Driving Change: The case for investing in community transport by Age Scotland

Driving Change: The case for investing in community transport

Driving Change

Thanks

The conclusions, recommendations and views expressed throughout this report are the work of Age Scotland. However our thanks to Lorraine Simpson and Ian Clark of The Lines Between, who undertook detailed research on community transport and older people which has informed this reportâ&#x20AC;&#x2122;s findings. Thanks also to John MacDonald, Director of the Community Transport Association Scotland, for his help in distributing a survey to community transport operators and sharing data for the purposes of this study. We would also like to express gratitude to the Community Transport providers who participated in interviews and all the individuals who contributed data and background reading material for the study.

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Contents Foreword 1 Executive Summary

Chapter One:

Introduction and overview of community transport in Scotland

Chapter Two:

Quantitative evidence of community transport’s role in sustaining the health and wellbeing of older people

Chapter Three:

Qualitative evidence of community transport’s role in sustaining the health and wellbeing of older people

Chapter Four:

Health board and local authorities spend on community transport

Chapter Five:

Current and projected numbers of older people using community transport – and some evidence on the cost of extending the scheme

Chapter Six:

Potential savings to the state

Chapter Seven:

Conclusions and recommendations

Appendix One:

Details about the Community Transport Sector

Appendix Two: Tables of data on transport in Scotland

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Foreword Scotland’s population is increasing and it is ageing, with the number of 75-year-olds projected to grow by 23% between 2008 and 2018, and by 84% between 2008 and 2033. Our ageing population is perhaps one of the greatest indicators of a healthier society but getting older can also increase the prevalence of isolation and loneliness; with women in particular more likely to survive their partner for longer periods of time. The issue of isolation is not to be underestimated. Currently around 18 percent of older people do not speak to friends or family on a daily basis and researchers rate loneliness as a higher health risk than lifelong smoking. Isolation can contribute towards depression and links have been found between a lack of social interaction and the onset of degenerative diseases such as Alzheimer’s. Research also shows that one of the key causes of isolation amongst older people is the lack of available transport, and infrequent or inappropriate bus services can leave many older people prisoners in their own home. Age Scotland has conducted a series of direct interviews with older people (see the Age Scotland community transport case study booklet) to discover exactly how the lack of transport options impacts on their lives. Worryingly, this transport poverty is prevalent across the country and some of those we spoke to feel so isolated and alone that they have little quality of life and spend their time simply “waiting to die”. This experience is not acceptable in this day and age. We need to shift our approach from simply examining the consequences of isolation and poor health amongst older people to addressing the causes, and in doing so, develop a sustainable and effective transport system for every community in Scotland. This report reviews the landscape of existing transport options for older people, their effectiveness in getting older people out and about, and puts forward recommendations to public bodies on how to improve bus service provision. In an era of reduced public spending, many will revolt at a paper that calls for increased spending, especially on an entitlement that already receives significant levels of public money. However these austere times cannot dent our ambition for progressive public policies that address our social ills nor alter the fact that failure to act will undoubtedly lead to higher health and care needs at a later date.

Brian Sloan Chief Executive

Driving Change

Th ec as ef or inv esting in communit y tr

t or sp an

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Executive Summary Background information Community transport helps older people to overcome barriers to accessing public transport. For example: • Commercial routes in rural areas may be infrequent, too far from people’s houses or non-existent. • Fear of crime and fear of falling prevents some older people from using public transport. • Those with disabilities and health issues may require specialist accessible vehicles. • Some people require ‘door–to–door’ transport support, for example people with mobility issues may be unable to walk to the nearest bus stop or from the bus stop to their destination. Community transport is a vital service for older people, enabling them to remain active and valued members of their communities, and to live independently in their own homes. This report considers the role of community transport and service providers in delivering these outcomes and examines the case that there are significant benefits to be realised from expanding the National Concessionary Travel (NCT) scheme to include community transport operators.

Older people’s current use of transport in Scotland The data identified key differences between urban and rural areas with regard to the NCT. For example, in remote rural areas, over two thirds (70%) of those aged 60 or over either do not have a free pass or do not use it. This contrasts with less than a third (31%) of older people in large urban areas. Overall, there is less travel by bus in rural Scotland and residents in the countryside are less happy with public travel services than their counterparts in urban places. Older people in rural areas make fewer journeys by bus to access health services than those in urban areas, and are more likely to drive or travel as a passenger (for example in taxis or being transported by a family member) to medical appointments. Access to cars is markedly lower in pensioner households in Scotland – almost two thirds of single pensioner households do not have access to a car.

Projected numbers of older people using community transport There are currently an estimated 70,000 older users of community transport in Scotland. Assuming there are no changes in demand, and factoring in General Register Office for Scotland (GROS) population projections, there will be almost 83,500 community transport users by 2022. Overall, demand for community transport is expected to rise, due to the growth in the population of older people and changes to the supply of patient transport services. Community transport providers highlight recent changes within the sector, including pressure on funding, increased recognition of the sector’s impact and financial constraints on passengers as leading to fewer journeys for social purposes.

Health board and local authority spend on community transport In 2011/12, local authorities and NHS Boards in Scotland spent approximately £4.5 million on all community transport services, an estimated £431,257 for Health Boards and an estimated £4,020,351 for local authorities.

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Health and wellbeing Community transport makes a significant and demonstrable contribution towards sustaining the health and wellbeing of older people and service users. This includes key impacts such as: • Increased physical activity, which can sustain mental wellbeing, mobility and muscle strength Physical activity is also linked to a reduction in cardiovascular disease, falls and fractures. • Greater ability to ‘shop around’ – increased opportunities for older people to obtain value for money, which can help tackle malnutrition. • Maintaining independence due to the renewed ability to access services, including health providers and important institutions such as banking, legal and advice services. • Improved quality of life as a result of independence and increased opportunities for social interaction. Although the cost of subsiding public transport can be substantial, the public health benefits for all older people, but particularly for those aged 85 and above and women, are significant.

Potential Savings Extending the Concessionary Travel Scheme to community transport providers could deliver significant savings for the State. Community transport may contribute to a reduction in yearly spend by NHS Scotland and local authorities on the following1: • £1.35 billion on treating cardiovascular disease, Type 2 diabetes and obesity. • £73 million on hip fractures. • £66.1 million on the mental health of older people in Scotland. • £1 billion on under-nutrition. • £5.7 million on missed hospital outpatient appointments by older people. • £1.4 billion on emergency hospital admissions by older people. • £11.4 million on residential care costs. • £318 million on providing personal care services to older people in their own homes. Furthermore, it is likely that community transport can facilitate increased economic activity within local communities, providing opportunities for spending disposable income. Older people contribute an estimated £2 billion per year to the Scottish economy through unpaid care, community and voluntary work, and community transport is an active enabler of this.

1 These are estimates. Full workings are shown in Chapter Six.

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Recommendations Based on the findings of this research study, the following recommendations are made for key stakeholders.

Scottish Government Recommendation One: Financial support provided to community transport operators by Scotland’s local authorities and health boards is inconsistent and, by extension, leads to high degree of variation in the provision of services. The Scottish Government should, therefore, establish a national strategy to expand community transport infrastructure in Scotland, alongside additional financial resources, with a view to effectively enabling older people to overcome barriers to accessible transport . This outcome can best be achieved by extending the the established NCT scheme to include all eligible community transport operators.

Recommendation Two: The Scottish Government should establish specific, measurable and quantifiable targets around an established National Community Transport Strategy, as a means of assessing older people’s access to, and use of, community transport services across Scotland. Where gaps are indentified, the strategy should be adapted to increase the supply of accessible community transport.

Recommendation Three: Policy makers should address gaps in the evidence base, as identified during the course of this project. For example: • The impact of (a) the current National Concessionary Travel scheme and (b) the community transport sector in relation to health and social outcomes. • The contribution of (a) the National Concessionary Travel scheme and (b) the community transport sector to Scotland’s economy in terms of preventative spend. • The role of community transport in the achievement of the Scottish Government’s National Outcomes. • The full impact of transport poverty on older people.

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Health boards and local authorities Recommendation Four: Health boards and local authorities should jointly support the development and implementation of community-based transport strategies. These must complement the existing commercial provision and meet older people’s health, wellbeing, and social purposes. The strategies should include: • Increased funding available for community operators. • The impact on older people of limitations to transport options. • A review of existing commercial provision. • Mapping of older people’s transport needs and identification of gaps in services. • Implications and solutions effective for the delivery of service across local authority boundaries (e.g. patient transport to hospitals in other areas). • Modelling to project future local demand. • An action plan to increase older people’s awareness of community transport services available in their areas.

