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NHS Medway 7/8 Ambley Green, Gillingham Business Park, Gillingham. ME8 0NJ www.medwaypct.nhs.uk

N H S M E D WAY A N N U A L R E P O R T 2 0 0 9

A year of growing healthier

A year of growing healthier NHS Medway Annual Report 2008/09

Designed by: Designbox Studio Limited. Tel: 01622 749111


CONTENTS Introductions

4-7

How we work

8-21

What we did - and what we’re planning

22-39

Medway Community Healthcare

40-47

Our staff

48-49

Making experiences count

50-51

Our environmental impact

52-53

Board and committees

54-56

How we did

57-66

Statement of Internal Control

66-71

Summary financial statements 2008/09

72-83

Feedback to this document It’s your NHS, and we would very much like to hear your views on our annual report. To comment on this report or get involved with helping NHS Medway shape health services in Medway, please email: engagement@medwaypct.nhs.uk or see our website: www.medwaypct.nhs.uk 3


Introduction Eddie Anderson, Chairman Welcome to the annual report for 2008/09 for NHS Medway, the body which plans and pays for all NHS healthcare for everyone who lives in Medway. Our job is to: ● improve local people’s health and well-being and prevent illness through our work with the community and our partners ● purchase healthcare for people in Medway, ensuring the right services are there when they need them

Among the many improvements that NHS Medway achieved with our healthcare colleagues in 2008/09 were: ● More convenient GP appointments: with financial support from us, more than 80 per cent of GPs in Medway started opening early, late or at weekends to make life easier for their patients ● Faster planned care and shorter waiting times. In December 2007 just 53 per cent of people needing an operation had it within four months of being referred by their GP; in December 2008 more than 95 per cent did. ● Faster diagnosis and treatment of stroke, including a 24/7 thrombolysis (clot-busting) service

Aims for 2009/10 In 2009/10, our overall focus is on improving the health and life expectancy of everyone in Medway, while making sure that the people who need most help and support get it, improving their chances of leading long and healthy lives.

Our staff also provide a range of healthcare services directly to patients. We serve 270,000 people: the 252,000 who live in the Medway Council area (which marks our boundary and has done since 2006), plus others just over the border who are registered with Medway GPs. Our budget for 2008/09 was £364million and we are responsible for using that money in the best possible way for the people of Medway.

It is an exciting and tremendously worthwhile enterprise and I am delighted to play a part in it. I would like to thank our staff, our partners, our patients, our amazing volunteers, and everyone else involved in improving health and healthcare in Medway for all that you do to make our local NHS as good as it can be.

New name In September 2008, we changed our name to NHS Medway from Medway Primary Care Trust. This followed national research which showed that many people found the name “primary care trust” confusing and hard to understand. It is our role to lead health services locally so that we, working with our partners in the NHS and outside it, and with local residents, bring about real improvements to people’s health and healthcare. Our new title NHS Medway indicates that we are the local leaders of the NHS, which is absolutely right. For legal purposes, we remain a primary care trust.

Board I chair the NHS Medway Board, which oversees the work of the entire organisation. We make sure that the priorities and plans are right, and that they lead to real change.

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Chief Executive Marion Dinwoodie The main focus in 2008/09 for us at NHS Medway, along with other areas up and down the country, was on improving our commissioning. The exciting thing about commissioning in the NHS is that done well - and the Department of Health has set us the challenge of becoming world class - it brings about real and dramatic change. It enables us to target services better than ever before so they meet the real needs of local communities, and to work with our clinical colleagues to achieve high-quality, personal, effective and safe healthcare for people in Medway. As commissioners, we identify what local people need to improve their health and their healthcare, where the gaps are in existing services, how best to fill those gaps, and make it happen. One example of real change in Medway: there were too few GPs for our growing population, particularly in Wayfield, Luton, Chatham and Gillingham. So, with the input of local people, in 2008/09 we commissioned three new practices, and the new Medway NHS Healthcare Centre in Gillingham. This means 21,000 more patients will be able to register for GP services over the next five years, matching demand. The Healthcare Centre increases choice and convenience for local people by offering services for those who are not registered with it but need to see a GP, as well as those who are.

Malvinder Raval, Professional Executive Committee chair NHS Medway’s Professional Executive Committee ensures clinical involvement in identifying people’s health needs in Medway and gaps in current services, and clinical input into the design of pathways for effective healthcare. Strong clinical leadership is vital to drive improvements in the quality of services that are purchased and provided for the residents of Medway. We also want to focus on clinical leadership in workforce planning and development, and to have strong clinical links with all the other partners involved in the health agenda. In 2008/09, we contributed to the development of NHS Medway’s Strategic Commissioning Plan, vision and Joint Strategic Needs Assessment. We put a particular focus on mental health, urgent care, and cancer treatment, where we ensured that clinical opinion was taken into account in the shaping of services. In 2009/10 we want to go even further in involving healthcare professionals, ensuring that their voice and the voice of patients, carers and the public, are at the heart of the decisions taken by NHS Medway.

In 2008/09 we developed rigorous processes to underpin commissioning in Medway, to support our drive to become world class commissioners. These enable us to make much more sophisticated use of information and to improve the way we work with people in Medway to develop services.

Medway Community Healthcare During 2008/09 our staff who provide services to patients directly - such as health visitors, therapists, dietitians, district nurses, the staff of the Wisdom Hospice, Darland House and St Bartholomew’s Hospital and many many more - prepared for increasing independence. They have formed a new organisation within NHS Medway known as Medway Community Healthcare and during the course of 2009/10 they will decide what type of organisation they would like to become for the future. Responsibility for taking the final decision rests with the NHS Medway Board. The Board is expected to do this at its meeting in September.

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I would like to give many thanks to everyone involved in improving health and health services in Medway. 7


Our role is to improve health and healthcare for people in Medway

Compared to the average for the rest of England, the population of Medway is: Younger More likely to smoke More likely to be overweight Less likely to eat five helpings of fruit and vegetables ● Likely to die younger ● ● ● ●

Medway has 22 electoral wards. Three of them (Gillingham North, Chatham Central, and Luton and Wayfield) are in the 20 per cent most deprived in England. Two (Rainham Central, and Hempstead and Wigmore) are in the 20 per cent least deprived. People in the most deprived parts of Medway suffer more ill-health and live on average 6.8 years less than people in the least deprived. The major causes of death in Medway are heart disease, stroke, cancer, and respiratory disease. (Source: Joint Strategic Needs Assessment 2008 carried out by NHS Medway and Medway Council)

Forecast By 2018, it is expected that there will be 4.6 per cent more people living in Medway. The biggest increase in numbers is expected to be of older people (over 65s up by 29 per cent, over 85s up by 32 per cent) and of children (up by seven per cent). Our planning takes these, and other predicted changes, into account.

Vision and values Our vision is Medway - a great place to live, work and thrive. We share this vision with Medway Council, one of our most important strategic partners. 8

We want to see: ● People in control of their own health and well-being ● Very best quality healthcare when needed ● Joined-up, patient-centred services ● More choice and a much stronger voice for patients ● Innovative, evidence-based care and support Our values include: ● Respect and dignity - treating patients and staff as individuals ● Commitment to quality of care - insisting on quality and getting the basics right ● Compassion - finding the time to listen and understand ● Improving lives through excellence and professionalism ● Working together for patients in everything we do ● Showing that everyone counts These values are those of the NHS as a whole. They are set out in the NHS Constitution which was published in January 2009. We support the concept of personalisation – giving people greater control and choice over how their health needs are met. One way of achieving this is by setting personal health budgets which people use to select services that meet their personal needs and preferences. This is just starting in the NHS and we expect to hear this autumn whether we have been given Department of Health funding for a pilot scheme in Medway (see p 39 for more details).

How we are doing The Healthcare Commission‘s Annual Health Check for 2007/08 rated us against a number of standards and targets and took into account our financial performance. For the second year running, we achieved a rating of “fair” for both our use of resources and quality of services. 9


In 2008/09 for the first time, primary care trusts in England including NHS Medway, were assessed on how well they are doing at commissioning. The World Class Commissioning Assurance Panel assessed us at stage two of four (with one being a starting point and four world class) on eight of ten measures (known as competencies), and at stage one on the remaining two. It put us at amber on strategy, finance and Board, the three governance areas. The panel also described us as having strong potential for improvement.

● Revenue resource limits – to maintain its expenditure within the resource limits set for revenue ● Capital resource limits – similarly, capital spending must be contained within prescribed resource limits ● Cash limit - each PCT has a statutory duty to remain within the cash limit set by the Department. NHS Medway achieved all three targets in 2008/09.

We aim to get a better rating on all these measures in 2009/10 and have plans in place to support this.

Most of NHS Medway’s budget is spent on commissioning services from health and social care providers (see page 16 for more details).

Our budget and financial context

The main differences between what we expected to spend and what we actually spent in 2009/09 were the result of:

After many years when Medway’s funding had been significantly below the Department of Health’s funding formula, our budget was increased by 12 per cent, or £37million in 2007/08.

● More day cases and outpatients being seen at Medway NHS Foundation Trust than anticipated, but a lower than expected use of the Neonatal Intensive Care Unit ● Lower than expected usage of an expanded renal dialysis service at East Kent Hospitals University Foundation Trust ● Additional activity at Guy’s and St Thomas NHS Foundation Trust, across a range of services including cardiology ● Savings on GP prescribing achieved as part of a national and local initiative to reduce the cost of branded drugs; and ● A reduction in the number of people needing learning disability services provided by Medway Council.

To make best use of this funding increase, we drew up detailed investment strategies for all major aspects of our business. We also invested heavily in the services we provide directly. However, because of the scale of the increase, it was not possible to plan and spend all the money in the best way within one financial year. We therefore lodged £20million for safekeeping with the South East Coast Strategic Health Authority. We drew in part on this money in 2008/09, and the rest will follow over the next few years.

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NHS Medway has three statutory financial targets to achieve each year:

Our Strategic Commissioning Plan sets out our financial plans for the next five years. We expect to remain financially stable and to be able to invest significantly in new services during this time. To do this we will need to: ● Be able to use money we have saved in the past ● Control costs tightly ● Make changes, including taking money out of services that are not effective, where necessary ● Achieve efficiency savings of £3million a year.

Principal Risks and uncertainties facing NHS Medway NHS Medway has identified the principal risks and uncertainties that may affect it in the medium to long term and is working to ensure that these risks are being effectively managed. In line with many other areas of the country the number of older people in Medway is increasing. NHS Medway is working with Medway Council to ensure that the services older people need will be in place as the population increases. These services include care for people in their own homes, nursing home capacity and services for people with dementia. The financial problems facing the world wide economy are likely to affect NHS Medway particularly in the financial year starting April 2011 when the current funding arrangements for NHS Medway come to an end. NHS Medway is working with its partners to identify ways of increasing the efficiency of healthcare provision in Medway to ensure that services are affected as little as possible.

The availability of trained healthcare staff is important to the provision of healthcare to the people of Medway. NHS Medway is responsible for planning the training requirements for healthcare staff with the local universities. Recruitment and training is more difficult for some staff groups than others and in some areas the average age of the workforce is high. NHS Medway has put plans in place to manage these issues.

Better Payments Practice Code Details of compliance with the Better Payments Practice Code are given within the Summary Financial Statements on page 82

Working in partnership Partnerships are core to the way that we work. They allow us to use public money in the most effective way and to ensure that services for people in Medway are joined-up and patient-centred. We work with Medway Council and other partners to plan services, in particular for children and young people, people with a learning disability or mental health problems, and older people. We have a joint NHS Medway/ Medway Council Public Health team led by Dr Alison Barnett, the Director of Public Health, which drives work to improve the health of local people. We work with a range of partners, including Medway Council and the police, as part of the Local Strategic

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Partnership and the Community Safety Partnership, participating in groups such as the Medway Community Cohesion Group and the Kent Equalities Network.

with emergency services, other NHS trusts and Medway Council and with the Kent Resilience Forum, including carrying out joint exercises.

We work with both the Health and Adult Social Care, and the Children and Adults Overview and Scrutiny Committee of Medway Council.

In 2008/09 we: ● Set up an NHS Medway Emergency Planning Committee ● Revised and tested our plan for a flu pandemic ● Updated our business continuity plans ● Contributed to the work of the Kent and Medway Local Resilience Forum and to the South East Coast Flu Committee ● Updated emergency training for key staff ● Reviewed the plans and preparedness of providers of healthcare in Medway, especially for flu pandemic, and for chemical, radiological or nuclear incidents.

We commission some services (such as mental health and cancer) on behalf of the whole of Kent and Medway, and our neighbouring primary care trusts commission other services on our behalf (for instance, commissioning of stroke services is led by NHS West Kent). We have formal agreements with voluntary groups such as the Stroke Association, and work closely with Age Concern, HiKent and others. One new partnership set up this year is to protect people living in hospitals or care homes who lack the capacity to make their own decisions about the arrangements for their care or treatment. Since 1 April, we along with Medway Council, NHS West Kent, NHS Eastern and Coastal Kent and Kent County Council, have been jointly providing a Deprivation of Liberty Safeguards (DoLS) service for people in Kent and Medway. Care homes or hospitals who believe they have to deprive someone of their liberty for their own safety must apply for permission to do so to the Kent and Medway DoLS Office.

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Emergency planning is a further area where we work in partnership. Under the Civil Contingencies Act 2004, we have a legal responsibility to prepare for emergencies such as flooding or flu pandemic to ensure that people’s health needs will be met with minimal disruption. We have a Major Incident Plan that is fully compliant with the requirements of the NHS Emergency Planning Guidance 2005 and all associated guidance. We work closely

How commissioning works As we review and improve health services for people from Medway, we first assess need. We do this by looking at: ● Information about the health of our population contained in the Joint Strategic Needs Assessment ● Programme budget information that benchmarks our spending on different services against the average for areas with a similar population to Medway’s ● Information from commissioning managers and managers of Medway Community Healthcare services about areas for improvement ● The views of patients, carers and members of the public ● The views of our partners in health and social care ● Models of best practice.

Having assessed how effective current services are at meeting need, what could do with improving, and what is lacking, we work with patients and members of the public and with our partners in health and social care to draw up specifications for new or improved services. We develop contracts which set out exactly what we expect the new service to deliver for patients. Part of this is about ensuring compatibility and integration between the new or improved service and other services. Then we identify a provider to deliver it and, once the service is established, we monitor it carefully and ensure any issues are dealt with. The other major form of commissioning is practice-based commissioning (PBC). This is when GPs and other healthcare professionals work together to improve services for the people they serve. They look in detail at the needs of the population in their areas and identify what would enable the NHS to meet those needs. Business cases can be submitted to NHS Medway by practice-based commissioning groups to enhance existing services or to create new services. All GPs in Medway participate in PBC which is organised in three areas: Rochester and Strood, Chatham, and Gillingham and Rainham.

