Improving health and healthcare in Medway NHS Medway Annual Report and Operating Financial Review 2009/10
www.medwaypct.nhs.uk1
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 it, get a copy in an alternative format, or get involved with helping NHS Medway shape health services for people in Medway, please email itsyournhsmedway@nhs.net; visit our website www.medwaypct.nhs.uk or call us on 01634 335173.
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Contents Introduction
4 -
5
How we work
6 -
25
What we did – and what we’re planning
26 -
44
Medway Community Healthcare
45 -
54
Our staff
55 -
59
Making experiences count
60 -
61
Our environmental impact
62 -
63
Board and committees
64 -
65
Performance against targets
67 -
76
Statement of internal control
77 -
86
Summary financial statements 2009/10
87 -
100
Auditor’s Opinion
101
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Introduction Welcome to the annual report for 2009/10 for NHS Medway, the body which plans and pays for NHS healthcare for everyone who lives in Medway. As the primary care trust for Medway, we lead the local NHS. Our role is to: engage with the local population to improve health and wellbeing;
commission a comprehensive and equitable range of high quality, responsive and efficient services, within allocated resources, across all service sectors
We aim to improve health outcomes, improve patient experience, and improve value for money. We also host Medway Community Healthcare which provides a range of healthcare services directly to patients. We serve just over 280,000 people: those who live in the Medway Council area (which marks our boundary), plus others just over the border who are registered with Medway GPs. Our budget for 2009/10 was almost £427million and we are responsible for using that money in the best possible way for the people of Medway. This report sets out our achievements in 2009/10, the challenges we faced and our plans for the future, along with risks. Achievements by NHS Medway in conjunction with our partners in 2009/10 included:
the launch of A Better Medway, a year-long campaign to encourage people living and working in Medway to find easy ways to be healthier
pilots to improve care for some of the most vulnerable people in our communities – teenage parents, people with dementia, people with long term conditions
very high uptake of Summary Care Records which enable faster, safer, better care by the NHS as a whole
the launch of the NHS Health Check to assess individuals’ risk of developing heart disease, Type 2 diabetes, kidney disease and stroke
improved urgent care, with faster treatment at A&E despite increased demand 4
lowest rate of prescribing high-risk antibiotics (which can trigger the healthcare associated infection Clostridium difficile) in Kent, Surrey and Sussex, and one of the lowest rates of C. difficile
much greater involvement by the public and by health and social care professionals in shaping services
Medway Community Healthcare During 2009/10 staff in Medway Community Healthcare – the part of NHS Medway which provides healthcare services to local people - continued to prepare for separation from NHS Medway, in line with national Transforming Community Services guidance from the Department of Health. In August 2009, the NHS Medway Board supported the Right to Request to explore the opportunities presented by becoming a social enterprise, submitted by Medway Community Healthcare. Other options for the future organisational form of Medway Community Healthcare continue to be considered; a final decision will be made by the NHS Medway Board in 2010. Aims for 2010/11 Our overall focus continues to be on improving the health and life expectancy of everyone in Medway, and on making sure that help and support are there for the people who need them the most, improving their chances of leading long and healthy lives. In line with the NHS nationally, we are focusing in particular on quality, innovation, productivity and prevention to help us improve the health and wellbeing of our population, outcomes for patients and their experience of local health services. In May 2010, we set up, with our partners, a Medway Whole System Delivery Board, which will ensure that commissioners and providers of health and social care in Medway work together to drive forward change and deliver seamless services for patients and value for money for taxpayers. In this way, Medway will play its part in the overall drive within the NHS to move from good to great and we at NHS Medway will move further on our journey towards becoming world class commissioners of health services. We would like to thank our staff, our partners, our patients, our 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. Denise Harker, Chairman Marion Dinwoodie, Chief Executive Dr Peter Green, Professional Advisory Committee Chairman 5
Our role 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 wards in England. People living in these areas have the shortest life expectancy in Medway. Two of the electoral wards in Medway (Rainham Central, and Hempstead and Wigmore) are in the 20 per cent least deprived in the country. With Cuxton and Halling, they make up the areas where people in Medway have the longest life expectancy. People living in Cuxton and Halling (the area with the longest life expectancy) live on average for 6.9 years longer than people living in Gillingham North (the area with the shortest life expectancy). The major causes of death in Medway are heart disease, stroke, cancer, and respiratory disease. 1 Forecast By 2018, it is expected that there will be 4.6 per cent more people living in Medway, including 5 per cent more children under 16. The population is ageing: by 2018, 17 per cent of the population will be over 65 (up from 14 per cent in 2008), and 2 per cent over 85. However, the proportion of older people will still be lower than the national average. Our planning takes these, and other predicted changes into account.
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(Source: Joint Strategic Needs Assessment 2008 carried out by NHS Medway and Medway Council, and Public Health Mortality File, 2004-2008, South East Public Health Observatory) 6
Medway - a great place to live, work and thrive Vision and values Our vision is for a healthy, safe and productive population in Medway where:
people are empowered to take control of their own well-being individuals and communities have access to the very best quality of healthcare
Our values include
respect and dignity commitment to quality of care compassion improving lives working together for patients everyone counts
(These are the shared values of the NHS and are set out in the NHS Constitution, which became law in January 2010.)