Community transport providers Recommendation Five: Operators should seek to maximise their contributions towards routine analysis and reporting of the impact of community transport services on users through effective data recording practices.

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Introduction and overview of Community Transport in Scotland Research overview In August 2012, The Lines Between was commissioned by Age Scotland to conduct research into community transport. Specifically, the research sought to identify: • The role of community transport in sustaining the health and wellbeing of older people. • The current and projected numbers of older people using community transport. • An estimate of savings which could be achieved by extending the NCT scheme to community transport providers. This report considers each issue in turn.

Methodology The research was conducted in two stages:

Collation and analysis of available information. This involved (i) the analysis of data from the

Scottish Household Survey and (ii) a literature review of relevant research.

Additional data gathering. This included (i) a survey of community transport providers, (ii) a

survey of local authorities and health boards and (iii) detailed interviews with a small number of community transport operators. Appendix One provides further information about the sector, including: • A definition of community transport. • An overview of licensing arrangements. • A summary of the main types of community transport. • Details of the National Concessionary Travel scheme.

Why community transport is important to older people At first glance, older people may appear to benefit from a range of measures designed to support their use of transport, including their eligibility for the NCT scheme, which provides free transport on public bus services for disabled people and those who are 60 or over. However despite this apparent support, older people encounter a range of barriers in accessing public transport, and community transport plays an important role in helping to overcome these barriers. For example: • Commercial routes in rural areas may be infrequent, too far from people’s houses or non- existent. • Fear of crime and fear of falling prevent some older people from using public transport. • Those with disabilities and health issues may require specialist accessible vehicles. • Some people require “door–to–door” transport support, for example people with mobility issues, and may be unable to walk to the nearest bus stop or from the bus stop to their destination. In addition to helping overcome access barriers, community transport has a major role to play in providing opportunities for socialising with peers, thus helpling to combat feelings of isolation. It brings health and well-being benefits and can facilitate direct access to public health and social services. 7

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The key factors influencing the community transport sector The Community Transport Association (CTA) Scotland’s State of the Sector report (2012) highlights some of the main drivers for change within the sector, including: • The growing consensuses that communities should have more involvement in developing local transport solutions, as suggested by the findings of the Commission on the Future Delivery of Public Services (2011). • Financial constraints experienced by funders (particularly local authorities), which have contributed to a reduction in locally subsidised bus services and increased demand for community transport. • The forecasted growth in the population of older people over the next decade will lead to a rise in the number of people with long-term health conditions. • Recent changes to non-emergency transport of patients (such as a reduction in the use of ambulance service vehicles for patient transfer) have left a gap in affordable transport services provision. • A fragmented approach to transport for health and social care purposes, as identified in Audit Scotland’s report on Transport for Health and Social Care (2011).

There have also been significant challenges to community transport providers: Pressure on funding While pressure on funding is not new, one participant commented that budget cuts are changing funders’ priorities. This ‘rethinking’ is pushing out mainstream community transport services for older people in favour of services for some hard-to-reach ‘target’ groups, such as people with severe disabilities.

Increased recognition of the sector’s impact Some providers reflected that funders (such as health boards and local authorities) understand the sector’s contribution to delivering health outcomes – but are impeded by budget constraints. They feel that statutory bodies rely on providers’ ability to ‘muddle through’ rather than offering a coherent framework for developing the local community transport infrastructure.

The impact of financial constraints on passengers One provider observed that older people are making fewer journeys for social purposes because, as there is “less money to go around” they feel they cannot justify such journeys.

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Quantitative evidence of community transport’s role in sustaining the health and wellbeing of older people This chapter examines: • Key differences between transport in urban and rural areas. • Variations in access to health services, and older people’s use of buses to access health services. • The availability of cars. A detailed breakdown of data is provided in the tables in Appendix Two.

A summary of Scottish Government Urban/Rural Classifications is useful when considering the data included in this section: Large Urban Areas - Settlements of over 125,000 people. Other Urban Areas – Settlements of 10,000 to 125,000 people. Remote Small Towns – Settlements of between 3,000 and 10,000 people and

with a drive time of over 30 minutes to a settlement of 10,000 or more.

Accessible Rural – Settlements of less than 3,000 people and within 30

minutes drive of a settlement of 10,000 or more.

Remote Rural - Settlements of less than 3,000 people and with a drive time of over 30 minutes to a settlement of 10,000 or more.

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Key differences between transport in urban and rural areas The infographic below highlights some of the key differences between travel in large urban and accessible rural areas.

Possession and use of Concessionary Travel Card for adults aged 60+ (%) use every day

no pass

all people 60+ sample size 4,858 large urban 1,582 other urban 1,456 small accessible town 422 small remote town 298 accessible rural 539 remote rural 560 key to usage regularity:

every day almost every day 2/3 times a week once a week

once a fortnight once a month not used no pass

Source: Scottish Household Survey, 2011

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Concessionary Travel (Appendix Two; Table 1) In total, 87% of people aged 60 or over in Scotland have an NCT card, however, the proportion varies across urban and rural Scotland. In large urban areas, 91% of older people have an NCT scheme card compared to just over three quarters in rural areas (77% in remote rural areas and 78% in accessible rural areas). Whilst the majority of older people have an NCT card, a significant proportion do not use it particularly those living in rural Scotland. Almost half (47%) of those living in remote rural areas and 43% in accessible rural areas do not use their card, compared to almost a third (31%) across the whole of Scotland and just a fifth of those (22%) in large urban areas. In remote rural areas, over two thirds (70%) of those aged 60 or over either do not have a NCT scheme card or do not use it (65% in accessible rural areas). In contrast, in large urban areas, less than one third (31%) of those aged 60 or over either do not have a pass or do not use it.

Bus Travel (Appendix Two; Tables 2 & 3) Access to bus services in rural Scotland is lower than in urban areas or Scotland as whole, with fewer convenient bus stops close by and less frequent services. In remote rural and accessible rural areas, the nearest bus stop is typically within a 6 minute walk for 58% and 65% of households respectively, compared to 89% of households in large urban areas and 84% of households in Scotland as a whole. Similarly, only 1% of households in remote rural and 2% of households in accessible rural areas have 5 or more buses per hour, compared to 43% in large urban areas and 23% for Scotland as a whole. Combining the distance of bus stops and expected waiting times, only 1% of households in remote rural areas and 2% of households in accessible rural areas have a bus stop within a 6 minute walk and 5 or more buses per hour compared to 39% in large urban areas and 22% for Scotland as a whole. The frequency of travelling by bus is significantly lower in rural Scotland than elsewhere. People in large urban areas are the most likely to travel by bus almost or every day (17%), compared to only 3% of those living in remote rural areas and 5% of people in accessible rural areas. Approximately three quarters of those in rural areas do not use the bus in any given month, compared to approximately half of those in Scotland as a whole.

Views on public transport (Appendix Two; Tables 4 & 5) Significantly fewer residents in rural Scotland highlight ‘good public transport’ as an aspect of their neighbourhood that they particularly like compared to residents of urban Scotland and Scotland as a whole. Only 2% of residents of remote rural areas and 9% of residents of accessible rural areas list good public transport as an aspect they particularly like about their neighbourhood. In contrast, good public transport is identified by almost a third of residents of large urban areas and over a fifth of residents of Scotland as a whole. While 16% of residents of remote rural areas and 15% of residents of accessible rural areas identify ‘poor public transport’ as an aspect of their neighbourhood that they particularly dislike, only 4% of residents of large urban areas and 6% of residents of Scotland as a whole feel the same way.

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Variations in access to health services, and older people’s use of buses to access health services (Appendix Two; Tables 6 to 13) Fewer people living in rural Scotland rate access to a number of public services as very or fairly convenient compared to those living in urban areas or Scotland as a whole. Specifically, those aged 60 or over are less likely than all other age groups to find any of the services – including hospital outpatients, dentists, chemists/pharmacists, GP’s surgeries, and public transport - very or fairly convenient. For example, under half (45%) of residents of remote rural areas and just over half (56%) of residents of accessible rural areas find accessing hospital outpatient department very or fairly convenient compared to almost two thirds (64%) of residents of large urban areas and 61% nationally. A similar pattern emerges in terms of access to public transport. Just over half (55%) of residents of remote rural areas and nearly two thirds (63%) of residents of accessible rural areas find public transport “very” or “fairly” convenient compared to 93% of residents of large urban areas and 85% of residents of Scotland as a whole. The infographic below shows access to GP’s surgeries by age group.

