Is transport the cure-all that the NHS needs?

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Greater Manchester’s Cycling and Walking Commissioner Chris Boardman was recently quoted as saying “Pick a crisis: congestion, obesity, inequality, air pollution, global warming, safety…Investing in cycling and walking is as close to a silver bullet as you’ll get.”

The NHS is certainly in the market for a cure-all, unveiling last month the ‘For a greener NHS’ campaign. The campaign aims to ensure that the NHS and its staff step up efforts to tackle what it calls the climate ‘health emergency’. It recognises that what is bad for the planet – global warming, flooding, air pollution – is also bad for people’s health, with evidence linking these conditions to heart disease, strokes, lung cancer, asthma and the spread of infections and diseases.

The campaign involves the establishment of an expert panel to chart a practical course to get the NHS to net zero emissions; a new NHS Standard Contract calling on hospitals to reduce carbon from buildings and estates; and a grassroots movement to encourage staff and hospitals to reduce their impact on the environment, and in doing so, improve people’s health.

Transport is recognised in the campaign as having a key role to play in placing the NHS on the path to net zero. It is estimated that patients and visitors to NHS facilities alone generate 6.7 billion road miles every year. The NHS Long Term Plan has previously committed to making better use of technology to reduce the number of face-to-face appointments patients need to attend. Staff travel is also a problem and the grassroots campaign will encourage more employees to travel on foot or by bike. In addition, NHS fleets are acknowledged as needing a clean-up, with NHS Chief Sir Simon Stevens pledging last year to help ‘blue lights go green’ to reduce their impact on climate and air pollution.

Transport, health and climate are inextricably linked to, and dependent on, one another. The transport choices we make as individuals, organisations and policy makers influence the speed of climate change and the quality of our air. They also help determine the amount of physical activity a person undertakes, their mental wellbeing and their access to opportunities.

For many years we have been calling for greater recognition of the connections between transport and health and for more collaboration between the two sectors. The tools and evidence base we have built and collected over this time can be found on our Health and Wellbeing hub. The ‘For a greener NHS’ campaign presents a big opportunity to strengthen and maximise those connections and relationships.

To this end, we have written to the newly appointed Chair of the NHS Net Zero Expert Panel, Dr Nick Watts, welcoming him to the role and expressing our wish to work with the NHS in a strategic way to address our shared challenges. Our letter includes four propositions that we believe could help:

  1. A health and transport champion in each region charged with making the connections between the sectors and bringing leadership on the issue.Evidence suggests that progress on making the connections between transport and health is frequently driven by passionate individuals keen to make a difference above and beyond their day jobs. When these individuals move on, or when their organisations are restructured, the momentum can be quickly lost.Creating a specific, permanent role within each NHS England regional team to champion and drive forward joined-up thinking between health and transport could provide a stable footing for strategic, long-term collaboration.
  2. A health and transport convention in each region of England co-owned by the Department of Health and Social Care (DHSC) and the Department for Transport (DfT) to seek to broker ways forward.Our research shows that despite growing collaboration between our two sectors, significant barriers remain, from differing standards of evidence to the use of codified languages. From a transport perspective, even identifying whom to engage in the NHS – and maintaining that engagement – can prove very challenging.There would be value in enabling key health and transport stakeholders in each region to meet, build relationships and broker ways forward.
  3. Require the NHS to consult with transport authorities when making decisions on healthcare locations. The DfT and DHSC should co-commission good practice guidance on ensuring sustainable transport access to healthcare to support this.Evidence gathered from our members suggests that consultation by the health sector with transport bodies about decisions to open, close, merge or re-locate healthcare settings is patchy. When transport bodies are consulted, too often location decisions have already been made. Sites that are poorly integrated with public transport, walking and cycling networks generate more car journeys, contributing to congestion, poor air quality, climate change and physical inactivity.These issues can be avoided if transport authorities are consulted at the earliest possible stage. They can provide expert advice about which sites would be most accessible, minimise traffic and support non-car access (and therefore positive climate and health outcomes), enabling these factors to be designed into the scheme from the outset.
  4. An independently chaired government review to examine the efficiency and effectiveness of non-emergency patient transport services (NEPTS) and potential reforms.We believe that there is considerable scope to improve the efficiency and effectiveness of NEPTS to reduce the number of journeys and vehicles on the road.In 2017, we worked with the Community Transport Association and the Association of Transport Coordinating Officers to explore alternative approaches to commissioning non-emergency patient transport and found that taking a ‘Total Transport’ approach to NEPTS has the potential to generate significant savings for the NHS as well as deliver better outcomes for patients.

    Total Transport would see multiple public and community sector fleets (e.g. NHS, social care, education) bought together into a shared pool under a single point of access catering for a wide range of passengers (from patients to school children). Often there is considerable overlap in the vehicle standards and care components required across sectors. The pool of vehicles would be coordinated and scheduled centrally, taking into account options on the mainstream network. It would ensure that the entire public sector vehicle fleet is put to maximum use throughout the day and that the right vehicle is deployed for the right job (avoiding over-specification).

