Patient TransportServices Toolkit

August 2009

UNISON National Ambulance Committee

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UNISON Patient Transport Services ToolkitIndex

Chapter Page No.

1 Introduction 3

2 Preparation 8 - 9

3 Quality Standards 10 - 12

4 PTS Procurement 13 - 15

5 Campaigning andInfluencing

19 - 21

Appendices1 (1) National Ambulance

Sector Briefing 4 - 7

1 (2) Excel PTS data workbook Separatedocument

2 (1) Letter to commissionersseeking information 9

4(1) to4(4)

Letters to commissionerson procurement issues

15 - 18

5 (1) to5 (4)

Letters to otherstakeholders

22 - 25

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UNISON Patient Transport Services (PTS) Toolkit - Introduction

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

In order to most effectively protect in-house PTS UNISON branches need to beprepared well in advance of the privatisation threat that is addressed in chapter 2.Until now it is fair to say that our responses have been more reactive thananticipative. As the main Commissioners of Patient Transport Services are Acute orPrimary Care NHS Trusts early collaboration with the relevant UNISON healthbranches in those trusts (through your regional office) should assist in helping identifyand lobbying the decision makers and raise general awareness of the issues.

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

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

The major focus of this toolkit is on preventative measures to keep PTS in the NHS.However it is important also to pursue those PTS contracts that have already beenout-sourced. Working in partnership with Ambulance employers and otherUNISON colleagues is essential to maximise chances of success. Maintaininghigh membership density in PTS and developing PTS activists are also vital toensure continuity of action and that our legitimacy and integrity on this issuecannot be challenged.

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

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

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

UNISON National Ambulance Committee.

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UNISON PTS Toolkit Appendix 1(1)

Ambulance Sector

UNISON briefing on NHS Patient Transport Services (PTS).

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

1. Who pays for PTS?

In England, current responsibility for commissioning PTS can be summarised as follows:

Description of Journey Responsible Organisation

Patient's home address to NHS Trust The receiving NHS Trust

Patient's home address to other healthcareprovider

Primary Care Trust

NHS Trust to patient's home address The transmitting NHS Trust

NHS Trust to NHS Trust transfer The transmitting NHS Trust

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

2. Who provides PTS?

PTS resources are primarily based in Ambulance services although somehospital and primary care trusts have their own in-house PTS. However the“market” system of NHS funding in England has already resulted in theprivatisation of PTS in many areas. This was enabled by “packaging” PTS as aseparate and unrelated entity, not just to Ambulance emergency services but tohealthcare in general.

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

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3. Why is UNISON concerned?

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

3.1 Service Quality

The criteria currently being used in England by many trusts to determine their PTSprovider is primarily based on cost rather than quality. This is particularly the casewhere commissioning trusts are in financial difficulty. Tender specifications willoften be quite vague when it comes to quality particularly of personnel, who are ofcourse key in providing the service.

3.2 Personnel - training

UNISON has revealed that that whilst NHS Ambulance services have a standardinduction training program for new PTS of three weeks duration this is not the casein the private sector where “training” is minimal and in some cases new staff withoutany healthcare or PTS experience get no training at all. UNISON members acrossthe NHS continually alert us that staff in the private PTS sector often appear to havehad little or no training in how to handle patients with mobility difficulties andcould actually be harming them.

3.3 Personnel - vetting

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

3.4 Personnel – pay and conditions.

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

3.5 Equipment

The minimum standards on staffing within NHS Ambulance services equally applywhen it comes to equipment including vehicles and lifting devices. NHS provided PTSbenefits from sharing hospital and ambulance A&E resources and the experiences oftheir staff. Again, whilst tender specifications may refer to equipment standards theseare rarely monitored. UNISON members regularly report that private sector PTSvehicles and equipment are not fit for purpose and the commissioners rarely haveany system in place to ensure equipment and vehicle standards.

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3.6 Regulation

There is currently no national system in place for any licensing, regulation ormonitoring of private PTS (or private ambulance) providers. The Department ofHealth (England) is not even aware of how many private ambulance companies existlet alone monitor their performance.

