Good Neighbour Schemes: filling gaps in transport services

Quite naturally voluntary and community organisations must account to funders their value and their return on investment. One aspect I find is that statutory funders tend to think of Good Neighbour Schemes (GNS) as a uniform product and so consider if statutory responsibilities can be fulfilled by facilitating GNS in a particular remit. Statutory funders would like to encourage GNS to assume responsibility for meeting some of their social care needs by offering the resources of funding and training and management support but want to account for that support with targets and budgets. GNS are keen for the support but are cautious about taking on responsibility for providing services on-demand. But in the way funders and sponsors provide support there is often the tacit suspicion that GNS serve people who could pay for their services, or because GNS do not have rigid controls on access; some must be taking unfair advantage. Also there is concern that GNS could duplicate services already being funded, thus provision must be steered in some way. GNS are often asked "how do you know there is a need for your service" but their answer "because people ask us" is not always satisfactory.

Every Good Neighbour Scheme (GNS) in Suffolk aims to support and complement the other community and social care services within the area it serves. A GNS is able to adapt and fit its resources around existing services because its organisational model is flexible and inherently in ‘standby’ mode without a costly overhead. Because of its ad-hoc nature and capability as a brokerage rather than offering a set menu of services, a call to a GNS is usually made when other provision is unable to meet a person’s need. GNS are a useful partner to many kinds of services and can be called up to take up any overload and then step down when normal demand returns. However, several GNS have reported that hospital social workers in Suffolk have sometimes discharged a 'bed blocker', unfairly imposing on the goodwill of GNS it should be said, and asked them to ensure their patient will be returning to a home with its heating on and a stocked larder and if someone could regularly call in on them to monitor their condition.

But those are extreme and isolated examples. Usually the first function of a GNS 'phone holder' when assistance is requested is to ascertain what other options have been already explored by the person in need. If by providing advocacy and advice the GNS can enable access to existing provision (for a lack of information is usually the case) this is usually a more efficient expenditure of the scarce and valuable resources of a volunteers’ time.

None of the Suffolk GNS in my experience were established with any advance views to only meet a particular need, e.g. to focus on befriending and not offer transport. The existence of established services is naturally considered and in nearly every case it is found that demand already exceeds supply and that the potential of the GNS to share the load and provide user choice and flexibility is welcomed by the existing provider. The impetus for people to establish a GNS is not that it is an amenity that would be “nice to have” but that there is an obvious, sometimes pressing, local need. It that need and the evidence that the GNS model can meet those needs within people’s capabilities which incentivises people to form and join local good neighbour schemes.

It would be hugely resource-intensive to map the variety of needs and resources available to the entire population with a GNS in Suffolk but the role of GNS in provision of transport to medical out-patient appointments at a local surgery or distant hospital can illustrate their value, as this task is the single greatest demand on them as a whole. Although from various factors it varies widely from scheme to scheme, it typically represents 50% of calls. 

Transport Types:

BUS - A public service running to a fixed route and schedule. Operated by both commercial operators and Community Transport Operators in rural areas in Suffolk. Some CTOs have paid drivers, some use volunteers. Bus passes are accepted.

CTO  - Community Transport Operator: either a charity, Community Interest Company or Industrial and Provident Society operating transport services on a non-profit basis with volunteer and paid staff. Some run regular buses on unprofitable but essential routes, some operate DRT and Community Car Schemes.

DRT - A demand responsive bus requiring advance booking and going anywhere in a limited area and designed to feed into towns from rural areas or to meet staged buses or trains. Does not normally operate within urban areas. In Suffolk they are run by several CTOs. Each has different call centres and opening times and different hours and days of service according to their contract with Suffolk County Council. Bus passes are accepted.

NEPTS - Non-Emergency Patient Transport Schemes operate like a DRT but only when the medical need is determined to a stringent criteria with a questionnaire when booking a journey. Services are round trip from the patients' door to the hospital or clinic with other calls on the way but free of charge. Run under contract to the Ambulance Service according to the NHS administrative structure so patients in Waveney District have a different service than the other districts in Suffolk. 

CCS - Community Car Scheme. A volunteer or paid driver with a car or minivan operating like a DRT and generally operated by larger charities, e.g. WRVS, or as a special service of a CTO with wider service footprint than GNS. 'Wheels Within Wheels' are DRT using disabled accessible minivans, avoiding the need for volunteers drivers to have a PSV license. These scheme have specialist Public Liability Insurance with driver training and a staffed call centre contributing to overheads. They usually charge 35 pence per mile and receive subsidy from Suffolk County Council to reduce the passengers' cost. The drivers volunteer at regular times and are matched to passengers by the call centre on a first-come, first-served basis. 

