Tactran Health & Transport Action Plan
Background report
Tactran Health & Transport Action Plan
Background report
JMP Consultants Limited CBC House 24 Canning Street Edinburgh EH3 8EG
T 0131 272 2705 F 0131 272 2805 E [email protected]
www.jmp.co.uk
Job No. SCT5059
Report No. 1
Prepared by CS
Verified TS
Approved by TS
Status Updated draft
Issue No. 2
Date 22 November 2010
Tactran Health & Transport Action Plan
Background report
Contents Amendments Record
This document has been issued and amended as follows:
Status/Revision Revision description Issue Number Approved By Date Updated draft For client comment 1 TJS 03/03/2010 Minor changes to account Draft Final for updated information 2 TJS 22/11/2010 available
Contents
1 INTRODUCTION ...... 1 Background to and Purpose of this Report ...... 1 2 CONTEXT ...... 4 Regional Health Context ...... 4 Regional Transport Context ...... 5 Policy Context ...... 6 3 PROMOTING ACTIVE TRAVEL ...... 8 Context ...... 8 Local Initiatives ...... 8 Best Practice...... 12 Constraints...... 14 Opportunities ...... 15 Vision ...... 17 Objectives ...... 17 4 TRANSPORT & PUBLIC HEALTH ...... 18 Context ...... 18 Road Safety ...... 18 Air Quality ...... 21 Noise ...... 22 Severance ...... 23 Local Initiatives ...... 23 Best Practice...... 26 Constraints...... 27 Opportunities ...... 28 Vision ...... 30 Objectives ...... 30 5 ACCESS TO HEALTHCARE ...... 31 Context ...... 31 Relevant Policies ...... 35 Local Initiatives ...... 36 Best Practice...... 38 Constraints: Delivery Systems ...... 40 Constraints: Patient Needs ...... 42 Constraints: Transport Provision ...... 43 Opportunities: Reduced Need to Travel ...... 45 Opportunities: Service Delivery ...... 46 Vision ...... 47
Objectives ...... 47 6 NHS STAFF TRAVEL ...... 48 Context ...... 48 Relevant Policies ...... 49 Initiatives ...... 49 Constraints...... 50 Opportunities ...... 51 Vision ...... 52 Objectives ...... 52
Tables and Figures
Table 2.1 Policy Linkages ...... 7 Table 4.1 Scottish Road Safety Targets 2020 ...... 20
Appendices
APPENDIX A ...... Glossary of Terms APPENDIX B ...... Policy Context
1 Introduction
Background to and Purpose of this Report Context 1.1 In September 2009, JMP Consultants was commissioned by Tactran, the Regional Transport Partnership for Stirling, Perth & Kinross, Angus and Dundee, to prepare an Action Plan to improve service delivery for the four main linkages between transport and health:
• Promoting Active Travel – that inappropriate use of some transport modes is contributing to sedentary lifestyles, whilst walking and cycling can be convenient transport modes for some journeys and improve physical activity levels;
• Transport & Public Health – that undesirable side-effects of the transport system have detrimental impacts on public health;
• Access to Healthcare – that transport is required to enable access to healthcare, and that accessing health services is a key transport demand; and
• NHS Staff Travel – that the NHS spends large sums on transport for its staff and there is potential for this to be reduced. HTAP area 1.2 The study area for this work is the geographic areas of Stirling, Perth & Kinross, Angus and Dundee Councils (the Tactran region). These boundaries are coterminous with those of the relevant Community Health Partnerships (CHPs). As such, this includes all of NHS Tayside’s area and part of that of NHS Forth Valley. 1.3 This work is intended to be relevant for all healthcare services provided within the Tactran region (even if for people residing elsewhere) and for all residents of the Tactran region (even if for healthcare services provided elsewhere). Process 1.4 As the first task in developing the HTAP, JMP undertook a detailed background study to obtain a better understanding of the key issues for the region under each theme. A Workshop Briefing Paper was prepared summarising the findings of the study and outlining the main issues, opportunities and constraints for each theme. 1.5 The Workshop Briefing Paper was issued to selected stakeholders including representatives from the four local authorities and CHPs in the Tactran region, NHS Tayside and NHS Forth Valley, the Scottish Ambulance Service (SAS), community transport representatives and patient representatives. These stakeholders were invited to a Stakeholder Workshop event held on Tuesday, 12 th January 2010 to discuss the note and develop options for implementation. A paper summarising the outcomes of the workshop was produced and issued to all attendees. 1.6 Following the workshop, JMP has produced a draft Action Plan, which consists of action plans for each of the four HTAP themes. 1.7 This report is therefore structured to provide, for each of the four themes, the background context, including the key issues, opportunities and constraints and the proposed HTAP vision and objectives. 1.8 The Action Plan itself is intended to be a ‘fluid’ document, updated as actions progress, and is available under separate cover.
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Study Themes in Brief
Active Travel
1.9 Active travel is the term used to describe modes of travel that incorporate some form of exercise. The term is generally limited to walking and cycling and it is these two modes we consider in this report. Cycling and walking are both important components of a sustainable transport network and contribute to healthy lifestyles. 1.10 Active travel has become increasingly important with increased awareness of high profile topics such as obesity and climate change. Walking and cycling provide useful physical activity and, unlike sedentary modes of travel such as the private car, they are pollution-free. Transport & Public Health
1.11 Transport networks can have both direct and indirect impacts on public health. Direct impacts include poor air quality from traffic pollution, high background noise levels due to road, rail and air links and injury/death in road traffic accidents, which can all affect the health and wellbeing of a population. 1.12 More indirect public health impacts of transport include severance (communities being 'cut off' from key services by a busy road or rail link), visual and landscape impacts and the impact on mental wellbeing and health deprivation through over-reliance on sedentary modes. 1.13 For the purposes of this study, we focus on the direct impacts of transport on public health (air quality, noise and road traffic accidents) and on one of the indirect impacts, community severance. Access to Healthcare 1.14 The ability of patients to access healthcare is essential to ensure that its benefits can be realised. The Social Exclusion Unit (SEU) report on transport published in 2003 noted that in the UK over a 12-month period 1.4 million people, “miss, turn down or choose not to seek medical help because of transport problems”. People unable to access healthcare are more likely to suffer ill-health and rely on acute care later. 1.15 As with most of the NHS boards in Scotland, both NHS Tayside and NHS Forth Valley are in a state of change. Key services are being relocated from the current 'central' focus to more local, community-based facilities and are being redesigned to include more preventative and self-care measures. Several of the acute centres are also in a process of large scale redevelopment. 1.16 The redesign will mean that the travel patterns to and from key services will change. It is important that we take account of this and make recommendations to ensure accessibility problems do not arise. 1.17 It is worth noting that, for the purposes of the HTAP, we have considered 'healthcare' to encompass a wide range of key services and facilities, from acute and emergency services, through to primary and local services including GPs, pharmacies, dentists, and opticians. NHS Staff Travel 1.18 It is expected that many staff are required to travel during the course of the working day for either face to face appointments with patients or to liaise with other health professionals. 1.19 The NHS incurs significant costs in travel of its staff, not only through direct reimbursement of travel expenses, but in the provision of fleet vehicles and travel-related infrastructure. Not only this, but it is estimated that approximately one-quarter of NHSScotland’s carbon emissions are from transport and as a public sector body, they are expected to lead by example in reducing emissions.
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1.20 Transport is the focus of this as it provides greater opportunities in the short term for NHS to reduce carbon emissions, and at the same time, there is a significant opportunity to reduce the financial burden of staff travel.
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2 Context 2.1 This section aims to set out the context for the development of the Action Plan. It briefly summarises key regional health and transport issues and gives an overview of pertinent policies.
Regional Health Context 2.2 Many statistics are published regarding the health and recent trends in Scotland. Life expectancy at birth for people in Scotland is continuing to improve. Recent trends show a slight narrowing of the gap between male and female life expectancy. However, life expectancy in Scotland remains low compared with most Western European countries and figures suggest that the Scottish population spend more years of life in poor health 1.
2.3 The Scottish Health Survey (2009) provides a picture of the health of Scotland’s population. Seventy seven per cent of adults rated their health in general to be ‘very good’ or ‘good’ whilst 7% rated it as ‘bad’ or ‘very bad’. The survey found that nearly 69% of men and 61% of women aged 16 or over were classed as either overweight or obese. This statistic supports a steady upward trend in the number of obese people in Scotland. Obesity in Scotland is linked to many premature deaths and remains a key concern.
2.4 The survey also collected data on the physical activity of the population. This included questions regarding their participation in all forms of activity, from housework and gardening to sport and exercise. From 2008 onwards there has been a change in the way that the survey measures adult physical activity and activities are now recorded if they lasted 10 minutes or more, rather than 15 minutes or more in previous surveys. However, the 2008 Scottish Health Survey found that the proportion of the population participating in any physical activity for at least 15 minutes has increased over recent years. Between 1998 and 2008, there was a significant increase for men and women aged 16-74 meeting physical activity recommendations, from 40% to 46% among men and from 29% to 35% among women
2.5 Mental health is another key issue in Scotland. In 2002/03 NHS boards in Scotland spent nearly £800 million on mental health services, whilst local councils spent an additional £52 million. There is strong evidence that physical activity has a positive effect on peoples’ moods, making them feel better about themselves. It can also have a positive effect on anxiety and stress. Moderate physical activity is a valuable way of treating mental illnesses such as depression and anxiety.
2.6 In relation to regional health issues, the Scottish Public Health Observatory has published a number of community health and wellbeing profiles for the Community Health Partnership areas in Scotland 2. These profiles provide a summary of the key health issues facing the local authorities in the Tactran region.
2.7 The statistical data shows that Stirling, Angus and Perth and Kinross all have a better than average life expectancy for both males and females compared to the average of Scotland. In Dundee however, life expectancy for males and females is significantly worse than the Scotland average.
2.8 The data also highlights that Dundee has a higher than average percentage of its population living in the 15% most deprived areas of Scotland. The area also sees more deaths from cancer than the Scottish average and significantly more problems with mental health problems.
1 http://www.scotland.gov.uk/Topics/Statistics/Browse/Health 2 http://www.scotpho.org.uk/home/Comparativehealth/Profiles/chp_profiles.asp
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2.9 Dundee residents are also much more likely to suffer alcohol-related deaths than the Scotland average. The other local authorities in the Tactran region have not experienced the same problem however.
2.10 This brief review highlights some key important issues for the Health & Transport Action Plan:
• The physical and mental health of Scotland’s population remains poor in comparison with similar nations;
• Health inequality remains stubbornly large, with residents of deprived communities much more likely to suffer physical and mental health problems;
• Obesity, and the health problems that it causes, is a worsening problem. Sedentary lifestyles are a contributory factor to this problem.
• Active lifestyles improve both physical health and mental wellbeing.
Regional Transport Context 2.11 The Scottish Household Survey provides some national transport statistics. The 2007/08 survey shows that most journeys undertaken in Scotland are by the private car; half of all journeys were driven compared to over a third by sustainable modes of transport such as walking and cycling. This survey also indicates that men were more likely to drive compared to women.
2.12 The survey also highlighted that the majority of journeys undertaken in Scotland are less than 5km and that 40% of all journeys were less than 2km.
2.13 The survey details the relationship between income and mode of transportation. It shows that the higher the annual net income, the higher the proportion of respondents who reported driving. Those households earning more net income are more likely to favour the car over other modes of transport such as public transport, walking and cycling. People living in more deprived areas use the bus or walk more.
2.14 Respondents to the survey were twice as likely to walk if they lived in large urban areas compared to those who lived in rural towns. This supports the issues that have been identified within the RTS, in that the rural nature and topography of many areas of Scotland prove to be a barrier for walking and cycling.
2.15 The Tactran region contains a number of Scotland’s key strategic important road and rail transport corridors and as such is considered a central hub in the national transport network. Even so, the area has a number of key transport issues.
2.16 The RTS states that the 61% of all car journeys in the Tactran region are single occupancy journeys and 84% of commuter car journeys are single occupancy.
2.17 A disparate settlement pattern in the region means that many people are heavily dependent on the private car in order to travel and people living in more remote areas are less able to walk and cycle. Statistics show that the private car is also being frequently used for small journeys and the RTS states that, “ 40% of trips less than 1km are made by car and 26% of all car trips are less than 2km in length .”
2.18 This shows that the population of the region are using their car to make short journeys that could be undertaken by an alternative mode. The RTS also states that currently “ Walking accounts for 19% of all trips in the region, while cycling makes up around 1% of total trips and while 65% of trips
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less than 1km are by walk or cycle, this falls to around 31% for trips between 1km and 2km and to 14% for trips between 2km and 3km .”
2.19 A disparate settlement pattern is coupled with pockets of deprivation and the RTS states that approximately 31% of household in the Tactran region do not have access to a car. This is a key concern as there is obviously a greater need for enhanced public transport provision in these areas. The RTS also states that 44% of adults in poor health have no access to a car, again highlighting the importance of good public transport provision, especially to public services such as health facilities. This coupled with an ageing population, defines the need for adequate non-car based access to healthcare.
2.20 Key issues for the Health & Transport Action Plan are therefore taken to be:
• A high proportion of journeys are undertaken by relatively unsustainable and sedentary modes;
• This proportion is lower for shorter journeys but remains high;
• The Tactran region is highly diverse in its population density and topography, necessitating a range of solutions;
• There are significant inequalities of accessibility, with people in more rural areas, with lower incomes and in poorer health less likely to have access to transport.
Policy Context 2.21 At the outset of Action Plan development, it is important to understand whether action to contribute to its key themes will support, or be supported by, key extant policies.
2.22 We have identified what are considered to be these key policies and provided an indication of the strength of the correlation between them and each of the four themes in Table 2.1. More detail on each of the policies listed is given in Appendix B.
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Table 2.1 Policy Linkages
Promoting Transport & Access to NHS Staff Active Travel Public Health Healthcare Travel
Community Plans and SOAs Tactran Regional Transport Strategy Local Transport Strategies Healthcare Transport Framework Better Health, Better Care Sustainable Development Strategy for NHSScotland NHS Tayside Health Equity Strategy SAS Our Future Strategy Delivering for Remote and Rural Healthcare Strategic and Local Development Plans Cycling Action Plan for Scotland Climate Change (Scotland) Act 2009 The Environment Act 1995
Key: Strong contribution Weak conflict Moderate contribution Moderate conflict Weak contribution Strong conflict No, or negligible, impact
2.23 We therefore identify that the four themes of the Health & Transport Action Plan can make notable contributions to key policies and that no conflicts arise at this strategic level 3.
3 Each recommendation of the Action Plan may need to be individually tested for conflicts with extant policies.
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3 Promoting Active Travel
Context 3.1 The increasing use of sedentary transport modes (in particular the private car) is a key contributor to the problems of obesity faced by much of the world’s population 4. Obesity significantly raises the risks from a range of chronic health conditions.
3.2 However, journeys by active travel modes (walking and cycling) make up only 20% of all journeys within the Tactran region 5. Increasing this proportion can both improve health of the individual but also contribute to a range of other public policy objectives, including:
• Reducing the adverse impacts of car use (see later sections of this report);
• Improving social cohesion (people walking or cycling in their neighbourhoods create stronger relationships with neighbours);
• Improving the local economy (by use of local services in preference to those further afield). 3.3 Active travel is also proven to be a cheap and time-effective way of managing to get more physical activity into a daily routine.
Local Initiatives 3.4 Much work is already underway to promote active travel. In this section, we briefly summarise relevant initiatives that are ongoing in the Tactran area.
Dundee Travel Active 3.5 A three-year Smarter Choices, Smarter Places-funded programme (running to March 2011) is delivering a package of infrastructure, information and behavioural change measures to promote walking and cycling for residents of the City Centre, Hilltown, Stobswell and the West End. The project draws together behavioural change expertise from transport and healthcare sectors.
3.6 Work is still ongoing, but results to date show that a significant increase in activity levels is resulting. More than 3,400 residents have participated in the project since August 2009. Forty per cent of everyone participating reported an increase in physical activity, at a level that is enough to make an improved contribution to health for many people (a little over 20 minutes per day on average).