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

However it should be noted that since section 53 of The Road Safety Act 2006 camein to effect in January 2008 the following licences are required to be obtained fromthe Local Authority for any vehicle that carries eight or less persons with a driverand where commercial benefit is obtained:

1. An operator’s licence. This is granted for up to one year, and placesvarious record-keeping requirements on licence holders;

2. A vehicle licence. This is granted for up to twelve months (pro-ratadepending on when the application is made) after completion of a compliancetest;

3. A driver’s licence. This is currently granted from one to three years to

drivers who can show they are ‘fit and proper’ after satisfactorily completing a

medical examination, an enhanced Criminal Record Bureau disclosure, and a

topographical Knowledge Test.

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

4 Wider implications in the privatisation of PTS

As well as reducing the quality of care and putting patients unnecessarily at risk theprivatisation of PTS has a wider, detrimental effect on the NHS. PTS resourcesplay a crucial support role in emergency and disaster contingency planning to dealwith incidents such as flu pandemics or terrorist acts, provide a vital entry point intothe ambulance workforce for members of the local community and will, throughcareer development and training help deliver the emergency ambulance crews oftomorrow.

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

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

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5. Resolving the problem

5.1 Many of the issues raised above are not unique to PTS as evidenced in theUNISON commissioned report “Driven by Dogma? Outsourcing in the healthservice” available at http://www.unison.org.uk/acrobat/B4360.pdf . The mosteffective solution to this problem would be to halt the privatisation of English PTSand bring back these services in-house. The current situation has arisen throughseparating the PTS element from ambulance accident and emergency provision tocreate a PTS “market”. The reality is this is wholly cosmetic and fails to recognisethe strategic importance of PTS to NHS emergency ambulance services and patientcare.

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

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

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

ii. Ensure commissioning trusts satisfy the requirement of section 242 of the NHSAct 2006 that requires them to consult users on proposals to change the wayservices are provided;

iii. Ensure commissioners carry out an equality impact assessment on anydecision to change provider with due regard to the impact on staffing and localcommunity;

iv. Introduce standard contract specifications that:

Ensure bidders meet existing licensing requirements,

Apply minimum standards to patient care quality, staff vetting, pay,conditions and training including detailing core competencies required,

Require evidence of a commitment and adherence to equalopportunities principles and related legislation

Prohibits sub-contracting;

v. Ensure that those trusts that commission private PTS have a robustmonitoring process in place for the duration of any contract;

Whilst the above measures will not address the wider impact of the NHS losing PTSresources they will at least provide some control over day to day patient care andquality standards.

UNISON will be providing more specific guidance to branches on the requirementsand obligations of commissioners and how patient groups and other stakeholders canget involved in protecting their PTS.

UNISON National Ambulance Committee August 2009

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UNISON Patient Transport Services Toolkit – Chapter 2 - Preparation

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

Chapter 4, section B (page 17) covers the issues for branches to consider and therecommended action necessary when developing a clearly defined strategy andunderpinning action plan / checklist in partnership with the UNISON regional office.

Mapping Tool – Contract Information

The better informed we are the more effective our actions are likely to be. Indeed, incases where we are not well informed it is likely that key decisions will be madewithout our knowledge and it will be too late to act decisively at all. To this end it isessential that branches have up to date intelligence in the following areas:

Existing PTS contracts;

UNISON PTS membership;

Other UNISON Health branch contacts.

Step 1 – Mapping basic PTS contract data.

The first step is to compile a database of existing PTS provision. This will bedelivered by the Ambulance Trust, in house or by the private sector. A starting pointwould be to identify the current PTS contracts held by the Ambulance trust. If theseare made with a consortium of NHS trusts break the data down so each trust is listed.Attached to this toolkit is an EXCEL workbook (appendix 2(1)). Enter this data intothe first spreadsheet entitled PTS Contract Info. Also input the basic contractinformation as indicated by the column headings.

