Great Western Ambulance Service, NHS, Annual Report and Accounts by Go Get Creative Design Communications

Annual Report and Accounts 2008/09

Picture courtesy of Rosie Windsor SWNS

Welcome David Whiting, Chief Executive

As the new Chief Executive of Great Western Ambulance Service, I am looking forward to working with our staff to ensure we deliver the highest quality services for our patients. Although I only joined the Trust on 1 April 2009, I recognise that 2008/09 was a challenging year and period of great change for the organisation. My initial aims will be to bring stability and continuity to the organisation, continue to improve the responsiveness and quality of our services and to provide a clear vision for the future. This coming year we will focus on getting the basics right and delivering the right care, at the right time, in the right place. Our staff are dedicated professionals and our greatest asset, delivering high quality care, sometimes in very difficult circumstances. We will also work collaboratively with all our stakeholders to ensure that our services best meet the diverse needs of the communities we serve. This year will be a year of consolidation, with a sharp focus on service delivery, quality standards and continued development of excellent patient care.

Please tell us what you think about our annual review. To give us feedback: email pals@gwas.nhs.uk, phone our PALS co-ordinator on 01249 858 500, write to GWAS, Jenner House, Langley Park Estate, Chippenham, Wiltshire, SN15 1GG.

Welcome Tony FitzSimons, Chairman

2008/09 has been a year of challenge and change. We finished the previous financial year achieving the Category A national target – at least 75% of life-threatening calls arriving within eight minutes. April 2008 saw the introduction of Call Connect, a new and challenging national target for England and Wales. Call Connect measures the time taken to arrive on scene from the moment the 999 call is connected into the ambulance control room. This means shorter waits for 999 calls to be answered and ambulances dispatched more quickly. To help the Trust with Call Connect, we invested in a new CAD (computer aided dispatch) system to speed up our response including answering calls faster than ever before – almost all within one or two seconds. The new CAD also means that we are able to dispatch ambulances and rapid response vehicles as soon as the call comes through to our control room. We are particularly pleased that our commissioners have recognised we need more resources and have given the Trust additional funding. This has helped us to recruit more staff for our control rooms and more emergency care assistants to help deliver faster responses. We still have work to do to achieve our national targets but we now have a better foundation from which to deliver a good performance in 2009/10. The Trust has also invested in 31 new ambulances. These new five-tonne ambulances can carry significantly more clinical equipment and are designed to minimise the risk of infection transmission, using materials that are scratch and bacterial resistant. The excellent clinical care provided by our staff was praised by patients this year in the Healthcare Commission’s survey of hospital emergency departments. The survey posed two specific

questions for patients who were taken to the emergency department by ambulance – one asking if the ambulance service explained their care and treatment in an understandable way and the other about the overall level of care from the ambulance service. In each case, GWAS staff performed significantly better than the national average. This year has had its challenges as well as successes. Like other Ambulance Trusts across the country, we had an extremely busy winter, with a considerable increase in demand – up by 25% in one week in December. There was also the challenge of the snow and ice in the first week of February. Thanks to the hard work of our staff and the co-operation of key partners we still were able to attend every 999, just a little more slowly. Overall, this has meant that performance on our key national targets is not as good as we wanted. But we are improving and we plan to be meeting those targets in the next financial year. The composition of the Executive Team has been unsettled during the year. However, we have now appointed an extremely talented chief executive, David Whiting, who gives us the strongest leadership possible to take the Trust forward. Despite these difficulties, this Trust has made significant improvements over the last year. We exit 2008/09 with more front line staff and ambulances, a new CAD, the inception of a strong Executive Team. We are reaching patients faster than ever before, delivering high quality clinical care. There is the challenge to deliver on all our key national targets under the Call Connect standard but I am confident that we now have all the measures in place to make Great Western Ambulance Service a high performing trust.

Saving lives over the phon Always there, however you Key facts • Our team: 75 call handlers and 48 dispatchers • 233,254: the number of 999 calls we responded to - 77,623 Category A - 96,777 Category B - 58,854 Category C

The ambulance service is committed to providing effective health care to all of our patients. Our paramedics are continually receiving further training giving them extended skills. When appropriate, they can treat you in your own home saving a trip to hospital. This process begins by assessing the type of response and care you might need and giving lifesaving instructions over the phone, which is the role of our Emergency Operations Centres (EOC). The EOC, in partnership with the Police and Fire and Rescue Service, also offers an emergency text service. The system also enables the call takers to give life-saving advice over the phone before the ambulance arrives.

Call Connect – new target • 90 seconds is the estimated difference that Call Connect, a new and challenging target for ambulance services, has made to our response time. Call Connect, where the clock start time is taken from the moment an emergency call is connected to the local ambulance control room, means that our responses have to be 90 seconds faster to meet our key national targets.

Natalie Davies

Natalie’s story: Inside the EOC When you ring 999 and get put through to the ambulance service you could find yourself talking to Natalie Davies one of our call handlers. Natalie became an Emergency Call Taker in July 2008 when she was trained to use the international system, Advanced Medical Priority Dispatch (AMPDS). AMPDS is used by our emergency call takers to categorise and prioritise every 999 call to ensure the patient receives the quickest and most appropriate response.

Earlier this year Natalie received a 999 call and was told there was a woman who was about to give birth. Natalie supported the caller and patient giving advice and instructions until the actual birth of the baby prior to the crew's arrival. A baby girl was delivered with no apparent complications. Natalie said: “It was such a quick delivery and I was so pleased to hear the baby cry. “I really wanted to join the ambulance service as when I was working in a GP surgery I had to do CPR on a patient and it made me want to take on a role where I could really make a difference to people’s lives everyday.”

e need us How we did under Call Connect Category A Calls • We arrived at 68.4% of immediately life threatening incidents within 8 minutes. The national target is 75%.

From left: Pete Sadler, Jenny Riley, Cordelia & Emrys Nolan, Sharon Baker, Louise Balson Picture courtesy of Rosie Windsor SWNS

Patient’s story – Cordelia and Emrys Nolan When ten-week-old premature baby Emrys Nolan suddenly stopped breathing one morning, mum Cordelia was glad she had learnt CPR while still in hospital after giving birth. However, learning the life-saving technique in a classroom environment was very different to being faced with the real thing – which is why she is so grateful to GWAS call handler Jenny Riley. While Cordelia began administering CPR to her tiny baby, cousin Kieran dialled 999. Jenny’s first priority was to dispatch emergency help, but once Critical Care Paramedic Pete Sadler was en route – backed up by Paramedic Louise Balson and Ambulance Practitioner Sharon Baker in an ambulance – she was able to talk through via Kieran what Cordelia needed to do. “I remember panicking that I wouldn’t remember what to do, so it really helped having Jenny calmly telling Kieran the correct procedures,” recalls Cordelia.

Jenny admits she feared the worst for Emrys when she signed off the call upon the arrival of Pete Sadler. “I was absolutely amazed and really happy when I heard he had come through. I didn’t think he had a chance,” she said. Although Emrys was breathing again when Pete arrived, he needed resuscitating three more times in the ambulance going to hospital, where a urinary infection was subsequently diagnosed.

• A transport vehicle arrived at 94.63% of immediately life threatening incidents within 19 minutes. The national target is 95%.

Category B Calls • We arrived at 87.3% of urgent but non-life threatening incidents within 19 minutes. The national target is 95%.

Category C Calls • We arrived at 86.7% of non-urgent, non-life threatening incidents within 60 minutes. Our local target is 95%.

After making a full recovery, Emrys accompanied Cordelia to Bristol Ambulance Station to meet the GWAS staff involved. After the unwanted drama, Cordelia was able to joke: “I guess he owes me – so he’d better behave when he gets older!” 5

Your emergency team Always there, however you Key Facts We employ • 351 Paramedics (including Critical Care Practitioners) • 204 Ambulance Practitioners • 236 Emergency Care Assistants

In Gloucestershire we second staff to the Midlands Air Ambulance based at Strensham motorway services. In Wiltshire we share a joint helicopter with the police – it has three crew: a pilot, a police observer and a paramedic. In Avon we have dedicated paramedics with extended skills, known as Critical Care Practitioners, who work on the Great Western Air Ambulance. Also on board is a trauma-trained doctor.

• 73 Clinical Team Leaders • 10 Station Managers

Our emergency team uses • 103 Ambulances • 77 Rapid Response Cars • 3 Air Ambulances Front Left from left: Jo Mundy, Sean Russell, Andy Newman, HRH Camilla Duchess of Cornwall, Rich Miller, Melanie Gee

Richard’s story: Wiltshire Air Ambulance The Wiltshire Air Ambulance is one of only two air ambulances in the country which work as a joint project with the local police. Richard Miller joined Wiltshire Ambulance Service back in 1990 and worked in the Ambulance Control Room for five years. From there he trained as an Ambulance Technician and was based at Malmesbury Ambulance Station, and after about 18 months trained to become a paramedic. He then joined the Wiltshire Air Ambulance in 2003 and became the Clinical Team Leader of the unit in August 2004. 6

After recently been awarded a Chief Officer’s Commendation, Richard said: “I feel very passionate about the Wiltshire Air Ambulance and the appeal. We wouldn’t be able to do what we do without the people of Wiltshire. “It is so rewarding to be able to save someone’s life and then meet them a few months later, knowing that without the Air Ambulance they wouldn’t be alive. “I feel slightly embarrassed although honoured to receive the award. I really just feel that I am doing my job, a job which I love.”

need us STREAM (STrategic Reperfusion Early After Myocardial Infarction) is an international clinical trial to evaluate the outcome of patients suffering from a heart attack given thrombolytic (clot-busting) drugs compared to those patients treated in hospital with primary angioplasty. There is a widespread assumption that angioplasty is always superior to thrombolysis. This study compares the outcome in the early hours for these two treatments delivered in a ‘real world’ setting.

Greg’s story – paramedic care, thrombolysis and STREAM Greg is a Paramedic who works on double manned ambulances as well as rapid response vehicles. He joined the Service as a Technician in 2005 and after completing further training, became a Paramedic in March 2008. Paramedics are trained to administer clot busting drugs and Greg has been able to help many patients with this. Recently he was one of two paramedics within GWAS to recruit a patient to the STREAM trial. Andy Halliday and Greg were the first Paramedics in England to recruit patients to the trial. This was a great result for the patients involved and a significant achievement for the Trust in terms of being involved in the research of pre-hospital care.

Greg Garrett

Key Facts • 40 - the number of STREAM trained staff in GWAS • 2 - the number of patients recruited by GWAS to the STREAM trial • 134 - the number of patients who received pre-hospital thrombolysis this year

Greg said: “On 17 February I was sent to a 54-year-old male described as collapsed and grey. When I arrived on scene we began by cannulating the patient and taking observations, including an electrocardiogram (ECG). I started assessing whether the patient would be eligible for the STREAM trial. “Once I had obtained the patient’s permission to participate in the trial and the patient was selected for primary angioplasty. I have been informed that he has now made a full recovery. “I have been interested in the STREAM trial and the results it will provide and have been involved since its launch at the Trust in August 2008.”

Image copyright of Bristol News & Media

Andy Halliday with interim CEO, Anthony Marsh

The right care Always there, however you Key Facts • 88 Ambulance Practitioners qualified as Paramedics • We employed and trained 142 Emergency Care Assistants • 47 Emergency Care Practitioners were trained • We trained 99 members of the public to be Community First Responders

Paul Clarke

Paul’s story – Emergency Care Assistant Emergency Care Assistants (ECAs) work on A&E ambulances alongside state registered paramedics and qualified ambulance practitioners to ensure that the needs of patients are met without delay. ECAs are trained in many aspects of pre-hospital care, some of these including dealing with all kinds of trauma, spinal care, medical conditions, maternity cases, basic and intermediate life support. Paul Clarke joined the Service in August 2004 as an emergency call taker and then an ambulance dispatcher. During this time Paul also volunteered as a Community First Responder in Portishead, which also helped him gain plenty of experience in dealing with patients during their hour of need. 8

In January 2008 Paul became an ECA working from Nailsea Ambulance Station. Paul said: “I was really glad to have been able to work as a Community First Responder. I enjoy being able to help people, especially those within my own community. “My time spent in the control room gave me a great overview of the ambulance service which I feel has been of great benefit to me since going out on the road as an ECA. “I am really looking forward to progressing my career within GWAS and gaining more clinical skills which I will be able to put to use helping our patients.”

• There are 314 active Community First Responders across the Trust • The average time it takes for a CFR to arrive on scene is 2.5 minutes

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• Around 294 life threatening incidents are attended each month across the Trust by Community First Responders, people using defibrillation equipment placed in public sites or by co-responders such as firefighters or police • CFRs operate within a three mile radius of their home or place of work • The Trust also works with other organisations including Avon, Gloucestershire and Wiltshire St John Ambulance

Third from left: Duncan Massey receives his commendation

Duncan’s story – Community First Responder Duncan Massey has been a Community First Responder (CFR) since November 2006. He responds in the village of West Harptree and is now very well known to the members of that community who are very grateful for his presence. One of those residents said in a thank-you letter to Duncan: “You are a truly lovely, clever and sincere guy and without you our daughter would not be still with us.” Duncan also volunteers for Avon and Somerset Search and Rescue so is very accustomed to being called out to respond to emergencies. He said: “My pager is linked to the 999 computer which gives me details and I can be on my way while the caller is still on the phone, sometimes arriving while they are still talking to the call handler. “Each and every call I get is potentially life-threatening and most of the patients do respond, I’m glad to say. But there are the tragedies of course. I’m just pleased to put my skills to work.”

Community First Responders Our Community First Responders are a vital part of our emergency care services. They are volunteers who respond from their home addresses or work places to patients suffering life-threatening emergencies. They either keep or have rapid access to a defibrillator and their speed of attendance can mean life or death while an ambulance is on the way. If you live in the Trust area and would like to know more about becoming a Community First Responder at work or from home, contact us on 0117 928 0485. All our CFRs are checked by the Criminal Records Bureau (CRB) and no previous experience is needed as all relevant training is provided. 9

Emergency care at home Always there, however you need us His continuing care also included follow-up contact to Halina when he was on duty on Boxing Day to ensure the treatment had been effective. “The role of an ECP is quite new and on this occasion it proved to work very well because I was able to treat Halina at her home,” said Roy. “That was clearly the preferred option for Halina herself – particularly as it was Christmas Eve – but also helped reduce pressure on valuable hospital beds.” Halina described Roy as her ‘Christmas star’. She added: “Roy was so professional and calm. He took over the situation, which made me feel calm. It felt as if he was a friend caring for me.” Halina Radoszewska and Roy Wagstaff Picture courtesy of the Gloucestershire Gazette

Emergency Care Practitioners (ECP) are trained to be able to give patients more treatment in their own home, saving them a trip to hospital. They are able to prescribe many medications, including some antibiotics. They can stitch minor wounds and have extended triage skills so they are able to rule out more serious conditions that would normally need further assessment in hospital. When patients are treated at home the ECP will also make follow-up contact with the patient to ensure that they are well on the road to recovery. Spending Christmas Eve in hospital is not something anyone would welcome, so 83-year-old Halina Radoszewska was delighted that her emergency help on that day was ECP Roy Wagstaff. Halina suffered a reaction to a course of antibiotics she had been prescribed and began choking on December 24. Instead of her 999 call resulting in a dash to hospital, Roy was able to use the enhanced clinical skills he has as an ECP to treat her at home. After diagnosing what had caused the problem, Roy adjusted Halina’s medication and also made arrangements to notify her GP practice when it reopened after the Christmas break. 10

Key Facts • 73 - the number of Emergency Care Practitioners employed by the Trust • 34.8% of patients did not need to be conveyed to hospital in 2008/09

Supporting the team Always there, whenever you need us Key Facts We employ • 1 manager • 15 mechanics • 29 make ready personnel

2008/09 • We bought 31 new ambulances

2009/10 • We plan to buy 12 new ambulances Alan Jones and Dave Messenger, at Staverton Ambulance Station for the new vehicle launch

During the year the Trust invested £5million in a fleet of 31 new ambulances. The five-tonne vehicles are now all in service, replacing several of the Trust’s older 3.9-tonne fleet. The new, state-of-the-art ambulances – specially designed and built to our requirements – are more user-friendly, offer greater comfort for patients and added room for crews to administer emergency treatment and care.

