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

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

Patient Transport Services

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

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

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

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

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

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

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

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

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

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

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

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  1. rotzeichen says:

    We here in 38 Degrees Gloucestershire alerted our Tory MP to fact that Arriva ambulances were second hand vehicles and in a dangerous condition and yet drivers were being forced to use them (doors were damaged and would not shut properly), some with 200,000 miles on the clock, needless to say very shortly afterwards even the local paper reported that an elderly (92)patient waited 24 hrs to attend appointment at hospital. The service is in chaos, staff treated appallingly, wages cut to minimum wage, trained staff left for better jobs elsewhere.

    And it goes on, but the private sector still gets the contracts.

    People in this country really do have to wake up.

    1. Me says:

      This is no different to many front line emergency ambulances being used by NHS ambulance services. In fact most private crews I see are in newer vehicles.

      1. Mervyn Hyde says:

        Sorry for the delay in replying but, you sound to me as though you support the chaos that the private sector wreak on the health service. Clearly the Ambulance service like every other part of the public sector has been underfunded, and no doubt could do with lots of more modern equipment, but for my own eyes I have seen the difference between the private providers and SWasft and have never seen that state in the public sector, whats more monitor would be breathing down their necks if the same were true.

  2. D Simpson says:

    Appalling service. The privatization of transport services for hospital appointments have left patients missing appointments and elderly patients waiting ALL day to be collected for hospital appointments. It is difficult for those needing wheelchairs to get taxis to hospital as an alternative. It is not only shambolic and disgraceful but the system needs to be audited. It is a corrupt system with the private transport services not fulfilling their responsibilites.

  3. D Simpson says:

    No. I do not support in your words the ‘chaos of the public sector’. You clearly have not read my post properly. I suggest you get your head out of the sand and re-read the post.

    I doubt very much the ‘monitor’ is or even would breathe down their necks. Who is the ‘monitor’? How many bureaucratic roles does the NHS have now? If the monitoring system worked then patients would not be experiencing the appalling service they are experiencing currently. There is no accountablity. All we get continually, is mere words.

    You complain the Ambulance service is underfunded. I was talking about the privatised Patient transport service. Not the Ambulance service. Clearly you do not understand the difference. Or perhaps there is no difference. It may be the Ambulance service getting more money by privatizing a part of it.

    However now that you mention it, successive governments have put billions of taxpayers money into funding NHS services. The NHS trusts should be audited and there should be transparency about precisely what the salaries are of the Amulance service, the nurses, the consultants and the managers to see exactly where the money is going.

    1. rotzeichen says:

      I’m sorry to say your post is somewhat confused, I made clear in my comment that the private sector is wreaking havoc in the NHS, I pointed also to the condition of so called private ambulances which gave concern to the safety of patients being conveyed in them. Swasft is the South West Ambulance service, as then – called a foundation trust.

      I of course made no mention of chaos ‘in the public sector’ but did mention this: “Sorry for the delay in replying but, you sound to me as though you support the chaos that the private sector wreak on the health service”.

      My comment was in fact directed at ‘Me’ dated March 2nd, 2017, so I don’t even follow your reasoning as to your assertion that it was directed at you, unless of course you are also ‘Me’.

  4. D Simpson says:

    No I am not the blogger ‘Me’. I was replying to ‘Mervyn Hyde’ not to you, ‘Rotzeichen’. You meanwhile were replying to ‘Me’. There does not seem to be any continuity to these posts. That is were the confusion lies.

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