Patients On Wheels Report From 2000

Date
28th January 2017
Type of archive
Publications
File Download Patients on Wheels CHC April 2000.compressed v2.docx (1.73 MB)
,

Transport and access to health services in Cornwall

April 2000

Table of contents

Foreword by Neil Burden, CHC Chairman

1. An overview

1.1 Aims of this study

1.2 Methods use

1.3 Summary of findings

1.4 Summary of recommendations

2. Where we started from - the background

2.1 Cornwall - population spread and distances

2.2

Transport services currently available 

11

3.

Where we went - our methods

12

3.1

Survey of voluntary car services 

12

3.2

Survey of outpatient clinic attendees 

13

3.3

Survey of practice managers 

14

3.4

Public transport journeys with Cornish MPs 

15

3.5

Consultation and views from the public 

17

3.6

Discussions with health care providers 

19

3.7

Background of research in other areas 

26

4

What we found when we got there - our findings in detail

24

5

Where we go from here - our recommendations in detail 

25

 

Concluding remarks from the project group

27

Appendix 1

Statistics 

29

Appendix 2

Survey of Voluntary (Independent) Car Services 

32

Appendix 3

Survey of outpatient clinic attendees 

36

Appendix 4

Survey of General Practice Managers

40

Appendix 5

Public Transport Journeys with MPs: full reports 

 

Appendix 6

Consultation - letters from the public 

49

Appendix 7

References 

50

Appendix 8 Acknowledgements51

Abbreviations used in this report

Accident and Emergency department

CABCitizen's Advice Bureau

C&loSHÅCornwall and Isles of Scilly Health Authority cccCornwall County Council

CCfVCornwall Centre for Volunteers

CCHCCornwall Community Health Council

CHCCommunity Health Council

CHIBSChristian Helpline for Breage and Sithney

CHINChristian Helpline for Newlyn

CHTCornwall Healthcare NHS Trust

CPRECouncil for the Protection of Rural England

CRCCCornwall Rural Community Council

DGHDistrict General Hospital

DNADid not attend

DETRDepartment of the Environment, Transport and the Regions

ECRTPEast Cornwall Rural Transport Partnership

General Practitioner

HAHealth Authority

HAZHealth Action Zone

MPMember of Parliament

OAPOld age pensioner

ONSOffice for National Statistics

PCGPrimary Care Group

PHTPlymouth Hospitals NHS Trust

PTSPatient Transport Service

RCHRoyal Cornwall Hospital (Treliske)

RCHTRoyal Cornwall Hospitals Trust

WASTWestcountry Ambulance Services Trust

WCHWest Cornwall Hospital

WRVSWomen's Royal Voluntary Service

Please note: the information in this report is accurate to our knowledge at the time of printing, please consult the relevant organisations for full details.

Percentage figures in tables may not add exactly due to rounding.

FOREWORD

I am pleased to be able to recommend this report to you, which is an in-depth investigation, carried out by members of Cornwall Community Health Council, into transport and access to health services in Cornwall. As you read this excellent report you will quickly grasp the depth of Cornwall's transport problems and the huge effect it has on those endeavouring to access healthcare.

You, like myself, have experienced, and have heard of many anecdotal stories of individuals encountering great difficulty and even trauma in getting to appointments at outpatient clinics and the acute hospitals. The problem is made worse for the low paid and the elderly, who do not have access to their own or family transport. This, in itself, creates worrying and stressful family circumstances.

The rurality of Cornwall, as all local people know, is exacerbated by deep valleys and estuarine tidal inlets, besides the effects of sparsity and pockets of low income and poverty.

My sincere thanks are extended to the project group members (Marna Blundy, (Chair), Mary Draper, Jasmine Holmwood, Alex Bryce, John Payne of the CHC, and Dorothy Rogers of Age Concern) for their purposeful and dedicated hard work and to Mary Lunnen for facilitating and holding the whole project together. Also special thanks to all those throughout the county who have co-operated in drawing the facts and figures together.

In recommending this report, I feel there is an urgent need for society to work closely with those providing NHS services to enable patients, wherever they may live in Cornwall, to have full access to all healthcare facilities.

 

NEIL BURDEN

Chairman

Cornwall Community Health Council

 

1 . An overview

1.1. Aims of this study

At the 1999 Annual General Meeting the members of the Cornwall Community Health Council agreed that a major concern for patients within the county was the issue of access to health services. Therefore a project group was set up to study and report on this.

The original terms of reference were:

To investigate the equity of provision of health care to all the residents of Cornwall when issues of cost and availability of transport (public or private) are included.

To investigate access to health services for all with particular attention to the needs of the elderly, and families with young children.

1.2 Methods used

The project group used a range of methods to collect information, both factual and the views of organisations and individuals, on the current situation with regard to patient access to health services in Cornwall.

