reported that they had seen funding from a range of sources decline in recent years and the short-term nature of funding makes it difficult to invest in developing services. 
Integrated transport units can lead to efficiencies
35. To make best use of available resources, organisations must make sure they coordinate how they arrange transport for people accessing their services. Not all NHS boards and councils have a central team to coordinate transport for health and social care and several different services can be involved in planning transport. For example, within councils, vehicles may be commissioned for general use (including education and social care); the education service may arrange special education needs transport; and the social work service may also commission taxis or use council fleet or drivers (Exhibit 5). Many different staff (including administrative staff and clinicians) can be involved in deciding if people are eligible for help with transport and arranging it. Staff are not always aware of the various transport options available and may not fully understand the service user’s needs or how best to access the most appropriate transport for them.
36. In England, the North West Centre of Excellence identified seven key areas where a transport unit can add value, rather than planning, organising and procuring transport through different departments:
•	more focused professional staff
•	more efficient utilisation of staff
•	better service planning
•	better value for money in procurement of external contracts
•	better in-house vehicle fleet utilisation
•	greater flexibility
•	consistency in the development and application of policy on service quality and eligibility criteria, and in legal compliance.29 
37. Only two NHS boards organise transport for their board through a central department.30 In 14 councils, responsibility for planning, organising and procuring transport for health and social care is divided between a number of departments. Eighteen councils have developed integrated transport units or are in the process of doing so. An integrated transport unit brings together all transport service planning, procurement and monitoring and management functions across a range of service areas. This may be within an organisation or across a number of different agencies (Exhibit 6).
38. There has been limited local work to try and improve how organisations work together to schedule transport services but there is scope to share learning from some current projects (Case study 1). 
Case study 1
Wigtown mapping exercise
As part of the Joint Improvement Team’s (JIT) Transport with Care project, Dumfries and Galloway Council, the ambulance service, NHS Dumfries and Galloway, SWESTRANS, private operators and community transport providers mapped health and social care transport in the Wigtown area. The aim was to assess and establish Wigtownshire as a pilot site for shared booking and scheduling of client and patient journeys. The primary focus was on transport for those with specific support or access requirements. This has now developed into a pilot of a shared services model which is EU-funded and has partners across Europe, including Shetland, Iceland, Finland and Sweden.
Partners involved in the Wigtown project:
•	reviewed national and local transport policies, finance and legislation
•	analysed existing transport use, needs and estimated demand
•	considered practical issues including booking and dispatch systems, and administrative and operational requirements and identified good practice.
As part of the pilot, partners are now using an IT scheduling and booking system used by the local community transport provider to bring information about all their journeys together. The pilot started in July 2011 and if this is successful, the system will be rolled out across Dumfries and Galloway. 
Source: Audit Scotland, 2011
Improved scheduling systems are needed
“[there are] cases where we had six buses servicing a day care centre and every single bus sat there all day with a driver…”
Source: Voluntary sector focus groups

39. The way transport for health and social care is scheduled needs to improve. Current arrangements are fragmented, although in some cases partners have tried to create an integrated system in their local area. In some areas, it has been difficult to get all partners to engage and commit to improved joint scheduling. This makes it difficult for organisations to meet the transport needs of people using their services. 
40. There is no standard IT scheduling package used across Scotland or even within sectors. Systems for scheduling transport for health and social care are a mixture of electronic and paper-based systems and there are several scheduling software packages available. Eleven councils and one NHS board use specialist electronic scheduling software. The ambulance service uses the system CLERIC and SPT uses Trapeze PASS, which enables real-time scheduling of services. The ambulance service is committed to introducing mobile technology by December 2011, which will enable it to track vehicles and deploy them in real-time.
41. In addition to scheduling transport well in advance of trips taking place, all councils need to provide some transport on an ad-hoc basis. SPT carried out work with Glasgow City Council to assess the scope for efficiency savings through better scheduling (Case study 2). The Clyde Valley review identifies a potential for £800,000 – £1.1 million of savings if a shared scheduling system was used among the eight councils in the area to arrange social care transport, with the potential to expand this to include NHS boards for further savings.
Case study 2
SPT and Glasgow City Council

Glasgow City Council provides 67 voluntary and community groups throughout Glasgow with transport to various activities and community centres. SPT has provided scheduling and management services for Glasgow City Council’s Social Work Department Voluntary Club  Transport Project since April 2010. This has led to a saving of £208,000 (a 42 per cent reduction in the former £500,000 cost of providing the service). This has been achieved through reviewing all the services that are provided by various organisations, more efficient scheduling and seeking to reduce duplication and improve joint working between partners. 
Source: Shared services – provision of social transport and fleet management, SPT, November 2010. Updated financial information provided by SPT, April 2011
Transport should be considered when planning the timing of appointments
42. The impact on people of transport not being considered as part of healthcare can be significant. Greater coordination at a central level, for example when allocating appointments, would make things easier both for service users and community transport providers  and may also make services more cost-effective:
“We quite often wish that people making appointments would look at the postcodes and maybe send two or three people to the same clinic at around the same time, because we’ve had people going to the same postcode, and I’ve had to send them in three different cars because of the time.”
Source: Voluntary sector focus groups
“I had to get a taxi to get the early bus to Inverness, then a bus to New Craigs, then back to the station, bus back to Skye and a taxi home. It was exhausting so in the end the treatment didn’t help much either.” 
Source: Transport and mental health, HUG Action for Mental Health, November 2009