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Who we commission from Primary care 133 GPs in 67 practices, 37 dental practices, 5 dental clinics, 1 specialist orthodontic practice, 1 home-visiting dentist, and the emergency dental service DentaLine, 47 community pharmacies, 21 optometrists (opticians).

Health promotion Joint NHS Medway / Medway Council teams providing Stop Smoking support, healthy weight advice and programmes, sexual health advice and Chlamydia testing.

Acute care Any hospital of people’s choice for most treatments so long as it offers care to

NHS standards for NHS prices. (Mental health services, maternity services, urgent care and very specialised care are excluded). In practice, most people choose to have their care in Medway or wider Kent – including at Medway NHS Foundation Trust, the Will Adams NHS Treatment Centre and the Spire Alexandra Hospital. Most specialist cancer services are provided by the Kent Oncology Centre in Maidstone and some by London hospitals. Medway NHS Foundation Trust will be opening a cancer unit this year.

Mental health Kent and Medway NHS and Social Care Partnership Trust, a number of voluntary or independent organisations such as KCA, and Kent and Medway Drugs and Alcohol Action Team.

How we make sure that people get good care We have detailed contracts with hospitals, GPs and the other providers from whom we commission most care. We carefully monitor their performance against a range of measures which include patient experience, patient safety and clinical effectiveness. During 2008/09 we held monthly meetings with both Medway NHS Foundation Trust and the Will Adams NHS Treatment Centre to monitor quality. In 2009/10 we will also have monthly quality performance meetings with Kent and Medway NHS and Social Care Partnership Trust, and Medway Community Healthcare. In 2009/10 for the first time, the NHS is introducing a financial incentive for providers who improve the quality of patient care. The Commissioning for Quality and Innovation (CQUIN) payment framework ties part of providers' income to quality and innovation improvements. These requirements - commonly known as CQUINs - cover a whole range of areas, including training - ensuring that staff get the updates they need - and patient surveys, looking at patient experience and satisfaction. They are mandatory in all contracts with acute hospitals - such as Medway NHS Foundation Trust - for 2009/10. At NHS Medway, we have also written them into contracts with Kent and Medway NHS and Social Care Partnership Trust, and Medway Community Healthcare.

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During 2009/10 we will be putting in place CQUINs for GPs too.

Success in infection control The rate of healthcare associated infections dropped significantly during 2008/09. The NHS in Medway achieved better than expected rates on both MRSA infections (12 cases compared to 21 in 2007/08) and Clostridium difficile (112 cases compared to 149 in 2007/08). This was partly due to targeted work by all parts of the NHS in Medway to ensure very high standards of hand hygiene. It also reflected a successful drive in Medway to reduce prescribing of high risk antibiotics (see page 29).

Single sex accommodation We know that patients want to be nursed in single-sex accommodation. We have therefore set Medway NHS Foundation Trust a target of reducing the number of patients nursed in mixed-sex accommodation to below four per cent by the end of March 2010. Areas such as intensive care units – which will continue to be mixed-sex are included in this four per cent. In May 2009, we were allocated £1.8m from the Department of Health’s Privacy and Dignity Fund to pay for improvements to Medway Maritime Hospital, A Block and other Kent and Medway NHS and Social Care Partnership Trust buildings, St Bartholomew’s Hospital and the Wisdom Hospice. Meanwhile, we are working closely with Medway NHS Foundation Trust, Medway Community Healthcare and Kent and Medway NHS and Social Care Partnership Trust to monitor this issue. All three organisations will be asking patients specifically about their accommodation, along with other aspects of the service they received, in patient experience questionnaires during 2009/10. 15


How we make sure information about you is kept safe NHS Medway manages information risks through its Information Governance and Informatics Team. Potential risk areas have been identified, action plans to mitigate the identified risks have been drawn up and those actions have been implemented. NHS Medway and all NHS providers work to a set of standards outlining how we handle, store and transmit all patient information, entitled the National Care Record Guarantee. The full document can be obtained from NHS Medway, or can be downloaded from the website of the National Information Governance Board for Health and Social Care at www.nigb.nhs.uk In NHS Medway we comply with the guarantee by: ● Ensuring staff and contractor contracts are clear about the duty of confidentiality ● Ensuring that all staff have training in data protection and Information

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● ●

Governance at their induction and annually thereafter Ensuring that we have a strong Registration Authority to ID check and register staff. Patient information can be accessed only by registered staff, with pin-protected smartcards Ensuring we have clear guidelines governing access to systems Ensuring that all our systems provide an audit trail which can identify who has viewed and accessed information Ensuring we have nominated officers who will investigate any unauthorised access to records (Caldicott Guardian and privacy officer) Complying with our NHS Information Governance Statement of Compliance – which is audited every year Encouraging and supporting General practice to undertake the Information Governance Statement of Compliance, and let their patients know when they have attained it through publicity in practice leaflets. Encrypting all mobile IT equipment and prohibiting the use of unencrypted memory sticks and removable data storage (floppy disks, digital camera memory, smartphones) Ensuring that all electronic data in transit is audited to ensure that it needs to be transferred and is always transferred using secure methods.

Summary of NHS Medway incidents involving personal-related data as reported to the Information Commissioner’s Office in 2008/09 Date of Incident

Nature of incident

Nature of data involved

May 2008

Theft of PC

-Name -Address -Carer -School -GP -At Risk Status

Further action on information risk

Number of Notification people steps potentially affected 300 (approx)

Families notified by postal letter

The organisation continues to improve the standards and security surrounding the protection and use of information.

Summary of other personal data related incidents in 2008-/09 Category

Nature of incident

Total

I

Loss of electronic equipment, devices or paper documents from secured NHS premises

3

II

Loss of electronic equipment, devices or paper documents from outside secured NHS premises

1

III

Insecure disposal of electronic equipment, devices or paper documents

0

IV

Unauthorised disclosure

5

V

Other

0

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How we work with local people The people who use the NHS in Medway are the real experts on it. That is why we ask local residents to get involved when we are reviewing or planning a service so we make sure we learn from their expertise. Our Patient Carer and Public Involvement Forum support this important work. In 2008/09 we consulted people as we were developing our Strategic Commissioning Plan and revised the final version to reflect what they told us. We consulted people on a range of service reviews, including Parkinson’s

Disease, diabetes, and mental health and social care services for older people.

PALS

People told us, for instance, they wanted one central phone number to call with diabetes queries - so now all calls are handled by the diabetes team based at Parkwood Health Centre.

In 2008/09 we introduced a new Patient Advice and Liaison Service (PALS), with a freephone number 0800 014 1641, to deal with people’s queries and concerns.

We also developed a commissioning engagement strategy which will allow us to involve more people in our decisions, and to involve them in more decisions, in a systematic way. January 2009 saw the inauguration of the new Medway Local Involvement Network (Medway LINk) which has a statutory role. Its job is to help people influence or change the way NHS and social care services are delivered in Medway. We are developing a good working relationship with the LINk to facilitate its work.

We make sure that issues raised through PALS and to our complaints team are followed up. Managers are required to rectify any problems in the services they run.

Achieving equality for all We are committed to ensuring that everyone in Medway can access the care they need and that everyone is treated with dignity and respect. We are also committed to achieving equality and diversity within our workforce. To help us meet the needs for health and healthcare of everyone in Medway including those who are from seldom-heard groups, we are: ● Reaching out into different communities in innovative ways recommended by those communities ● Targeting our health promotion initiatives at the people who need them most ● Gaining a better understanding of the cultural needs of people in Medway and any barriers that exist to achieving better health ● Carrying out equality impact assessments which look at the impact on different communities of NHS Medway policies and commissioning decisions, so that we can take corrective action if necessary. We provide opportunities for people, including patients and our staff, to observe the rituals of their faith or belief. Ministers of different religions are welcome in our buildings and we have an arrangement with the Church of England to provide chaplaincy services.

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Supporting this work is the Equality and Diversity Strategy which was approved by the NHS Medway Board in September 2008. Results so far include: ● The drafting of a Single Equality Scheme covering race, gender, disability, age, sexual orientation and religion and belief ● The introduction of an equality and diversity training module as part of NHS Medway’s statutory and mandatory training programme for all staff ● The accreditation of NHS Medway under the Government's Positive about Disability scheme - 'Two Ticks'.

Our priorities and targets Our priorities include achieving national targets and standards, regional targets, and targets that we set for ourselves in Medway. We have set out our long-term, mediumterm and short term plans in three documents: A Healthy Medway which lays out the strategic direction for healthcare in Medway from March 2007 to 2015 Growing Healthier, the Strategic Commissioning Plan, which describes our plans for 2008/09 - 2012/13 and Our Operational Plan which sets out the detailed work we will be carrying out in 2009/10. Over the last two years the NHS nationally, regionally and locally has been looking at what needs to be done to make services as good as they possibly can be. This work has been led by doctors, nurses and other health professionals at the forefront of delivering care.

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As a result of this, the South East Coast Strategic Health Authority which covers Kent, Surrey and Sussex, produced a vision for our region, entitled “Healthier People Excellent Care” which looks at health services for every stage of people’s lives, covering: 1 2 3 4 5 6 7 8

maternity and newborn children’s services staying healthy long-term conditions planned care urgent and emergency care mental health end of life care

disease, cancer, renal services, primary care, older people, and learning disabilities.

The local outcomes we chose are to: Reduce teenage pregnancies Encourage more mothers to breastfeed

Our priorities are: ● Improving health and well-being ● Targeting killer diseases ● Improving care and choice for patients ● Supporting future generations ● Promoting independence and better quality of life ● Improving mental health

Help over 1160 people a year stop smoking Support people with diabetes to gain control of their blood glucose Ensure many more people with symptoms of a Transient Ischaemic Attack (mini stroke) have a brain scan within 24 hours Reduce early deaths from heart disease

We have set up strategic change programmes to drive forward improvements to health and healthcare in Medway in each of these areas. Further strategic change programmes in Medway cover: diabetes, stroke, substance misuse, coronary heart

As part of World Class Commissioning, all primary care trusts have set eight local health outcomes which they will achieve for their local population by March 2012. To do this we looked carefully at what would make the most difference to people in Medway.

Halve the increase in alcohol-related admissions to hospital Encourage more over-65s to have a flu jab All of these would contribute to the national priorities to: Reduce health inequalities Increase life expectancy

By March 2010 we are aiming for: End of life care Maternity and new born care

Mental health

Acute care 20

Children

Staying healthy

Planned care

Long-term conditions

● Teenage pregnancy to fall so that only 29 per 1000 girls aged 15, 16 or 17 become pregnant (compared to the 2007 rate of 48 per 1000) ● 90 per cent of newborns to start life being breastfed, and 46 per cent still to be breastfed at six - eight weeks old ● 68 per cent of people with diabetes to have an HbA1c test result of 7.5 per cent or less ● 63 per cent of people at high risk of mini strokes to have a brain scan within 24 hours ● Early deaths from heart disease to fall to 75.9 per 100,000 people compared to 95.0 in 2006 ● The rate of increase of alcohol-related admissions to fall to six per cent a year, down from 13 per cent in 2007/08. 21


Making sure the right care is there when you need it how we did in 2008/09

1. Maternity and newborn Good maternal health and maternity care are important factors in the health, life chances and development of babies, children and their mothers. Our main focus in 2008/09 was on ensuring high-quality care and continuity of care for mothers-to-be, new mothers and their babies, increasing choices for women about their care. This is in line with Maternity Matters, the national plan for maternity care. By December 2009, we aim for mothersto-be to be able to choose: ● How they access the midwife who will care for them (via their GP’s surgery or the hospital) ● What type of antenatal care they have ● Where they give birth ● Where they get their postnatal care.

In 2009/10 we plan to build on all of this and: ● Further improve the ratio of midwives at Medway NHS Foundation Trust to 1:28 births ● Ensure all new mothers are encouraged to breastfeed and that support is available on the ward and at home if they need it ● Ensure that Medway NHS Foundation Trust sets up a special phoneline for mothers-to-be to call to discuss their options for care ● Fund the new specialist service to support existing teams in providing care for mothers with profound postnatal depression.

Breastfeeding It is important for mums to breastfeed if they can because it is better for them and better for their baby. Research shows breastfeeding protects women against breast and ovarian cancer. It improves babies’ immunity and makes them less likely to be obese when they get older.

In 2008/09 we: ● Worked with Medway NHS Foundation Trust and Medway Maternity Services Liaison Committee to plan a new midwifery unit, due to open at the hospital in 2010 ● Funded more midwives at Medway NHS Foundation Trust - so the ratio of midwives to births improved to 1:35 ● Approved funding and plans for a specialist Mother and Infant Mental Health Service to improve care for mothers in Medway with profound postnatal depression. ● Ensured there is a consultant on the labour ward at Medway Maritime Hospital for at least 60 hours a week.

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2. Children and young people Our main focus in 2008/09 was on improving the way services for children work together in Medway. This is vital because it ensures children get the care and support they need to: ● Be healthy ● Stay safe ● Enjoy and achieve ● Make a positive contribution ● Achieve economic well-being (the outcomes set out by the national “Every Child Matters” programme). Organisations involved include health, children’s social services, housing, education, the police, probation, the voluntary sector and the independent sector. In 2008/09 we and our partners: ● Set up the new Children’s Trust, which came into force on 1 April 2009, and leads services for children in Medway ● Developed the Medway Children and Young People’s Plan ● Set up five Children’s Trust partnership boards to co-ordinate and commission different aspects of children’s services ● Completed a fundamental review of Child and Adolescent Mental Health Services and agreed its recommendations. In 2009/10 we plan to: ● Play a full part in the new Children’s Trust ● Ensure Looked After Children (children in local authority care) have access to health checks and appropriate healthcare ● Continue to develop opportunities for children, young people and their parents to have their say and shape services

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● Improve Child and Adolescent Mental Health Services (CAMHS) in Medway by: ◆ Retendering for CAMHS for children and young people with the highest levels of need ◆ Improving care for children and young people with a learning disability or drug or alcohol problems ◆ Creating a single point of access for referrals for children and young people requiring mental health services ◆ Establishing a Targeted Mental Health Services (TaMHS) programme in Medway schools ● Improve care for children with disabilities by: ◆ Investing a further £335,000 (matching additional funding by Medway Council) in short breaks and respite services for children with disabilities, as part of the Aiming High programme ◆ Commissioning more services in the community (rather than in hospital) ◆ Providing support for the families of very young children diagnosed with disabilities by adding specialist Early Support Health Visitors to the Medway Community Healthcare Children’s Therapy Team ◆ Examining and deciding on options for the best services for children with physical or learning disabilities ● Support teenage parents through the new Family Nurse Partnership Programme which offers weekly visits from four family nurses who will each help 25 young mothers look after their babies ● Improve our contracting arrangements so we achieve better services for children and young people.