These methods included:

  • Surveys: six voluntary car services (Age Concern, WRVS, CCfV, CHIN, CHIBS and the Red Cross), looking at well over 200 journeys in the week commencing 19 July and following up some individual case studies
  • Visits: to outpatient clinics at Treliske, Bodmin, Camborne/Redruth and Stratton Hospitals, interviewing around 260 patients
  • Interviews: with practice managers in 21 GP surgeries across the county, asking for information and opinions about transport issues
  • Journeys: on public transport with all five Cornish MPs from their constituency bases to Treliske or Derriford hospitals
  • Consultation: seeking the views of the general public through articles in local newspapers, and of the five Primary Care Groups
  • Discussions: with health care providers including RCHT (Deputy Director of

Nursing, Waiting List and Business Managers), CHT (Community General

Manager) and WAST (PTS and ambulance liaison)

    • Research: into work done in other areas such as Dorset, Wiltshire, Norfolk, and Cumbria and by the Rural Development Commission
  • 1.3 Summary of findings
  • Travelling to access healthcare is a small problem for the majority, but a huge problem for a minority
  • The vast majority of patients travel to healthcare services by private car, but up to half of these have to ask a relative, friend or neighbour to drive them
  • Access to healthcare by public transport is at best difficult, at worst impossible
  • Information for patients about transport is poor and inadequately coordinated
  • The cost of transport is a real concern, not only for those on benefits who receive only partial reimbursement for car journeys but also for those on pensions or low incomes who do not qualify for any help
  • There is a tendency for all agencies, whether health, social services or county council, to assume that any responsibility for transport should lie with someone else and not with themselves
  • Practices provide a wide range of services at their main bases (for example, chiropody, physiotherapy, etc), but it is not possible to provide this range of services in the outpost surgeries which are sometimes held in outlying villages.
  • Little research has yet been done into the reasons why some people do not attend for appointments
  • We therefore conclude that the provision of healthcare to the residents of Cornwall is not equitable, and depends upon where you live, your ability to travel and your financial circumstances

1 .4.Summary of Recommendations

These can be summarised in three key headings:

Communication

  • Healthcare providers should develop procedures for ascertaining the transport needs of their patients.
  • Patients thus found to have transport needs should be identified in all patient records, to enable all healthcare providers to take this into consideration.
  • Healthcare providers should provide clear information to all patients of any entitlement to assistance as well as details of public and voluntary transport.
  • Rules for reimbursement should be clear, and uniformly applied.
  • Providers should also explain to patients why they might have to travel to distant locations for treatment.
  • Sign-posting schemes should be developed further, and initiatives such as a single free phone information number for all transport enquiries should be supported.
  • Patients should ensure that they communicate their needs, and their preferences for locations and times of treatment.

Consideration

  • Health services should be provided as close as possible to the patient
  • There is a need for both healthcare and transport providers to be sensitive to the possible transport needs and problems of patients.
  • It is important to consider the impact of issues such as:
  • long trying journeys  travelling without an escort at a traumatic time  the timing of appointments
  • the difficulties encountered by the elderly and infirm in using public transport (the comfort of buses, access for the infirm, the siting of bus stops, etc).

• Consideration of both patient needs and environmental factors should combine in a desire to reduce the need to travel and to provide services as close as possible to the patient's home.

Co-operation and Co-ordination

e The co-ordination of existing information held by different bodies needs to be improved, and funding for transport awareness and sign-posting projects should be further encouraged.

  • Voluntary transport schemes should work to integrate their services more closely, to standardise their charges, and to publish a Community Transport Directory - such as that being prepared by Helen Renfree, CRCC.
  • Partnerships should work together to explore innovative ways of improving access to health services - we have a number of suggestions in our detailed recommendations. (See Section 5)

 

2. Where we started from - the background

Transport is a problem in many rural areas of the country, and often those with most difficulty gaining access to transport services are those with greatest need of access to health services. When this is combined with a national policy of reducing the use of private cars, real dilemmas emerge. (Though the statement by Transport Minister Lord McDonald (November 1999) recognising that car ownership would continue to increase does appear to indicate a change in this policy).

The CPRE (Council for the Protection of Rural England) in t Rural Services: a framework for action' (September 1999) suggest that local and national government should promote ? transport modes that steer a middle course between the economies of scale but inflexibility of conventional bus and rail services, and the flexibility and customer responsiveness of the private car. ' Suggestions in this report by the CPRE include:

  • Small buses with a capacity to make detours to respond to requests phoned in to a central control centre by rural residents.
  • Transport brokers which seek to match demand and supply across a variety of providers and passengers
  • Incentives to car-share and car-pool where conventional public transport is unavailable.

Cornwall County Council has recently conducted a consultation procedure on the Local Transport Plan. There is very little consideration given in the document to health issues, but in the section 'Access for all', one of the key targets of the plan is stated to be:

'Reduction in the number and percentage of persons who experience difficulty in accessing essential services' (p. 93)

Another of the key aims is the reduction of the need for travel (p. 21 ), particularly by private car. This may be a laudable aim, but conflicts with the increasing centralisation of health services in the District General Hospitals (DGHs). As has been shown by this study, this centralisation has caused an increase in the number of journeys necessary, and usually residents of Cornwall who need to access health services have no alternative but to travel by private car.