Life Pack 12 defibrillators, ensuring they are always charged and ready for use. They are also fitted with closed circuit television (CCTV) cameras which can be activated in the event of incidents against staff or patients. For example, camera footage could be used as evidence in court if a member of a crew is assaulted.

The layout of the new ambulances is also designed to minimise the risk of infection transmission, using materials that are both scratch and bacterial resistant and make cleaning easier and more effective. Three of the new vehicles – one in GWAS sector of Gloucestershire, Wiltshire and the former Avon – are bariatric ambulances, specially adapted to accommodate heavy patients.

They have been adapted to improve staff and patient welfare. They have robust tail lifts and more equipment to enable crews to move patients both comfortably and safely. The vehicles boast enhanced clinical equipment, including a choice of two carry chairs – one of which is designed to assist crews transferring patients up and down stairs – and an onboard charging unit for the 11

Our staff There for you, however you Over 70 staff, volunteers and members of the public were honoured for their dedication and bravery at Great Western Ambulance Service’s first Chief Officer Commendations ceremony in February. The awards were presented in front of an audience of dignitaries, guests and family members of the recipients at a prestigious ceremony in Gloucestershire. In total over 200 people attended the event. The invited guests included patient Bill Hardingham, whose life was saved in January by student nurse Claire Thomas and Trust staff after he collapsed outside Claire’s house. Despite being fitted with a pacemaker only a week before the awards evening, Mr Hardingham was determined to attend – with his wife Pearl – to thank the people who saved his life and see them receive their commendations. Before presenting the awards, our interim Chief Executive Anthony Marsh said: “Tonight is an opportunity for me to recognise and thank all the staff and the many volunteers who do a fantastic job on a daily basis. “These are people who have made a real difference to patients’ lives.” The commendations were presented to staff who had saved patients’ lives in dramatic circumstances, attended particularly difficult incidents or shown a high degree of dedication beyond the call of duty. Volunteers and members of the public were commended for ongoing or particular acts of outstanding service.

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More than 50 staff were joined by the Lord Lieutenant of Wiltshire in June to celebrate their length of service. During the ceremony at the STEAM museum in Swindon, the Queen’s Medal for Long Service and Good Conduct was presented to 18 members of staff with 20 years service, at least seven of which were spent on the frontline. Trust Awards were granted in recognition of loyalty and dedication during 20 and 30 years service and three staff were presented with their 40 years service award. Staff work extremely hard throughout the year to provide the best possible care to every patient we are called to attend. This will always be a challenge and this year that included overcoming the weather. During the snow our staff were exceptional, ensuring that every patient was reached and cared for with as little disruption to the service as possible.

The staff within the Service are updated each week through the Chief Executive’s weekly briefing. In this way we seek to engage and inform staff on matters which affect them. The Trust works closely with the unions and all policies and procedures are approved by staff representatives, prior to implementation, through the Joint Consultative and Negotiating Committee (JCNC).

Key Facts We employed 1,682 staff at the end of March 2009 – of those: • 351 were new starters • 39 declared an ethnic origin other than White British* • 12 declared a disability* • 5.3% sickness and absence rate • Over 130 staff and volunteers received awards *GWAS has an Equality and Diversity policy and a Disability policy. Declaration of this information is voluntary and not all staff choose to disclose it.

Transporting patients Always there, however you Key Facts • 217 - the number of people we employ in our Patient Transport Service • 112 - the number of volunteer drivers • 84 - the number of patient transport ambulances • 14 - the number of vehicles with stretchers

Patient Transport Service (PTS) Team Leaders are responsible for looking after and managing the teams of staff responsible for conveying patients within PTS. They are also involved in the day-to-day activity – the transport of patients, which means they drive ambulances and other vehicles within the Trust and are able to administer first aid, oxygen therapy, entonox and defibrillation as required. Like other PTS staff, Team Leaders are responsible for providing intermediate life support to patients where necessary but they also offer supervision, advice and guidance to less experienced members of the PTS team. Our Patient Transport Service provides essential journeys to many people within the Trust area.

• 293,325 - the number of patient journeys

These can include routine hospital appointments and regular treatment such as dialysis. From left: Gemma Bradley, Kevan Gray, Tracey Stearnes

The PTS team provide an invaluable service to many of our patients.

Gemma’s story – PTS Team Leader Gemma Bradley joined the ambulance service in October 2001 as an operational member of staff. In August 2004 she moved into the control room at Avon as an Ambulance Dispatcher. She then became a PTS Team Leader in June 2008. Gemma is based at Weston Ambulance Station and also covers Nailsea Station. Many of the journeys undertaken will involve taking patients into Bristol hospital for appointments and treatment and bringing them home again. Gemma said: “I really enjoy being a PTS Team Leader and ensuring we 14

run a smooth service within the area I cover. “I love being able to help so many patients and I get to spend quite a lot of time with many of them as they sometimes have to travel across the Trust area to different hospital appointments. “I am glad to be able to make their journeys as pleasant and comfortable as possible and enjoy the challenges often presented to us such as the snow during February this year. “It is a really important role and the patients are usually so grateful. It can be a very daunting time for them so we always try to lighten the mood and keep their spirits up.”

need us Also, as a former police officer whose father spent many years in the Somerset ambulance service, he is very knowledgeable about how the emergency services have changed over the years. Even though many of the journeys Mr Burroughs needs to make are to the local Weston General Hospital, within half-a-mile of his home, he appreciates the assistance the PTS crews provide for the regular short trip. “I am grateful and very impressed by them – nothing is too much trouble and they are very friendly. There are rare but inevitable occasions where my appointments overrun, but invariably another form of transport home is arranged.”

Nelson Burroughs

Nelson’s story – a Patient Transport Service regular Nelson Burroughs is philosophical about his distinction of being one of the most frequent users of the Patient Transport Service (PTS). The 78-year-old from Weston-super-Mare makes at least one journey a week – usually two and possibly three – to one of several hospitals in Weston or Bristol. “Unfortunately, I do need to make rather a lot of use of the service,” said Mr Burroughs, whose complex medical problems mean he has regular appointments with any of six consultants, and also requires other ongoing treatment. Despite that, or perhaps because of it, he has developed a close rapport with the crews and fellow passengers he sees week in week out. “To me, they are not simply ambulance crews, they are more like personal friends. I know all about their dogs, their children and other things in their lives,” said Mr Burroughs. 15

Locality Directors Giving local support to our We have three Locality Directors, one for each sector of Great Western Ambulance Service. They report directly to the Chief Executive and each have a Divisional Commander and three Station Managers (four in Wiltshire) assisting them in the running of their sector. The Locality Directors work together to ensure the Trust is providing excellent patient care across our entire area and striving to meet our national performance targets. This is a new post for the Trust so here are our three Locality Directors to introduce themselves and give an understanding of the role they play within the Trust.

Falfield

Sharon Hinsley – Avon locality

Almondsbury Yate

As Avon’s Locality Director I am responsible for A&E Operations for Bristol, South Gloucestershire and North Somerset as well as the Patient Transport Service for the whole of the Trust.

Avonmouth Soundwell

BRISTOL

Nailsea

Keynsham

I started with the Trust in October and have enjoyed meeting and working with staff across Avon. I have been extremely impressed by their commitment and professionalism – they are clearly dedicated to providing excellent patient care.

Weston

Churchill

Avon (West) sector

The Avon sector is the most highly populated in the Trust and the health needs of our patients are diverse. I have been working to develop strong working relationships with our NHS partners and patient groups. In particular I have been working to strengthen our urgent care networks to make sure patients get the right type of care and don’t call 999 when they don’t have to.

Sector HQ Executive Office Control Centre

My priorities for 2009/10 are to build on the good work so far and continue delivering our key A&E performance targets. Our priorities for the Trust’s Patient Transport Service are to make sure we match our service to the agreements we have in place with the hospitals we serve. As responsibility for buying patient transport services moves to Primary Care Trusts in 2010/11, our challenge will Cinderford be to make sure we have the right resources in Coleford place and deliver a selffunding service. Lydney

Air Ambulance Ambulance Station

Tewkesbury Moreton-in-Marsh Staverton

QUEDGELEY Stroud

Cinderford Dursley

Sharon Hinsley

Gloucestershire (North) sector

staff and you Keith Scott

Jonathan Brotherton – Gloucestershire locality

Keith Scott – Wiltshire locality

As Locality Director for Gloucestershire my remit covers A&E Operations within Gloucestershire as well as Urgent Care and Air Operations Trust-wide.

Having worked in various positions in the ambulance service for the last 18 years I was pleased to be offered the opportunity, in November 2008, to undertake the role of Locality Director, Wiltshire. In addition to A&E services, my role encompasses overseeing the Civil Contingencies Team, which includes business continuity and events.

There have been extensive changes within the Trust during 2008/09. Our staff have remained extremely supportive of what we are trying to achieve and dedicated to providing the best patient care they can for the people of Gloucestershire, Avon and Wiltshire. Since taking up my post six months ago, with the strong ground work that had previously been put in place, Gloucestershire’s performance against the key national targets for frontline ambulance provision has steadily moved forward. This is due to the dedication of the whole workforce pulling together with a common aim to succeed. The Out-of-Hours Service in Gloucestershire also remains compliant with all its key national requirements and continues to play a vital role in the local health community, largely due to the dedication of the management, clinicians and staff involved. The public can continue to be reassured by the availability of the Air Support Units covering all three localities within our Trust area and look forward to developments that will further enhance patient care. I believe it is recognised by all of us that we are not at the end of our journey but at the beginning and making sustainable progress, jointly working on ways to continue our improvement. Malmesbury Swindon

CHIPPENHAM Marlborough Bath Devizes Paulton

Wiltshire (East) sector

Trowbridge

Warminster Amesbury

Salisbury

• In 2009 Philip DeBruyn joined GWAS, replacing Jonathan Brotherton

Being a large rural area presents a challenge to deliver the national ambulance performance standards in the Wiltshire sector. The team is concentrating on three priorities to improve performance. These are about ensuring that all core resources are available and means maximising the use of Community and Co responder schemes. It also requires constant review of our deployment to make sure we put our vehicles in the right place, so they can respond as quickly as possible. We remain confident that we can sustain and improve response standards and patient care within the area. A great deal of work has been done by the Civil Contingencies Team to improve our response to major incidents and also to improve the resilience of the Trust. There have been a number of exercises undertaken and our plans have been updated given the lessons learnt. The future will see many more developments. This includes the introduction of a Hazardous Area Response Team (HART) and Urban Search & Rescue (USAR).

Patient and Public Involvem Listening to you, whenever How long have you been involved with the Trust? How did you become involved? I have been involved with the ambulance service as a member of the patient and public forum since the service was formed. Interim CEO Anthony Marsh with representatives from LINks

Local Involvement Networks (LINks)

External Reference Group

This was the first year that Local Involvement Networks (LINks) were in operation. They aim to give the public a stronger voice in how their health and social care services are delivered. Run by local individuals and groups and independently supported, the role of LINks is to find out what people want, to monitor local services and to use their powers to hold them to account.

As customers of our services, the public have an important role to play in how we deliver those services. During 2008/09 one of the ways of becoming involved was through the Trust’s External Reference Group (ERG).

Our Trust is covered by seven LINks, funded by the seven local authorities that cover our Trust. We are working with these LINks host organisations, as they establish and develop, to consult and engage them on issues that affect our patients. We hope to continue this work, perhaps through a joint ambulance working group next year.

Anne Keats

Anne Keats is one of 12 members of the ERG. We interviewed her about involvement with ambulance services.

I was extremely pleased that the ERG was formed, so we could keep alive the expertise and interest of the old forum and continue working with the ambulance service. What are the benefits of the new ERG? For the ambulance service, we are a link into the local community, and to local patients. We can use these networks to open up dialogue with the public and get views and patient feedback. For the ERG we continue our interest in the service and help make a difference for patients. What can the group do? Raise awareness of key issues, for example when to dial 999 and when it is best to go to your GP or pharmacist. We can work with the Trust on their priorities and reflect the thoughts and experiences of the public. We are also keen to work with the Service to build up our membership base and draw in as wide and diverse a group as possible as the Trust works towards foundation trust status.

2008/09 • We hosted an event with the Chairs and Hosts of the seven new LINks. • PPI Forums were disbanded last year but the members of the GWAS Forum agreed to stay with the Trust and became our new External Reference Group 2009/10 • GWAS will be working towards a joint ambulance working group drawn from all seven LINks for our area and the ERG will work to support us in preparation for foundation trust status. 18

ment you need us PALS Patient Advice and Liaison Service (PALS) is an accessible and confidential service for patients, relatives, carers and the general public. It is there when you don’t know where to turn, when you need information and advice, or have concerns about the Ambulance Service. The Trust had 237 inquiries this year.

Overview and Scrutiny A vital function of local government, on behalf of the people they serve, is to oversee the work of the NHS. Great Western Ambulance Service is served by seven separate Health Overview and Scrutiny Committees (HOSCs). Six of those seven committees agreed to form the one joint HOSC dedicated to our ambulance service. This has been an extremely successful relationship.

Andrew Gravells’ story: Chairman of the Joint HOSC

Key Facts • 237 - the number of patient inquiries received • 362 - the number of complaints responded to • 384 - the number of letters received, praising our crews

“The joint scrutiny arrangements have really helped in maximizing engagement with Great Western Ambulance Service. Our members have been able to increase their knowledge and understanding of the ambulance service and how it works within the wider NHS. “We have developed a very solid working relationship, with tremendous openness and honesty. The scrutiny and feedback that we provide is taken very seriously and used to improve the quality of care for patients. “We are valued as an important critical friend, and I am very grateful to the Service for that." Councillor Andrew Gravells

Partnerships Always there, whenever you need us Key Facts

Pandemic flu

• 3 – the number of Local

Pandemic flu is an outbreak of flu that affects many hundreds of thousands of people in every area of the world. It spreads rapidly between people and around 25 per cent of the world population could be affected.