Dundee Healthy Living Initiative 3.7 The Dundee Healthy Living Initiative’s mission is to promote positive health and wellbeing by delivering health improvement activities as identified by local people in areas of deprivation using a community development approach.
3.8 Dundee Healthy Living Initiative is a partnership supported by Keep Well, the Health Improvement Fund, Fairer Scotland Fund, NHS Tayside, Dundee CHP and Dundee City Council. It has four main aims:
• Develop local activities to improve health;
• Help bring health services into the community;
4 Unfit for Purpose: How Car Use Fuels Climate Change and Obesity. Institute for European Environmental Policy, 2007 5 Tactran RTS
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• Provide local health advice and information; and
• Involve local people in decisions about health. 3.9 Actions promoted include exercise classes, health walks and regular health checks within the community.
Healthy Working Lives Award Programme 3.10 The Scottish Centre for Healthy Working Lives emerged from the former Scottish Executive’s strategy document ‘Healthy Working Lives: a plan for action’ published in August 2004. Healthy Working Lives offers an award programme for employers to develop health promotion activities and safe working practices within the workplace.
3.11 Healthy Working Lives aims to play a key role in achieving the Scottish Government’s objectives of reducing work-related ill health by 20%, and days lost to ill health by 30%.
3.12 Once registered on the scheme, organisations work to achieve either Bronze, Silver or Gold awards. There is also a Commendation Award for Mental Health and Wellbeing. A number of stakeholder organisations within the Tactran region have received awards, for example, NHS Forth Valley has been awarded Silver status across their sites and NHS Tayside Board hold a Gold award.
I Bike 3.13 Sustrans has recently launched a two year pilot project in Perth to encourage primary school children to take up cycling. Known as I Bike, the target group will be girls who are in their transition year from primary school to secondary school.
3.14 Cycling initiative the Bike Hub has funded a Cycling Officer to work with three secondary schools and their feeder primary schools. Key activities will be cycle to school events, cycle training and bike maintenance for girls, as well as encouraging girls to overcome image concerns with cycling. The project will also include cycling for boys, through the promotion of school-wide activities.
Paths for All 3.15 Paths for All is a partnership of more than twenty national organisations committed to promoting walking for health and the development of multi-use path networks in Scotland. The charity was established in 1996 and receives support from the Centre for Healthy Working Lives, NHS Health Scotland, ScotRail, Scottish Government Health and Well-being Directorate and Scottish Natural Heritage.
3.16 Its priorities are to reduce the proportion of the population who are physically inactive through a national walking programme; and to promote an increase in the number, quality, and accessibility of paths for everyone.
Steps Tay Health 3.17 Steps Tay Health was launched in Angus in 2009 and is funded by NHS Tayside and Paths for All. Its aim is to improve the health and activity levels of the sedentary population in Angus. Walking groups have been established in Monifieth, Carnoustie, Letham and Arbroath and Forfar.
3.18 The walks take place on a weekly basis and are open to everyone. The project is continually developing across Angus and has established link with dieticians, physiotherapists, weight management, exercise referral and smoking cessation.
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The project is also closely linked with the Angus Gold project, which works with the 50 plus population in Angus, and many of the Angus Gold members are walk leaders for Steps Tay Health.
Local authority travel planning 3.19 All four local authorities in the Tactran region have developed travel plans, and a summary of each is provided.
3.20 Angus Council’s travel plan was formally approved in 2005 and a number of measures have been introduced such as www.angusliftshare advertising and promotion; implementation of car share bays at three sites; enclosed cycle lockers and a travel plan guidance leaflet distributed to all staff.
3.21 Dundee City Council’s travel plan was adopted in 2008. With funding of £22,000 from Tactran, a joint Council and Health Board cycle path was developed to link the city’s Green Circular route past the city’s three largest employers: Dundee City Council; Dundee University and Ninewells Hospital.
3.22 Perth and Kinross Council’s travel plan was approved by committee in September 2010 and covers two of its key sites, with £12,000 also allocated for cycle parking at three school campuses.
3.23 Stirling Council’s travel plan was formally adopted in 2009, but measures have been in place since 2006. In 2008, a number of interventions were implemented including a personalised travel planning pilot project, secure cycle lock up compound, clothes lockers, and promotional activities including complimentary park and ride passes for staff.
NHS Tayside travel planning 3.24 Ninewells Hospital and Perth Royal Infirmary both have travel plans which have been adopted and by the NHS Board. The Ninewells travel plan has been held up as an exemplar of good practice and a recent staff travel survey highlighted significant modal shift to sustainable modes.
3.25 A number of measures have been implemented at the site, including a shared use path providing a direct link to the Green Circular route, investment in additional pool cars for staff use and removal of mileage claim allowance for staff travelling between Ninewells and PRI.
3.26 At the time of writing, it is understood that a travel plan is being prepared for Stracathro Hospital.
NHS Forth Valley travel planning 3.27 The development of the new Larbert hospital has required a Travel Plan to be submitted and approved by Falkirk Council. Meanwhile, the Stirling Royal & Falkirk and District Royal Infirmaries are supported by the NHS Forth Valley Strategic Travel Planning Framework.
3.28 Travel Plan measures implemented throughout NHS Forth Valley include a liftsharing website for all staff as well as travel road shows. NHS Forth Valley has worked alongside Stirling Council to link up Stirling Royal Infirmary to the park and ride site at Castleview.
Tactran Sustainable Travel Grant Scheme 3.29 Tactran operates a Sustainable Travel Grant Scheme (STGS) to support and encourage travel planning and travel awareness throughout the region by providing funding for organisations to implement measures to promote sustainable travel. Total budget for the scheme for 2010/2011 is £20,000.
3.30 The scheme is open to all public sector and non-profit organisations. Tactran is required to ensure that local authority and Health Board travel plans cover at least 80% of staff by 2010.
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Cycle to Work Scheme 3.31 The Cycle to Work Scheme is a national tax exemption scheme for bicycles. It was introduced by the Finance Act 1999 and offers eligible staff the opportunity to hire a bicycle and accessories through salary sacrifice. Revised HMRC rules were brought into effect from August 2010 resulting to changes in how the scheme is operated.
3.32 Employees enter into a one year salary sacrifice scheme for 100% of the cost of the bicycle, however the hire period can now exceed the repayment period, which HMRC defines as six years. Employers can continue to offer the bicycle for sale at the end of the hire period. HMRC state that bicycles will have nil value after six years therefore, there is no payment by the employee at the time of transfer of ownership from employer to employee at this time.
3.33 If the employee leaves or wishes to purchase the cycle before the six year hire period, the price they pay is dependent on the original purchase price (previously, employees paid a standard 5% of the original cost of the bicycle, regardless of its worth)
3.34 All of the local authorities and NHS boards within the Tactran region operate a Cycle to Work scheme for their employees.
Active Stirling 3.35 Active Stirling promotes sport and physical activity throughout the Stirling area, offering fitness classes, swimming and outdoor activities. The initiative also included ‘Walk about Stirling’ which offers walks suited to different levels of fitness and led by trained walk leaders. Active Stirling works in partnership across the public, private and voluntary sector in order to work together and achieve shared goals.
Going Carbon Neutral Stirling 3.36 This is an initiative supported by Keep Scotland Beautiful that promotes low carbon living to individuals, communities, businesses and schools within the Stirling area. Over 7,000 people have joined the initiative and are encouraged to develop a ‘Carbon Cutter Plan’; a plan of action to
reduce emissions. One of the key objectives is to achieve an 8% to 10% reduction in CO 2 per participant, per year. Travel is featured as one of the key ways to reduce personal carbon emissions.
Active Travel Scotland – Get Active Getting There! 3.37 Sustrans Active Travel Scotland is working in partnership with Paths to Health and Cycling Scotland on three projects in the Tactran region under the banner of Get Active Getting There! that “aim to increase walking and cycling levels, reduce traffic congestion and emissions and ultimately improve the health and wellbeing of communities”.
3.38 Get Active Getting There! University of Stirling: this initiative aims to encourage staff, students and visitors to travel to campus more sustainably. Baseline travel surveys have been completed and there are plans to develop a campus travel guide and travel website, as well as offer cycle training for staff and students.
3.39 Get Active Getting There! North Perth: this initiative with aims to enhance the image of one of Perth's green corridors, the Perth Lade, to promote it as an attractive route for commuting and leisure activities amongst people. Two co-ordinators have been employed to act as liaison with the local community and businesses. Activities to date have included engagement with primary schools, opinion surveys and open days.
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3.40 Get Active Getting There! Dundee: centred on the network of walking and cycling paths in south west Dundee, this project provides leaflets and maps of walking and cycling routes to encourage school children and householders use the paths more for everyday trips.
Sustrans Connect2 River Tay pedestrian/cycling bridge Perth – Scone 3.41 Connect2 is a scheme which aims to complete missing links on active travel networks. One of its projects will improve the connection between Scone and Perth, by continuing the desirable paths through Quarrymill Woodland Park, via a bridge over the Tay to reach North Inch. This link will create a much more attractive route to pedestrians and cyclists, many of whom dislike using the current main road.
Perth & Kinross Healthy Communities Collaborative 3.42 The Scottish Healthy Communities Collaborative was initially established as a one year pilot project within Perth & Kinross in March 2005, led by Perth & Kinross Council and Perth & Kinross CHP. It encourages local volunteers to work in partnership with multi-agency professionals in a number of identified communities to promote mental wellbeing and ‘active ageing’, reduce isolation and improve social capital.
3.43 The initial remit of the Collaborative was “falls in the over 65 year old age group” which achieved a reduction in falls within the project team areas. This remit was expanded to include “promotion of an active lifestyle and the development of physical activity opportunities for the older population”. In 2007, it was agreed to allocate permanent funding to the project to enable the Collaborative to become a mainstream service.
Safer Routes to School 3.44 Safer Routes to School initiatives have been ongoing since the mid 1990s with the aim of providing pedestrian and cycle routes to schools that can be safely used by children. Schemes have incorporated a wide range of initiatives to overcome obstacles to walking and cycling, such as:
• Installation of new pedestrian crossing facilities, road markings, traffic calming, traffic management changes etc;
• Junior Road Safety Officers where school children are given responsible roles in implementing schemes;
• Walking buses providing an escort for children;
• Walk/cycle-to-school weeks/days. 3.45 Routes have been implemented at a large number of schools across the Tactran region.
Best Practice 3.46 This section provides brief details of selected projects outwith the Tactran region that are successfully promoting active travel.
Other Smarter Choices, Smarter Places projects 3.47 The Scottish Government’s Smarter Choices, Smarter Places programme is funding seven projects (one of which, in Dundee, is in the Tactran area) to promote sustainable and active travel. £15m is available for the whole programme, which runs to March 2011. It aims to trial a range of established measures (including infrastructure enhancements) and those more innovative (including personal travel planning).
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English Sustainable Towns (Darlington, Worcester, Peterborough) 3.48 In 2003 around 50 English towns underwent a competitive bidding process to receive a share of £10m Department for Transport funding to implement a package of smarter choices measures and infrastructure improvements to promote sustainable travel between 2004 and 2009. Three towns, Darlington, Peterborough and Worcester, were awarded the funding, under the collective name of Sustainable Travel Demonstration Towns.
3.49 The results from all three projects have been very positive, with public transport trips up between 13 and 22%, walking trips increased by 17 to 29%, cycling increased by 25% to 79% and a decrease in car trips of between 11 and 13%.
Active Bristol 3.50 Active Bristol is a five-year programme, launched in summer 2008. It aims to bring about a significant and sustainable increase in physical activity levels for Bristol residents, largely predicated on increasing the use of active travel modes. It is owned by the Bristol Partnership (a multi-agency group including voluntary sector). Initial funding for the programme has come through the Primary Care Trust but resources for the 5-year programme are to be sought from the Partnership, including Bristol City Council as a key agency.
GetAbout – Aberdeen City and Shire 3.51 GetAbout is a collaborative project between Nestrans, Aberdeen City Council, Aberdeenshire Council, Robert Gordon University, the University of Aberdeen, Aberdeen College, NHS Grampian, The Energy Savings Trust and Dyce Transportation Management Organisation.
3.52 The programme (which began in April 2009) promotes healthy and sustainable travel choices for people travelling in Aberdeen City and the Shire, with the aim of tackling road congestion and reducing single occupancy car use. The campaign features a high profile marketing campaign using celebrity lookalikes, website, discounted travel offers, as well as a programme of events within local communities.
Go For It - Aberdeenshire 3.53 To demonstrate how successful school travel initiatives can be, the Go For It project it in Aberdeenshire showed positive results at the end of its one year campaign during 2007-2008. Managed by Aberdeenshire Council and Grampian Police's Road Safety Unit, the aim was to promote healthier ways of travelling to school.
3.54 Twenty local primary schools participated in the project which saw walking increase by 21% on average, cycling from 3% to 5% and a two-fold increase in park and stride initiatives. Car trips to school dropped by more than 40%.
3.55 One of the greatest successes was at Oyne Primary School which saw car journeys reduce from 74% to 16%. This was due to a range of initiatives including cycle rack provision and an effective 'park and stride' system for the school which rose in popularity from 2% to 46%. The school previously had no sustainable/active travel initiatives.
Steps for Stress 3.56 Steps for Stress is a Scottish Government initiative that encourages people to take practical actions to reduce stress and promote wellbeing via an interactive website. It includes reference to the benefits that an active lifestyle can have.
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Change4Life 3.57 Change4Life is a three year public health campaign launched in January 2009 and supported by the Department of Health and hosted by NHS Choices. It aims to encourage people in England to make changes to their diet and activity levels. The campaign is focusing on families, particularly parents with younger children (0-11) and those who are pregnant or attempting to become pregnant, with the objective of instigating healthier behaviours amongst their children.
3.58 Over 480,000 families have signed up to the initiative to date to receive an action plan for ideas on how to adopt a healthier lifestyle. The campaign has an interactive website, and health professionals in England are being encouraged to promote the Change4Life message through their own activities.
Take Life On 3.59 Take Life On is a Scottish Government-promoted public health campaign to promote healthy lifestyles. The campaign has featured TV, radio and billboard adverts and a dedicated interactive website, with the message of ‘Take life on, one step at a time’. The website features advice on how to be more active, with top tips, a calorie counter, plus links to partner websites such as Active Scotland for information on activities in an individual’s local area.
Constraints 3.60 This section summarises the main identified constraints to promoting active travel.
Land-use planning 3.61 Travel choices are influenced by the location of homes, goods and facilities. Whilst these locations do change over time, the potential for significant change in a short time period is limited. Many recent land-use planning decisions still favour relatively dispersed development, thus promoting longer journeys less able to be undertaken by active modes. Attractive active travel infrastructure is not being consistently specified for all new developments.
Desire and scope for increased car use 3.62 Parts of the Tactran area have relatively low levels of car use and congestion. Recent research undertaken for the Scottish Government 6 has shown that a high proportion of residents have low car use and aspire to use cars more. If this is combined with low perceived traffic congestion, there is potential for significant further increases in the use of motorised and sedentary transport.
Lack of understanding of benefits 3.63 Many people do not perceive the benefits to their physical health and mental wellbeing of maintaining an active lifestyle. In addition, there can be a lack of knowledge of the alternatives to private car use, and a misunderstanding of the time implications of active travel. There is likely to be a significant elderly population within the region who do not feel that they are capable of being more active. All of these factors can limit the potential for changed behaviour.
Road safety 3.64 Perceived road safety concerns are proven to make some people less likely to travel actively, and hence not travel or use sedentary modes.
6 Smarter Choices, Smarter Places Baseline Monitoring Report Main Report. Scottish Government. 2010.
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Personal security 3.65 Fear of crime is proven to make some people less likely to travel actively, and hence not travel or use sedentary modes.
Condition of infrastructure 3.66 Much active travel infrastructure in the region is not conducive to attracting additional use. Many foot- and cycle-ways are poorly maintained, with poor surfacing, drainage and limited winter maintenance, all of which conflict with travel mode hierarchy. Small-scale barriers (kerbs at road crossing points, paths with steps, etc) preclude active travel entirely for some people and are a major deterrent for many others.
3.67 The lack of active travel infrastructure such as safe cycle storage, lockers, shower and changing facilities for when people arrive at key locations (transport hubs, workplaces etc) is also a significant deterrent.
