Patient Transport Services toolkitAug2009

Patient Transport Services Toolkit

August 2009 UNISON National Ambulance Committee

UNISON Patient Transport Services Toolkit Index Chapter

Page No.

1 Introduction

3

2 Preparation

8-9

3 Quality Standards

10 - 12

4 PTS Procurement

13 - 15

5 Campaigning and Influencing

19 - 21

Appendices 1 (1) National Ambulance Sector Briefing 1 (2) Excel PTS data workbook 2 (1) Letter to commissioners seeking information

4-7 Separate document 9

4(1) to Letters to commissioners 4(4) on procurement issues

15 - 18

5 (1) to Letters to other 5 (4) stakeholders

22 - 25

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UNISON Patient Transport Services (PTS) Toolkit - Introduction Like other essential, but less high profile NHS functions Patient Transport Services (PTS) have been seen as a potentially lucrative market for the private sector in England. As elsewhere, in order to undercut internal NHS bids and make a profit the private sector bidder must inevitably reduce levels of quality or staff pay and conditions – and often does both. There are also wider implications of NHS Ambulance services losing their PTS. A detailed UNISON briefing on many of the issues is attached at appendix 1(1).

In order to most effectively protect in-house PTS UNISON branches need to be prepared well in advance of the privatisation threat that is addressed in chapter 2.

Until now it is fair to say that our responses have been more reactive than anticipative. As the main Commissioners of Patient Transport Services are Acute or Primary Care NHS Trusts early collaboration with the relevant UNISON health branches in those trusts (through your regional office) should assist in helping identify and lobbying the decision makers and raise general awareness of the issues.

Effective action should not be limited to working in partnership with your own trust on the in-house bid. As this toolkit will illustrate as much effort should be put into influencing and persuading the Commissioners before any decision on PTS is made, either to reject the market option or to ensure that tender specifications properly describe both the quality of the services to be provided and the minimum commitments in respect of staff training, pay and conditions of service (chapters 3 and 4).

Another area that deserves specific attention relates to other stakeholders such as charities, patient user groups, politicians and strategic health authorities. Chapter 5 gives some suggestions on key campaigning and lobbying issues that will be of relevance to them.

The major focus of this toolkit is on preventative measures to keep PTS in the NHS. However it is important also to pursue those PTS contracts that have already been out-sourced. Working in partnership with Ambulance employers and other UNISON colleagues is essential to maximise chances of success. Maintaining high membership density in PTS and developing PTS activists are also vital to ensure continuity of action and that our legitimacy and integrity on this issue cannot be challenged.

Many of the tools referred to take the form of existing UNISON guidance that can be accessed via the UNISON website. Electronic versions of the toolkit will give the user a direct link to these and to other documents. We are indebted to the many UNISON staff and activists who have created these.

We would also like to draw special attention to the benefit of ensuring ongoing involvement of our PTS members in these issues who are often under-represented in Ambulance branches. They can provide key information on patient user groups and service delivery issues that might not be accessible elsewhere. It is also very important to keep reminding all concerned that PTS is about people and patient care and not just a matter of transport as some would like us to believe.

Finally, it is vital that your experiences in this area and in using this toolkit are fed back to UNISON’s National Ambulance Committee. Like a real toolkit this is not set in stone – tools are routinely added and discarded to improve capability and performance. We hope that in sharing successes and failures we will be able to provide a resource that is continuously relevant and “fit for purpose”.

UNISON National Ambulance Committee.

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UNISON PTS Toolkit

Appendix 1(1)

Ambulance Sector UNISON briefing on NHS Patient Transport Services (PTS).

Patient Transport Services (also known as Patient Care Services (PCS)) provide nonemergency ambulance transport for the NHS. They convey patients to and from healthcare providers and are particularly essential in ensuring patients with long term and chronic conditions can access treatment on a regular basis.

1. Who pays for PTS? In England, current responsibility for commissioning PTS can be summarised as follows: Description of Journey

Responsible Organisation

Patient's home address to NHS Trust

The receiving NHS Trust

Patient's home address to other healthcare provider

Primary Care Trust

NHS Trust to patient's home address

The transmitting NHS Trust

NHS Trust to NHS Trust transfer

The transmitting NHS Trust

In Wales progress is well underway to moving to a one country NHS that will incorporate emergency ambulance services as well as PTS (PCS). Scotland is funding its Ambulance Service directly and that includes PTS provision. Northern Ireland is also retaining its PTS in-house.

2. Who provides PTS? PTS resources are primarily based in Ambulance services although some hospital and primary care trusts have their own in-house PTS. However the “market” system of NHS funding in England has already resulted in the privatisation of PTS in many areas. This was enabled by “packaging” PTS as a separate and unrelated entity, not just to Ambulance emergency services but to healthcare in general.

This distorted view of PTS is reflected by the fact that invitations to tender for PTS are advertised in the Official Journal of the European Union (OJEU) under transport rather than healthcare. UNISON believes PTS do have a substantial impact on patients’ health and wellbeing and that should not be ignored.

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3. Why is UNISON concerned?

UNISON represents the majority of PTS staff across the UK and we have a number of serious concerns about developments in England.

3.1 Service Quality The criteria currently being used in England by many trusts to determine their PTS provider is primarily based on cost rather than quality. This is particularly the case where commissioning trusts are in financial difficulty. Tender specifications will often be quite vague when it comes to quality particularly of personnel, who are of course key in providing the service.

3.2 Personnel - training UNISON has revealed that that whilst NHS Ambulance services have a standard induction training program for new PTS of three weeks duration this is not the case in the private sector where “training” is minimal and in some cases new staff without any healthcare or PTS experience get no training at all. UNISON members across the NHS continually alert us that staff in the private PTS sector often appear to have had little or no training in how to handle patients with mobility difficulties and could actually be harming them.