43. There are examples where health appointments and transport have been planned together, for example at the Golden Jubilee National Hospital (Case study 3). 
Case study 3
Golden Jubilee National Hospital

The Golden Jubilee National Hospital has a central transport office. Individual departments from within the hospital, staff from referring hospitals and users themselves can contact this office directly to organise transport.
The hospital has a transport policy which includes criteria to determine eligibility for different types of transport and staff can use flow charts to determine which transport options are available to different people in different circumstances. 
The hospital operates a small fleet of minibuses which link in with other NHS boards to transport patients for planned surgery. The central transport office also holds information about other transport provision such as community transport operators and public transport so that staff can provide good information to patients.
Source: Audit Scotland, 2011

44. Changes to social care day centre opening and closing times could lead to a reduction in the number of vehicles required to service them and make better use of the vehicles available. SPT carried out a scheduling exercise which analysed data from Glasgow City Council and estimated that by changing the time when vehicles were needed for schools and day centres, 49 vehicles could be removed from the fleet and this could potentially save £3.4 million per year. SPT has also estimated that by coordinating stand-by buses in the Clyde Valley area, there is potential for a saving of £2.5 million. When setting up or reviewing health and social services, partners should ensure that they consider all the factors that will help support people getting services that they need when they need them.31 
There is scope to improve the PTS scheduling system
45. There are a number of ways for patients and staff to book the ambulance service PTS, for example by telephone or through the internet. NHS staff, such as GPs or practice nurses, generally make bookings for patients. The ambulance service has two policies to determine who can use the PTS and who is prioritised:
•	eligibility criteria to determine medical need
•	priority bands of patients and clinics, eg cancer or cardiology.32 
46. PTS bookings can be made up to three months in advance. However, confirmation of a place in a PTS vehicle is not confirmed until 24 hours before the appointment, and some patients may be cancelled and rescheduled if there is someone with higher priority who needs transport. If this happens the ambulance service does not arrange alternative transport – the patient or the NHS board has to do this. The ambulance service is currently reviewing these procedures.
47. Since August 2010, the ambulance service has conducted a pilot programme in partnership with NHS Lanarkshire to inform the ambulance service’s national work. The pilot aims to address:
•	the lack of consistency in applying the PTS eligibility criteria
•	the way that PTS is requested through several different departments.
48. Under the pilot scheme, patient eligibility for PTS is assessed through a central booking service, using a telephone triage tool developed in conjunction with clinicians. Patients are also given an information leaflet which allows them to self-assess before making direct contact with  the service to book ambulance transport. The ambulance service reports that key results of the pilot to date include a reduction in patient appointments being cancelled; a 45 per cent reduction in the number of unnecessary journeys; and releasing clinical and administrative staff time.33 The ambulance service and NHS Lanarkshire plan to expand the pilot during 2011.
There is scope to save money by more efficient use of taxis
49. Information on the use of taxis for health and social care is limited but work carried out in Clyde Valley estimated that about £4 million could be saved in that area alone through better use of taxis (Case study 4). During our fieldwork, only 15 councils and five NHS boards were able to provide us with details of how much they spend on taxis to transport people to health and social care services. The total spend reported by these bodies was just over £6.7 million.34 We have not reviewed the efficiency of all taxi use in the public sector, for example staff transport, but it is likely that a review of these services could also lead to further efficiencies.
Case study 4 
Efficient use of taxis
Glasgow City Council reassessed individual travel needs and arrangements for children with additional support needs. This resulted in reduced scheduled taxi use and reduced spend by between 20 and 25 per cent since August 2010. A review of social transport carried out in partnership with SPT as part of the Clyde Valley Review made assumptions on this basis and identified potential savings of £3.2 – £4 million across the Clyde Valley if this exercise was carried out across all councils in the area. 
Source: Clyde Valley Review – social transport and fleet management outline business case, November 2010.
Recommendations
Regional Transport Partnerships, councils, NHS boards and the ambulance service should:
•	put in place a plan to achieve efficiencies through improved joint working including sharing resources and good practice.
The Scottish Government should:
•	review the Highlands and Islands Travel Scheme and issue updated guidance, and consider whether there is a more efficient way to use this funding in relation to transport for health and social care.
Partners should:
•	develop a better understanding of the activity, cost and quality of services provided and routinely benchmark performance and costs to ensure resources are used efficiently
•	regularly review funding arrangements for transport for health and social care to ensure that they maximise value for money and reflect levels of local need
•	work with the voluntary sector to reduce the impact of short-term funding on the provision of transport for health and social care
•	improve how they arrange transport services within their own organisation and in partnership with other organisations and consider the need for a central team or coordinated approach
•	review the timing of appointments and care services to make sure that transport provision is considered
•	review the use of taxis and scope for efficiencies in their own organisation and in partnership with others.