Climate, topography, rurality 3.68 Poor weather and hilliness make active travel less attractive. Residents of rural areas often have reduced opportunities for active travel due to longer journey distances and limited infrastructure. The geography of the Tactran region is highly diverse and, combined with significant rural population; there are challenges with trying to adopt a common approach to promoting active travel. This, however, could be overcome in part by encouraging active travel as part of a longer journey.
Limited partnership working 3.69 Many organisations are working to promote active travel, but often with differing objectives (including health improvement, social cohesion, tourism/leisure activities and reducing environmental impacts of transport). The lack of co-ordination can lead to a dilution of the public understanding of the opportunities and benefits of active travel.
Finances 3.70 Funding for the provision and maintenance of infrastructure and for work to ensure that people understand the benefits of active travel is limited.
Opportunities 3.71 This section summarises the main identified opportunities to promote active travel.
Synergy with cost savings, climate change 3.72 Improvements to health are rarely an effective incentive to changing individuals’ behaviour. Saving money is a much more effective incentive for many people. Meanwhile, there is increasing recognition of personal actions on climate change and the local environment. Given the strong correlation between increasing active travel and reducing the costs and environmental impacts of transport, there are good opportunities to link these policy objectives to enhance behavioural change.
Partnership working 3.73 There is significant scope for improved efficiency of outcomes through improved partnership working between public sector service providers and between them and other organisations, including community groups and charities that support sustainable and active behaviours.
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Enhanced accessibility 3.74 The location and layout of some developments detract from their potential to be attractive to travel to by active modes. Relatively small-scale changes in some locations can elicit an increase in active travel.
Changing social norms 3.75 Travelling actively is perceived to be unappealing by some people and peer pressure encourages many to choose other modes over walking and cycling. This is particularly prevalent in some locations and some groups (teenagers, for example). Careful targeting of messages has been proven to be able to overcome some of this adverse image. There are particular opportunities to engender change in young children, particularly through effective school-based interventions.
Active prescriptions 3.76 Some health professionals are already prescribing activity programmes to individuals with specific health improvement needs. These can be effective, albeit that programme completion rates tend to be low. Increased use of such active prescriptions can play a part in increasing active travel.
Use of health behavioural change techniques in transport 3.77 Some transport projects (notably personalised travel planning) are using direct behavioural change interventions. There is significant benefit from increased knowledge sharing between transport and health professionals, building on many decades of health promotion activity by the health sector.
Building social capital 3.78 There is clear willingness for some people within communities to help promote active travel 7. There is potential for public sector service providers to capitalise on and expand this opportunity in order to provide more resource than would otherwise be available.
Land-use planning 3.79 Whilst the short-term potential for land-use planning changes to increase active travel may be limited, there is clear scope in the long-term for denser development patterns to significantly increase the range of destinations accessible within short journeys that are attractive by active modes.
7 The Dundee Travel Active programme, amongst others, provides evidence of this.
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Vision 3.80 As a result of the information presented above, the HTAP vision for promoting active travel is:
For everyone living in the region to be able to, and choose to, travel safely by active modes such as walking and cycling for the majority of their local journeys.
Objectives 3.81 Key HTAP objectives required to achieve this vision are:
• To increase the number of journeys made by active travel modes.
• To make people aware of the benefits of active travel, including physical and mental health, costs savings and the environment.
• To ensure that active travel infrastructure is available and attractive to use.
• To contribute to achieving road safety targets.
• To ensure actions achieve best value.
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4 Transport & Public Health
Context 4.1 The transport system and its use have a variety of adverse impacts on public health. In this section we outline the key effects, which are considered to be road safety, air quality, noise levels and community severance. Focus is given to the adverse impacts of road traffic; other modes, notably air travel, do have adverse impacts also, but are less directly under the influence of regional or local decision makers.
Road Safety 4.2 It is estimated that the total cost of all road accidents on Great Britain's roads is £1,500 million and the cost for a serious injury is £185,220 8.
4.3 In March 2000, the UK Government, the then-Scottish Executive and the National Assembly for Wales announced a new national road safety strategy and casualty reduction targets for 2010. These new targets were introduced to focus on achieving a further substantial improvement in road safety over the next ten years, with particular emphasis on reducing child casualties.
4.4 The new targets, which are prescribed in the Department for Transport (DfT) document, 'Tomorrow’s roads – safer for everyone', are based on the annual average casualty levels over the period 1994 to 1998. By 2010 it is hoped that there would be, compared with the average for 1994- 98:
• A 40% reduction in the number of people killed or seriously injured (KSI) in road accidents;
• A 50% reduction in the number of children KSI; and
• A 10% reduction in the slight casualty rate, expressed as the number of people slightly injured per 100 million vehicle kilometres. 4.5 The Scottish progress against these 2010 targets is discussed below. These have been taken from the Scottish Government report, Key 2009 Reported Road Casualty Statistics 9. This shows the provisional statistics of reported injury road accidents in Scotland in 2009. Final figures for 2009 are expected to be published in November 2010.
• 2,485 people were provisionally reported as KSI in 2009, 49% below the 1994-98 average of 4,838 and 13% less than in 2008;
• 257 children were provisionally reported as killed or seriously injured in 2009, 69% below the 1994-98 average of 842 and 14% less than in 2008; and
• The slight casualty rate of 29 casualties per 100 million vehicle kilometres in 2008 was 38% below the 1994-98 baseline average of 46. (Note that the 2008 figure is reported as is the latest year for which there is an estimate of the total volume of vehicle traffic in Scotland). 4.6 Hence all the targets for 2010 for road safety improvements have been met (assuming they can be sustained until 2010).
8 http://www.scotland.gov.uk/Publications/2009/03/20124132/0
9 http://www.scotland.gov.uk/Publications/2010/06/17155946/0
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4.7 In the Tactran region as a whole, much progress has been made over the past few decades to reduce the number of people killed or seriously injured in road traffic accidents, through partnership working between many different agencies at local, regional and national levels.
4.8 However, there are still several casualty ‘hotspots’ on the region’s inter-urban road network, in particular:
• A9 between Stirling and Drumochter;
• A84/A85 between Callander and Crianlarich;
• A90 north of Dundee;
• A92 in Angus;
• A811 between Stirling and Loch Lomond; and
• A977 between Kinross and the Kincardine Bridge. 4.9 The local authorities within the Tactran region have significantly reduced the number of casualties from road accidents, in line with national targets, as reported below.
Angus • 67 adults were reported as KSI in 2009, 55% below the 1994-98 average of 149;
• 5 children were reported as KSI in 2009, 76% below the 1994-98 average of 21;
• The slight casualty rate of 26 casualties per 100 million vehicle kilometres in 2008 was 35% below the 1994-98 baseline average of 40. 4.10 %). Therefore Angus is on course to achieve the three 2010 targets.
Dundee • 70 adults were reported as KSI in 2009, 43% below the 1994-98 average of 124;
• 14 children were reported as KSI in 2009, 60% below the 1994-98 average of 35;
• The slight casualty rate of 29 casualties per 100 million vehicle kilometres in 2008 was 41% below the 1994-98 baseline average of 49. 4.11 Therefore Dundee is on course to achieve the three 2010 targets.
Perth & Kinross • 118 adults were reported as KSI in 2009, 50% below the 1994-98 average of 236;
• 6 children were reported as KSI in 2009, 71% below the 1994-98 average of 21;
• The slight casualty rate of 16 casualties per 100 million vehicle kilometres in 2008 was 37% below the 1994-98 baseline average of 25. 4.12
4.13 Therefore Perth & Kinross is on course to achieve the three 2010 targets.
Stirling • 59 adults were reported as KSI in 2009, 58% below the 1994-98 average of 142;
• 3 children were reported as KSI in 2009, 81% below the 1994-98 average of 16;
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• The slight casualty rate of 24 casualties per 100 million vehicle kilometres in 2008 was 19% below the 1994-98 baseline average of 31. 4.14 Therefore Stirling is on course to achieve the three 2010 targets.
4.15 The Scottish Road Safety Framework, published in June 2009, includes Scotland-specific 2020 targets which were adopted in 2010. The document has outlined its vision as “a steady reduction in the numbers of those killed and those seriously injured, with the ultimate vision of a future where no-one is killed on Scotland’s roads, and the injury rate is much reduced”.
4.16 To help fulfil this vision, the following targets have been set.
Table 4.1 Scottish Road Safety Targets 2020
Target 2015 milestone % reduction 2020 target % reduction
People killed 30% 40% People seriously injured 43% 55% Children (aged <16) killed 35% 50% Children (aged <16) seriously 50% 65% injured
4.17 To enable flexibility in local circumstances, and to allow for changing trends and advances in technology, Scotland’s road safety priorities are not ordered or ranked. However, there are specific topics which have been identified as important and need to be addressed in order to achieve the targets set and achieve the vision outlined in framework document. The topics include:
• leadership; • sharing intelligence and good practice; • children; • drivers aged 17 – 25; • rural roads; • drink drive; • seatbelts; and • speed.
4.18 To address these priorities, a number of strategic aims have been outlined in the framework document, as summarised below:
• Helping to joining up the strands of road safety across the various delivery partners, so as to work more effectively;
• Reinforcing, at every opportunity, the message of the responsibility of all road users for their own and other’s safety on the roads;
• Encourage a drive for life culture;
• Reducing the tolerance of risk in the road; and
• Upholding the rights of all road users to expect safe road travel.
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Air Quality 4.19 The NHS estimates that over 10,000 people die prematurely in the UK each year because of poor air quality 10 . Exposure to air pollution can have a serious effect on public health, in particular causing premature deaths due to cardiopulmonary (heart and lung) effects. In the short-term, high pollution episodes can trigger increased admissions to hospital and contribute to the premature death of those people that are more vulnerable to daily changes in levels of air pollutants.
4.20 Air pollution also has negative impacts on our environment, both in terms of direct effects of pollutants on vegetation, and indirectly through effects on the acid and nutrient status of soils and waters.
4.21 The Environment Act 1995 requires local authorities to undertake regular reviews and assessments of air quality. In areas where an air quality objective is not anticipated to be met, local authorities are required to establish AQMAs and implement action plans to improve air quality.
4.22 Over 200 local authorities in the UK have declared Air Quality Management Areas (AQMAs); areas where pollutant concentrations fail to meet required levels to protect human health. The majority of these AQMAs are located close to or along busy roads and are due to high levels of road traffic pollutants such as nitrogen dioxide (NO2) and particles (PM10).
4.23 Road traffic emissions are a key source of air pollutants impacting on air quality in the TACTRAN
area, particularly from nitrogen dioxide (NO 2) and particulate matter (PM 10 ). Dundee and Perth have declared Air Quality Management Areas and Stirling has areas of the city that are causing concern over air quality. In each case traffic is the main contributor to the local air quality problem.
4.24 There are currently no other Air Quality Management Areas across the region, but the local authorities are undertaking statutory monitoring to ensure they remain within increasingly stringent national air quality limits.
Perth Air Quality Management Area (AQMA) 4.25 The whole of Perth was declared as an AQMA in 2006 as a result of a series of air quality investigations within the city, which predicted that the national objective for nitrogen dioxide and particulates would not be achieved at a number of locations.
4.26 The AQMA for Perth was declared after the second round of air quality Review and Assessments had been completed.
4.27 Most of the Perth and Kinross area does not have an air quality problem. However, high concentrations of nitrogen dioxide and particulates were observed and predicted within Perth city centre and along major routes into the city.
4.28 Nitrogen oxides react to form nitrogen dioxide, and in Perth over 80% of nitrogen oxides within the AQMA originate from road vehicles. The situation with particulates is different in that the greatest proportion of the measured concentrations comes from background sources – approximately 79% across the city as an average (although the traffic component at the worst locations is much more significant). Levels of nitrogen dioxide and particulates are being considered in detail through the ongoing Further Assessment of Air Quality and an Air Quality Action Plan (AQAP) for Perth has recently been developed.
10 Source: ‘Making the Case: Improving health through transport’, Health Development Agency, 2005
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Dundee AQMA 4.29 The whole of Dundee was declared as an AQMA in 2006 as a result of a series of air quality investigations within the city, which predicted that the national objective for nitrogen dioxide would not be achieved at a number of locations. Dundee City Council has undertaken three major air quality updating and assessments reviews.
4.30 The principal conclusion of Dundee City Council's Stage 1 Report (1998) was that a Stage 2 and/or 3 Review was required for all seven key pollutants. The main reasons for this conclusion were:
• a lack of specific monitoring information;
• the existence of certain processes considered to be significant sources of key pollutants;
• the lack of information concerning these sources; and,
• the uncertainty about the effects of road traffic. 4.31 The principal findings of the Stage 2 report (2000) were that the National Air Quality Standards would be achieved for all pollutants with no action required. The guidance on nitrogen dioxide has since been amended, now including specific reference to street canyons and streets where there is a significant proportion of heavy duty vehicle (HDV) traffic.
4.32 As a result, the main conclusions of the third review was that, that without air quality management, the nitrogen dioxide annual mean air quality standard will not be achieved in certain areas of the city. Levels of nitrogen dioxide are being considered in detail through ongoing Further Assessment of Air Quality.
4.33 At the time of writing, a Draft Air Quality Action Plan is being produced by Dundee City Council that details a number of measures and initiatives to address air quality management obligations.
Noise 4.34 Ambient noise, and the degree to which those exposed to high noise levels find them a nuisance, is obviously a point of perception. The World Health Organisation (WHO) uses figures to indicate noise levels that invoke minimum impact to the exposed community. These are taken from the Environmental Health Criteria 12 – Noise report published in 1980, which states: “ …general daytime outdoor noise levels of less than 55 dB (A) Leq are desirable to prevent any significant community annoyance…”, and “ …based on limited data available, [an indoor] level of less than 35 dB (A) is recommended to preserve the restorative process of sleep…”.
4.35 However, it is noted that these are the ideal, and in urban locations it is very difficult to achieve these levels. Planning Advice Note 56, Scottish Government, suggests the use of Noise Exposure Categories (NECs) to help planning authorities determine applications for residential development on sites subject to transportation noise. The categories range from A (<55 dB) to D (>72 dB), with category A sites noise is unlikely to be a determining factor, while for Category D sites refusal of planning permission is likely to be the most appropriate outcome.
4.36 The European Union has estimated that around 20% of the EU’s population, or close on 80 million people, is subject to noise levels that scientists and health experts consider unacceptable. They are annoyed, their sleep is disturbed, and adverse health effects are expected.
4.37 The European Parliament and Council Directive for Assessment and Management of Environmental Noise 2002/49/EC, more commonly referred to as the Environmental Noise
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Directive (END), deals with noise from road, rail, air traffic and industry. The directive focuses on the impact of such noise on individuals, complementing existing EU legislation which sets standards for noise emissions from specific sources. The Scottish Government, in response to the requirements of the END, published the Environmental Noise (Scotland) Regulations 2004, which describes a two-round process to manage environmental noise. Round One involved production of ‘Strategic Noise Maps’ for the country, which has now been completed. These are available online 11 and include those locations in the Tactran region where transport noise is considered to be a problem.
4.38 Round Two requires local authorities to draw up ‘Action Plans’ to manage noise within their areas.
Severance 4.39 High traffic levels discourage active travel and reduce independent play for children (so contribute to sedentary lifestyles) and reduce community cohesion (which detracts from mental wellbeing for some people). In communities with poor public transport or active travel links, more individuals will use the private car which has associated implications for road safety as individuals can face a greater risk of being involved in road accident.
4.40 It is important to recognise that it is not only rural communities that can experience severance. There are particular instances in the Tactran region of urban or peri-urban communities that are isolated because of inadequate transport links or due to the design of the road network. These communities include Downfield in Dundee, which is separated from the city centre from the Kingsway, a four lane dual carriageway, and settlements along the Carse of Gowrie which have experienced lack of access to local primary healthcare facilities because of a lack of public transport (although the establishment of a voluntary car scheme will assist to overcome some of the issues).
4.41 As well as inter-community severance, severance can also occur within communities (intra- community) which has implications for community cohesion.
Social deprivation 4.42 Poor air quality and high noise levels tend to depress property prices. There is therefore a correlation between low income and increased exposure to these health risks.