Access to GP’s surgeries by age (%) all 16+ sample size 8,106

16-29 1,099

30-39 1,186

40-49 1,344

50-59 1,287

60-69 1,430

70-79 1,134

80+ Source: Scottish Household Survey, 2011

KEY:

626

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In terms of age, people aged 60 or over across Scotland are more likely than other ages to: • Access the doctors’ surgery by bus. • Access dentists by bus. • Access hospital outpatients by bus. People aged 60 or over are more likely than other age groups to access health services by bus, although dependence on friends or family for health transport also increases with age. For example, in the 70-79 age group, roughly a quarter of journeys to health services are made as a passenger; rising to almost half of health journeys for people aged 80 or over. Across the general population, far fewer people in rural areas use the bus to access health-related services (GPs, hospital and dentists) than in urban areas, most likely because of fewer appropriate services. People in rural areas are also much more likely to drive.

Doctors’ surgery: Only 2% of people in remote rural areas and 5% of people in accessible rural

areas usually travel by bus to the doctors’ surgery compared to 14% of people in large urban areas and 9% of people in Scotland as a whole.

Hospital Outpatients: Only 6% of people in remote rural areas and 9% of people in accessible rural

areas usually take a bus to travel to the hospital outpatients’ department compared to 24% of people in large urban areas and 18% of people in Scotland as a whole.

Dentists: Only 5% of people in remote rural areas and 10% of people in accessible rural areas usually travel by bus to the dentists compared to 15% of people in large urban areas and 11% of people in Scotland as a whole.

Availability of Cars (Appendix Two; Tables 14 & 15) Scottish Household Survey dataI confirms that car availability is higher in rural Scotland than in urban areas and the country as a whole. In accessible rural areas, 87% of households, and 86% in remote rural areas have at least one car available, compared to 61% of households in large urban areas and 70% across Scotland. The survey also notes that: “Car availability is also strongly associated with income; the higher a

household’s income the higher likelihood it will have access to at least one car – and in contrast, at least half of households with an income of £15,000 or below do not have access to a car at all. This means that fewer households from groups with below average income levels (such as single adults/parents/pensioners) have access to a car”.

There is no breakdown by age of car availability within urban and rural areas; but it is generally understood that car ownership decreases with age. Information from Transport and Travel in Scotland 2011II shows that access to cars is markedly lower in pensioner households in Scotland, and that almost two thirds (63%) of single pensioner households do not have access to a car. All households containing only one adult (single adult, single parent and single pensioners) have significantly lower levels of car access than those households containing more than one adult. While only one fifth (18%) of older smaller households do not have access to a car, this is the highest proportion of any household containing more than one adult, for example only 11% of large family households do not have access to a car.

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Chapter conclusion Older people in rural areas are much less likely to use their NCT pass than friends or family in urban areas and, as people get older, they are more dependent on friends and family to help them access health services. For older people in rural areas, it is clear that the current NCT scheme and transport network does not meet their needs and that informal arrangements are necessary for older people to remain active or get outdoors.The data is indicative of the growing trend of transport poverty amongst older people. Furthermore, the increased reliance on family or friends for health transport could have an economic impact for those required to take time off work to transport older or disabled friends and relatives. There are, therefore, economic incentives for a strengthening of community-based transport services to provide the necessary flexibility so that family members are supported to remain in work.

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Qualitative evidence of community transport’s role in sustaining the health and well-being of older people in Scotland While there is a paucity of research into the impact of community transport, much of the research on the impact of the National Consessionary Travel system is appropriate to this study, as it relates to supporting older and disabled people to remain active in their communities.

Qualitative Evidence Increased physical activity The 2011 Scottish Health Survey found that the majority of older people in Scotland do not achieve the recommended daily amount of physical activity. It detailed that about a fifth (20%) of 65-74 year olds meet physical activity recommendations, while, amongst over 75s, only 11% of men and 7% of women reach recommended levels of activity. Imperial College London identified the health benefits of the NCT scheme, and concluded:

“Older people in England with a free bus pass seem more likely to use active transport and buses, and to undertake regular walking than those without…. 15 minutes of moderate daily exercise is linked to a 12 percent lower risk of death in individuals 60 and over…. These findings suggest that public subsidies enabling free bus travel for older persons may confer significant population health benefits through increasing incidental physical activity levels…. Maintaining physical activity helps sustain mental wellbeing, mobility and muscle strength in older people. It also reduces their risk of cardiovascular disease, falls and fractures”. III While this research considered the health benefits of the free bus pass (and therefore focused on public transport options), the central argument – that greater levels of bus use result in increased physical activity - is equally applicable to community-based transport services. Extension of community transport within the framework of the NCT scheme would facilitate greater activity levels by service users and, therefore, health benefits in line with the findings above. In addition, qualitative evidence gathered during interviews points to community transport having an even greater impact in preventing falls. This is because community transport vehicles are particularly suitable for older people, with staff and volunteers uniquely trained in, and aware of, the specific support needs (physical, mental and emotional) of individual service users. This includes assistance in accessing vehicles, no requirement to stand while the vehicle is in motion to alert drivers to stop and certainty that the driver will stop the vehicle before passengers leave their seats to disembark. Age UK found that 800 older people fall on buses every day, and that the fear of falling is a major barrier to using public transportIV.

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Reduction in malnutrition Malnutrition has a severe impact on the health of older people. It is linked to an inability to fight infection, depression, impaired wound-healing, reduced strength and fatigue. An economic evaluation of the Food TrainV – a project delivering food services in the community to older people in Scotland - notes that “malnutrition affects 10% of people over 65”. Age UK’s 2011 report Living on A Low IncomeVI found that, across the UK, “local shops in rural

areas were considered to be very expensive and did not always sell the basic food times that people required. Participants also complained that in rural areas there was a limited range of shops, meaning that they had to travel if they wanted more choice”. Community transport can play a role in reducing malnutrition in older people with low levels of income because it allows them to “shop around” and take advantage of cost savings available from various retailers. This is particularly important in rural areas, where access to shops may be limited if people do not have their own car. While there is often a cost attached to use of the community transport service when visiting retailers, this still compares favourably to the long-term costs of car ownership and the opportunities consumers have to compare prices between retailers.

Improved quality of life Geoffrey Paul Andrew’s research paper Just The TicketVII explored the contribution and limitations of the NCT scheme in England to the quality of later life. In particular, he identified: • Feelings of isolation, loneliness and depression can occur when mobility is lacking. • Factors that make car use difficult, such as visual impairment and physical frailty, can often inhibit older people from using commercial buses. However, encouragingly, the report also detailed: • Mobility provides a feeling of independence and opportunities for social interaction and the NCT card allows holders to justify trips they could not otherwise have done if there had been a cost. • Older card holders (those aged 85 or over) are more likely to report the pass improving their quality of life compared to younger pass holders, suggesting that a free bus pass offers benefits above and beyond the simple ability to facilitate travel. The benefits of the pass to the user identified in the report are numerous and often the actual journey was a secondary benefit compared to what it facilitated or helped avoid, such as feelings of isolation. This, however, is less prounced in rural areas, where there are fewer services available and users cannot access regular bus services. While this research examines the English scheme, the same can reasonably be expected to apply in Scotland. Further, during the course of our interviews with Scottish community transport providers, a number of additional positive outcomes were identified, including, that it: • Offers respite opportunities for carers, which helps them maintain support to partners or relatives so that they can remain living at home. • Increases mobility and facilitates older people’s involvement in community affairs or participation in activities such as volunteering. • Facilitates mobility and access to banking and legal services and (of particular importance for vulnerable older people) advice services.

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Quantitative evidence Key quantitative findings: These findings, from Just The Ticket, were based on an on-board bus survey of 487 concessionary pass holders conducted in South West England in December 2009.VIII • 66% felt the cost of the journey was a preventative factor in travelling prior to having a pass. • 74% agreed that having a free bus pass had improved their quality of life to some extent. • Older pass holders were found to be making more trips by bus than younger pass holders. • In descending order, pass holders’ main trip purposes were shopping (47%), social trips (26%), other (for reasons including escorting children, travelling for travel’s sake, tourist days out and voluntary work) (19%), work (5%), health-related appointments (3%) and education (1%).