3.3 Personnel - vetting All ambulance trusts must vet any new recruits through a Criminal Records Bureau (CRB) check as standard employment practice. Again, depending on the robustness of the specification this may or may not be a stated requirement when PTS contracts are put out to tender. However, even where a requirement to vet all staff has been specified in PTS tendering documentation there is no independent monitoring system in place to make sure this is being carried out. An investigation by the BBC in December 2008 revealed that a private PTS provider in Birmingham was employing staff without carrying out a CRB or even driving license checks and were employing one individual to work at Birmingham Women’s and Children’s hospitals who had just been released from serving a jail term for a violent offence.

3.4 Personnel – pay and conditions.

UNISON members have advised us that the pay and conditions of many PTS staff employed in the private sector are considerably worse than those enjoyed by directly employed NHS staff. In some cases private sector providers only pay staff when they are in the process of transporting patients. We know from our previous experiences in the privatisation of cleaning and other support services that subsistence wages and providing little or no staff training and development leads to a de-motivated, unskilled and transient workforce that has a major detrimental impact on quality.

3.5 Equipment The minimum standards on staffing within NHS Ambulance services equally apply when it comes to equipment including vehicles and lifting devices. NHS provided PTS benefits from sharing hospital and ambulance A&E resources and the experiences of their staff. Again, whilst tender specifications may refer to equipment standards these are rarely monitored. UNISON members regularly report that private sector PTS vehicles and equipment are not fit for purpose and the commissioners rarely have any system in place to ensure equipment and vehicle standards.

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3.6 Regulation There is currently no national system in place for any licensing, regulation or monitoring of private PTS (or private ambulance) providers. The Department of Health (England) is not even aware of how many private ambulance companies exist let alone monitor their performance.

At a time when the Government claims to have a policy of a risk based approach to the regulation of health and social care providers at the top of its agenda it is surprising that they are condoning the use of an unlicensed, unregulated and uncontrolled workforce who are given access to patients homes and are entrusted with the unsupervised care of some of our most vulnerable citizens including children and the very elderly and infirm.

However it should be noted that since section 53 of The Road Safety Act 2006 came in to effect in January 2008 the following licences are required to be obtained from the Local Authority for any vehicle that carries eight or less persons with a driver and where commercial benefit is obtained: 1. An operator’s licence. This is granted for up to one year, and places various record-keeping requirements on licence holders; 2. A vehicle licence. This is granted for up to twelve months (pro-rata depending on when the application is made) after completion of a compliance test; 3. A driver’s licence. This is currently granted from one to three years to drivers who can show they are ‘fit and proper’ after satisfactorily completing a medical examination, an enhanced Criminal Record Bureau disclosure, and a topographical Knowledge Test.

Private sector PTS providers should hold all these licences. However the PTS tender specifications scrutinised by UNISON have not referred to this as a requirement and with the lack of any proper monitoring it is unknown how many actually do.

4 Wider implications in the privatisation of PTS As well as reducing the quality of care and putting patients unnecessarily at risk the privatisation of PTS has a wider, detrimental effect on the NHS. PTS resources play a crucial support role in emergency and disaster contingency planning to deal with incidents such as flu pandemics or terrorist acts, provide a vital entry point into the ambulance workforce for members of the local community and will, through career development and training help deliver the emergency ambulance crews of tomorrow.

In addition, the English Ambulance Service Review Report “Taking Healthcare to the Patient” advocated that Ambulance Trusts should provide a wider, more patient responsive service involving all levels of healthcare provision. The depletion of PTS resources has already compromised some trusts ability to deliver this.

In the 2008/2009 Christmas / New Year period Ambulance services have had to respond to more calls than ever before. An overall increase in demand of around 10% per year has been the trend for the last decade and shows no signs of tailing off. It is only because of the extraordinary efforts of all their staff, on the front line and in support services that services have been able to cope. It is absurd that in such circumstances the key resources provide by PTS are being lost or under threat.

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5. Resolving the problem 5.1 Many of the issues raised above are not unique to PTS as evidenced in the UNISON commissioned report “Driven by Dogma? Outsourcing in the health service” available at http://www.unison.org.uk/acrobat/B4360.pdf . The most effective solution to this problem would be to halt the privatisation of English PTS and bring back these services in-house. The current situation has arisen through separating the PTS element from ambulance accident and emergency provision to create a PTS “market”. The reality is this is wholly cosmetic and fails to recognise the strategic importance of PTS to NHS emergency ambulance services and patient care.

It is in the national interest that all ambulance services, like the other emergency services are properly resourced to deal with disasters and emergencies. PTS play an essential supporting role, and some services that have already lost significant elements of their PTS privately acknowledge that they are already in a position where they would not be able to properly cope in such circumstances.

5.2 In the event that common sense does not prevail in England and the “market” continues to take priority over the patient and the public the very least that should be done is: i.

Immediately introduce a rigorous national system of regulation and monitoring of all private sector PTS and ambulance providers;

ii. Ensure commissioning trusts satisfy the requirement of section 242 of the NHS Act 2006 that requires them to consult users on proposals to change the way services are provided; iii. Ensure commissioners carry out an equality impact assessment on any decision to change provider with due regard to the impact on staffing and local community; iv. Introduce standard contract specifications that:  Ensure bidders meet existing licensing requirements,  Apply minimum standards to patient care quality, staff vetting, pay, conditions and training including detailing core competencies required,  Require evidence of a commitment and adherence to equal opportunities principles and related legislation  Prohibits sub-contracting; v. Ensure that those trusts that commission private PTS have a robust monitoring process in place for the duration of any contract; Whilst the above measures will not address the wider impact of the NHS losing PTS resources they will at least provide some control over day to day patient care and quality standards.