2.1 .Cornwall - the vital statistics

2.1 .1 Geography

Cornwall is a rural and maritime county. Its population of 488,500 remains, despite improvements in transport infrastructure, relatively isolated. There are only nine towns with more than 10,000 population, and none with populations over approximately 20,000. About two thirds of the population live in smaller towns, villages and the rural areas. The county has a long coastline and only one border, with Devon. Health and other public services are therefore required to be delivered almost solely from within the county, with residents in the east of the county looking to Plymouth for their health services and a tiny proportion of residents in the far north of the county looking to North Devon for their health services.

 

District General Hospitals

Treiiske

Derriford

Barnstaple

Exeter

Torbay

Homes of selected CHC Members:

St lust

Mullion

Bodmin

Launceston

Boscastle

 

 

 

    
       

 

 

 

    

 

 

 

 

 

 

  

 

 

A patient in the far west of Cornwall has to make a round trip of 70 miles to reach the District General Hospital at Treliske in Truro, and 174 miles to access specialist services at Derriford in Plymouth.

A resident in Boscastle on the north coast has a journey of 90 miles return to Truro, and 100 miles return to Plymouth.

Residents in locations such as Mullion on the Lizard peninsula, Bodmin or Launceston have to undertake round trips of approximately 60 miles to access their nearest District General Hospital.

As well as access to hospital services, travel to GP surgeries is also an issue in rural areas. Practices provide a wide range of services at their main bases (for example, chiropody, physiotherapy, etc.) and even where branch surgeries are held in villages, it is not possible to provide the full range of services there.

2.1 .2 Poverty and deprivation

Cornwall's Gross Domestic Product per capita is 69% of the European Union average. It has been granted Objective One funding in recognition of its relative poverty and deprivation. Carrick, Kerrier and Penwith contain nine of the ten poorest wards in Cornwall. In the four poorest wards in Cornwall more than a quarter of all households live in poverty. All are in West Cornwall.

(Details taken from the C&loS Health Improvement Programme 1999-2002)

 

 

 

  
     
     
     
 

 

  

 

As the map above shows, even in the wealthier areas of Cornwall, over 16% of households have incomes of less than €10,000 a year, and there are pockets where the situation is much worse than this. According to many measures of deprivation, Cornwall is rated among the worst areas in the country.

The funding allocated for healthcare in Cornwall is lower than in many other areas of the country. Cornwall and the Isles of Scilly Health Authority spends E648 per head of population, in contrast to E1204 in the Western Isles, (the highest allocation) and €506 in Cambridge and Huntingdon (the lowest). (1999/ 2000 allocation figures from Channel 4 Television, 'The Sick List', programme website at http://www.channe14.com/nextstep)

2.1 .3 Population

The total population of Cornwall is 488,500 (Source: ONS 1998 mid year estimate).

25

0 20

23

0-19

Cornwall 

24

20-39

Distribution

27

40-59

21

60-79

80+

In mid-1998 25 percent of Cornwall's population were over 60 years of age, 23 percent were under 19. These are the two sections of the population most likely to have difficulty in accessing transport. (See also Appendix 1, Tables 1.1 & 1.2)

For comparison, the latest figures for England and Wales as a whole which were available to us at the time of writing are for mid 1997 when 15.8 percent of the population were over 65 years of age, compared with 20 percent over 65 in Cornwall.

In 1991, 24.5 percent of all households in Cornwall had no access to a car. (Appendix 1 , Table 1.3). There are some differences between the different district council areas of Cornwall. For example, in Penwith the proportion of households with no access to a car was over 32 percent, whereas in Caradon this figure was 20 percent. The figure for England and Wales at the same time was over 33 percent of households having no access to a car, but of course this includes urban areas with extensive public transport services.

Even though car ownership in Cornwall is relatively high, (and this hides the age and condition of the vehicles which is much less satisfactory than in other areas of the country), between one fifth and one third of households have no access to a car.

14.5 percent of people in Cornwall were recorded as having a limiting long-term illness in the 1991 Census (compared with 13.1 percent for England and Wales). Again there are variations, with Penwith having the highest level (16 percent), and North Cornwall the lowest (13.5 percent). (Appendix 1, Table 1 .4)

It is not valid to compare the two measures directly but it is interesting that the area with the highest level of long-term illness also has the lowest level of access to a car.

2.1.4 Unemployment

Cornwall has an above-average rate of unemployment. Traditional industries such as agriculture, china clay extraction, tin mining and defence, have undergone a severe decline, and farming and fishing incomes have fallen.