GNS - The patient's neighbour using their own car and expecting reimbursement from the passenger at 45 pence per mile for journeys arranged between the driver and the passenger. Patients are matched to willing neighbours by the GNS phone-holder. Passengers are covered by the driver's car insurance under social use but insurers are increasingly reluctant to permit this. The schemes have Public Liability Insurance but it is very limited in order to be affordable, so the boundaries of their duty of care must constantly be asserted.

Hospital Rides - A Suffolk-wide online journey matching service which in practise is no different to a GNS although the patient and driver are not usually neighbours.

The primary option for a patient needing to travel to an out-patient appointment would be to attend by driving their their own car or be taken there by a friend or family member.

If they do not have a car or access to a car, their second option would likely be to get there on public transport with buses or trains and buses. Considering the cost of hospital parking - set to discourage car use rather than raise revenue it is supposed - people with access to frequent public transport would readily consider this option. Their concern would be whether its schedule was compatible with the appointment without undue waiting times and there is enough frequency if there was a delay or alteration to the scheduled appointment.

Large swathes of rural Suffolk do not have direct access to their hospitals and GP surgeries by staged bus routes, trains or combination thereof. Demand Responsive Transport is available in rural areas but this requires advance booking by telephoning an operator, sometimes in a very limited window, at least 24 hours in advance. Very often in practise a DRT journey to a distant hospital requires coordination between two separate DRT operators, with some juggling of both schedules by telephone. Therefore there is an exponential increase in failure points and feedback from users is that such multi-stage journeys can also involve waiting for a connection outside in unsheltered places.

If the patient is having a treatment that will make them unwell or incapacitated in some way (such as dilatory eye-drops) or is already unwell, then self-driving and solo public transport would be unlikely and unwise choices. They would therefore seek an accompanied mode of transport but two passengers would then double their cost. 

Besides a friend, a GNS volunteer with a car is the only other mode of transport that can provide the patient with an escort throughout the journey and allows for waiting time as an integral part of the service without increasing the cost of use. With CCS they usually cannot afford to provide a volunteer willing to wait for (or with) a patient for a long period so an out-patient journey may necessitate them charging the patient for two trips; there and back, with the CCS volunteer fulfilling another journey in-between.

The GNS volunteer driver is also the patients' neighbour and so is generally more willing and able to give the patient not only door to door service, but can offer support while waiting for treatment and when the patient returns home.

All the calls for medical transport that GNS have recorded have arisen whenever these transport options are not available. Transport requests when someone is capable of driving themselves are rare as the cost of GNS use would be higher than using their own car or bus fares. With the uncertainty of a volunteer being available against the reliability of the buses, calls to GNS by people who have the option of suitable public transport are also very infrequent.  

Without access to a car or public transport, the next option is a private taxi. A return trip from IP17 to the Ipswich Hospital with two hours waiting time is widely quoted at around £100, beyond the means of many, even those with an average salary or pension. Whilst there are some state benefits available to meet the cost of medical transport, several of the modes that rural populations are limited to using (such as taxis) are ineligible to be claimed, unless in exceptional circumstances. The role of GNS as advocates in claiming these benefits and providing transport planning can steer demand away from consumption of the scarcer resource of volunteer transport.

GNS are not a cheap taxi service, nor do they take away business from taxi firms although some have made this complaint to licensing bodies. When people cannot afford to travel, they do not travel. Suffolk GNS report that their transport service can actually stimulate local taxi use by keeping people active and sometimes a choice of modes enables a person to afford use of a taxi for one leg and GNS for another, according to the circumstances.

GNS ‘phone holders’ are adept at ascertaining the client’s need and generally, as they are neighbours too, they can signpost callers to the appropriate public transport options and can weigh if another mode of transport is more appropriate and are informed enough of local conditions to know if it is available.

Whilst being free of charge, NEPTS has stringent criteria of medical need for usage which have lately been tightened, or more uniformly enforced, which has lately shifted demand onto CTOs that operate minibuses and CCS with point to point service. CTOs report they have seen demand increase by 30% since September 2012. Due to their subsidy from local government, most CCS provide transport at a cost of 35 pence per mile but this is charged from the volunteer’s point of origin and return so is a variable on predicting the cost of journeys for the passenger. While run as non-profit organisations, CCS have a larger service footprint to GNS but also higher overheads, some with paid staff and offices.

GNS do not have any funding directly to subsidise transport costs (but having this would open up several issues with insurance and put greater demand on administrative resources) and so generally they ask the passenger to reimburse the volunteer at the HMRC permitted rate of 45 pence per mile (though this is below the true cost of motoring).

NEPTS users report that the service is sometimes late or too early (reliability is difficult to manage because of variables in collecting several passengers) while the journeys are shared with other patients and so are often of long duration “going around all the villages” and some patients have been stranded when a delay at their appointment has caused them to miss their ‘slot’ booked for the return journey. Also it is not usually possible to be accompanied on NEPTS by a friend or family member, though given that only patients with the most severe needs can qualify for it, the support of someone familiar to them is often necessary to that patient.