Personalisation We support personalisation, which gives people greater control and choice over how their health needs are met. During 2009/10 we were selected as a pilot site for personal health budgets, which aim to give NHS patients choices in the same way that direct payments give choice to people using social care services. Our pilot scheme, which is part-funded by the Department of Health and started in April 2010, is for 75 people with neurological conditions, chronic obstructive pulmonary disease, stroke, or dementia. We work out how much it costs to provide the services normally offered by the NHS for people with their conditions and they are offered this money to spend on services of their choice which meet their health needs. The aim is to find out whether personal health budgets deliver real benefits for people.
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How we are doing Our performance is monitored by different bodies and organisations. The Healthcare Commission‘s Annual Health Check for 2008/09 rated us against a number of standards and targets and took into account our financial performance. We achieved a rating of “good” for our use of resources and “fair” for our quality of services. In 2007/08, we were rated as “fair” on both, so this is an improvement. Core services were for the first time rated independently for the commissioning and provider parts of NHS Medway. Both scored “almost met”. World Class Commissioning is a Department of Health initiative to ensure that primary care trusts have the skills and ability to commission effectively. At our first World Class Commissioning Assurance Panel assessment, in November 2008, we were assessed as being 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. In addition to the competencies, there are three governance areas: strategy, finance and Board. The assessment rated us as “amber” on all three. In May 2010 we had our second World Class Commissioning Assurance Panel Assessment. The results will not be published or calibrated nationally but in the scores received by NHS Medway we improved in all but one competency measure, which remained the same, and in the governance areas went from amber to green for finance and Board and remained amber for strategy. We were in the top quartile in the country for the rate of improvement to reduce health inequalities in females; smoking quitters; flu vaccines for over 65 and reduction in blood sugar levels. We were in the bottom quartile for rates of improvement in life expectancy of men. In December 2009, the first Comprehensive Area Assessments were published. These are an overview of how well public bodies, such as local authorities, primary care trusts and the police, working together, meet the needs of the people they serve. There was no overall score, but a narrative which highlighted successes and challenges. From a health perspective, the assessment praised our work to reduce smoking and increase people’s activity levels. It recognised that teenage pregnancy continues to be a challenge but that NHS Medway and Medway Council have introduced initiatives which have made, and continue to make, a difference.
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Our budget and financial context NHS Medway has three statutory financial targets to achieve each year:
revenue resource limits – to maintain revenue expenditure within the limits set
capital resource limits – similarly, capital spending must be contained within prescribed limits
cash limit - each primary care trust has a statutory duty to remain within the cash limit set by the Department of Health
NHS Medway achieved all three targets in 2009/10. Your money We had £426.7million to spend on healthcare between 1 April 2009 and 31 March 2010: more than £1,520 for each man, woman and child in Medway. Out of every £100:
£46 was spent on acute hospitals (of which £29 went on services provided by Medway NHS Foundation Trust)
£19 was spent on community health services (mostly on services provided by Medway Community Healthcare)
£13 was spent on primary care (GPs, pharmacies, dentistry, optometry)
£6 was spent on mental health and learning disability services (of which £5 went on services provided by Kent and Medway NHS and Social Care Partnership Trust)
£11 was spent on medicines
£1 was spent on our public health team and healthy living services
£2 was spent on ambulance services
£2 was spent on operational and management costs of the commissioning arm of NHS Medway
During 2009/10, NHS Medway monitored expenditure in all these areas. The main differences between what we expected to spend and what we actually spent were the result of:
more patients than expected being treated at Medway Maritime 9
Hospital, especially patients admitted urgently (see Urgent Care section on p.37-39 for details of actions being taken to address this)
additional running costs incurred while the Cancer Unit was being transferred from Maidstone and Tunbridge Wells Trust to Medway Maritime Hospital
additional activity at Guy’s and St Thomas’ NHS Foundation Trust, particularly in adult critical care where almost twice as many bed days as expected were needed savings achieved as part of a national initiative to reduce the cost of branded drugs In total, we spent £423million of our revenue budget, giving a surplus of £3.7million. We also spent £5.2million on capital costs, including:
£3.1million on improvements to NHS buildings £1.2million on buying a site near Chatham High Street for development into a healthy living centre £800,000 on IT equipment and software
Our Strategic Commissioning Plan sets out our financial plans for the next five years, how we plan to remain financially stable and how we plan to invest in new services during this time. To do this we will need to:
be able to use money we have saved in the past
make changes, including taking money out of services that are not effective, where necessary
control costs tightly and achieve efficiency savings of £18million a year
We are working with Medway Community Estates (LIFTCo) to enable the development of new healthy living centres at Chatham, Luton and Canterbury Street, within existing revenue resources.
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Principal risks and uncertainties We have assessed the principal risks and uncertainties that may affect NHS Medway in the medium to long term as being:
financial risks: inflation could be higher than assumed, national funding to the NHS lower than expected, changes to national tariffs could impact on affordability, higher activity levels than planned could result in higher costs
health of our population: growing need for services, falling capacity within the NHS, or an increased focus on Kent-wide services, could result in NHS Medway being unable to meet the specific health needs of our population.
whole system risks: different parts of the NHS and social care, in Medway and beyond, could fail to co-ordinate in every aspect needed to deliver necessary improvements to quality, innovation, productivity and prevention
enabling risks: in an era of transformational change, our staff need far greater capacity and flexibility from estates and information technology to support skills which enable that transformation
NHS Medway has plans in place to mitigate each of these risks, to ensure that we are able to continue improving health and healthcare in Medway. We have carried out detailed financial modelling for a range of scenarios, some more challenging than the zero growth from 2011 which is in the NHS Operating Framework, and planned how we would deal with them. We are working with Medway Council, NHS providers and other commissioners in Medway and wider Kent to increase the efficiency of health and social care provision in Medway and make sure we can meet local needs while getting the best possible value for taxpayers’ money. With the commitment of all partners, we are developing a Medway Whole System Delivery Board with a joint programme office to drive delivery of agreed objectives in Medway. Consultants, GPs and other frontline professionals are more involved than ever before in the review and redesign of care in Medway. All partners have workforce plans to ensure an empowered, flexible, highlytrained staff and we also have strategies for estates and information management and technology to support them.