In January 1999 the unemployment rate in the county was 6.3%. This compares with 4.8% in the UK and 3.7% in the South West Region. However, it is important to note that

  • The figures quoted relate only to people in receipt of benefits - various estimates calculate the true number of unemployed people as being much higher
  • The extent of the unemployment situation in Cornwall is masked by the good figures in other parts of the South West when an average for the South West Region is calculated
  • The employment rate varies according to the area and the season, with tourism offering temporary employment in the main holiday areas during the summer season - this seasonal employment however does not offer long-term security to the workforce who are thrown back onto benefits for the winter months.

Thus Newquay had 1 1.4% unemployment in January 1999, dropping to 5.8% in

July 1999. However, Launceston had 3.5% in January 1999 and 3.2% in July 1999. Falmouth's figures were 7.1% in January 1999 and 6.7% in July 1999

Unemployment blackspots such as Penwith, Helston and Camelford all had levels over 9% in January 1999

(see Appendix 1, Table 1.5)

2.2. Transport services currently available

Services currently available to the people of Cornwall in making journeys to access health services include:

  • the main railway line from Plymouth to Penzance, with the remaining branch lines offering a variable level of service,  a network of bus routes with a number of operators  taxis  private cars
  • voluntary (independent) car services - for a which a charge of between 25p and 30p per mile is made
  • passenger transport services (both ambulances and hospital cars with volunteer drivers) provided by the Westcountry Ambulance Service Trust (WAST) - available only to certain categories of patient, assessed by medical condition
  • 'Dial-a-ride' Schemes being set up in various areas, such as Gorran

(Community Minibus) and Saltash (East Cornwall Rural Transport Partnership).  air  bicycle  on foot

Help with transport for residents in Cornwall is only available to two groups of people:

  • those who are considered "unfit to travel by other means" and who have their transport arranged by the ambulance service
  • those in receipt of benefits such as Income Support and Family Credit, who can claim help with travelling costs by going to the General Office at the hospital and presenting their ticket or receipt proving what they have paid, plus their benefit book.

Patients who qualify in this way are reimbursed as follows:

  • the full cost of travel by public transport
  • the full cost of the taxi fare to the nearest point of access to public transport, if the patient does not live close to a bus stop or a railway station
  • a contribution of 10p per mile for transport by car (but note that if the patient has no car of his own and has to use a taxi or voluntary car service, the reimbursement in no way matches the charge made - up to 30p per mile for voluntary car schemes, and even more for taxis)

Patients are advised to contact the General Office at the hospital they have to attend to find out the latest details of the rules for reimbursement.

However, every Isles of Scilly resident is apparently entitled to payment of ALL travelling expenses necessarily incurred in making the entire journey between the Isles of Scilly and any hospital in England and Wales, less only the first E5 of such expenses. The RCHT meets the cost of these journeys from its overall budget allocation. This is clearly an inequitable situation, as patients resident throughout Cornwall have to pay their full transport costs unless they are on benefits or have transport arranged by the ambulance service.

 

 

4

3 Where we went - our methods

As described earlier, it was decided to use a range of methods to investigate the issue of patient access to health services, full details are given below.

3.1. Voluntary car services

There are a number of voluntary (independent) car services available to patients in Cornwall. Some are very local such as CHIBS and CHIN; others cover a particular area, such as the WRVS service in Restormel; some, such as Age Concern and the Cornwall Centre for Volunteers, aim to cover the whole county.

The following volunteer car services agreed to participate in a study during the week of 1 9th July 1999:

  • Age Concern (Bude and Truro)
  • Cornwall Centre for Volunteers
  • CHIN (Christian Helpline in Newlyn)
  • CHIBS (Christian Helpline in Breage & Sithney)
  • Red Cross
  • WRVS

A questionnaire form (see Appendix 2) was distributed. This was completed by the staff and volunteers manning the phones during the week as they took calls from people booking a car for transport to hospital or GP's surgery.

208 questionnaires were completed covering people who were paying for their own transport (cash jobs' as they are known, as distinct to contracts for the Health Authority, WAST or Social Services).

These were split between the different volunteer car services as follows;

  • Age Concern - total 67

Bude - 51

  • Truro - 16
  • Cornwall Centre for Volunteers - 36
  • CHIN (Christian Helpline in Newlyn) - 17
  • CHIBS (Christian Helpline in Breage & Sithney) - 2
  • Red Cross - 0
  • WRVS - 41

Age Concern Bude, and the WRVS (Restormel) were particularly active in supplying transport to local health centres and surgeries, most at the minimum charge. This varies between areas and whether the driver waits with the patient, but is around €3.00 or less.