3. Staying Healthy Supporting people to improve their health, preventing ill health and reducing health inequalities benefits the public and the NHS. It reduces the demand on services and improves the quality and length of people’s lives. We and Medway Council work together through one joint public health team to improve the health of people in Medway. It focuses on helping people to stop smoking, be a healthy weight, and achieve sexual health. In 2008/09 we: ● Produced a Joint Strategic Needs Assessment, looking in detail at people’s health in Medway and identifying the areas where ill-health is highest ● Encouraged smokers through a new initiative with GPs to “Stop Before the Op” ● Recruited Punjabi and Polish advisers to give support to quitters from those communities ● Produced a Stop Smoking Strategy to support people to quit and exceeded our target for the number of people quitting for four weeks ● Worked with GPs to increase the number of smokers they refer to the Stop Smoking team: although at 2.7 per cent of smokers it is still short of the 5 per cent that is nationally recommended ● Assessed rates of obesity in pregnant women and young children and identified gaps in services ● Extended the 4Life exercise and healthy weight programme into the All Saints area of Chatham, Twydall, and Strood ● Evaluated the success of our Tipping the Balance project for overweight adults

● Employed a strategic co-ordinator to oversee our newly revised action plan for reducing teenage pregnancy ● Set up a robust system for collecting data on teenage pregnancy ● Introduced Speakeasy courses to provide parents and carers with the confidence and skills to talk to young people about sex and relationships ● Successfully introduced a new immunisation programme to protect girls against the strains of the HPV virus that cause almost 75 per cent of cases of cervical cancer. In 2009/10 we plan to: ● Develop a health and well-being strategy for Medway - a blueprint for targeting health improvement interventions ● Offer training to all Medway GPs in supporting smokers who want to quit ● Develop plans for contacting smokers not reached by current methods ● Run a series of mini-MEND (Mind, Exercise, Nutrition, Do it!) courses for children aged two to four and their families, so from a very young age children get used to eating well and taking exercise, minimising their risk of becoming overweight later ● Develop and start to implement a plan for preventing obesity, focusing on pre conception and antenatal care, breastfeeding and infant nutrition ● Open up the Tipping the Balance programme to people with medical conditions that are currently excluded ● Set up self-esteem groups and counselling for very overweight people ● Launch a Health Trainers programme to encourage people to make healthy lifestyle choices ● Evaluate sex and relationships education in Medway ● Develop a system for identifying girls whose behaviour puts them at risk of teenage pregnancy, and agree a co-ordinated response ● Use data from the new teenage 25


pregnancy data collection system to target services where they are most needed ● Offer HPV immunisation to girls aged between 14 and 18 ● Implement Medway’s Alcohol Strategy.

“MEND and Tipping the Balance have helped our whole family to change our lifestyle. We are much more active, taking part in activities together which we never did before.” A Medway father.

“I really wanted to stop smoking but, because of my disability, I find it hard to get about. I called Medway Stop Smoking Service and they told me about telephone support. “I was able to choose the treatments I wanted to use. Each week the advisor helped me identify times when I might be vulnerable to relapse and what I could do to avoid these situations.

Screening

Primary care

In 2008/09 we: ● Agreed funding to offer younger women (aged under 50) screening for breast cancer ● Funded GPs to carry out Chlamydia screening and employed a Chlamydia screening nurse working in targeted areas ● Sent out a postal invitation to all 15 to 24-year-olds to come for a Chlamydia screen.

Primary care is provided by GPs, dentists, optometrists, pharmacists, and the healthcare staff who work in the practices with them.

In 2009/10 we plan to: ● Offer NHS Health Checks to people aged 40-74 – reaching everyone in that age group over the next five years - to assess their risk of developing heart disease, diabetes and kidney disease ● Introduce bowel cancer screening for everyone aged 60 - 69 ● Offer women a first screening for breast cancer before the age of 50 ● Introduce digital mammography for breast screening ● Develop a robust Chlamydia screening action plan to meet increased targets in the future ● Pilot Chlamydia screening by an outreach team.

Our main focus in 2008/09 was making it easier for patients to get GP appointments at times that are convenient for them.

We ● Funded GPs to open early, late or at weekends – and more than 80 per cent of practices now offer extended hours ● With public input into the evaluation, commissioned three extra practices in Luton, Wayfield and Chatham, and a GP-led health centre (Medway NHS Healthcare Centre in Gillingham) ● Worked with GPs to improve effective prescribing, achieving the lowest rate

of prescribing of high-risk antibiotics (which increase the risk of Clostridium difficile) in Kent, Surrey or Sussex. ● Achieved flu vaccination rates of 74.7 per cent among people over 65 – the highest in Kent, Surrey or Sussex ● Funded a new dental practice in Rainham and increased slots at many existing dentists, increasing the number of patients treated. In 2008/09, Malling Health took over the provision of three GP practices and a branch surgery in Medway, following a tendering process in 2007/08. In 2009/10 we plan to: ● Develop a strategy for independent contractors - GPs, dentists, optometrists and pharmacists - that sets out how NHS Medway will deliver high quality care for all ● Benchmark the level of services currently provided in Medway and identify what needs to change,

“The service I received on the phone was very good and helpful. Thank you for helping me to stop smoking.” Pauline from Chatham.

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following this up through a transparent contract management process ● Continuously improve quality by listening to individual patients and practice views, then designing and supporting the delivery of services to meet local needs and address inequalities ● Plan further developments of healthy living centres in Medway: Balmoral Gardens (due to open late summer 2010), Chatham Town and Luton. Three GP practices in Medway are piloting the Summary Care Record, a secure way of the NHS sharing important information about patients. It is a national scheme which will initially allow different bits of the NHS to access three pieces of information about patients: their allergies, their medication, and any reactions they have previously had to treatment. The practices involved in the pilot in Medway are ● The Parks Surgery (Dr Green and Partners) ● Walderslade Village Dr JK Raval and Partners) ● 151 Napier Road (Dr PP Jana) Thirty-four out of 37 dental practices in Medway have space for new patients – so anyone who wants care from an NHS dentist can easily get it. Almost two thirds of people in Medway - 64.7 per cent - receive NHS dental care, compared to 52.9 per cent nationally.

In 2008/09, more than 32,000 referrals by Medway GPs were booked using the Choose and Book system which enables patients to get an appointment at a time that suits them.

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Planned care

Cancer

Planned or elective care is care arranged ahead of time when immediate, urgent treatment is not needed.

NHS Medway hosts the Kent Cancer Network, which plans and oversees standards of cancer care for the whole of Kent and Medway.

The main focus for planned care in 2008/09 was on reducing waiting times. Our target is for at least 90 per cent of inpatients and 95 per cent of outpatients to have their operation or start their specialist treatment within 18 weeks of being referred by their GP. In 2008/09 we: ● Achieved the 18 week targets ● Reduced waiting times for 15 key diagnostic tests, including MRI scans, CT scans and colonoscopies, with more than 97 per cent of patients being seen within six weeks ● Agreed funding for a sleep apnoea service at Medway NHS Foundation Trust - started April 2009 ● Commissioned the first cataract service to be provided in Medway – started April 2009 at the Will Adams NHS Treatment Centre in Gillingham ● Funded new phlebotomy (bloodtaking) sessions run by Medway Community Healthcare at Rainham, Lordswood and Twydall to meet local need. Further sessions started at Parkwood in May 2009 ● Funded new wound clinic sessions in Lordswood and Rainham, in addition to those already available in Rochester. In 2009/10 we plan to: ● Review and consult upon spinal services in Kent and Medway ● Review dermatology services to ensure treatment is provided in the most appropriate setting ● Introduce direct access to scans (MRI, CT) for GPs at Medway NHS Foundation Trust.

In 2008/09: ● All people being referred with suspected cancer were seen, had diagnostic tests and, where necessary, started treatment within 62 days ● Quality standards for the service met national peer reviewed standards ● Laporoscopic colorectal surgery was routinely offered at Medway Maritime Hospital ● NHS Medway invested in radiotherapy allowing waiting times to be consistently under four weeks.

Life with and beyond cancer Medway is one of 16 pilot sites in the country looking at the needs of patients and carers who are living with and beyond cancer. The Medway Survivorship Project involves patients, carers and professionals looking at what services people need to support them (such as employment advice, guidance on benefits, counselling). It aims to launch a service that will offer people the help they need from April 2010.

In 2009/10: ● Tenders will be sought for a new service for primary and secondary lymphoedema (for fluid retention) ● The new Chemotherapy Unit at Medway Maritime Hospital will open, improving the experience of people requiring chemotherapy by allowing treatment much closer to home ● We will work with our colleagues in NHS West Kent and NHS Eastern and Coastal Kent to improve access to cancer drugs and will endeavour to commission new drugs where there is good evidence of their effectiveness and safety, even if they have not yet been considered by the National Institute for Health and Clinical Excellence ● People living with and beyond cancer will benefit from the Survivorship Project (above right).

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Practice-based commissioning Practice-based commissioning enables groups of family doctors and community clinicians to develop better services for their local communities. In 2008/09 the three PBC groups in Medway focused on diabetes, dermatology, minor surgery, anti-coagulation (blood thinning), ophthalmology, gynaecology and ear, nose and throat services. They: ● Led work on improving care for people with diabetes, integrating with the work of the diabetes commissioning manager to develop a specification for a more joined-up patient-centred service, with a single point of contact for triage (assessment) ● Explored options for a more local dermatology service – leading to a

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Urgent care

dermatology nurse specialist being employed by Medway Community Healthcare to provide dermatology in the community ● Agreed to increase through a local enhanced service the range of minor surgery that can be carried out in GP practices ● Put together a business case for anti-coagulation services in the community-approved November 2008 ● Agreed a pilot scheme to provide assessment of acute eye conditions in the community started April 2009. In 2009/10 PBC groups will build on work done previously and will also focus on improving care for: ● people with common mental health problems ● people with musculo-skeletal conditions ● women with bladder problems, and ● people with diabetes and coronary heart disease.

The focus of urgent and emergency care is on providing high quality, safe and responsive care, at the right time and in the right place. Most urgent care for people from Medway is provided by A & E at Medway Maritime Hospital, Medway On Call Care (MedOCC) at the Urgent Care Centre and its other bases, minor injuries units in Eastern and Coastal Kent, and the South East Coast Ambulance Service.

PBC aims for 2009/10 include: ● Agreeing a cohesive and integrated approach to care for all patients with mild to moderate depression and anxiety, stress, anger, phobias, mild obsessions and compulsions, and difficulty with demanding life events ● Enabling rapid access to appropriate psychological treatment for every patient with depression or anxiety, educational training for practice nurses, and a closer working relationship between the service and the patient’s GP ● Enabling rapid access for patients with musculo-skeletal pain to physiotherapy, acupuncture, manipulative therapies and GPs with an interest in joint injections who can refer on to secondary care if appropriate ● Commissioning a community-based service for women with urinary incontinence and over-active bladder, with training for practice nurses and other staff, including nurses in care homes ● Development of training and support services for practices to reduce illness and death rates in their patients from diabetes and coronary heart disease.

A major focus for urgent care in 2008/09 was improving waiting times at A & E at Medway Maritime Hospital. Despite intense efforts by the hospital, supported by NHS Medway and particularly Medway Community Healthcare, A & E failed to achieve the target of dealing with 98 per cent of patients within four hours. In 2008/09 we: ● Jointly commissioned, with Medway NHS Foundation Trust, three external reviews of A & E. These will help the whole NHS locally to improve our planning in the future. Medway Community Healthcare: ● Increased the number of medical, nursing and call-taking staff at MedOCC and the Urgent Care Centre to assist the hospital in handling increased demand ● Agreed a new triage (assessment) system to cut long waits for patients ● Arranged for Urgent Care Centre staff to visit A & E hourly to identify patients suitable for UCC care ● Increased support from healthcare practitioners and the Rapid Response Team to identify patients who could be cared for safely at home, at St Bartholomew’s Hospital or another community setting.

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In November 2007, we set up an Urgent Care Board with colleagues from the ambulance service, hospital trust, mental health trust and NHS Direct to reduce attendance at and admissions through A & E, and the length of patients’ stays in hospital. As a result of projects initiated by the Urgent Care Board, in 2008/09 we: ● Extended the hours of service provided by community nursing teams and advanced practitioner care teams to enable patients to get the care they need at home ● Using information from Medway NHS Foundation Trust, introduced a computer program, called PARR++, so that healthcare practitioners can identify any patient at risk of being readmitted and ensure that information is shared with their GP or other health professional who can then arrange all the care they need treating them on a “Virtual Ward” ● Introduced Telehealth units, electronic devices that allow people with long term conditions to monitor their own health at home ● Worked with the hospital to identify people who, having fallen once, are at risk of falling a second time, helping them to avoid future falls. In 2009/10 we plan to: ● Implement recommendations from the external reviews in A&E to ensure oer 98 per cent of people are seen within four hours

● Fund a single telephone number for professionals to use when referring patients to community services. Improving urgent care In 2009/10 we have developed an action plan which has been agreed by all the key organisations in Medway and takes account of the findings of our reviews. The plan looks at all aspects of urgent care, including the services provided by GPs and MedOCC, processes within A & E to make sure that patients are seen and treated or admitted to hospital smoothly, and services to make sure that people who have to stay in hospital are supported to return home as soon as possible. The action plan is being overseen by the Urgent Care Board, which has also been changed as a result of the review. The Board is chaired by NHS Medway's Director of Commissioning and Performance, and all organisations are represented at a very senior level. The Board supports a huge network of teams who are working on different aspects of improving urgent care services. We recognise that one very real issue is that people come to A & E because they don't know about other services which might be better for them. One of our key workstreams is to improve communications so that people in Medway are aware of the range of services which are available for minor illnesses and injuries.

Learning disability Services for people with a learning disability in Medway are commissioned jointly by NHS Medway and Medway Council through a partnership agreement. The Medway Valuing People / Learning Disability Partnership Board, which includes people who use services and their carers, oversees this work. In 2008/09, this included: ● Appointment of a health facilitator in September 2008 ● Delivery of the first annual health checks and health action plans to people with a learning disability ● Continued work on the ‘Green Light’ tool-kit which provides a framework for co-ordinating and improving services for people with a learning disability and other health problems ● Publication of information leaflets explaining to people with a learning disability how to get a health action plan ● A Health Inequalities and People with a Learning Disability event In 2009/10 together we will: ● Continue to deliver annual health checks and health action plans for people with a learning disability in Medway ● Deliver more Health Action Plan training days ● Continue to improve co-ordination of care and support between learning disability and other healthcare services. This is in line with the vision for services for people with a learning disability set out in the Government’s White Paper in January 2009, Valuing People Now.