Findings from the Review of the Scotland-wide free bus travel scheme for older and disabled people (2009) Despite the poor uptake and limitations of the bus pass in rural areas, many of the key conclusions of the Scottish Government’s 2009 review of the NCT scheme complemented the findings from ‘Just the Ticket’. • 85% agreed with the statement that the introduction of the NCT had enhanced their access to services including shopping, health and leisure activities. • Older and disabled people agreed the introduction of the NCT scheme had allowed them to visit friends and families more, which in turn mets the scheme’s social inclusion objectives. • 54% used their card to access health services, suggesting health improvements may also be attributed to the NCT scheme. • Respondents strongly agreed the scheme had helped them develop a more active lifestyle – including walking more.

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Chapter conclusion The positive impact of the NCT in terms of improving health and wellbeing outcomes for Scotlandâ&#x20AC;&#x2122;s older people is clearly demonstrable by the range of evidence, research and testimonies available. Where there are fewer commercial bus services (i.e. most typically in remote and rural areas), there is a marked reduction in the ability of older and disabled people to achieve the potential health outcomes .

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Health board and local authority spend on community transport

As Chapter 3 suggested, there is a broad recognition that the community transport sector contributes to a range of health and social outcomes. For example • “The benefits to funders are significant: better value for money, lower funding administration

costs, enhanced local capacity and greater reliability. Community transport meets previously unmet transport needs – its development has been driven by the desire to meet unmet needs, identified locally, often at the neighbourhood level” IX (CTA guidance for community transport

funders ).

• “There is considerable secondary evidence, and some primary evidence, of ‘transport to health-

care’ schemes achieving direct savings in health sector budgets or time inputs, or contributing to NHS targets” (Countryside Agency).

Audit Scotland’s 2011 report on Transport for Health and Social Care states that: “from the

information available we have identified that the public sector spent £93 million for health and social care (transport) in 2009/10, however this is likely to be a significant underestimate since the quality of data from NHS boards and councils is poor”. The report suggested that health boards, local authorities and the Strathclyde Partnership for Transport (SPT) spent at least £2.4 million on community transport for health and social care. However, this study looks at all spending on community transport, as opposed to just the spend for health and social care purposes, as was the case with the Audit Scotland study. When taking into account all spending, local authorities and NHS Boards across Scotland in fact spent at least £4.5 million last year on community transport, with health boards accounting for an estimated £431,257 and local authorities (and the SPT) an estimated £4,020,351.

Information from health boards While data from health boards is presented below, NHS Grampian’s data was not forthcoming and has, therefore, been extracted from Audit Scotland’s report on Transport of Health and Social Care. This is, consequently, likely to be an underestimate, as Audit Scotland asked solely for spending on health and social care purposes.

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Health Board

Spend on CT

Last available year of data

NHS Ayrshire & Arran*

£0

2011/12

NHS Borders**

£-

2011/12

NHS Dumfries & Galloway ***

£-

2011/12

NHS Fife

£5,854

2011/12

NHS Forth Valley*

£0

2011/12

NHS Grampian*

£0

2011/12

NHS Greater Glasgow & Clyde

£148,251

2011/12

NHS Highland

£62,301

2011/12

NHS Lanarkshire

£112,000

2011/12

NHS Lothian

£30,065

2011/12

NHS Orkney

£63,826

2011/12

NHS Shetland

£3,960

2011/12

NHS Tayside*

£0

2011/12

NHS Western Isles

£5,000

2011/12

Total

£431,257

* These boards reported zero spend on CT in the last financial year. ** NHS Borders does not fund individual voluntary community transport providers. In certain circumstances, voluntary driver organisations may be reimbursed for transport costs incurred in providing patient transport services. There is no hospital visitor transport service provided by the Board. *** NHS Dumfries & Galloway acknowledges that it does fund CT in the area, but cannot provide a figure.

From spending within eight of the fourteen NHS Boards amounting to £431,257 (ranging from nil in five boards - Ayrshire and Arran, Dumfries and Galloway, Forth Valley, Grampian and Tayside to £148,251 in NHS Greater Glasgow and Clyde), the average spend across each of the fourteen health boards equates to £30,804. Examples of health board use of community transport include: • NHS Highland: “On Skye there is the Older Adult transport scheme - this supports trips from the rural areas into Portree – so can facilitate access to health and social care services. West Ross has a community car scheme which again receives a small grant from the service and supports people to access hospital appointments but not to visit other people in hospital. We also have an arrangement with the Red Cross to support hospital to home travel and vice versa for patients.” • NHS Shetland: “We commission a community transport service which transports Shetland patients from Sumburgh airport to various hospitals within NHS Grampian”.

Spend on community transport by local authorities While data from local authorities is presented below, data from Edinburgh was not supplied and has therefore been extracted from Audit Scotland’s report on Transport of Health and Social Care. (This is likely to be an underestimate as Audit Scotland asked solely for spending on health and social care purposes). The SPT provided data on the spend within East Ayrshire, East Renfrewshire, Glasgow, Inverclyde, North Ayrshire and Renfrewshire. Each of these local authority areas was contacted to identify if there was any additional spend, and this revealed that East Ayrshire makes an additional contribution within its own area (this has been added to the figure supplied by SPT). 20

Driving Change

Local Authority

Spend on CT

Last available year of data

Aberdeen City*

£0

2011/12

Aberdeenshire

£369,249

2011/12

Angus**

£-

2011/12

Argyll & Bute

£96,500

2011/12

Clackmannanshire***

£-

2011/12

Dumfries & Galloway

£95,293

2011/12

Dundee*

£0

2011/12

East Ayrshire

£130,601

2011/12

East Dunbartonshire***

£-

2011/12

East Lothian

£110,529

2011/12

East Renfrewshire

£14,000

2011/12

Edinburgh****

£727,228

2009 / 10

Falkirk

£190,760

2011/12

Fife*

£0

2011/12

Glasgow

£161,619

2011/12

Highland

£50,196

2010/11

Inverclyde

£10,000

2011/12

Mid Lothian

£266,312

2011/12

Moray

£231,775

2011/12

North Ayrshire

£118,971

2011/12

North Lanarkshire

£59,000

2011/12

Orkney

£213,641

2011/12

Perth & Kinross

£217,379

2011/12

Renfrewshire

£18,200

2011/12

Scottish Borders

£59,750

2011/12

Shetland*****

£-

2011/12

South Ayrshire******

£-

2011/12

South Lanarkshire

£65,500

2011/12

Stirling

£325,822

2011/12

West Dunbartonshire*******

£-

2011/12

West Lothian

£211,037

2011/12

Western Isles

£265,281

2011/12

Total

£4,020,351

* These councils reported that they do not fund CT services ** Angus Council does not support directly any community transport services but highlights that it operates a Taxicard Scheme for individuals who are unable to use buses - allowing travel at reduced fares. *** No data available from Clackmannanshire and East Dumbartonshire Councils. **** Data for Edinburgh and West Dumbartonshire extracted from the Audit Scotland report on Transport for Health and Social Care. ***** All transport in Shetland is organised & contracted by ZetTrans for Shetland Islands Council, which subsidises all services. ****** South Ayrshire reports that its funds go to SPT which distributes them to CT providers on its behalf - no data on this spend was provided. ******* West Dumbartonshire responded “We hold no records of any financial support to community transport providers in 2011/12”.

Driving Change

In total, just over £4 million was spent across the 31 local authorities. Spend ranged from £0 in Aberdeen City, Fife, Dundee and Angus to £369,249 in Aberdeenshire. The average spend per local authority was £125,635.

Chapter Conclusion Across Scotland, approximately £4.5m is currently spent annually by health boards and local authorities on community transport. While the amount is small in relation to the totality of the local government and NHS budgets, it nonetheless has produced evidence of substantial return on investment, such as improved quality of life and health and wellbeing outcomes. It further highlights the positive impact the sector has made and what it might be capable of achieving were sufficient funding allocated to it. Strengthened government commitment to this valuable resource would, arguably, further enhance the already-evident outcomes and complement the goal of maximising return on investment.

Driving Change

Current and projected numbers of older people using community transport – and some evidence on the cost of extending the scheme

Fares The average fare for a one-way dial-a-ride trip is £3.20. This is a rough approximation based on information supplied by 18 dial-a-ride service providers. The 18 respondents represent nearly one quarter of the 80 recognised community transport providers in Scotland . Unlike public transport providers, community transport operators do not make profits, and fares are not charged on a full cost recovery basis. Detailed financial returns supplied by four providers for the purposes of this study indicate that the fares charged by these providers covered between 10% and 20% of their total costs. The Plunkett Foundation concurs that fares typically represent an average 20% of operators’ total revenue.