This list of trusts can then be cross referenced with a list of all NHS trusts in yourStrategic Health Authority (SHA) area that can be obtained from the SHA / Trustmapping tool in the excel workbook. Go to the spreadsheet in the workbook entitledSHA & Trust Data and click on the drop down list in the column headed SHA name.Then click on your regional SHA and that will bring up all the NHS trusts in the area.Compare this list with those trusts you have already identified as holding contractswith the Ambulance trust. Any not on the first list are likely to be either providing theirown PTS or using the private sector.

Step 2- More detailed information.

Branches may find it difficult to access details of existing privatised PTS contracts.Hopefully your Ambulance employer will help identify these. If you still do not alreadyhave sufficient details of non-ambulance service PTS provision then you can write tothe commissioning trusts seeking this information from them voluntarily. A draft letteris attached below as appendix 2(2) for this purpose. Trust contact details can benormally be obtained via the SHA website that can be accessed athttp://www.nhs.uk/servicedirectories/Pages/StrategicHealthAuthorityListing.aspx

Please ensure that you alert the respective UNISON health branch of your request bycopying them into this letter.

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

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Patient Transport Services Preparation– UNISON Membership data

It is important to maintain a high membership density in areas under threat fromprivatisation. Good membership density strengthens UNISON’s legitimacy andrecognition and is also vital to protect members who may already have, or are at riskof being transferred to the private sector. It is recommended that this information isheld in a spreadsheet alongside that relating to PTS contracts. See page 18 of theUNISON procurement guide for advice on identifying weaknesses in membership /activist density and working with the region to address this.

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

Dear

Re: PTS contracts, Freedom of Information Request.

I am the Branch Secretary of the Ambulance Branch of UNISON. I understand youhave contractual arrangements with other agencies relating to Patient TransportServices.

Please can you provide me with the following information:

(I request the following information under the Freedom of Information Act):-

1. All tendering / contract documents.

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

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

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

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

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

Thank you in anticipation.

Yours sincerely

UNISON Branch Secretary

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

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UNISON PTS Toolkit – Chapter 3 - Quality Standards

A private consultancy firm that advises both commissioning trusts and ambulanceservices on managing PTS contracts has publicly stated that the private sector optionwill always prove costlier to the commissioners in the long run, and argues delivery ofservices by NHS Ambulance trusts (or in house) is the only viable option on qualitygrounds also.

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

Measurable standards of quality.

Like any other Health Services, patient transportation is required to meet qualitystandards and staffing obligations. We know that it is often the case that theserequirements are not specified in contracts and even where they are specifiedcommissioners have no monitoring system in place to ensure they are being met.This does not mean those standards do not apply.

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

Standards for Better Health

NHS standards in England are set out in the Department of Health’s Standards forBetter Health available athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4086057 . The key areas around which standards are set in thisdocument are called “domains”. Within these domains “core” (compulsory) and“developmental” (aspirational) standards are specified. The key standards to focuson are the Core standards as these are expected to be met immediately.

The first domain is Safety and the specified outcome sought is:

“Patient safety is enhanced by the use of health care processes, workingpractices and systemic activities that prevent or reduce the risk of harm topatients.”

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

What the current tendering processes fail to acknowledge and recognise is that NHSAmbulance Services already have to comply with the healthcare standards includingthose on safety. Therefore the Commissioners can assume compliance. The privatesector, however is totally unregulated and has no obligation to comply with thesestandards, except insofar as is specified by any contract. In any event responsibilityfor failures in this area will solely be borne by the commissioning trust.

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

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

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

The concerns outlined above are also particularly relevant to other domains asfollows:

2nd Domain - Clinical and Cost Effectiveness.

Core standard C6 provides for Health care organisations to cooperate with eachother and social care organisations to ensure that patients’ individual needs areproperly managed and met.

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

3rd Domain - Governance

Managerial and clinical leadership and accountability, as well as theorganisation’s culture, systems and working practices ensure that probity,quality assurance, quality improvement and patient safety are centralcomponents of all the activities of the health care organisation.