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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. The most important partnership in the area is the Local Strategic Partnership (LSP) which brings together Medway Council, NHS Medway, Kent Police, Kent Fire and Rescue, higher and further education, businesses, voluntary organisations, and others which can influence developments and improvements in Medway. The organisations involved in the LSP have signed up to a local area agreement (LAA) with central government which sets out specific priorities for the wellbeing of people in Medway. There are 45 targets in the LAA covering five main issues: working towards a safe and strong Medway; promoting healthier communities and the needs of older people; supporting children, young people and families; regeneration, including housing, the environment and culture; developing the local economy, transport and skills The LSP has five main groups to achieve these priorities Community Safety Partnership Health Partnership Board Children’s Trust Board Regeneration Partnership Economic Partnership
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Partnerships to deliver services 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 Directorate led by Dr Alison Barnett, the Director of Public Health, which drives work to improve the health of local people. We host some services such as mental health commissioning and the Kent Cancer Network which work on behalf of the whole of Kent and Medway and our neighbouring primary care trusts host other services which they commission on our behalf. We have formal agreements with voluntary groups such as the Stroke Association and work closely with Age Concern, HiKent and others. Macmillan Cancer Support is working jointly with us and Medway Council to provide a cancer welfare benefits service. We commission the Sunlight Development Trust and Medway Council for Voluntary Service (CVS) and use their local connections, experience and expertise to help us deliver particular schemes. For instance, in 2009/10 we commissioned the Sunlight Development Trust to set up a Health and Lifestyle team which works one-to-one with local people to tackle long standing health issues; and a dementia advisor service, to help people with dementia and their family carers access information and support. CVS employs a development worker on behalf of NHS Medway to improve engagement with people who use mental health services. We, along with Medway Council, NHS West Kent, NHS Eastern and Coastal Kent and Kent County Council, jointly provide a Deprivation of Liberty Safeguards (DoLS) service to protect people living in hospitals or care homes in Kent and Medway who lack the capacity to make their own decisions about the arrangements for their care or treatment. 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.
Emergency planning 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 are a Category 1 responder which means we are at the core of any emergency response and subject to the full set of civil protection duties.
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We lead NHS emergency planning in Medway, and have a robust major incident plan which is compliant with the requirements of the NHS Emergency Guidance 2005 and all associated guidance. It is regularly updated and published on our website. We are responsible for the performance management of emergency planning of all NHS organisations in Medway. We work closely with emergency services, other NHS trusts, Medway Council and other partners on the Kent Resilience Forum, including carrying out joint exercises. During 2009/10, we also updated and tested business continuity plans for NHS Medway and major incident plans for Medway as a whole.
Swine Flu The main challenge for emergency planning in 2009/10 was the swine flu pandemic. The local health economy delivered an effective response, led by Dr Alison Barnett, Director of Public Health for Medway. Key factors were careful planning and preparation, and close working between different parts of the NHS and Medway Council, supported by national campaigns. For most people, the infection was comparatively mild but some became very seriously ill: 1,529 people were admitted to hospital across South East Coast region (Kent, Surrey and Sussex) and there were 22 deaths. At the beginning of the first wave, in early July, the burden of response fell mainly on GPs and on MedOCC, the out-of-hours GP and nurse service in Medway, run by Medway Community Healthcare. MedOCC handled swabbing for the Health Protection Agency, and was the sole distribution centre for antivirals. In July, MedOCC took more than 10,000 calls - a 40 per cent increase compared to the previous year - as a result of swine flu. The National Pandemic Flu Service started in July, taking much of the burden of diagnosis and referral for antivirals. Thirty pharmacies acted as antiviral collection points. Vaccination against swine flu was offered by all GP practices in Medway from November. Community nurses from Medway Community Healthcare vaccinated more than 1,000 housebound patients in at risk categories. By the end of March 2010, 34.3 per cent of Medway people in clinical at risk groups (including pregnant women) and 22.7 per cent of healthy children under five had been vaccinated against the H1N1 virus. The seasonal flu vaccine for winter 2010/11 will include a swine flu component.
