Patient Transport Services and Damaging Privatisation

The rationale of the now discredited Health and Social Care Act embedded the idea that the NHS should be regarded as just a collection of services. Regulations required that (with some few exceptions) these services should be tendered out with independent autonomous providers, public and private, competing for the business on a level playing field. The process was overseen by the 200+ Clinical Commissioning Groups who were assumed to have the expertise to understand service requirements, run competitive tendering processes, design appropriate contracts and manage them. This “market” method meant that commissioners could not talk to providers about what might be best for patients and providers could not discuss better models as this would be anti-competitive. Quality of service would be managed through contracts and overseen by the Regulator (Care Quality Commission).

A study by UNISON into the problems some staff faced when their jobs in Patient Transport Services  were transferred from the NHS to private providers turned out to be a valuable insight into wider problems in our NHS caused by this “market” viewpoint.

Patient Transport Services

It has always been part of the NHS that, for some patients transport, would be free with the obvious example of any response to a 999 call. But there were also Patient Transport Services to take patients to and from an outpatient appointment or to take them home after discharge. At the time the ambulance services moved into the NHS in the early 1970s they were regarded as the transport providers1 – quick scoop and drop to A&E and a slow journey to outpatients or to home.

Since 2012 there was an acceleration in the outsourcing of the Patient Transport Services away from the traditional providers and UNISON studied the consequences.

Many staff transferred from the NHS into private providers had very poor experiences. There were also a series of very well documented failures with disruption to services and considerable inconvenience to patients. Some providers that moved into the Patient Transport Services “market” were wholly unsuitable and soon proved unable to cope. Some providers with a questionable record are still winning contracts and reports of poor practices continue. Some more reputable providers entered the market, tried hard but discovered that profits were not to be forthcoming.

Feedback from the staff impacted by privatisation was either neutral or angry. In almost no instances were any staff positive about their experience. Some staff who were moved out then back into the NHS expressed the opinion that they had been rescued from the Titanic. Such evidence as is available, and it is limited, shows that there is no improvement in services because of competition, no innovation coming from new providers but many examples of very bad patient experiences; issues being caused by organisational problems rather than by treatment by staff which is almost universally praised.

Emerging conclusions in the UNISON study are that commissioners had poor understanding of the requirements even for the simpler transport situation and no understanding of the strategic possibilities of how transport fitted into a bigger picture. Many looked for low cost solutions, almost as if this was a taxi service. There were far too many small and different contracts generated by multiple CCGs; there was a huge variety in Key Performance Indicators – no attempt was made to have a simpler national template with a few local variations.

Contracts were awarded to totally unsuitable providers. The Coperforma saga in Sussex is the extreme example where major issues with a Patient Transport Services contract (signed off by 7 CCGs) were apparent within days of the contract start. It was clear no appropriate due diligence could have been done and an independent report highlighted how poor the process of procurement had been. In another well reported case the contract with a provider had to be terminated when it was discovered that reporting had been less than honest.

Elsewhere it became clear that contracts were badly drawn up even in one case failing to include the correct geographical area to be covered! Because of inadequate contracts there were disputes between commissioners, providers and hospitals about who paid for what – with the poor patient stranded. Ambulance services lost contracts but kept some costs and assets. Contract monitoring is not well developed and inspection by CQC is superficial (the CQC are seeking help with improving this). Commissioners looked at a narrow view of costs savings and failed to do any whole system analysis of the costs and benefits.

But even if all that were not true the bigger issue is that most commissioners are still looking at services in isolation. With a couple of notable exceptions they are not looking at the opportunity of reducing fragmentation and taking a wider system view.

If this sounds familiar then that is because the farce around NHS 111 (and to a lesser extent NHS Direct and GP out-of-hours) has many similarities. The NHS does not learn!

So tactically this process of outsourcing of Patient Transport Services has failed on any sensible economic test. The strategic opportunities have also been missed; so we would hope for better solutions in the new STP world of collaboration and cooperation. Sadly no STP addresses properly either PTS or the role of the Ambulance Services as the integrators of urgent and emergency care.

1 There have always been some private providers of some non-urgent patient transport and some hospitals have used their own service. But until the era of markets the service was predominantly provided by ambulance services alongside and possibly loosely attached to the blue light 999 service.