Resilience Forums covered by the Service

• 7 – the number of Major Incident Support Units across the Trust area

• 140 – the number of Special Operations Response Team personnel trained to deal with chemical decontamination

2008/09 • We took part a live major incident exercise in Wiltshire – Exercise Equinox

• We took part in two major incident exercises on pandemic flu preparations

• We completed our Pandemic Flu Plan with 98% compliance

2009/10 • We will be part of the NHS Resilience project for the South West

Exercise Equinox A military aircraft crashing on to a railway line in Wiltshire was the dramatic scenario that allowed the Trust and other emergency services and local agencies to practise their readiness for such major disasters. The two-day Exercise Equinox last September – organised by the Wiltshire and Swindon Local Resilience Forum – provided a realtime opportunity for Great Western Ambulance Service to test its major incidents procedures, including gold, silver and bronze levels of command. The exercise brought together staff from our Trust, University West of England, British Red Cross, St John Ambulance, Royal United Hospital – Bath, Yorkshire Ambulance, South Central Ambulance, British Association for Intermediate Care (BASICS) and South Western Ambulance to provide the medical response to the simulated disaster. It also tested how our command and control arrangements integrated into a multi-agency response and how the Trust would cope in dealing with large numbers of casualties.

Pandemic flu is a key issue for and it is vital our Trust continues to prepare and build its resilience. The recent Swine Flu pandemic demonstrated just how virulent these outbreaks can be. On 26 February a number of staff from around the Trust attended a table top exercise to check our preparedness and the details of the flu plan. The day was run by our civil contingencies department alongside the South West Health Protection Agency (HPA). There were three exercises containing relevant questions to confirm whether our knowledge and our Flu Plan would stand up in simulated practice. It has now been confirmed that our Trust is the best performing health trust in the South West, with our flu plan being 98 per cent compliant. This is thanks to the hard work of our Civil Contingencies Team and especially our Business Continuity Manager, Wayne Darch.

Help from the Hub Always there, however you need us Gloucestershire is leading the way on urgent care with its Hub for Health and Social Care. Gloucestershire’s Out-of-Hours service is run in partnership between Gloucestershire PCT and Great Western Ambulance Service. The Hub has continued to work collaboratively with its stakeholders to ensure it is providing a high standard of patient care.

Sometimes this can mean not only making arrangements for the patient themselves but also for any dependants they may have.

The Hub works very closely with district nurses and colleagues within the emergency social work services. This joint working allows the patient to receive the most appropriate care whether a patient has health or social care needs.

If patients are the sole carer for a partner, they may be unhappy to travel to hospital until provision can be made for their partner.

This year the Hub received 117,463 calls, an increase of 8% on last year’s 108,547. When patients contact the Hub our staff are able to use many different networks which means all the patient’s needs can be met. This is very important for our patients and helps alleviate many of their fears during their time of need.

In conjunction with local social care providers this can be arranged and the patient can receive the treatment they need. With the hard work and dedication of all the staff within the Out-ofHours Hub we have been able to offer excellent care to all of our patients and have met the national performance standards.

Key Facts We employ • 15 Urgent Care Doctors • 58 Call Takers, Clinicians and Support Staff

We use • 5 Urgent Care vehicles

We took • 117,463 calls at Gloucestershire Hub for Health

Our impact on the environ

Reducing our carbon footpr

The Trust is committed to reduce its carbon footprint. This includes the commitment to deliver a waste management programme and a fleet management system that meets all environmental standards.

Waste

Procurement

The Trust now has a waste management action plan and work will start on meeting environmental standards in 2009/10. The Trust has appointed a waste manager to work with us to deliver the top priorities in our action plan. This includes setting up systems for the correct coding and recording of waste, identifying suitable storage containers and facilities, and devising training proposals to ensure that staff are trained to understand their role in environmentally sustainable waste management.

As part of sustainable procurement, the Trust aims that all our buildings and all the goods and services we procure are manufactured, delivered, used and managed at the end of their useful life in an environmentally and socially acceptable way. All our products are delivered in environmentally friendly, reusable tote boxes and roll cages. This reduces the amount of packaging that the Trust has to dispose of and ultimately the amount of waste we have to manage. The procurement department will continue to work with our suppliers to look at ways to reduce supplier miles and the amount of packaging on products. It has already started to join with other ambulance trusts in tendering exercises so it can benefit from economies of scale, increase leverage over suppliers and secure best value for money. We will also work to acquire more local supply sources and further reduce supplier miles.

ment int Fleet The Trust’s fleet is made up of more than 400 vehicles of all types, 103 of these are ambulances and 77 are rapid response vehicles, all of which run on low sulphur diesel reducing emissions. The Trust Fleet Department is actively pursuing greener policies across the procurement and management of its fleet to reduce its carbon footprint. In 2009/10 we will be launching ‘Fleetwave’, our new fleet management system, which will improve the way we manage our fleet by providing a greater range of information such as fuel consumption, annual mileage, frequency of breakdowns. This will help us proactively manage our CO2 emissions and set robust emissions targets. Our Fleet Department currently operates a fleet maintenance programme to maintain our vehicles to the highest standards to make sure we use fuel as efficiently as possible. Emissions are checked at every service and the current fleet servicing programme inspects its vehicles on average three to four times more often each year than the manufacturer’s guidelines, ensuring maximum safety and efficiency. Previously only 70% of our vehicles used engines that reduce pollutants by 30%. Now, 100% of the Trust’s A&E vehicles are fitted with these engines. When the Trust was formed approximately 65% of the total ambulance fleet was fitted with Euro 3 standard engines which further reduce emissions by 30%. Subsequently 100% of our ambulances were fitted with Euro 3 standard engines and now 30% have been fitted with the latest Euro 4 standard engines which reduce emissions further still. The Trust’s Procurement Plan is to continue to purchase the latest Euro standard vehicles. The Trust cars currently average the government tax threshold of 165g/km and the new lease car standard is below that at 154g/km. The fleet department actively encourages its volunteer drivers to choose cars with the lowest CO2 emissions. Modern satellite navigation systems are now fitted to all A&E vehicles, which means more efficient journeys and reduced mileage. Our dispatch protocols actively use a ‘least vehicle movement’ policy when dispatching vehicles to get the closest vehicle to the patient, which further reduces miles travelled.

Our Board of Directors

Great Western Ambulance Service Board of Directors June 2009 Back row from left to right – Jonathan Brotherton, Simon Davies, Gerard Barclay, John Newman, Tony FitzSimons, Leo Doyle, Chris Davidson, Keith Scott Front row from left to right – Sharon Hinsley, Liz McLoughlin, David Whiting, Kerry Pinker, Ossie Rawstorne

Part Two Operating and Financial Review 2008/09 Accounts 2008/09

Operating and financial rev

Structure of the business, se The following sections outline the services that Great Western Ambulance Service currently provides, what it has achieved in 2008/09 and what it will be focusing on in the future, and how well the Trust is positioned financially.

Services

Communities served

The Great Western Ambulance Service provides the following services to the communities of the Primary Care Trusts:

• • • • • • • •

• Emergency Care • Patient Transport Services • Urgent Care and Out-of-Hours service

Bath and North East Somerset City of Bristol County of Gloucestershire County of Wiltshire North Somerset South Gloucestershire Swindon Watchfield and Shrivenham

Emergency Care and Patient Transport Services are provided to all of these communities. Gloucestershire also receives support with their Urgent Care service.

Urgent Care and Out-of-Hours • Call taking by trained staff • Triage (clinical assessment) of some Category C calls and clinical support for healthcare professionals by qualified staff • Out-of-hours access to care services signposting patients and clinical staff to appropriate social or medical care solutions and an out-of-hours mobile doctors’ service

Emergency Care A 24-hour clinical response to 999 and healthcare professional (HCP) calls. Provided by: Critical Care Paramedics and Emergency Care Practitioners (ECPs), Paramedics, Ambulance Practitioners and Emergency Care Assistants. Arriving by: Air Ambulance, Rapid Response Vehicles (RRVs), ECP cars and ambulances.

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ervices and users Patient Transport Service This service involves the transport of patients to and from secondary care environments. The service is based on assessed need. See pages 16-17. Provided by: Ambulance Care Assistants, Intermediate Care Assistants and Volunteer Drivers Arriving by: Ambulances equipped with stretchers, patient transport vehicles, ambulance cars and volunteer cars Patient Transport Services are supplied to the following Hospital Trusts within the Great Western Ambulance Service area: • • • • • • • • • •

University Hospitals Bristol Trust North Bristol NHS Trust Weston Area Health Trust Avon and Wiltshire Mental Health Partnership Trust Great Western Hospital Swindon Gloucestershire Hospitals Foundation Trust Gloucestershire Together Foundation Trust Community Hospitals within Gloucestershire Community Hospitals within Wiltshire Royal National Hospital for Rheumatic Diseases

Location and type of facilities provided The services provided by Great Western Ambulance Service operate from a diverse range of locations.

Ambulance stations and stand-by points • 30 ambulance stations and three air bases • The largest stations are based in Bristol, Swindon and Staverton • Various stand-by points across the Trust area

Control rooms and offices • The Emergency Operations Centre (EOC) in Almondsbury takes all incoming 999 calls across the Trust • Two further EOCs are located in Quedgeley and Devizes. The Out-of-Hours Hub is also housed at Quedgeley

• The Patient Transport Service control room has now been centralised in Bristol • PTS operate from 18 of the ambulance stations across the Trust • Trust headquarters is located in Chippenham, Wiltshire

Vehicle workshops • There are four workshops based in Bristol, Quedgeley, Trowbridge and Swindon. These ensure that the maximum number of ambulances and support vehicles are available

Operating and financial rev

Achievements, impact and o Our achievements and impact on the community Great Western Ambulance Service has delivered significant improvement in the services it provides. Here are some of the key achievements in 2008/09: • We trained 88 Ambulance Practitioners to become fully qualified Paramedics • We continued to work closely with colleagues in the Emergency Departments of hospitals to directly admit patients to the appropriate place, rather than going through Accident and Emergency Departments • Continued recruitment of Community First Responders has meant we have put additional resources in more areas across the Trust • A new Computer Aided Dispatch system was implemented • We have recruited 142 Emergency Care Assistants and 49 Emergency Call Takers • We bought 31 new ambulances

Our business objectives in 2008/09 The Trust has made good progress during this year in meeting its corporate objectives. These focused on the following areas: • Performance – national performance standards • Financial stability • Developing urgent and emergency care in line with the national strategy • Development of strong partnership working • Improving clinical quality • Establishing a framework for leadership development

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our development Our development in 2008/09 • During this year the Learning and Development Department in conjunction with the University of the West of England (UWE) have successfully developed 80 Ambulance Practitioners to Paramedic status, with a further eight Ambulance Practitioners developed by being outsourced to West Midlands Training School. The 80 Paramedics developed at UWE were also given the opportunity to gain 20 academic credits by completing the ‘Evidence in Work-based Learning’ module thereby allowing them the first step towards achieving the Paramedic Science Degree/Diploma. During this same period the Trust also facilitated the education to Paramedic status of 12 Royal Air Force medics as part of the partnership working that has taken place between the two organisations over the past few years. • From 1 April 2008 the national response time target started from the moment the 999 call hits the call centre. We call this Call Connect. Previously timing started once the call taker had the address, telephone number and chief complaint. This means our challenge is to arrive with our patients 90 seconds earlier. • In September 2008, following a long consultation process and rigorous training schedule, the Trust implemented a new Computer Aided Dispatch system (CAD). The new system is more sophisticated and helps our staff to perform to the best of their ability as quickly as possible. • This year has seen many changes within the Trust. In September Chief Executive, Tim Lynch moved to a position with the Countess of Chester Hospital and Anthony Marsh joined for six months while a new permanent Chief Executive was found. David Whiting joined Great Western Ambulance Service from East Midlands Ambulance Service, where he was the Director of Operations. He has more than 28 years in ambulance service and is a qualified paramedic. He took up the Chief Executive post on 1 April.

• Out-of-Hours service – The Trust has continued working closely with Gloucestershire PCT and other service providers in the area and has achieved its key national performance standards for urgent care. We implemented the ADASTRA call prioritisation protocols to ensure that more urgent clinical problems receive telephone triage (clinical assessment) from a doctor as soon as possible. • In 2008 we centralised our PTS control rooms to standardise the service across the entire Trust area. The control room is now based in the centre of Bristol with 18 operational sites across the Trust. • Following the training of a dedicated team with advanced trauma skill, the Great Western Air Ambulance was launched on Tuesday 3 June 2008, giving the Trust its own dedicated Air Ambulance as well as the Wiltshire Air Ambulance and the Midlands Air Ambulance which also operate within the Trust area. • During the year we brought into service 31 brand new ambulances across the Trust and installed Terrafix, the latest in satellite tracking and communication systems, to all of the Trust’s operational vehicles. • We completed the roll-out of new Great Western Ambulance Service operational uniform to staff. • The Trust has a Major Incident Plan that satisfies statutory requirements, particularly Department of Health Emergency Planning Guidance. This year the Trust has been focusing on pandemic flu preparations. Great Western Ambulance Service is the best performing Trust in the South West, as our Flu Plan is 98% compliant.

Operating and financial rev

Looking beyond and positio 2009/10 financial position The Trust is planning to achieve financial balance in 2009/10. The Trust has agreed with its commissioners and the Strategic Health Authority an increase in its income of £7.5 million which will fund pay and price rises on the costs that the Trust incurs. The income will also allow the Trust to expand its workforce and develop further Community First Responder schemes across the Trust area. In order to balance current expenditure levels with the planned income the Trust will need to make savings of £5 million in 2009/10 representing 3.5% of its recurrent income baseline.

Position of the business The Trust has ended the 2008/09 financial year with a small surplus of £5,000 which reflects a significant achievement after such a challenging financial year. The operational challenges that the Trust has experienced in this financial year have exerted significant pressure on the Trust’s finances. However, tight financial control and vigorous financial review have resulted in the financial targets being achieved. The Trust has also under-spent against its capital expenditure targets.

The medium term financial view The medium term financial view for the Trust will be challenging as it strives to drive out inefficiencies throughout the organisation. The Trust will need to deliver savings equivalent to 3.5% of its baseline expenditure in 2010/11, and 4% thereafter, while achieving the operational targets. This will be addressed by benchmarking its services with other Ambulance Trusts to identify where efficiencies can be achieved and continuing the modernisation of the workforce and fleet.

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on of the business Other challenges The main challenge for the Trust in 2009/10 will be to continue to improve against our performance targets alongside an ever increasing demand and changes in local healthcare provision. This challenge is even more prevalent since the introduction of Call Connect on 1 April 2008. This is a national clock start time for all ambulance services where the national targets are measured from the time the emergency operator passes the 999 call to the relevant service. To ensure we are able to meet these key national targets we introduced standards for each individual section of the emergency response process. Our call handlers must answer the call within 5 seconds and have a further 25 seconds to verify the location of the incident. Our dispatchers then have 30 seconds to allocate the appropriate resource and the operational staff have 45 seconds to mobilise to the incident. This leaves the maximum amount of time possible for the ambulance to travel to the scene of the emergency.

Looking beyond 2008/09 In 2009/10 we will be using a different training route for our Ambulance Practitioners. They will receive the extended training and development needed to take them to Paramedic standard, through Higher Education Institutes. This is in-line with the Emergency Care Practitioner training which is also delivered via this pathway.