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How commissioning works In order to improve health services for people from Medway, we first assess need and requirements. We do this by looking at: information about the health of our population contained in the Joint Strategic Needs Assessment benchmarking information that shows our spend and performance against the average for areas with a similar population to Medway’s 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 needs to be improved, what is not delivering good outcomes for patients, and what is lacking, we work with patients and members of the public, and with our partners in health and social care, to make changes. We draw up specifications for new and improved services, and 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, through a process of assessment that considers the benefits of taking a co-operative or competitive route, we identify a provider to deliver it, monitor it carefully and ensure any issues are dealt with. This process is set out in our Service Procurement and Market Framework strategy. In addition to this work on new and improved services, we are also developing specifications for existing services, so that we can be sure they are delivering good outcomes for patients and value for money. Practice-based commissioning (PBC) is integral to this process. 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 are 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
167 GPs in 63 practices 36 dental practices. 1 specialist orthodontic practice, 1 home-visiting dentist. Medway Community Healthcare provide the emergency out of hours dental service DentaLine and special needs dentistry through 5 dental clinics based in Medway 49 community pharmacies 21 optometrists (opticians)
Community care Medway Community Healthcare (district nursing, health visiting, speech and language therapy, podiatry, occupational therapy, nutrition and dietetics, physiotherapy, continence, blood tests, help with breathing problems, diabetes, heart or stroke problems, assessing difficulties with muscles or bones, end-of-life care and equipment loans) West Kent Community Health (newborn hearing screening) Eastern and Coastal Kent Community Services (care management and secure placement services for people with learning disabilities, plus contraception and sexual health services) Kent and Medway NHS and Social Care Partnership Trust (wheelchair services) Health improvement Joint NHS Medway / Medway Council Directorate (Stop Smoking support, healthy weight advice and programmes, sexual health advice, Chlamydia testing, co-ordination of teenage pregnancy strategy, tobacco control programme, and alcohol strategy). Sunlight Development Trust (Health and Lifestyle Team) 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, 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 Maritime Hospital (run by Medway NHS Foundation Trust), the Will Adams NHS Treatment Centre and the Spire Alexandra Hospital. Mental health Kent and Medway NHS and Social Care Partnership Trust Medway NHS Foundation Trust Independent organisations offering a range of provision, encompassing services from psychological therapies to secure accommodation
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Prisons GP, dental, optical and pharmacy services for offenders at Rochester and Cookham Wood Young Offenders’ Institutions Mental health services including Child and Adolescent Mental Health Services and substance misuse services Nurses and pharmacists working in the institutions are employed by the prison service. We also commission pharmacy services for all ten prisons in Kent and Medway.
How we make sure you 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 2009/10, we held regular quality meetings with all the main providers: Medway NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust, Medway Community Healthcare and the Will Adams NHS Treatment Centre. In 2009/10, for the first time, the NHS introduced 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 requirements. These requirements - known as CQUINs - cover a whole range of areas, including training, so ensuring that staff get the updates they need, and patient surveys, looking at patient experience and satisfaction. They were mandatory in all contracts with acute hospitals – such as Medway NHS Foundation Trust - for 2009/10. At NHS Medway, we also wrote them into contracts with Kent and Medway NHS and Social Care Partnership Trust, and Medway Community Healthcare. All three organisations ask patients specifically about their experience of being nursed in a single sex environment, along with other aspects of the service they receive, as part of quarterly surveys undertaken for the patient experience CQUIN (2009/10). Results from the surveys are monitored by NHS Medway, and providers draw up action plans to address issues identified by the public. In 2010/11, the patient experience CQUIN requires results from patient surveys to show improved satisfaction levels, quarter by quarter. 17
Healthcare associated infections During 2009/10, the Department of Health improvement and cleanliness team reviewed the approach to reducing healthcare associated infections in Medway. It found that there is good leadership by NHS Medway, strong and effective partnership working, and innovative and targeted initiatives across the health economy. The significant drop in healthcare associated infections achieved in 2008/09 was sustained in 2009/10.The rate of both MRSA (3.65 cases per 10,000 admissions) and Clostridium difficile (0.24 per 1,000 occupied bed days) were below average for the South East Coast region. This is in part due to targeted work on high-risk antibiotics, which play a role in the development of Clostridium difficile. In 2009/10, GPs in Medway, supported by the NHS Medway medicines management team, continued to prescribe high-risk antibiotics with caution and, for the second year running, had the lowest rate of use in South East Coast. NHS Medway’s aim is to eliminate avoidable healthcare associated infections.
Single sex accommodation We know that patients want to be nursed in single-sex accommodation which preserves their privacy and dignity. During 2009/10, ÂŁ1.75million was given to NHS Medway by the Department of Health to enable the three main local providers of NHS care, Medway NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust (KMPT), and Medway Community Healthcare, to improve their facilities so that, for instance, women do not need to walk past male patients to reach their bathroom. Medway NHS Foundation Trust carried out a significant amount of work on bathroom, toilet and sleeping facilities, improved signage for all wards, introduced gowns designed to provide more privacy, improved curtaining around beds, and provided privacy and dignity training for all staff. KMPT provided women-only lounges, bathroom and toilet facilities clearly designated as male and female areas, and training for staff. Medway Community Healthcare improved signage and curtaining, and installed doors across bays. Patient experience surveys showed Medway Community Healthcare achieved 100 per cent compliance in delivering same sex accommodation in all inpatient units. 18
How we make sure information about you is kept safe 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 http://www.nigb.nhs.uk/guarantee/crs_guarantee.pdf 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 governance at their induction and annually thereafter
ensuring that we have a strong Registration Authority. This ID-checks and registers staff, with pin-protected smartcards, to enable appropriate access to patient information on general practice, pharmacy and community information systems, based on the job role they do
ensuring we have clear guidelines governing access to systems
ensuring that all our systems 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
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 etc)
ensuring that all electronic data in transit is audited to ensure that it needs to be transferred and is transferred using secure methods only.
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Information risks 2009/10 No personal-related data incidents were reported to the Information Commissioner’s Office in 2009/10.
Summary of other personal data related incidents in 2009/10
Category
Nature of Incident
Total
I
Loss of electronic equipment, devices or paper 0 documents from secured NHS premises
II
Loss of electronic equipment, devices or paper 1 documents from outside secured NHS premises.
III
Insecure disposal of electronic equipment, devices or 0 paper documents.
IV
Unauthorised disclosure
0
V
Other*
2
* Two complaints letters put in wrong envelopes; * Patient’s arthroscopy photographs wrongly labelled.
