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Keeping Patients Moving

Keeping Patients Moving
8 December 2014

Last year over 7 million vulnerable patients received planned patient transport, funded by the NHS and costing just over £320million. Today this essential service is mainly commissioned by clinical commissioning groups (CCGs), rather than hospitals or now-defunct primary care trusts (PCTs). This new approach sees CCGs demanding a more varied service, delivering better quality and performance and often for a substantially reduced budget. 

Last year over 7 million vulnerable patients received planned patient transport, funded by the NHS and costing just over £320million. Today this essential service is mainly commissioned by clinical commissioning groups (CCGs), rather than hospitals or now-defunct primary care trusts (PCTs). This new approach sees CCGs demanding a more varied service, delivering better quality and performance and often for a substantially reduced budget. 

Commonly once a non-emergency patient transport service (NEPTS) contract gets underway, the patient requirements have changed compared to the original specification. Added pressures from the NHS reconfiguration and Patient Choice mean patients travel further and to more points of care than ever before. Furthermore, underlying everything else is the need for every patient to experience a timely, reliable and pleasant journey to and from their treatment. 
There are various complexities involved when putting together a specification for NEPTS and a need for a flexible and responsive provider to deliver the service efficiently. 
In order to deliver a successful NEPTS service and award the right contract, planning must start early. The contract must serve the interests of our complex healthcare system – the needs of patients and all the organisations with a stake in the process such as NHS acute trusts, community services and other specialist providers, such as mental health trusts. For example, ensuring that patients can be discharged and sent home contributes to increased bed capacity in an acute trust.
The former contract specification may not have delivered what an acute stakeholder required, and they sometimes organised their own services to supplement which added to the public spend. In Greater Manchester, acute services needed an extended out-of-hours service, and for those patients found eligible, this was organised. NEPTS can only be provided for those found eligible and our job is to make the future provision fit for all.
By working with stakeholders, procuring an adaptable and responsive provider and by sharing best practice, it is possible to improve a service that is already under tremendous pressure. NEPTS is vital for thousands of vulnerable, often elderly and isolated patients.
Effective commissioning 
Previously there were 80 contracts in the North West operated by North West Ambulance Service. Each had different service requirements, performance and quality standards. The Department of Health’s 2007 eligibility criteria were being interpreted and applied differently throughout and there was a need to move from a finance-driven to a quality-driven service with better patient focus and improved flexibility.
We needed to offer extended hours and develop specialist, community and enhanced services. Growing demand for stretcher and wheelchair assistance meant the need for more vehicles and more staff.
An extensive review was undertaken resulting in essential consolidation. Five contracts were awarded in the North West. The commissioning strategy and specifications had to drive up quality while increasing efficiency to enable the surplus monies to be reinvested into other areas of the NHS. Overall the NEPTS budget was reduced by £4m. 
One of the five contracts, Greater Manchester’s NEPTS three-year contract, was awarded to an independent provider, Arriva Transport Solutions (ATSL). All the remaining contracts were awarded to the North West Ambulance Service NHS Trust.
Commissioned by NHS Blackpool on behalf of all the CCGs in the North West, the NEPTS across the region now operates an enhanced service with more stringent performance targets compared to earlier contracts.
Case study: Greater Manchester NEPTS
ATSL was awarded the contract in October 2012 and started operating on the 1 April 2013. The service had been developed considerably compared to earlier specifications taking into account the views of patients and the need to deliver a service with better standards for all. 
The service includes:
The core service, from 8am–6pm Monday to Saturday.
The enhanced service for haemodialysis and oncology patients, from 6am–1am daily throughout the week.
The out-of-hours service (from 15 April 2013) which runs from 6pm–11pm Monday to Friday and between 8am–6pm at weekends.
Measurement and key performance indicators
The NEPTS provider is measured against 19 different performance metrics around:
Call answering.
Timely inward journeys.
Timely outward journeys.
Time on vehicles.
Complaint handling.
The more stringent key performance indicators (KPIs) proved difficult to achieve in the first few months. NHS Blackpool worked with ATSL on the apparent large gap in performance. In reality, compared to the old standards, ATSL was delivering better performance from the start but the service was not where it aspired to be. 
For example, the former standards stated 60% of patients should arrive no more than 45 minutes early or 15 minutes late for their appointment. 