On 21 June 2007, the Department of Health announced that ambulance trusts will be eligible to apply for Foundation Trust (FT) status from April 2009. We believe that this is a logical progression for Great Western Ambulance Service and fits with our aspiration of becoming a high performing Ambulance Trust. We are confident our integrated business plan will place us in a strong position to achieve our aspirations. Successful application to NHS FT status will also allow us, as an organisation, to use the financial freedoms and greater local accountability that FT status provides and we are confident that this will bring major benefits to our patients. We believe that the FT regime also provides a strong incentive for our staff to deliver the most cost-effective services and to create surpluses to reinvest in new developments. A strong financial platform will help to attract further investment through partnerships with other NHS providers and the commercial sector. Our continuously improving performance demonstrates that changes to our management and governance arrangements are already taking effect, with all staff becoming clearer about the opportunities and benefits of becoming a Foundation Trust. If successful in our application, we will use our independence as an FT to build on our strong brand, reputation and high public profile. We will be able to clearly brand our services in other areas to allow more patients to be treated closer to home. Independence, in this respect, will also help us to attract the very best specialist staff, who want to be assured of a strong future, with a rich clinical practice, research opportunities and career development.

This Operating and Financial Review has been compiled in accordance with the requirements set out in The Companies Act 1985 (The Operating and Financial Review and Directorsâ&#x20AC;&#x2122; Report etc.) Regulations 2005 (Statutory Instrument, SI, 2005 No.1011) and are effective for the financial years beginning on or after 1 April 2005.

How much does it cost? In 2008/09 we spent £80.16m

Operations centre Control rooms who take the initial call and respond to the request, sending a message to a waiting vehicle.

£5.47m

Fleet Maintenance and service of all the Trust’s vehicles.

£7.65m

Logistics Management of the supplies held in the Trust vehicles.

£0.83m

Urgent Care Providing primary care services outside core working hours.

£2.96m

Operations Emergency Response including ambulance staff and Emergency Care Practitioners.

£41.83m

Patient Transport Service Transporting patients for nonemergency treatment.

£6.79m

Central Overheads Cost of IT, Finance, Human Resources, Executive Management, Board, Training, Governance.

£13.74m

Financing Costs Trust debt remuneration minus interest from investments.

£0.89m

Accident and Emergency

£67.63m

Urgent Care

£3.39m

Patient Transport Service

£7.25m

Other

£1.89m

Our overall financial performance for this year was £5,000 surplus

Our finances The financial section of this annual report has been prepared with the latest information available to the Director of Finance of the Great Western Ambulance Service NHS Trust.

Mr S Davies Director of Finance Great Western Ambulance Service NHS Trust

This annual report includes copies of the full financial statements, required by NHS governance arrangements.

Accounts 2008/09 Remuneration report This Remuneration Report is prepared in accordance with the requirements of the Companies Act 1985. The level of remuneration and terms and conditions of the directors is approved by the Remuneration Committee. The Remuneration Committee is a sub-committee of the Trust Board, formally constituted with terms of reference. The Remuneration Committee comprises the Chair and Non-Executive members of the Board. The Chief Executive also attends for all matters other than his own remuneration. Membership is shown below: A FitzSimons, Chairman E McLoughlin, Non-Executive Director L Doyle, Non-Executive Director G Barclay, Non-Executive Director C Davidson, Non-Executive Director J Newman, Non-Executive Director

The Committee meets at least annually to approve directorsâ&#x20AC;&#x2122; remuneration and terms of conditions. Great Western Ambulance Service NHS Trust was formed on 1 April 2006 by the merger of the former Ambulance Trusts of Avon, Gloucestershire and Wiltshire. Responsibility for the remuneration of directors transferred to the Board of the new Trust on that date.

Salary and pension entitlements of senior managers A) Remuneration

2008/09

2007/08 Salary

Other

(bands of £5,000) £000

remuneration (bands of £5,000) £000

15-20

Benefits in kind rounded to nearest £100 -

105-110

3,700

40-45

4,500

80-85

3,100

6 months

110-115

5,000

130-135

3,800

01/03/07

6 months

45-50

4,200

75-80

4,000

01/08/08

6 months

45-50

3,400

05/05/08

29/08/08

35-40

02/10/06

30/05/08

10-15

800

65-70

1,000

30/10/06

6 months

35-40

3,600

60-65

400

01/07/06

30/06/09

5-10

01/07/06

30/06/09

5-10

01/07/06

30/06/08

0-5

5-10

01/07/06

30/06/09

5-10

01/11/07

30/10/11

5-10

0-5

01/07/08

30/06/11

0-5

Contract start date

Duration/ notice period/ end date

Salary

Other

(bands of £5,000) £000

remuneration (bands of £5,000) £000

P A FitzSimons, Chairman

01/04/06

31/03/11

15-20

Benefits in kind rounded to nearest £100 -

A Marsh, Chief Executive T Lynch, Chief Executive P Selwood, Managing Director S Davies, Finance Director K I Henderson, Finance Director S. Rawstorne, Medical Director S. West, Operations Director K Pinker, HR Director J Porter, HR Director J Saunders, HR Director R Pearce, Corporate Development Director E M McLoughlin, NonExecutive Director M L H Doyle, NonExecutive Director J V Higginson, NonExecutive Director C S Davidson, NonExecutive Director J Newman, Non-Executive Director G Barclay, Non-Executive Director

01/10/08

31/03/09

60-65

18/04/06

30/09/08

55-60

3,800

01/01/09

55-60

05/09/08

105-110

01/04/06

6 months

01/04/06

Name and title

Salary costs exclude employer’s superannuation and employer’s National Insurance Contributions. Benefits in kind relate to provisions of a car. 35

Salary and pension entitlements of senior managers B) Pension benefits Name and title

£000

(bands of £2,500) £000

(bands of £5,000) £000

(2.5)-0

30-35

100-105

631

488

0-2.5

20-25

65-70

368

276

0-2.5

40-45

125-130

870

658

138

0-2.5

10-15

40-45

245

180

0-2.5

5-7.5

15-20

55-60

255

184

(2.5)-0

10-15

35-40

174

140

Lump sum at age 60 related to accrued pension 31/03/09 (bands of £5,000) £000

Real increase in cash equivalent transfer value funded by employer

Employer’s contribution to stakeholder pension £000

£000

As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members. A Cash equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV 36

Cash equivalent transfer value at 31/03/08

Total accrued pension at age 60 at 31/03/09

(bands of £2,500) £000

T Lynch, Chief Executive K I Henderson, Finance Director S. Rawstorne, Medical Director S. West, Operations Director K Pinker, HR Director J Saunders, HR Director R Pearce, Corporate Development Director

Cash equivalent transfer value at 31/03/09

Real increase in lump sum at age 60 in 2008/09

Real increase in pension at age 60 in 2008/09

Figures, the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and faculty of Actuaries. Real Increase in CETV – This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and end of the period.

Audit disclosure The external auditorâ&#x20AC;&#x2122;s fee for statutory audit services in 2008/09 was ÂŁ107,000. There were no additional services.

Accounts 2008/09 Statement of Chief Executive’s responsibilities as the Accountable Officer of the Trust The Secretary of State has directed that the Chief Executive should be the Accountable Officer to the Trust. The relevant responsibilities of Accountable Officers are set out in the Accountable Officers Memorandum issued by the Department of Health. These include ensuring that: • there are effective management systems in place to safeguard public funds and assets and assist in the implementation of corporate governance; • value for money is achieved from the resources available to the Trust; • the expenditure and income of the Trust has been applied to the purposes intended by Parliament and conform to the authorities which govern them; • effective and sound financial management systems are in place; and • annual statutory accounts are prepared in a format directed by the Secretary of State with the approval of the Treasury to give a true and fair view of the state of affairs as at the end of the financial year and the income and expenditure, recognised gains and losses and cash flows for the year. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an accountable officer.

Statement of directors’ responsibilities in respect to accounts The directors are required under the National Health Services Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the income and expenditure of the Trust for that period. In preparing those accounts, the directors are required to: • apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury; • make judgements and estimates which are reasonable and prudent; • state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts. The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to make sure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. By order of the Board

Accounts 2008/09 Statement of directors’ responsibilities in respect of internal control 2008/09 1 Scope of responsibility The Board is accountable for internal control. As Accountable Officer, and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum. During the course of the year, meetings were held with the Strategic Health Authority (SHA), commissioners and other partners to ensure that the policies, aims and objectives of the wider health economy were supported. The Board, with the support of the SHA, has also commissioned interim executive support to the Board to drive improvements throughout the organisation. This reflected the recognition by the Board that performance improvement was a priority as was the strengthening of Governance arrangements. The Trust attends meetings with other healthcare organisations in relation to a number of joint initiatives to ensure that local and national targets are met, including urgent and emergency care networks and the Coronary Heart Disease Collaborative. The plans for the year which were developed in conjunction with the Primary Care Trusts (PCTs) and the SHA recognised the need for significant capacity developments within the Trust. The Trust developed joint responses to some key risks with other agencies such as the development of emergency preparedness with the police, fire service, county councils and others, including the management of vulnerable adults with social services and police and child protection with social services. In order to involve stakeholders in managing risk, the Trust has established relationships with local authorities through the Joint Health Overview and Scrutiny Committee and, following national changes to the patient and public involvement arrangements, is developing and improving links with patients and the public to establish mechanisms for greater involvement of the public in consulting on future plans. Alternative provision with former Patient Forum members ensured that the Trust continued to engage with patient representatives as the forum ceased to exist. Public participation at Board meetings is encouraged and Board papers are published on the Trust’s website.

2 The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives: it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to: â&#x20AC;˘

identify and prioritise the risks to the achievement of the organisationâ&#x20AC;&#x2122;s policies, aims and objectives

â&#x20AC;˘

evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically

The system of internal control has been in place in Great Western Ambulance Service NHS Trust for the year ended 31 March 2009 and up to the date of approval of the annual report and accounts. Some internal controls had not been operating effectively and these are addressed within current action plans.

3 Capacity to handle risk The authority and responsibility for risk management is vested in the Trust Board as described in the Trust Risk Management Strategy, which is updated annually. Implementation of this policy is delegated to the Chief Executive. The Finance Director has overall responsibility for risk management. However, individual Trust directors have day to day responsibility to identify and manage risk within their areas of responsibility as have all managers within their roles as corporate managers. The Head of Integrated Governance, acting on behalf of the Finance Director, co-ordinates the risk management process and provides an advisory and co-ordinating role to directorate and department managers. The Risk Manager, working to the Head of Integrated Governance, supports the effective implementation of risk management processes by departmental managers and staff as described in the Risk Management Strategy and associated policies. The role of each directorate and departmental manager is to ensure appropriate follow-up and responses to findings related to these processes. Trust managers with risk management responsibilities are provided with appropriate advice, guidance and training. An overview of risk management is included in the Trust induction and mandatory training programmes.

Accounts 2008/09 4 The risk and control framework The Trust’s Risk Management Strategy sets out the aims and objectives of the management of risk, the relationships between the Trust’s committees with specific responsibilities for risk, and the roles and responsibilities of managers and staff. The strategy takes a holistic view of risk including the management of clinical risk as well as operational, financial, human resource and information risks and includes: •

identification of risk

•

analysis, control and treatment of risk

•

incident reporting and investigation

•

claims and complaints management

•

establishment and management of risk registers

•

educating staff on issues of risk

•

reporting incidents to the relevant external authorities

•

achieving compliance with relevant statutory legislation

•

ensuring that there is compliance with relevant accreditation standards and codes of practice

The Trust Board retains overall responsibility and authority for the risk management process but delegates authority and responsibility for risk management to the Audit and Risk Committee in line with the Risk Management Strategy. The Trust’s corporate risk register is presented to the Board on a monthly basis as part of its performance report and new and escalating risks are identified. The Trust Board is advised by the Audit and Risk Committee on the adequacy of risk management and processes through the receipt of the minutes from Trust Board sub-committees, by review of the Assurance Framework, and receipt of summary reports indicating the status and progress of Trust-wide risk management activities through the annual Board cycle. Risks that cannot be addressed or managed locally are incorporated into directorate risk registers. These risks are reviewed by each director with the Risk Manager and at the Audit and Risk Committee and those risks which threaten the achievement of the Trust’s corporate objectives are escalated to the Corporate Risk Register and thence to the Trust Board. The content of the Assurance Framework, based on national guidance, is reviewed and updated regularly in response to the updating of Trust corporate objectives, the development of strategic plans and service developments. New and emerging risks are identified and recorded. The Assurance Framework is reviewed regularly by the Executive Team and quarterly by the Audit and Risk Committee. The Trust Board reviews the Assurance Framework twice a year as part of the Board cycle.

In 2008/09 a review of the Assurance Framework highlighted that there were some gaps in control and assurance of risks. This work was underpinned by a more in-depth review commissioned by the Board from the Trustâ&#x20AC;&#x2122;s new Internal Auditors and by work undertaken by the new Interim Executive Team. Action has been taken to address these gaps and to successfully mitigate the risks with the Trust strengthening its governance arrangements throughout 2008/09. Importantly, further work is underway and required to strengthen these controls appropriately.

Delivery of national performance targets Achievement of performance targets for Category A and Category B was highlighted as being at risk. A Performance Improvement Plan was developed to address the risks through the strengthening of controls and was monitored on a weekly basis. Implementation of Call Connect standards and the introduction of a new Computer Aided Dispatch system during the autumn impacted upon performance. This was further exacerbated by a significant increase in demand coupled with extreme weather conditions and lengthy hospital delays during the peak winter period which resulted in operational standards not being consistently achieved. Considerable planned investment in 2008/09 focusing on the Emergency Operation Centre (EOC) capacity has been reflected in the plan agreed with PCTs and is now reflected in the Local Operational Plan for 2009/10. This has been underpinned by a complete review of operational delivery plans informing stage 1 of the 2009/10 plan and driving the longer term plan for the Trust in terms of improving performance delivery. The Trustâ&#x20AC;&#x2122;s delivery of pre-hospital thrombolysis to patients suffering an acute myocardial infarction is an important marker of its commitment to quality patient care. The Trustâ&#x20AC;&#x2122;s appointment of a Reperfusion Lead with specific focus on achieving the national target has had a positive impact with the Trust making progress with the achievement of this target.

Financial balance The Trust has taken a number of actions to ensure that it achieved a breakeven position for 2008/09. These have been agreed in planning throughout 2008/09 with PCTs and the SHA and in particular to support the changing demands in terms of workforce development within the Trust, activity growth and winter pressures. The Trust secured additional resource from its commissioners. Planned in-depth audits of the Trust financial controls identified a number of gaps in controls and assurance and additional capacity to address these issues has been commissioned.

Staff development In managing the operational risks to delivery of performance targets, the Trust has been unable to support all staff through organisational and personal development programmes or to ensure that staff concerned with all aspects of the provision of healthcare have participated in mandatory training programmes. The Trust has undertaken a significant recruitment 43

Accounts 2008/09 programme during 2008/09 to ensure there are sufficient resources to achieve both operational performance and staff development. Further planning with PCTs in the early part of 2009/10 will focus on achievement of these important targets. The Trust is not fully compliant with the all core Standards for Better Health including the standard associated with staff development. Other compliance gaps are highlighted in Section 5. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. As an employer with staff entitled to membership of the NHS Pension scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the scheme are in accordance with the scheme rules, and that member pension scheme records are accurately updated in accordance with the timescale detailed in the regulations.