Local Initiatives 4.43 Much work is already underway to reduce the adverse impacts of transport on public health. In this section, we briefly summarise relevant initiatives that are on-going in the Tactran area.
Air Quality Action Plans Perth Air Quality Action Plan (AQAP) 4.44 The Perth AQAP examines local air quality issues that have lead to the declaration of the built up area of Perth as a traffic-related AQMA. The plan has the following key objectives:
• Improve local air quality, in pursuit of the Scottish air quality objectives for nitrogen dioxide
(NO 2) and particulate material (PM 10 ) that are currently exceeded at several locations within the AQMA;
11 http://www.scottishnoisemapping.org/public/view-map.aspx
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• Contribute to improving the health and wellbeing of the local community by reducing air pollution in Perth;
• Enable members of the community, where and when possible, to change their transportation mode to a more sustainable means;
• Reduce the economic impacts associated with health related air pollution impacts; and
• Integrate air quality into PKC decision making and relevant plans and strategies.
AQAP measures for Perth and Kinross AQMA include :
• New crossing of the Tay linking the A9 to the A94 north of Scone, including a package of associated bus priority, cycle and pedestrian measures thereby ‘locking in the benefits’ to Perth city centre.
• Park and Ride measures including:
• Maintaining high levels of use at existing sites
• Improvements to existing sites
• Investigate provision of additional Park and Ride sites
• Bus quality improvements, including:
• Develop bus strategy and bus quality partnerships
• Work to improve local bus quality
• Encourage fleet operators to report fleet improvements
• Ensure emissions are formally included in procurement decisions for public transport
• Green Travel Planning including
• Car sharing schemes
• Improved facilities to encourage cycling (secure bike parking and showers)
• Provision of travel information, including:
• Develop, promote and maintain a comprehensive travel information system;
• Investigate and develop the provision of real time travel information for bus stops in Perth
• Maintain current public transport guides and section of website
• Hearts and minds campaign to promote sustainable travel options
• Consideration of a Freight Consolidation Centre.
Dundee Air Quality Action Plan 4.45 The Dundee Air Quality Action Plan (draft produced July 2010) has recently undergone a period of statutory consultation with the final plan to be presented to committee for approval. The Action Plan has been produced by the Air Quality Steering Group which includes relevant environmental and planning representatives from Dundee City Council and representatives from Tayside and Central Scotland Transport Partnership.
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4.46 The Action Plan identifies a number of policies and plans that are already in place to address road traffic and transport in Dundee, and it is recognised that, given that air quality is primarily a traffic- related issue, many of these would directly benefit air quality. A number of measures have been referred to within the Plan, including:
• Existing road infrastructure improvements;
• Urban Traffic Management and Control (UTMC) enhancements;
• Smarter Choices, Smarter Places;
• Measures to improve bus emissions and services; and
• Park & Ride facilities.
Safety Camera Partnerships 4.47 In 2000, eight Safety Camera Partnership areas were piloted in the UK, and following the success of these schemes, partnerships were further rolled out nationally. Before the launch of Safety Camera Partnerships, the UK Treasury retained all revenue from fixed penalties. In 2002 a new arrangement enabled the Safety Camera Partnerships to recover operational costs directly associated with camera sites that have a proven history of road accidents and/or speeding vehicles.
4.48 The Tayside Safety Camera Partnership (TSCP) was launched in July 2003 and is a multi-agency partnership consisting of Angus Council, Dundee City Council, Perth and Kinross Council, the Scottish Government and Tayside Police with support from NHS Tayside, Tayside Fire and Rescue and the Scottish Ambulance Service.
4.49 The main aim of the partnership is to “ reduce the numbers killed and seriously injured on Tayside roads ”. The TSCP undertakes safety camera activity at 15 fixed camera and 40 mobile camera sites within the Tayside area. Details of fixed and mobile camera locations are publicised weekly on the TSCP website and in the local media.
4.50 The Central Scotland Safety Camera Partnership commenced operation on 1 April 2006 and operates a very similar process to TSCP. The partnership operates two mobile camera units at twelve identified sites across Stirling, Falkirk and Clackmannanshire areas that have a history of collisions.
Safe Drive Stay Alive 4.51 Safe Drive Stay Alive is a hard-hitting road safety initiative aimed at senior school pupils. Launched in 2002 throughout Scotland by local Community Safety Partnerships, the initiative aims to educate young drivers on road safety, primarily through an annual road show. The road show uses graphic audio visuals and theatre education to demonstrate the circumstances that can lead to a road traffic accident and subsequent repercussions.
4.52 In December 2009, over 3,000 S5 and S6 pupils in Angus, Dundee and Perth & Kinross attended the road show in Perth, along with approximately 1,500 students from Angus, Dundee and Perth Colleges. In Stirling, approximately 4,000 pupils attended the road show in January 2010.
4.53 Safe Drive Stay Alive is a multi-agency initiative consisting of partners from police forces, fire and rescue, Scottish Ambulance Service, NHS Boards, Safety Camera Partnerships, local authorities and Community Safety Partnerships.
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Pass Plus 4.54 Pass Plus is a national scheme designed by the Driving Standards Agency that aims to reduce the number of young drivers involved in road accidents. The scheme was introduced as a result of research which showed that new drivers are more likely to have an accident in the first two years of passing their test than at any other time in their driving career.
4.55 As such, Pass Plus is primarily aimed at young drivers in the first year after passing their test, and consists of at least six additional driving lessons covering aspects such as motorway, long distance and night-time driving. Eleven local authorities in Scotland support the scheme including, within the Tactran region, Angus Council and Perth & Kinross Council.
4.56 Perth & Kinross Council provides grant assistance to drivers who sign up to the scheme, currently subsidising 50% of the cost of the training. Perth & Kinross Council operates a similar scheme for motorcyclists called Bike Plus. Again, 50% subsidy is available and the scheme is open to all motorcyclists, consisting of a one day course available split between theory and a practical, on- road, bike to bike instruction with a qualified instructor.
Best Practice 4.57 This section provides brief details of selected projects outwith the Tactran region that are successfully reducing the adverse impacts of transport on public health.
North East Scotland Road Casualty Reduction Framework 4.58 The North East Scotland Joint Public Sector Group (NESJPSG) was formed in 2000. It comprises of Chief Executives of Aberdeen City, Aberdeenshire and Moray Councils, NHS Grampian, Scottish Enterprise Grampian, Grampian Police and Grampian Fire and Rescue. The NESJPSG set up a road safety steering group, all of which have an interest in on-going road safety initiatives. It is the officers of the working group who have helped produce the Casualty Reduction Framework.
4.59 The Framework was introduced to build on the progress that has already been made and sets out actions for the short term that will create a framework for service providers to take the strategy forward in partnership, thus adding value to what could be delivered separately. The key issues the Framework identifies are the high number of accidents experienced on rural roads, the high incidents of speeding on rural roads, the higher accident rates for young male drivers and drink driving.
4.60 The overall Vision of the strategy is “ to improve road safety within the North East of Scotland in order to significantly reduce the levels of death and injury ”.
4.61 The key actions that have been identified in order to deliver this vision are Education, Engineering, Enforcement and Encouragement. The plan also details actions to assist with improving driving standards, improving vehicle specifications, reducing the number of young drivers involved in collisions and public perception of road safety and road awareness.
Safe Drive Stay Alive 4.62 In the Grampian region, the Safe Drive Stay Alive programme has provided a wealth of information to young drivers about the importance of safe driving. Every pupil in the Nestrans area in S4/5 has attended a workshop on road safety. The campaign has also used the social networking site, Bebo, to further convey the message.
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Constraints 4.63 This section summarises the main identified constraints to reducing the adverse impacts of transport on public health.
Conflicting objectives 4.64 Air quality action plans, which are put in place in order to mitigate the effects of air pollution in Air Quality Management Areas, can introduce conflicts with other objectives. Typically, the presence of an AQMA may preclude the construction of new developments which would attract more people into areas with poor air quality. Given that these areas are frequently in the centres of cities, however, this approach can push developments to more peripheral locations.
4.65 Whilst exposure to air pollution in excess of established guidelines is then reduced, overall travel, and hence emissions from it, can be increased.
Challenging outcomes 4.66 Around 80% of the emissions in Perth’s AQMA are due to background concentrations of pollutants, therefore even with significant efforts to reduce car use, it is recognised that there will still be an air quality problem.
4.67 It is recognised that there is a challenge for the Health & Transport Action Plan to add significant value for reducing adverse noise levels.
Societal pressures 4.68 Peer and societal pressures encourage some drivers, particularly younger ones, to take risks. Motorsports are a popular pastime and media coverage is becoming increasingly high profile. This reduces the potential for road safety improvements.
4.69 There are also particular challenges with promoting change for public health or climate change reasons. Pollutants that are harmful to health are also largely invisible and for the vast majority of people, do not cause any noticeable, immediate effects. Similarly, being asked to change behaviour for climate change reasons can be a major turn off for people, particularly when parts of the scientific community are disputing anthropogenic influences on the environment.
Car dependence 4.70 Many residents of the Tactran region are, or perceive they are, dependent on private motorised transport for many of their journeys. This limits scope for short-term change.
Political sensitivities 4.71 Many of the actions that would most significantly reduce the adverse impacts of transport on health would reduce road traffic. Any measures that do so tend to be politically unpopular 12 .
Land uses 4.72 Much of the exposure to poor air quality or transport noise is a result of historic land-use decisions. These cannot be changed on a large scale in a short timeframe. Similarly, community severance can be a product of long term planning policies. Full engagement with the development planning process is required to successfully effect change in both short and long term.
12 Witness Edinburgh’s proposals for road pricing, for example.
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Finances 4.73 At this time of particularly constrained public sector funding, some authorities are finding it difficult to prioritise expenditure on the implementation of air quality action plans or road safety improvements over other calls for the same resources.
Opportunities 4.74 This section summarises the main identified opportunities to reduce the adverse impacts of transportl on public health.
Joint working to promote cost saving, climate change and obesity 4.75 There are close correlations between actions that would reduce individuals’ exposure to the adverse impacts of transport and those that would contribute to other public policy objectives of improving public health and the environment. There is also the potential to link this with individuals’ desire to save money on travel. Capitalising on these synergies may provide an opportunity for increased funding and reduced opposition to such actions.
Air Quality Action Plans 4.76 Many of the actions detailed in Perth and Dundee’s Air Quality Action Plans are being progressed, therefore there is potential for the Health and Transport Action Plan to support the continued development and implementation of the measures within the AQAPs to maximise benefits.
Partnership working 4.77 Partnership working has been demonstrated to deliver significant benefits to improving public health already by co-ordinating the activities of service providers with shared objectives. There are opportunities for significant further benefits, however, by improved joint working between and within these organisations.
Increased active travel and public transport use 4.78 More active travel and/or public transport use will tend to reduce use of those transport modes that most affect health. They can also provide an indirect political support, as it is easier to restrict use of motorised modes in locations where streetspace is already well used by pedestrians, cyclists and public transport 13 .
Planning guidance 4.79 Planning guidance provides the opportunity to take a holistic view about where land-uses should change to reduce the adverse impacts of transport on public health. This relates not just to the siting of individual developments away from exposure to health risks but also development patterns that, by their design, reduce transport air pollution, noise, severance and crashes.
Industry responses 4.80 There is significant investment ongoing within the transport industry to improve vehicle and driver performance and efficiency to reduce emissions. Many businesses and organisations are now making significant investment into ‘greening’ their fleet vehicles. The Energy Savings Trust in Scotland offers free green fleet reviews to organisations with more than 20 vehicles and has estimated that this could save Scottish organisations over £250 million a year.
13 As witnessed in many town and city centres.
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4.81 Therefore there is potential for further roll out of green fleets with opportunities for public sector organisations to lead on progress.
4.82 The bus industry has made significant investment in cleaner technologies, over and above those standards required by legislation, such as Euro engine standards. For example, Stagecoach uses fuel additives to improve engine performance, is trialling bio-fuels and also testing in-cab driver system to improve safety, reduce fuel costs and cut carbon emissions.
4.83 The Perth and Dundee AQAPs already includes actions to improve bus quality as a means of reducing emissions within their AQMAs, through partnership working with local operators. Such partnerships have obvious benefits for public health.
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Vision 4.84 As a result of the information presented above, the HTAP vision for transport and public health is:
For everyone in the region to live without exposure to air quality or noise levels that are detrimental to health or a threat to personal safety associated with the transport network.
Objectives 4.85 Key HTAP objectives required to achieve this vision are:
• To improve air quality within any designated Air Quality Management Area (AQMA) to a point where the AQMA is revoked.
• To minimise the number of people exposed to intrusive noise levels.
• To reduce the rate of road accident casualties and achieve or better national road safety targets.
• To reduce the effects of severance on communities caused by transport infrastructure or its use.
• To ensure actions achieve best value.
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5 Access to Healthcare
Context 5.1 Access to healthcare services is, arguably, the most prominent component of the health and transport agenda. The majority of healthcare episodes involving NHS staff rely on face-to-face interaction with the patient, so either the staff member or the patient must make a journey.
5.2 In parts of the Tactran region, many of these journeys will be of long-distance. For many people needing to access healthcare, any journey can be a painful or uncomfortable experience; many patients must rely on the goodwill of others to assist them with the journey whilst for many others the cost of travelling to healthcare can be restrictive. Being able to receive visitors is a recognised contribution to recovery for in-patients; many of these visitors will also face long or difficult journeys.
5.3 Meanwhile, the NHS invests substantial amounts in patient travel, either through direct provision of transport (notably through the Scottish Ambulance Service), through reimbursement of travel costs to some patients or through subsidising transport services and facilities.
Hierarchy of Care 5.4 NHS Tayside consider that care should be provided through a five-level hierarchy 14 :
i. National (specialist care) ii. Regional (acute centres) iii. Community Health Partnerships iv. Primary healthcare v. In-community and by-citizen care 5.5 It is the aspiration of NHS Tayside to move each patient episode lower in this hierarchy wherever appropriate.
5.6 The hierarchy has significant implications for transport demand. Patients needing treatment at the upper levels will typically face longer journeys. These journeys will, in general, be to larger sites, however, to where it is more feasible to provide high quality mass-transport (including scheduled public transport, the NEPTS and community transport).
5.7 At the lower levels of the hierarchy, journeys for many patients may be easier (as they are shorter) but will not necessarily result in better access for everyone, particularly people reliant on public transport.
Travel to healthcare 5.8 Nearly three percent of all journeys in Scotland are to “visit hospital or for other health” reasons 15 . A further eight percent of all journeys are as an escort for someone else and eleven percent visiting friend or relatives; both of these categories will have some healthcare-related journeys within them.
5.9 Car is the predominant mode for travel to healthcare in Scotland, comprising 64% of all healthcare journeys (41% as driver, 23% as passenger). Fifteen percent of journeys to healthcare are on foot, a further 15% by bus and the remainder by a variety of other modes.
14 We assume that NHS Forth Valley operate to similar principles, though this remains to be confirmed. 15 Data from Scottish Household Survey: Travel Diary 2007/08.
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5.10 A high proportion of journeys to healthcare by car is to be expected: many people will be unwell or frail so find travel by active modes or public transport difficult.
5.11 It is interesting to note, therefore, that the proportion of journeys to healthcare by car is lower than the proportion by car of journeys to work (71% of commuting is by car, 63% as driver, 8% as passenger).
5.12 This comparison arises from a number of factors, including that people without access to a car make a much higher proportion of all their journeys to healthcare than people that do have access to a car (around 4% and 2.5% respectively). This demonstrates a significant inequality in access to healthcare opportunity: that people with greater health needs have, in general, poorer access to the mode of transport that may be most suited to people with limited mobility (car).
Changing demand 5.13 Demand for access to healthcare is changing, and is predicted to continue to change in coming decades. Our ageing population is anticipated to place added pressures on healthcare services; this population may be particularly limited in its ability to travel independently, so demand for specialist transport will increase. There is evidence too that there is a marked tendency for a disproportionate rise in the elderly population in remote and rural parts of Scotland; this increases journey lengths, times and cost for these more needy people.