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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 systematically ask local residents to get involved when we are reviewing or planning a service so we make sure we learn from their expertise. In 2009/10, we held a series of public meetings as we were developing our Strategic Commissioning Plan so we could take account of what the public told us about the priorities in their local area. We consulted people on a range of service reviews, including end of life care, maternity, cancer, depression, lower back pain and respiratory conditions. Our commissioners used the information gathered by these consultations to improve services. People told us, for instance, they wanted a self-help group for people living with and beyond cancer - so we commissioned the Sunlight Development Trust to run one. Ultimately, however, patients felt they could not commit to the ongoing group so we are now working with the Health and Lifestyle Team to develop a sustainable model of patient support. Carers of people in Medway with dementia told us they needed help and support to find out what services are available and make use of them, so we, with Medway Council, commissioned a Dementia Advisor Service, partly funded by the Department of Health. We also work closely with the 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 have a good working relationship with the Medway LINk and are committed to supporting and facilitating its work. The NHS is required by law to consult local Overview and Scrutiny Committees about any planned substantial health service variations or developments. We work with both the Health and Adult Social Care Overview and Scrutiny Committee and the Children and Adults Overview and Scrutiny Committee of Medway Council on this.
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Working towards equality for all We are committed to ensuring that everyone in Medway can access the care they need and is treated with dignity and respect. We are also committed to working towards equality and supporting 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 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
in
innovative
ways
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. We participate in groups such as the Kent and South East Coast equalities networks. Supporting this work is the equality and diversity strategy which was approved by the NHS Medway Board in September 2008 and the equality, diversity and human rights implementation plan which was approved by the Board in October 2009. Progress to date has included: the revision of NHS Medway’s single equality scheme covering race, gender, disability, age, sexual orientation and religion and belief upgraded roles for equality and diversity lead officers for both Medway Community Healthcare and NHS Medway mandatory equality and diversity training for all commissioning staff to support them to promote equality through all aspects of the commissioning process face-to-face equality and diversity training for more than 53 per cent of Medway Community Healthcare staff during 2009/10 the accreditation of NHS Medway under the Government's Positive about Disability scheme - 'Two Ticks' an improved equality impact assessment tool and an EqIA plan for critical aspects of organisational policy and service development. 22
Our plans Our plans are framed by the national and regional vision for the NHS, set out in documents such as “NHS 2010 - 2015: from good to great. Preventative, people-centred, productive” a national five-year plan to reshape the NHS to meet the challenge of delivering high quality healthcare in a tough financial environment, and “Healthier People, Excellent Care” which sets out the vision for the South East Coast region with pledges covering different stages of life:
maternity and newborn children’s services staying healthy long-term conditions planned care urgent and emergency care mental health end of life care
We, like the other 151 primary care trusts in England, are striving to become world class at commissioning health services for our population, and the world class commissioning competencies provide a framework for our work. We have set out our long term, medium term and short term plans in three documents: A Healthy Medway which lays out our strategic direction for healthcare in Medway from March 2007 to 2015 Growing Healthier, the Strategic Commissioning Plan, which describes our plans for 2009/10 - 2014/15 and is underpinned by our drive to become world class at commissioning. Our Operational Plan which sets out the detailed work we will be carrying out in 2010/11.
Our priorities and targets 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
We set up 16 strategic change programme groups to enable us to achieve the changes needed. Members include clinicians, patients and carers. 23
The groups cover: maternity and newborn, children’s services, staying healthy, long-term conditions, planned care, urgent and emergency care, mental health, end of life care, diabetes, stroke, substance misuse, coronary heart disease, cancer, primary care, older people, and learning disabilities. Targets We strive to achieve national standards and targets, targets for our region, and targets we set for ourselves in Medway. As part of world class commissioning, all primary care trusts have set eight local health outcomes they will achieve for their local population by March 2014. To do this in Medway, we looked carefully at what would make the most difference to the health and wellbeing of local people. The ones we chose are
encourage more mums to breastfeed help over 1,945 people a year stop smoking support people with diabetes to gain control of their blood sugar ensure many more people with strokes have a brain scan within 24 hours reduce early deaths from heart disease halve the increase in alcohol-related admissions to hospital encourage more over-65s to have a flu jab achieve recovery for 54 per cent of people using Improving Access to Psychological Therapies (IAPT) services (a new service which started in 2009/10)
All of these will help us in our two bigger goals (shared by every primary care trust up and down the country) to
reduce health inequalities (so that people in all parts of Medway enjoy equally good health and good healthcare)
increase life expectancy
Progress towards achieving these targets We are in the top 25 per cent of primary care trusts nationally for our rate of improvement on:
reducing health inequalities for women helping people to stop smoking uptake of flu vaccine people with diabetes controlling their blood sugar
We are in the bottom 25 per cent for improvement on life expectancy for men. 24
Note: We have changed one of the targets since last year: reducing teenage pregnancy has been replaced by recovery rates for people using IAPT services. The IAPT target is new this year and its adoption reflects the importance that NHS Medway places on improving mental health for people in Medway. There will be no loss of focus on teenage pregnancy, which is monitored as part of the Local Area Agreement and is a priority for the Medway Children’s Trust.