    In doing so, NHS and other public sector partners could achieve more using fewer vehicles and reduce the number of trips made overall. The benefits would be further extended if the pooled fleet was made up of zero or low emission vehicles.

As well as the Chair of the NHS Net Zero Expert Panel, we have also shared these ideas with HM Treasury, Sir Simon Stevens (CEO of the NHS) and the Director of the Sustainable Development Unit (the body which supports the sustainable environmental, social and financial development of the NHS, public health and social care).

We hope that colleagues in the health sector find the ideas useful and take up our invitation to work more closely together at strategic level to fully realise the potential of clean, active transport as a prescription to cure the ills of people and planet alike.

Rebecca Fuller is Assistant Director at the Urban Transport Group

A city that works for children, works for everyone

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‘A city that works for children, works for everyone’ – this was a phrase repeated time and again at this year’s International Healthy Streets Summit, an event that the Urban Transport Group is proud to have sponsored for the second year running.

The host for this year’s event was Glasgow, a city with big plans for its wide, traditionally car-friendly streets, many of which are being transformed by the £150m ‘Avenues’ programme. Glasgow City Council has taken the bold step of saying that it is ‘prepared to put the private car last’ – something it sees as absolutely the right thing to do, particularly as less than half of Glasgow households own a car.

The Avenues scheme will be transformative, placing people and their health at the heart of streets. Streets will be designed for vehicle speeds of up to 15 mph, they will be tree-lined, pleasant and safe, with more space for pedestrians and cyclists and less for motor vehicles.

But the real test will be their suitability for the city’s smallest citizens.

95cm tall and full of beans

Helen Forman, West Yorkshire Combined Authority’s Urban Design Manager, presented a thought-provoking challenge for delegates at the Summit. What do streets look and feel like from the height of a 95cm child, a child who is full of energy, curious about the world and looking for fun? What are the opportunities in the environment for that child? What are the restraints?

Can they run, jump, climb and explore? Are there trees, plants and wildlife to discover, water to splash in, interesting things to see, hear and smell?

Or is the environment designed in such a way that they must proceed directly from A to B with no diversions, hand held tight to an adult for safety? Are their tiny lungs and airways assaulted with fumes from passing cars as they walk in the wake of exhaust pipes that are low to the ground, just like them? Are they confronted with a sea of grey, dotted with high windows and closed doors?

Glasgow’s Avenues will certainly provide the former, rather than the latter experience, a goal that is increasingly being pursued by cities across the world. Whilst play equipment is undoubtedly valued, designing for children in a way that benefits everyone is about more than that. Children are skilled at finding opportunities to play anywhere.

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Playful anywhere

Travelling back from Glasgow on the train, I tried to think of the carriage from a child’s perspective. I saw large, low windows presenting an ever-changing view – animals, fields, the sea, houses, castle walls. I saw tray tables to flip up and down. Seats to hide under, aisles to run up and down. Buttons to push. People to meet. There was no play equipment but there were certainly opportunities to play.

When we think about streets in the same way it makes sense to restrict motor traffic to enable wide, safe spaces to walk and run, cycle and scoot. It makes sense to provide walls to balance on; stones to hop between; benches to rest on; sculptures that can be climbed on; water to splash in; trees to hide behind; flowers to smell; bees to spot; fruit and veg to pick; windows to look into. The list is endless. And the best thing is – these are features that everyone likes – whatever their age.

So let’s play and find joy together. And let’s not confine these opportunities to ‘destination’ places. Let’s spread them to the back streets and neighbourhoods – communities beyond the city centre – just as Glasgow is doing with its next phase of work – ‘Avenues Plus’. And to bring hearts and minds with us, let’s design with, rather than for, communities. Let’s not talk about ‘transport projects’ or ‘streetscape improvements’ but focus on what benefits these will bring to how people live their daily lives. How we will create what one speaker called ‘loveable’ neighbourhoods that people young and old can be proud of and, crucially, part of.

Becky Fuller is Assistant Director at the Urban Transport Group

Getting beyond the MaaS hysteria

MaaS Movement cover social size

I don’t know about you but I’ve seen more than enough Power Points by now explaining with breathless excitement what Mobility as a Service (MaaS) is – as if no-one had ever heard about it before. And as if frequent repetition of the phrase in itself has alchemic properties which render immaterial base considerations as economics. So in the report we recently published on MaaS, we’ve tried to get beyond the MaaS hysteria and delve deeper into the real issues on turning the considerable potential of the concept into reality on the ground.

However, first it’s worth acknowledging how understanding of what people mean when they say Mobility as a Service has shifted in recent years. When this clumsy technocratic phrase (which unfortunately we are all now stuck with) first emerged it was commonly understood to mean the purchasing of packages for access to public transport combined with different forms of vehicle hire and sometimes bikes. It has since morphed to include portals for access to information and purchase of individual trips, and further evolved into the potential for the creation of ‘walled gardens’ where international corporations seek to ensure that you always go to them for transport information and payment (thus seeking to reproduce the monopoly platform model that has ultimately proved so profitable for Airbnb, Amazon, Google et al).