5 Review of effectiveness As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed in a number of ways. The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Assurance Framework and on the controls reviewed as part of the internal audit work. The Head of Internal Audit opinion provides an opinion of limited assurance following their review of the full year and recognises that considerable effort is now underway to address any identified weaknesses. Executive managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review is also informed by external assessments undertaken by the Audit Commission, the Healthcare Commission, NHS Litigation Authority and the Health and Safety Executive. In 2008/09 further expertise at executive level has been brought in to provide further assurance and identify areas of weakness and implement action plans to address those identified. I have been advised on the implications of the results of my review of the effectiveness of the system of internal control by the Audit and Risk Committee and the work commissioned from the Trust’s new Internal Audit Team. A plan to address weaknesses and ensure continuous improvement is in place. A governance action team has been established to address these overseen by the establishment of the Trust Governance Committee. The Audit and Risk Committee reviews risk management activities within the Trust and advises the Board on the effectiveness of these activities. This committee receives reports on the risks identified by the Trust’s systems and processes including the risk register, assurance framework and through internal and external audit reports.

The Board is informed of the effectiveness of the system of internal control through the Board sub-committees. Executive Directors of the Trust are responsible for, and manage the risks within their areas of responsibility and are members of appropriate sub-committees. Regular reports are provided to the Trust Board on financial performance, risk management, information governance, infection control, health and safety and emergency planning through the annual Board cycle. Performance is reviewed against identified key performance indicators at the Trust Board and progress against compliance with external assessment requirements. The draft Auditors Local Evaluation (ALE) of the arrangements for internal control, financial management and value for money undertaken by the Audit Commission has assessed that the Trust’s arrangements in these areas are adequate. Whilst the Audit Commission assessed that the Trust had adequate arrangements in relation to financial management, internal control and value for money, inadequate arrangements in the following elements resulted in level 1 assessments: •

Financial Management (KLOE 2.2) – The organisation manages itself against budgets – further work to be done to ensure a full programme of training is in place for managers in relation to budgetary control and earlier sign off of budgets required.

•

Internal Control (KLOE 4.2) – Arrangements in place to maintain a sound system of internal control – this was primarily due to a nil assurance report from Internal Audit in relation to the Trust’s payroll controls.

•

Value for Money (KLOE 5.3) – Arrangements for monitoring and reviewing performance, including arrangements to aligned to data quality – some issues requiring improvements in data quality were identified and need to be addressed.

These assessments reflect the identification of controls weaknesses by the Trust through its planned internal audit review work and action plans to address these in payroll and budgetary control systems. An overall assessment of level 2 is expected for ALE, and needs to recognise some important strengthening of the Trust’s controls in the areas identified above. These are the focus of work for the Trust’s new Governance Committee moving forward into 2009/10. Actions are already underway to appropriately manage these areas and must be closely monitored in 2009/10. Through the implementation of its risk management processes, the Trust has confirmed that there are no uncontrolled risks but has acknowledged that it needs to take action, to further strengthen controls where significant control issues (as defined in the Department of Health Statement of Internal Control guidance), have been identified. The Assurance Framework identified the delivery of national performance targets, financial balance and staff development as areas where further action was required. The Trust had performance improvement plans in place to achieve these targets during 2008/09 and these were agreed as part of the Local Operating Plan with PCTs in 2009/10. In 2008/09 the Trust achieved the following standards of performance: Category A 8, actual 68.4% against target of 45

Accounts 2008/09 75%; Category A19 actual 93.9% against target of 95% and Category B19 actual 87.2% against target of 95%. All these performance gaps are being addressed through the 2009/10 Local Operating Plan, a review by Operational Research in Health (emergency deployment and resourcing specialists), and the development of a full performance improvement plan for the Trust, supported by PCTs and the SHA. During 2008/09 lapses were identified in four of the Healthcare Commission Standards for Better Health (out of a total of 42 standards) and therefore did not comply with the following standards in 2008/09: C4b – The Trust keeps patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised The Trust commissioned a review of the medical device management arrangements as part of an ongoing programme of improvements. The report arising from this audit identified some gaps in the existing arrangements and a comprehensive action plan is being developed overseen by the Trust Governance Committee. Key personnel have been identified to deliver the actions identified. C4e – The Trust keeps patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. The Trust commissioned an audit of the waste management arrangements as part of an ongoing programme of improvements. The report arising from this audit identified some gaps in the existing arrangements and a comprehensive action plan has resulted. A waste manager has been appointed to implement the plan. C8b – Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff and address, where appropriate, under-representation of minority groups In managing the operational risks to delivery of performance targets, the Trust has been unable to support all staff through organisational and personal development programmes or to ensure that staff concerned with all aspects of the provision of healthcare have participated in mandatory training programmes. The Trust has undertaken a significant recruitment programme during 2008/09 to ensure there are sufficient resources to achieve both operational performance improvements and staff development. Further planning with PCTs in the early part of 2009/10 focuses on achievement of these important targets in 2009/10. The Trust has some further work to do to become fully compliant with the core standards. Control measures are in place to ensure that all the Trust’s obligations under equality, diversity and human rights legislation are complied with. In managing the operational risks to delivery of performance targets, the Trust did not achieve compliance with this standard during 2008/09 but has a plan in place to achieve compliance during 2009/10. 46

C11b â&#x20AC;&#x201C; Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare, participate in mandatory training programmes. The Trust has changed its approach to the delivery of mandatory training during 2008/09 and has made progress with achieving compliance with this standard. Managing the operational risks to delivery of performance targets has impacted on the completion of the programme by 31 March 2009 and the Trust plans to achieve compliance by June 2009.

6 Summary The Board has commissioned a comprehensive review of internal control mechanisms within the Trust in 2009/10 primarily through strengthening executive support and the full programme of audit review work commissioned through the new Internal Audit team. It has actively identified control gaps and established action plans to address these which are now overseen directly by the Trustâ&#x20AC;&#x2122;s Governance Committee. The delivery of key performance targets in 2008/09 has fallen short but with new investment and robust planning for the forthcoming year which have been formally agreed with the PCTs, the Trust is seeking to address its key performance gaps. These plans are now central to the Trustâ&#x20AC;&#x2122;s integrated planning and monitoring arrangements for 2009/10 and beyond. As the new Chief Executive appointed on the 1 April 2009 this statement reflects my understanding for the 2008/09 position on internal control and I underline my commitment to improve controls throughout the organisation in 2009/10.

Accounts 2008/09 Audit and Risk Committee Annual Report Introduction 1. This report of the Audit and Risk Committee to the Trust Board covers the main items of work undertaken by the Committee during 2008/09.

Remit and Terms of Reference 2. The Committee’s Terms of Reference require it to take a wide responsibility for scrutinising the risks and controls which affect all aspects of the Trust’s work, whilst continuing to cover traditional financially orientated issues.

Membership 3. I continued as Chair of the Audit and Risk Committee, having been appointed by the Trust Board at the start of the 2007/08 financial year. Both of the existing members of the Committee, Elizabeth McLoughlin (an original member of the Committee) and John Newman (appointed December 2007), served on the Committee throughout the period under review. John Newman also continued as the vice Chair of the Committee. We have considered our own expertise which covers both the private and the public sector. All of us have Audit Committee and Board level experience in organisations with budgets of similar or greater size than that of the Trust (two of us have been Finance Directors). Additionally two of us are or have been members of Office of Government Commerce’s Gateway Review Teams, accredited to cover large scale high-risk, mission-critical programmes. On this basis we have concluded that our experience and competences are fully adequate for our role. 4. Meetings of the Committee are attended on a regular basis by the Finance Director, the Director of Corporate Development (until September 2008), Board Secretary, the Internal and External Auditors and the Local Counter Fraud Service. The Trust Chair and Chief Executive attend at their discretion. 5. The members of the Committee meet annually in private with the Internal and External Auditors.

Achievements 6. The Committee met five times during 2008/09, in accordance with its agreed plan of work. 7. The newly appointed Internal Auditors, PricewaterhouseCoopers (PwC), took over at the beginning of the period. They acted promptly to turn their indicative internal audit plan, prepared during the tender process, into an agreed plan. This plan has been adjusted throughout the year to ensure their focus on key areas of risk to the Trust.

8. Whilst early reports from the Internal Auditors indicated progress with internal control arrangements, further in-depth reviews carried out later in the year showed certain deficiencies in controls relating to payroll and overtime recording that had not previously been identified. The Committee noted that the Finance Director had a sound plan to address these deficiencies but were concerned that the need to commit management resources to operational performance had delayed implementation of the improved procedures. This situation was reported to the Board following the presentation of the internal audit reports to the Committee. 9. PwC also provided assistance to the Trust in planning for the implementation of the Trust’s new Computer Aided Dispatch system. They supplied an experienced project auditor who helped ensure the quality of the plan. 10. The Committee recognised that the level of risk to the organisation increased significantly following the departure of the Chief Executive and Finance Director at the end of September 2008 and their replacement by interim appointees. This risk was further increased in early October by the secondment from the Trust of the previous Directors of Operations and of Corporate Development. The Committee directed at its December meeting that this risk be added to the Risk Register. 11. We have continued with our formal programme of review of Risk Management (as linked to the Assurance Framework) with each of the Trust’s Executive Directors (or those holding comparable responsibilities). Our understanding of how risk is identified and managed has given us confidence in our review of the internal audit programme and helps us to ensure that it is directed to appropriate areas. 12. We have considered how the Trust’s declarations to the Healthcare Commission (and other comparable bodies) have been developed and tested and are satisfied with the relevant processes. The declarations that have been made are consistent with our understanding of the Trust’s position, obtained through our work on Risk Management and the Assurance Framework. 13. We have continued to press for the implementation of Internal Audit recommendations and believe that the Trust has now reduced the backlog to an acceptable level. 14. The Committee has received regular reports from the Local Counter Fraud Service and considered their programme of work. No issues of particular concern have arisen. We are pleased to record that the Trust was awarded a rating of four (the highest possible) as part of the NHS Counter Fraud Service’s Quality Assurance Programme. 15. There are no areas of significant duplication or omission in the systems of governance in the organisation that have come to the Committee’s attention and have not been adequately resolved. 16. The Committee has considered the draft statement on Internal Control presented to the External Auditors and confirms that it is consistent with their view on the Trust’s system of internal control. It supports the Board’s approval of the statement.

Accounts 2008/09 17. Lastly I would like to thank the staff of the Trust for their cooperation and assistance over the past year and to pay tribute to my colleagues for their continuing dedication to ensure the success of our work.

23 Apr

19 Jun

11 Sep

12 Dec

16 Mar

Leo Doyle

√

John Newman

√

Elizabeth McLoughlin

Leo Doyle Chair, Audit and Risk Committee

√

Full Accounts 2008/09

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

FOREWORD TO THE ACCOUNTS Great Western Ambulance Service NHS Trust These accounts for the year ended 31 March 2009 have been prepared by the Great Western Ambulance Service NHS Trust under section 98(2) of the National Health Service Act 1977 (as amended by section 24(2), schedule 2 of the National Health Service Community Care Act 1990) in the form which the Secretary of State has, with the approval of the Treasury, directed.

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

INCOME AND EXPENDITURE ACCOUNT FOR THE YEAR ENDED 31 March 2009

2007/08 NOTE

£000

Income from activities

78,723

67,481

Other operating income

1,440

1,505

(79,246)

(67,026)

917

1,960

(1)

SURPLUS (DEFICIT) BEFORE INTEREST

916

1,987

Interest receivable

157

431

Operating expenses

5-7

OPERATING SURPLUS (DEFICIT) Cost of fundamental reorganisation/restructuring Profit (loss) on disposal of fixed assets

Interest payable

(17)

(2)

Other finance costs - unwinding of discount

(24)

(22)

1,032

2,394

(1,027)

(945)

1,449

SURPLUS (DEFICIT) FOR THE FINANCIAL YEAR Public Dividend Capital dividends payable RETAINED SURPLUS (DEFICIT) FOR THE YEAR The notes on pages 57 to 81 form part of these accounts. All income and expenditure is derived from continuing operations.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

STATEMENT OF TOTAL RECOGNISED GAINS AND LOSSES FOR THE YEAR ENDED 31 March 2009 2007/08 ÂŁ000

ÂŁ000

1,032

2,394

(3,052)

1,736

Increases in the donated asset and government grant reserve due to receipt of donated and government grant financed assets

Additions (reductions) in "other reserves"

(2,020)

4,130

(2,020)

4,130

Surplus (deficit) for the financial year before dividend payments Fixed asset impairment losses Unrealised surplus (deficit) on fixed asset revaluations/indexation

Total recognised gains and losses for the financial year Prior period adjustment Total gains and losses recognised in the financial year

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

CASH FLOW STATEMENT FOR THE YEAR ENDED 31 March 2009 £000

2007/08 £000

2,877

9,208

RETURNS ON INVESTMENTS AND SERVICING OF FINANCE: Interest received Interest paid Interest element of finance leases

155 (17) -

428 (2) -

Net cash inflow (outflow) from returns on investments and servicing of finance

138

426

CAPITAL EXPENDITURE (Payments) to acquire tangible fixed assets Receipts from sale of tangible fixed assets (Payments) to acquire intangible assets Receipts from sale of intangible assets (Payments to acquire)/receipts from sale of fixed asset investments (Payments to acquire)/receipts from sale of financial instruments

(5,343) 41 -

(2,971) 36 -

Net cash inflow (outflow) from capital expenditure

(5,302)

(2,935)

DIVIDENDS PAID

(1,027)

(945)

Net cash inflow (outflow) before management of liquid resources and financing

(3,314)

5,754

MANAGEMENT OF LIQUID RESOURCES (Purchase) of investments with DH (Purchase) of other current asset investments Sale of investments with DH Sale of current asset investments

Net cash inflow (outflow) from management of liquid resources

(3,314)

5,754

Public dividend capital received Public dividend capital repaid Loans received from Department of Health Other loans received Loans repaid to Department of Health Other loans repaid Other capital receipts Capital element of finance leases Cash transferred (to)/from other NHS bodies

215 2,460 (224) -

(2,327) -

Net cash inflow (outflow) from financing

2,451

(2,327)

(863)

3,427

NOTE OPERATING ACTIVITIES Net cash inflow (outflow) from operating activities

Net cash inflow (outflow) before financing

18.1

FINANCING

Increase (decrease) in cash

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

NOTES TO THE ACCOUNTS 1

Accounting policies The Secretary of State for Health has directed that the financial statements of NHS Trusts shall meet the accounting requirements of the NHS Trusts Manual for Accounts which shall be agreed with HM Treasury. The accounting policies contained in that manual follow UK generally accepted accounting practice and HM Treasury's Financial Reporting Manual to the extent that they are meaningful and appropriate to the NHS. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of fixed assets at their value to the business by reference to their current costs. NHS Trusts are not required to provide a reconciliation between current cost and historical cost surpluses and deficits. 1.2 Acquisitions and discontinued operations Activities are considered to be 'acquired' only if they are acquired from outside the public sector. Activities are considered to be 'discontinued' only if they cease entirely. They are not considered to be 'discontinued' if they transfer from one public sector body to another. 1.3 Income recognition Income is accounted for applying the accruals convention. The main source of income for the Trust is from commissioners in respect of healthcare services provided under local agreements. Income is recognised in the period in which services are provided. Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred. 1.4 Intangible fixed assets Intangible assets are capitalised when they are capable of being used in a Trust's activities for more than one year; they can be valued; and they have a cost of at least ÂŁ5,000. Intangible fixed assets held for operational use are valued at historical cost and are depreciated over the estimated life of the asset on a straight line basis, except capitalised Research and Development which is carried at current cost. The carrying value of intangible assets is reviewed for impairment at the end of the first full year following acquisition and in other periods if events or changes in circumstances indicate the carrying value may not be recoverable.