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Making sure the right care is there when you need it how we did in 2009/10 1. Maternity and newborn Good maternal health and maternity care are important factors in ensuring that all children get a good start in life, improving the life chances and development of babies, children and their mothers. Our main focus in 2009/10 was on delivering safe, accessible, high-quality care to women and their families, and on increasing the choices that women have in pregnancy and beyond. This is in line with Maternity Matters, the national plan for maternity care. In 2009/10 we:
continued to work with Medway NHS Foundation Trust on the new midwifery led unit, which is due to open at the hospital in late 2010 approved funding and plans for a specialist Mother and Infant Mental Health Service which started in April 2010 secured additional funding to support the development of an infant feeding strategy in Medway to help mums-to-be and new mums with their breastfeeding support and information needs
In 2010/11 we plan to build on all of this and:
continue to work with Medway NHS Foundation Trust and Medway Community Healthcare to develop the maternity workforce to ensure high quality care for women and their families throughout pregnancy and beyond implement the infant feeding strategy in Medway to ensure all new mothers receive the information and support that they need to breastfeed, both in hospital and at home work with the Medway Maternity Services Liaison Committee to overview the information given to women and families during and after pregnancy to ensure that the right information is available at the right time, and in the right format
It is important for mothers 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.
2. Children and young people The Medway Children’s Trust (part of the Local Strategic Partnership) is the body which sets the strategic direction for children and young people’s services in Medway, and makes sure that the priorities in the Medway Children and Young People’s Plan are being delivered. 26
It brings together health, children’s social services, housing, education, the police, probation, the voluntary sector and the independent sector to ensure Medway children get the care and support they need to:
be healthy stay safe enjoy and achieve make a positive contribution achieve economic well-being
(these are the outcomes set out by the national “Every Child Matters” programme) The Medway Children’s Trust has six partnership boards which co-ordinate and commission different aspects of children’s services. As a result of this work, in 2009/10 we:
dramatically improved access to health checks and appropriate healthcare for looked after children improved Child and Adolescent Mental Health Services (CAMHS) in Medway by: o retendering for CAMHS for children and young people with higher levels of need o creating a single point of access for professionals referring children and young people to mental health services o establishing a targeted mental health services (TaMHS) programme in some Medway schools
improved care for children with disabilities by: o investing a further £135,000 (matching additional funding by Medway Council) in short breaks and respite services for children with disabilities, as part of the Aiming High programme o commissioning more services in the community (rather than in hospital) o 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 o examining and deciding on options for the best services for children with physical or learning disabilities
continued to develop opportunities for children, young people and their parents to have their say and shape services started to support teenage parents through the Family Nurse Partnership Programme which offers weekly visits from four family nurses who each help up to 25 young mothers look after their babies improved our contracting arrangements so we achieve better services for children and young people 27
In 2010/11 we plan to:
review and improve how children and young people access care at different stages and the treatment they receive, particularly for emotional wellbeing/CAMHS and children with disabilities invest a further £200,000 in short breaks and respite services, in partnership with Medway Council invest to continue the single point of access for CAMHS referrals extend the Child and Adolescent Support Team (CAST) service to allow longer-term support to young people and their families develop local mental health services for young people with learning disabilities continue with the Family Nurse Partnership with the aim of supporting 100 families further build on improvements made in healthcare for looked after children by providing more flexible health checks and reviewing the skill mix of health professionals working with looked after children
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 directorate to improve the health of people in Medway. It focuses on helping people to make lifestyle changes to improve their health by, for example, stopping smoking, becoming more active, and achieving sexual health. In 2009/10 we:
launched A Better Medway, a year-long social marketing campaign to encourage people living and working in Medway to make small but significant changes to improve their health offered training to all Medway GPs in supporting smokers who want to quit launched a new interactive website, www.smokefreemedway.co.uk to help people quit through virtual group sessions and online support. It is the first of its kind in the country and other primary care trusts are following suit launched a section of the website for young people designed with involvement from local students set up Smokefree United to encourage local football fans to quit smoking with support from the NHS and each other succeeded in helping 1,949 people quit smoking ran mini-MEND (Mind, Exercise, Nutrition, Do it!) courses for children aged 2-4 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 28
developed and started to implement a plan for preventing obesity, focusing on pre conception and antenatal care, breastfeeding and infant nutrition extended the Tipping the Balance programme to people with medical conditions that were previously excluded set up self-esteem groups and counselling for very overweight people launched a Health and Lifestyle team offering one to one support to people who want to make changes to improve their health reduced teenage pregnancy rates in Medway, for the first time in 3 years improved sex and relationships education in Medway developed a system for identifying girls whose behaviour puts them at risk of teenage pregnancy, and agreed a co-ordinated response used up to date information data about teenage pregnancy to target services where they are most needed offered HPV immunisation to girls aged between 12 and 18 developed Medway’s Alcohol Strategy
In 2010/11, we plan to:
develop a health and well-being strategy for Medway - a blueprint for targeting health improvement interventions continue to deliver the campaign, A Better Medway, extending its reach through a small grants scheme to support initiatives by community and voluntary organisations recruit community champions to become stop smoking advisors oversee implementation of the infant feeding strategy to improve breastfeeding rates in Medway, working closely with NHS and other colleagues introduce training for NHS and social care professionals to help prevent and identify early mental ill health, and to prevent suicides/self harm improve access to contraceptive and sexual health services, including long acting reversible contraception develop brief interventions in a range of settings for minimising harm caused by alcohol increase uptake of HPV immunisations
Screening In 2009/10, we:
launched the NHS Health Check for people aged 40-74 – who are invited in by GPs by birthdate, reaching everyone in that age group over the next five years - to assess their risk of developing heart disease, diabetes, stroke and kidney disease introduced bowel cancer screening for everyone aged 60 - 69 offered women a first screen for breast cancer before the age of 50 carried out innovative research to build a social marketing approach to Chlamydia screening piloted Chlamydia screening by an outreach team 29
In 2010/11, we plan to:
develop ways of reaching those who do not take up their invitation to have an NHS Health Check implement a marketing campaign for Chlamydia screening so we can reach our targets now and in the future
4. Primary care Primary care is provided by GPs, dentists, optometrists, pharmacists, and the healthcare staff who work in the practices with them. 4a. GPs Our main focus in 2009/10 was making it easier for patients to get GP appointments at times that are convenient for them. In 2009/10 we:
continued to encourage GPs to open early, late or at weekends – more than 83 per cent of practices now offer extended hours funded two new practices: in Chatham (in the Boots store in the Pentagon Shopping Centre) and on land adjoining Greenacres School, Wayfield, and two new branch surgeries for the Medway NHS Healthcare Centre, in Twydall and Parkwood implemented the quality development framework with the agreement of key stakeholders, to support GP surgeries in improving quality of care for patients and quality of data collection. This will enable comparative analysis of practices in NHS Medway across a range of indicators secured £1.7m of Deanery funding (up from £500,000 initially offered) to enable nine practices to extend their premises or refurbish disused rooms so they can take on additional trainee GPs, building capacity for the future awarded small capital grants totalling £208,000 to 26 practices so they can improve facilities, particularly in their minor procedures rooms, to meet infection control standards
NHS Medway patient offer In 2010/11 we plan to pilot a patient offer to ensure that over time all Medway residents can access the full range of services through primary care. Alternative arrangements will be made for people if their own practice is unable to offer the services. The aim is to ensure equitable access to primary care for all.