The rates charged per mile are between 28p and 30p. This is aimed at refunding the volunteer drivers for fuel costs and a contribution towards running costs. The mileage is calculated from the driver's home rather than from the home of the passenger. This can add to the difficulties experienced as shown by the case study below:

A Tintagel patient has extremely bad rheumatoid arthritis and walks with difficulty on two sticks. She travels from Tintagel to the East Cornwall hospital in Bodmin regularly and uses the Age Concern voluntary car scheme. If the driver comes from Tintagel it costs CIO return, and if she can share the car, the fare is €5 each. If the driver comes from Boscastle the fare is El 1, and if the driver comes from Crackington Haven the fare is between E16-E18. When she has to go to Treliske the fare is E27. She is not on any of the benefits that qualify for a partial refund and has to pay everything herself.

(For more detail of case studies see Appendix 2)

3.2.Survey of out-patient clinic attenders

CHC members and staff visited out-patient clinics at Royal Cornwall Hospital, (Treliske), East Cornwall Hospital (Bodmin), Camborne/ Redruth Community Hospital, and Stratton Hospital. The clinics included haematology, orthopaedics, rheumatology, opthamology, surgical and urology.

The questionnaire (see Appendix 3) investigated the means of transport used, the distance travelled, and whether the patient was able to claim any reimbursement. The full results of the survey are included in Appendix 3.

A total of 259 patients were interviewed. 43 percent travelled more than 10 miles, 13 percent more than 20 miles.

Distances travelled to clinics

 

 

 

0

 

 

 

  
         
         

(For comparison: in a study by West Dorset Community Health Council in 1996, 63 percent of patients had travelled more than 10 miles to a clinic, 16 percent more than 20 miles.)

Of those interviewed, 85 percent travelled to the clinic by private car. Of these, around half had to ask a relative, friend or neighbour to drive them. In many cases this was difficult, sometimes family members had to take leave from work or lose pay in order to do this. Some patients commented that they could ask neighbours for a lift occasionally but felt they were imposing too much if there was a need for regular transport or if the journey was a long one.

I cannot get reimbursement even though an OAP as I am not on income support. I hope the new Bodmin Community Hospital will mean more access to seruces locally in the area. "

My husband drove, but he is self-employed so it costs him money to take the time off

We have only one car in the family. My husband had to borrow a car to go to work so I could keep my appointment.

There are only two buses a day where I live.

IfI did not have a car the only bus is on a Wednesday, at 10.15, back at 1.15. 1 could not have managed if my neighbour had not been willing to take me. I didn't know about the voluntary car services.

Crossing the dual carriageway to the bus stop is very dangerous, especially after dark, no zebra crossing, I live in Newquay and the consultant was there lust week but I couldn't get an appointment so had to travel to Treliske. Car service cost El 0.00, E3.30 refund as I am on income support.

 

I got a liftfront Penzance, will catch train home, We've got to manage somehow.

 

Thefree voluntary system Was abused, but we do need a service for those who really cannot afford it. Perhaps a fixed price. It should be paid direct instead of the patient having to pay and collect reimbursement.

 

 

Few people were entitled to reimbursement for transport, and even amongst those who were, several did not bother to claim. One young mother mentioned it was too difficult to go to the General Office with her child when he had already been hanging around for a long time.

3.3.Survey of practice managers

The questionnaire (see Appendix 4) included questions covering the hospitals most frequently attended by patients from the practice, the number of patients who ask for assistance in arranging transport, and asked for other comments that the practice manager thought relevant.

21 practices were interviewed out of 79 in total. These were spread fairly evenly across the county as shown in (see Table 4.1 , Appendix 4)

The hospitals used by the practices showed a predictable distribution, (Table 4.4), several practice managers mentioned that their practices referred patients to local clinics whenever possible.

When asked what mode of transport their patients used to attend out-patient clinics, most practice managers could only give a vague answer. In the Camborne/Redruth district, one of the worst areas of social deprivation in

Cornwall, the person interviewed was aware of a low level of car ownership.

All the practices interviewed had some information available on the voluntary car services, though often only one at each practice. Sometimes details of charges were available, and patients were normally warned that they would have to pay for these services.

All practices were enthusiastic about the idea of a central contact number to book voluntary car service transport. 

Open comments included:

  • 'deprived area, many problems' (Redruth)
  • 'many people ask for transport when they have a car or family who could drive them' (Stratton)
  • 'The free voluntary system was abused, but we do need a service for those who really cannot afford it. Perhaps a fixed price. It should be paid direct instead of the patient having to pay and collect reimbursement.' (Bodmin)
  • 'Patients should let the hospital know if they can't afford transport' (Camelford)
  • 'Charges vary between the voluntary car services - some charge for a second person travelling with the patient.' (St Ives)
  • 'Patients should be aware that it is their own responsibility to arrange transport.' (Illogan)
  • 'Transport is a major problem for the elderly, if on benefits they have no ready cash to pay with even if they are reimbursed, and there is the discrepancy between the cost and the level of reimbursement. ' (Newquay)
  • 'It is difficult to get to Derriford - lack of a bus service.' (Callington)

3.4. Public transport journeys with Cornish MPs

All five MPs agreed to take part in the research and trips were made with CHC staff and members from a point within the constituencies to either Treliske Hospital or Derriford Hospital.