19	This does not include spend by RTPs as it is not possible to disaggregate how much they spend on health and social care. 
20	Net resource outturn, Scottish Ambulance Service Annual Accounts (2009-10).
21	This includes just under £23 million for staffing, just over £2 million for fleet and fuel costs and just over £9 million in other costs, including equipment, administration and management costs. 
22	The East Central division covers NHS Fife, Forth Valley and Tayside. The North division covers NHS Highland, Orkney, Western Isles and Shetland.
23	Costs book 2010, ISD Scotland, 2010.
24	Patients’ Travelling Expenses Schemes MEL 1996 (70), The Scottish Office and Department of Health, 1996. A letter was issued to NHS boards on  15 March 2006 stating that the minimum contribution would increase from £8 to £10 from 1 April 2006.
25	Are you entitled to help with health costs? HSC1, NHS Scotland, 2007.
26	This figure only includes data from NHS Ayrshire and Arran, Fife and Grampian. NHS Dumfries and Galloway, Forth Valley, Lothian and Tayside noted that this information was not available. NHS Highland and Greater Glasgow and Clyde noted that they did not have any additional discretionary payments.
27	The councils’ figure is based on information from 11 councils which provide funding through a grant, service level agreement or contract. Twenty-one councils did not provide funding in this way or could not provide the financial information. The NHS boards’ figure is based on four NHS boards (NHS Fife, Tayside, Grampian and Greater Glasgow and Clyde). This figure includes payments to volunteer drivers.
28	Between 2003 and 2006, grant funding was made available for pilot community transport measures in urban areas through the Urban Community Transport Initiative and the Rural Demand Responsive Transport Initiative. These schemes were combined in 2006/07 to create the Demand Responsive Transport Initiative.
29	Integrated Transport Units, North West Centre of Excellence, September 2006.
30	Golden Jubilee National Hospital and NHS Orkney.
31	Shared services – provision of social transport and fleet management, SPT, November 2010.
32	Priority 1 patients are those who have cancer, coronary heart disease, renal disorders, or mental illness.
33	Unnecessary journeys are known by the ambulance service as aborted journeys. These are where a vehicle is dispatched but there is no one to pick up and the journey has not been cancelled in advance.
34	Details were provided by NHS Ayrshire and Arran, Borders, Fife, Greater Glasgow and Clyde, Lothian, and the following councils: Argyll and Bute, Aberdeen City, Aberdeenshire, City of Edinburgh, Dumfries and Galloway, East Ayrshire, East Lothian, East Renfrewshire, Fife, North Ayrshire, North Lanarkshire, Perth and Kinross, South Ayrshire, Stirling and West Dunbartonshire.

Part 3. Working together to meet need
Public sector organisations need to work better together to meet transport needs. 
Key messages
•	Decisions taken in one organisation can have far-reaching consequences for the services provided by another. Transport can have a significant impact on the efficiency of services and on the lives of people who need to access health and social care services. The various public sector organisations involved in delivering these services must work together to assess, plan and meet local needs. 
•	Joined-up planning of transport provision with healthcare appointments could improve efficiency and lead to a better service.
•	Poor access to transport has a disproportionate effect on people in low incomes, older people and people with ongoing health and social care needs. The public sector needs better information on individual needs and on the quality of the transport services it provides in order to deliver an efficient and effective service which meets people’s needs.
•	There are many public sector bodies involved in delivering transport for health and social care. There needs to be a clearer system for organising resources in Scotland, alongside clarity about the roles of services and partners and how they link together so that everyone who needs to access transport for health and social care is able to do so.
50. We have highlighted the challenges around funding and the lack of information on costs and efficiencies. In this Part we look at how the services are planned, how organisations work together and the impact on people.
There is a lack of clear leadership and focus on improving services at a national, regional and local level
51. There is a lack of strategic oversight of transport for health and social care in Scotland and overall responsibility is fragmented. Given the number of organisations involved, stronger leadership and decision-making is essential if transport for health and social care is to be developed to fully meet people’s needs. Decisions taken in one organisation can have far-reaching consequences for the services provided by another. A lack of coordination among public sector organisations was raised as a concern through our fieldwork interviews and focus groups. There are some key principles of partnership working that organisations should apply to improve how they work together.35 There have been a number of initiatives to improve transport services but problems around a lack of planning and joined-up working remain (Exhibit 7). 
Exhibit 7
Summary of the main initiatives relating to transport for health and social care
There have been several initiatives over the last six years which relate to transport for health and social care.

Date	Policy/development	Summary	
June 2005	The Transport (Scotland) Act	The Act placed a duty on Scottish ministers to create Regional Transport Partnerships (RTPs). An order to create seven RTPs was made by the Scottish ministers on 30 November 2005.	
2005–10	Transport with Care, Joint Improvement Team (JIT)	The Joint Improvement Team along with partners in RTPs, councils, the ambulance service, and the voluntary sector conducted pilots to explore the potential for efficiency gains through joint working, and the impact on service users.	
May 2006	Review of Demand Responsive Transport (DRT) in Scotland, Scottish Government	Sets out the contribution that transport makes to reduce the risks of people becoming isolated and how easy people find it to access services. The report assessed the impact of pilot schemes set up to develop transport provision that meets people’s needs. It also included recommendations on how future transport arrangements should be developed in Scotland along with best practice guidelines.	
December 2007	Better Health, Better Care Action Plan, Scottish Government	Committed the Scottish Government Health Directorates to developing a national approach to managing travel. It recognised that greater coordination between the ambulance service, local NHS boards and councils could make the system more efficient as well as benefiting patients. The plan also outlined the need for the NHS in Scotland to engage more effectively with the seven RTPs. 	
May 2008	Delivering for Remote and Rural Healthcare, Scottish Government	Notes that the lack of a joined-up approach to transport has been consistently raised as a problem, resulting in delays for patients trying to access healthcare. It states that there appears to be little or no planning or coordination between and within agencies and that there is sometimes duplication and inefficient use of resources. The report called for a nationally coordinated and collaborative response to the development of an integrated transport infrastructure to support healthcare across Scotland, particularly in rural communities.	
November 2009	Healthcare Transport Framework, Scottish Government	Designed to support the planning and improvement of transport at a local level and included a Transport Action Plan checklist to help NHS boards identify local needs and improve access. Eight NHS boards have completed action plans.1 Analysis of the action plans submitted show wide variety in the level of detail included and approach to taking this work forward.	
May 2010	NHSScotland Quality Strategy – putting people at the heart of our NHS, Scottish Government	Builds on the Better Health, Better Care strategy. It sets three quality ambitions to support the Scottish Government’s aim of delivering the best quality healthcare to people in Scotland. It also identifies the need for effective joint working between health and social care to move more services from hospitals to the community. 	
October 2010	The final report of the Remote and Rural Implementation Group, Scottish Government	Mainly focuses on emergency transport and calls on the Scottish Government to consider developing an integrated transport strategy responsive to remote and rural needs.	