It is my experience that apart from staged buses and trains, the provision of rural transport information is very poor in Suffolk. Journey planning by DRT or community car schemes with web-based information is nearly impossible. The NaPTAN database and so Suffolk Traveline website cannot reflect DRT service times and every request directs the passenger to make telephone enquiries which are available in different areas at different times due to the variety of operators. The Suffolk On Board leaflet promoting CCS is confusing by lumping a wide variety of services in the CCS model together though each one offers very different services ranging from DRT, disabled accessible minivans and volunteers with their own cars. One CCS apparently offering volunteer drivers is actually delivering library books, not medical transport. Mapping the provision of medical transport at present would require considerable research. The changing menu of services can apply to the GNS too, which is why a county-wide GNS leaflet is not published.

This lack of information in turn frustrates the consideration of transport availability at the point when the appointment is set. GNS report that many hospital requests come for times that are outside the service times of public transport, though if the appointment was later, the journey would be possible by public transport. If a journey plan could be generated as every appointment was set and so times adjusted to suit, there might be much greater efficiency and improvement in numbers of missed appointments and delivery of medical treatment.

Between 2009 - 2012 there were 184,947 missed NHS appointments in Suffolk, costing£17.6 million. There is no hard data on the reasons why people miss appointments but local anecdotal evidence shows that poor transport, particularly in rural areas, is one reason. The West Suffolk Hospital says the cost of each 'DNA' to them varies according to whether it is a first or follow up appointment and for which speciality but the estimated loss is about £110 per appointment. That means a typical GNS can break-even in terms of public support by simply transporting three to five passengers per year who would have otherwise not shown up and based on 2008 figures, prevention of ambulance call-outs would have an even better return on investment as they cost in Suffolk £260 per call.

As voluntary organisations, CCS and CT operators are naturally subject to the vagaries of private and statutory funding of the Voluntary and Community Sector and the supply of volunteers and other resources. CTOs normally operate in places of ‘market failure’ where operation of a route on a commercial basis is not viable. In some instances, only non-profit operators have tendered for rural bus routes subsidised by the county council but pressure is still exerted in the tendering process to lower costs further by redesigning them after a few years as longer or different routes that CT operators are less willing to tender for, as recruiting volunteer drivers for longer shifts is difficult.

A recent case saw a long established and popular subsidised route that was taking volunteer drivers 4 hours to complete was withdrawn and re-tendered as an extended route requiring a driver for a 7 hour shift. A new bid from the original CT operator was rejected but their concerns that a consequence of the route re-design would be that the numbers of passengers boarding the service at the first stop would now fill the 13 seat minibus provided by Suffolk County Council, preventing other passengers from boarding the bus elsewhere on the route went unheeded but has proved to be the case. CT operators running staged services are finding in increasingly difficult to recruit volunteer drivers because of the licensing issues around derogation of the D1 license category and calls for action by Suffolk's CTOs on this have gone unheeded. In the short term this will force CTOs with volunteer drivers to be limited to offering smaller minivans under 3250 kg MAM which are financially unviable for staged or DRT service.

Some GNS find it difficult to recruit volunteers willing to give several hours of their time on long-distance distant hospital trips - such as Addenbrokes or Papworth from Suffolk Coastal - so will steer those callers to the local CCS who in turn sometimes have to refuse due to demand or limits on their service footprint. However these GNS are kept busy enough and can usually find volunteers willing to offer shorter trips to local GP surgeries and the ‘cottage’ hospitals, freeing the CCS for longer trips.

Whilst most forms of CCS and CT require a volunteer to commit their time according to a regular schedule, the GNS model asks the volunteer to be in a dormant or ‘standby’ mode. The volunteer is only called if needed and has permission to refuse the journey request. This GNS commitment is more palatable to many volunteers who would not join a CCS. Cooperation between a CCS and GNS can be very productive and be an efficient use of human resources and it can be a way for GNS volunteers to graduate onto more involved volunteering or greater responsibility, according to their choice.

The only disadvantage of the GNS and other voluntary help models for the statutory funder is their localism. Statutory bodies can't create more GNS by the stroke of a pen with investment of money and support services alone. It is generally but not entirely the case that GNS are active in areas where there are more affluent retired people because this socio-economic group are able to provide the mission-critical resource the GNS needs;  the able and active volunteer with a car. Those able people wish to support those less able and the needy of which there are enough in their area. The larger CCS schemes can redistribute their resources more widely this but make volunteering a less attractive offer and has far greater overhead cost.

There is considerable need for development of more volunteering for CCS or GNS patient transport but based on feedback from volunteers; issues with insurance, CRB checks and unmet costs are disincentives. It would be worthwhile for Whitehall to listen to the small plaintive voice of Good Neighbour Schemes and note their value.