Summary of details:

Public transport journeys with Cornish MPs

 

Matthew

Taylor

Cdlin

Breed

Andrew George

 

Candy

Atherton

 

St Dennis

Polruan

Sancreed

Launceston

Kehelland

 

RCHI

RCH

RCH

Derriford H.

RCH

Distance by road

One way, approx.

19.5 miles

36 miles

30 miles

29 miles

il miles

Cost by public transport?

0.90

E8.40

€10.00

€4.60

€4.45

One way-travetting ime

1 hr 40 mins

2 hr 30 mins

1 hr 30 mins 

1 hr 35 mins 

1 hr 30 mins

Total time needed for return trip and appointmene

4 hrs 45 mins

6 hrs 45 nuns

6 hrs 10 m Ins

8 hrs 

Not possible in one day4
  • Royal Cornwall Hospital, Treliske
  • Return fares are given, in some cases fares are more if travelling before 9.00

a.m.

  • Allowing one and a half hours in the hospital.
  • It is not possible to get back to Kehelland by public transport on the same day with enough time to attend an appointment.

Charges vary between the voluntary car services — some chargefor a second person travelling with the patient.

 

'The journeyfrom St Dennis to Thuro shows how a modern bus can be confortable and pleasant, but in it took almost two hours to reach Treliske. We missed our connection, and an elderly person would havefound it hard work to negotiate steps and get across the Treliske site. This shows how centralising services in nuro carries real problemsfor the one in five Cornish people who do not have access to a car.

Matthew Taylor MP

 

 

Full details of the trips are given in Appendix 5.

Matthew Taylor travelled from St Dennis to

Treliske involving a change of buses at Lemon

Quay and experienced a delay due to the St Dennis bus arriving late causing the connecting service to be missed.

Natthew Taylor MP and Mary Draper, CHC member, at St Dennis

Colin Breed travelled from Polruan, taking the ferry to Fowey, bus to Par Station, train to Truro, and bus to Treliske.

Colin Breed MR alighting from the Po!ruan Ferry at Fowey

Paul Tyler travelled from Launceston to Derriford, with a change of buses at Yelverton necessary to avoid a long walk and having to cross a busy main road at Derriford roundabout.

Paul Tyler MP, and Jasmine Holmwood, CHC member, at

Yelverton

Andrew George took part in an exercise illustrating the difficulty of travel from Sancreed to Treliske Hospital, travelling from Hayle to Truro by train, and from Truro Station to Treliske by bus.

Andrew George MP, and John Payne, CHC member, at the bus stop at Truro Station

Candy Atherton arranged to meet project group members at Treliske after they had travelled with two Labour party volunteers (Mr and Mrs Don Clarke) from Kehelland to Treliske, changing buses at Camborne and having to walk from the main road into the hospital site.

Mr and Mrs Clarke at Kehelland

The main points arising were:

Wide variation in standard of buses in terms of:

  • accessibility for wheelchairs and those with mobility problems
  • comfort of the journey - some were very noisy and bouncy (partly due to road surfaces)  helpfulness of drivers

 Patients from many parts of Cornwall would be unable to reach RCH Treliske or Derriford Hospitals for an appointment before 11.00 a.m., and would have difficulty returning home the same day in some cases (e.g. Boscastle, Kehelland)

  Cost of public transport varies considerably, some routes are subsidised and have lower fares than shorter, unsubsidised routes.

e The difficulty of obtaining timetable information from the bus companies:

  • lines always engaged
  • being referred to a different office  enquiry offices in Cornwall not having details for a 'cross-border' journey when travelling to Derriford Hospital

3.5. Consultation and views from public

In response to publicity in local papers covering the whole of Cornwall, ten letters were received from members of the public. Details of these are included in Appendix 6. Some useful suggestions were made, for example:  

• Free 'taxi-pass' (with photo-ID) for all OAPs requiring regular on-going hospital treatment who live in areas without a direct bus service to hospital

 

'Anyone attending an appointment at Treliske from anywhere west ofPenzance or soulh of Helslon would most likely need to commit whole day to the one event. (if travelling by public transport) Andrew George MP

'Those sectors ofthe population most in need of expert-delivered or mediated health care are precisely those groupsfind travetling most difficult' Lindley Owen, CE,

Restormel PCG

 

'I do not own a car and do not drive, myfamily is not close by, and I cannot expect neighbours, however willing, to take me and perhaps hace a long wait before returning. Because of the timing of rny appotntments it was not convenient to use public transport, and in any case it is not easy to leave RCH by bus as crossing a main road is so dangerous at that point. '

(St Ives resident)

 

'In my opinion these costs should be fully recognised, both by you (the CHC) and also by the central government. They do, in fact, become an additional tax on the ill. ' (Penzance resident)

 