5.14 Meanwhile, providers across the healthcare system report increased expectations of easy access to healthcare. In part this is driven by political pressures to make healthcare services more widely and conveniently accessible (and which often makes accessing them easier). This is accompanied, however, with a reported unwillingness of patients to wait (for either healthcare or transport to/from it) and expectations that all healthcare sites will be readily accessible by a variety of modes and that parking be freely available.
Locations accessed 5.15 Much work to date on improving access to healthcare, both in the Tactran region and elsewhere, has focussed on large acute settings. As the largest generators of travel demand this is entirely logical. It is important to recognise, however, that a small proportion of patient episodes result in referral to an acute centre; approximately 10% on average.
5.16 The remaining 90% will largely take place in primary or community settings. These will usually rely on only relatively short journeys for most patients, but issues or problems relating to these journeys will have a larger bearing on overall accessibility of healthcare.
5.17 Furthermore, transport is typically cited as the biggest single reason why patients do not attend appointments 16 . The Social Exclusion Unit (SEU) report on transport published in 2003 noted that in the UK over a 12-month period 1.4 million people, “miss, turn down or choose not to seek medical help because of transport problems”. These DNAs create inefficiencies in healthcare delivery and a large cost for NHS boards. The information also suggests that, for some patients, transport will be a barrier to accessing healthcare. This is most likely to result in patients missing preventative health treatment and exacerbating health problems.
5.18 This highlights the importance of information on transport availability being an integral part of the planning of healthcare appointments.
16 Though the author believes there may be strategic response bias in the answers to market research underpinning these findings.
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Reliance on informal networks, community and voluntary services 5.19 Many patients accessing healthcare, or their visitors, are unable because of age, incapacity or illness to travel independently. They therefore rely on drivers and escorts. A huge amount of goodwill is provided to patients and their visitors by family, friends, formal or informal community support networks and a range of voluntary services.
5.20 Both healthcare and transport service providers should be aware of the benefits to them of this goodwill and to support these drivers and escorts; any reduction in these services provided voluntarily is likely to lead to increased costs of service provision.
Cross-boundary travel 5.21 Travel to healthcare for most patients will be to services provided in the local CHP or health board area. Some specialist services are only provided at a limited number of locations, however, so patients will need to travel longer distances (in particular to the central belt, but also into Ninewells from across Scotland).
5.22 The Tactran region is not coterminous with health board boundaries, however, covering all of NHS Tayside but only part of NHS Forth Valley. This leads to significant demand for travel to healthcare between the Tactran and SEStran areas (as SEStran includes the remainder of the Forth Valley area). These cross-boundary flows will increase as the new acute hospital at Larbert opens.
Reimbursement of travel costs 5.23 Patients receiving Income Support or Family Credit are entitled to reimbursement of travel expenses to and from hospital sites. People on lower incomes, that are unemployed or a pensioner may be entitled to receive all or part of their expenses. It is believed, however, that a large proportion of people may be unaware of the availability of this benefit and/or dissuaded from claiming by the reimbursement mechanisms.
5.24 Other patients, all visitors and all patients travelling to primary healthcare are expected to pay for their transport. This can be a particular burden for patients or visitors that need to travel frequently. Evidence for this is provided from the various Taxicard schemes across Scotland (which mostly provide help with costs of taxi travel for those people unable to use other transport); many of them report that a large proportion of all journeys undertaken are for healthcare, but taxi journeys can remain expensive, even with this financial help.
Telemedicine 5.25 Telemedicine is already being used successfully by the NHS in Scotland to provide patients with access to healthcare advice without the need to travel. This can be in part through telephone and internet advice services direct to patients but also by e-mail of scans, X-rays, etc from community healthcare settings to specialists based in distant acute settings.
5.26 It is clear that there is considerable potential to expand such provision, but that confidence which patients and practitioners have in the quality of care available without face-to-face contact remains to be fully accepted.
Pressures on NEPTS 5.27 The SAS East Central division, as with other divisions in Scotland, is facing particular pressures on its resources. Whilst it is acknowledged that the increasing focus on localised care is beneficial for patients, the NEPTS has been designed for transport to the major acute centres, however the
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requirement to travel to multiple sites is putting pressure on vehicle and staff resources as these journeys cannot be undertaken using a single vehicle.
5.28 A&E activity has increased by 10% in the past year with NEPTS underpinning the ‘blue light’ service, creating additional pressure on the system.
5.29 Pressures on the NEPTS are reported to be particularly high in areas of rural Perthshire; to Stracathro Hospital from throughout the Angus region and from Forfar to Ninewells Hospital (preferably patients should be transported to nearby Whitehills Hospital, but lack of SAS resources prevents this). The SAS report that they are not always given sufficient advance notice of changes to health service provision.
5.30 Shift patterns have had to change to cope with changing patterns of service delivery, for example Saturday working has now been incorporated into shift patterns, with four double crews working an eight hour shift to convey dialysis patients.
5.31 GP surgeries no longer book a patient onto NEPTS for their first appointment, therefore SAS are receiving approximately 10% of their bookings directly from patients to their call centre. Where an individual is deemed not eligible for transport, SAS staff will endeavour to provide them with information on alternative options.
5.32 The SAS has recently commenced dialogue with NHS Tayside about how NHS clinic staff can make appropriate referrals to NEPTS for the remaining 90% of bookings, as it is reported by the SAS that a significant proportion of patients do not have a genuine medical need, however are being offered a booking on the service.
5.33 The SAS has established partnership working with Perth & Kinross Community Transport Group whereby requests for transport by non-eligible patients are passed onto the relevant community transport group by PKCTG. The SAS would like to see similar partnership arrangements established with transport providers in the three remaining local authority areas within the Tactran region.
5.34 The SAS also funds the provision of volunteer drivers with transport being free to the patient if booked directly with SAS. However, recent changes to mileage reimbursement rates for volunteer drivers has meant that there are now fewer drivers available as they do not perceive reimbursement rates to be in line with motoring costs.
Planned changes to primary care locations in Stirling 5.35 As well as redesign of acute care provision within NHS Forth Valley, there are also a number of ongoing changes to GP provision within the Stirling area. There are currently six GP surgeries within the CHP area and practice populations are historical rather than geographical.
5.36 Within the next 12months, two surgeries will be relocated to Orchardhouse, with three moving to Stirling Royal Infirmary site in 2013. The remaining GP is due to retire therefore the catchment population will be required to travel to either of the new sites. Overall, this will result in approximately 30,000 patients travelling to two primary care centres.
5.37 In addition, 30% of outpatient appointments are held at Stirling Royal Infirmary, with patients travelling from throughout the NHS Forth Valley area. This level of outpatient provision will continue despite the opening of the new Larbert site. A new community hospital will be established in Stirling in 2011 catering for community rehab, with some long stay provision (which is currently provided at the community hospital in Bannockburn).
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Relevant Policies Tayside Acute Balance of Care – “twin-site, single-campus” 5.38 NHS Tayside’s Acute Balance of Care (ABC) project arose out of recognition that the existing model of service provision at Ninewells Hospital and Perth Royal Infirmary (PRI) was not sustainable, however there is very strong depth of feeling from both the local community and the health profession that limiting PRI capability to outpatient and day cases only was not a viable option.
5.39 The development of Ninewells Hospital and PRI as “twin acute centres” of a “single university hospital campus, means that both continue to deliver core acute services to their local communities (including A&E, orthopaedic trauma), whilst other services are redistributed to ensure shared responsibility for delivering more complex treatment for the Tayside area.
5.40 The “twin-site, single campus” model means that Ninewells and PRI are joined:
• Physically, by a regular transport link • Virtually, by technological developments, including video-conferencing • Operationally, through increased staff mobility and sharing of key resources • Academically, with support from the University of Dundee, through shared training provision and the presence of the Medical School on both sites. Healthcare Transport Framework 5.41 In November 2009, the Scottish Government Health Directorate issued the Healthcare Transport Framework to all NHS Boards in Scotland. The Framework is intended to help meet the commitment to develop a national approach to travel management set out in Better Health, Better Care.
5.42 The Framework encourages planning and partnership working to “take forward the healthcare transport agenda” and provides guidance for NHS Boards to address transport for healthcare. It identifies three areas in which most health boards can improve access to healthcare: car parking, improved public transport and increased DRT, and recognises that joint working with partners is essential if potential benefits are to be realised.
Scottish Ambulance Service: Working Together for Better Patient Care 5.43 The recent publication of this framework setting out priorities for the future of the SAS provides an important basis for improved access to healthcare for patients and improved efficiency of service delivery. It may, however, also place new challenges on other partners as the most effective delivery mechanisms are identified and demands on each change. More details of the framework are given in Appendix B.
Free car parking (except Ninewells) 5.44 From 1 January 2009, the Scottish Government has insisted that no parking charges be levied at NHSScotland hospitals that do not have Private Finance Initiative-funded car parks. In the Tactran region this led to the removal of charges at the Perth Royal Infirmary, though charges remain at Ninewells hospital because of the PFI scheme there.
5.45 The removal of charges has reduced the cost to patients or their visitors accessing healthcare by car. At the majority of sites affected, and including in Perth, parking controls have had to be retained to ensure that parking remains available for patients and does not become saturated by staff or other uses.
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5.46 The move has also led to some complaints of inequity as it encourages car use and removes a fee for those patients and visitors that have access to a car when some of the revenue raised was, in many of the health boards, used to fund more sustainable transport options that are available to a broader range of target social groups.
Local Initiatives 5.47 Much work is already underway to improve access to healthcare. In this section, we briefly summarise relevant initiatives that are ongoing in the Tactran area.
Murray Royal Hospital redevelopment 5.48 The existing Murray Royal Hospital site is currently undergoing a major redevelopment which, from 2012, will enhance the existing level of service provision but will also include a new regional secure unit for the North of Scotland NHS Boards. As well as a large increase in the number of patients and visitors, there will be about 180 new staff travelling to the site.
5.49 The site planning application was approved by Perth & Kinross Council on 20 January 2010. The site specific travel plan was a key factor in obtaining planning permission and has set a number of ambitious targets, including a 25% reduction in staff car travel to be implemented before the opening of the new hospital premises.
5.50 There is currently a limited bus service serving the existing site, financially subsidised by Perth & Kinross Council and concerns have been raised over adequate sustainable and active travel links to the site.
Broxden Dental Centre 5.51 Construction has recently been completed on a new dental treatment and training centre located at Broxden Business Park in Perth, with anticipated opening in spring 2011. The centre houses 20 surgeries, clinical skills training rooms, dental laboratory and office accommodation and 7,000 people are expected to be registered there.
5.52 Following a request from Perth & Kinross CHP, Perth & Kinross Council has already funded the re- routing of the Perth Park & Ride service to serve a point near the dental centre site and adjacent business park.
Kings Cross Hospital 5.53 Kings Cross Hospital in Dundee is undergoing a process of redevelopment to accommodate a new multi-agency child protection unit, with the planning application submitted to Dundee City Council in October 2009.
5.54 The unit will house staff from Social Work, NHS and Tayside Police and will replace a vacant former ward building within the Kings Cross Hospital campus. As part of the new development, the internal road system will be redesigned to remove a blind bend. Eighteen car parking spaces and ten cycle spaces will be provided. Parking within the hospital campus has been raised as an issue and a travel and parking statement has been submitted alongside the planning application. The application also states that a travel plan will be implemented within one year of the opening of the building.
5.55 Dundee City Council’s Development Quality Committee recommended that planning permission be granted subject to a number of conditions, including specifically related to travel; before first use of
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the building, cycle parking, car parking and turning areas are completed and that a travel plan must be in place and agreed with Dundee City Council within one year of first use of the unit.
Public transport enhancements Perth Royal Infirmary – Ninewells 5.56 The PRI – Ninewells bus service (Service 333) was launched in 2008 as a key part of NHS Tayside’s acute balance of care programme. Providing a direct hourly connection between the two hospitals for staff, patients and visitors, passenger usage has already exceeded original forecasts. New stops have been added to the route since the service commenced and it will be extended to serve Royal Victoria Hospital in Dundee in the near future.
5.57 The service is funded by NHS Tayside, Perth & Kinross Council and the SAS. NHS staff are entitled to travel free on business travel between the two sites, and the service is timed to arrive at both sites before the hour to tie in effectively with meeting/shift start times. Due to the provision of the service, staff are no longer entitled to claim mileage expenses for car use between the two sites. Free Wi-Fi has recently been introduced to enable staff to use portable laptops when travelling.
Broxden park & ride to Perth Royal Infirmary 5.58 In spring 2010, the existing park & ride service was extended to provide a half hourly off peak service between Broxden park & ride site and Perth Royal Infirmary. This is a commercial initiative by the operator to make use of spare capacity on the existing service outside of the peak period, with Perth & Kinross Council providing some funding support.
Transport with Care, Blairgowrie 5.59 Transport with Care (TWC) was developed as a national pilot project intended to deliver efficiency savings in transport services provided by local authorities, the Scottish Ambulance Service and NHS Boards, through better collaborative working.
5.60 One of the pilot areas was at Blairgowrie Community Hospital whereby a number of changes were implemented to transport provision for NHS patients and Perth & Kinross Council Community Care clients. Evidence showed a duplication of provision between the various partners and clear areas where, with greater co-ordination, this duplication could be minimised. It was not unusual for the partners’ vehicles to follow each other to collect their passengers from the same community or neighbouring streets and then return to Blairgowrie.
5.61 NHS and Community Care staff were also travelling as passenger escorts on their respective vehicles and this role prevented them from spending time at the care facility preparing for the arrival of clients. Both vehicles had a dedicated driver.
5.62 During 2008, approximately £100 per week was being spent to take clients home following attendance at hospital. The use of taxis ended in 2009 and WRVS volunteer drivers were used to provide the journeys wherever possible .
5.63 In early 2009, the responsibility for transport planning was handed back to Blairgowrie Community Hospital (previously Community Care staff prepared their own passenger lists for day care clients and hospital administrative staff prepared passenger lists for their own vehicle and for the Scottish Ambulance Service). In addition, an ‘independent’ member of NHS staff was given responsibility for route planning on a weekly basis.
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5.64 An update report into the project in June 2009 set out five recommendations for action, one of which was to keep the project at Blairgowrie under review but focus on different localities within Perth & Kinross where the successful TWC model can be implemented.
Community First Responders 5.65 A Community First Responder is a volunteer from the local community who responds to medical emergencies while the ambulance is on its way. The SAS operates more than fifty Community First Responder schemes across Scotland and there are five regional co-ordinators who are responsible for supporting the schemes.
5.66 Volunteers are trained in the use of automatic external defibrillators, oxygen therapy and a wide range of emergency skills. There are a number of schemes within the East Central division area, and those in the Tactran region are within the communities of Bridge of Earn, Comrie, Dunblane and Dundee Overgate Centre. A scheme has also been established in Kinloch Rannoch due to issues with GP and SAS availability during out of hours.
Delivering for Remote and Rural Healthcare 5.67 The ‘Delivering for Remote and Rural Healthcare’ report was published by the Scottish Government in 2008. The report identified that transport infrastructure is crucial in the support of healthcare in remote and rural communities and is not the responsibility of any one organisation to resolve.
5.68 The report identified that there is a “pressing need for a co-ordinated and collaborative response to the development of an integrated transport infrastructure necessary to support healthcare across Scotland and in particular in remote and rural communities”. It proposed that a national co- ordinated approach is adopted, bringing together all of the existing or proposed services under the umbrella of one organisation that is more embedded in the NHS Boards than the SAS currently is.
Best Practice 5.69 This section provides brief details of selected projects outwith the Tactran region that are successfully improving access to healthcare.
West of Scotland Transport to Health Project 5.70 A regional NHS Transport Steering Group has been established in the west of Scotland to develop a strategy to improve access to healthcare in the area. The key partners are NHS Greater Glasgow & Clyde, Ayrshire & Arran, Lanarkshire, the Golden Jubilee National Hospital and Strathclyde Partnership for Transport (SPT). NHS Highland is also a partner as Argyll & Bute lies within the SPT area. Other NHS boards, including Dumfries & Galloway and Fife also participate as observers and share in aspects of its work.
5.71 NHS Greater Glasgow & Clyde has appointed a project manager to support the work of the Steering Group and help progress some of the actions. The project manager works across the partnership’s areas to build capacity to respond to the transport agenda and to lead on the development of a number of initiatives common to all Boards.