Data caveats Median fare data was based on a single type of transport (dial-a-ride services) as a result of this variation across the sector. Reasons for differences in fare across the sector include, but are not limited to, the following factors: • Providers, by law, cannot profit from services delivered, so fares fluctuate depending on income streams such as grants and fundraising throughout the year. Ultimately, the fare charged depends on the provider’s overall financial situation, and each provider’s circumstances are unique. • There are different fare structures in place for different types of service - for example, volunteer drivers are recompensed based on mileage, whereas ‘flat’ group hire costs can be divided between the number of passengers using the service on any given day. • Providers have different priorities; some charge fares which incorporate contributions to budgets such as vehicle replacement funds,while others only charge enough to pay for fuel and rely on fundraising to cover capital costs. Within the 18 responses from providers, a variety of fares are described – from flat fees to fares based on zones; and others which included return journeys and include refreshments such as a cup of tea.

Driving Change

Passenger projections based on CTA Scotland’s State of the Sector research As noted above, the most comprehensive data on community transport in Scotland stems from CTA Scotland’s State of the Sector research, which produced the following estimates: • 3.5 million passenger trips per year. • 62% of service users are 60 or older. • 16% of service users are disabled. • 28,000 registered members of community transport operating organisations. • An estimated 100,000 people benefit from community transport in Scotland each year.

Data caveats Operators provided data on total passenger trips per year. This prevents examination of information at an individual level. For example, it is not possible to aggregate the number of journeys made per passenger, nor can journeys by varying transport modes be quantified (for example dial-a-ride journeys). Similarly, community transport providers’ definitions of “60 or older” and “disabled” are not mutually exclusive. It is, therefore, likely that some of the disabled passengers were also over 60. On the basis that at least half of the UK’s disabled population are of a pensionable age , we have estimated that an additional 8% of passengers (half of the disabled passenger group) are 60 or older. Our working assumption is, therefore, established on the basis of 70% of all passengers being 60 or over.

Driving Change

Projected community transport use by older people In the table below, two sets of projections are provided; one based on registered members of community transport providers (28,000) and another derived from CTA Scotlandâ&#x20AC;&#x2122;s estimate of the total number of people who use community transport2 (100,000).

Time period

% increase in older population aged 60 and older*

Model 1: (based on the

Model 2: (based on CTA

current total of registered

Scotlandâ&#x20AC;&#x2122;s estimated number of

members = 28,000)

people benefiting from community transport = 100,000)

Users aged 60 or older (estimated 70% of total)

19,600

70,000

2013

1.482%

19,890

71,037

2014

1.537%

20,196

72,129

2015

1.547%

20,508

73,245

2016

1.685%

20,854

74,479

2017

1.788%

21,227

75,810

2018

1.876%

21,625

77,232

2019

1.944%

22,045

78,733

2020

1.948%

22,475

80,267

2021

2.011%

22,927

81,881

2022

2.035%

23,393

83,547

Based on ONS principal projection population estimatesXII (2011)

2 CTA Scotland notes that it is not possible to produce an exact figure for the number of users due to the many different kinds of community transport services and operators and variance in data collection methods. Records pertain to the volume of passenger trips; not individual passengers. Some people may use a daily/regular service and others may only use Community Transport once a year. CTA Scotland suggest the 100,000 figure is a reasonable estimate of user numbers which includes every type of user including group hire, dial-a-ride, car schemes, etc.

Driving Change

Chapter conclusion Around 70,000 older people currently use and benefit from community transport because commercial services do not meet their transport needs. While this figure is expected to increase to almost 84,000 by 2022, this is based on projections that assume demand will stay static. It is highly likely, however, that extending the NCT scheme would, in practice, lead to increased demand from (a) new users drawn to community transport as a result of the free pass and (b) existing passengers increasing the number of journeys they make. Bringing more community transport operators within the scope of the NCT scheme would, therefore, expand the travel options for older and disabled people and, unquestionably, lead to increased volumes in those travelling with community transport operators. With 3.5m community transport passengers per year and an average fare of ÂŁ3.20, we estimate the cost of including all these journeys within the NCT framework would currently equate to around ÂŁ11.2m. However this investment would actively save money in the long term, by helping older people to remain active and reducing the demand for higher-level healthcare outcomes.

Driving Change

Potential savings to the state

While there has been no detailed cost-benefit analysis of the NCT scheme, its broad links to achieving the Scottish Government’s national policy objectives have been well-established. If financial data about the cost-benefit implications of the current NCT scheme were available, we could use this information to estimate the additional savings which could be realised through an extension of the scheme to include community transport operators. Without resources to undertake such a large-scale research project, it is not possible to produce an exact figure for this. Furthermore, an estimate at this stage is likely to be counter-productive, drawing attention away from any debate about the value of extending the NCT scheme. Instead, this chapter examines the potential financial savings (and other positive economic outcomes) that an extension of the NCT scheme may help to achieve. These outcomes support the argument that expenditure on extending the NCT scheme may be considered an investment and would save national resources over the longer-term. The savings identified during the research fall into the following categories: • Savings for the NHS. • Savings for local authorities. • Other savings for Scotland.

Savings for the NHS The financial value of improvements in the health of older people As Chapter 3 showed, there is qualitative evidence showing that transport is inextricably linked to the health of older people. Despite this, there has been little attempt to quantify the financial savings that public and/or community transport contributes to our national health budget. This research has identified the following health outcomes for older people, which are associated with the use of public and community transport: • Reduction in preventable health conditions. • Reduction in falls. • Reduction in depression. • Healthier eating. • Reduction in health inequalities.

Driving Change

Reduction in preventable health conditions due to an increase in physical activity The link between bus travel and increased physical activity was explained in Chapter 3. In summary, Imperial College found that free buses contributed towards supporting ‘active travel’ - additional physical activity by older people each journey. The study concluded:

“Although the costs of the scheme are considerable, it may offer value for money as it seems to promote physical activity among older people, thereby helping to reduce inactivity related mortality and morbidity. To maximize the population health benefits of the current [national travel scheme] policy, other barriers to public transport use in older persons, such as poor access and inconvenience, ease of car use, and poor pedestrian access of neighborhoods, should be addressed”. Increased physical activity is associated with a reduction in the (preventable) health conditionsXIII listed below. As the table illustrates, all these conditions incur significant treatment costs. Any reduction in these conditions would result in financial savings for NHS Scotland.

Preventable condition

Estimated yearly spend on treatment by NHS Scotland

Cardiovascular disease

£187 millionXIV (2009/10)

Type 2 diabetes

£1 billionXV (2011) (this includes spending on Type 1 as no breakdown available)

Obesity

£175 millionXVI (2011)

Osteoarthritis

Unknown

Over £1.35 billion is, therefore, spent by NHS Scotland treating cardiovascular disease, Type 2 diabetes and obesity. It is reasonable to assume that increased mobility among older people brought about by an extension of the NCT scheme would contribute to the prevention of some of these conditions, or a reduction in their incidence and, therefore, significant savings to the health service.

Reduction in falls Physical activity has been linked to a reduction in the incidence of fallsXVII. There are an estimated 6,000 hip fractures in Scotland annually - costing an average £12,163 per admissionXVIII - a total of £73million per year. It is also worth highlighting that after an osteoporotic fracture, 50% of people can no longer live independentlyXIX. We explore the cost of residential care later in this chapter.

Reduction in depression Research by the Royal College of General PractitionersXX (2011) found that one in four older people have symptoms of depression that require treatment. This equates, in Scotland, to over a quarter of a million people of pensionable age (258,211). By extension, the average domiciliary spend for older mental health patients in Scotland could be as much as £66.1 million per yearXXI. Increased physical activity - an outcome of improved transport options - has been linked to reduced symptoms of depression in older people. It is reasonable to assume that a consequence of improved community transport options for older people, combined with the acknowledged improvements in physical activity facilitated by these transport options, could be significant savings around treatment of mental health and depression.

Driving Change

Healthier eating As highlighted above, malnutrition can have a severe impact on the health of older people.While the financial savings to NHS Scotland from healthy eating have not been quantified,a 2011 report found that malnutrition costs the UK in excess of £13 billion a yearXXII which equates, on a prorata basis, to approximately £1 billion per year for Scotland. Again, these are costs which could be considerably reduced by effective public policy planning towards preventative support such as extended community transport services.