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Mental health There is no health without mental health. Mental health problems create high levels of personal suffering, isolation and financial hardship. They are also closely linked to physical illness and can result in more admissions to hospital, investigations and treatment.

NHS Medway is the lead commissioner for adult mental health services for the whole of Kent and Medway, which has a population of over 1.6million. In 2008/09 we oversaw the investment of £140 million in health and social care services for people with mental health needs. This money came from NHS Eastern and Coastal Kent, NHS West Kent, Kent County Council NHS Medway, and Medway Council.

Dementia Dementia is one of the biggest challenges we face nationally and locally. At NHS Medway, we recognise that significant investment will be needed to ensure early diagnosis, co-ordination of care and delivery of high quality services for people living with dementia and their families. Therefore our intentions for dementia care are being clearly set out in a commissioning strategy. It will focus on ensuring early diagnosis and intervention, the provision of community support services that are tailored to the individual needs of people with dementia, and on raising awareness of dementia through public education and information. 34

About £23million of the total came from Medway and was spent on behalf of people in Medway. Our main focus is on recovery, well-being and inclusion for people with mental health needs. In 2008/09 we worked towards attaining the seven standards in the National Service Framework for Mental Health. These cover primary care and access, suicide prevention, people with severe mental illness, caring for carers and mental health promotion. In 2008/09 we: ● Involved users and carers for the first time in our planning and monitoring processes ● Funded three new mental health advisers under the national Improving Access to Psychological Therapies programme to offer support to people in Medway with mild anxiety or depression who can refer themselves or be referred by their GP ● Introduced a six-month initiative to reduce waiting times for primary care psychological therapy ● Agreed with urgent care services how we will improve care for people with mental health needs attending A & E and other centres ● Acquired £700,000 additional funding from the National Offender Management Service for Prison Health at HM Young Offenders’ Institute Rochester of which about £500,000 is for improved mental health services ● Developed our Operational Plan, and the Mental Health Joint Strategic Needs Assessment ● Recruited Community Development workers to work with Black and Minority Ethnic communities across Kent and Medway - people from these communities are at greater risk of mental health problems than the rest of the community

● Agreed with Kent Police a scheme to base psychiatric nurses at police stations in Medway and Eastern and Coastal Kent so mental health assessments can be swiftly offered to people who need them and who are in police custody ● Agreed funding for extra care for people placed out of area in low-secure settings. In 2009/10 we plan to build on this and: ● Improve the crisis resolution and home treatment service (CRHT) in line with best practice, initially increasing CRHT to 24 hours ● Introduce a 24/7 A & E liaison service so that patients who need an emergency psychiatric assessment in the Emergency Department or acute wards can be seen quickly ● Review services in Medway for people having a mental health crisis and consult about different options for care in the future ● Work with GPs to ensure that all patients with schizophrenia get annual health checks (with effect from December 2009) ● Develop a joint mental health promotion strategy ● Complete an audit of local suicides ● Improve access to psychological therapies services for people in prison, and review and go out to tender on inpatient services for people in prison ● Begin the pilot of the police station-based scheme.

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Long-term conditions Long-term conditions are those that people have to live with and manage on a day to day basis, such as diabetes or asthma. Our focus is on supporting people with long-term conditions to take control of their own health and well-being, so they stay as well and as independent as possible.

In 2008/09 we: ● Employed, for the first time, a commissioning manager specially for long-term conditions

hospital discharge with the South East Coast Specialised Commissioning Team, East Kent Hospitals University NHS Foundation Trust and the Renal Network ● Worked with the Specialised Commissioning Team to ensure Medway patients have appropriate access to services and treatment

Diabetes ● Worked with people with diabetes to plan an improved service ● Introduced DESMOND courses Training for people newly diagnosed with Type II diabetes, to help them take control of their condition.

Neurological ● Consulted local people about services for people with Parkinson’s disease ● Worked with the Parkinson’s disease Society to provide support to two new posts of Parkinson’s Disease nurse specialist. NHS Medway has agreed to fund these posts after the funding from the Parkinson’s Disease Society ends ● Began a review of services for people with long-term neurological conditions

Heart disease ● Worked with 12 GP practices on improving the accuracy of their registers for heart failure ● Funded a counsellor to offer psychological support to cardiac patients ● Agreed funding for a new community arrhythmia service (for people with irregular heartbeat which increases the risk of having a stroke)

Renal ● Agreed how patients will be cared for at every stage from diagnosis to 36

In 2009/10 we plan to: ● Introduce personalised care plans for people with complex long-term conditions

Neurological ● Increase the size of the community brain injury team to ensure adults who have had a traumatic brain injury receive personalised integrated care ● Improve multi-disciplinary community neurological rehabilitation with Medway Council, allowing better care closer to home ● Review how the expert patient courses for people with long-term conditions are supplied, looking at the best way of helping people to manage their own condition. The courses, led by people with long-term conditions, are designed to help people maintain their independence and share experiences

Heart

Wheelchairs

● Offer a new service for the diagnosis and treatment of irregular heartbeat in the community, reducing the need for patients to be referred to hospital ● Work with GP practices across Medway on improving their heart failure registers ● Review cardiac rehabilitation services and identify more patients who could benefit from them ● Support the work of the Kent Cardiac Network in developing the most up-to-date lifesaving treatment round the clock for people who have had a heart attack in Kent and Medway

To reduce waiting times for people needing a wheelchair, we invested nearly £500,000 of extra money in 2008/09. This enabled Kent and Medway NHS and Social Care Partnership Trust (KMPT) which provides the service to dramatically reduce the waiting list.

Renal

NHS Continuing Healthcare is a package of care arranged and solely funded by the NHS. People are eligible for NHS Continuing Healthcare if their primary need is for healthcare.

● Continue to work with the other primary care trusts and across the South East Coast region (Kent, Surrey and Sussex) to ensure consistent care and support for people with renal conditions from primary care through to specialist hospital services

Diabetes ● Strengthen the community diabetes team so people with diabetes can be offered more of their care closer to home ● Develop a local insulin pump service for children who currently have to travel to London ● Enhance the knowledge, education and skills of people with diabetes, carers and healthcare professionals, to reduce the negative impact of diabetes on patients’ lives.

NHS Continuing Healthcare and NHS Funded Nursing Care

NHS Funded Nursing care is the payment made by the NHS for individuals in registered nursing care homes who are not eligible for NHS Continuing Healthcare, but who have registered nursing care needs. This payment is set by the Department of Health and for 2008/09 was £103.80 a week. In 2008/09 NHS Medway’s Continuing and Funded Nursing Care Team ● Received the following new requests for assessment for eligibility for NHS Continuing Healthcare: Number of Number applications assessed as received eligible for NHS Continuing Healthcare 375

“It was very interesting working with the team that was laying out the diabetes treatment pathway from diagnosis to self care. I learned a lot and I hope I made a real contribution too.” 81-year-old patient.

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Number assessed as not eligible or referred to an alternative service 147

● Undertook 1,664 assessments as part of the NHS Continuing and Funded Nursing Care process ● Focused on the full implementation of the Department of Health Framework 37


for NHS Continuing Healthcare and NHS Funded Nursing Care ● In conjunction with colleagues from Medway Council Social Care, provided training to over 100 health and social care staff to develop their understanding of the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care, and to increase their assessment skills ● Started working with the NHS South East Coast Procurement Hub on developing regional commissioning arrangements with care providers to ensure quality, needs-focused, timely care ● Participated in an audit by NHS South East Coast Audit, in which NHS Medway’s Continuing and Funded Nursing Care department were assessed as excellent In 2009/10 we plan to: ● Meet the challenges of the National Framework and to implement changes planned by the Department of Health in autumn 2010 ● Continue training health and social care staff, including specific training for staff in the acute hospital settings and in nursing care homes ● Further develop partnership working with the local authority to ensure a seamless path between health and social care.

Older people

End of life care

We have been working with our partners to develop a plan to improve health and well-being of older people in Medway. The plan will cover the period 2009 to 2012. The vision of the plan is to support older people to live healthy, fulfilling lives that meet their personal aspirations enabling them to maintain or regain their independence to the greatest extent possible.

End of life care offers support and palliative treatment for both patients and their families through the last phase of life and into bereavement.

To achieve this we will work alongside our partners and Medway residents to: ● Make services such as routine tests and investigations more accessible in local communities ● Improve flexibility of opening times for primary care ● Develop preventative programmes to improve health and well being, with a resulting decrease in the need for hospital care and allowing older people to work for as long as they want ● Improve support for carers through better monitoring and access to short breaks ● Extend use of assistive technology to improve independence at home and support better management of long term conditions ● Raise standards of care in residential and nursing homes ● Consider the use of personal health budgets to drive the principle of personalisation. Work by the Urgent Care Board (see page 32), has already resulted in a number of improvements to services for older people.

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The main focus for end of life care in 2008/09 was on starting the work to open up this kind of care to more patients (rather than just those with terminal cancer), and to increase the number and range of professionals involved in delivering it. This was in line with the Government’s End of Life strategy launched in July 2008 aimed at helping commissioners and providers improve the quality of life and well-being of individuals approaching the end of their lives. In 2008/09 we: ● Recruited a facilitator who is training nursing home staff in the principles of the Liverpool Care Pathway and the Gold Standards Framework (best practice in end of life care) ● Worked with GPs to increase the number involved in delivering care which follows the Gold Standards Framework ● Started developing a strategy for end of life care in Medway ● Co-ordinated a forum to bring together representatives of the local authority and other professionals involved in delivering care, to bring a wider emphasis and whole systems approach

involved in end of life care ● Commission more training for GPs and other primary care staff as well as those in residential homes ● Explore options for centrally storing patient details so different agencies can access their details promptly ● Develop mechanisms to enable a smooth transition from children’s to adult services for adolescents who are seriously ill.

Personal health budgets pilot Personal health budgets allow patients to choose how to spend NHS money on elements of their care. We are interested in offering these budgets to people with between six and 12 months left to live who also have neurological, heart or lung conditions which require care. The bid is enthusiastically supported by Medway Council, clinicians, patients and community groups. Our scheme was picked by the Department of Health as one for possible national funding. We expect to hear the final outcome of the bid this autumn.

In 2009/10 we plan to: ● Complete the local strategy and commissioning plan for end of life care ● Consult service users and carers ● Commission 24/7 nursing services ● Improve links between agencies

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Medway Community Healthcare The majority of NHS Medway’s staff are involved in providing frontline care to patients. During 2008/09, in line with national guidance, this part of the organisation moved to arm’s length from the rest of NHS Medway. At the end of 2009/10 Medway Community Healthcare is expected to become fully independent of NHS Medway. NHS Medway Board will consider the preferred business model for this part of the organisation in September. In December 2008, a dedicated board for Medway Community Healthcare met for the first time. It has responsibility for overseeing the work of Medway Community Healthcare and its governance arrangements, and is

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accountable to the main NHS Medway Board. Medway Community Healthcare provides care at every stage of people’s lives.

Children’s services Services for children in Medway are delivered by ● Three teams of health visitors and speech and language therapists ● One Children’s Therapy team which cares for children with complex needs Medway Community Healthcare staff also participate in: ● Youth Offending Team (along with police, social workers, probation and education staff) ● Young Parents Integrated Team (supporting teenage parents) ● Child and Adolescent Support Team which focuses on emotional well-being

Achievements in 2008/09 include: ● Setting up the Young Parents Integrated Team to provide a holistic service for teenage girls and their babies from specialist midwives, specialist health visitors, and Connexions advisers. Scanning sessions just for this age group once a week have increased the proportion of girls attending antenatal screening and clinics, and getting support and advice. The team - one of only a few of its kind in the country - offers a structured programme of support with parenting, through a group called Step4ward ● Gaining a certificate of commitment (towards international recognition) from UNICEF’s global Baby Friendly initiative ● Improving breastfeeding support for new mothers through a new co-ordinator with responsibility for improving training for GPs and health visitors and ensuring NHS Medway premises are baby-friendly.

Sanderson Centre

Plans for 2009/10 include: ● Improving support for the families of very young children diagnosed with disabilities by expanding the Children’s Therapy Team to include early support health visitors ● Developing the Peer Supporter Service - a group of volunteer mothers with experience of breastfeeding who support new mums in breastfeeding their babies ● Following approval and funding from the Department of Health, recruiting a team of family nurses to provide support to teenage parents and their babies, for two years, through the Family Nurse Partnership programme ● Moving to a new community IT system, Community Care Records, to enable staff to record their clinical activity more efficiently and update their electronic records as they see people, reducing the need for paperwork.

We will remain in discussion with the Children and Adults Overview and Scrutiny Committee about this.

In early January 2009, the Sanderson Child Development Centre moved location to allow Medway NHS Foundation Trust to open more beds for very sick patients at a time of exceptional demand. Services began again over the weeks that followed at Rainham Healthy Living Centre, Rochester Healthy Living Centre and Chaucer ward at Medway Maritime Hospital. Appointments for children normally seen at nursery, at school or at home continued as usual. Parents and carers whose children were normally seen at the Sanderson’s former base at the hospital were offered the opportunity of an appointment at home if they felt they needed one urgently. In 2009/10 we are working with parents, carers, our staff, and others in the community to find out what they would like to happen next for the Sanderson Centre. We will use what they tell us to plan the way we organise services for the future.

Urgent and out-ofhours care - MedOCC NHS Medway’s 24-hour on call care service MedOCC, provides out-of-hours medical cover for people in Medway when their GP surgery is closed. MedOCC can dispense urgently-required medication prescribed by its GPs, such as pain relief and antibiotics, out-of-hours. MedOCC will also see patients during the day if they need an urgent appointment which their own surgery cannot provide. In these cases, their surgery refers them. 41


Most patients who get in touch with MedOCC need urgent care. Others contact the service because they have not registered with a GP locally. In 2008/09, MedOCC had more than 90,000 patient contacts – mainly self-referred but with some referrals from A & E and some from GPs. In particular, MedOCC faced much increased demand over the winter period. More than 45,000 patients were seen at one of MedOCC’s three centres, at Quayside House, Chatham; Rochester Healthy Living Centre; and alongside A & E at Medway Maritime Hospital, Gillingham. More than 30,000 received telephone advice and around 10,000 received home visits. Monthly patient survey data for 2008/09 shows satisfaction levels of 89 per cent. In 2008/09 MedOCC: ● Fitted out the fleet of cars that its GPs use for home visits with computersthis enables electronic note-taking so updates are available for patients’ own GPs first thing next day ● Took on the management of the GP practice within the Sunlight Centre in Gillingham, with a list of registered patients In 2009/10 MedOCC plans to: ● Streamline the management of deep vein thrombosis (a blood clot blocking circulation to the legs) with access to increased ultrasound to cut waiting times ● Use the new Summary Care Record system (see more on p28) to improve care for patients

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“The reception staff at MedOCC were very friendly and helpful. I was seen within a matter of minutes after arriving at the centre and, as it was a Sunday evening, medication was given out too. I was very impressed with the service.” “I don’t think the service can be improved - it’s first class already!!” “The service is greatly needed and we are very grateful to all those doctors who are on call. Thank you.”