5.72 A 19 point action plan has been developed covering: partnership working; transport services; transport infrastructure; accessibility planning and travel planning. Good progress has been made on improving access to hospital sites. An audit on progress against actions to date has been made which has shown that in two years the project has helped deliver approximately 80% of ‘NHS actions’.
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SAS Orkney 5.73 Joint working in Orkney is the implementation of the successful Efficient Government bid. The stated outcome was to achieve efficiencies by implementing closer working between NHS Orkney and Orkney Islands Council. As well as looking at shared IT and HR the bid included the introduction of a booking system which could be used by the Council, NHS, SAS and the Third Sector to better integrate transport for those needing care.
5.74 The project has now been expanded to look at the transport needs associated with potential changes to primary care provision throughout Orkney. The SAS is supporting the initiative through the provision of vehicles in remote communities that are available for community use when not required for ambulance use.
Norwich – health and social transport integration 5.75 Norfolk County Council and East Anglian Ambulance Service (EAAS) have integrated social services client and EAAS patient transport using the CLERIC scheduling system. In recognition of the synergy between the two operations, the IT technology used by EAAS was adapted to also schedule social care journeys.
5.76 Social workers responsible for booking client transport have access to the scheduling system via the PTS Online Services booking portal. The CLERIC system provides the central IT facility for the receipt and storage of journey bookings, and is used to plan and schedule journeys to available vehicles and provides costing and reporting.
5.77 The main benefits of the integrated service are reported to be reduced costs through shared transport and system resources, improved journey planning and centralised call taking for a range of services.
Glasgow transport for cancer patients 5.78 Patient Transport Works was a project established in April 2004 to provide improved transport provision for cancer patients accessing cancer clinics in Glasgow. The main aim of the service was to deliver patient transport that focussed on the particular needs of cancer patients to aid recovery from treatment.
5.79 The project was set up as a partnership between SAS, Greater Easterhouse Development Company, NHS Greater Glasgow Health Promotion and the Beatson Oncology Centre. A secondary aim of the project was to tackle social inclusion issues through enhanced access to healthcare and the provision of job opportunities for long term unemployed people in the Social Inclusion Partnership areas of Glasgow. To enable this, the project incorporated the recruitment of long-term unemployed people to train as ambulance drivers.
5.80 The service operated by the SAS taking bookings from the central booking service, as one of a number of transport providers. A fleet of seven specialised MPVs were used to provide the transport and drivers were trained to be able to provide support for cancer patients pre- and post- treatment.
5.81 The service was set up with a budget of £390,000 for two years half of which came from the New Opportunities Fund, with 40% contribution from the SAS. The evaluation by Stirling University showed that Patient Transport Works was able to reduce journey times, improve comfort for patients, provide and enhanced level of support for cancer patients and provide a successful route to employment for the long-term unemployed.
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NHSGGC Travel to Healthcare Advice 5.82 In August 2009, NHS Greater Glasgow and Clyde, SPT and Traveline Scotland launched the personal journey plan initiative at Gartnavel General Hospital in Glasgow. This initiative provides outpatients and visitors public transport journey plans to all the main hospital sites in the Greater Glasgow and Clyde area, with the work to create and issue the journey plans being administered by NHS staff via a contact centre at Gartnavel, where the original pilot project was undertaken.
5.83 The Gartnavel pilot issued questionnaires to users with the aim of obtaining feedback on the scheme. The results showed that:
• Seventy five per cent of respondents found the journey plans useful; • Fifty four per cent of respondents stated that the journey plan had informed them of public transport options they were not previously aware of; • More than half of respondents chose to walk or travel by public transport when attending their appointment; • The majority of respondents still travelled as a car passenger (23%), however the second most popular mode was bus (21%); and • Using the subway and walking and using the train and walking were more popular than NEPTS. Glasgow Evening Visitor Hospital Transport Service 5.84 The Evening Hospital Visitor Transport Service collects hospital visitors from their homes, take them to hospital and home again. The service is available to anyone living in certain parts of Glasgow and travelling to specific hospitals. Priority is given to older people, people with disabilities or in receipt of benefits. It is operated by Community Transport Glasgow.
Constraints: Delivery Systems 5.85 This and the following sections summarise some of the key identified constraints to the improvement of access to healthcare services.
Competing priorities 5.86 Transport and healthcare service delivery systems are both hugely complex. Neither can bow entirely to the needs of the other. The opportunities to improve access to healthcare are tempered by the need for the transport system to also cater for many other journey purposes and that the healthcare system also has a wide range of competing priorities (efficient use of staff and other resources, cost savings, etc).
Range/fragmentation of transport providers 5.87 Patients rely on a wide range of private (walk, cycle, car as driver, car as passenger), public (bus, train) and intermediate (taxi, PTS, community/voluntary transport) modes. This complexity of provision, and the fact that some of operators are in competition with each other whilst many cannot or do not work with effective joint planning, limits scope for effective integrated service planning, leading to duplication of services and spare capacity.
Reliance on voluntary sector and funding sustainability 5.88 Many patients and their visitors rely on volunteer-provided transport to healthcare facilities. These are either formally-arranged schemes or lifts given by family or friends. Many people volunteer large amounts of time to support others accessing healthcare, for example there are 650 volunteer
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drivers in Perth & Kinross alone. The contribution of volunteer drivers is sometimes undervalued by public sector service providers.
5.89 Some volunteers are reimbursed costs for so doing, though schemes have found it more difficult to retain volunteers as reimbursement rates have tended to lag behind increasing motoring costs. The cost that the patient pays to make their journey also differs depending on the service used.
5.90 Some service providers express concerns about reliance on the voluntary sector. Volunteers provide a hugely valuable service, which can be difficult to replace if/when this voluntary input ceases. Concerns are ever present about the long term sustainability of voluntary transport services.
Dynamic healthcare delivery 5.91 As the needs of patients change, new services become available and efficiency savings are sought, there is a natural flux in the locations and times at which healthcare services are offered. This then requires a complementary response from the transport system to provide accessibility to the services. Particular concerns are evident at the present time surrounding the development of the acute hospital at Larbert and corresponding roles of existing NHS Forth Valley sites.
Land use planning and inflexibility of NHS estate stock 5.92 Existing land uses, planning policy and land available within NHS estates obviously is a key determinant of the location of healthcare services. It is not feasible to expect these factors to change for any large proportion of health facilities in the short or medium term, and this constrains opportunities for redesigning health services to be more accessible by existing transport provision.
Limited partnership working 5.93 Both transport and healthcare systems are large and complex, requiring input from a large number of service providers. Whilst there are many examples of good partnership working to share resources and contribute to joint objectives, this complexity does pose challenges for the comprehensive co-ordination of efforts.
Patient choice 5.94 Patient choice about where and when to access healthcare, especially for primary services, is embedded within the NHS. Whilst this is often to the benefit of the patient (not least if the patient can choose to go to a location that is readily accessible for them), it can cause challenges for co- ordination of transport, as a wider diversity of journey requirements results.
Responsibility for accessibility 5.95 No one person or organisation is responsible for ensuring that a patient, or their visitor, can access the healthcare facility. There is a spectrum of need (broadly between the patient taking responsibility for travelling to most primary healthcare episodes and the SAS taking responsibility for moving an emergency case). There is a lack of clarity about responsibility at several points on this spectrum.
5.96 The manifestation of this uncertainty can be patient confusion or inefficiencies in service delivery if patients demand more assistance that they should be entitled to.
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Differing IT systems and complexity of patient booking procedures 5.97 The challenge of integrating healthcare appointments with transport services, and of making joint bookings for patients, is exacerbated by the complexity of the logistics and different IT systems that are in place.
5.98 These systems’ complexities affect not just synergies between transport and healthcare sectors but within each sector, reducing scope for co-ordination for example between different transport providers.
Out of hours cover 5.99 Delivering cost-effective out of hours primary healthcare is a particular challenge, especially in more rural areas. Much work has been completed by health boards to improve the level of cover; these typically rely on a combination of patients needing to travel to central locations and healthcare professionals travelling to patients’ homes.
Finances 5.100 Current and anticipated financial pressures, especially in the public sector, will reduce opportunities to invest in improvements to access to healthcare.
Constraints: Patient Needs Diversity of need 5.101 People accessing healthcare facilities have a wide diversity of need for transport whilst they travel: from the ability to travel alone by active modes through to specialised vehicles and accompanied by trained medical staff. This constrains some opportunities for sharing of transport resources and adds complexity to the challenge of integrating transport services.
'Physical' versus 'social' accessibility 5.102 Just because a patient can theoretically access a site by public transport does not mean they can or will actually use that service. Anecdotal evidence suggests that, for many patients, the cost of public transport is a problem. There are also other social barriers to consider such as perceptions of safety and the ability of some patients (including those with, for example, mental health issues) to travel by public transport.
Very restricted mobility/housebound patients 5.103 There is anecdotal evidence that some patients with very restricted mobility, or indeed that are housebound, are less likely to access to self care or preventative care measures and so become acute patients as a result.
Local versus accessible 5.104 Important and valuable work is underway in many locations to provide healthcare services within communities, closer to patients’ homes. This provides real benefits to access to healthcare for most people because of shorter journey distances.
5.105 In a small number of cases, however, problems can arise if this approach is applied inflexibly. In particular for patients reliant on public transport, it can be that a larger, more distant healthcare facility may in fact be more accessible than a closer one.
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Rurality 5.106 Some parts of the Tactran area are highly rural, remote from the provision of services. By their nature, these rural areas tend to have lesser public transport provision. This poses some particularly challenging problems for access to healthcare services for some residents of the region.
Specific locations 5.107 During consultations for this review, access to healthcare services has been highlighted as being particularly problematic in some locations. These are predominantly in rural areas, notably provision of out of hours cover for Kinloch Rannoch and transport availability and travel time from rural north-west Stirling area (Killin, Crianlarich etc) into the main acute centres.
5.108 However, problems are not exclusive to rural areas: other areas noted have been in the Carse of Gowrie corridor in Perth & Kinross, where the settlements of Errol and Invergowrie lack public transport access to local GP surgeries. This issue is being addressed in part by the provision of a voluntary car scheme for the area.
5.109 Interchange between services remains a major barrier for many people. Issues have been reported with residents from the Downfield area of Dundee accessing Ninewells Hospital by public transport.
Constraints: Transport Provision Parking 5.110 Availability of parking is a problem at many healthcare facilities. Demand exceeds supply in many locations, causing access problems and stress for patients, visitors and staff. The NHS also must pay for the provision, maintenance and supervision of parking spaces.
5.111 From work at many healthcare sites across the UK, JMP estimates that it is typical for approximately two-thirds of supply to be utilised by staff and the remaining one-third by patients and their visitors.
Loss of parking charges 5.112 The removal of car parking charges at NHSScotland sites (with the exception of those with PFI arrangements, including Ninewells Hospital in Dundee) has increased demand for travel by car to some locations. The loss of income from charges now means that alternative revenue streams must be used to provide, maintain and manage parking stock.
5.113 The policy is seen by some as inequitable, as it provides a benefit only to those patients or visitors that have access to a car, in general more affluent than those without.
Public transport access to healthcare sites 5.114 Scheduled public transport provides high quality services to some healthcare sites from some parts of the region, but convenient coverage is not, and cannot expected to be, provided for all patients travelling to all sites.
5.115 Access for visitors causes particular challenges, given that many wish to visit in the evenings or at weekend when public transport services are, in many instances, much reduced from weekday daytime levels.
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5.116 Particular concerns have been raised by stakeholders about access to Stracathro Hospital by public transport.
Public transport service contraction 5.117 There are concerns in parts of the Tactran region that increasing costs of operating public transport services and constrained public funds will lead to further contraction in the public transport network.
5.118 This creates direct problems for those people that wish to make use of these services to access healthcare and indirect ones for the providers of other transport services, as people unable to use public transport are more likely to call on the services of community transport, the NEPTS and others.
Lack of awareness of transport services 5.119 Just as with most journey purposes, people accessing healthcare will in general have limited knowledge of the transport choices available to them. This is particularly the case if they are making a journey to a location that they do not frequently travel to. Knowledge of public and community transport options is often particularly limited. This lack of awareness tends to increase use of private transport and reliance on the use of family or friends to provide escort journeys.
5.120 Given that many patients and visitors are travelling at times of some duress, it is unreasonable to expect a large proportion to wish to invest time in researching travel options.
Limited published travel information 5.121 Although there are many good examples of published information on how to access healthcare facilities, the ready availability of such information is by no means universal. That the information is published by a variety of providers (NHS, transport operators and others) in varying formats and media compounds confusion.
Cumbersome cost-reimbursement processes 5.122 Travel costs may be reimbursed for some patients’ journeys to healthcare, dependent on their income and other criteria. It is believed, however, that many of those people entitled are unaware of the benefits available to them. Relatively cumbersome reimbursement procedures are also believed to act as a disincentive to people making claims.
Inappropriate use of NEPTS 5.123 There is evidence from many locations that the NEPTS is still at times offered to patients that could travel by more cost effective means. This places a burden on the service beyond their core objectives. Furthermore, a significant proportion of NEPTS journeys are wasted (i.e. the service arrives at a patient's house to find nobody home or that the health appointment has been cancelled)17 .
5.124 The SAS is working with NHS Tayside, through the Clinical Manager at Ninewells, to identify how clinic staff can assist to reduce the number of patients they refer to the service, through better understanding of eligibility criteria and alternative transport provision that is available to patients who do not qualify under medical need.
17 We do not have data for the Tactran region, but the SAS report that approximately 9% of NEPTS journeys in Glasgow are wasted.
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Opportunities: Reduced Need to Travel 5.125 This and the following section summarise key identified opportunities to improve access to healthcare.
Telemedicine and video-conferencing 5.126 Increased use of electronic communications does provide increased opportunities for patients to access healthcare without travel or by travelling only to local settings rather than acute centres. Much work is ongoing already in the region to promote this.
In-community treatment 5.127 In line with the hierarchy of care there are, in general, benefits where healthcare services can be provided within community settings. This is taken to include self-care and treatment at home which precludes the need for travel, at least by the patient.
Multi-agency sites 5.128 Sharing of premises by different public sector service providers (including NHS, Police and local authorities) provides an opportunity for more healthcare services to be provided in accessible community settings whilst minimising costs. The potential for some such sites to be developed in the Tactran region is already being explored.
Outposting clinics to community settings and GP branch surgeries 5.129 Outposted healthcare facilities (where a health professional is based part-time at a location ordinarily used for other purposes) can provide an opportunity for more services to be provided in accessible community settings.
5.130 Trials have not been universally successful, however, with some not proving sustainable.
Patient choice and patient-focussed booking systems 5.131 Healthcare appointment booking systems that incorporate the desires of patients can assist in identifying convenient appointment times and locations.
5.132 Note however that, whilst many patients have imperfect knowledge of the transport options available to them, benefits will be limited unless relevant transport information can also be provided. Maximum benefits to patients can only be realised, therefore, if information on these transport options can be provided to patients during the booking process.
Travel planning 5.133 Travel plans have already had significant success in making access to healthcare easier and in increasing use of sustainable modes. Given that not all healthcare sites benefit from travel plans and that on-going interventions are required in order to ensure that new patients and visitors are aware of opportunities then there is scope for further interventions to provide benefits.
Health service redesign 5.134 Transport is only one of a large number of factors that must be taken into account in the design of any health service; it cannot be expected to be of over-riding importance. It appears that the importance of transport as a factor is increasing, however, so as health services are redesigned there is scope for access to them to be made easier.
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Integrated health, transport and spatial planning 5.135 Integration of health, transport and development planning presents an opportunity to ensure historical access issues are not continued into new development. Proper consideration of transport and accessibility in development planning for new healthcare services would identify issues early and allow them to be addressed.
Opportunities: Service Delivery Reduce DNAs 5.136 Transport is typically cited as the biggest single reason why patients do not attend (DNA) appointments. Given the cost to the NHS of DNAs, there is scope to improve healthcare delivery efficiency by improving transport.
Partnership working 5.137 There is significant scope for benefits to access to healthcare from improved partnership working. These benefits can arise from redesign of healthcare or transport systems to create direct benefits of easier journeys and through service delivery efficiencies by sharing resources.