UNISON will be providing more specific guidance to branches on the requirements and obligations of commissioners and how patient groups and other stakeholders can get involved in protecting their PTS. UNISON National Ambulance Committee August 2009

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UNISON Patient Transport Services Toolkit – Chapter 2 - Preparation UNISON has developed a full and comprehensive guide to campaigning and negotiating around procurement entitled From Commissioning to Contract Evaluation that can be accessed at http://www.unison.org.uk/acrobat/17808.pdf Chapter 4, section B (page 17) covers the issues for branches to consider and the recommended action necessary when developing a clearly defined strategy and underpinning action plan / checklist in partnership with the UNISON regional office.

Mapping Tool – Contract Information The better informed we are the more effective our actions are likely to be. Indeed, in cases where we are not well informed it is likely that key decisions will be made without our knowledge and it will be too late to act decisively at all. To this end it is essential that branches have up to date intelligence in the following areas: 

Existing PTS contracts;



UNISON PTS membership;



Other UNISON Health branch contacts.

Step 1 – Mapping basic PTS contract data.

The first step is to compile a database of existing PTS provision. This will be delivered by the Ambulance Trust, in house or by the private sector. A starting point would be to identify the current PTS contracts held by the Ambulance trust. If these are made with a consortium of NHS trusts break the data down so each trust is listed.

Attached to this toolkit is an EXCEL workbook (appendix 2(1)). Enter this data into the first spreadsheet entitled PTS Contract Info. Also input the basic contract information as indicated by the column headings.

This list of trusts can then be cross referenced with a list of all NHS trusts in your Strategic Health Authority (SHA) area that can be obtained from the SHA / Trust mapping tool in the excel workbook. Go to the spreadsheet in the workbook entitled SHA & Trust Data and click on the drop down list in the column headed SHA name.

Then click on your regional SHA and that will bring up all the NHS trusts in the area.

Compare this list with those trusts you have already identified as holding contracts with the Ambulance trust. Any not on the first list are likely to be either providing their own PTS or using the private sector.

Step 2- More detailed information.

Branches may find it difficult to access details of existing privatised PTS contracts.

Hopefully your Ambulance employer will help identify these. If you still do not already have sufficient details of non-ambulance service PTS provision then you can write to the commissioning trusts seeking this information from them voluntarily. A draft letter is attached below as appendix 2(2) for this purpose. Trust contact details can be normally be obtained via the SHA website that can be accessed at http://www.nhs.uk/servicedirectories/Pages/StrategicHealthAuthorityListing.aspx Please ensure that you alert the respective UNISON health branch of your request by copying them into this letter.

If commissioners of PTS refuse your initial request the Freedom of Information Act (FOI) can then be utilised to obtain this. Please see UNISON’s FOI guide at http://www.unison.org.uk/acrobat/B1959.pdf for full details. The draft letter below can be adapted to refer to this.

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Patient Transport Services Preparation– UNISON Membership data It is important to maintain a high membership density in areas under threat from privatisation. Good membership density strengthens UNISON’s legitimacy and recognition and is also vital to protect members who may already have, or are at risk of being transferred to the private sector. It is recommended that this information is held in a spreadsheet alongside that relating to PTS contracts. See page 18 of the UNISON procurement guide for advice on identifying weaknesses in membership / activist density and working with the region to address this.

Appendix 2 (2) Draft letter seeking information on private sector PTS contracts (to individual trust or consortium).

Dear Re: PTS contracts, Freedom of Information Request.

I am the Branch Secretary of the Ambulance Branch of UNISON. I understand you have contractual arrangements with other agencies relating to Patient Transport Services.

Please can you provide me with the following information: (I request the following information under the Freedom of Information Act):1. All tendering / contract documents.

2. Evidence of your authority to represent each of the Trusts covered by the tenders / contracts.

3. Details of any complaints made in relation to these contracts.

4. Copies of all impact assessments made regarding the pre-contract tendering process including Risk, SWOT, PESTLE and Equality.

5. Details of systems in place to monitor contract compliance.

I look forward to acknowledgment of this request and the subsequent information (preferably electronically).

Thank you in anticipation.

Yours sincerely UNISON Branch Secretary C.C: UNISON Regional Office, Commissioning Trust Branch, Ambulance Trust Employer, Strategic Health Authority

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UNISON PTS Toolkit – Chapter 3 - Quality Standards A private consultancy firm that advises both commissioning trusts and ambulance services on managing PTS contracts has publicly stated that the private sector option will always prove costlier to the commissioners in the long run, and argues delivery of services by NHS Ambulance trusts (or in house) is the only viable option on quality grounds also.

Where commissioners decide to opt for a competitive tendering process it is essential that they factor in all the additional costs of doing so, not just those that are submitted by bidders. In particular they need to properly reflect the cost of managing the PTS contract and putting in place systems to ensure quality standards are met as detailed below whether or not they use an NHS or private sector provider.

Measurable standards of quality.

Like any other Health Services, patient transportation is required to meet quality standards and staffing obligations. We know that it is often the case that these requirements are not specified in contracts and even where they are specified commissioners have no monitoring system in place to ensure they are being met.

This does not mean those standards do not apply.

It is important therefore to know what these standards are, who is responsible for monitoring them and remedying any failure in this area.

Standards for Better Health NHS standards in England are set out in the Department of Health’s Standards for Better Health available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_4086057 . The key areas around which standards are set in this document are called “domains”. Within these domains “core” (compulsory) and “developmental” (aspirational) standards are specified. The key standards to focus on are the Core standards as these are expected to be met immediately.

The first domain is Safety and the specified outcome sought is: “Patient safety is enhanced by the use of health care processes, working practices and systemic activities that prevent or reduce the risk of harm to patients.”

It can safely be said that few if any contracts with private patient transport service providers are governed by any process, working practices or systemic activities that prevent or reduce the risk of harm to patients. It is often the case that once the contract is signed the only measure of the service is whether or not appointments are kept, and no system is in place to ensure that the personnel or vehicles being used to deliver the service are safe.

