In this article Lesley Barron, Poverty Proofing Co-ordinator at Children North East, explores the impact of travel and the Healthcare Travel Costs Scheme on how people access and experience healthcare services.
Through our Poverty Proofing© work in a range of healthcare settings, Children North East have been digging deep to unearth the barriers faced by millions of people who live in poverty, when attempting to access healthcare services. Our work has already identified several recurring themes in health inequalities, but one theme that presents itself over and over again, is the cost of travel to and from healthcare settings.
‘If you’re referred to hospital or other NHS premises for specialist NHS treatment or diagnostic tests by a doctor, dentist or another primary care health professional, you may be able to claim a refund of reasonable travel costs under the Healthcare Travel Costs Scheme (HTCS).’
This is the opening paragraph taken from the NHS Healthcare Travel Costs Scheme, which should be a ‘quick win’ for those struggling to afford healthcare travel costs. But is it?
A familiar story
Let me introduce you to Sam…
Sam is one of around 14.4 million people living below the poverty line in 2022 and her story is typical of many we hear when Poverty Proofing©.
Sam has an appointment to have an expired contraceptive removed and is in a lot of pain. She arrives 20 minutes late and is told she can’t be seen. The receptionist may think ‘serves her right, she should have been on time.’ However, what isn’t realised is that Sam relies on the Metro to get anywhere, and through no fault of her own, the Metro was delayed. Another assumption is that she could have phoned ahead to let them know she was running late. However, the reality is that Sam has no credit on her phone, and can’t top it up until her benefit payment is paid in three days.
Perhaps she just needs to speak to the receptionist, explain what’s happened to make her late, and persuade them to fit her in? The reality is that Sam feels incredibly uncomfortable talking to the receptionist, whom she feels looks down on her and can be very rude and unwelcoming towards her. Sam feels stigmatised and disrespected, and this negatively impacts on her confidence and self-esteem, and on her ability to articulate that she is actually in a lot of pain and really needs help. Many people in a similar situation could perhaps just ring in the morning to make another appointment. However, the urgency for Sam is more acute because remember, she’s got no credit on her phone. She also can’t afford to pay the Metro fare to come back another day. She would end up travelling without paying, risking prosecution and a hefty fine.
At every turn, Sam was faced with a barrier, preventing her from accessing the care she needed. This is not uncommon for the millions of people living below the poverty line. As Dr Laura Neilson (founder of Shared Health Foundation, Focused Care CIC and Hope Citadel CIC) says, “In areas of deprivation, the stories behind the stories are really important”.
We owe it to people like Sam to understand what the barriers are and to make changes in our structures and processes, on an organisational level, in order to make our healthcare system accessible to everyone.
Healthwatch UK (2019) revealed that 9/10 people consulted said a convenient way of getting to and from health services was important to them. Difficulties with transport were also identified as a common reason why patients miss appointments.
Common problems with the NHS Healthcare Travel Costs Scheme
Patient perspective & staff perspective
“You used to be able to claim travel expenses. I think they make it so difficult and awful, people just don’t bother. Now there’s no petty cash. No petty cash but lots of petty rules.”
“If you’ve got somebody out in Northumberland and you send them an appointment for a face to face, and they’ve got no money, how are they going to get in?”
“It’s not uncommon to say to someone, ‘I’ve got an appointment for you’ and they say ‘I can’t come because I physically cannot get there’.”
This is a fairly typical response from staff when asked about the travel reimbursement scheme: “We don’t do travel expenses. It’s not discussed, we don’t reimburse travel.” However, some staff members from the same setting contradicted this, “Everything’s free, I think they can get travel costs back, I don’t know much about that though.”
Some patients have spoken to us about not using the claim forms that are available, due to the fear that they are taking away support from other families who may be worse off: “There is an expense attached to attend clinic because we use buses. You can claim this back I think but I don’t because I always think there’s someone worse off than me.”
Here are some other examples of barriers we have found out through the lived experience of patients:
A patient goes to the desk to claim their expenses from petty cash, only to be told that the petty cash tin isn’t kept here. It is kept on the hospital’s other site, three miles away on the other side of town. Poverty Premium at its best! The person who can’t afford to travel to hospital, has to make an extra journey in order to claim their travel costs back.
Following their appointment on Tuesday, a patient goes to the desk to claim their travel expenses from petty cash, only to be told that it’s not possible to claim this back today, because the key holder of the box only works on Thursdays and Fridays! The patient is asked to come back later in the week.
A patient goes to the desk to ask the receptionist how they can go about claiming their travel costs back. The receptionist is very friendly, says she will go and get the necessary form and asks the patient to have a seat. This helpful and enthusiastic response goes horribly wrong when the receptionist returns, waving the form in the air, whilst declaring to the whole (rather full) waiting room, “Here’s the form to claim your travel back!”. The poor patient turns a vivid shade of scarlet and is left feeling humiliated and embarrassed.
For potential claimants, there are too many hoops to jump through, which make the process too much of a rigmarole. NHS staff themselves are often unaware that the travel costs scheme even exists; or if they do know it exists, they are often confused about how it works. Also, being reimbursed assumes that the person can afford the cost of travelling to the setting in the first place. However, if people can’t afford the upfront cost of travel, they may fail to attend at all, leading to wasted appointments and huge unnecessary costs to the NHS. There must be things we can do better to help overcome this unnecessary barrier caused by the cost of travel.
What you can do to help
– Ask patients about travel: Can you afford it? Can you get here?
– Provide a travel pass/ticket up front for those with no resource at all
– Provide staff training about the travel scheme
– Improve staff awareness of poverty and its impact on patient health outcomes
– Explain the process clearly and openly and reassure patients that claiming what they are entitled to does not directly affect another person’s ability to claim, then more patients would feel able to access the financial help they need and are eligible for
– Ensure easy access to petty cash tin
– Make reimbursement available at time of appointment to reduce/avoid unnecessary trips
– Leaflets/signs/posters to raise patient awareness of scheme
– Advise everyone of the scheme, so as not to single out or stigmatise anyone
The NHS Healthcare Travel Costs Scheme is often seen to be a poorly-thought-out and executed system, yet it has the promise of so much more. Its profile must be raised and its existence made common knowledge. It needs to be simplified and streamlined in its systems and processes, with fewer hoops to jump through, and it must be broached with sensitivity by staff. Only then can it make a genuine attempt to alleviate just one of those many barriers faced by people in poverty.
Poverty Proofing© is a concept developed at Children North East. For further information or to look at a bespoke process designed around the needs of your organisation please contact Emma.Leggott@children-ne.org.uk.