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Balmoral Gardens During 2009/10, work began on the new £4.7million healthy living centre for Balmoral Gardens, in the centre of Gillingham. It is on target to open in August 2010 and will offer a range of health services to the local community, including three GP practices, a pharmacy, health promotion services, and clinics run by Medway Community Healthcare, Medway NHS Foundation Trust and Kent and Medway NHS and Social Care Partnership Trust. The land around the building is also being redeveloped, to offer play space for children and a pleasant place for people to sit in the centre of Gillingham. The partners in the project are NHS Medway which is funding the centre, Medway LIFT Co which has built and will maintain it, and Medway Council, which made available the land on which the new centre has been built. Faster, better, safer care Around 120,000 people in Medway are already benefiting from summary care records, a secure way for the NHS to share important information about patients and offer faster, better, safer care. It is a national scheme, offered to patients who are registered with a GP practice. Patients are invited to allow the record to be created from information held by their practice. Fewer than one per cent of patients in Medway have chosen to opt out of the scheme so far. Initially, summary care records contain three pieces of information about patients: their allergies, their medication, and any reactions they have previously had to treatment. In August 2009, MedOCC became one of the first out-of-hours services in the country to make use of summary care records. MedOCC GPs say they have already potentially saved lives. Two examples are a woman who said she had no allergies but was in fact allergic to the antibiotic she was about to be prescribed, and a diabetic, whose summary care record allowed him to be given the correct dose of insulin even though he was unable to tell the GP which brand he used and how much he took. 4b. Dentistry In 2009/10 we: 
carried out a public survey on dental health in Medway. Responses from more than 3000 people highlighted reasons why some groups 31
rarely or never go to the dentist – this will be used to target future services to them introduced a dedicated helpline manned Monday to Friday, 9am to 5pm, to assist people in Medway to find an NHS dental practice and to receive emergency treatment during normal surgery hours increased numbers of urgent access slots, with 24 dental practices now providing appointments throughout the week. removed an NHS contract from one practice where quality and capacity targets had consistently not been reached and re-invested in dentistry elsewhere continued the three- year cycle of inspections of dental premises to ensure compliance with service regulations. funded additional NHS dental sessions in Rainham, Gillingham, Walderslade and Chatham, where patient need was identified employed two part-time oral health promoters who liaise with other services to target the young, older people and hard to reach groups
In 2010/11 we plan to: tender for an additional dental practice close to the Medway Tunnel to serve patients in the vicinity of Chatham Maritime and the surrounding areas to meet future population growth. tender for additional services in periodontal (gum disease) and endodontic (complex root canal treatment) services which can be provided by local dentists with the specialised skills. This will reduce the need for out of area specialist services. Dentistry in Medway 33 out of 36 dental practices in Medway are able to see new patients. 65.8 per cent (up from 64.7 per cent last year) of people in Medway receive NHS dental care compared to 54.7 per cent nationally. Medway is currently 14th out of 152 primary care trusts in the country for improved dental access since April 2006.
4c. Pharmacy In 2009/10, we:
developed a medicines commissioning policy and policy for dealing with individual funding requests made significant progress on a robust commissioning process for cancer drugs and the new South East Coast commissioning process sustained lowest percentage use of high risk antibiotics in the South East Coast region 32
co-ordinated much of the response to swine flu, ensuring community pharmacies were available as antiviral collection points across Medway, and monitoring uptake of vaccination rolled out Chlamydia screening and treatment in community pharmacies
In 2010/11 we plan to:
effectively manage the net growth of medicines expenditure. There is likely to be a significant increase in high cost drug expenditure over the next financial year, particularly with cancer therapies. support all prescribers to ensure that patients receive the most appropriate therapy extend non-medical prescribing assess the quality of Medicine Use reviews offered by pharmacists to patients with long-term conditions, to ensure they are taking the right medication in the right way ensure and support a high standard of quality and safety in all areas relating to medicines management
4d. Optometry In 2009/10 we:
piloted a Primary Eye Assessment and Referral Service (PEARS) for acute eye conditions by high street optometrists in Strood and Rochester, (developed by the local practice based commissioning group). developed glaucoma and cataract referral schemes for roll-out in 2010/11 in a joint project with NHS West Kent.