What the current tendering processes fail to acknowledge and recognise is that NHS Ambulance Services already have to comply with the healthcare standards including those on safety. Therefore the Commissioners can assume compliance. The private sector, however is totally unregulated and has no obligation to comply with these standards, except insofar as is specified by any contract. In any event responsibility for failures in this area will solely be borne by the commissioning trust.

Before any decision on PTS provider is made is made the Commissioners should be required to specify the systems and processes that they will have in place to ensure a non-NHS provider will not compromise patient safety. This should include an 10

independent, ongoing system of monitoring personnel to ensure they have been CRB checked and properly trained and vehicles are roadworthy and are properly cleaned.

The most relevant Safety core standards are C1, C2 and C4.

The concerns outlined above are also particularly relevant to other domains as follows: 2nd Domain - Clinical and Cost Effectiveness.

Core standard C6 provides for Health care organisations to cooperate with each other and social care organisations to ensure that patients’ individual needs are properly managed and met.

Many patients requiring transport, particularly those with mental health illnesses or severe physical infirmities require particular care at all times. Private sector PTS providers will rarely be able to provide this.

3rd Domain - Governance Managerial and clinical leadership and accountability, as well as the organisation’s culture, systems and working practices ensure that probity, quality assurance, quality improvement and patient safety are central components of all the activities of the health care organisation.

The lack of any effective monitoring and control mechanism over private PTS providers would result in failure to meet this domain outcome. In addition the core standard C7 promotes equality and respect for human rights as well as challenging discrimination. This should be a core component of any tender process with bidding organisations having to prove their commitment in this area evidenced by having an equal opportunities policy, undertaking equalities impact assessments.

Core standard C8 refers to the requirement with respect to staff equality issues and C10 & C11 reflect the responsibility of health care organisations to undertake employment checks and are properly trained. Where PTS has been privatised it is the responsibility of the commissioning trust to actively ensure these standards are met. They cannot simply rely on the word of the contractor. If they cannot show they have a working system in place to do this they risk failing on this standard.

4th Domain – Patient Focus The core standards in this domain underline the requirement for systems to be in place. The question for Commissioners using private PTS providers is what systems are in place to monitor their staff and the service they deliver?

6th Domain - Care Environment and Amenities The key area here is the PTS care environment. This is not just the mode of transportation but also very often the patients home. As previously stated the lack of any system in place to ensure PTS vehicle roadworthiness, cleanliness and access to appropriate equipment would indicate problems in this area.

Raising Concerns The standards for better health guidance note on the independent sector states on page 8: “Those commissioning NHS services from the private sector must also take compliance with the Standards for Better Health into account before commissioning contracts are made.”

Commissioners of PTS services should be reminded of their obligations ideally in advance of any decision being made on whether to tender. A draft letter to commissioning trusts is attached to this toolkit as appendix 1.

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In the event that the commissioning trust shows no inclination or evidence that will ensure core healthcare standards will be met after a change of provider the Healthcare Commission should be contacted along the lines of the letter attached as appendix 2.

Ironically, in some cases following PTS privatisation Commissioning trusts have realised they lack the systems, resources and expertise to ensure standards are being met and have sought the Ambulance Trusts’ assistance in this area. It is recommended that it is made very clear to Commissioners prior to provider decisions being made that even if such services are forthcoming they will be very costly and should be factored in to the cost of choosing any private sector option.

Other Equality Standards In addition to healthcare core standard C7 of the 3rd domain (Governance) commissioning trusts are also required to meet general and specific public sector equality duties. Please see section 4D (page 23) of the UNISON procurement guide and also http://www.unison.org.uk/file/16965_Equality_Guidance.pdf for more specific guidance in this area that states on page 12: “An (public) authority cannot abdicate responsibility for meeting the duties by contracting out its functions; where functions are carried out by an external supplier, the authority remains responsible for meeting the duties.”

This is another area on which the private sector cannot compete with the NHS in terms of compliance. As well having in place equal opportunity policies and procedures NHS trusts can access NHS Staff Council and Department of Health resources in these areas.

In addition NHS Ambulance trusts are members of the Ambulance Service Network’s Diversity Forum that provides among other things a comprehensive suite of community engagement initiatives including the provision of a multi-lingual emergency phrase book and pocket edition community handbook.

Commissioners should be asked to ensure that bidders provide evidence of their equal opportunities policies and procedures, gender and ethnic staff breakdown, community and race awareness training. In the event that commissioners ignore their responsibilities in this regard page 16 of the UNISON gives details of methods of enforcement.

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UNISON PTS Toolkit – Chapter 4- Procurement Influencing the PTS procurement process – before a decision to tender.

UNISON has developed a full and comprehensive guide to campaigning and negotiating around procurement entitled From Commissioning to Contract Evaluation that can be accessed at http://www.unison.org.uk/acrobat/17808.pdf .

As with other public services in England the policy of commissioning PTS has been introduced on the premise that by adopting “market” systems you will increase efficiency and improve value for money. The inherent flaw in using this model is that the prime determining factors in awarding contracts are financially rather than patient focused and the process ignores both the longer term and wider impact of privatising PTS that are dealt with in detail in the UNISON briefing document.

It is important to note that there is no current compulsion on NHS Primary Care or Acute trusts to put PTS contracts out to tender. The method of commissioning these services is for local determination although central (Department of Health) and to a lesser extent regional (Strategic Health Authority) policy tends to encourage the “market” approach.

In order to influence the commissioning process and specifications Branches will need to be aware of when the contracts are due for renewal. Experience shows that we have a poor record of anticipating these and as a consequence a vital opportunity to influence the outcome is lost. A PTS mapping tool like the one outlined in chapter 2 will help address this.