Purchased computer software licences are capitalised as intangible fixed assets where expenditure of at least ÂŁ5,000 is incurred. They are amortised over the shorter of the term of the licence and their useful economic lives.

Great Western Ambulance Service NHS Trust

1.5

Annual Accounts 2008/09

Tangible fixed assets Capitalisation Borrowing costs associated with the construction of new assets are not capitalised. Tangible assets are capitalised if they are capable of being used for a period which exceeds one year and they: -

individually have a cost of at least £5,000; or

collectively have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or

form part of the initial equipping and setting-up cost of a new building, ward or unit irrespective of their individual or collective cost.

Valuation

Tangible fixed assets are stated at the lower of replacement cost and recoverable amount. On initial recognition they are measured at cost (for leased assets, fair value) including any costs such as installation directly attributable to bringing them into working condition. They are restated to current value each year. The carrying values of tangible fixed assets are reviewed for impairment in periods if events or changes in circumstances indicate the carrying value may not be recoverable.

All land and buildings are restated to current value using professional valuations in accordance with Financial Reporting Standard 15 every five years and in the intervening years by the use of indices. The buildings index is based on the All in Tender Price Index published by the Building Cost Information Service (BCIS). The land index is based on the residential building land values reported in the Property Market Report published by the Valuation Office.

Professional valuations are carried out by the District Valuers of the Revenue and Customs Government Department. The valuations are carried out in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual insofar as these terms are consistent with the agreed requirements of the Department of Health and HM Treasury. In accordance with the requirements of the Department of Health, the last asset valuations were undertaken in 2004 as at the prospective valuation date of 1 April 2005 and were applied on the 31 March 2005.

The valuations are carried out primarily on the basis of Depreciated Replacement Cost for specialised operational property and Existing Use Value for non-specialised operational property. The value of land for existing use purposes is assessed at Existing Use Value. For non-operational properties including surplus land, the valuations are carried out at Open Market Value. Additional alternative Open Market Value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal.

Gains arising from indexation and revaluations are taken to the Revaluation Reserve. Losses arising from revaluation are recognised as impairments and are charged to the revaluation reserve to the extent that a balance exists in relation to the revalued asset. Losses in excess of that amount are charged to the current year’s Income & Expenditure account, unless it can be demonstrated that the recoverable amount is greater than the revalued amount in which case the impairment is taken to the revaluation reserve. Diminutions in value when newly constructed assets are brought into use are charged in full to the Income & Expenditure account. These falls in value result from the adoption of ideal conditions as the basis for Depreciated Replacement Cost valuations.

Assets in the course of construction are valued at current cost using the indices as for land and buildings, as above. These assets include any existing land or buildings under the control of a contractor.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

Residual interests in off-balance sheet Private Finance Initiative properties are included in tangible fixed assets as 'assets under construction and payments on account' where the PFI contract specifies the amount, or nil value at which the assets will be transferred to the Trust at the end of the contract. The residual interest is built up, on an actuarial basis, during the life of the contract by capitalising part of the unitary charge so that at the end of the contract the balance sheet value of the residual value plus the specified amount equal the expected fair value of the residual asset at the end of the contract. The estimated fair value of the asset on reversion is determined by the District Valuer based on Department of Health guidance. The District Valuer should provide an estimate of the anticipated fair value of the assets on the same basis as the District Valuer values the NHS Trust's estate. Operational equipment carried at current value. Where assets are of low value, and/or have short useful economic lives, these are carried at depreciated historic cost as a proxy for current value. Equipment surplus to requirements is valued at net recoverable amount. Depreciation, amortisation and impairments Tangible fixed assets are depreciated at rates calculated to write them down to estimated residual value on a straight-line basis over their estimated useful lives. No depreciation is provided on freehold land and assets surplus to requirements. Assets in the course of construction and residual interests in off-balance sheet PFI contract assets are not depreciated until the asset is brought into use or reverts to the Trust, respectively. Buildings, installations and fittings are depreciated on their current value over the estimated remaining life of the asset as advised by the District Valuer. Leaseholds are depreciated over the primary lease term. Equipment is depreciated on current cost evenly over the estimated life of the asset. Assets are depreciated over their expected useful lives as follows:

Software Licences Buildings exc dwellings Plant & Machinery Transport Equipment Information Technology Furniture and Fittings

Minimium life (Years) 5 3 5 5 3 5

Maximum life (Years) 5 83 15 7 10 10

Where the useful economic life of an asset is reduced from that initially estimated due to the revaluation of an asset for sale, depreciation is charged to bring the value of the asset to its value at the point of sale. 1.6 Donated fixed assets Donated fixed assets are capitalised at their current value on receipt and this value is credited to the Donated Asset Reserve. Donated fixed assets are valued and depreciated as described above for purchased assets. Gains and losses on revaluations are also taken to the Donated Asset Reserve and, each year, an amount equal to the depreciation charge on the asset is released from the Donated Asset Reserve to the Income and Expenditure account. Similarly, any impairment on donated assets charged to the Income and Expenditure Account is matched by a transfer from the Donated Asset Reserve. On sale of donated assets, the value of the sale proceeds is transferred from the Donated Asset Reserve to the Income and Expenditure Reserve. 1.7 Government grants Government grants are grants from government bodies other than funds from NHS bodies or funds awarded by Parliamentary Vote. Gains and losses on revaluations are also taken to the Government Grant Reserve and, each year, an amount equal to the depreciation charge on the asset is released from the Government Grant Reserve to the Income and Expenditure account. Similarly, any impairment on grant funded assets charged to the Income and Expenditure Account is matched by a transfer from the Reserve.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

1.8 Private Finance Initiative (PFI) transactions The NHS follows HM Treasury's Technical Note 1 (Revised) "How to Account for PFI transactions" which provides practical guidance for the application of Application Note F to FRS 5 and the guidance 'Land and Buildings in PFI schemes Version 2'. Where the balance of the risks and rewards of ownership of the PFI property are borne by the PFI operator, the PFI obligations are recorded as an operating expense. Where the Trust has contributed assets, a prepayment for their fair value is recognised and amortised over the life of the PFI contract by charge to the Income and Expenditure Account. Where, at the end of the PFI contract, a property reverts to the Trust, the difference between the expected fair value of the residual on reversion and any agreed payment on reversion is built up over the life of the contract by capitalising part of the unitary charge each year, as a tangible fixed asset. Where the balance of risks and rewards of ownership of the PFI property are borne by the Trust, it is recognised as a fixed asset along with the liability to pay for it which is accounted for as a finance lease. Contract payments are apportioned between an imputed finance lease charge and a service charge. 1.9

Stocks and work-in-progress Stocks and work-in-progress are valued at the lower of cost and net realisable value. This is considered to be a reasonable approximation to current cost due to the high turnover of stocks. Work-in-progress comprises goods in intermediate stages of production. Partially completed contracts for patient services are not accounted for as work-in-progress.

1.10 Research and development Expenditure on research is not capitalised. Expenditure on development is capitalised if it meets the following criteria: -

there is a clearly defined project; the related expenditure is separately identifiable; the outcome of the project has been assessed with reasonable certainty as to: - its technical feasibility; - its resulting in a product or service which will eventually be brought into use; adequate resources exist, or are reasonably expected to be available, to enable the project to be completed and to provide any consequential increases in working capital.

Expenditure so deferred is limited to the value of future benefits expected and is amortised through the income and expenditure account on a systematic basis over the period expected to benefit from the project. It is revalued on the basis of current cost. The amortisation charge is calculated on the same basis as used for depreciation i.e. on a quarterly basis. Expenditure which does not meet the criteria for capitalisation is treated as an operating cost in the year in which it is incurred. NHS Trusts are unable to disclose the total amount of research and development expenditure charged in the Income and Expenditure account because some research and development activity cannot be separated from patient care activity. Fixed assets acquired for use in research and development are amortised over the life of the associated project. 1.11 Provisions The Trust provides for legal or constructive obligations that are of uncertain timing or amount at the balance sheet date on the basis of the best estimate of the expenditure required to settle the obligation. Where the effect of the time value of money is material, the estimated risk-adjusted cash flows are discounted using the Treasury's discount rate of 2.2% in real terms.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases the legal liability remains with the Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Trust is disclosed at note 16. Non-clinical risk pooling The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHSLA and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any 'excesses' payable in respect of particular claims are charged to operating expenses as and when they become due. 1.12 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The Scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The Scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying Scheme assets and liabilities. Therefore, the Scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the Scheme is taken as equal to the contributions payable to the Scheme for the accounting period.

The Scheme is subject to a full actuarial valuation every four years (until 2004, based on a five year valuation cycle), and a FRS17 accounting valuation every year. An outline of these follows: a) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the Scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and Scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2004 and covered the period from 1 April 1999 to that date. The conclusion from the 2004 valuation was that the Scheme had accumulated a notional deficit of ÂŁ3.3 billion against the notional assets as at 31 March 2004. However, after taking into account the changes in the benefit and contribution structure effective from 1 April 2008, the Scheme actuary reported that employer contributions could continue at the existing rate of 14% of pensionable pay. On advice from the Scheme actuary, Scheme contributions may be varied from time to time to reflect changes in the Schemeâ&#x20AC;&#x2122;s liabilities. Up to 31 March 2008, the vast majority of employees paid contributions at the rate of 6% of pensionable pay. From 1 April 2008, employees contributions are on a tiered scale from 5% up to 8.5% of their pensionable pay depending on total earnings. b) FRS17 Accounting valuation In accordance with FRS17, a valuation of the Scheme liability is carried out annually by the Scheme Actuary as at the balance sheet date by updating the results of the full actuarial valuation. Between the full actuarial valuations at a two-year midpoint, a full and detailed member data-set is provided to the Scheme Actuary. At this point the assumptions regarding the composition of the Scheme membership are updated to allow the Scheme liability to be valued. The valuation of the Scheme liability as at 31 March 2009, is based on detailed membership data as at 31 March 2006 (the latest midpoint) updated to 31 March 2009 with summary global member and accounting data.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

The latest assessment of the liabilities of the Scheme is contained in the Scheme Actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Resource Account, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. Scheme provisions as at 31 March 2009 The Scheme is a “final salary” scheme. For early retirements other than those due to ill health the additional pension liabilities are not funded by the Scheme. The full amount of the liability for the additional costs is charged to the Income and Expenditure account at the time the Trust commits itself to the retirement, regardless of the method of payment.

The Scheme provides the opportunity to members to increase their benefits through money purchase Additional Voluntary Contributions (AVCs) provided by an approved panel of life companies. Under the arrangement the employee/member can make contributions to enhance an employee's pension benefits. The benefits payable relate directly to the value of the investments made. From 1 April 2008 a voluntary additional pension facility becomes available, under which members may purchase up to £5,000 per annum of additional pension at a cost determined by the actuary from time-to-time.

Early payment of a pension is available to members of the Scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement, less pension already paid, subject to a maximum amount equal to twice the member’s final year’s pensionable pay less their retirement lump sum for those who die after retirement, is payable. Existing members at 1 April 2008 Annual pensions are normally based on 1/80th of the best of the last 3 years pensionable pay for each year of service. A lump sum normally equivalent to 3 years pension is payable on retirement. From 1 April 2008 there is the opportunity of giving up some of the pension to increase the retirement lump sum. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. On death, a pension of 50% of the member’s pension is normally payable to the surviving spouse or eligible unmarried partner. New entrants from 1 April 2008 Annual pensions for new entrants from 1 April 2008 will be based on 1/60th of the best three-year average of pensionable earnings in the ten years before retirement. Members wishing to obtain a retirement lump sum may give up some of this pension to obtain a retirement lump of up to 25% of the total value of their retirement benefits. Survivor pensions will be available to married and unmarried partners and will be equal to 37.5% of the member's pension. 1.13 Liquid resources Deposits and other investments that are readily convertible into known amounts of cash at or close to their carrying amounts are treated as liquid resources in the cashflow statement. The Trust does not hold any investments with maturity dates exceeding one year from the date of purchase. 1.14 Value Added Tax Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

1.15 Foreign exchange Transactions that are denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. Resulting exchange gains and losses are taken to the Income and Expenditure Account. 1.16 Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Trust has no beneficial interest in them. Details of third party assets are given in Note 28 to the accounts. 1.17 Leases the asset is recorded as a tangible fixed asset and a debt is recorded to the lessor of the minimum lease payments discounted by the interest rate implicit in the lease. The interest element of the finance lease payment is charged to the Income and Expenditure Account over the period of the lease at a constant rate in relation to the balance outstanding. Other leases are regarded as operating leases and the rentals are charged to the Income and Expenditure Account on a straight-line basis over the term of the lease. 1.18 Public Dividend Capital (PDC) and PDC Dividend Public Dividend Capital represents the outstanding public debt of an NHS Trust. At any time the Secretary of State can issue new PDC to, and require repayments of PDC from, the NHS Trust. A charge, reflecting the forecast cost of capital utilised by the NHS Trust, is paid over as public dividend capital dividend. The charge is calculated at the real rate set by HM Treasury (currently 3.5%) on the forecast average carrying amount of all assets less liabilities, except for donated assets and cash with the Office of the Paymaster General. The average carrying amount of assets is calculated as a simple average of opening and closing relevant net assets. A note to the accounts discloses the rate that the dividend represents as a percentage of the actual average carrying amount of assets less liabilities in the year. 1.19 Losses and special payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way each individual case is handled. Losses and special payments are charged to the relevant functional headings in the Income and Expenditure account on an accruals basis, including losses which would have been made good through insurance cover had NHS Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). 1.20 EU Emissions Trading Scheme (EU ETS) EU Emission Trading Scheme allowances are accounted for as Government Granted Other Current Assets, valued at open market value. As the Trust makes emissions a provision is recognised, with an offsetting transfer from the Government Grant Reserve. The provision is settled on surrender of the allowances. The current asset, provision and Government Grant Reserve are valued at current market value at the Balance Sheet date.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

1.21 Financial assets Financial assets are recognised on the balance sheet when the Trust becomes party to the financial instrument contract or, in the case of trade debtors, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are initially recognised at fair value. Financial assets are classified into the following categories: financial assets ‘at fair value through profit and loss’; ‘held to maturity investments’; ‘available for sale’ financial assets, and ‘loans and receivables’. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition. Financial assets at fair value through profit and loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the Income and Expenditure Account. The net gain or loss incorporates any interest earned on the financial asset. Held to maturity investments Held to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Available for sale financial assets Available for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the Revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to the Income and Expenditure Account on derecognition. Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the net carrying amount of the financial asset. At the balance sheet date, the Trust assesses whether any financial assets, other than those held 'at fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Income and Expenditure Account and the carrying amount of the asset is reduced directly, or through a provision for impairment of debtors. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through the Income and Expenditure Account to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised. Financial liabilities Financial liabilities are recognised on the balance sheet when the Trust becomes party to the contractual provisions of the financial instrument or, in the case of trade creditors, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired. Financial liabilities are initially recognised at fair value Financial liabilities are classified as either financial liabilities ‘at fair value through profit and loss’ or other financial liabilities. Financial liabilities at fair value through profit and loss. Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the Income and Expenditure Account. The net gain or loss incorporates any interest earned on the financial asset. Other financial liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method. 2

Segmental analysis All the Trust's activities are healthcare related, hence there is no segmental analysis.