Increased awareness of options 5.138 Given the relatively poor knowledge of transport options that many potential users have, there is scope to improve access to healthcare by raising awareness of these options, such as during the healthcare appointment booking process.
Fleet management/integration 5.139 There are a variety of transport operators offering door-to-door services for residents of the Tactran region (these including the NEPTS, local authority education and social care departments, community and voluntary transport providers). This variety inevitably creates some overlap of provision and there is scope for more efficient service provision and use of resources from improved integration.
Expansion of DRT 5.140 Demand Responsive Transport (DRT) services tend to be well used for access to healthcare and provide a valuable support to those people unable to use scheduled public transport. There is scope for access to healthcare to be improved for many people through expanded DRT provision and for this to reduce pressure on other transport providers, notably the NEPTS. Costs per user of DRT can be very high, however, and achieving financial sustainability of services is often challenging.
Building capacity in voluntary sector 5.141 There is recognised willingness of many volunteers to assist with transport to healthcare. Considered intervention by public sector service providers has the potential to assist with overcoming some of the barriers that may limit capacity in the voluntary sector; these including training, availability of vehicles and cost reimbursement.
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Vision 5.142 As a result of the information presented above, the HTAP vision for access to healthcare is:
To achieve integrated healthcare and transport service delivery that enables all patients and their visitors to access healthcare by convenient, affordable transport appropriate to their needs. For the environmental impacts of journeys to healthcare services to be minimised.
Objectives 5.143 Key HTAP objectives required to achieve this vision are:
• To improve equality of access to healthcare.
• To provide, where possible, healthcare services in locations and at times that are readily accessible.
• To make transport to healthcare accessible for all, physically, socially and financially.
• To ensure transport to healthcare is undertaken by sustainable modes wherever possible.
•
• To ensure actions achieve best value.
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6 NHS Staff Travel
Context 6.1 Many NHS staff travel frequently as part of their normal duties, either for patient-facing appointments or to interact with other professionals. Much of this travel is essential for the efficient operation of the healthcare system but the costs of travel are large and so opportunities to reduce these costs should be considered.
6.2 It is considered that the costs of NHS staff travel arise under three broad headings:
• The direct financial cost to the NHS of the travel itself;
• The time cost for expert NHS staff as, broadly, much of the travel time will be ‘wasted’ in that the staff cannot apply their expertise whilst travelling; and
• The environmental costs of travelling, and in particular the conflict with NHSScotland carbon reduction targets. Cost of staff travel 6.3 We understand that NHS Tayside staff incur around £5 million per annum in travel costs that are reimbursed through expenses (an average of around £350 for each staff member). We anticipate that significant additional costs are incurred through the leasing of vehicles for staff and the provision and maintenance of travel-related infrastructure, particularly car parks for NHS staff. We would expect NHS Forth Valley to incur broadly similar costs. We anticipate that there is potential for some of any savings in financial cost of travel that could be made to be reinvested in other NHS priorities.
6.4 The opportunity cost of staff travel time is less easy to quantify. However, as with other professionals, much staff travel time is largely wasted as there is limited opportunity to apply their expertise whilst travelling. This is particularly true if staff are driving; public transport journeys do offer greater opportunity for productive work whilst travelling.
NHS carbon emissions 6.5 Recently-published research 18 estimates that approximately one-quarter of NHSScotland’s carbon emissions come from transport of staff, patients and their visitors (and that buildings/energy use forms another quarter and procurement the remaining half). Total NHSScotland emissions are
estimated by the research to be 2.6MtCO 2; 23% of Scotland’s public sector emissions and nearly 4% of all emissions in Scotland.
6.6 The Scottish Government has made clear that it expects the public sector to lead by example in reducing carbon footprints to contribute to the national target of an 80% reduction in greenhouse gas emissions by 2050, based on 1990 levels 19 . With transport representing a large proportion of total emissions, it is clear that major changes in travel patterns are required for this target to be met.
6.7 In “A Sustainable Development Strategy for NHSScotland” (April 2009), the Government lists six areas of NHS activity that should be foci for reduced emissions. Transport is listed first amongst these; it is believed that it takes this place because transport provides greater short-term opportunities for emissions reductions than other areas.
18 Carbon Footprint of NHSScotland. Health Facilities Scotland, October 2009 19 Climate Change Act (Scotland) 2009
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Balance of travel needs for staff and patients 6.8 When considering suitable actions to reduce NHS staff travel, an appropriate balance between the travel needs of staff and patients must be achieved. Financial costs to the NHS may be minimised by retaining services in central locations and ensuring patients travel to them (as, whilst the NHS provides transport for some patients and reimburses travel costs for others, this is a small proportion of all patient journeys). Such an approach is likely to increase total travel and hence carbon emissions, however, careful assessment of the net transport implications of decisions about when and where to provide healthcare services is needed for an optimal solution to be identified.
Relevant Policies Free car parking (except Ninewells) 6.9 See details in Section 5 above.
Initiatives 6.10 Much work is already underway to influence NHS staff travel. In this section, we briefly summarise relevant initiatives that are ongoing in the Tactran area.
NHS Tayside 1 in 5 journeys 6.11 Two of NHS Tayside’s divisions have adopted a target to reduce the number of staff journeys by 20% over two years in order to reduce financial costs and carbon emissions. One of the divisions was on track at the end of year 1 to meet the target.
6.12 Staff are being encouraged to travel less, or by more effective means, through a variety of other initiatives including the ready availability of hire cars (which are typically more cost effective than use of personal vehicles) and criteria for staff parking permits at some sites that do not permit parking for people living relatively close by. There is also anecdotal evidence that teleconferencing is being well used.
PRI – Ninewells Link 6.13 As reported in Chapter 5, the Perth Royal Infirmary – Ninewells bus link (the 333 service) is a good example of effective and relatively sustainable transport supporting the twin-site, single-campus approach to the delivery of efficient healthcare for the region.
6.14 To avoid duplication of costs and carbon emissions, staff are now prevented from claiming mileage costs when travelling between the two sites.
Cycle to Work scheme 6.15 Both NHS Boards offer the national Cycle to Work scheme for their staff. Further details on the scheme are provided in Chapter 3. Eligible staff are able to hire bicycles and equipment in a tax- efficient manner and high quality cycle infrastructure is provided at some sites, notably Ninewells. In NHS Tayside, over 500 staff have signed up for the scheme to date and others do cycle on a regular basis.
Good Corporate Citizenship 6.16 The Good Corporate Citizenship scheme was developed by the Sustainable Development Commission in 2006 and revised in 2009 in association with NHS Sustainable Development Unit. It is aimed at NHS organisations to identify how their activities can contribute to sustainable
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development in six key areas: travel, procurement, facilities management, workforce, community engagement, and buildings.
6.17 The scheme features an online self-assessment tool that enables organisations to receive scores on their progress in each of the key areas, along with guidance on what they should be achieving by 2012, 2015 and 2020.
Healthy Working Lives 6.18 Healthy Working Lives aims to play a key role in achieving the Scottish Government’s objectives of reducing work-related ill health by 20%, and days lost to ill health by 30%.
6.19 Both NHS Boards within the Tactran region have received an award through the scheme; NHS Forth Valley with Silver status across their sites and NHS Tayside Board hold a Gold award.
6.20 Further information on the Health Working Lives scheme is presented within Chapter 3.
Constraints 6.21 This section summarises the main identified constraints to influencing NHS staff travel.
Hierarchy of care promotes community settings 6.22 The increasing focus on provision of healthcare services in community settings does rely on some NHS staff travelling more to meet patients. This will of course tend to increase staff travel times and costs. Careful design of such services should mean that these can be more than offset by reduction in travel by patients, as well as other health improvement benefits.
Face-to-face culture 6.23 We find that NHS culture expects face-to-face meetings for much internal communications. This clearly creates demand for travel on a regular basis for many staff.
Staff attitudes to travel/parking 6.24 We observe that a higher proportion of NHS staff than those of many other organisations have an expectation that cars are appropriate modes of transport for journeys and that parking will be freely available.
6.25 This expectation is enhanced by the fact that many NHS sites are not in urban centres and so direct public transport may serve relatively few journeys.
6.26 There is also the issue of how to influence support staff who work in GP surgeries, as they will be employed directly by the surgery and not the NHS.
Mileage reimbursement 6.27 It is reported that some staff perceive that reimbursement rates for use of private vehicles exceed the costs of running the vehicle, so there is financial gain from their use. This clearly incentivises unsustainable travel.
Technology issues 6.28 It is reported that issues with technology have had an impact on the ability to influence more sustainable travel and working practices amongst staff.
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6.29 For example, staff based at Murray Royal Hospital are not able to access the NHS Tayside liftshare website as they use a different IT system to other NHS sites. The travel plan required for the site’s redevelopment sets an ambitious target of a 25% reduction in car parking with an additional 180 staff, therefore it is imperative that measures such as liftsharing, are made known and available to staff.
6.30 It is reported that technology issues and broadband speeds have prevented wider uptake of tele- and video conferencing.
Site constraints 6.31 It is reported that a lack of on-site space at Ninewells Hospital and PRI is preventing further introduction of active travel infrastructure. At Ninewells, there is a lack of shower facilities specifically for cyclists to use; and although showers do exist, these are used primarily for clinical staff. At PRI, there is limited space to erect cycle stands without the loss of car parking spaces. It was the intention at PRI to use revenue from car parking to fund active travel measures, however with removal of car parking charges, this has not been implemented.
Opportunities 6.32 This section summarises the main identified opportunities to influence NHS staff travel.
Promotion of public transport 6.33 Use of public transport, where practicable to do so, can in general reduce financial costs and the carbon footprint of journeys and increase productive work time.
Telemedicine and video-conferencing 6.34 Telemedicine is already providing opportunities for patients to be diagnosed by specialist staff without the need for patients and these staff to travel to meet. Potential remains for expansion of such facilities.
6.35 Meanwhile, video-conferencing provides opportunity for inter-staff interactions without the need to travel.
Tighter budgets 6.36 The increasing financial pressures that the NHS is expecting in coming years may limit scope for investment in new facilities or services. They may, however, increase the incentive for cost savings, which are broadly aligned with other transport objectives.
Travel planning 6.37 Travel plans are at different stages of development across the key sites in NHS Tayside and NHS Forth Valley, with certain sites such as Ninewells Hospital having demonstrated evidence of successful travel planning interventions.
6.38 Given that travel planning has received board level support within both of the NHS Boards, this provides further opportunity for travel plan development and implementation at key facilities.
Effective engagement of staff 6.39 Our experience of working with NHS boards across the UK suggests that sensitive and well- planned engagement with staff can significantly reduce adverse reactions to policies that seek to influence travel behaviour away from established norms.
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Increased awareness of options 6.40 As with patients, many staff will have an incomplete knowledge of the transport options (particularly of public transport) for the journeys they wish to make. Accurate information can assist in supporting a change in behaviour, as alternative options are often more convenient than may be perceived.
Vision 6.41 As a result of the information presented above, the HTAP vision for NHS staff travel is:
For the environmental and financial costs of NHS staff travel to be minimised, whilst maintaining an efficient, effective healthcare service.
Objectives 6.42 Key HTAP objectives required to achieve this vision are:
• To find alternatives to travel for staff communications wherever appropriate.
• To ensure that essential journeys are undertaken by the most appropriate sustainable modes.
• To ensure actions achieve best value.
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Appendix A
Glossary of Terms
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Glossary of Terms
• A&E – Accident and Emergency
• AQAP – Air Quality Action Plan
• AQMA – Air Quality Management Area
• CT – Community Transport
• DNA – did not attend (patient fails to turn up for or cancel a healthcare appointment
• DRT – Demand Responsive Transport
• NEPTS – non-emergency Patient Transport Service, provided by the Scottish Ambulance Service
• PRI – Perth Royal Infirmary
• SAS – Scottish Ambulance Service
• SOA – Single Outcome Agreement
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Appendix B
Policy Context
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B.1. This appendix provides more detail on the key policies listed in section 2 and highlights issues from those policies that are considered to be particularly pertinent to the Tactran Health & Transport Action Plan.
Community Plans and Single Outcome Agreements B.2. In November 2007, national and local government signed an agreement which committed both to moving towards Single Outcome Agreements (SOAs) for all 32 of Scotland’s councils and Community Planning Partnerships (CPPs). B.3. All the Tactran authorities have Community Plans and SOAs in place. Many objectives and actions within the SOAs are relevant to the study themes of transport and public health, promoting active travel and access to healthcare. B.4. The Stirling Community Plan sets out a 15 year vision for the area, which is aimed at increasing the well being of all citizens. The Plan’s visions are to make sure Stirling has a growing population and economy, high quality infrastructure, joined up services and citizen-focused services. Strategic topic 4 within Stirling’s SOA focuses on encouraging healthy lifestyles and life choices and identified actions include “promote and improve standards of diet, activity and healthy weight for children and young people”. B.5. The first Community Plan for Dundee was launched in 2001. The Community Plan for 2005-2010 acts as both a progress report and the second plan. It details the actions that have been undertaken to date and the progress that has been made in the area. The vision for Dundee as set out in the plan is for a vibrant and attractive city and a strong and sustainable city. B.6. One of the strategic priorities of Dundee’s SOA is to achieve physical and mental wellbeing in the region. Outcomes 4 and 10 of the SOA are particularly relevant to the study themes and focus on identifying methods to reduce the gap in healthy life expectancy between those in the most deprived areas and the Dundee average. Improving access to services and improving transport has been identified as a short term outcome. Outcome 10 supports this in that it aims to ensure communities have high quality and accessible local services. It notes that in 2008/09 improvements to healthcare facilities were made including investment in the Kings Cross Health and Community Care centre. B.7. The first Community Plan for Perth & Kinross was approved in November 2006 and sets out the key aims, outcomes and strategies for the area until 2020. The key aims of the Perth & Kinross plan is to create a vibrant and successful area, safe, healthy and inclusive communities and nurtured and supported people. B.8. Perth & Kinross Council states that there are a number of priorities that have been identified for the region but the one most relevant to this study is that of “improving the health of the population and providing high quality care”. B.9. The Community Plan of Angus sets out the agenda for the period of 2007 to 2012 in the area. The plan uses three principles of sustainability to guide its outcomes and actions, sustainable development, social inclusion and active citizenship. B.10. Angus’ SOA includes as Local Outcomes “the health of the Angus population is improved”, “children and young people in Angus will enjoy the highest attainable standards of physical and mental health, with access to suitable healthcare and support for safe and healthy lifestyle
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choices”, “children and young people in Angus will be active with opportunities and encouragement to participate in play and recreation, including sport” and “people in Angus can access amenities and services through a variety of affordable and sustainable means”.
Better Health, Better Care B.11. The ‘Better Health, Better Care’ Action Plan was published by the Scottish Government in 2007, and sets out a programme of work for the following five years to tackle health issues in Scotland. The development of the Action Plan is seen to be a significant step towards a ‘Healthier Scotland’ which has three main components: health improvement, tackling health inequality and improving the quality of healthcare in Scotland. The Action Plan sets out a programme of activities and targeted actions which are designed to accelerate progress of the three main components identified by ‘Healthier Scotland’. B.12. There are three main themes to the report: towards a mutual NHS, helping people to sustain and improve their health and ensuring better, local and faster access to healthcare.
Sustainable Development Strategy for NHSScotland B.13. Public sector bodies in Scotland, including NHSScotland, have a duty to contribute to the Scottish Government’s purpose “to create a more successful country where all of Scotland can flourish through increasing sustainable economic growth”. The Sustainable Development Strategy for NHSScotland provides a strategy for a 5 year period from 2009/10 to 2013/14, which draws on the principles and commitments arising from relevant international and national sustainable development policies. B.14. The strategy provides a clear framework which will help to provide a shift in behaviour within NHSScotland, encouraging more environmental friendly and sustainable ways of working. The document highlights the fact that there is an inextricable link between sustainable development and health improvement and healthcare provision. B.15. The strategy follows the six key issues as identified in the Sustainable Development Commission’s (SDC) tool used in England. The SDC is the UK Governments independent watchdog on sustainable development and the six key issues it identifies are; Transport Procurement, Facilities Management, Employment and Skills, Community Engagement and New Build Projects.