So far, despite all the fervour and theology about MaaS, what’s been achieved on the ground so far is rather less clear cut. At scale take up of MaaS (as originally defined as packages of mobility) is difficult to find. Indeed, we are at a point where the future of MaaS is still to be determined. It could be a system that steers people towards greater use of cars or away from them. It could make travelling easier for all, no matter their income, disability or location, or it could make mobility easier for tech-savvy, city centre dwellers and harder for those who are already excluded and marginalised. It could be a great concept that takes off at scale or one that people don’t need or want in practice.

Our report identified three factors that will determine the future of MaaS. The first is the topic that nobody seems to want to talk about when it comes to MaaS – which is money. The challenge for MaaS (where this means packages of mobility) is how you price the package at a rate where all the different providers involved make a return at a price the punters are willing to pay. Not easy unless either the public sector or the private sector is prepared to take a hit to ensure that cost is kept low.

A purely private sector-led MaaS could be prepared to burn cash in the short term in the hope of establishing a profitable monopoly in the long term. A purely public sector-led MaaS may be willing to do the same because the outcomes are worth the costs.

And then there’s the awkward question of how many people want to buy a package of mobility in the first place, rather than pay as they go – and who are they? Not clear yet. However, I always remember speaking to the person who runs the MaaS offer in a German city where the transport authority has been doing what is now described as MaaS for years and he said he thought it was good to be able to offer it, but it’s a niche product. He said most people will get a taxi when they want one rather than pay up front for access to taxis they may not use. One radical viewpoint on the economics of MaaS is that the real breakthrough would be to fuse MaaS with the pricing of road use to put paying to use your own car on contested and congested road space on the same app and pricing framework as for public transport, taxis and car hire.

The second make or break for MaaS is access to data. This factor is much more commonly covered in the debate on MaaS – so I won’t go into detail here. But with data now commonly seen as the earth’s most valuable commodity there are some big questions around how you get to the point of ‘if I show you mine will you show me yours?’

The third determinant is around the extent to which wider environmental, transport and social goals are encoded into the objectives of MaaS schemes. So, alongside the consumer benefits of a MaaS scheme to what extent does it relate to the wider goals that cities have to become healthier, greener, fairer and more prosperous places? For example, will MaaS schemes encourage people to make more short journeys on foot or by bike (good for public health and for reducing road congestion) or will they subtly promote the use of modes which can be more readily monetised for profit (such as taxis). The same risk is there for public transport if MaaS schemes promote taxi and hire car use at the expense of buses in particular.

Another big question is the extent to which MaaS schemes will also enable everyone in a city region to access opportunity or whether they default to targeting wealthier, city centre living early adopters?

If MaaS is about more than just those who already have the luxury of choice on transport (and much else besides), how could it be adapted to provide affordable options to low income groups?

Or how could it be used to precisely target information about transport options that work best given the nature of a person’s particular disabilities?

And in relation to this to what extent could MaaS dovetail with the concept of Total Transport to also incorporate currently silo-ed provision of social services, education and non emergency patient transport services to provide a more efficient service overall?

How MaaS evolves may also vary between the very largest city regions in the world and the rest. The world cities are those where the impacts of the big tech ‘platforms’ are being most widely felt. The world cities also have the most clout and resources to assert themselves if they so wish. At a time when housing costs are already the number one public concern in many of these cities, Airbnb is turning precious private and public housing stock into quasi-legal flop houses and pouring more petrol onto the flames of extreme financialisation of housing in the process. Meanwhile, on transport there is evidence that Uber and equivalents can eat into mass transit use (particularly in the US). And now there is the potential (depending on how MaaS develops) for Californian corporations to usurp the city’s role as trusted and impartial provider of transport information and access in the process, they are potentially also extending their control into cities’ transport planning role. In short, the world cities have some big decisions to make about the big tech platforms.

In the UK the role that second tier city regions play on MaaS may also be a product of their different circumstances and aspirations as they may well be hemmed in by their, as yet, limited influence over the core of any MaaS offer – public transport. This role could also be hampered by the hollowing out of local government by recent national administrations which means the resources that even some of the larger city regions have at their disposal to engage with issues like MaaS are highly constrained. However, we still suggest ‘five tests for good MaaS’ in our report that could be a useful frame for any urban area to think about MaaS:

  1. Does it incentivise public transport use?
  2. Does it reduce congestion and pollution?
  3. Is there a culture of openness/data sharing?
  4. Is it socially inclusive?
  5. Does it encourage active lifestyles?

Whether we are on the verge of a MaaS movement, or experiencing MaaS delusion, is not yet clear. But what is clear is that city regions will have a key role to play in determining whether MaaS is fool’s gold or the real thing.

Jonathan Bray is Director at Urban Transport Group

The blog first appeared in Passenger Transport Magazine.