Note: 1. Based on 13 responses. Source: Audit Scotland, 2011

52. The Scottish Government Health and Social Care Directorates have responsibility for transport for health and social care. Transport is also relevant to many other broader issues such as equality and diversity, remote and rural areas, and older people. 
53. In January 2011, the Scottish Government established a short-life working group to lead a review of the delivery of effective patient transport to healthcare services. It is considering a range of issues including delivering greater integration of service provision, improving the national planning framework, addressing inequity in the provision of transport to hospitals and reviewing the Healthcare Transport Framework (Exhibit 7). The group is due to report in September 2011 and will consider the findings in this report as part of its work.36 A revised version of the Healthcare Transport Framework will be issued in October 2011.
National performance monitoring is limited to the Patient Transport Service
54. There were two national health standards for the PTS for 2009/10. 
•	70 per cent of Priority 1 patients should arrive at hospital at least 30 minutes before their appointment
•	87 per cent of Priority 1 patients should be picked up no longer than 30 minutes after their appointment.37
55. The ambulance service achieved the first standard, with a rate of 71.8 per cent in 2009/10. The standard has been increased to 72 per cent for 2010/11. The ambulance service just missed the second standard in 2009/10 – just over 85 per cent of Priority 1 patients were picked up within 30 minutes after their appointment. The standard for 2010/11 has been increased to 90 per cent.
56. Transport may be cancelled by patients, clinics, or the ambulance service, for example because a patient no longer needs to attend the appointment, because a clinic is cancelled or the ambulance service does not have a vehicle available. The ambulance service introduced a third national health standard for 2010/11, that it should cancel less than one per cent of journeys. A cancelled journey is a journey which can be re-allocated to another person. An unnecessary journey is a journey where a vehicle is dispatched but there is no one to pick up and the journey has not been cancelled in advance.38 
57. Between 2007/08 and 2009/10, the number of PTS cancellations decreased by 12 per cent from 294,223 to 259,815. However, unnecessary PTS journeys across Scotland increased by ten per cent from 97,982 to 107,921. At an individual board level, between 2007/08 and 2009/10, unnecessary journeys have increased in every board area except NHS Ayrshire and Arran, Grampian, Greater Glasgow and Clyde, Orkney and Western Isles. Cancelled journeys have decreased in every NHS board area except the previous NHS Argyll and Clyde area, Borders, Fife and Forth Valley.39
58. There are no national targets for transport for health and social care services for other agencies, and 11 Community Planning Partnerships made no reference to these services in their local Single Outcome Agreements.40 During our fieldwork, only Golden Jubilee National Hospital reported that it had assessed the impact that transport has on people not attending appointments. No NHS board had assessed the impact on waiting times, waiting for discharge from hospital and other targets. 
Transport planning is fragmented and responsibilities are unclear
59. It is not clear who is responsible for getting patients to and from health appointments if they do not have a medical need for transport. There is a risk that people are left without the support they require to get to the services they need. NHS boards do not see transport as their main area of responsibility and councils do not have a statutory duty to provide transport other than for education. 
“It’s no good trying to get the local authorities…and the [ambulance service] trying to talk to each other. That’s just…at the edges of what’s needed. It actually needs a fundamental restructuring of how transport is delivered and funded in Scotland…That’s a big thing…but that’s the only way it’s going to fix it.”
Source: Voluntary sector focus groups