Services for adults Community health services for adults in Medway are delivered by: ● Six integrated health and social care teams which offer care, support and advice for people in their own homes. The teams include district nurses, care managers, social workers, occupational therapists and physiotherapists ● Rapid response team which offers intensive short-term health and social care support to people recovering from an illness or injury ● Community equipment service which supplies beds, hoists, walking aids and similar equipment to patients being cared for at home ● St Bartholomew’s Community Hospital (St Barts) which offers rehabilitative care for four to six weeks to adults (18+ though in practice mostly older people) recovering from an illness or injury ● Continence care service which supports, treats and manages people with bowel or bladder dysfunction,

and offers advice and guidance for patients, carers and healthcare professionals Speech and language therapists who offer assessment and advice to adults with swallowing and/or communication difficulties resulting from for example, a stroke or head injury, conditions such as multiple sclerosis, Parkinson’s disease, Motor Neurone Disease, dementia or head and neck cancer Dietetics team who provide advice to individual patients with special dietary needs, and support on healthy eating for people with conditions such as diabetes and heart disease, as well as information and training for healthcare professionals Orthopaedic clinical assessment service which consists of an orthopaedic physician (GP with a special interest in orthopaedic conditions); consultant physiotherapist; orthopaedic physiotherapy practitioners; extended scope practitioners in physiotherapy, occupational therapy and podiatry; and an administration team. They assess patients to diagnose problems and can arrange x-rays and magnetic resonance imagings (MRIs) or give injections if appropriate. Conditions seen by the service include hip, knee, shoulder and other joint problems, arthritis, lower back pain Podiatry service which offers assessments, treatment and preventative care for problems affecting the legs and feet including those caused by diabetes, arthritis and age-related conditions Occupational therapists who provide specialist assessment, advice, treatment and education to people with a range of different conditions, and help patients get the equipment they need to be as independent as possible

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● Blood-taking (phlebotomy) team which runs sessions at Rainham, Lordswood, Parkwood and Twydall ● The Walter Brice Rehabilitation Centre which provides day rehabilitation to help adults recovering from an illness or injury or with a progressive condition to achieve and maintain confidence and independence. The team includes physiotherapists, rehabilitation nurses and occupational therapists. Patients attend one day each week until discharge. People with a progressive condition return to the centre as long as they need to, where appropriate. ● The advanced clinical assessment team consists of a consultant practitioner and advanced clinical practitioners who support people in their own homes, care homes and at St Bartholomew’s Community Hospital. The team helps them avoid going into hospital or a nursing home before they need to, and supports them to return home from hospital as soon as they are able to.

Community equipment During 2008/09 the community equipment team dramatically reduced waiting times. Beds are usually now delivered within two days of the order coming in from an occupational therapist, district nurse or physiotherapist. This is even though demand is steadily increasing (and was up 20 per cent last year) as more people choose to be cared for at home. In April 2009, the service took over the supply of social care as well as health equipment, improving convenience for patients.

St Bartholomew’s Community Hospital

Specialist services

In September 2008, St Barts started work on The Productive Ward, a national NHS initiative which aims to help staff spend more time with patients. Staff on Andrew Ward looked closely at the way they worked, to cut down on anything that kept them away from direct patient care. They made changes which means they now have up to 11 hours a week longer to spend with patients.

NHS Medway Specialist Services are: ● DentaLine, the out-of-hours emergency dental service for Kent and Medway, and the West Kent Primary Care Dental Service, which provides community dental care for vulnerable people in West Kent and Medway, as well as oral health promotion work in schools and care homes ● Darland House in Gillingham – a 40bed modern specialist nursing home for people over the age of 65 with mental health needs, including dementia ● Wisdom Hospice in Rochester, which has 15 beds and provides a day hospice as well as advice and support for patients and carers. It hosts the Macmillan team which provides care for people in their own homes and a

A community hospital which offers care close to home for Medway people, St Barts has 50 beds, including a 15-bed unit for newly diagnosed stroke patients, and two rehabilitation wards, in which nurses, physiotherapists and occupational therapists help people get back on their feet again and, in the majority of cases, back to their own homes. There are also two end of life care beds.

specialist team of palliative care social workers who offer psychosocial and family support Community respiratory team, which provides assessment, breathing tests, rehab, advice and support to people in Medway and Swale with chronic lung disease Community cardiology team, which both carries out non-urgent tests for diagnosing heart conditions and offers rehab support including exercise classes Stroke service, which cares for everyone registered with a Medway or Swale GP who has had a new stroke Specialist diabetes service which gives advice and support to people with diabetes and professionals caring for them Tissue viability service, which offers wound care for people with chronic wounds or recovering from surgery or

Other services based there include the clinical assessment service along with part of the community mental health Team, and there are dietetic, speech and language therapy, health promotion and pharmacy staff on site.

“Your care and dedication has improved Mum’s health considerably. She has become very content, and would have no problems staying with you! Thank you for everything.” Carer of patient at St Barts

“I would like to say that this clinic (at Rainham) is very clean, efficient, and the staff very good, this is very much needed and is extremely busy. Well done, all of you.” Phlebotomy patient

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an injury, and advice and support ● Falls prevention team, which offers older people who have fallen a full assessment and works with them to prevent a recurrence ● Voluntary services.

Voluntary services NHS Medway hosts the Voluntary Services and Work Experience Unit for Kent and Medway. In 2008/09 it had 1450 active volunteers to manage – an increase of 16 per cent on the year before. Between them, they gave 95,000 hours of volunteering, and covered 178 areas of the NHS, benefiting patients and staff, and gaining a great deal themselves from the experience.

In 2008/09, the unit developed links with the South East Coast Ambulance Service, enabling student paramedics to complete their training within the NHS by assisting ambulance service staff. In 2009/10 there are plans for specially trained volunteers to support breast-feeding and people recovering from stroke. It is also planned, in association with the Thames Gateway Project – Manpower Planning, to look at the role volunteering can play in training/ re-training for the new work placements. Work experience In an innovative new approach during 2008/09, the unit successfully placed not just 155 students but also a number of health and social care teachers, giving them first-hand, up-to-date experience of areas about which they teach.

For 2009/10, a formal programme is being developed to give would-be recruits into medicine a medical career placement to help with their career choices. The unit continues to work closely with Education Business Partnerships.

Wound care Since January 2009, patients with wounds that need expert care have been able to get it at Rainham and Lordswood Healthy Living Centres as well as at Rochester, following a big increase in the number of people working in the Medway Community Healthcare tissue viability team. This was in answer to patient demand. The team is able to look after patients with larger and complicated surgical wounds who “a few years ago” would have been kept in hospital or nursed at home. This is still happening in other parts of the country where advanced therapies are not available, particularly VAC therapy (vacuum assisted wound closure) which has been available to community patients in Medway since 2001. Managers and commisioners from other primary care trusts across the country have been to see our service and have adopted our model.

Diabetes courses The specialist diabetes service is preparing to deliver training (DAFNE courses) for people with Type I diabetes, including people whose work commitments make it hard for them to attend existing five-day courses. An additional diabetes specialist nurse has joined the team, and another nurse and a dietitian have undergone training to enable this service to be offered to patients.

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Our staff In total, NHS Medway has 1519 staff (1228 whole time equivalent posts) of whom 194 work in commissioning and 1325 in Medway Community Healthcare. In 2008/09, our sickness absence rate was 4.29 per cent. In 2008/09, a major focus was engaging with staff in preparation for the split of Medway Community Healthcare from the commissioning part of the organisation. Another important focus was workforce planning. All primary care trusts are required to develop workforce plans for their local healthcare community, based on current and future needs.

Pensions Past and present employees are covered by the provisions of the NHS Pension 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. For further details of the valuation of the scheme, please refer to pages 10 and 11 of NHS Medway’s Annual Accounts (published separately).

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In 2008/09 we: ● Completed a workforce plan for the NHS in Medway ● Held a conference (at which Parliamentary Under Secretary for Health, Ann Keen was a speaker) with the University of Kent at Medway, Medway NHS Foundation Trust and others to discuss a shared understanding and vision for ‘A High Quality Workforce’ as outlined by Lord Darzi ● Signed the Skills Pledge, a public declaration of our commitment to the development of all staff and the intention for all staff to have at least a level 2 qualification in literacy, numeracy and/or IT, together with a relevant vocational award ● Invited all staff in bands 1-4 (the lower pay grades in the NHS) to take part in a survey about their future development and held a conference for them ● Worked with the Medway universities to design a new Foundation Degree for administrative and clerical staff working in health and social care ● Relaunched the BME (Black and Minority Ethnic) Staff Support Network with, in the first year, a range of master classes for our staff from these communities ● Developed an accredited, Medwayspecific Leadership Programme, aimed at first line managers and with an induction session for new managers ● Brought the commissioning of statutory and mandatory training inhouse, streamlined systems and offered flexible options for training, for example at team meetings or through e-learning ● Substantially improved the Electronic Staff Record to help the organisation understand the demographics of the workforce ● Implemented a learning management system which links to the Electronic Staff Record for more robust management and reporting

● Outsourced our notification of sickness absence to an external company, allowing staff to report illness at any hour of the day or night and, if necessary, speak to a nurse for support or advice. Each morning a report giving an up-to-date picture of absence is received by NHS Medway. ● Introduced a Disabled Staff Support Network to help, advise and support disabled staff or those caring for someone with an impairment. In 2009/10 Our main focus will be on securing Investor in People status for NHS Medway and Medway Community Healthcare. This involves developing the support we provide for staff and ensuring that everyone understands the importance of their contribution to improving health and healthcare in Medway. Our 2008 Staff Survey showed that job satisfaction of NHS Medway staff has increased and is now above the national average, and our rate of work-related stress has dropped. We have an action plan for other areas where we need to improve – including reducing harassment, bullying or abuse from patients or relatives.

Disability and Employment We are committed to ensuring that disabled employees and job applicants experience equality of opportunity and that their strengths and abilities, including their knowledge and experience, are welcomed and valued. We recognise that an inclusive approach to employment benefits both our employees and our organisation. Our policy on this is set out in our Disability and Employment policy.

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NHS Medway works hard to ensure errors or accidents do not happen. However, sometimes mistakes are made, and in these cases NHS Medway follows the principles of good practice with regard to remedying the problem. This means:

Getting it right NHS Medway puts an emphasis on acknowledging complaints quickly and putting right what went wrong. NHS Medway aims to consider all relevant factors when deciding the appropriate remedy and ensure fairness for the complainant and, where appropriate, for others as well.

Principles for remedy – how we deal with complaints

Being customer focused NHS Medway apologises for any errors made and explains the causes to those involved. We work with those involved to devise and implement solutions.

Being open and accountable NHS Medway explains to people involved what went wrong and how we will put it right. We have the policy of being honest about our mistakes and how we decide remedies.

Acting fairly and proportionately The solutions we offer will be fair, and proportionate to the circumstances of the complaint. We endeavour to treat everyone equally and without bias.

Putting things right NHS Medway works with those who may have been harmed to determine what would be an appropriate outcome.

Seeking continuous improvement

receive quarterly reports of complaints received, including trend analysis. These reports also go to the Clinical Governance and Clinical Risk Groups. In 2008/09 there were 192 complaints to NHS Medway about directly managed services, compared to 151 in 2007/8. It seems likely that this is linked at least in part to much wider advertising of the NHS Medway complaints service and PALS. In April 2009, NHS Medway introduced the new NHS complaints procedure, Making Experiences Count. People making a complaint are now offered a range of options for resolving it. These include a phone call from the service manager to discuss the issues or a meeting with staff, as well as the more traditional formal letter. People will also be able to come straight to NHS Medway if they have a complaint about their GP, dentist or other independent practitioner, rather than complaining to them first. The aim is to deal with complaints faster and in a way that suits the person making the complaint, keeping them informed all the way through and ensuring the experience is resolved to their satisfaction. The focus continues on ensuring lessons learned are shared throughout NHS Medway to improve services. Should complainants remain unhappy after all attempts to resolve a complaint locally are exhausted, they may request an independent review of the complaint by the Health Services Ombudsman.

NHS Medway seeks to use the lessons learned from complaints to ensure that services are improved as a result. Complaints are reported to the NHS Medway Board, and service directors 50

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At NHS Medway we strive constantly to reduce our carbon footprint and our general environmental impact.

Our environmental impact

● All new buildings run with efficient systems and have sensor-operated lights which activate when someone enters a room ● We have replaced some of the outdated boilers in our buildings with cost-effective energy conservation systems, and more are being upgraded each year ● St Barts operates a Combined Heat and Power (CHP) generator which converts waste emissions into free hot water, via a heat exchanger, giving an estimated saving of £4,000 to £6,000 a year ● It is NHS Medway’s policy to run heating only between October and March ● NHS Medway supports the green transport plan and encourages staff to: Car share Use public transport Plan journeys to best effect Embrace flexible working Use video / telephone conference facilities ✦ Cycle or walk ● Recycling is encouraged on all sites and a new recycling system has got underway in 2009/10 which should reduce the amount of trade waste in both volume and cost ● A Microfibre cleaning system has been introduced in the clinics which has reduced the need to use chemicals as well as the risk of infection ✦ ✦ ✦ ✦ ✦

Our environmental performance Given that 64% of our buildings are more than 30 years old, we have achieved fairly good scores in the environmental management section (based on utility usage) of the land and property appraisal (the 6 facet survey) which is carried out every other year. For example, Elm House in July 2005 used 39.23 gigajoules per 100m3 however in July 2007 the figure was 34.36 GJ per 100m3 – a marked improvement. In September 2008, the Government introduced Display Energy Certificates a performance rating assessed by a qualified Low Carbon Energy Assessor (LCEA) on buildings over 1000m2. To date, NHS Medway’s Darland House and St Bartholomew’s Hospital have been assessed. Both were awarded a ‘C’ grade meaning they have an energy performance of between 51-75 CO2 emissions; the typical rating for buildings of their age and size would be ‘D’ with emissions between 76-100. In 2008/09 for all sites we used: 2,075,018 KwH of Electricity at a cost of £157,705 4,478,061 KwH of Gas at a cost of £129,540 In 2008/09 NHS Medway produced approximately: 56 tonnes of clinical waste costing £23,000 to dispose of 225 tonnes of trade waste costing £21,500 to dispose of

Relocation In autumn 2009, NHS Medway will move its headquarters to a new location, expected to be in Chatham.