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

Core standard C8 refers to the requirement with respect to staff equality issues andC10 & C11 reflect the responsibility of health care organisations to undertakeemployment checks and are properly trained. Where PTS has been privatised it isthe responsibility of the commissioning trust to actively ensure these standards aremet. They cannot simply rely on the word of the contractor. If they cannot show theyhave a working system in place to do this they risk failing on this standard.

4th Domain – Patient Focus

The core standards in this domain underline the requirement for systems to be inplace. The question for Commissioners using private PTS providers is what systemsare in place to monitor their staff and the service they deliver?

6th Domain - Care Environment and Amenities

The key area here is the PTS care environment. This is not just the mode oftransportation but also very often the patients home. As previously stated the lack ofany system in place to ensure PTS vehicle roadworthiness, cleanliness and accessto appropriate equipment would indicate problems in this area.

Raising Concerns

The standards for better health guidance note on the independent sector states onpage 8:

“Those commissioning NHS services from the private sector must also takecompliance with the Standards for Better Health into account before commissioningcontracts are made.”

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

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

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

Other Equality Standards

In addition to healthcare core standard C7 of the 3rd domain (Governance)commissioning trusts are also required to meet general and specific public sectorequality duties. Please see section 4D (page 23) of the UNISON procurement guideand also http://www.unison.org.uk/file/16965_Equality_Guidance.pdf for morespecific guidance in this area that states on page 12:

“An (public) authority cannot abdicate responsibility for meeting the duties bycontracting out its functions; where functions are carried out by an externalsupplier, the authority remains responsible for meeting the duties.”

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

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

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

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UNISON PTS Toolkit – Chapter 4- Procurement

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

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

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

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

In order to influence the commissioning process and specifications Branches willneed to be aware of when the contracts are due for renewal. Experience shows thatwe have a poor record of anticipating these and as a consequence a vital opportunityto influence the outcome is lost. A PTS mapping tool like the one outlined in chapter2 will help address this.

In addition to neglecting the impact on meeting healthcare standards Commissionersoften ignore their obligations to consult both staff and user groups before they makea decision on whether to go out to tender. These obligations are set out on page 33of the guidance for NHS organisations on section 242(1 B) of the NHS Act 2006entitled Real Involvement: Working with people to improve Health services andavailable athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_089787

It is also the case that Cabinet Office Statement of Practice on Staff Transfers in thePublic Sector available at http://beta.civilservice.gov.uk/Assets/stafftransfers2_tcm6-2428.pdf provides for staff and recognised unions to be informed at the earliestappropriate stage of any intention that staff will transfer. UNISON believes that suchan intention would be evidenced by consideration of tendering for PTS.

Attached as appendix 4(1) and 4(2) are self-explanatory draft letters that should besent to all commissioners preferably at least 6 months in advance of a contractrenewal date. The first letter is applicable where the contract is currently held in-house and the second where it is already outsourced. There will also be occasionswhere “New Business” will arise. Either of these letters should be adapted to dealwith such circumstances.

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

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

Without condoning the process, if commissioners insist on putting PTS contracts outto tender branches should do what they can to ensure the specifications are robust.Commissioners themselves often don’t know enough about PTS to make themcompetent in this area. UNISON has identified this as a major recurring problem inthe application of the tendering system, namely that the PTS specifications that areput out for tender often:

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

2 fail to ensure that bidders meet all the required quality standards (see chapter3 for details of these.)

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

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

The Commissioners’ general lack of knowledge of PTS is also a major weaknessfollowing privatisation. As an NHS body Ambulance Trusts can be relied upon notjust to deliver a service with patient care rather than profit as their motivation but thatthey are also accountable on generic NHS quality standards to the HealthcareCommission. Commissioners need be made aware that, in choosing a private PTSprovider they are now solely responsible for ensuring that these standards are met(see Tool on Healthcare Standards)

Commissioners often have no system or infrastructure in place to monitor privateproviders and as a result are powerless to control the risk to patients through sub-contracting and inappropriate staff being used. The BBC undercover team reportreferred to in the UNISON PTS briefing (page 5) can be accessed athttp://news.bbc.co.uk/1/hi/uk/7761564.stm .