Reduction in health inequalities One of the key arguments for extending the NCT scheme is that it will help to reduce inequality in access to transport options. By extension, an improvement in access to transport will result in an increase in access to health services. Audit Scotland’s report on Transport for Health and Social Care found that 13% of older people living in rural areas had poor access to a range of basic services, including GPs, dentists and hospitals. Those on low income and those aged over 80 years were significantly more likely to report poor access. Equally Well, the 2007 report by the Scottish GovernmentXXIII found that “a reduction in health

inequalities, by improving the health of those most deprived, is likely to result in a reduction of costs to the NHS and society as a whole.”

Financial savings due to a reduction in missed appointments While the link between poor transport provision and missed NHS appointments is well known, the relationship has not been quantified. It is reasonable to assume that greater access to appropriate transport would reduce the number of DNAs (patients who Did Not Attend, i.e.missed appointments). Researchers from EnglandXXIV detailed missed outpatient appointments in 2007/08 by age, as per the table below. Applying the percentage of missed appointment by age and using Audit Scotland’s estimate of an average cost of £112 per missed appointment, gives us the following: Table 1: Average annual cost of missed appointments

Age

% DNA

DNAs per age group (total = 168, 476)

Total cost (average cost per missed appointment = £112)

65-69

4.4

7,413

£830,256

70-74

4.1

6,908

£773,696

75-79

4.3

7,244

£811,328

80-84

5.0

8,424

£943,488

85-89

5.6

9,435

£1,085,025

90+

7.1

11,962

£1,229,744

44,578

£5,673,537

Total

We can apply these percentages to the last published figures of all outpatient appointments in Scotland recorded as DNA – a total of 168,476XXVI, on the basis that the proportions apply equally in Scotland and that they remain consistent each year. 29

Driving Change

This suggests an estimated total cost of approximately £5.7million per annum for missed hospital outpatient appointments by older people in Scotland. Two findings from the literature review support the suggestion that community transport may help to reduce DNAs: • A report by the CTAXXVII notes that “health appointment Did Not Attends - a proportion of which

are caused by patients experiencing difficulties getting there - have been reduced by voluntary car schemes in rural areas”

• In 2008, a pilot research project for the Scottish GovernmentXXVIII found that the provision of community transport caused a 1% decrease in DNAs from those aged 65 and over in Dumbarton. The health professionals involved in the study also noted there was a reduction in the need for domiciliary visits. We can apply the 1% identified in the Dumbarton pilot study to our estimated number of appointments missed by people aged 65 and over in 2010 (44,578 – shown in the table above). If all the assumptions hold true, community transport would result in 446 “saved” out patient appointments – with a value of almost £50,000. We highlight that this is a saving for just one type of missed appointment – outpatients. There will also be savings from a reduction in many other types of appointments across the health service.

Reduction in emergency hospital admissions In 2009/10, just under 5% of people in Scotland aged 65 and over (approximately 51,000 individuals) were admitted as emergency inpatients two or more times in a single yearXXIX. NHS Scotland spends an estimated £1.4 billion on emergency hospital admissions by older people each yearXXX. Community transport’s role in helping older people avoid emergency admission to hospital could lead to significant cost savings for the NHS.

Better value for money Community transport services can potentially offer health services greater value for money than other transport providers, as they: • Enable health boards to outsource the costs and risks associated with employing their own transport staff. • Respond to local demand, and can reach areas within which public and private sector providers do not operate.

Savings for local authorities The financial value of maintaining older people’s independence The Scottish Government publication (2011) Reshaping Care for Older People suggests that £1.1 billion was spent in 2006/07 on social care for older people. The document highlights this cost will increase as the percentage of older people rises in future. The report makes the economic argument for a move towards: • A greater emphasis on self care and supported self care. • Anticipatory and preventative approaches to care. • Enabling older people to stay at home with maximum independence for as long as possible. 30

Driving Change

As explained above, one important outcome from community transport provision is that it can maintain older people’s ability to remain living independently. The cost benefits to the state of sustaining independent living are explained below.

Cost of residential accommodation As a result of both maintaining independence and improving health outcomes, community transport can reasonably be expected to contribute towards delays in any move into residential accommodation for older people, particularly where the costs (to the state or individual) are high. The number of older people in care homes in Scotland was estimated to be around 31,000 in 2010/11XXXI, approximately 70% of whom are publically funded (around 21,600). Standard residential care ratesXXXII for publicly funded service users are currently: • £565.96 per week with nursing care. • £487.20 per week without nursing care. Applying the average cost of care (with and without nursing) at £526.58 to the approximate numbers of people in Scotland receiving free residential care (21,600) suggests that local authorities are currently paying around £11,374,128 per year in residential care costs, some of which could be mitigated by an increased pool of community transport service providers.

Cost of domiciliary care As in the case of residential accommodation, by maintaining independence and improving health outcomes, community transport could also reasonably be expected to contribute towards a delay in the need for personal care at home for some older people. The cost to the state of this aspect of care is significant, with an estimated 46,000 older people receiving personal care services in their own homes in 2010/11. The latest NHS Information Services Division’s (ISD) figures on free personal care found that

“…the amount of money spent by local authorities on providing personal care services to older people in their own home has risen steadily each year from £133 million in 2003/04 to £318 million in 2009/10”. Reducing the level of need for personal care would provide economic benefits for all local authorities.

Other economic impacts Greater mobility results in greater economic activity within local communities Mobility is a key enabler for older people in assisting with child care and undertaking voluntary work. The value of this activity is significant; a 2011 report commissioned by MGM advantage calculated that pensioners contribute more than £2 billion a year to the Scottish economy through unpaid care, community and voluntary work. In addition, an extension of the bus pass would save older people money they would otherwise spend on paying for community transport services. This would have the benefit of increasing the amount of disposable income they would have to spend within their local communities.

Driving Change

Chapter conclusion There are a multitude of means by which community transport delivers substantial savings to the public purse and would allow older people to remain as valued consumers within their local economy. Most of these fall into the category of preventing the need for spending on health and social care. However,we have also identified a number of additional economic benefits that occur when older people have increased transport mobility.

Driving Change

Conclusions and Recommendations

Conclusions Local bus travel is a lifeline for many in later life. It helps people to remain independent, access local amenities and services and can be an important means of maintaining contact with friends and family, helping to tackle social isolation. The Scottish Government’s own report of May 2009 showed that the NCT scheme promotes social inclusion and revealed that, based on analysis against the Scottish Index of Multiple Deprivation, the take-up and usage of the scheme is highest in the most deprived areas. This report presents the evidence base on the effectiveness and impact of both the NCT scheme and the community transport sector. The research identifies that, in remote rural areas, over two thirds (70%) of those aged 60 or over either do not have a free pass or do not use their NCT scheme card. This contrasts with less than a third (31%) of older people in large urban areas. Clearly, the current system does not meet the needs of all of Scotland’s older people. For those in rural and remote communities underserved by commercial bus routes or for those who are infirm and are unable to get to their nearest bus stop, community transport services afford people the opportunity to get out of their home. Although many outcomes are difficult to measure, this report also draws out a number of objectives on which community transport delivers, such as helping older people maintain their independence and improving their quality of life. Lack of transport is often considered the tipping point that forces many older people into health and care setting, and the availability of community transport delays and avoids these expensive interventions. While subsidising transport for older people can be expensive, the associated health benefits can significantly outweigh the initial financial outlay. Community transport is a key pillar of preventative spending, helping to delay and even avoid entry into health settings or care homes.

Given the findings Age Scotland believe the current NCT scheme should be extended to include community transport routes and the fares charged by community operators are fully reimbursed. Community transport operators only charge between 10-20% of the overall cost, with an average fare costing around £3.20. With approximately 3.5m community transport journeys every year, this would equate to an estimated additional spend of £11.2m per annum. Even considering the inevitable increase in demand, and the initial capital costs from set-up, we believe the social policy outcomes delivered by expanding the concessionary fares scheme demonstrate the key preventative spend nature of investing in community transport.

Driving Change

Recommendations Based on the findings of this research study, the following recommendations are made for key stakeholders.

Scottish Government Recommendation One: The Scottish Government should establish a national strategy to expand community transport infrastructure in Scotland, alongside additional financial resources, with a view to effectively enabling older people to overcome barriers to accessible transport. This outcome can best be achieved by extending the established NCT scheme to include all eligible community transport operators.

Recommendation Two: The Scottish Government should establish specific, measurable and quantifiable targets around an established National Community Transport Strategy as a means of assessing older people’s access to, and use of, community transport services across Scotland. Where gaps are indentified, the strategy should be adapted to improve the supply of accessible community transport.