Delivering for Remote and Rural Healthcare B.16. ‘Delivering for Remote and Rural Healthcare’ was launched by the Cabinet Secretary for Health and Wellbeing in May 2008. The North of Scotland Planning Group (NoSPG) has been tasked with leading the implementation of a programme to identify national, regional and interregional actions and to monitor progress made by NHS Boards. A sub-group, the Remote and Rural Implementation Group (RRIG), is leading this work. B.17. The RRIG has been tasked with developing a policy for sustainable remote and rural healthcare services following the recommendation that “robust and responsive local community emergency response systems should be developed and that an integrated transport strategy that is responsive to remote and rural patients’ needs must also be developed”. B.18. RRIG has established an Emergency Response and Transport workstream with a Lead Clinician, Manager and Project support to progress the implementation of a number of recommendations.
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Strategic and Local Development Plans B.19. The Planning etc. (Scotland) Act 2006 provides for the removal of structure plans and the creation of strategic development plans (SDPs). The Act gives Scottish Ministers powers to designate Strategic Development Planning Authorities (SDPAs), which are groups of planning authorities working together to prepare these plans. B.20. The Scottish Government published its Statutory Guidance on Strategic Development Planning Authorities (Planning Circular 2 2008) in April 2008. Strategic development plans should set out a clear vision and spatial strategy for their area, specifically focussing on the key land use and development matters that cross planning authority boundaries. As a result they should be shorter, more strategic and easier to use than structure plans. B.21. The Guidance highlights the important regional relationship between spatial planning and transport and identifies how SDPAs can utilise expertise from other agencies, including specifically RTPs.
B.22. SDPs are required to be prepared and reviewed at least every five years, so that plans can effectively lead and manage change. B.23. TAYplan was formed in June 2008 and comprises Dundee City, Perth and Kinross, Angus and Fife Councils. TAYplan is required to prepare and maintain an SDP for the area covered by the four Councils, which when completed will replace the existing Dundee and Angus Structure Plan 2002, the Perth and Kinross Structure Plan 2003 and the Fife Structure Plan 2009 (specifically the North of Fife). B.24. In addition each Council will have to prepare and keep under review a Local Development Plan (LDP) for their geographic area which will replace the Local Plan. All local authorities will be required to identify whether there have been any changes in the physical, economic, social and environmental characteristics of the area since the preparation of the existing Local Plan, as well as the impact of the policies and proposals of the existing plan. B.25. LDPs are required to contain a spatial strategy , which is a detailed statement of the local authority's policies and proposals as to the development and use of land. Outside SDP areas, LDPs must also contain a vision statement. This will be a broad statement of how the development of the area could and should occur and the matters that might be expected to affect that development.
Climate Change (Scotland) Act 2009 B.26. The Climate Change (Scotland) Act 2009 received Royal Assent on 4 th August 2009. Part 1 of the Act sets the long-term statutory framework for greenhouse gas emissions reduction by creating a statutory target for Scotland’s net emissions to reduce by at least 80% by 2050 compared with the 1990 baseline. B.27. The ‘emissions’ referred to in the Act cover the basket of six greenhouse gases recognised by the United Nations Framework Convention on Climate Change (carbon dioxide; methane; nitrous oxide; hydrofluorocarbons; perfluorocarbons and sulphur hexafluoride). B.28. In addition to the 2050 target, there is the target for net Scottish emissions to be 42% lower by 2020 compared with the baseline figure. This interim target is higher than the UK government target to reduce greenhouse gas emissions by 34% by 2020. However, the Act also contains provisions for the Scottish Ministers to vary targets following expert advice from such a body as the UK Committee on Climate Change.
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B.29. To help ensure the delivery of both the 2020 and 2050 targets, the Act also requires that annual targets are set, using secondary legislation, from 2010 to 2050. Ministers must set the first batch of annual targets by order, covering 2010-2022, by June 1, 2010 and annual targets to cover 2023- 2027 must be set by October 31, 2011 with further batches set every five years by 31 October thereafter. B.30. Part 4 of the Act imposes duties on Scottish public bodies, in that through exercising their functions, they must act in such a way as to ensure the delivery of the targets of the Act.
Cycling Action Plan for Scotland B.31. The draft Cycling Action Plan for Scotland has been developed following public and stakeholder consultation during 2008 and 2009. The Plan’s overarching aim is “to get more people cycling more often” with an overall target of a 10% share of all journeys undertaken by cycling by 2020. B.32. To achieve this, four strategic objectives were established, as described below:
• By 2020, we will have created communities where people of all ages and abilities can cycle safely and comfortably; • For cycling to be the natural choice for your daily journeys; • For people to have the confidence and the right information to make cycling a realistic choice for some journeys; and • Legal powers will promote access and keep people safe and active.
B.33. A report detailing the responses to the final consultation document was published in December 2009 and the final Cycling Action Plan was published in June 2010 alongside an updated version of Cycling by Design.
Tactran Regional Transport Strategy B.34. The Tactran Regional Transport Strategy (RTS) sets out a vision and objectives over a 10-15 year period for the region. The region includes a number of Scotland’s key transport corridors, and as such is a central hub in the national transport network. The Tactran vision is of “a transport system, shaped by engagement with its citizens, which helps deliver prosperity and connect communities across the region and beyond, which is socially inclusive and environmentally sustainable and which promotes the health and well being of all”. B.35. Specifically in relation to the themes of promoting active travel, transport and health and access to healthcare, the RTS states that “the RTS must consider the respects in which transport in the region needs to be provided, developed or improved and operated, in particular; enhancing social, economic and public health promoting public safety, including road safety and the safety of users on public transport, and facilitating access to hospitals, clinics and surgeries”. B.36. There are a number of objectives within the RTS that are aimed at improving accessibility, promoting health and wellbeing and encouraging active travel. The RTS also details key future trends that are likely to have an impact on access to healthcare. These key trends are that:
• “an ageing population will increase the need for improved non car based access to health facilities;
• further centralisation and the relocation of health care services will mean that proportions outside acceptable journey times to hospital by public transport will increase; and
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• the provision of ambulance based transport to hospitals for non emergency patients is likely to decrease in the near future ”. B.37. Road safety issues are also addressed within the RTS and several routes have been identified as having a serious accident record. These are the A9, A84/A85, the A90, A811 and the A977. RTS Sub-Strategies B.38. The RTS is supported by four sub-strategies (for buses, walking & cycling, transport information and park & ride). B.39. The Bus Strategy and Action Plan details how that, in general, access to GP surgeries is good around major areas however there are still pockets of poor access to healthcare, especially in the Northern highland area of the region. Poor areas of access are also identified along the A90 Perth- Dundee and the A85 Perth-Crieff corridors. It states that there are opportunities therefore, for Demand Responsive Transport (DRT) and Community Transport (CT) services to be developed here, where a lower proportion of the population have access to a car and where bus services are limited. B.40. The Walking and Cycling Strategy and Action Plan recognises that increased use of active modes will contribute to improved health as well as a range of other public policy objectives (though the health benefits are less explicit within the plan than those for economy, accessibility and environment). The plan seeks to increase the amount of active travel though a combination of measures to improve strategic integration, infrastructure, sharing best practice and influencing travel behaviour. B.41. The Travel Information Strategy and Action Plan includes recommendations to improve awareness of active travel modes and enable effective planning of active travel options. Promoting knowledge of some of the outcome benefits to the individual of active travel (which includes improved health alongside social interaction, reduced stress and reduced cost) could provide further contribution to the achievement of strategy objectives. B.42. The Park & Ride Strategy and Action Plan outlines that park & ride services can potentially contribute to improved access to healthcare, amongst other key journey purposes.
Local Transport Strategies B.43. Local Transport Strategies (LTSs) are published by local authorities, their aim being to communicate a local authority’s transport strategy and future proposals. Each LTS sets out a vision for the area and a series of objectives designed to increase and improve the transport in the area. B.44. The LTS vision for Stirling Council is to develop a “transport system that meets everyone’s needs, respects our environment and contributes to health”. There are a number of objectives within Stirling’s LTS that support the study themes of health and transport and active travel. These include Policy 1 which concerns promoting safer travel for all and reducing the number of road accidents, Policy 2, to maintain and manage the existing transport network, which includes introducing schemes to encourage walking and cycling, and Policy 4, which aims to increase travel choices and reduce the need to use the private car. B.45. Perth & Kinross Council’s LTS was published in 2000 and contains a number of objectives aimed at promoting active travel and reducing dependence on the car. Relevant policies to this study contained within Perth and Kinross LTS include the provision of adequate pedestrian facilities, safe cycle routes, traffic calming measures and working closely with other agencies such as Sustrans and VisitScotland promote and provide on and off-road cycle routes.
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B.46. Dundee City Council’s LTS was published in 2000 with the long-term vision of providing a sustainable transport strategy for the city to ensure that residents have a “genuine choice in fulfilling their transport needs, with less need for reliance on the private car and greater opportunity for public transport use, walking and cycling”. B.47. The strategy describes a three-pronged approach, by: Reducing the Need to Travel; Promoting Alternative Modes of Travel; and Restraining the Use of the Private Car, with a set of specific objectives and targets set to be achieved, for example “to increase by 2011 the modal share of people walking to work within the city to 22%”. The Council has identified a number of actions to be implemented including improved pedestrian crossings, upgrading existing off-road cycle routes, consideration of park and ride schemes. B.48. Angus Council’s LTS is only available as a printed version upon request to Angus Council and therefore no information has been obtained.
NHS Tayside Health Equity Strategy – “Communities in Control” B.49. The NHS Tayside draft Health Equity Strategy is aimed at closing the health inequalities gap within a generation and is one of the four NHS Tayside Strategic Aims over the next five years. The draft strategy document was published for a consultation period from October 2009 to December 2009. B.50. The objective of the strategy is to reduce the years of life lost annually to poverty in Tayside from being measured in thousands to being measured in hundreds. The NHS recognises that requires fundamentally different approaches to health and as such the strategy focuses on cultural changes and outcomes, and gives illustrative examples but does not prescribe detail. B.51. Once the strategy is approved, specific and detailed actions will be laid out in annual commissioning plans. The strategy does however, make a number of commitments, including:
• using social marketing techniques; • supporting mainstream services to promote social capital; • Develop training and development so that all staff see health inequalities as the most important issues; • progress on integrated measures of improved mental health and well being, less long term ill health and less early death; • Integrate services with partner agencies so they are easier to access, and provide more holistic services for people’s social and health needs.
Healthcare Transport Framework B.52. The Healthcare Transport Stocktake Report published by the Scottish Government in 2009 identified a broad range of local, regional and national initiatives and approaches to healthcare and specialised healthcare transport services across Scotland. The report identified that there are three main categories to describe healthcare transport:
• Transport for Health – Active and sustainable travel options to reduce the social, economic and environmental costs associated with daily travel.
• Transport for Healthcare – Public Transport, Patient Transport and Demand Responsive Transport.
• Urgent Transport for Healthcare – Immediate transport for the critically ill.
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B.53. One of the key actions arising out of the Stocktake Report was the development of a framework document (‘Healthcare Transport Framework’) to provide guidance for NHS Boards to address the Transport for Healthcare agenda. The Framework identifies the need for NHS Boards to work in partnership with other agencies, such as Regional Transport Partnerships (RTPs), local authorities, Scottish Government and transport providers, to improve access to major healthcare facilities. B.54. The document states that to work effectively in partnership, NHS Boards “will need to understand the transport and access issues affecting their patients, visitors and staff and be clear about the solutions that are required to improve access to healthcare” and there are a number of areas where NHS Boards can implement changes to improve access to their facilities. B.55. The Framework contains a checklist to assist NHS Boards draw up an action plan to improve access to major healthcare facilities and develop internal and external capacity to respond to and deliver on the healthcare transport agenda. B.56. Actions fall under several key themes: board structure, car parking, travel plans, taxi usage, hospital or health centre site specific measures, information, taxi usage and partnerships.
Preventing Overweight and Obesity in Scotland B.57. In February 2010 the Scottish Government produced ‘Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight’. This provides policy direction for national and local government decision makers, working in partnership with other agencies, to undertake short and medium term actions to prevent the continued trend in obesity levels in Scotland. B.58. The Route Map identifies preventative actions under four categories: energy consumption, energy expenditure, early years and working lives. Of most relevance to the Health and Transport Action Plan is that of energy expenditure, “increasing opportunities for and uptake of walking, cycling and other physical activity in our daily lives and minimising sedentary behaviour”. B.59. The report details a number of policy commitments under the theme of energy expenditure that will directly support behaviour change:
• expanding safe cycling and pedestrian routes to link key community destinations including public transport hubs, hospitals, supermarkets and centres of employment; • publicising the availability and benefits of local pedestrian and cycle routes and improving signage to popular destinations; • clearing up environmental dereliction such as poor lighting, vacant sites and animal faeces that discourage people from walking in their local neighbourhoods; • using social marketing approaches tailored appropriately to audiences depending on their current levels of activity and motivation, with particular attention on those who are especially inactive or vulnerable in other respects • Implementing widely the lessons learned from the Smarter Choices Smarter Places active travel demonstration towns about which interventions, including both incentives for active travel and disincentives for car use, are most effective in achieving greater uptake of travel options, particularly by the least active groups.
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Scottish Ambulance Service: Working Together for Better Patient Care B.60. In February 2010, the SAS published its strategic framework for the future of ambulance care, ‘Working Together for Better Patient Care 2010-2015 ’. This seeks to achieve three main goals:
• to improve access and referral to the most appropriate care; • to deliver the best service for patients; and • to engage with all partners and communities to deliver improved healthcare.
B.61. Within the remit of transport for scheduled care (emergency treatment being outwith the scope of this Action Plan), the framework highlights the confusion that many users of transport to healthcare currently have regarding the options available to them and that there are inefficiencies in current delivery systems. Consultation undertaken by the SAS has shown that there is little awareness amongst some users of alternatives to the NEPTS. B.62. The document sets out the SAS’s willingness to work with stakeholders to ensure more efficient and better quality services, stating that “ Ensuring there is clarity and consistency in how patients access services for emergency and unscheduled care is key to our strategy. The principle is exactly the same for scheduled care, although the final outcome would be either an ambulance or referral to an alternative transport provider. The SAS will work with local and regional transport groups to develop a similar system for these requests which properly assesses patient need and routes patients to the most appropriate provider to meet those individual needs ”. B.63. The SAS undertakes to “ work with NHS Boards and transport groups to develop [an] assessment tool for determining eligibility for ambulance transport based on clinical need and linking in with a more integrated health care to transport system so we can route patients to other appropriate providers ”. Clearly, this will pose challenges to these other providers in some instances to ensure they have the systems and capacity to respond to the changing demand that will inevitably arise.
The Environment Act 1995 B.64. The Environment Act 1995 provides a framework for Local Air Quality Management (LAQM). The provisions in Part IV of the Act are largely enabling and give local authorities the flexibility to take forward local policies to suit local needs. Circumstances will determine the content of local air quality strategies, the designation of AQMAs and the content of action plans. B.65. The Act states that the Secretary of State shall prepare and publish a statement (“the strategy”) containing policies with respect to air quality assessment or management. The National Air Quality Strategy (NAQS) was first published by the Department of The Environment in 1997. It sets out a framework of standards and objectives for the air pollutants of most concern, with the aim of reducing the number and extent of episodes of air pollution, both in summer and winter. The eight priority pollutants are:
• sulphur dioxide (SO 2) • particulate matter (PM 10 ) • nitrogen dioxide (NO 2) • carbon monoxide (CO) • lead • benzene
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• 1, 3-butadiene
• tropospheric ozone (O 3)
B.66. The strategy identifies air quality standards for these pollutants and specific objectives set out the required concentration limit of each pollutant, the degree of compliance with each standard expected and the relevant measurement timescale. B.67. The strategy was updated and published by the Department for Environment Food and Rural Affairs (Defra) and the devolved administrations in July 2007. B.68. The 1995 Act states that every local authority must undertake a periodic review of current and predicted future air quality within their area. Whenever a review is commissioned, the assessment of air quality should determine whether statutory air quality standards and objectives are being achieved. If it is found that standards and objectives are not being achieved then the local authority must by order designate the area an Air Quality Management Area (AQMA).
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