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

Total Transport: totally worth it?

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As the nation awaited the announcement of the next Prime Minister this week, the Department for Transport (DfT) – quietly and without fanfare – released its review of the 37 Total Transport pilot projects which begun in 2015. The information on which the review is based was collected back in April 2017 and – reportedly by popular demand – the findings have now been made public.

The reasons for sitting on the report for so long are unclear. Whilst results have been modest, Total Transport, as DfT recognise, is and always will be a ‘slow burn’ with ways of working taking time to bed-in and produce tangible results in terms of savings and improvements in passenger experience.

That the process takes time is something we have made clear since we first coined the phrase ‘Total Transport’ in our 2011 report of the same name to describe a task that many local authorities have attempted over the years with varying success. The task being to work across public policy divides to deliver better outcomes for communities and taxpayers through the sharing of transport resources (e.g. vehicles, scheduling/booking systems, budgets) and expertise. In doing so, the idea is to remove unnecessary duplication; design complementary networks; utilise what would otherwise be vehicle downtime; reduce administration costs; and ultimately deliver savings and a better passenger experience.

We followed our Total Transport report with an event the following year for local authorities and their partners to share their experiences of working on these kinds of approaches with one another. The key learning points that arose from that event seven years ago echo many of those included in the DfT’s review this week.

Back in 2012, our delegates told us that Total Transport projects may have a long-term strategic vision in mind, but usually start small to build trust and buy-in from would-be partners. DfT’s review also found no easy ‘one size fits all’ solution and that constructive local engagement took time, as did realisation of bigger savings.

At our event, delegates pointed out the central importance of knowing your stakeholders and putting in at least six months of preparatory work in order to build trust and relationships. Even then, as the DfT pilots found, people come and go and too often this means that engagement is severed and relationship building must start again from scratch.

Our delegates expressed particular frustration with getting the health sector on board. Similarly, DfT note in their review that many participants saw integration with NHS non-emergency patient transport (NEPT) fleets as representing ‘the biggest prize for better integration’ but also ‘the most difficult to unlock’. Indeed, difficulties in engaging with the health sector, not least finding and keeping hold of the right person to speak to, is described by DfT as ‘perhaps the single most significant barrier to the adoption of Total Transport’.

This certainly chimes with what we have heard over the years in respect of Total Transport and more widely for other areas of potential collaboration with the health sector. Whilst the situation has improved considerably for collaboration with public health (having moved under the umbrella of local authorities), the NHS more widely frequently feels like an unknowable and impenetrable entity.

This is something we have sought to address in numerous ways from roundtables bringing stakeholders from health and transport together to companion guides for the two sectors to help them understand one another. In 2017, we worked with the Community Transport Association to specifically explore the potential of Total Transport for NEPT, estimating that the NHS could save some £74.5 million per year if more efficient patient transport could prevent just 10% of missed appointments.

More recently, we have written to the Chief Executive of the NHS suggesting the need for an independent government review to examine the efficiency and effectiveness of NEPT and potential reforms. Our letter also calls for a health and transport champion in each region charged with making the connections between health and transport and bringing leadership on the issue.

A key recommendation from DfT’s review is that ‘more work is needed to involve the NHS in Total Transport and unlock the substantial opportunities for joint working which remain untapped.’ It goes so far as to say that local engagement alone may not be enough and that ‘some degree of coercion might be appropriate to encourage organisations to participate that have so far declined to do so.’ We certainly agree that some form of push at the highest level is required, hence our decision to write directly to the NHS Chief Executive highlighting what we believe to be huge potential for more joined up thinking and working between our two sectors. We will also be making the case to the new Government in the coming months.

It is telling that despite the difficulties encountered, the majority of Total Transport pilots are continuing in some form, using their own resources. Local authorities and their partners would not do this if they could not see the potential of Total Transport and what is, necessarily, a ‘softly, softly’ approach. Like the release of the DfT’s review, the results will come slowly and without fanfare but that does not mean they will not be worth celebrating.

Rebecca Fuller is Associate Director at the Urban Transport Group

(Image: North West Ambulance Service)