In addition to neglecting the impact on meeting healthcare standards Commissioners often ignore their obligations to consult both staff and user groups before they make a decision on whether to go out to tender. These obligations are set out on page 33 of the guidance for NHS organisations on section 242(1 B) of the NHS Act 2006 entitled Real Involvement: Working with people to improve Health services and available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_089787 It is also the case that Cabinet Office Statement of Practice on Staff Transfers in the Public Sector available at http://beta.civilservice.gov.uk/Assets/stafftransfers2_tcm62428.pdf provides for staff and recognised unions to be informed at the earliest appropriate stage of any intention that staff will transfer. UNISON believes that such an intention would be evidenced by consideration of tendering for PTS. Attached as appendix 4(1) and 4(2) are self-explanatory draft letters that should be sent to all commissioners preferably at least 6 months in advance of a contract renewal date. The first letter is applicable where the contract is currently held inhouse and the second where it is already outsourced. There will also be occasions where “New Business” will arise. Either of these letters should be adapted to deal with such circumstances.

These letters also remind Commissioners of their obligations under equalities legislation to carry out an impact assessment into the potential consequences of opting for a private sector as opposed to NHS PTS provider. For more details on this subject please see chapter 4, section D on page 23 of the UNISON guide to campaigning and negotiating around procurement (link above).

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Influencing the PTS procurement process – after a decision to tender.

Without condoning the process, if commissioners insist on putting PTS contracts out to tender branches should do what they can to ensure the specifications are robust.

Commissioners themselves often don’t know enough about PTS to make them competent in this area. UNISON has identified this as a major recurring problem in the application of the tendering system, namely that the PTS specifications that are put out for tender often: 1,

fail to properly reflect the actual requirements of the commissioners and;

2 fail to ensure that bidders meet all the required quality standards (see chapter 3 for details of these.)

An example of 1 is where commissioners failed to specify that PTS should be provided on a Saturday. As a result the contract had to be re-negotiated with the private provider at considerable extra cost to rectify this. More commonly specifications fail to identify precisely the level of training and expertise required of PTS staff and the vetting and checks to be made on them before they are allowed to have any contact with patients.

Standards of vehicle roadworthiness and cleanliness are given minimal if any mention and the same applies to staff pay and conditions including equal opportunities commitments. In the specifications UNISON has seen, no mention has been made of the legal requirement that “for profit” PTS providers must have appropriate local authority operator, vehicle and drivers licenses.

The Commissioners’ general lack of knowledge of PTS is also a major weakness following privatisation. As an NHS body Ambulance Trusts can be relied upon not just to deliver a service with patient care rather than profit as their motivation but that they are also accountable on generic NHS quality standards to the Healthcare Commission. Commissioners need be made aware that, in choosing a private PTS provider they are now solely responsible for ensuring that these standards are met (see Tool on Healthcare Standards) Commissioners often have no system or infrastructure in place to monitor private providers and as a result are powerless to control the risk to patients through subcontracting and inappropriate staff being used. The BBC undercover team report referred to in the UNISON PTS briefing (page 5) can be accessed at http://news.bbc.co.uk/1/hi/uk/7761564.stm .

Ironically, in many cases Commissioners have sought assistance from their local Ambulance Trust in overseeing and monitoring contracts made with the private sector when it has become clear they are not capable of doing this. UNISON recommends that Ambulance trusts make clear to Commissioners that should they not be awarded the main contract such monitoring services will not be forthcoming except at a very high price!

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Once a decision has been to go out to tender the Commissioners are obliged to consult the affected staffs’ union “at the earliest opportunity” if they haven’t already done so. Again it is often the case that this does not happen and tender documentation is drawn up without any consultation. A draft letter to remind commissioners of this obligation is attached as appendix 4(3).

Unfortunately in some instances the branch only becomes aware of the tendering process at a late stage when the tender documentation has already been issued.

The commissioners can be quite reluctant to release full details and it may be necessary to use the Freedom of Information (FOI) Act to obtain these. The content of a letter used by SWAST Ambulance branch to obtain this information is attached as appendix 4(4). See also the UNISON FOI guide at http://www.unison.org.uk/acrobat/B1959.pdf ).

UNISON PTS Toolkit Appendix 4(1) Draft letter to Commissioners on obligations to NHS Staff that need to be met before deciding on the procurement option (current provision in-house) Dear Re: Patient Transport Services I am writing on behalf of the UNISON Ambulance Branch in relation to the contract for the provision of Patient Transport Services (PTS) to your trust currently held by ?

Ambulance Services Trust that expires on (date). A significant number of our members are employed in delivering these services. I enclose a UNISON briefing on the issue.

I would be grateful if you would advise me of any deliberations being made by the Trust on the future provision of these services after the above expiration date.

In the event that such considerations might result in changes to current staffing arrangements including potential transfer please confirm that you will provide their accredited representatives at this branch with the opportunity to be involved in those before any decisions on future provision are made.

Such consultation is a requirement of the provisions of the Cabinet Office Statement of Practice on staff transfers in the public sector (revised November 2007) and recommended practice as detailed in the Guidance for NHS organisations on section 242(1 B) of the NHS Act 2006, the duty to involve and good involvement practice, that states on page 33.

People working in the NHS have considerable knowledge and understanding of their service and clinical good practice and they may have ideas on how a service can be improved. You may find it helpful to let staff know about any changes that are being planned, developed or consulted upon, to make sure that they are informed about the proposals and that they are given opportunities to get involved from the beginning of the process.

I would also like to take this opportunity to point out your obligation to carry out an Equality Impact Assessment on the implications of any options you may be considering including the impact on staff. We would be happy to assist you in this regard.

I look forward to hearing from you, UNISON Ambulance Branch Secretary Cc UNISON Regional Office, Commissioning Trust Branch, Ambulance Trust Employer, Strategic Health Authority 15

UNISON PTS Toolkit Appendix 4 (2) Draft letter to Commissioners on obligations to be met before deciding on the procurement option (current provision privatised) Dear Re: Patient Transport Services I am writing in relation to the contract for the provision of Patient Transport Services (PTS) to your trust currently delivered by (Private Company) that expires on (date).

