Key messages
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.

Key messages

Background
1. The availability of transport is an essential part of making health and social care services work efficiently. 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.1
2. 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. 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.
3. 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.
Our work
4. Our audit assessed 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 identified potential savings and good practice examples.
5. In the audit, we:
•	reviewed key documents including relevant policies, financial and performance information about the ambulance service, and regional transport strategies
•	carried out a data survey of all councils and NHS boards, collecting information on activity, costs and joint working
•	interviewed staff who plan and deliver transport for health and social care 
•	conducted focus groups with voluntary sector providers of transport for health and social care. 
6. 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
Key messages
1 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.
7. 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. 
8. 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 private and voluntary 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

9. Regional Transport Partnerships (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 part of what they do. All RTPs have established working groups on transport for health and social care issues with their partners although for some this is a recent focus.
10. 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. (See paragraphs 51 and 52 of the main report.)
11. 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 to and from health and social care services need to work together to make best use of available resources.
12. There are significant gaps in how transport for health and social care is planned, for example people’s transport needs are not routinely considered as part of planning clinic times. 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. 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. This means that there is a risk that people are left without the support they require to get to the services they need. (See paragraphs 59 to 65 of the main report.)
13. Decisions taken in one organisation can have far-reaching consequences for the services provided by another. Therefore, joint working across sectors is crucial for the successful, sustainable development of transport for health and social care. There needs to be a clearer system for organising transport resources in Scotland, alongside clarity about the roles of services and partners and how they link together so that everyone who needs transport for health and social care is able to get it. Organisations should come together to jointly plan services, share resources and evaluate whether they are meeting local needs.
2  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. 
14. 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. 
15. 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. Therefore it is not possible to compare the cost-effectiveness of different services. 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. However, transport costs are often part of service budgets such as education and social work and not separately identified. 
16. 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. 
17. Councils, NHS boards and the ambulance service spent over £93 million in 2009/10 on providing transport to health and social care services. Regional Transport Partnerships spent £85 million in 2009/10 but it is not possible to identify how much of this money was directed at transport for health and social care. (See Exhibit 4 and paragraph 24 of the main report.)
18. The ambulance service spent £201 million in 2009/10.2 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.3 (See paragraph 25 of the main report.)
19. In 2009/10, NHS boards spent over £4.5 million on transport for patients. This includes reimbursement of £2.5 million for the Healthcare Travel Costs Scheme, which is a means-tested reimbursement scheme.4 NHS boards receive money for this scheme as part of their overall budget allocation. 
20. In addition, NHS boards claimed £9.2 million from the Highlands and Islands Patient Travel Reimbursement Scheme (HITS) over the same period.5 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. (See paragraph 30 of the main report.)
21. 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 and funding is not ring-fenced and these costs are not necessarily separately identified in larger service budgets.
3  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.
22. Although transport for health and social care represents a small percentage of overall public  sector funding, there is scope for efficiency savings.
23. 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 (See Exhibit 7 in the main report.). The group is due to report in September 2011 and will consider our audit findings as part of its work. 
24. Greater coordination of transport would make things easier both for service users and providers and may also make services more cost-effective. Only two NHS boards organise transport through a central department and 18 councils have developed integrated transport units or are in the process of doing so. An integrated transport unit brings together all transport 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. (See Exhibits 5 and 6 in the main report.)
25. Without a central team 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. 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. (See paragraphs 35 to 37 of the main report.)
26. To date, there has been limited work considering the scope for sharing services including fleet, staff, procurement, and booking systems but there are some examples of good joint working at a local level. For example, the Clyde Valley councils in partnership with Strathclyde Partnership for Transport (SPT) have started to investigate the potential for shared transport for social care and fleet management. Some councils and NHS boards told us that they are planning more joint working in future. (See paragraphs 68 to 74 of the main report.)
27. The way transport for health and social care is scheduled needs to improve. Current arrangements are fragmented. In some cases partners have tried to create an integrated system in their local area, but in some areas it has been difficult to get all partners to engage and commit to improved joint scheduling. 
28. 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.
29. Work carried out in Clyde Valley 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.  (See paragraph 41 of the main report.)
30. The voluntary sector plays an important role in providing transport for health and social care in many areas of Scotland. 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.6 Councils and NHS boards should consider the voluntary sector as part of their overall strategy for commissioning transport services for health and social care. (See paragraphs 75 to 79 of the main report.)
4  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 always put in place. The public sector needs better information on individual needs and on the quality of the transport services they provide. 
31. 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.7
32. Using public transport 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 areas where buses are infrequent or not available, there are rarely any alternative transport options for people who are not mobile or do not have access to a car. This affects people in urban as well as remote and rural areas. (See paragraphs 11 to 13 of the main report.)
33. Under the current arrangements, people do not have enough information to access the transport services they need. 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. Staff also need good information so that they can make appropriate arrangements for service users. There is a need for awareness raising amongst practitioners such as GPs and clinical and social care staff at all levels. (See paragraphs 80 to 82 of the main report.)
34. There are a range of eligibility criteria in place including those within the ambulance service PTS, councils, NHS boards and voluntary and private sector providers. 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 the 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. 
35. The ambulance service is currently reviewing how the PTS eligibility criteria are being applied. Pilot work is under way to review the effect of applying the criteria more consistently. The ambulance service, NHS boards and councils need to work together to properly evaluate the impact 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. (See paragraphs 63 and 64 of the main report.)
36. Service changes have an impact on people’s transport needs, for example changes to the location of clinics or day centres. Public sector organisations must involve users to ensure that the transport services they are providing meet their needs. 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. 
37. There are weaknesses in planning for reducing funding to services. Councils, NHS boards and the ambulance service have a duty to conduct equality impact assessments where this is judged to be relevant and proportionate. Equality impact assessments can help staff make better and more transparent decisions. However, only six councils and five NHS boards told us that they have carried out equality impact assessments on service change which affects transport needs. 
38. National performance monitoring is limited to PTS activity. There were two national health standards for the PTS for 2009/10. The ambulance service achieved the first standard that 70 per cent of Priority 1 patients should arrive at hospital at least 30 minutes before their appointment, with a rate of 71.8 per cent in 2009/10.8 The ambulance service just missed the second standard that 87 per cent of Priority 1 patients should be picked up no longer than 30 minutes after their appointment. (See paragraphs 54 and 55 of the main report.)
39. There are no national targets for transport for health and social care services for other agencies, and 11 Single Outcome Agreements make no reference to these services.9 During our fieldwork, only Golden Jubilee National Hospital reported that it had assessed the impact that transport has on people not attending appointments, and no NHS board had assessed the impact on waiting times or on the number of people waiting to be discharged from hospital. 
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	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.
2	Net resource outturn, Scottish Ambulance Service Annual Accounts (2009-10).
3	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.
4	Are you entitled to help with health costs? HSC1, NHS Scotland, 2007.
5	The Highlands and Islands Travel Scheme (HITS) provides non-means-tested reimbursement to NHS boards for journeys to healthcare for people living in the Highlands and Islands. Patients’ Travelling Expenses MEL 1996 (70), The Scottish Office and Department of Health, 1996.
6	Community transport means any kind of transport provided by the voluntary sector but not necessarily using volunteers, for example, local dial-a-bus schemes or car schemes.
7	Building a society for all ages, HM Government, July 2009.
8	Priority 1 patients are those who have cancer, coronary heart disease, renal disorders, or mental illness.
9	In April 2008, following agreement of a concordat between the Scottish Government and the Convention of Scottish Local Authorities (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.