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

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

Unfortunately in some instances the branch only becomes aware of the tenderingprocess at a late stage when the tender documentation has already been issued.The commissioners can be quite reluctant to release full details and it may benecessary to use the Freedom of Information (FOI) Act to obtain these. The contentof a letter used by SWAST Ambulance branch to obtain this information is attachedas appendix 4(4). See also the UNISON FOI guide athttp://www.unison.org.uk/acrobat/B1959.pdf ).

UNISON PTS Toolkit Appendix 4(1)

Draft letter to Commissioners on obligations to NHS Staff that need to be met beforedeciding on the procurement option (current provision in-house)

DearRe: Patient Transport Services

I am writing on behalf of the UNISON Ambulance Branch in relation to the contractfor the provision of Patient Transport Services (PTS) to your trust currently held by ?Ambulance Services Trust that expires on (date). A significant number of ourmembers are employed in delivering these services. I enclose a UNISON briefing onthe issue.

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

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

Such consultation is a requirement of the provisions of the Cabinet Office Statementof Practice on staff transfers in the public sector (revised November 2007) andrecommended practice as detailed in the Guidance for NHS organisations on section242(1 B) of the NHS Act 2006, the duty to involve and good involvement practice,that states on page 33.

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

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

I look forward to hearing from you,

UNISON Ambulance Branch SecretaryCc UNISON Regional Office, Commissioning Trust Branch,Ambulance Trust Employer, Strategic Health Authority

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UNISON PTS Toolkit Appendix 4 (2)

Draft letter to Commissioners on obligations to be met before deciding on theprocurement option (current provision privatised)

DearRe: Patient Transport Services

I am writing in relation to the contract for the provision of Patient Transport Services(PTS) to your trust currently delivered by (Private Company) that expires on (date).(A significant number of our members are employed in delivering these services).

I enclose a UNISON briefing on the issue.

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

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

Please also note that the Healthcare Standards state as follows:

“Those commissioning NHS services from the private sector must also takecompliance with the Standards for Better Health into account beforecommissioning contracts are made.”

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

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

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

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

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

I look forward to hearing from you,

Signed

UNISON Ambulance Branch Secretary

CcUNISON Regional Office, Commissioning Trusts’ Branch,Ambulance Trust Employer,Strategic Health Authority

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UNISON PTS Toolkit Appendix 4(3)

Draft letter to Commissioners after decision to tender has been notified but beforeissuing of documentation.

DearRe: Patient Transport Services

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

I enclose a UNISON briefing on this issue.

I understand that the Trust will be tendering for the future provision of these services.We are disappointed that you have not decided to commission these services fromthe Ambulance Trust.

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

Such consultation is a requirement of the provisions of the Cabinet Office Statementof Practice on staff transfers in the public sector (revised November 2007) andrecommended practice as detailed in the Guidance for NHS organisations on section242(1 B) of the NHS Act 2006, the duty to involve and good involvement practice,that states on page 33.

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

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

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

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

I look forward to hearing from you,

Signed

UNISON Ambulance Branch Secretary

CcUNISON Regional Office, Commissioning Trust Branch,Ambulance Trust Employer,Strategic Health Authority

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

Dear

Re: PTS contracts, Freedom of Information Request.

I am the Branch Secretary of the Ambulance Branch of UNISON. I havebecome aware of the tenders that you have put out in respect of Patient TransportServices.

I request the following information under the Freedom of Information Act:-

1. All tendering documents.

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

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

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

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

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

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

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

9. A list of the dates that you consulted the Ambulance Service onthese tenders.

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

Thank you in anticipation.