(A significant number of our members are employed in delivering these services).

I enclose a UNISON briefing on the issue.

I would like to bring to your attention that as a profit making enterprise the current provider is required to hold local authority operator, vehicle and drivers’ licenses in accordance with section 53 of The Road Safety Act 2006.

I would also like to point out your obligation to ensure that relevant personnel employed by the PTS provider commissioned by you are registered with the Independent Safeguarding Authority (ISA) from July 2010.

Please also note that the Healthcare Standards state as follows: “Those commissioning NHS services from the private sector must also take compliance with the Standards for Better Health into account before commissioning contracts are made.”

Please can you advise what systems you have in place to ensure these standards will be met on an ongoing basis including that staff of any potential provider have received the minimum training considered necessary to carry out PTS, typically of 4 weeks duration including 1 week driving training.

As well as falling short in the training and education area I understand that the current PTS provider’s rates of pay and employee service conditions are of significantly less value than those provided by the NHS and (and those enjoyed by staff who have TUPE transferred over) contrary to the undertaking provided by the Two Tier Workforce Agreement.

I would also like to take this opportunity to point out the obligation on your trust to carry out an Equality Impact Assessment on any continuation or variance of current arrangements including any impact on staff.

In addition please can you advise of the arrangements in place to fulfil your other public sector equality duties relating to PTS in the event it is commissioned from a private sector provider.

We would be happy to assist you in this regard with the provision of the Ambulance Trust’s equality policies and procedures in respect of staff and the communities we serve.

I look forward to hearing from you, Signed UNISON Ambulance Branch Secretary Cc UNISON Regional Office, Commissioning Trusts’ Branch, Ambulance Trust Employer, Strategic Health Authority

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UNISON PTS Toolkit Appendix 4(3) Draft letter to Commissioners after decision to tender has been notified but before issuing of documentation.

Dear Re: Patient Transport Services I am writing in relation to the contract for the provision of Patient Transport Services (PTS) to your trust currently held by ? Ambulance Services Trust / private company that expires on (date). (A significant number of our members are employed in delivering these services).

I enclose a UNISON briefing on this issue.

I understand that the Trust will be tendering for the future provision of these services.

We are disappointed that you have not decided to commission these services from the Ambulance Trust.

(Please confirm that you will consult the affected PTS staffs accredited union representatives at this UNISON branch on the content of any tender specifications before they are finalised.)

Such consultation is a requirement of the provisions of the Cabinet Office Statement of Practice on staff transfers in the public sector (revised November 2007) and recommended practice as detailed in the Guidance for NHS organisations on section 242(1 B) of the NHS Act 2006, the duty to involve and good involvement practice, that states on page 33.

People working in the NHS have considerable knowledge and understanding of their service and clinical good practice and they may have ideas on how a service can be improved. You may find it helpful to let staff know about any changes that are being planned, developed or consulted upon, to make sure that they are informed about the proposals and that they are given opportunities to get involved from the beginning of the process.

I would also like to take this opportunity to point out the obligation on your trust to carry out an Equality Impact Assessment on any continuation or variance of current arrangements including any impact on staff.

In addition please can you advise of the arrangements in place to fulfil your other public sector equality duties relating to PTS in the event it is commissioned from a private sector provider.

We would be happy to assist you in this regard with the provision of the Ambulance Trust’s equality policies and procedures in respect of staff and the communities we serve.

I look forward to hearing from you, Signed UNISON Ambulance Branch Secretary Cc UNISON Regional Office, Commissioning Trust Branch, Ambulance Trust Employer, Strategic Health Authority

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UNISON PTS Toolkit Appendix 4(4) Draft letter seeking information on tender documentation.

Dear Re: PTS contracts, Freedom of Information Request.

I am the Branch Secretary of the Ambulance Branch of UNISON. I have become aware of the tenders that you have put out in respect of Patient Transport Services.

I request the following information under the Freedom of Information Act:1. All tendering documents.

2. The dates of the meetings where the decision to tender was discussed and subsequently taken.

3. A list of the organisations and individuals present at those meetings (post holders if not names).

4. The meeting minutes. (I understand that these may be altered to protect individuals).

5. A copy of the terms of reference for the meetings/group.

6. Evidence of your authority to represent each of the Trusts covered by your tenders.

7. All correspondence fed back to the Trusts covered by your tenders.

8. Copies of all impact assessments made regarding the tenders including Risk, SWOT, PESTLE and Equality.

9. A list of the dates that you consulted the these tenders.

Ambulance Service on

I look forward to acknowledgment of this request and the subsequent information (preferably electronically).

Thank you in anticipation.

Yours sincerely UNISON Branch Secretary C.C: UNISON Regional Office, Commissioning Trust Branch, Ambulance Trust Employer, Strategic Health Authority

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UNISON Patient Transport Service Toolkit – Chapter 5, Campaigning and Influencing A key element in any campaign is gaining the support and involvement of other influential bodies and groups. A first step in that direction is to identify who they are and then seek to establish communications with them. Some key influential organisations outside of the commissioning trust(s) are: 

Patient and service user groups



Charities



Politicians



Health Overview and Scrutiny Committees



Strategic Health Authorities



The media

Included in this toolkit is a generic PTS briefing paper that can be sent to these key groups. However branches are encouraged to supplement this with details of the specific local potential impact of PTS outsourcing and include, where possible testimonials from individual patients and user groups.

1. Patient and service user groups.

The key patient / user organisation is the Local Involvement Network (LINk). These came into existence in April 2008 to replace Patient Forums. LINks are made up of individuals and community groups who work together to improve local services.