60. Organisations focused on addressing the day-to-day transport needs of people accessing services should come together to jointly plan services, share resources and evaluate whether they are meeting local needs. There are significant gaps in how transport for health and social care services is planned, for example transport issues and the location of patients are not routinely considered as part of planning clinic times. 
61. There are weaknesses in planning for reducing funding to services. Councils and NHS boards (including the ambulance service) have a duty to conduct equality impact assessments where this is judged to be relevant and proportionate, for example when councils are considering financial proposals that may have an impact on particular groups in the community.41 Decisions should always be subject to a thorough assessment, including consulting with the people who will be affected by any cuts in services.42 Equality impact assessments can help staff make better and more transparent decisions. However, there is little evidence of councils and NHS boards assessing the impact of changes to transport for health and social care. Only six councils and five NHS boards told us that they have carried out equality impact assessments on service change which affects transport needs. One council is in the process of completing an assessment.
62. Eligibility criteria for transport services are not clear and there is a risk needs are not being met. There are a range of eligibility criteria in place including those within the PTS, councils, NHS boards and voluntary and private sector providers. Twenty-two councils and seven NHS boards reported that they had some kind of eligibility criteria in place. This variation and a lack of transparency can make it difficult for both staff and users to know what services are available and if and how they will be funded. There is also a risk that responsibility for trips is shifted between agencies, causing further confusion to those using the service. It is essential that eligibility criteria are clearly defined and understood by everyone using transport services and by the staff who refer them. 
63. In 2009, the annual review of the ambulance service found the PTS to be one of the main areas for improvement, highlighting that it needed to deliver better services to patients and work with partners to support patients who do not have a medical need for transport.43 The ambulance service has enhanced its PTS over the last few years by investing in more specialist resources to reduce the length of time patients need to wait for transport and to provide vehicles that better meet their needs, such as dedicated palliative care vehicles. The ambulance service has also introduced extended hours and weekend availability. Its strategic framework document for 2010 to 2015 includes a commitment to develop and improve the patient transport service by:
•	reviewing and developing eligibility criteria (by 2010/11)
•	reviewing and improving ambulance service processes and service delivery (by 2010 to 2012)
•	working with NHS partners and transport providers to assist development of an Integrated Transport Strategy (2010 to 2013)
•	working with regional and local transport providers to ensure fully integrated solutions are available when an ambulance is not necessary (2010 to 2012).44
64. The ambulance service is carrying out a pilot in NHS Lanarkshire to review the effect that applying its PTS eligibility criteria more consistently would have on other organisations and service users. This pilot included a one-week review to consider to what extent the PTS eligibility is being applied. The results showed that the eligibility criteria were being applied inconsistently due to the variation in booking methods, and that for 70 per cent of patient bookings there was evidence to suggest that the eligibility criteria were either not applied at all or applied inconsistently, and therefore the ambulance service could not confirm whether or not patients had a clinical need for transport. The ambulance service, NHS boards and councils need to work together to properly evaluate the impact on other transport services of any changes to the PTS. This includes an assessment of the impact on cost, activity and workforce across all organisations and the potential impact on service users.
Needs are not routinely assessed
65. Planning should be underpinned by an assessment of local need; however, there is limited national data on transport for health and social care activity. Organisations do not work together to assess need for transport for health and social care services and there is a risk that people do not have access to transport to help them get to the services they need. For example, the 2010 Scottish Inpatient Patient Experience survey asked people whether they were given any help with arranging transport once they were ready to leave hospital. Forty-six per cent of the total sample reported that they needed help with arranging transport. Of these, two-thirds reported that they were given help.45
There is scope to better join up services 
66. RTPs were introduced to help coordinate transport at a regional level. Transport for health and social care is a small part of their overall remit although it is an important aspect of what they do. All RTPs have carried out some work with their partners to try to improve transport for health and social care, although for some this is a recent focus. All RTPs have recently established working groups on transport for health and social care issues with their partners. RTPs have worked with partners to carry out some modelling and mapping of journeys but this focuses mainly on distances from nearest hospital or health service and the time it would take to travel there. They have also carried out mapping which shows gaps in public transport provision. 
67. Strathclyde Partnership for Transport (SPT) has carried out more work on transport for health and social care than other RTPs and has been able to demonstrate potential savings if councils shared resources and used SPT’s scheduling system. SPT has also worked with partners, including NHS Greater Glasgow and Clyde, to explore the feasibility of a multi-agency integrated transport project and provides scheduling services for a range of organisations. 
68. There has been limited work on considering the scope for sharing services including fleet, staff, procurement, and booking systems to date but there are some examples of good joint working at a local level (Case study 5). Some councils and NHS boards told us that they are planning more joint working in future.
Case study 5
The Grampian Health Transport Action Plan

NHS Grampian has been working with Nestrans (the Regional Transport Partnership), the ambulance service, councils and transport operators to develop a Health and Transport Action Plan. In addition, the group is developing a transport charter which sets out responsibilities for service providers and users, underpinned by criteria of eligibility for access to transport services. The group is also running four pilot projects to test out integration of healthcare and transport provision. Nestrans, NHS Grampian and the Scottish Government have contributed funding for a programme manager to facilitate the Grampian Health Transport Action Plan.
Source: Audit Scotland, 2011

69. Participants in our focus groups and interviews felt that joint working across sectors is crucial for the successful, sustainable development of transport services, in particular securing an overview of all the vehicles owned in one area and their capacity, including councils, NHS boards and community transport providers:
“If we could get a system in place…with a common booking entry, so that somebody could call up a vehicle that was available, irrespective of whether that was actually in the ownership of the health board, the council, the third sector, then it might lead to more viability, more sustainability all round…That is what we should be aiming for.”
Source: Voluntary sector focus groups

70. In December 2009, Sir John Arbuthnott published his report on joint working and shared services in the eight councils in the Clyde Valley area.46 The report highlighted that there is no real joined-up approach to the procurement, maintenance and scheduling of fleet across the eight councils or neighbouring councils. The Clyde Valley Review recommended that councils in the area consider and refine an outline business case to establish an area-wide social transport service. Specifically the report recommended that work should be carried out by the councils to:
•	pilot the improved scheduling of current social transport to reduce the amount of down-time for vehicles and drivers in each local authority
•	better coordinate socially necessary transport, eg dial-a-ride and ring-and-ride services, providing a better overview, particularly across neighbouring authorities where services can cross boundaries 
•	improve use of the school bus service across council boundaries
•	improve the standardisation of vehicle design and procurement for social transport
•	consider sharing of fleet.
71. The Clyde Valley councils have started to investigate potential for shared services across a number of areas, including social transport and fleet management in partnership with SPT. Glasgow City Council is the lead authority for this work. We have drawn on this work as part of this audit.
72. NHS Forth Valley has employed a Travel Manager to work on transport issues on a full-time basis. This has led to some joint initiatives with partners, such as the NHS board funding six bus services to the Forth Valley Royal Hospital in Larbert at a cost of £3.6 million over three years (2010–13).47 The buses are registered as public transport routes so they can be used by any member of the public (not just patients and visitors). Responsibility for public transport routes would normally fall to the council and it is unusual for NHS boards to fund this kind of service but this is a good example of joint working between NHS Forth Valley, Clackmannanshire Council and Falkirk Council.
73. In April 2010, The Griffiths Review – Non Emergency Patient Transport in Wales made recommendations about the need for stronger management arrangements, better joint working with the voluntary sector and a need for stronger partnership working and joint use of resources.48 Four pilot sites are under way in Wales to test out various approaches to making services more patient-centred. An independent evaluation will be carried out after the pilots have been running for one year and a report is expected in 2012.49 Our audit suggests that many of the issues raised in Wales are also relevant to Scotland.
74. There is evidence from England that there is value in councils, NHS boards and the ambulance service coming together to assess who could best provide transport services in their area (Case study 6).
Case study 6
Councils and the NHS working together