  • Pressure to be applied to local bus companies to provide direct services to/ from all hospitals within the county
  • More healthcare services provided in the home to reduce the need for travel
  • Drivers should be available to drive people who have their own cars but are unable to drive them.
  • Each patient should be responsible for the cost of travelling to their nearest hospital and the NHS should provide free shuttle transport between the nearest hospital and any other hospital or healthcare facility in the county or beyond. (This also to be available to NHS staff thus reducing traffic congestion)

Other letters contained complaints about centralisation of healthcare in Truro Can additional tax on the ill' ), the cost of even the voluntary car services, the problems of visitors (particularly elderly spouses) paying for transport for regular visits

Each of the five Cornish Primary Care Groups (PCGs) was invited to comment. Responses were received from:

North Cornwall PCG: from Phoebe Stileman, Partnership Manager. The PCG's view that is that it favours the approach of influencing other initiatives such as the County Council Local Transport Plan and the East Cornwall Rural Transport Partnership.

Restormel PCG: a very detailed reply from Lindley Owen making a number of points, in conclusion stating:

'The need to travel is one of the prices paid by country dwellers. Those sectors of the population most in need of expert-delivered or mediated health care are precisely those groups who find travelling most difficult. It costs the NHS more to provide a local service than a centralised one. So, unless or until the funding formula is changed to reflect true costs, the NHS in Cornwall would appear to be condemned to provide either less good care where it is needed or good care in places where, for many, it is difficult to reach. For this reason it is important that we use such advantages as we have, not least the HAZ and Objective One initiatives, radically to modernise our health care delivery systems, to minimise the drawbacks of distance. '

West Cornwall PCG: reply from Ann Stone, who has done some work on transport issues for the PCG, including meetings with CHT (Sid Deeble), West Cornwall Healthwatch (Marna Blundy), and telephone interviews with practice managers. The letter says that the PCG currently has no active work on-going as it would be a duplication of effort, and also that:

eThe service review currently being undertaken by the health economy will work towards more accessible health provision, wherever possible, in accordance with clinical governance and equitable affordability across the county.

West Cornwall Healthwatch: Also a detailed letter was received from Coordinator Marna Blundy, with points made in response to the CCC Draft Transport Plan for Cornwall. The comments made cover three key areas:

  • Reducing the need to travel: the view of West Cornwall Healthwatch is: "We particularly support this key objective in the Cornwall County Council Draft Transport Policy. This will necessarily involve the NHS reversing its policy of centralising services, especially on the Treliske site in Truro. "
  • Integrating and improving public transport: a number of points are made in relation to the public transport services from West Cornwall to Treliske Hospital.
  • Considering individualised transport schemes: examples given are dial-a-ride schemes, more assistance to voluntary car services, subsidies for taxis to take part in an integrated scheme.

3.6.Discussions with health care providers

Staff concerned with transport issues in various health care organisations assisted with this study, including:

  • Hilary Clarke, Deputy Director of Nursing, RCHT

 Les Slade, Group Station Officer, Westcountry Ambulance Service Trust (WAST)  Andrée Trethewey, Transport Liaison Assistant, WAST at Treliske:

Stella Ellis, Patient Waiting List Manager, RCHT, and Angela Davey, Assistant Patient Waiting List Manager

 Sid Deeble, Community General Manager, Kerrier/Penwith/ Isles of Scilly, CHT

Pam Rabbett, Carers' Co-ordinator, Cornwall Rural Community Council

During these discussions several key areas were highlighted:

The WAST Patient Transport Service (PTS)

  • the Patient Transport Service can only take those patients entitled to free transport on medical grounds
  • clear ground rules and procedures are required for eligibility criteria and ordering of transport.
  • need for training of staff in application of the rules to ensure consistency and fairness.
  • abuse Of the system is a concern, such as people obtaining free transport when a family member was available with a car.

patients themselves should have clear guidance as to their entitlement.

  • GPs will also require training as they are responsible for evaluating entitlement for the first referral appointment and booking transport if applicable.

Management of waiting lists and booking systems

  • the booking systems staff are aware of the problems of distance for patients in Cornwall.
  • attempts are being made to introduce extra flexibility - for example, all appointment letters give a phone number for the patient to call if the time and day is not convenient

'I really do feel that some special arrangement should be madefor North Cornwall. We are a long way away

from any of the main hospitals, and we have to pay much more to get to them than in other areas. ' (Bude resident)

 

  • appointment letters also give information on the reasons for an early morning appointment, perhaps that tests are needed before a day surgery procedure, etc.
  • the transport problem is a complex issue and it is difficult to arrange public transport that can serve patients' needs. For example, a bus service from Redruth to out-patients clinics at Camborne/Redruth Community Hospital had to be withdrawn due to lack of use.

an investigation was made into reasons for DNAs ('did-not-attend') at Launceston clinics, but transport did not feature as a factor, the majority stating they 'forgot' or 'felt better'.

car-sharing schemes may be a possibility but there is an issue of patient confidentiality.