Great Western Ambulance Service NHS Trust 3

Income from activities

Strategic Health Authorities NHS Trusts Primary Care Trusts Foundation Trusts Department of Health NHS Other Non NHS: - Road Traffic Act / Injury cost recovery - Other

£000 4,438 2,228 67,146 4,465 295 -

2007/08 £000 5,251 59,879 1,845 236 93

137 14

30 147

78,723

67,481

£000 43 660 17 374 346

2007/08 £000 3 625 57 820

1,440

1,505

Other operating income

Patient transport services Education, training and research Charitable and other contributions to expenditure Transfers from donated asset and government grant reserves Non-patient care services to other bodies Income generation Other income †

Annual Accounts 2008/09

† Other income relates to call handling, paramedic cover at private events and miscellanous income. Operating expenses

5.1 Operating expenses comprise:

Services from other NHS Trusts Services from PCTs Services from other NHS bodies Services from Foundation Trusts Purchase of healthcare from non NHS bodies Directors' costs Staff costs Supplies and services - clinical Supplies and services - general Consultancy Services Establishment Transport Premises Impairment of debtors Depreciation Amortisation Fixed asset impairments and reversals Audit fees Other auditor's remuneration Clinical negligence Redundancy Education and Training Other

£000 755 55,892 2,109 724 210 2,815 8,699 3,496 45 2,622 57 107 152 947 616

2007/08 £000 765 47,428 1,472 1,266 496 1,797 6,978 3,208 2,596 35 129 125 412 319

79,246

67,026

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

5.2

Operating leases

5.2/1

Operating expenses include: £000

Hire of plant and machinery Other operating lease rentals

5.2/2

156 936

54 891

1,092

945

Annual commitments under non - cancellable operating leases are: Land and buildings 2007/08 £000 £000

Operating leases which expire: Within 1 year Between 1 and 5 years After 5 years

Staff costs and numbers

6.1

Staff costs

1 154 -

91 655 -

168 543 -

235

155

746

711

£000

Salaries and wages Social Security Costs Employer contributions to NHSBSA- pensions division Other pension costs

Other leases 2007/08 £000 £000

16 209 10

Total

6.2

2007/08 £000

48,475 3,141 4,979 56,595

Permanently Employed £000

40,467 3,141 4,979 48,587

Other

2007/08 £000

£000

8,008 8,008

40,819 2,859 4,468 48,146

Other

2007/08

Average number of persons employed Total

Medical and dental Ambulance staff Administration and estates Healthcare assistants and other support staff Other Total

Permanently Employed

Number

9 864 385 150 1,408

7 852 349 149 1,357

2 12 36 1 51

9 798 317 172 1,296

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

6.3 Employee benefits No amounts were paid in respect of employee benefits (2007/08: £Nil). 6.4 Management costs 2007/08 £000 Management costs Income

£000

6,212

5,030

80,163

69,418

6.5 Retirements due to ill-health

During the year there was 1 early retirement from the Trust agreed on the grounds of ill-health (2007/08: 5). The estimated additional pension liabilities of these ill-health retirements will be £253,000 (2007/08: £280,000). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - pensions division. 7

Better Payment Practice Code

7.1 Better Payment Practice Code - measure of compliance 2008/09

2008/09

Number

£000

Total Non-NHS trade invoices paid in the year

22,075

28,746

Total Non-NHS trade invoices paid within target

20,905

25,421

Percentage of Non-NHS trade invoices paid within target

95%

88%

Total NHS trade invoices paid in the year

1,233

7,236

Total NHS trade invoices paid within target

1,134

6,677

Percentage of NHS trade invoices paid within target

92%

The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. 2007/08 7.2 The Late Payment of Commercial Debts (Interest) Act 1998

£000

Amounts included within Interest Payable (Note 9) arising from claims made under this legislation

Compensation paid to cover debt recovery costs under this legislation

Other gains and losses Profit/loss on the disposal of fixed assets is made up as follows: 2007/08 £000

£000

Profit/(loss) on disposal of fixed asset investments

Profit/(loss) on disposal of intangible fixed assets

Profit/(loss) on disposal of land and buildings

Profit on disposal of plant and equipment

Loss on disposal of plant and equipment

(12)

(1)

Gain/(loss) on foreign exchange

(1)

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

9 Finance costs and interest receivable 2007/08 £000

£000 Finance costs Finance leases Late payment of commercial debt Loans Bank overdraft Other

Interest receivable Bank accounts Impaired financial assets Other financial assets

17 -

2 -

157 -

431 -

157

431

Total

Development expenditure

Patents

Software Licences

Licences and trademarks

10 Intangible fixed assets

£000 420 420

£000 -

£000 420 420

343 57 400

Net book value 1 April 2008 - Purchased - Donated - Government Granted Total at 1 April 2008

77 77

Net book value 31 March 2009 - Purchased - Donated - Government Granted Total at 31 March 2009

20 20

Gross cost at 1 April 2008 Indexation Impairments Reclassifications Other revaluation Additions purchased Additions donated Additions government granted Disposals At 31 March 2009 Amortisation at 1 April 2008 Indexation Impairments Reversal of Impairments Reclassifications Other revaluation Charged during the year Disposals At 31 March 2009

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

11 Tangible fixed assets

Buildings excluding dwellings

Dwellings

Plant & Machinery

Transport Equipment

Information Technology

Furniture & fittings

Total

£000 13,543 (2,596) 10,947

£000 10,724 428 (715) 10,437

£000 -

£000 3,165 5,344 (7,334) 1,175

£000 3,382 418 88 (633) 3,255

£000 12,409 4,130 324 (777) 16,086

£000 2,998 2,358 5,356

£000 238 6 244

£000 46,459 5,344 (2,893) (1,410) 47,500

517 (119) 398

2,993 172 78 (633) 2,610

7,450 1,574 195 (736) 8,483

2,798 352 3,150

194 7 5 206

13,435 2,622 159 (1,369) 14,847

Net book value - Purchased at 31 March 2008 - Donated at 31 March 2008 - Government Granted at 31 March 2008 Total at 31 March 2008

13,543 13,543

10,724 10,724

3,165 3,165

368 21 389

4,959 4,959

200 200

44 44

33,003 21 33,024

- Purchased at 31 March 2009 - Donated at 31 March 2009 - Government Granted at 31 March 2009

10,947 -

10,039 -

1,175 -

641 4 -

7,603 -

2,206 -

38 -

32,649 4 -

Total at 31 March 2009

10,947

10,039

1,175

645

7,603

2,206

32,653

Cost or valuation at 1 April 2008 Additions purchased Additions donated Additions government granted Impairments Reclassifications Indexation Other in year revaluation Disposals At 31 March 2009 Depreciation at 1 April 2008 Charged during the year Impairments Reversal of Impairments Reclassifications Indexation Other in year revaluation Disposals At 31 March 2009

Assets under construction and payments on account

Land

11.1 Tangible fixed assets at the balance sheet date comprise the following elements:

Of the totals at 31 March 2009, £Nil related to land valued at open market value, £Nil related to buildings valued at open market value and £Nil related to dwellings valued at open market value.

There are no reversals of impairments.

During the period no assets had a material change in the estimate of useful economic life/residual value. No assets were held under finance leases or hire purchase contracts at the balance sheet date. No depreciation has been charged to the income and expenditure account in respect of assets held under finance leases and hire purchase contracts (2007/08: £Nil).

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

11.2 The net book value of land, buildings and dwellings comprises: 2007/08 £000

£000

20,986

24,267

Long leasehold

Short leasehold

20,986

24,267

Freehold

Total 12

Stocks and Work in Progress 2007/08

Raw materials and consumables

£000

295

249

Work-in-progress

Finished goods

295

249

Total 13

£000

Debtors

13.1 Debtors at the balance sheet date are made up of:

2007/08 £000

£000

993

3,054

Amounts falling due within one year: NHS debtors Non NHS Trade Debtors Provision for impairments of debtors Other prepayments and accrued income Other debtors Sub total

(51)

(6)

1,423

1,632

768

1,214

3,133

5,894

Amounts falling due after more than one year: 452

431

Non NHS Trade Debtors

NHS debtors

Provision for impairments of debtors

1,219

1,236

Other prepayments and accrued income Other debtors

Sub total

1,671

1,667

Total

4,804

7,561

Other Debtors include £Nil prepaid pension contributions at 31 March 2009 (31 March 2008: £Nil). 2007/08 £000

£000

Balance at 1 April 2008

Amount written off during the year

Amount recovered during the year

13.2 Provision for impairment of debtors

Increase/(decrease) in debtors impaired

Balance at 31 March 2009

13.3 Debtors past due date but not impaired: 398

612

By 3 to 6 months

By more than 6 months

398

690

By up to 3 months

Great Western Ambulance Service NHS Trust

Annual Accounts 2008/09

Other financial assets The Trust has no fixed or current financial assets (2007/08: £Nil).

Creditors

15.1 Creditors at the balance sheet date are made up of: 2007/08 £000

£000

Amounts falling due within one year: Bank overdrafts

448

Interest payable

Payments received on account

586

886

1,132

Current instalments due on loans

NHS creditors Non - NHS trade creditors - revenue Non - NHS trade creditors - capital

Tax

706

VAT

Social security costs

568

Obligations under finance leases and hire purchase contracts

547

Accruals and deferred income

5,479

3,981

Sub total

6,586

7,820

Other creditors

Amounts falling due after more than one year: Long - term loans

1,788

Obligations under finance leases and hire purchase contracts

NHS creditors

Sub total

1,849

Total

8,435

7,820

Other

Other creditors include; -

£Nil for payments due in future years under arrangements to buy out the liability for early retirements over 5 years (31 March 2008: £Nil); and

- £Nil outstanding pensions contributions at 31 March 2009 (31 March 2008: £524,000).

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

15.2 Loans and other long-term financial liabilities Dept of Health

Other

2007/08 £000

£000

Amounts falling due: In one year or less

448

Between one and two years

448

Between two and five years

1,340

TOTAL

2,236

Wholly repayable within five years

Over 5 years

2,236

Wholly repayable after five years, not by instalments

Wholly or partially repayable after five years, by instalments

2,236

TOTAL Total repayable after five years by instalments

Loans and long-term financial liabilities wholly or partially repayable after five years:

The Trust has no loans or long term liabilities wholly or partially repayable after five years at 31 March 2009 (2007/08: £Nil). 15.3 Finance lease obligations

The Trust has entered into no contracts to lease assets under a finance lease and has no finance lease obligations (2007/08: £Nil). 15.4 Other financial liabilities The Trust has no fixed or current financial liabilities (2007/08: £Nil).

Other

£000

2007/08 Total

Restructurings

£000

Total Legal claims

Pensions relating to other staff

Provisions for liabilities and charges Pensions relating to former directors

£000

£000 5,103

At 1 April 2008

3,234

3,333

Arising during the year

378

382

572

Utilised during the year

(6)

(648)

(654)

(1,524) (840)

Reversed unused

(1,520)

Unwinding of discount

At 31 March 2009

1,466

1,565

3,333

2,300

Expected timing of cashflows: Within one year

472

479

Between one and five years

199

225

215

After five years

795

861

818

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

Material items included within the above provisions are: Pensions for former staff (£99,000), injury benefits for former staff (£803,000), accrued leave for existing staff (£232,000), NHSLA liabilities to third parties (£144,000), grievances (£100,000), and backlog maintenance (£187,000). Amounts relating to former staff have been notified to the Trust by the NHS Business Services Authority and are subject to partial reimbursement by Gloucestershire PCT. Provisions relating to staff are calculated separately for each individual, taking account of their expected remaining life where appropriate, and will be paid as they fall due over a number of years. The remaining provisions are expected to be paid during 2009/10. £199,000 is included in the provisions of the NHS Litigation Authority at 31 March 2009 in respect of clinical negligence liabilities of the Trust (31 March 2008: £3,092,000). 17 Movements on reserves Movements on reserves in the year comprised the following:

Other transfers between reserves At 31 March 2009

Income and Expenditure Reserve

Transfers to the Income and Expenditure Account for depreciation of donated assets

Other Reserves

Transfer of realised profits/ (losses) to the Income and Expenditure Reserve

Government Grant Reserve

Surplus/(deficit) on revaluations/ indexation of fixed assets

Donated Asset Reserve

Transfer from the Income and Expenditure Account

Revaluation Reserve At 1 April 2008 as previously stated

Total

£000

3,180

484

3,685

(3,052)

(27)

(17)

(41)

196

421

621

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

Notes to the Cash Flow Statement

18.1

Reconciliation of operating surplus to net cash flow from operating activities: 2007/08

Total operating surplus (deficit) Depreciation and amortisation charge Fixed asset impairments and reversals Transfer from donated asset reserve Transfer from the government grant reserve

£000

917

1,960

2,679

2,631

(17)

(57)

(46)

(106)

(Increase)/decrease in debtors

2,757

2,223

Increase/(decrease) in creditors

(1,621)

4,349

Increase/(decrease) in provisions

(1,792)

2,877

9,208

2,877

9,208

(Increase)/decrease in stocks

Net cash inflow/(outflow) from operating activities before restructuring costs Payments in respect of fundamental reorganisation/restructuring Net cash flow from operating activities 18.2

£000

Reconciliation of net cash flow to movement in net debt 2007/08

Increase/(decrease) in cash in the period

£000

(863)

3,427

(2,460)

Cash outflow from debt repaid and finance lease capital payments

224

Cash (inflow)/outflow from (decrease)/increase in liquid resources

(3,099)

3,427

Cash (inflow) from new debt

Change in net debt resulting from cashflows Non - cash changes in debt Net debt at 1 April 2008 Net debt at 31 March 2009 18.3

£000

3,921

494

822

3,921

Analysis of changes in net debt At 1 April 2008

Cash Transferred (to)/from other NHS bodies

Cash changes in year

Non-cash changes in year

At 31 March 2009

£000

3,735

(841)

2,894

186

(22)

164

Bank overdraft

Loans from DH due within one year

(448)

Other debt due within one year

Loans from DH due after one year

(1,788)

OPG cash at bank Commercial cash at bank and in hand

Other debt due after one year

Finance leases

Current asset investments

Current financial assets

3,921

(3,099)

822

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

Capital commitments Commitments under capital expenditure contracts at the balance sheet date were £371,000 (31 March 2008: £853,000).