Their role is to find out what the public like and dislike about local health and social care. They will then work with the people who plan and run these services to improve them. This will include influencing proposals for change.

Please see the UNISON guide at http://www.unison.org.uk/acrobat/A6681.pdf for more details. As LINks deal with health and social care they are organised through local authorities. To identify your local LINk contact see the list at: http://www.nhscentreforinvolvement.nhs.uk/index.cfm?content=110&Menu=36 .

Local authority websites should have a section on LINks that might provide more detailed contact information. Details of these are available at http://www.direct.gov.uk/en/Dl1/Directories/Localcouncils/AToZOfLocalCouncils/DG_ A-Z_LG . These websites should also have details of local support and community groups who might have an interest in any potential changes to PTS provision.

It should be noted that in some areas LINks have been slow to get started and some patient forums are still operating. Check your Ambulance and the commissioning Trust websites for details.

2 Charities Some charities, particularly those dealing with the elderly and conditions requiring lifelong treatment have a major interest in this issue (and will often be members of LINks). Some of these are listed on the table below along with their website addresses. However the Charities Commission website provides details of all registered charities in England and Wales including a search facility that will identify these by location at http://www.charitycommission.gov.uk/Showcharity/RegisterOfCharities/AdvancedSearch.aspx .

Branches should access these for local contact information and of course use their own local knowledge in this regard.

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Charity

Website address

Age Concern

http://www.ageconcern.org.uk/AgeConcern/local.asp

Help the Aged

http://www.helptheaged.org.uk/engb/WhatWeDo/InYourArea/Committees/

Macmillan Cancer Support

http://www.macmillan.org.uk/Get_Involved/In_your_a rea/England/England.aspx

MIND

http://www.mind.org.uk/Mind+in+your+area/

3. Politicians Local councillors can be identified through the local authority websites link http://www.direct.gov.uk/en/Dl1/Directories/Localcouncils/AToZOfLocalCouncils/DG_ A-Z_LG .

Details of Members of Parliament can be accessed at http://www.upmystreet.com/commons/l/ .

The current Health Minister with responsibility for urgent and emergency care is Mike O’Brien MP who can be contacted at obrienm@parliament.uk .

4. Health Overview and Scrutiny Committees A UNISON guide detailing how to use scrutiny in the fight against outsourcing can be accessed via the UNISON website at http://www.unison.org.uk/acrobat/17621.pdf .

Like LINks your local Health Overview and Scrutiny Committee is administered by the Local Authority and contact details should be accessible via their website.can be accessed at 5. Strategic Health Authorities (SHA’s).

Strategic health authorities are responsible for: 

developing plans for improving health services in their local area,



making sure local health services are of a high quality and are performing well,



increasing the capacity of local health services - so they can provide more services, and



making sure national priorities - for example, programmes for improving cancer services - are integrated into local health service plans.

Strategic health authorities manage the NHS locally and are a key link between the Department of Health and the NHS. Contact details for your SHA can be found at http://www.nhs.uk/servicedirectories/Pages/StrategicHealthAuthorityListing.aspx If possible these stakeholders should be contacted and alerted in advance of any decision to put contracts out to tender. In addition to the briefing a covering letter should identify the key decision makers in the commissioning process to encourage stakeholders to raise their concerns directly with them.

Attached below as appendices 5(1) to 5(3) are draft letters that could be used before and, if necessary after a decision has been made to go out to tender. Thanks to the South West Ambulance branch for these.

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6 The media It is essential that the work undertaken to influence all the above groups is coordinated with a media campaign that is designed to influence the service user and gain public support.

Regions will have media contacts and will help branches to write and distribute press releases. The region can also help with the development of a campaign strategy.

It has proved to be useful to spend some time building a relationship with the local television news teams (they will have a local health correspondent) prior to ‘going public’. This will enable the branch to plan a systematic approach. If possible the aim should be that the MPs and local politicians, who will wish to use the opportunities, are approached by the media after they have received your briefing.

This will give them the opportunity to use your information or to contact the branch for more details.

It is also useful to prepare patients and members of the public who will be willing to give interviews to the press throughout your campaign, passing on these details to the media ensuring that there is positive consistent press on your issues, in line with the branch message.

The branch and region should nominate two or three people that will be available to answer all press inquiries and give appropriate interviews. This will ensure that there is consistency in all public statements. The branch or region can then manage the pace and content of the campaign, informing your press contact of all important milestones such as meetings with politicians.

Attached as appendix 5 (4) is a copy of a recent South West Ambulance Branch press release issued as part of their successful PTS campaign.

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UNISON PTS Toolkit appendix 5 (1) Draft letter to patient / service user groups / charities: Dear Re: Potential Privatisation of Patient Transport Services I am writing to draw your attention to the fact that commissioners on behalf of your local NHS (are considering whether) (have decided) to tender aspects of the Patient Transport Services (PTS) that are provided by (insert commissioning trust(s)).

Currently these services are provided by the (name of Ambulance NHS trust).

However, if the tendering process is followed through these may in future be provided by an unregulated private company which we believe would have a detrimental impact on the safety and the quality of the service to patients.

Services covered by these (potential) tenders include:Outside Core Hours, Short Notice, Timed Response, Long Distance, Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

This issue affects some of the most vulnerable patients that are conveyed by Patient Transport Services. Indeed it is our understanding that some of these patients would normally be transferred by qualified ambulance staff with the training, experience and equipment to deal with any complications that might arise during the journey.

UNISON, as a public service union, is committed to maintaining a safe and secure ambulance service, as well as being committed to the maintenance of our member’s employment status and future. We believe that (any) (the) decision to tender undermines both of these considerations. Therefore we wish to highlight the issues to yourself, your colleagues and the public.

We enclose a briefing paper on the main areas of concern. We would welcome the opportunity to discuss the issues with you directly and will be happy to expand on these and answer any questions you may have.