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NHS Medway Board sets the strategy and direction of NHS Medway, monitors its performance and makes financial and policy decisions.

Non Executive Directors Eddie Anderson Chair

Executive Directors Marion Dinwoodie Chief Executive

Other members of the executive team John Bakker, Interim Director of Integrated Commissioning Pippa Barber, Director of Clinical Performance / Executive Nurse Helen Buckingham, Director of Commissioning and Performance Cheryl Clements, Director of Human Resources and Workforce Development, until May 2009 Natalie Davies, Company Secretary Murray Duncanson, Interim Director of Corporate Strategy, became Interim Director of Organisational Development and Workforce Planning from May 2009 Dr Peter Green, Medical Director

Jane Bastow

Dr Alison Barnett Director of Public Health

Lauretta Kavanagh, Director of Commissioning for Mental Health and Substance Misuse, Kent and Medway Martin Riley, Director of Provider Development, became Managing Director of Medway Community Healthcare from April 2009

Trevor Cooper

Glyn Griffiths Declared interest: elected member of Medway Council

Professional executive committee Jonathan Bates Director of Finance and Assurance

Malvinder Raval Professional Executive Committee Chair

Azhar Mahmood Dr Gill Fargher Professional Executive Committee - GP representative

Malvinder Raval, Chair Dr Gill Fargher, GP Dr Nathan Nathan, GP Mary Kirk, Nurse Consultant in Heart Failure Kath Plumbe, Consultant Physiotherapist Richard Redmond, Interim Assistant Director of Social Care, Medway Council Dr Chau Shum, GP Sue Whiting, Clinical Nurse Lead Marion Dinwoodie, NHS Medway Chief Executive Dr Alison Barnett, Director of Public Health Jonathan Bates, NHS Medway Director of Finance and Assurance Helen Buckingham, NHS Medway Director of Commissioning and Performance Martin Riley, Director of Provider Development, became Managing Director of Medway Community Healthcare from April 2009

Practice based commissioning clinical leads Marcus Sherwood-Jenkins – Audit Committee chair

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Rochester and Strood: Dr Christopher Markwick Chatham: Dr Nathan Nathan Gillingham and Rainham: vacant (overseen by Dr Markwick) The NHS Medway Board holds six meetings a year in public at NHS Medway‘s HQ at Ambley Green. The Board is supported by a number of sub committees chaired by non executive directors. 55


Performance NHS Medway has achieved success in a number of key areas in 2008/09: ● Reduction in cases of MRSA bacteraemia and Clostridium difficile ● Meeting and sustaining 18 weeks targets for-inpatients and outpatients ● Reducing the waiting times for diagnostic tests ● GP practices offering extended opening hours ● Number of people who have stopped smoking with NHS support ● Access to primary dental services

Performance in some areas indicates the need for further improvement ● To further improve the quality of stroke care ● To reduce the rate of teenage pregnancy ● To improve the number of mothers breastfeeding at six to eight weeks ● To promote Chlamydia screening for 15 to 24 year olds

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National priority indicators for Primary Care Trusts This table sets out our performance against Quality of Services Indicators, which are set by the Department of Health to ensure the NHS delivers high standards of healthcare. It features the national priority (Vital Signs) and existing commitment indicators. Vital Signs Description

2008/09 Target

Latest Comments performance

18 week referral to treatment times - reported waits for admitted elective care

> _ 90%

94.25% as at The target for December 2008 31/03/2009 was for 90% of patients whose treatment includes a hospital admission to be treated within 18 weeks of referral. This was achieved and has been sustained to March 2009

18 week referral to treatment times - reported waits for non admitted elective care

Direct access audiology waiting times Access to primary care patient reported measure of GP access

Access to primary care practices offering extended opening hours

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> _ 95%

100%

> _ 89%

> _ 50.75%

96.46% as at The target for December 2008 31/03/2009 was for 95% of patients whose treatment is carried out in an outpatient setting to have commenced within 18 weeks of referral. This was achieved and has been sustained to March 2009 100% as at 31/03/2009

2008/09 Target

31-day standard for subsequent cancer treatments (chemotherapy and surgery) All treatments to start within 31 days of patient being added to the waiting list for that treatment

100% by Qtr 4 2008/09

31-day standard for subsequent cancer treatments (radiotherapy) All treatments to start within 31 days of patient being added to the waiting list for that treatmen

100% by Qtr 4 2008/09

All cancers: One month diagnosis (decision to treat) to treatment (see also VSA 11 & 12)

100%

Applicable to children’s newborn hearing screening

82% (Patient Average of the five elements Survey of access to primary care 2007/2008) telephone access, see GP within 48 hours, book GP consultation 3+days ahead, see a specific GP and GP practice opening times 81% as at 31/03/2009

Vital Signs Description

51 of 63 practices were providing extended hours

Extended 62-day cancer treatment targets. Percentage of patients who receive a first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status

100% by Qtr 4 2008/09

Latest Comments performance

{ 99.78%

The 31 day standard for cancer treatment has been extended to include subsequent cancer treatments. Performance information for this will not be available until later in 2009 as the national cancer waiting times database is being updated

The national cancer waiting times database is being updated to record the extended targets. Information for January to March 2009 will not be available until the update is completed

The

62 day standard for cancer treatment has been extended to include cancer treatments that are required as a result of a consultant decision. Performance information for this will not be available until later in 2009 as the national cancer waiting times database is being updated

Number of patients receiving NHS primary dental services in Medway

Access to primary dental services

153,300

162,635

All-age all cause mortality (AAACM) rate per 100,000 female

2008 520.20

2007 544.56

The 2007 statistics are the most recent data available

All-age all cause mortality (AAACM) rate per 100,000male

2008 721.20

2007 780.32

The 2007 statistics are the most recent data available 59


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Vital Signs Description

2008/09 Target

All cancers: Two month GP urgent referral to treatment (see also VSA13)

> _ 95%

Breast symptom two week wait (two week wait standard for patients referred with 'breast symptoms' not currently covered by two week waits for suspected breast cancer)

100% by Qtr 4 2008/09

Latest Comments performance 98.78%

The national cancer waiting times database is being updated to record the extended targets. Information for January to March 2009 will not be available until the update is completed

The two week standard for cancer treatment has been extended to referrals for patients with 'breast symptoms' that are not included in the existing two week waits for suspected breast cancer. Performance information for this will not be available until later in 2009 as the national cancer waiting times database is being updated

All cancers: two week waits

100%

100% year to The national cancer waiting date as at times database is being 31/12/2008 updated to record the extended targets. Information for January to March 2009 will not be available until the update is completed

Breast cancer screening for women aged 53 to 70 years

National Target to achieve > _ 70%

81.2% aged Good uptake of screening. Programme is being extended 53-64 80.7% aged (phased) from 2010 65-70 (KC63 07/08)

Childhood obesity measured in year R (reception)

8.65% < _ (86% coverage)

Childhood obesity measured in year 6

18.68% < _ 86% coverage

Chlamydia prevalence (screening) percentage of population aged 15 to 24 screened or tested for chlamydia

> _ 17%

8.0% (83% coverage)

NHS Medway is working hard to reduce the number of overweight young children

This represents a 1.1 % 20.4% 87% coverage increase on the 2006/07 results of 19.3 % To ensure we meet elevated 14.94% target we have tendered out contraceptive and sexual health services to increase coverage

Vital Signs Description

Commissioning a comprehensive child and adolescent mental health service (CAMHS). Has a full range of child and adolescent mental health Services (CAMHS) for children and young people with learning disabilities been commissioned? (Scale 1-4) Commissioning a comprehensive child and adolescent mental health service (CAMHS). Do 16 and 17 year olds who require mental health services have access to services and accommodation appropriate to their age and level of maturity? (Scale 1-4) Commissioning a comprehensive child and adolescent mental health service (CAMHS). Are arrangements in place to ensure that 24 hour cover is available to meet urgent mental health needs of children and young people and for a specialist mental health assessment to be undertaken within 24 hours or the next working day where indicated? (Scale 1-4) Commissioning a comprehensive child and adolescent mental health service (CAMHS). Is a full range of early intervention support services delivered in universal settings and through targeted services for children experiencing mental health problems commissioned by the local authority and PCT in partnership? (scale 1-4)

2008/09 Target

Latest Comments performance

> _3

3 as at 31/03/2009

The CAMHS re-provision is currently under development and the tender exercise is underway to improve capacity and capability

> _3

3 as at 31/03/2009

The CAMHS re-provision is currently under development and the tender exercise is underway to improve capacity and capability

> _3

3 as at 31/03/2009

The CAMHS re-provision is currently under development and the tender exercise is underway to improve capacity and capability

> _2

2 as at 31/03/2009

The CAMHS re-provision is currently under development and the tender exercise is underway to improve capacity and capability

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Vital Signs Description

Self reported experience of patients/users (national priority for local delivery)

Smoking prevalence (number of 4 week smoking quitters who attended NHS stop smoking service) Rate per 100,000 population aged 16 and over for smoking quitters

Incidence of C diff (commissioner) Includes hospital and community acquired infections for NHS Medway registered population Incidence of community acquired C diff (Medway community healthcare) NHS staff survey based measures of job satisfaction

Number of drug users recorded as being in effective treatment

Prevalence of breastfeeding at 6-8 weeks (totally or partially breastfed) of mothers due a 6-8 weeks check Percentage of children with a breastfeeding status recorded at the time of their 6-8 weeks check 62

2008/09 Target

Latest performance

80.9

> _ 1165

> _ 569

< _ 118

< _ 37

3.6

630

1675

569

2008/09 112

2008/09 53

3.6

670 to December 2008

> _ 39.90%

2008/09 22.65%

> _ 85%

2008/09 55.36%

Comments

Vital Signs Description

2008/09 performance will be based on the GP patient survey: Your doctor, your experience, your say. This fieldwork was carried out in January, February and March 2009

Immunisation rate for children aged 1 who have ben immunised for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus Influenza type b

Referral rates have risen due to General Practice Quality Incentives Increasing referrals are providing more opportunities for people to quit smoking through access to the Smoking Cessation Team This represents Medway Maritime Hospital, NHS Medway Community Healthcare and the local Acute Trust for all NHS Medway patients The route cause analysis for these infections indicates that only two involved community services All staff are given the opportunity to feed back on their working lives Numbers reported as being in effective treatment are 670 for problematic drug users, 762 all drugs. For the rolling period Jan-Dec 2008 The Medway Matters agenda is promoting breastfeeding and NHS Medway is supporting this programme There are now local targets for Medway Maritime Hospital and NHS Medway Community Healthcare

Immunisation rate for children aged 2 who have been immunised for Pneumococcal infection Immunisation rate for children aged 2 who have been Immunised for Haemophilus Influenza type b, meningitis C Immunisation rate for children aged 2 who have been immunised for measles, mumps and rubella Immunisation rate for children aged 5 who have been immunised for Diphtheria, Tetanus, Polio, Pertussis Immunisation rate for children aged 5 who have been immunised for measles, mumps and rubella Immunisation rate of 90% for human papilloma virus vaccine for girls aged around 12-13 years

Immunisation rate for children aged 13 to 18 who have been immunised with a booster dose of tetanus, diphtheria and polio

Cancer mortality rate (People aged under 75) rate per 100,000

2008/09 Target

> _ 95%

> _ 95%

Latest Comments performance

2008/09 96.2%

97.80%

> _ 95%

96.50%

> _ 88%

93.80%

> _ 95%

> _ 95%

This target has been met as a result of considerable effort from the likes of practice staff, health visitors and the child health service This target has been met as a result of considerable effort from the likes of practice staff, health visitors and the child health service This target has been met as a result of considerable effort from the likes of practice staff, health visitors and the child health service This target has been met as a result of considerable effort from the likes of practice staff, health visitors and the child health service

93.50%

Work continues to meet this target

94.50%

Work continues to meet this target

> _ 90%

78.78

> _ 90%

52.88

2008 < _ 112.20

2007 125.80

This vaccination programme is directed at preventing cervical cancer. It is being delivered in schools and practices and more results are likely to be received This vaccination programme is directed at preventing cervical cancer. It is being delivered in schools and practices and more results are likely to be received Initiatives identified for 2009/10 to improve early diagnosis and awareness of cancer 63


Existing commitment indicators for Primary Care Trusts continued Vital Signs Description

2008/09 Target

CVD mortality rate per 100,000 (heart disease, stroke and related diseases in people aged under 75)

2008 < _ 79.20

2007 86.18

Quality stroke care proportion of people who spend at least 90% of their time on a stroke unit

> _ 75.00%

2008/09 69%

Quality stroke care proportion of people who have a high risk of TIA who are scanned and treated within 24 hours

> _ 37.50%

Teenage conception rate (number per 1,000 females aged 15-17)

< _ 35

> _ 80% Early access for women to maternity services (number of women seen within first 12 weeks of pregnancy as a proportion of the total number of women at 12 weeks of their pregnancy)

Latest performance

2008/09 16%

2007 48.4

94%

This is the performance of Trust improving monitoring progress in Medway for cardiovascular disease

Ambulance Trust - category A calls meeting 8 minute standard from Call Connect

75% > _

2008/09 75.15%

Ambulance trust - category A calls meeting 19 minute standard

_ 95% >

2008/09 96.91%

Ambulance trust - category B calls meeting 19 minute standard

95% > _

2008/09 94.57%

Commissioning of crisis resolution / home treatment services

473

2008/09 512

Number of people receiving home treatment services in Medway

Commissioning of early intervention in psychosis services

33

2008/09 20

Following a review of early intervention services, it has been agreed that Medway will pay more care co-ordinators to achieve the targets in 2009/10

_ 85% >

2008/09 85.46%

NHS Medway makes every effort to maintain data quality

Delayed transfers of care

<3.5%

2008/09 5.9%

Review of cause of delay in moving patients from acute and non acute beds will be undertaken as part of the urgent care strategic commissioning programme

Diabetic retinopathy screening - percentage of diabetes patients identified by the practices who have been offered digital retinopathy in the last 12 months (less exclusions)

100%

99.94% 2008/09

Medway Foundation Trust provides the service which is essential in supporting diabetic patients

Inpatients waiting longer than the 26 week standard

0%

2008/09 0.027%

Six patients waited longer than 26 weeks for an inpatient admission

This is the target which measures the number of people who having had a stroke spent 90 % of their hospital admission on a dedicated stroke ward This measures our performance at getting patients at risk of a stroke a scan within 24 hours

NHS Medway is working with our providers to improve access NHS Medway has commissioning arrangements in place to maintain access to maternity services