Since 2002, Cheshire County Council Transport Coordination Service (TCS) has been working in partnership with the NHS to make use of the council’s vehicles for social care and special education needs when they are not being used to help provide journeys for NHS patients.
The partners have made sure that the vehicles meet the required standard of quality and have the necessary equipment, and that appropriate criminal record checks have been carried out on staff. The council is reimbursed at marginal rates so that costs to the health sector are broadly equivalent to direct ambulance-operating costs. 
TCS worked with North West Ambulance Service so that the council’s fleet of vehicles can be used during down-time to assist the ambulance service at times of peak demands, for example transporting less mobile patients home. This helped avoid using taxis which are more expensive.
The partners identified that transport for renal dialysis and oncology patients, due to its regular nature and defined times for arrival and collection, could be readily undertaken by TCS. 
Source: Providing Transport in Partnership – A guide for health agencies and local authorities, North West Centre of Excellence, 2009
There is potential for better joint working with the voluntary sector
75. The voluntary sector plays an important role in providing transport for health and social care, offering a diverse range of services and a strong relationship with service users. Recent flexibilities in the legislation around community transport services mean that there is more scope for the voluntary sector to provide its services to support public sector providers in this area (Exhibit 8). Councils and NHS boards should consider the voluntary sector as part of their overall strategy for commissioning transport services for health and social care.
76. Voluntary organisations can hold two different permits to operate bus services – Section 19 or 22 of the Local Transport Act 2008. Currently around 20 community transport operators in Scotland have secured or are in the process of securing Section 22 permits with support from the Community Transport Association. Since the Local Transport Act 2008, the process for issuing permits has also been simplified. These changes came into effect from 6 April 2009. 
77. Some community transport providers have concerns that where there is no alternative transport available, council and NHS board staff automatically assume that voluntary sector providers will fill the gap and that arrangements are not always formalised: 
“And social work are constantly calling us and saying,  ‘Can you do this?’  And you say,  ‘You want me to give you a price on it?’  ‘What, you mean charge us?’  And then they don’t want it…They were thinking we were going to do it for nothing.”
“The only real contract we have is with [council] which give us some funding…it was agreed that…something like 30 per cent of our rounds would be [for the council] so they know they can ask us to do a certain number of rounds. I mean that’s taking people to resource centres or day centres etc…it’s not even in print actually, but it was an agreement that we made with them that was possible.”
Source: Voluntary sector focus groups

78. Voluntary organisations have taken steps to improve the way they work, for example by implementing MiDAS (minibus driver awareness scheme) training and the Community Transport Association has developed a Quality Mark Scheme (UK-wide).It hopes this will provide reassurance to commissioning organisations that may have concerns about the quality of services delivered by community transport operators. 
79. There are examples of successful partnership working between the public and the voluntary sectors, for example the Order of Malta dial-a-journey works with Falkirk, Stirling and Clackmannanshire Councils to provide door-to-door transport in these areas for people who are unable to use public transport (Case study 7). Voluntary Action Lewis successfully tendered for contracts from Comhairle nan Eilean Siar to run bus services in Lewis. A full report of the views of voluntary sector transport providers is available on our website.

Case study 7
Partnership between the public and voluntary sectors in Forth Valley

Dial-a-journey is a door-to-door transport service for people who have a mobility problem and who cannot use conventional public transport. People who use the service can book trips in advance or on the day. Dial-a-journey is mainly funded through three councils in the Forth Valley area (Clackmannanshire Council, Falkirk Council and Stirling Council). It receives additional financial support from the Order of Malta (an international charity), through fundraising. There is also an understanding with the ambulance service which allows dial-a-journey vehicles to drop off and pick up people at the ambulance pick-up points.
The service carries 27,000 door-to-door journeys annually across the three council areas. Dial-a-journey also works with NHS Forth Valley and the ambulance service, running a door-to-door service to Forth Valley Royal Hospital. This is primarily to provide journeys to day care hospitals but the vehicle may also do some transfer journeys to Glasgow or Edinburgh in any down-time. 
Source: Audit Scotland, 2011
People do not have enough information to access the transport services they need
80. People should be given good, timely information about the travel options available to them when they arrange a hospital appointment or attend a social care service:
“I know a lady from Glen Park who had to go to the Western General and she didn’t know anything about us, and she hired a taxi. Seventy pounds there and seventy pounds back…Then she found us.”
Source: Voluntary sector focus groups