Yours sincerely

UNISON Branch Secretary

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

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UNISON Patient Transport Service Toolkit – Chapter 5, Campaigning andInfluencing

A key element in any campaign is gaining the support and involvement of otherinfluential bodies and groups. A first step in that direction is to identify who they areand then seek to establish communications with them. Some key influentialorganisations outside of the commissioning trust(s) are:

Patient and service user groups

Charities

Politicians

Health Overview and Scrutiny Committees

Strategic Health Authorities

The media

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

1. Patient and service user groups.

The key patient / user organisation is the Local Involvement Network (LINk). Thesecame into existence in April 2008 to replace Patient Forums. LINks are made up ofindividuals and community groups who work together to improve local services.Their role is to find out what the public like and dislike about local health and socialcare. They will then work with the people who plan and run these services toimprove them. This will include influencing proposals for change.

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

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

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

2 Charities

Some charities, particularly those dealing with the elderly and conditions requiringlifelong treatment have a major interest in this issue (and will often be members ofLINks). Some of these are listed on the table below along with their websiteaddresses. However the Charities Commission website provides details of allregistered charities in England and Wales including a search facility that will identifythese by location at http://www.charity-commission.gov.uk/Showcharity/RegisterOfCharities/AdvancedSearch.aspx .Branches should access these for local contact information and of course use theirown local knowledge in this regard.

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Charity Website address

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

Help the Aged http://www.helptheaged.org.uk/en-gb/WhatWeDo/InYourArea/Committees/

Macmillan CancerSupport

http://www.macmillan.org.uk/Get_Involved/In_your_area/England/England.aspx

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

3. Politicians

Local councillors can be identified through the local authority websites linkhttp://www.direct.gov.uk/en/Dl1/Directories/Localcouncils/AToZOfLocalCouncils/DG_A-Z_LG .

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

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

4. Health Overview and Scrutiny Committees

A UNISON guide detailing how to use scrutiny in the fight against outsourcing can beaccessed via the UNISON website at http://www.unison.org.uk/acrobat/17621.pdf .Like LINks your local Health Overview and Scrutiny Committee is administered by theLocal Authority and contact details should be accessible via their website.can beaccessed at

5. Strategic Health Authorities (SHA’s).

Strategic health authorities are responsible for:

developing plans for improving health services in their local area,

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

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

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

Strategic health authorities manage the NHS locally and are a key link between theDepartment of Health and the NHS.

Contact details for your SHA can be found athttp://www.nhs.uk/servicedirectories/Pages/StrategicHealthAuthorityListing.aspx

If possible these stakeholders should be contacted and alerted in advance of anydecision to put contracts out to tender. In addition to the briefing a covering lettershould identify the key decision makers in the commissioning process to encouragestakeholders to raise their concerns directly with them.

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

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6 The media

It is essential that the work undertaken to influence all the above groups iscoordinated with a media campaign that is designed to influence the service user andgain public support.

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

It has proved to be useful to spend some time building a relationship with the localtelevision news teams (they will have a local health correspondent) prior to ‘goingpublic’. This will enable the branch to plan a systematic approach. If possible theaim should be that the MPs and local politicians, who will wish to use theopportunities, are approached by the media after they have received your briefing.This will give them the opportunity to use your information or to contact the branch formore details.

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

The branch and region should nominate two or three people that will be available toanswer all press inquiries and give appropriate interviews. This will ensure that thereis consistency in all public statements. The branch or region can then manage thepace and content of the campaign, informing your press contact of all importantmilestones such as meetings with politicians.

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

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UNISON PTS Toolkit appendix 5 (1)Draft letter to patient / service user groups / charities:

Dear

Re: Potential Privatisation of Patient Transport Services

I am writing to draw your attention to the fact that commissioners on behalf of yourlocal NHS (are considering whether) (have decided) to tender aspects of the PatientTransport Services (PTS) that are provided by (insert commissioning trust(s)).

Currently these services are provided by the (name of Ambulance NHS trust).However, if the tendering process is followed through these may in future be providedby an unregulated private company which we believe would have a detrimentalimpact on the safety and the quality of the service to patients.