Data quality on ethnic group

Access to genito-urinary medicine (GUM) clinics within 48 Hours

64

2008/09 Target

Latest performance

100%

2008/09 98.935%

Latest Comments performance

Vital Signs Description

Existing commitment indicators for Primary Care Trusts Vital Signs Description

2008/09 Target

Comments

Comments

A review of the pathway has been completed to ensure that all patients access the service and are offered an appointment within 48 hours

This is the performance of the South East Coast Ambulance Trust (SECAmb). NHS Medway, along with the other primary care trusts in the south east coast area, commission their ambulance services from SECAmb. The achievement of the category A targets and the performance on category B reflect the high level of effort and commitment from everyone in the Trust

65


Existing commitment indicators for Primary Care Trusts continued Vital Signs Description

2008/09 Target

Latest Comments performance

Outpatients waiting longer than the 13 week standard

0%

2008/09 0.059%

Thirty patients waited longer than 13 weeks for a first outpatient appointment

Patients waiting longer than three months (13 weeks) for revascularisation

0%

2008/09 0%

No patients, except those who choose to, waiting longer than three months for their procedure

Proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help

68%

Total time in A&E: Four hours or less

98%

2008/09 82.76%

This monitors our improving performance at getting patients who have had a heart attack into hospital for thrombolysis within one hour

2008/09 97.1%

This is the performance for 2008/09 for the Medway local health economy. NHS Medway is working with Medway NHS Foundation Trust to sustain agreed improvements

Statement of the Chief Executive’s responsibilities as the Accountable Officer of the primary care trust

66

The Secretary of State has directed that the Chief Executive should be the Accountable Officer of the primary care 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 primary care trust; ● the expenditure and income of the primary care 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 net operating cost, 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. " Marion Dinwoodie

Chief Executive Date 10 June 2009

Statement of Internal Control 2008/09 1. Scope of responsibility The Board is accountable for internal control. As Accountable Officer, and Chief Executive Officer 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. In particular, I am responsible for: ● The propriety and regularity of NHS finances ● The keeping of proper accounting books and records ● Prudent, efficient and effective administration ● The avoidance of waste and extravagance ● The efficient and effective use of all resources in my charge ● Ensuring managers at all levels have a clear view of their objectives, the means to assess achievement against those objectives, and the information and training to exercise their responsibilities effectively I also have responsibility for developing and maintaining the following key relationships: ● With local communities through public meetings and the publishing of annual reports and accounts. ● With patients through the PCT’s

Patient, Carer and Public Involvement Group and the Public Patient Involvement Forum ● With the South East Coast Strategic Health Authority through a range of regular meetings and forums ● With other partners through the Medway Local Strategic Partnership, the Medway Renaissance Partnership and through a range of service and care specific committees and working groups The context in which risk within the organisation is managed takes into consideration the stakeholders listed above. My responsibilities are fulfilled and monitored through a range of committees, groups, and actions as follows: ● Regular reporting to the Board and Professional Executive Committee by both clinical and operational management teams ● The Audit Committee ● The Risk Management Committee. ● The implementation of a Risk Management Policy/Strategy agreed by the Board which clearly defines roles and responsibilities in relation to Risk Management at all levels from the Chief Executive to front line staff and addresses both clinical and non clinical risk ● The Health and Safety Group. ● The Clinical Governance Sub Committee of the Professional Executive Committee. ● Regular briefings to the Strategic Health Authority ● Internal and external audit ● The use of the Assurance Framework to manage principal risks associated with key objectives together with a report on corporate objectives

67


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 eliminate all risk of failure to achieve these policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on a continuing process designed to: ● Identify and prioritise the risks to the achievement of the organisation’s policies, aims and objectives ● Evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them effectively and economically The system of internal control has been in place in Medway PCT for the year ended 31 March 2009 and up to the date of approval of the annual report and accounts.

3. Capacity to handle risk

The following key principles are observed in implementing the risk management strategy:

● There is Board, PEC and Management Team commitment to, and leadership of the total risk management function, with the ultimate responsibility resting with the Chief Executive ● The PCT has a Risk Management Committee charged by the Board with the oversight of the risk management function in the organisation ● The PCT has developed its clinical governance framework to include the formal application of the risk management process to clinical practices ● There is widespread employee

68

participation and consultation in risk management processes. There are risk leads and clinical governance leads in all services There is a mechanism for all incidents and complaints to be immediately reported, categorised by their potential consequences and investigated to determine system failures and lessons learned where appropriate There are management systems in place that provide safe practices, premises and equipment in the working environment. Systems of work are designed to reduce the likelihood of human error occurring The risk management process is applied to contract management especially when acquiring, expanding or outsourcing services, equipment or facilities. Contracts are reviewed and written to ensure that only reasonable risks are accepted In all PCT premises, whether owned or shared, safe systems of work are in place to protect patients, visitors and staff The PCT maintains an effective system of emergency preparedness, emergency response and contingency planning The effectiveness of risk management strategies, plans and processes are measured against NHS best practice through the Healthcare Standards and NHS Litigation Authority Assessments. Where weaknesses are identified, action plans are developed, monitored and delivered to ensure continued compliance. The PCT provides realistic staffing and financial resources to implement and support effective risk management

It is recognised that failure to manage risk effectively could seriously impact on the above. Every care is taken to ensure that key controls put in place to manage risk do not have a detrimental effect on stakeholders.

Training: ● Staff within each service and on each site have been trained in both physical and environmental risk assessment of their work areas and up to date assessments have been carried out in year, which have fed into the Risk Register ● New staff have risk management training as part of their induction to the organisation ● Work continues to further embed risk awareness into the culture of the organisation as service teams risk rate the effectiveness of internal controls in place to ensure team objectives are met. This involves continuing risk management training and the promotion internally of the risk management policy

4. The risk and control framework The risk management process is designed to identify the principal risks to the achievement of the organisation’s objectives; to evaluate the nature and extent of those risks; and to manage them efficiently, effectively and economically. The PCT’s Risk Management System covers four types of risks and controls: 1. Clinical risks – Covered by the annual report on clinical governance and recorded in the clinical risk register. Executive accountability for clinical risk management rests with the Director of Provider Development. 2. Organisational risks – Covered by the annual report on risk management, and in the Corporate Objectives report. Executive accountability for organisational risks rests with the Chief Executive.

3. Financial risks - Covered by the annual report on risk management and recorded in the Assurance Framework and Corporate Objectives Report. Financial risks are also reported in finance Reports to the Board. Executive accountability for financial risk management rests with the Director of Finance and Assurance. 4. Strategic risks (risks which will impact on the achievement of corporate objectives) – Covered by the annual report on risk management and the statement of internal control. These risks are also recorded in the Assurance Framework. Risk assessment forms part of all strategic policy decisions. Using the reports detailed above, and regular update reports, these risk areas are monitored regularly by: ● The Board ● The Audit Committee ● The Risk Management Committee Risk management awareness and the purpose of assessment and monitoring of risk is embedded in the activity of the organisation at all levels through: ● Including risk and residual risk rating in business cases, Board reports/papers relating to all development proposals and all performance reports, corporate and team objectives ● The development of local risk registers in all services and sites informed by risk assessments carried out by staff trained and competent to assess both physical and geographical risks posed by location and client group ● The development of action plans to address risks identified and monitoring mechanisms to ensure key controls are effective

69


The Assurance Framework demonstrates the processes in place to ensure the organisation meets its objectives. The risk associated with failure to deliver against an objective is rated, actions to ensure delivery and monitoring mechanisms are described and each objective is further rated for the residual risk. All gaps in control and assurance, where there is significant risk, have action plans. The Assurance Framework has also identified some weakness, and these are managed through the risk management process: ● The PCT has a large investment programme in 2009/10, being managed through 17 work streams, whice report to a Strategic Change Programme Board. With such large scale investment, there is a risk that some schemes may start later than planned, and interim solutions may need to be deployed ● Some of the delays may arise through difficulties in recruiting staff. The PCT has responded to this by identifying dedicated HR resources to assist in the recruitment process, and the changing economic climate may also assist. ● The PCT has developed business continuity plans. They are robust for individual areas, but they have not yet been thoroughly tested in a co-ordinated way across the whole PCT. To ensure public stakeholder involvement, the Public Patient Involvement Forum is kept informed of key risks impacting on service to the public, and the PCT's actions to address them. Compliance with NHS Pension Scheme Regulations: 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 in to the scheme are in accordance with the scheme rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. 70

5. Significant Control Issues

Review of effectiveness

Self assessment of compliance against the NHS core standards.

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. Executive managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with the assurance through regular performance reporting to the Board.

The PCT will be submitting a declaration of compliance in respect of the majority of core standards. However the PCT did not comply for the full year with four standards and had a lack of evidence of compliance on one standard as set out below: ● Standard C1a – Patient Safety. (Compliant by 12th March 2009) Issue: the area of non compliance related to the Falls Policy which was not approved until 12th March 2009. ● Standard C7e - Equality (Compliant by 25th March 2009) Issue: The PCT was not compliant for the whole assessment year as there was no Single Equality Scheme. This scheme was approved by the Board on the 15th March 2009. ● Standards C9 and C13c - Records Management and Patient Confidentiality (compliant by 31st March 2009) Issue: While systems were in place throughout the year, a number of data losses occurred. As a result the PCT improved systems and staff training in the second half of the year. ● Standard C14b –Complaints Arrangements (Lack of Assurance) Issue: A complaints questionnaire was sent out to all individuals who made a complaint. Some patients wrote back to say that they were unhappy with the way the complaint had been handled. The PCT felt that, although there was some evidence that its complaints arrangements could be improved more evidence needed to be collected. Actions planned/taken: Further surveys will be conducted and further measures will be introduced under ‘Making Experiences Count’. These will include face to face interviews, links with advocacy services and independent review process. The PCT has action plans to address these control issues and has put in place management arrangements to oversee implementation.

The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risk to the organisation achieving its principal objectives have been reviewed. My review is also informed by clinical audit and external audit. I have been advised on the implications of the results of my review of the effectiveness of the system of internal control by the: ● Board ● Audit Committee ● Risk Management Committee A plan to address weaknesses and ensure continuous improvement of the system of internal control is in place.

Preparing for International Financial Reporting Standards (IFRS) The NHS currently prepares its annual accounts using principles and standards laid down by the Accounting Standards Board (called “UK GAAP”). From 1 April 2009, the NHS has adopted International Accounting Standards, and will complete its 2009/10 annual accounts on this basis. The key changes for readers of the accounts are:1 Changes in the format and naming of the financial statements. 2 Additional disclosure (i.e. more narrative explaining the figures) in the notes to the accounts. 3 PFI and LIFT Schemes will be treated as finance leases (and therefore fixed assets) rather than operating leases (charged to revenue)

To prepare for IFRS the PCT has: Signed Dr. Alison Barnett Director of Public Health for the Chief Executive

Date 10 June 2009

1 Trained finance staff in the implications of IFRS 2 Restated the opening 2008/09 balance sheet onto an IFRS basis 3 Completed the 2009/10 financial plans and budgets, (and its 5 year plans) on an IFRS basis

(On behalf of the Board)

71


NHS Medway summary financial statements 2008/09

BALANCE SHEET AS AT 31 March 2009 31 March 2009 £000

31 March 2008 £000

265

294

31,640

28,334

0

560

559

0

32,464

29,188

0

0

13,168

18,152

Other financial assets

0

0

Cash at bank and in hand

9

6

13,177

18,158

(27,414)

(29,390)

0

0

(14,237)

(11,232)

18,227

17,956

Creditors: amounts falling due after more than one year

0

0

Other financial liabilities falling due after more than one year

0

0

Provisions for liabilities and charges

(3,302)

(4,539)

TOTAL ASSETS EMPLOYED

14,925

13,417

2,061

1,943

11,313

9,936

1,551

1,538

Government grant reserve

0

0

Other reserves

0

0

14,925

13,417

OPERATING COST STATEMENT FOR THE YEAR ENDED 31 March 2009 The following tables set out the summary financial statements. These financial statements might not contain sufficient information for a full understanding of NHS Medway’s financial position and performance. The full annual accounts are available from Jonathan Bates, Director of Finance and Assurance. The directors of NHS Medway confirm that all the accounting records of the PCT have been made available to the auditors for the purpose of carrying out their audit. 2008/09 £000

2007/08 £000

Commissioning Gross operating costs

343,796

316,957

Less: miscellaneous income

(22,264)

(7,540)

Commissioning net operating costs

321,532

309,417

Gross operating costs

49,067

43,523

Less: miscellaneous income

(9,987)

(9,274)

Provider net operating costs

39,080

34,249

360,612

343,666

(111)

(38)

0

0

360,501

343,628

Interest receivable Interest payable Net operating cost for the financial year

STATEMENT OF RECOGNISED GAINS AND LOSSES FOR THE YEAR ENDED 31 March 2009 2008/09 2007/08 Fixed asset impairment losses Unrealised surplus / (deficit) on fixed asset revaluations/indexation Increase in the donated asset reserve and government grant reserve due to receipt of donated and government granted assets

£000

0

0

1,827

2,037

0

127

0

0

Additions / (reductions) in "other reserves"

0

0

1,827

2,164

0

0

1,827

2,164

Prior period adjustment - other 72

£000

Additions / (reductions) in the general fund due to the transfer of assets from/(to) NHS bodies and the Department of Health Recognised gains and losses for the financial year Gains and losses recognised in the financial year

Tangible assets Investments Financial assets CURRENT ASSETS Stocks and work in progress Debtors

TOTAL CURRENT ASSETS

Provider

Net operating costs before interest

FIXED ASSETS Intangible assets

CREDITORS: amounts falling due within one year Other financial liabilities falling due within one year NET CURRENT ASSETS / (LIABILITIES) TOTAL ASSETS LESS CURRENT LIABILITIES

FINANCED BY: TAXPAYERS EQUITY General fund Revaluation reserve Donated asset reserve

TOTAL TAXPAYERS EQUITY

The full financial statements were approved by the Audit Committee on behalf of the Board on 10 June 2009 and signed on its behalf by Jonathan Bates Director of Finance for Chief Executive

Date: 10 June 2009 73


CASH FLOW STATEMENT FOR THE YEAR ENDED 31 MARCH 2009

OPERATING ACTIVITIES Net cash outflow from operating activities

Financial Performance Targets

2008/09 £000

2007/08 £000

(356,779)

(340,533)

0

0

111

38

0

0

SERVICING OF FINANCE AND RETURNS ON INVESTMENT: Interest paid Interest received Interest element of finance leases Net cash inflow/(outflow) from servicing of finance and returns on investment

111

38

CAPITAL EXPENDITURE Payments to acquire intangible assets

The PCTs' performance for 2008/09 is as follows:

2008/09 £000

2007/08 £000

Total net operating cost for the financial year

360,501

343,628

1,927

1,811

Operating Costs less non-discretionary expenditure

358,574

341,817

Final Revenue Resource Limit for year

363,633

345,028

5,059

3,211

2008/09 £000

2007/08 £000

3,199

1,667

0

0

(70)