We would respectfully request that you raise these issues with your local NHS organisations as we believe that tendering (would) constitute(s) a substantial change in the delivery of PTS services. Attached are contact details of the respective commissioners.

I look forward to meeting you in the near future. In the mean time, if I can assist you with any further information please do not hesitate to contact me.

Yours sincerely

UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (2) Draft letter to MP’s / Councillors Dear Re: Potential Privatisation of Patient Transport Services I am writing to draw your attention to the fact that commissioners on behalf of your local NHS (are considering whether) (have decided) to tender aspects of the Patient Transport Services (PTS) that are provided by (insert commissioning trust(s)) to the people in your constituency.

The tenders (would be) (are) for several aspects of PTS transport and will, we believe, inevitably impact on the safety and the quality of service to many of the patients covered by the proposals.

Services covered by these tenders include:Outside Core Hours, Short Notice, Timed Response, Long Distance, Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

The total estimated value of one of these contracts is between two and four million pounds; therefore they represent a substantial element of the patient transport for the area.

This issue affects some of the most vulnerable patients that are conveyed by Patient Transport Services. Indeed it is our understanding that some of these patients would normally be transferred by qualified ambulance staff with the training, experience and equipment to deal with any complications that might arise during the journey.

UNISON, as a public service union, is committed to maintaining a safe and secure ambulance service, as well as being committed to the maintenance of our member’s employment status and future. We believe that the proposals put forward undermine both of these considerations. Therefore we wish to highlight the issues to yourself, your colleagues and the public.

We would welcome the opportunity to discuss these issues with you directly and will be arranging for a number of our PTS staff to visit their MPs at Westminster / councillors surgeries to lobby them on the issues.

We would respectfully request that you raise these issues with your local NHS organisations, with ministers, and raise the concerns that we have identified. We attach contact details of the respective trusts / ministers.

I look forward to meeting you in the near future. In the mean time, if I can assist you with any further information please do not hesitate to contact me.

Yours sincerely UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (3) Draft letter to Overview and Scrutiny Committee Dear Re: Potential Privatisation of Patient Transport Services I am writing to draw your attention to the fact that commissioners on behalf of your local NHS (are considering whether) (have decided) to tender aspects of the Patient Transport Services (PTS) that are provided by (insert commissioning trust(s)) to the people covered by your Overview and Scrutiny Committee and the neighbouring counties.

The tenders (would be) (are) for several aspects of PTS and will, we believe, inevitably impact on the safety and the quality of service to many of the patients covered by the proposals.

Services covered by these tenders include:Outside Core Hours, Short Notice, Timed Response, Long Distance, Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

The total estimated value of one of these contracts is between two and four million pounds; therefore they represent a substantial element of the patient transport for the area.

This issue affects some of the most vulnerable patients that are conveyed by Patient Transport Services. Indeed it is our understanding that some of these patients would normally be transferred by qualified ambulance staff with the training, experience and equipment to deal with any complications that might arise during the journey.

UNISON, as a public service union, is committed to maintaining a safe and secure ambulance service, as well as being committed to the maintenance of our member’s employment status and future. We believe that the proposals put forward undermine both of these considerations. Therefore we wish to highlight the issues to yourself, your colleagues and the public.

We enclose a briefing paper on the main areas of concern. We would welcome the opportunity to discuss these issues with you directly and will be happy to attend your committee to expand on these and answer any questions you may have.

We would respectfully request that you raise these issues with your local NHS organisations as we believe that this constitutes a substantial change in the delivery of PTS services.

I look forward to meeting you in the near future. In the mean time, if I can assist you with any further information please do not hesitate to contact me.

Yours sincerely UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (4) Draft Press Release Patient Transport Services (PTS) provided within the South West are at direct threat of outsourcing to the private sector. UNISON the union that represents the South Western Ambulance Service staff that currently provide the service have expressed their deep concern for the future reliability and safety of the services if they are handed over to the private sector.

These tenders cover some of the most vulnerable patients that will be conveyed by Patient Transport Services. Indeed it is UNISON’s understanding that some of these patients would normally be transferred by qualified ambulance staff with the training, experience and equipment to deal with any complications that might arise during the journey.

Ian Hopkins the ambulance Branch Secretary said: “Services to these vulnerable patients need to be provided by trained, skilled and dedicated staff. Patients and their relatives need to feel they are in safe hands. We understand that the NHS is striving to cut costs and save money but these patients need more than just taxis. It would be better for all concerned if patient transport services remained the responsibility of ambulance trusts."

UNISON is also concerned that the loss of the staff and vehicles would compromise the services ability to cope with major incidents. The PTS staff are used to back up the front line service in times of extraordinary demand. They are used by the service to transport the less injured patients away from incidents as varied as explosions, major motorway incidents and civil emergencies such as floods when people need evacuation.

The services so far out to tender include, Outside Core Hours, Short Notice, Timed Response, Long Distance, Repatriation, Bariatric, Mental Health, Renal and NeoNatal. However, UNISON believes that this could be the start of a process that would lead to all services being tendered.

UNISON has already written to all of the MPs that have constituencies covered by the threat, and are taking their concerns to the local Overview and Scrutiny Committees that cover health issues. We believe that these proposals represent a significant change in service delivery and have not been consulted upon.

UNISON, as a public service union, is committed to maintaining a safe and secure ambulance service, as well as being committed to the maintenance of our member’s employment status and future. We believe that the proposals put forward undermine both of these considerations.

UNISON Regional Officer Chris Dayus added.

“This is not just a campaign by UNISON to protect our members. This is about public services provided to the weakest and most vulnerable in our area. The public deserve be informed about these proposals and should have a say in the debate. We must point out the true folly of chipping away at these vital services and putting people at risk.”

For more information etc please contact: Name

UNISON Position Branch Secretary Assistant Branch Secretary UNISON Regional Officer UNISON Press Officer

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Contact Tel.Number