Services covered by these (potential) tenders include:-

Outside Core Hours, Short Notice, Timed Response, Long Distance,Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

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

UNISON, as a public service union, is committed to maintaining a safe and secureambulance service, as well as being committed to the maintenance of our member’semployment status and future. We believe that (any) (the) decision to tenderundermines both of these considerations. Therefore we wish to highlight the issuesto yourself, your colleagues and the public.

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

We would respectfully request that you raise these issues with your local NHSorganisations as we believe that tendering (would) constitute(s) a substantial changein the delivery of PTS services. Attached are contact details of the respectivecommissioners.

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

Yours sincerely

UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (2)Draft letter to MP’s / Councillors

Dear

Re: Potential Privatisation of Patient Transport Services

I am writing to draw your attention to the fact that commissioners on behalf of yourlocal NHS (are considering whether) (have decided) to tender aspects of the PatientTransport Services (PTS) that are provided by (insert commissioning trust(s)) to thepeople in your constituency.

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

Services covered by these tenders include:-

Outside Core Hours, Short Notice, Timed Response, Long Distance,Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

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

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

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

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

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

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

Yours sincerely

UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (3)Draft letter to Overview and Scrutiny Committee

Dear

Re: Potential Privatisation of Patient Transport Services

I am writing to draw your attention to the fact that commissioners on behalf of yourlocal NHS (are considering whether) (have decided) to tender aspects of the PatientTransport Services (PTS) that are provided by (insert commissioning trust(s)) to thepeople covered by your Overview and Scrutiny Committee and the neighbouringcounties.

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

Services covered by these tenders include:-

Outside Core Hours, Short Notice, Timed Response, Long Distance,Repatriation, Bariatric, Mental Health, Renal and Neo-Natal.

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

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

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

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

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

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

Yours sincerely

UNISON Branch Secretary

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UNISON PTS Toolkit appendix 5 (4)Draft Press Release

Patient Transport Services (PTS) provided within the South West are at direct threatof outsourcing to the private sector. UNISON the union that represents the SouthWestern Ambulance Service staff that currently provide the service have expressedtheir deep concern for the future reliability and safety of the services if they arehanded over to the private sector.These tenders cover some of the most vulnerable patients that will be conveyed byPatient Transport Services. Indeed it is UNISON’s understanding that some of thesepatients would normally be transferred by qualified ambulance staff with the training,experience and equipment to deal with any complications that might arise during thejourney.Ian Hopkins the ambulance Branch Secretary said: -

“Services to these vulnerable patients need to be provided by trained, skilledand dedicated staff. Patients and their relatives need to feel they are in safehands. We understand that the NHS is striving to cut costs and save moneybut these patients need more than just taxis. It would be better for allconcerned if patient transport services remained the responsibility ofambulance trusts."

UNISON is also concerned that the loss of the staff and vehicles would compromisethe services ability to cope with major incidents. The PTS staff are used to back upthe front line service in times of extraordinary demand. They are used by the serviceto transport the less injured patients away from incidents as varied as explosions,major motorway incidents and civil emergencies such as floods when people needevacuation.The services so far out to tender include, Outside Core Hours, Short Notice, TimedResponse, Long Distance, Repatriation, Bariatric, Mental Health, Renal and Neo-Natal. However, UNISON believes that this could be the start of a process that wouldlead to all services being tendered.UNISON has already written to all of the MPs that have constituencies covered bythe threat, and are taking their concerns to the local Overview and ScrutinyCommittees that cover health issues. We believe that these proposals represent asignificant change in service delivery and have not been consulted upon.UNISON, as a public service union, is committed to maintaining a safe and secureambulance service, as well as being committed to the maintenance of our member’semployment status and future. We believe that the proposals put forward undermineboth of these considerations.UNISON Regional Officer Chris Dayus added.

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

For more information etc please contact:

Name UNISON Position Contact Tel.NumberBranch SecretaryAssistant Branch SecretaryUNISON Regional OfficerUNISON Press Officer