(185)

Less: non-discretionary expenditure

Under/(over) spend against Revenue Resource Limit Capital Resource Limit The PCT is required to keep within its Capital Resource Limit

(83)

(113)

0

0

(3,058)

(1,524)

69

185

Payments to acquire fixed asset investments

0

0

Receipts from sale of fixed asset investments

0

0

Payments to acquire financial instruments

0

0

less: net book value of assets disposed of

Receipts from sale of financial instruments

1

0

less: capital grants

0

0

(3,071)

(1,452)

less: donations

0

(127)

Charge Against the Capital Resource Limit

3,129

1,355

Capital Resource Limit

3,195

1,516

66

161

Receipts from sale of intangible assets Payments to acquire tangible fixed assets Receipts from sale of tangible fixed assets

Net cash inflow/(outflow) from capital expenditure Net cash inflow/(outflow) before financing and management of liquid resources

(359,739)

(341,947)

Gross Capital Expenditure Add: loss in respect of disposals of donated assets

(Over) / Underspend against Capital Resource Limit

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

0

0

Provider full cost recovery duty

Sale of other current asset investments

0

0

Net cash inflow/(outflow) from management of liquid resources

0

0

The PCT is required to recover full costs in relation to its provider functions. The performance for 2008/09 is as follows: 2008/09 £000

(359,739)

(341,947)

Net cash inflow/(outflow) before financing FINANCING

49,067

43,523

less: miscellaneous income relating to provider functions

(9,987)

(9,274)

39,080

34,249

(40,277)

(35,240)

(1,197)

(991)

341,759

Other capital receipts surrendered

0

0

Net operating Cost

Capital grants received

0

0

less: costs met from PCT's own allocation

Capital element of finance lease rental payments

0

0

Under / (over) recovery of costs

Cash transfers (to)/from other NHS bodies

0

215

Net cash inflow/(outflow) from financing

359,761

341,974

22

27

Increase/(decrease) in cash

2007/08 £000

Provider gross operating cost 359,761

Net parliamentary funding

74

Revenue Resource Limit

75


2008/09 Remuneration

Name and title

Mr E Anderson Ms P Barber Dr A Barnett Ms J Bastow Mr J Bates Ms H Buckingham Mrs A Burchell Dr J Clarke Mrs C Clements Mr T Cooper Ms N Davies Ms M Dinwoodie Dr G Fargher Dr P Green Mr G Griffiths Ms M Kirk Mr A Mahmood Dr G Martin Dr N Nathan Miss L Parker Ms K Plumbe Ms M Raval Mr M Riley Dr S Selvan Mr M Sherwood-Jenkins Dr C Shum Ms S Whiting

Contract of service dated

Chairman Director of Nursing Director of Public Health Non Executive Director Director of Finance Director of Commissioning and Performance Acting Director of Commissioning and Performance GP - PEC Member Director of Human Resources Non Executive Director Company Secretary Chief Executive GP - PEC Member Medical Director Non Executive Director Nurse - PEC Member Non Executive Director GP - PEC Member GP - PEC Member Director of Commissioning and Performance Physiotherapist - PEC Member Health visitor - PEC Chair Director of Provider Development GP - PEC Member Non Executive Director GP - PEC Member Nurse - PEC Member

15.05.02 22.10.07 03.03.08 1.12.06 13.11.06 01.03.09 01.12.08 01.12.08 01.04.05 17.02.03 18.02.08 01.10.06 01.09.06 01.09.07 01.08.07 01.05.08 10.09.02 01.05.02 01.05.08 11.08.03 01.04.02 01.04.02 13.11.06 01.10.06 01.10.06 01.09.06 01.04.05

Date of leaving

30.04.08 30.04.08

28.02.09 31.08.08

30.11.08

Salary (bands of £5000)

30 - 35 45-50 115-120 5-10 95-100 5-10 15-20 0-5 85-90 5-10 60-65 135-140 20-25 50-55 5-10 5-10 5-10 0-5 10-15 65-70 10-15 25-30 95-100 0-5 10-15 10-15 10-15

2008/09 Other Benefits in remuneration kind (bands of (bands of £1000) £5000) £00 £000

35-40 45-50 0-5 20-25 35-40 10-15 -

0.6-0.7 1.8-1.9 2.9-3.0 2.3-2.4 2.3-2.4 -

Salary (bands of £5000) £000

30 - 35 10-15 5-10 5-10 90-95 5-10 70-75 5-10 5-10 120-125 10-15 35-40 5-10 5-10 25-30 90-95 5-10 25-30 95-100 15-20 10-15 10-15 5-10

2007/08 Other remuneration (bands of £5000) £000

Benefits in kind (bands of £100) £000

90-95 40-45 10-15 -

13-14 18-18 -

-

-

Benefits in kind relate to the tax-free amount paid by the PCT in respect of expenses claims, which is in excess of the amount nationally agreed by the Inland Revenue. In the main, these benefits relate to leased cars and mileage claims. Remuneration waived by directors and allowances paid in lieu £0 (2008-09 £0) remuneration was waived by 0 (2007-08 0) directors. £0 (2008-09 £0) of allowances were paid in lieu to 0 (2007-08 0) directors. 76

77


2008/09 Pension entitlement Real increase in pension at age 60 (bands of £2500)

Name and title

Ms M Dinwoodie Mr J Bates Ms P Barber Dr A Barnett Ms C Clements Ms N Davies Dr P Green Miss L Parker Ms A Burchell Ms H Buckingham Mr M Riley

Chief Executive Director of Finance Director of Nursing Director of Public Health Director of Human Resources Company Secretary Medical Director Director of Commissioning and Performance Acting Director of Commissioning and Performance Director of Commissioning and Performance Director of Provider Development

£000 5 - 7.5 2.5 - 5 5 - 7.5 0 - 2.5 0 - 2.5 2.5 - 5 0 - 2.5 0 - 2.5 0 - 2.5 2.5-5 2.5 - 5

As Non-Executive Directors do not receive pensionable remuneration, there are no entries in respect of pensions for Non-Executive Directors Cash Equivalent Transfer Values 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 members' 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 benefit 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 NHS pension scheme, not just their service in a senior capacity to which disclosure applies.

78

Real increase in lump sum at age 60 (bands of £2500)

Total accrued Lump sum at Cash Cash Real increase pension at 60 related to equivalent equivalent in cash age 60 at 31 accrued transfer value transfer value equivalent March 2009 pension at at 31 March at 31 March transfer value (bands of 31 March 2009 2008 £5000) 2009 (bands of £5000)

£000 20 - 22.5 7.5 - 10 17.5 - 20 5 - 7.5 2.5 - 5 10 - 12.5 5 - 7.5 2.5 - 5 0 - 2.5 7.5-10 7.5-10

£000 55 - 60 15 - 20 15 - 20 25 - 30 15 - 20 5 - 10 40 - 45 15 - 20 10 - 15 15 - 20 15.20

£000 170 - 175 50 - 55 55 - 60 85 - 90 50 - 55 25 - 30 130 - 135 55 - 60 30 - 35 50 - 55 45 - 50

£000 1278 315 296 531 328 96 793 247 111 223 248

£000 823 202 154 383 239 48 581 180 86 152 157

Employer’s contribution to stakeholder pension (rounded to nearest £00)

£000 304 76 96 97 58 33 138 29 4 47 61

-

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 scheme or arrangement) and uses common market valuation factors for the start and end of period. Policy on the Remuneration of Senior Managers The VSM Pay Framework introduces new arrangements that were implemented in 06/07. The total reward package for very senior managers includes: Basic Pay: A spot rate for the post Additional payments where appropriate An annual performance bonus scheme

The CETV figure, and from 2004-05 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.

A performance bonus was given to the Chief Executive and three Executive Directors in the last financial year.

Self-employed GPs who are members of the Professional Executive Committee (PEC) have pension entitlements. However, the proportion of those entitlements that relates to their membership of the PEC is not significant compared to the proportion that relates to their work as practitioners independent of the PCT. It is not, therefore, appropriate to disclose their pension entitlements.

Signed

All senior managers are on permanent contracts and the notice periods do not exceed 6 months

Dr. Alison Barnett Director of Public Health for Chief Executive

Date: 10 June 2009 79


** Outstanding council invoices are a recharge of costs incurred and are not treated as Income in the Accounts.

Note 20. Related Party Transactions Medway Primary Care Trust is a body corporate established by order of the Secretary of State for Health.

In addition, the Primary Care Trust has had a significant number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the NHS Pensions Agency, HM Revenue and Customs, and the NHS Business Services Authority (Prescription Pricing Authority).

During the year one of the Board Members or members of the key management staff or parties related to them has undertaken a material transaction with Medway Primary Care Trust as follows: Jane Bastow, Non Executive Diretor of Medway PCT, is also Director of P&J Dust Extraction Ltd. During 2008/09 Medway PCT had the following transaction with P&J Dust Extraction Lld.

Income 0

Charitable funds collected by Medway PCT are invested in the charitable funds managed by the Kent and Medway NHS & Social Care Partnership Trust.

Balances with related parties 2008/09 £ Expenditure Debtors Creditors 370.13 0 0

PEC GPs are members of the following practices:

Prior year comparators

City Way Surgery, Rochester St Marys Medical Centre, Chatham The Thorndyke Centre, Rochester Walderslade Village Surgery, Chatham 119 Long Catlis Road, Rainham

South East Coast Strategic Health Authority

Payments to GPs and practices are determined by the Board following recommendations made by the PEC. GPS are not in the majority on the Board. The Department of Health is regarded as a related party. During the year Medway Primary Care 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. Balances with related parties 2008/09 £000 Income Expenditure Debtors Creditors South East Coast Strategic Health Authority

630

0 Croydon PCT 5,993 Eastern and Coastal Kent PCT 17,148 West Kent PCT 202 Dartford and Gravesham NHS Trust 0 East Kent Hospitals University NHS Foundation Trust 0 Guys and St Thomas' NHS Foundation Trust 21 Kent and Medway NHS and Social Care Partnership Trust 0 Kings Healthcare NHS Foundation Trust 10 Maidstone and Tunbridge Wells NHS Trust 1,131 Medway NHS Foundation Trust 52 Queen Victoria Foundation Trust 0 South London and Maudsley Foundation Trust 0 University College Foundation Trust 112 Kent County Council 427 Medway Council 80

127

38

0

0 4,086 14,285 2,774 5,903 8,681 23,582 4,682 11,028 103,748 3,340 1,861 1,082 2,470 10,013

0 2,884 2,787 202 302 0 51 0 20 1,336 26 0 0 1,496** 1,697**

0 2,279 669 270 0 595 2,758 116 764 3,686 61 313 165 628 669

Croydon PCT Eastern and Coastal Kent PCT West Kent PCT Dartford and Gravesham NHS Trust East Kent Hospitals NHS Trust Guys and St Thomas' NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Kings Healthcare NHS Foundation Trust Maidstone and Tunbridge Wells NHS Trust Medway NHS Foundation Trust Queen Victoria NHS Foundation Trust Kent County Council Medway Council

Balances with related parties 2007/08 £000 Income Expenditure Debtors Creditors 467

277

89

104

0 6,407 3,531

1,326 2,922 12,116

0 3,108 2,569

0 1,085 1,722

194 25 0 12

2,782 4,968 8,200 20,869

39 25 0 37

354 337 0 2,947

0 20 1,101 0

4,442 11,787 101,151 3,110

26 20 1,082 0

0 734 3,890 76

29 260

272 15,817

7,982 1,878

90 1,030

Management costs Management costs (£000) Weighted population (number) Management cost per head of weighted population (£)

2008/09

2007/08

6,767

6,326

246,027

246,027

27.51

25.71

The PCT measures its management costs according to the definitions provided by the Department of Health The 2007/08 management costs have been restated for consistency. The weighted population figure used in 2007/08 was not calculated on the same basis as that used in 2008/09 81


Independent auditor’s report to the Board of Directors of Medway PCT

External Audit External Auditors are appointed by the Department of Health. The auditors appointed to the PCT are PKF (UK) LLP.

We have examined the summary financial statements which comprises the Operating Cost Statement, Statement of Recognised Gains and Losses, Balance Sheet, Cash Flow Statement, the Financial Performance Targets, the Remuneration Report, Related Party Transactions and Management Costs set out on pages 72 to 82.

External audit fees (excluding VAT) for 2008/09 were: £ Accounts and governance 111,000 Use of resources 46,000 Cross cutting area work 12,000 Total 169,000

This report is made solely to the Board of Directors of Medway PCT 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.

No non audit work has been carried out by PKF for this PCT.

Respective responsibilities of directors and auditor

Value for Money

The Directors are responsible for preparing the Annual Report.

The audit fees for value for money incuded: ● Use of resources assessment (mandatory) ● PCTs as providers review ● Cross cutting work on the national programme for IT (NPfIT)

Our responsibility is to report to you our opinion on the consistency of the summary financial statement within the Annual Report with the statutory financial statements.

Audit Committee The PCT Audit Committee members are:Marcus Sherwood-Jenkins, Non Executive Director and Chair of the Audit Committee Jane Bastow, Non Executive Director Glyn Griffiths, Non Executive Director Also in attendance:

Basis of opinion We conducted our work in accordance with Bulletin 1999/6 ‘The auditors’ statement on the summary financial statement’ issued by the Auditing Practices Board. Our report on the statutory financial statements describes the basis of our audit opinion on those financial statements.

Jonathan Bates, Director of Finance PKF LLP, PCT External Auditor South Coast Audit, PCT Internal Auditor and counter fraud specialists

Opinion

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

2008/09

2007/08

2007/08

Non-NHS Creditors

Number

£000

Number

£000

Total bills paid in the year

18,777

59,448

13,680

47,188

Total bills paid within target

17,564

54,092

11,627

42,029

90.99%

89.07%

89.07%

Percentage of bills paid within target 93.54% NHS Creditor

In our opinion the summary financial statement is consistent with the statutory financial statements of the PCT for the year ended 31 March 2009. We have not considered the effects of any events between the date on which we signed our report on the statutory financial statements (12 June 2009) and the date of this statement.

Signature:

Total bills paid in the year

3,405

202,688

2,860

178,331

Total bills paid within target

2,398,

186,864

2145

163,554

92.19%

75.00%

91.71%

Percentage of bills paid within target 70.43%

The Better Payment Practice Code requires the PCT to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. 82

We also read the other information contained in the Annual Report and consider the implications for our report if we become aware of any misstatements or material inconsistencies with the summary financial statement.

Date: 10 July 2009

Robert Grant Partner on behalf of PKF (UK) LLP London, UK

83


A year of growing healthier