  • there does not seem any immediate prospect of the introduction of direct booking of appointments by GPs such as has been publicised in the media recently

Visitors and carers

Although this study is concerned with access to healthcare for patients, the CHC project group is of the opinion that visits from family members have an important part to play in the recovery of patients.

  • patients' recovery can be delayed by isolation when family are unable to visit regularly
  • health of the carers themselves is also an important issue which can be adversely affected by transport difficulties
  • currently there is only one taxi in Truro with wheelchair access (though the rules applying to new taxis have recently been changed to make this compulsory)
  • those involved with patient transport are unable to offer any assistance to visitors

Reducing the need to travel

There are some initiatives underway that can play a part in reducing the need for travel and sometimes remove it altogether. These include:

  • NHS Direct - phone advice service can assess patients with concerns and advise the best course of action, so possibly saving unnecessary trips to GPs or A&E departments.
  • Telemedicine: (use of camera and video images relayed by computer link, either live or stored and forwarded) - can provide expert consultations quickly at very little cost. A pilot project is linking minor injuries clinics at St Austell, Launceston, Liskeard, Stratton, Newquay and Bodmin to at Treliske. 

3.7. Background research of work in other areas

Community Health Councils in other areas have looked at the issue of transport for patients.

West Dorset CHC published a report 'Survey of Patients' Views on Hospital Transport Services' (1996), one of the issues highlighted was that different

 

Trusts in Dorset had different policies in operation as to which patients should be exempt from charges for transport. Somerset and Gloucester CHCs had both had a considerable number of complaints in their areas about the criteria for eligibility for free hospital transport.

Hastings and Rother CHC has had a continuous study of transport in operation since 1994, using a locked box available for comment slips. A report as at 31 st October 1998, mentions attempts to improve public transport access, some without success - a Dial-a Ride service covering five routes in Hastings was discontinued due to lack of use. The CHC produced a Transport Information Leaflet giving details of statutory and voluntary transport services and how to get help with travel costs.

Rural Development Commission

In rural areas the use of services often declines in proportion to the distance from the facility where it is offered due to difficulties of access or lower expectations. A 1993 study in Norfolk found that:

  • More remote rural households without access to a car were three times less likely to visit their GP, given similar levels of need, than urban households with cars.
  • Rural households generally were less inclined to visit their GP than urban dwellers
  • There was an association between low use of hospital services and households in villages without a GP's surgery, suggesting that access to a GP is crucial to hospital use.

The Rural Development Commission report of 1996 which quotes the study above states that: 'increasing concern is being expressed by rural people that discretionary transport services provided by local authorities, such as free school transport for over-16s, and other statutory authorities (especially health authorities) are under pressure due to financial constraints. This can result in greater transport burdens being placed on individuals and voluntary transport schemes. '

The report goes on to say: 'Where appropriate service-providers should be encouraged to bring services closer to the people and to develop new, more flexible means of delivery. '

Countryside Agency

A more recent example of the value of improved information for patients was given in the Countryside Agency newsletter 'Countryside Focus' (December 1999/ January 2000). An article: 'Rural GPs - gateways to wellbeing' , describes an arrangement in the Peak District where GPs were providing sessions with Citizen's Advice workers in areas of rural deprivation. To quote the article, at one practice: 'After the first year, the CAB had identified over E35,000 in previously unclaimed benefits for villagers. '

This success encouraged more practices to employ a CAB worker, and analysis showed that on average clients bring more than six enquiries each into the practice. Although the experiment began under GP fundholding, the High Peak and Dales PCG has made extending the service to all their practices a high priority.

Northern Fells Rural Project

Another project in the north of England, the Northern Fells Rural Project, launched on 4th November 1999, is part of the Prince of Wales' Rural Revival Initiative. The aims are given as:

  • To pilot methods for the development of services in rural areas using health care as an entry point
  • To identify the unmet health and social needs of rural residents

 To identify causes of social exclusion

  • To map the provision of existing support services and to identify gaps.
  • To prioritise and implement actions to meet unmet need.

To evaluate the project and disseminate the findings so that solutions can be replicated in other areas

Transport is acknowledged as a key factor and the project is providing a minibus with wheelchair access: 'to be used to get people to and from doctors' surgeries, dentists, optometrists, etc., as well as to visit people in hospitals, nursing and residential homes.' This project would obviously have great relevance and practical applications in Cornwall, and the CHC project group will be following its progress with interest.

Wiltshire Wigglybus Project

This is a pilot project for a flexible bus service in the Devizes area developed with funding from DETR and local councils. The main elements are:

  • Three buses work an hourly service on circular routes, directed by an in-cab screen system operated by Wiltshire Ambulance Control.
  • People can join as members and then their address becomes a stop and the bus will divert ('wiggle') from its route to pick them up as close as possible to their door.
  • Membership costs €20.
  • Fares for members are 30p (60p return), trips have to be booked, no more than 24 hours in advanc