Driving Change

Health boards and local authorities Recommendation Four: Health boards and local authorities should jointly support the development and implementation of community-based transport strategies. These must complement the existing commercial provision and meet older people’s health, wellbeing, and social purposes. The strategies should include: • Increased funding available to community operators. • Assessing the impact on older people of limitations to transport options. • Reviewing existing commercial provision. • Mapping older people’s transport needs and identifying gaps in services. • Examining the implications and solutions effective for the delivery of service across local authority boundaries (e.g. patient transport to hospitals in other areas). • Modelling to project future local demand. • Preparing and implementing action plans to increase older people’s awareness of community transport services available in their areas.

Community transport providers Recommendation Five: Seek to maximise contributions towards routine analysis and reporting of the impact of community transport services on users through effective data recording practices.

Driving Change

Appendix 1 An overview of Community Transport in Scotland and relevant background information For the purposes of clarity, this appendix sets out the key contextual information of relevance to the study. It provides: • A definition of community transport. • An overview of licensing arrangements. • A summary of the main types of community transport. • An overview of the development of the NCT scheme.

Defining community transport Community transport is a not-for-profit solution to local transport issues. Each scheme is designed to suit the local community it serves. Services may address a gap in commercial provision, offer a bespoke facility for a specific community group, or provide specialist transport for people who have difficulties using conventional transport. Provision can range from informal, small-scale initiatives, such as a lunch club hiring a bus for community members every now and then – to large operators, that may run a range of not-forprofit services across a sizeable area. The volume of passengers transported by providers can range from single numbers into the thousands. It is estimated that there are approximately 80 “formal” community transport providers in Scotland – these are organisations that recognise their role as the provision of transport for their local community. Most of these organisations are members of the Community Transport Association (Scotland). In addition, there are an unknown number of smaller “informal” providers that fulfil a community transport function without necessarily recognizing their role within the sector. For example, they may simply view their organisation as an interest group (for example, church group) that provides transport for their members for specific events. In terms of staffing arrangements, some community transport services are provided by volunteers; some by social enterprise employees, and others through a combination of both. The key reasons for using community transport are typically: • Social purposes. • Shopping trips. • Accessing services, for example health services. • School bus journeys.

Driving Change

Licensing Community transport operators use the following licenses for passenger transportation: Section 19 (S19) permits “can be issued to organisations concerned with education, religion, recreation, social welfare and other activities of community benefit but only entitles them to carry a defined population (not the general public). The defined population can include those in a geographical area who do not have access to their own private transport”. Dial-a-ride services use this type of permit. Section 22 (S22) permits are “granted for non-profit groups that use unpaid volunteer drivers, to enable them to operate registered bus services for the public using a minibus”. Community bus schemes use this permit. Section 1(4) S1(4) relates to car sharing, and “allows not-for-profit contributions to vehicle running costs to be accepted by drivers without bringing this within PSV or taxi licensing. This is the legal basis for social car schemes, ambulance car services, some other community transport activities and is the common basis for small vehicle dial-a-ride operations for people with disabilities”.

Key types of community transport Each operator develops their own bespoke service depending on local need, but generally the types of transport provided fall into one of four categories:

Group hire – in which a provider rents out vehicles to community groups, for example, minibus

hire to a scouts group for a camping trip. The group hiring the transport decides where it wants to go to and pays an agreed charge to the community transport provider for that journey. Individual passengers do not pay the driver; they may contribute to the overall hire cost but any payment is between the community group and the hiring organisation. The hiring group may “self drive” or may require a “hired driver” – in which case the operator provides a trained driver for an additional fee. Where the service is provided to a third party, the hiring organisation must be a member of that organisation and meet the Community Transport provider’s membership criteria (usually based on the group existing for the benefit of a specific geographic area or community of interest). These services use a Section 19 permit.

Community bus schemes - these are not-for-profit local bus services, operated under the Section 22 permit. Such services run to a regular timetable and can be used by members of the general public. Passengers alight in the same way as they would a commercial bus service at pre-defined stops. Individuals pay a fare for the journey directly to the driver and the fare may be a flat fare e.g. 50p or £1 irrespective of distance, or variable depending on the journey e.g. 50p for a short journey or £3.50 for a longer journey. The driver may be a volunteer or member of staff of the community transport provider.

‘Dial-a-ride’ services – this is provision for people who have difficulty using public transport. In these cases, passengers telephone the provider to request a journey, usually from their own home to a specific destination of their choosing; passengers usually pay a fare to the driver which can be fixed irrespective of distance or variable depending on distance. Dial-a-ride services generally involve specialist accessible vehicles to meet the mobility needs of the passengers. Passengers need to meet the eligibility criteria for the service which is usually focused on a specific geographic area or community of interest. The general public are not allowed to board and alight these services.

Driving Change

‘Dial-a-bus’ services – are similar to the above in the sense that the service is aimed at people who have difficulty using public transport, passengers usually have to telephone in advance to book a place on the bus and usually pay a fare to the driver. The services use accessible vehicles, passengers need to meet the eligibility criteria and the general public are not allowed to board and alight. However, dial-a-bus differs from dial-a-ride in the sense that the service operates at set times and the destinations are fixed and could, for example, be a town or city, a specific shopping centre or a leisure centre or swimming pool. Both dial-a-ride and dial-a-bus are types of Demand Responsive Transport (DRT). Community car schemes –tend to be where volunteer drivers use their own vehicles to provide

journeys for individuals booked through a community transport provider. A charge will normally be paid to the provider and the volunteer driver will receive an expenses payment, usually the HMRC rate of £0.45 per mile. Some Community Transport providers also have cars or people carriers that can be booked by members to provide a community car scheme.

The concessionary travel scheme The Scotland-wide Free Bus Travel Scheme was introduced on 1 April 2006 for eligible disabled people and those aged 60 or over. The initiative superseded the previous policy in which local authorities operated off-peak schemes for travel within council borders. The key policy1 objectives were to: • Allow older and disabled people (especially those on low incomes) improved access to services, facilities and social networks by ‘free’ scheduled bus services; and so promote social inclusion. • Improve health by promoting a more active lifestyle for the elderly and disabled. • Remove the restrictions of the previous local off-peak concessionary fare scheme which produced differences in access to facilities in different areas of Scotland. • Promote a modal shift from private car to public transport. • Maintain a no better; no worse off position for bus operators with a standard reimbursement rate. • Provide an opportunity for improvements to public transport (e.g. assist the development of multi-operator ticketing; the use of improved Electronic Ticket Machine (ETM) technology). • Facilitate a more effective administration of the system with the adoption of a standard reimbursement rate and a shift of operational responsibility from local authorities to Transport Scotland. • Provide a stimulus for the introduction of SMARTCARD. To date, research on the National Concessionary Travel scheme has focused on (i) the cost of reimbursement and (ii) a general monitoring of uptake and trends in pass use. The key documents are Improving the Evidence for Setting the Reimbursement Rate for Operators…(2010); Review of the Scotland wide Free Bus Scheme for Older and Disabled People (2009); and the Evaluation of National Concessionary Travel in Scotland (2009). Although the cost of the NCT initiative has exceeded initial forecasts, there has been no in-depth assessment of the scheme’s impact in terms of health and social outcomes, and a cost benefit analysis of the policy has yet to be undertaken.

Driving Change

Appendix 2 The role of community transport in sustaining the health and wellbeing of older people Table 1: Possession and use of Concessionary Travel Card for adults aged 60+, 2011 (%) Every day

Almost every day

2/3 times a week

Once a week

Once a fortnight

Once a month

Not used

No pass

Sample size (=100%)

All people aged 60+

4,858

Large urban areas

1,582

Other urban

1,456

Small accessible towns

422

Small remote towns

298

Accessible rural

539

Remote rural

560

Source: Scottish Household Survey, 2011

Table 2: Householdsâ&#x20AC;&#x2122; public transport availability, 2011 (%) Up to 6 mins walk to nearest bus stop

5+ buses per hour (but may have a long walk)

Bus stop within 6 min and 5+ buses per hour

Sample size (=100%)

All households

14,358

Large urban areas

5,166

Other urban

4,318

Small accessible towns

1,231

Small remote towns

775

Accessible rural

1,550

Remote rural

1,316

Source: Scottish Household Survey, 2011

Driving Change

Table 3: Frequency of using local bus service in past month (%) Almost or every day

2 or 3 times per week

Once a week

Less often

Not used

Sample

All people aged 16+

12,888

Large urban areas

4,520

Other urban

3,937

Small accessible towns

1,111

Small remote towns

716

Accessible rural

1,384

Remote rural

1,218

Source: Scottish Household Survey, 2011

Table 4: Aspects of neighbourhood particularly liked by urban/rural classification (%) Adults