Post Balance Sheet Events There were no post balance sheet events having a material effect on the accounts for the year (2007/08: £Nil).

Contingencies Contingent liabilities: Great Western Ambulance Service NHS Trust is waiting to be advised about arrangements for a national panel to review the consistency of the Technician band 4 role. Due to the potentially complex nature of the possible obligation it is not practicable to estimate the financial effect. The outcome of the national panel is uncertain. (Contingent liabilities 2007/08: £Nil). Contingent Assets: The Trust has no contingent assets at the balance sheet date (2007/08: £Nil).

Movement in Public Dividend Capital 2007/08

Public Dividend Capital as at 1 April 2008 New Public Dividend Capital received Public Dividend Capital repaid in year

£000

29,994

32,321

215

(2,327)

Public Dividend Capital written off

Public Dividend Capital transferred to Foundation Trust

Other movements in Public Dividend Capital in year Public Dividend Capital as at 31 March 2009

30,209

29,994

The Trust repaid £2,327,000 of PDC in 2007/08 relating to an impairment for which both the cost of the impairment and the related offsetting income were accrued in the 2006/07 accounts. The receipt of cash in 2007/08 in respect of this impairment resulted in repayment of an equivalent amount of PDC. 23

Financial performance targets

23.1 Breakeven performance The Trust's breakeven performance for 2008/09 is as follows: 2006/07

2007/08

2008/09

£000

61,938 (1,430)

68,986 1,449

80,163 5

- Use of pre 1.4.97 surpluses [FDL(97)24 Agreements]

- Prior Period adjustments in 1997/98 to 2007/08 relating to 1997-2008

- in-year

(1,430)

1,449

- cumulative

(1,430)

- in-year, as a percentage of turnover

(2.31%)

2.10%

0.01%

- cumulative, as a percentage of turnover

(2.31%)

0.03%

Turnover Retained surplus/(deficit) for the year Adjustment for:

Break-even position:

Break even position materiality test:

The Trust was formed on 1st April 2006, hence no breakeven performance data is available prior to 2006/07.

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

23.2 Capital cost absorption rate The Trust is required to absorb the cost of capital at a rate of 3.5% of average relevant net assets. The rate is calculated as the percentage that dividends paid on public dividend capital, totalling £1,027,000, bears to the average relevant net assets of £28,928,000, that is 3.6,%. The variance from 3.5% is within the Department of Health's materiality range of 3.0% to 4.0%. 23.3 External financing The Trust is given an external financing limit (EFL) which it is permitted to undershoot.

£000 External financing limit Cash flow financing Finance leases taken out in the year Other capital receipts External financing requirement Undershoot/(overshoot)

£000

2007/08 £000

5,104

(5,751)

3,314

(5,754) (5,754)

1,790

3,314 -

23.4 Capital Resource Limit The Trust is given a capital resource limit (CRL) which it is not permitted to overspend.

Gross capital expenditure Less: book value of assets disposed of Plus: loss on disposal of donated assets Less: capital grants Less: donations towards the acquisition of fixed assets Charge against the CRL Capital resource limit (Over)/Underspend against the CRL

£000

2007/08 £000

5,344 (41) 5,303 5,847

2,958 (6) 2,952 2,959

544

Great Western Ambulance Service NHS Trust 24

Annual Accounts 2008/09

Related party transactions Great Western Ambulance Service NHS Trust is a body corporate established by order of the Secretary of State for Health.

During the year none of the Board Members or members of the key management staff or parties related to them has undertaken any material transactions with Great Western Ambulance Service NHS Trust. The Department of Health is regarded as a related party. During the year Great Western Ambulance Service NHS Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are listed below: Bath & NE Somerset Primary Care Trust Bristol Primary Care Trust Gloucestershire Primary Care Trust Gloucestershire Hospitals NHS Foundation Trust NHS Purchasing and Supply Agency North Bristol NHS Trust North Somerset Primary Care Trust Royal United Hospital Bath NHS Trust South Gloucestershire Primary Care Trust Swindon & Marlborough NHS Trust/Great Western Hospital NHS Foundation Trust Swindon Primary Care Trust United Bristol Healthcare NHS Trust/University Hospital Bristol Foundation Trust Wiltshire Primary Care Trust Balances with the above are included within Note 29. In addition, the Trust has had a number of material transactions with other Government Departments and other central and local Government bodies. Most of these transactions have been with local authorities in respect of business rates for ambulance premises. The Trust has also received income from Great Western Ambulance Service NHS Trust Charitable Fund, the Trustee for which is the Great Western Ambulance Service NHS Trust Board. 25

Private finance transactions

25.1

PFI schemes deemed to be off-balance sheet The Trust has no PFI schemes (2007/08: Nil).

25.2

'Service' element of PFI schemes deemed to be on-balance sheet No amounts are included in these accounts in respect of PFI schemes. The Trust is not committed to make any PFI payments during the next year (2007/08: Nil).

Pooled budgets The Trust has no Pooled Budget Projects (2007/08: Nil).

Financial instruments Financial Reporting Standard 29 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Trust has with Primary Care Trusts and the way those Primary Care Trusts are financed, the NHS Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which these standards mainly apply. The NHS Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Trust in undertaking its activities. The Trust's treasury management operations are carried out by the finance department, within parameters defined formally within the Trust's Standing Financial Instructions and policies agreed by the Board of Directors. Trust treasury activity is subject to review by the Trust's internal auditors.

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations.

Interest-rate risk The Trust borrows from Government for capital expenditure subject to affordability as confirmed by the Strategic Health Authority. The borrowings are for 1-25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations.

Credit risk Because of the majority of the Trust's income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposure as at 31 March 2009 are in receivables from customers, as disclosed in the debtors note.

Liquidity risk The Trust's new operating costs are incurred under contract with Primary Care Trusts, which are financed from resources voted annually by Parliament. The Trust funds its capital expenditure from funds obtained within its Prudential Borrowing Limit. The Trust is not, therefore, exposed to significant liquidity risks.

27.1 Financial assets Non-interest bearing

Fixed rate Total

Floating Fixed rate rate

Non-interest bearing

Weighted average interest rate

Currency

Weighted average period for which fixed

Weighted average term

£000

Years

3,510

2,894

452

164

3,510

2,894

452

164

4,352

3,735

431

186

4,352

3,735

431

186

At 31 March 2009 Sterling Other Gross financial assets At 31 March 2008 Sterling Other Gross financial assets

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust

27.2

Financial liabilities Noninterest bearing

Fixed rate Total

Floating rate

Fixed rate

Noninterest bearing

Weighted average interest rate

Weighted average period for which fixed

Weighted average term

Currency £000

£000

Years

(2,899)

(3,333)

At fair value through profit and loss

Loans and receivables

At 31 March 2009 Sterling Other Gross financial liabilities At 31 March 2008 Sterling Other Gross financial liabilities

27.3

Financial assets

£000

27.4

£000

Held to maturity £000

Available for sale

Total

£000

Embedded derivatives

NHS debtors

452

Non NHS debtors

Cash at bank and in hand

3,058

Other financial assets

Total at 31 March 2009

3,510

Financial liabilities At fair value through profit and loss

Non trading liabilities

Other

Total

£000

£000 -

Embedded derivatives

NHS creditors

Non NHS creditors

(2,236)

Borrowings

(2,236)

Private Finance Initiative and finance lease obligations

Other financial liabilities

(663)

Total at 31 March 2009

(2,899)

Annual Accounts 2008/09

Great Western Ambulance Service NHS Trust Notes a

These debtors reflect agreements with commissioners to cover creditors over 1 year for early retirements and provisions under contract, and their related interest charge/unwinding of discount. In line with note c below, fair value is not significantly different from book value.

To obtain fair value, cash flows have been discounted at prevailing market interest rates for finance leases for a similar term.

Fair value is not significantly different from book value since, in the calculation of book value, the expected cash flows have been discounted by the Treasury discount rate of 2.2% in real terms.

Third party assets The Trust held £Nil cash at bank and in hand at 31 March 2009 (31 March 2008: £Nil) which relates to monies held by the NHS Trust on behalf of patients.

Intra-Government and other balances Debtors: amounts falling due within one year

Balances with other Central Government Bodies Balances with Local Authorities Balances with NHS Trusts and Foundation Trusts Balances with Public Corporations and Trading Fu Balances with bodies external to government At 31 March 2009

£000 956 416 236 1,525 3,133

1,950 213 1,104 2,627 5,894

Debtors: amounts falling due after more than one year £000 452 1,219 1,671 1,667 1,667

Creditors: amounts falling due within one year £000 244 342 6,000 6,586

Creditors: amounts falling due after more than one year £000 1,788 61 1,849

2,248 183 5,389 7,820

Losses and Special Payments There were 3 cases of losses and special payments (2007/08: 5 cases) totalling £17,419 (2007/08: £27,796) paid during 2008/09. There were no clinical negligence cases where the net payment exceeded £250,000 (2007/08: no cases). There were no fraud cases where the net payment exceeded £250,000 (2007/08: no cases). There were no personal injury cases where the net payment exceeded £250,000 (2007/08: no cases). There were no compensation under legal obligation cases where the net payment exceeded £250,000 (2007/08: no cases). There were no fruitless payment cases where the net payment exceeded £250,000 (2007/08: no cases).

Independent auditor’s statement to the Board of Directors of Great Western Ambulance Service NHS Trust Opinion on the financial statements I have audited the financial statements of Great Western Ambulance Service NHS Trust for the year ended 31 March 2009 under the Audit Commission Act 1998. The financial statements comprise the Income and Expenditure Account, the Balance Sheet, the Cashflow Statement, the Statement of Total Recognised Gains and Losses and the related notes. These financial statements have been prepared in accordance with the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to the National Health Service set out within them. I have also audited the information in the Remuneration Report that is described as having been audited. This report is made solely to the Board of Directors of Great Western Ambulance Service NHS Trust in accordance with Part II of the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 36 of the Statement of Responsibilities of Auditors and of Audited Bodies prepared by the Audit Commission. Respective responsibilities of Directors and auditor The directors’ responsibilities for preparing the financial statements in accordance with directions made by the Secretary of State are set out in the Statement of Directors’ Responsibilities. My responsibility is to audit the financial statements in accordance with relevant legal and regulatory requirements and International Standards on Auditing (UK and Ireland). I report to you my opinion as to whether the financial statements give a true and fair view in accordance with the accounting policies directed by the Secretary of State as being relevant to the National Health Service in England. I report whether the financial statements and the part of the Remuneration Report to be audited have been properly prepared in accordance with the accounting policies directed by the Secretary of State as being relevant to the National Health Service in England. I also report to you whether, in my opinion, the information which comprises the commentary on the financial performance included within the Operational and Financial Review, included in the Annual Report, is consistent with the financial statements. I review whether the directors' Statement on Internal Control reflects compliance with the Department of Health's requirements, set out in ‘Guidance on Completing the Statement on Internal Control 2008/09’ issued 25 February 2009. I report if it does not meet the requirements specified by the Department of Health or if the statement is misleading or inconsistent with other information I am aware of from my audit of the financial statements. I am not required to consider, nor have I considered, whether the directors' Statement on Internal Control covers all risks and controls. Neither am I required to form an opinion on the effectiveness of the Trust’s corporate governance procedures or its risk and control procedures.

I read the other information contained in the Annual Report and consider whether it is consistent with the audited financial statements. This other information comprises the unaudited part of the Remuneration Report and the remaining elements of the Operating and Financial Review. I consider the implications for my report if I become aware of any apparent misstatements or material inconsistencies with the financial statements. My responsibilities do not extend to any other information. Basis of audit opinion I conducted my audit in accordance with the Audit Commission Act 1998, the Code of Audit Practice issued by the Audit Commission and International Standards on Auditing (UK and Ireland) issued by the Auditing Practices Board. An audit includes examination, on a test basis, of evidence relevant to the amounts and disclosures in the financial statements and the part of the Remuneration Report to be audited. It also includes an assessment of the significant estimates and judgments made by the directors in the preparation of the financial statements, and of whether the accounting policies are appropriate to the Trust’s circumstances, consistently applied and adequately disclosed. I planned and performed my audit so as to obtain all the information and explanations which I considered necessary in order to provide me with sufficient evidence to give reasonable assurance that: •

the financial statements are free from material misstatement, whether caused by fraud or other irregularity or error; and

•

the financial statements and the part of the Remuneration Report to be audited have been properly prepared.

In forming my opinion I also evaluated the overall adequacy of the presentation of information in the financial statements and the part of the Remuneration Report to be audited. Opinion In my opinion: •

the financial statements give a true and fair view, in accordance with the accounting policies directed by the Secretary of State as being relevant to the National Health Service in England, of the state of the Trust’s affairs as at 31 March 2009 and of its income and expenditure for the year then ended;

•

the part of the Remuneration Report to be audited has been properly prepared in accordance with the accounting policies directed by the Secretary of State as being relevant to the National Health Service in England; and

•

information which comprises the commentary on the financial performance included within the Operational and Financial Review, included within the Annual Report, is consistent with the financial statements.

Conclusion on arrangements for securing economy, efficiency and effectiveness in the use of resources Directors’ Responsibilities The directors are responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in the Trust’s use of resources, to ensure proper stewardship and governance and regularly to review the adequacy and effectiveness of these arrangements. Auditor’s Responsibilities I am required by the Audit Commission Act 1998 to be satisfied that proper arrangements have been made by the Trust for securing economy, efficiency and effectiveness in its use of resources. The Code of Audit Practice issued by the Audit Commission requires me to report to you my conclusion in relation to proper arrangements, having regard to the criteria for NHS bodies specified by the Audit Commission. I report if significant matters have come to my attention which prevent me from concluding that the Trust has made such proper arrangements. I am not required to consider, nor have I considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Conclusion I have undertaken my audit in accordance with the Code of Audit Practice. In so doing, I identified the following: •

I was unable to satisfy myself that adequate arrangements were in place in respect of all aspects of input and monitoring of budgets, including training

•

the Trust had not put in place systems with a clear link to the accounts to produce materially reliable financial information

•

I was unable to satisfy myself that an adequate framework was in place for monitoring performance in relation to data quality.

Having regard to the criteria for NHS bodies specified by the Audit Commission and published in December 2006, I am satisfied that, in all significant respects, Great Western Ambulance Service NHS Trust made proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2009 except that it did not put in place:

•

arrangements for managing performance against budgets;

•

arrangements to maintain a sound system of internal control; and

•

arrangements to monitor the quality of its published performance information, and to report the results to Board members.

Certificate I certify that I have completed the audit of the accounts in accordance with the requirements of the Audit Commission Act 1998 and the Code of Audit Practice issued by the Audit Commission.

Richard Lott Engagement Lead Officer of the Audit Commission Westward House Lime Kiln Close Stoke Gifford Bristol BS34 8SR June 2009

You can write us at: Great Western Ambulance Service Jenner House, Langley Park Estate Chippenham, Wiltshire SN15 1GG

You can telephone or fax us on: Tel: 01249 858 000 Fax: 01249 850 091 You can email us at pals@gwas.nhs.uk www.gwas.nhs.uk

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