81. Staff also need good information so that they can make informed decisions about arranging transport for service users. For example, GPs and their staff should be aware of alternatives to the PTS for people who do not meet the eligibility criteria and be able to give this information to patients. There is a need for awareness-raising among practitioners such as GPs and clinical and social care staff at all levels. This may improve the experience for users as well as contribute to more efficient services. 
82. As part of a PTS pilot in NHS Lanarkshire and NHS Tayside, patients receive a leaflet with their appointment letter about how to book transport. This refers people to Traveline Scotland and highlights local voluntary services.50 Patients are also signposted to other services when booking on the phone if they do not meet PTS criteria. NHS Greater Glasgow and Clyde also uses Traveline Scotland to produce personal travel plans with patient appointments. This has been successful and other areas are now also looking at developing and using this approach.
There is a need to do more to involve users in developing services
83. Public sector organisations not only need to work well with each other to deliver transport services but they must also involve users to ensure that the services they are providing meet their needs. Many service changes have an impact on people’s transport needs, for example changes to the location of clinics or day centres. Councils and the NHS are required to engage with local communities about service changes and this includes implications for transport provision.51 The extent to which public bodies do this varies. Twenty-one councils and ten NHS boards provided evidence of engaging with service users about transport for health and social care. This ranged from dealing with transport problems as and when issues arise or asking one question in a survey; to regular meetings with people the service affects, for example NHS Greater Glasgow and Clyde’s Transport and Access Forum, which meets quarterly to explore all issues relating to transport and access. 
Recommendations
The short-life working group on healthcare transport led by the Scottish Government should:
•	take account of the findings and recommendations of this report in its work. 
The Scottish Government and partners should:
•	work together to clarify responsibilities for planning and delivering transport for health and social care and how these link together.
Partners should:
•	put systems in place to routinely engage with service users to ensure that their views inform the development of transport for health and social care services
•	assess the impact of proposed service changes on users and other services, taking account of transport needs
•	ensure that staff are well informed about all transport options in their area and provide better information to the public about available transport options, eligibility criteria and charges
•	integrate or share services where this represents more efficient use of resources and better services for users, including considering an integrated scheduling system
•	ensure that transport for health and social care services are based on an assessment of need and that they are regularly monitored and evaluated to ensure value for money. Partners need more information and a greater understanding of the individual needs of people accessing services to do this successfully
•	collect information on the personal characteristics of people who need transport for health and social care to allow monitoring of equality and diversity and to develop services to meet their needs.
Councils and NHS boards should:
•	involve the voluntary sector in planning and delivering transport for health and social care to meet the needs of the local population.

35	Community Health Partnerships, Audit Scotland, 2011.
36	Representation on the group includes the Convention of Scottish Local Authorities (COSLA), NHS Highland, NHS Greater Glasgow and Clyde, Scottish Ambulance Service, Director of a Regional Transport Partnership, Community Transport Association, Voices (voluntary sector representatives), and Transport Scotland.
37	Priority 1 patients are those who have cancer, coronary heart disease, renal disorders, or mental illness. 
38	Unnecessary journeys are known by the ambulance service as aborted journeys.
39	The ambulance service still collects data based on the previous NHS Argyll and Clyde NHS board configuration. 
40	In April 2008, following agreement of a concordat between the Scottish Government and COSLA, Single Outcome Agreements (SOAs) were introduced across Scotland. SOAs set out how each council and its partners, including the local NHS board, will address their priorities and improve services for the local population. They are intended to encourage councils and their partners to focus on outcomes rather than on measuring process. However, detailed management information on services, quality and cost is still needed to underpin work on outcomes to assess how well needs are being met. 
41	At the time of our audit, public sector bodies were required to publish Equality Impact Assessments. Guidance about duties for public bodies under the Equality Act 2010 is on hold pending further discussion by the Scottish Parliament.
42	Using the equalities duties to support fair financial decisions, Equality and Human Rights Commission Scotland, January 2011. 
43	Scottish Ambulance Annual Review: 13 October 2009, Scottish Government. The Cabinet Secretary for Health, Wellbeing and Cities Strategy conducts an annual review of all NHS bodies. The annual review is a formal process by which the Scottish Government assesses NHS board performance during the previous year. The meeting is held in public.
44	Working Together for Better Patient Care 2010-2015, Scottish Ambulance Service, 2010.
45	Scottish Inpatient Patient Experience Survey 2010 Volume 1: National Results, Scottish Government, September 2010. 
46	Clyde Valley Review, Sir John Arbuthnott, December 2009.
47	This was part of a formal Planning Agreement when planning the new Forth Valley Royal Hospital. 
48	The Griffiths Review – Non Emergency Patient Transport in Wales, Welsh Assembly Government, April 2010.
49	Non-Emergency Patient Transport National Programme Board – A Report on the Progress of the Non-emergency Patient Transport Pilot Projects, Welsh Assembly Government, May 2011. 
50	Traveline Scotland provides a 24-hour phone line and a website where people can plan journeys by public transport in Scotland.
51	Informing, engaging and consulting people in developing health and community care services, CEL 4, Scottish Government, 2010.

Exhibit 8
Permits for providing community transport
The Local Transport Act 2008 has introduced some additional flexibility. 