Large urban areas

Other urban areas

Accessible small towns

Remote small towns

Accessible rural

Remote rural

Scotland

Good public transport

Pleasant environment

Safe environment

Good amenities

Sense of community / friendly people

Other

None

Base

3,402

2,917

839

539

1,059

899

9,655

Source: Scottish Household Survey, 2011

Driving Change Table 5: Aspects of neighbourhood particularly disliked by urban/rural classification (%) Adults

Large urban areas

Other urban areas

Accessible small towns

Remote small towns

Accessible rural

Remote rural

Scotland

Poor public transport

Unpleasant environment

Unsafe environment

Poor amenities

No sense of community / problem residents / substance abuse

Other

None

Base

3,402

2,917

839

539

1,059

899

9,655

Source: Scottish Household Survey, 2011

Table 6: Percentage finding services very or fairly convenient by urban/rural classification Adults

Large urban areas

Other urban areas

Accessible small towns

Remote small towns

Accessible rural

Remote rural

Scotland

Hospital outpatient dept

Dentist

Chemist/ pharmacist

Doctors surgery

Public transport

Small amount of grocery or food shopping

Cash machine / ATM

Post office

Petrol station

Banking services

Base

3,397

2,936

814

559

1,056

921

9,683

Source: Scottish Household Survey, 2011

Driving Change Table 7: Percentage finding services very or fairly convenient by age Adults

16 - 39

40 - 49

50 - 59

60 +

Scotland

Hospital outpatient department

Dentist

Chemist/pharmacist

Doctorsâ&#x20AC;&#x2122; surgery

Public transport

Small amount of grocery or food shopping

Cash machine or ATM

Post office

Petrol station

Banking services

Base

2,796

1,647

1,600

3,641

9,683

Source: Scottish Household Survey, 2011

Table 8: Access to GPâ&#x20AC;&#x2122;s surgery by age, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All people aged 16+

8,106

16-29

1,099

30-39

1,186

40-49

1,344

50-59

1,287

60-69

1,430

70-79

1,134

80+

626

Source: Scottish Household Survey, 2011

Table 9: Access to Dentists by age, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All people aged 16+

7,440

16-29

1,124

30-39

1,203

40-49

1,443

50-59

1,318

60-69

1,242

70-79

786

80+

324

Source: Scottish Household Survey, 2011

Driving Change Table 10: Access to hospital outpatients department by age, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All people aged 16+

3,984

16-29

494

30-39

539

40-49

564

50-59

640

60-69

715

70-79

643

80+

389

Source: Scottish Household Survey, 2011

Table 11: Access to GPâ&#x20AC;&#x2122;s surgery by urban rural split, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All aged 16+

8,106

Large urban

2,806

Other urban

2,487

Small accessible towns

687

Small remote towns

464

Accessible rural

896

Remote rural

765

Source: Scottish Household Survey, 2011

Table 12: Access to hospital outpatients department by urban rural split, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All aged 16+

3,984

Large urban

1,406

Other urban

1,236

Small accessible towns

302

Small remote towns

225

Accessible rural

432

Remote rural

383

Source: Scottish Household Survey, 2011

Driving Change Table 13: Access to Dentists by urban rural split, 2011 (%) Walking

Driver Car/Van

Passenger Car/Van

Bicycle

Bus

Rail (inc. U/g)

Other

Sample size (=100%)

All aged 16+

7,440

Large urban

2,554

Other urban

2,362

Small accessible towns

636

Small remote towns

375

Accessible rural

848

Remote rural

664

Source: Scottish Household Survey, 2011

Table 14: Number of cars normally available to the household for private use by urban rural classification (%) Households

Large urban areas

Other urban

Small accessible towns

Remote small towns

Accessible rural

Remote rural

Scotland

No access to cars

At least one

One

Two or more

Base

5,166

4,318

1,231

775

1,550

1,316

14,356

Source: Scottish Household Survey, 2011

Table 15: Households with cars and bicycles available for private use, 2011 Cars available for private use: none

one

two

one +

two +

three +

1+ Bicycles that can be used by adults

14,358

Single adult

2,360

Small adult

2,371

Single parent

766

Small family

1,838

Large family

863

Large adult

1,386

Older smaller

2,438

Single pensioner

2,336

All households in 2011:

Sample size (=100%)

by household type:

Source: Scottish Household Survey, 2011

Driving Change

References I

http://www.scotland.gov.uk/Resource/0040/00403747.pdf

http://www.transportscotland.gov.uk/files/documents/reports/Transport_and_Travel_in_Scotland_2011_-_Final_ Publication_from_APS_-_PDF_2.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4080981.pdf

III

http://www.ageuk.org.uk/brandpartnerglobal/londonvpp/documents/id111566%20london%20transport%20report%20 final%20lr.pdf IV

http://www.communityfoodandhealth.org.uk/wp-content/uploads/2010/05/ cfhseconomicevaluationfoodtrainmay2010-6432.pdf

http://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Living_on_a_low_income_full_report. pdf?dtrk=true

www2.uwe.ac.uk/faculties/FET/Research/.../andrews_2012_thesis.pdf

VII

www2.uwe.ac.uk/faculties/FET/Research/cts/projects/reports/andrews_2012_thesis.pdf

VIII IX X

http://www.ratransport.co.uk/images/CTA%20Funders.pdf

http://www.plunkett.co.uk/whatwedo/RCT.cfm

http://www.dlf.org.uk/content/key-facts

XII http://www.ons.gov.uk/ons/search/index.html?nscl=Population&pubdateRangeType=allDates&sortBy=none&sortDirection =none&newquery=scotland+population+projections&pageSize=50&applyFilters=true XIII

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4080981.pdf

XIV

http://showcc.nhsscotland.com/isd/6536.html

http://www.c3health.org/wp-content/uploads/2009/09/C3_DIABETES_BOOK_SCOTLAND_FINAL.pdf

http://www.heraldscotland.com/mobile/news/health/heavyweight-patients-put-extra-strain-on-scots-nhs.14875790?_= 3e2feb47655ed2eb9623395ebfa3b54bdc7d2b7d

XVI

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4080981.pdf

XVII

http://www.google.co.uk/url?sa=t&rct=j&q=ann%20murray%20hip%20fracture%20scotland&source=web&cd =1&ved=0CC4QFjAA&url=http%3A%2F%2Fwww.shiftingthebalance.scot.nhs.uk%2Fdownloads%2F1254233652ANN%2520MURRAY%2520-%2520Falls%2520Prevention%2520workshop.pdf&ei=ULG0UK2lO-eX0QXTi4CoBA&usg=AFQjCN FRyCS9uu8xI5ChTjLa7RqrUaFFgg

XVIII

XIX

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4080981.pdf

http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/Policy/A-Z%20policy/Mental%20health%20 forum/Primary-care-guidance-Management-of-depression-in-older-people-Feb-2011.ashx

XXI http://www.oef.com/free/pdfs/menukec.pdf - based on average domiciliary spend per mental health patient (ÂŁ256) as 2007 figure XXII http://www.patients-association.com/Portals/0/Public/Files/AdvicePublications/Malnutrition%20in%20the%20 community%20and%20hosptial%20settting.pdf XXIII

http://www.scotland.gov.uk/Publications/2008/06/09160103/3

XXIV

http://www.drfosterhealth.co.uk/features/outpatient-appointment-no-shows.aspx

XXV

http://www.scottish.parliament.uk/S4_ChamberDesk/WA20120328.pdf

XXVI

http://www.ctauk.org/UserFiles/Documents/Consultancy/CTA_ValuingCT_Brochure-final2.pdf

XXVII

http://www.scotland.gov.uk/Resource/Doc/244763/0068596.pdf

XXVIII XXIX XXX

http://www.scotland.gov.uk/About/Performance/scotPerforms/indicator/admissions

http://www.scotland.gov.uk/Publications/2012/07/1181/5

http://www.scotland.gov.uk/Resource/Doc/924/0120565.pdf

XXXI

http://www.careinfoscotland.co.uk/how-do-i-pay-for-care/paying-care-home-fees/standard-rates.aspx

XXXII

http://www.mgmadvantage.co.uk/news-centre/new-report-society-undervalues-retired-population/

Review of the Scotland-Wide Free Bus Travel Scheme for Older and Disabled People, May 2009

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Age Scotland, part of the Age Network, is an independent charity dedicated to improving the later lives of everyone on the ageing journey, within a charitable company limited by guarantee and registered in Scotland. Registration Number: 153343 Charity Number SC010100