The new standards require 90% of patients should not arrive more than 45 minutes early or 15 minutes late for their appointment. 
Three quarters of telephone calls received at the contact centre have to be answered within 20 seconds, as opposed to 40% under the former service. 
Formerly, haemodialysis and oncology patients received the same service as other patients. In response to patient consultation, an enhanced service was designed whereby 85% of patients can expect to be in the vehicle less than 40 minutes and 90% should arrive within 30 minutes of their appointment time. 
Working together to meet the KPIs
Between April 2013 and December 2013 the service was performing better than before and improving month-on-month. It became clear that meeting all the new, more stringent, standards was going to take time. 
For example, the majority of staff employed by ATSL were transferred under transfer of undertakings (TUPE) regulations. Although highly skilled and very familiar with their jobs, people had to be consulted about change, which takes time. Staff rotas were eventually modified to meet the new service requirements and crew resources were adapted to suit patients’ needs. 
More ambulance satellite bases opened to ensure ambulances were better able to reduce time on the vehicle for patients. New technology and systems were introduced to log completed jobs and allocate jobs faster. 
ATSL provided more training for NHS staff in the clinics and hospitals. By staff using the correct patient classifications, the right vehicle and number of carers could be assigned to the job first time. More online training sessions led to the same with the online booking service.
Engagement took place between ATSL managers and key NHS staff at a provider to provider level and a patient notification service was developed to alert patients of pick-up times so they can be ready.
All in all, working closely and in partnership with your provider is what ultimately improves the service, not only for the patients but also for those operating it. NEPTS is under pressure, just like so many NHS services free at point of care, and requires flexibility and responsiveness by both provider and commissioner. 
Lessons learned from commissioning of our NEPTS
1. Look at the whole health economy and patient flow when considering a new NEPTS contract
NEPTS is often commissioned in isolation. When considering your specification get a full understanding of the existing patient flows and how transport impacts them. How many points of care are there? When are the busy times for the acutes? How many patients are travelling out of the region for their care? All this information will make your specification as accurate as possible.   
2. Base KPIs on operational reality 
KPIs must take into account what is affordable within the cost framework available. A great patient experience is vital and new KPI regimes, especially those set in predominantly urban areas, tend to be extremely demanding. Some specifications are just unachievable and some are so tight that there is no scope for efficiencies, ie. there would only be time to transport one patient per vehicle. An operational expert can sense-check the reality of a specification whilst considering the quality aspects of the requirement.
3. Cross-boundary and long-distance journeys change resource requirements
Within most contracts, there is a requirement to undertake long-distance and cross-boundary journeys. Often, when bidding for these contracts, this type of journey isn’t recorded accurately. They are often subcontracted out. A supplier will make an assumption about the level of resource required to manage this type of journey and what is affordable to subcontract. However, even a small increase in number of these journeys will have a significant impact on a fleet of 40 vehicles. Losing one ambulance for a long-distance journey is equivalent to losing a doctor for the day. Where a long-distance journey is cross-boundary, the supplier is left to seek approvals from the cross-boundary CCG and arrange that payment, even if the home CCG contract obliges the supplier to take those journeys. We recommend treating long-distance and cross-boundary journeys differently, co-ordinating them more effectively and separately. This would lead to more efficient local PTS. 
4. Communication can’t be underestimated
The change of service provider requires significant amount of prior communication with all stakeholders including patients, carers, GPs, care homes, ward staff, staff involved with TUPE, media and many more. It is about when the service will change, what it will offer and what impact people can expect.  It usually takes at least a month to create a meaningful contact list and prepare the initial communication materials. It often takes longer to get the right people in the local hospital and stakeholder groups to agree to meet because PTS is often not considered that important compared to day-to-day business. 
5. Commissioners working in isolation
Commissioners often design the specification for contracts in isolation when they should consult one another. As a service, NEPTS could offer greater value for money if managed in a more transparent fashion. Even when procurements are led jointly, CCGs often work independently, making the management less streamlined and more time consuming. ATSL would like to propose a national NHS-led panel to help with commissioning of NEPTS. The sharing of best practice is what will secure a better service. 

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