Permit	Description	Additional flexibilities under the Local Transport Act 2008	
Section 19	Section 19 permits may be granted to organisations which run buses to transport their members or people whom the organisation exists to help, but do not make a profit.1 Section 19 permits can only be used to transport members of the organisation and cannot be used to carry members of the general public.	Organisations holding Section 19 permits can now use vehicles of fewer than nine seats in addition to the larger vehicles they could use under the previous legislation.	
Section 22	Section 22 permits are issued to organisations providing a community bus service, but not making a profit. Unlike Section 19 permit vehicles, community bus services are local bus services and can carry the general public.	Organisations holding Section 22 permits and providing services for the general public can now pay their drivers and vehicles of more than 16 seats can now be used on those services.	

Note: 1. These are either standard permits for vehicles which are adapted to carry no more than 16 passengers (excluding the driver) or large bus permits for vehicles which are adapted to carry 17 or more passengers. Source: Audit Scotland, 2011

Appendix 1.
Audit methodology
We reviewed existing information to inform our audit, including:
•	the work of local auditors – including NHS external and internal audit reports and audit work on best value
•	NHS boards’ annual reviews
•	Regional Transport Partnerships’ strategies
•	local transport strategies
•	local projects on transport services or initiatives
•	Local Financial Returns (LFR3) which record councils’ spend on social care services
•	publications by other UK  audit organisations and other scrutiny bodies
•	other published reports, including The Griffiths Review of patient transport services in Wales. 
We reviewed published and unpublished data including:
•	NHS Information Services Division published data – NHS costs book
•	General Register Office – population statistics
•	Scottish Household Survey data – population trends
•	national and local patient satisfaction survey results.
We issued a data survey to all NHS boards and councils which was restricted to collect only data that we were unable to obtain from existing sources. We also used this survey to collect information on partnership working which has led to service improvements and improved efficiency. 
We carried out interviews in five councils and three NHS boards to examine some of the main issues in more detail. We used these interviews to find out more about:
•	challenges in remote, rural and island areas
•	challenges in urban areas
•	local work to evaluate partnership work or pilot projects to improve transport for health and social care services.
We carried out additional interviews with the Scottish Government, the ambulance service, RTPs and representatives from the voluntary sector to gather information on the strategies used to improve transport for health and social care and to investigate the extent of partnership working.
We also commissioned George Street Research to carry out focus groups with voluntary sector transport providers on our behalf. We have published a report on this work on our website: www.audit-scotland.gov.uk

Appendix 2.
Project advisory group members
Audit Scotland would like to thank the members of the project advisory group for their input and advice throughout the audit.
Member	Organisation	
John Berry	Association of Transport Coordinating Officers (ATCO)	
Alex Davidson	Scottish Government Joint Improvement Team Associate	
Dave Duthie	Director, HITRANS Regional Transport Partnership	
Heather Kenney	Director of Strategic Planning and Quality Improvement, Scottish Ambulance Service	
Bruce Kiloh	Head of Transport Planning, Strathclyde Partnership for Transport	
John MacDonald	Director, Community Transport Association (Scotland)	
Niall McGrogan	Head of Community Engagement and Transport, NHS Greater Glasgow and Clyde	
Robbie Pearson	Deputy Director of Healthcare Planning, Scottish Government	
Callum Percy	Senior Policy Manager, Scottish Government	
Gordon Third	Service Change Manager, Scottish Health Council	
Roseanne Urquhart	Head of Healthcare Strategy, NHS Highland	
Note: Members of the project advisory group sat in an advisory capacity only. The content and conclusions of this report are the sole responsibility of Audit Scotland.

Appendix 3.
Self-assessment checklist for partners
The checklist on the next few pages sets out some of the issues around transport for health and social care raised in this report. Regional Transport Partnerships, the ambulance service, NHS boards, councils and other partners, where relevant, should assess themselves against each statement as appropriate and consider which statement most accurately reflects their current situation. This will enable partners to identify what actions need to be taken.
Self-assessment for Regional Transport Partnerships, the ambulance service, NHS boards, councils and other partners to improve transport for health and social care
The last column in the checklist can be used to record sources of evidence, supplementary comments to support your assessment or to highlight areas of interest.	
	Assessment of current position	
	No – action needed	No – but action in hand
	Yes – in place but needs improving	Yes – in place and working well
	Not applicable
	Comments	
Spending and efficiencies	
We routinely collect data on the activity, cost (including unit costs) and quality of services we provide. 							
We routinely benchmark performance and costs to ensure resources are used efficiently.							
We regularly review funding arrangements for transport for health and social care to ensure that they maximise value for money and reflect levels of local need.							
We work with the voluntary sector to reduce the impact of short-term funding on the provision of transport for health and social care. 							
We have improved how we arrange transport services within our own organisation and considered the need for a central team or coordinated approach.							
We have reviewed the timing of appointments and care services to make sure that transport provision is considered.							
We have reviewed the use of taxis and considered scope for efficiencies within our own organisation and in partnership with others.							
Working in partnership 	
We have worked with partners to clarify responsibilities for planning and delivering transport for health and social care.							
We have put systems in place to routinely engage with service users to ensure that their views inform the development of transport for health and social care services. 							
We assess the impact of proposed service changes on users and other services, taking account of transport needs.							
We ensure that transport for health and social care services are based on an assessment of need and regularly  monitor and evaluate them to ensure value for money. 							
We have ensured that staff are well informed about all transport options in our area so that they provide good information to the public about available transport options, eligibility criteria and charges.							
We have put in place a plan to integrate or share services where this represents more efficient use of resources and better services for users, including considering an integrated scheduling system.							
We collect information on the personal characteristics of people who need transport for health and social care to allow monitoring of equality and diversity and to develop services to meet their needs.							
We involve the voluntary sector in planning and delivering transport for health and social care to meet the needs of the local population.