In 2010/11 we:
plan to roll out the PEARS project across Medway so everyone with an acute eye condition can benefit from a convenient local service undertake three-yearly inspections of premises and record-keeping within practices which provide optical services.
From 1 April 2010, primary care trusts took over responsibility for the optometry budget which provides opportunities for more services to be developed to meet local needs.
5. Planned care 5a. Planned care Planned or elective care is care arranged ahead of time when immediate, urgent treatment is not needed. 33
In 2009/10 we consistently achieved the national target of at least 90 per cent of inpatients and 95 per cent of outpatients having their operation or starting their specialist treatment within 18 weeks of being referred by their GP. In 2009/10 we:
achieved the 18 week target improved usage of the choose and book system introduced direct access to scans (MRI, CT) for GPs at Medway Maritime Hospital reviewed and consulted upon spinal services in Kent and Medway reviewed the provision of dermatology services to ensure treatment is provided in the most appropriate setting
In 2010/11 we plan to: introduce a community lymphoedema service introduce a community anti-coagulation service extend the provision of community dermatology review the provision and access to phlebotomy (blood-taking) services introduce enhanced recovery services (which optimise patients’ preparation for surgery and treatment) at Medway Maritime Hospital review provision of community based ophthalmology improve access to diagnostic tests 5b. Cancer NHS Medway hosts the Kent Cancer Network, which supports the commissioning of cancer care for the whole of Kent and Medway. In 2009/10: 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 the new chemotherapy unit at Medway Maritime Hospital opened, improving the experience of people requiring chemotherapy by allowing treatment much close to home In 2010/11 we plan to:
raise awareness of the risk factors associated with cancer within communities ensure people referred to Medway Maritime Hospital with any breast symptoms are seen within two weeks review services offered to patients living with and beyond cancer introduce holistic needs assessments for people with cancer at key 34
points in their treatment and care introduce health and wellbeing services for people living with and beyond cancer introduce a Macmillan Cancer welfare benefits service to support the financial needs of people living with cancer introduce a two-week turn around time for cervical screening results introduce image-guided radiotherapy at the Kent Oncology Centre review the potential for more laparoscopic surgery
Medway Survivorship Project Medway is one of 16 pilot sites in the country looking at the needs of patients who are living with and beyond cancer and their carers. The Medway Survivorship Project involves patients, carers and professionals in looking at what services people need to support them (such as employment advice, guidance on benefits, counselling). A pilot support and signposting service for people at the end of active treatment will launch over the summer with the aim to address better the holistic needs of people living with and beyond cancer. The Macmillan Cancer Welfare Benefits Service, due to launch in autumn 2010, is one of the results of this work.
5c. Practice-based commissioning In 2009/10 PBC groups focused on mental health, dermatology, anticoagulation (blood thinning), ophthalmology, gynaecology and diabetes In 2009/10 they:
worked closely with mental health commissioners to roll out the Improving Access to Psychological Therapies service (IAPT) in primary care, building relationships between IAPT providers and primary care practitioners agreed protocols for a single point of access for people with mild to moderate depression and anxiety worked with stakeholders to develop a service specification for a community based anti-coagulation service developed the evidence base for a community based dermatology service. This included a stakeholder event attended by 24 service users and a range of NHS staff piloted the Primary Eye Assessment and Referral Service (PEARS), reviewed the pilot and produced project plans to roll the service out across Medway. 35
In 2010/11 PBC will build on work done previously and also focus on improving care for : women with a range of specified gynaecological conditions, and people with diabetes and coronary heart disease. PBC aims for 2010/2011 include:
procuring a community-based anti-coagulation therapy service producing a business case and procuring a community based dermatology service with local access rolling out the Primary Eye Assessment and Referral Service (PEARS) across Medway developing an evidence base and business case for a community based gynaecology outpatients service exploring community based access for retinal screening for diabetic patients and developing proposals for change providing an alternative pathway for patients needing non-complex catheterisation working closely with NHS Medway to strengthen PBC involvement in monitoring referrals and activity in hospitals, taking action to understand and influence changes in referral patterns using information from audits to improve a range of clinical pathways
6. Urgent care The focus of urgent or 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), minor injuries units in Eastern and Coastal Kent, and the South East Coast Ambulance Service. During winter 2008/09, Medway NHS Foundation Trust experienced increased pressure on its A&E services. This resulted in its A&E performance against the target for 98 per cent of people to be seen and admitted, transferred or discharged within four hours, being one of the poorest in the South East Coast region. As a result, NHS Medway and Medway NHS Foundation Trust jointly commissioned three external reviews of the urgent care system to look at systems and processes as well as clinical issues. The output of these reviews was developed into a Medway whole system delivery plan to ensure that the local health economy continues to work towards achieving and sustaining the 98 per cent A&E target. The plan is monitored by the Urgent Care Board, which is chaired by NHS Medway Director of Commissioning and Performance, and has Director level membership from all partners in the health system. 36
Additionally, NHS Medway and Medway NHS Foundation Trust jointly undertook an audit to look at whether patients admitted for short stays for unscheduled care, including those admitted via A&E, are getting the most appropriate, timely and efficient care. Performance in 2009/10 Medway NHS Foundation Trust’s A&E performance was above 98 per cent for the first three quarters of 2009/10 – a significant improvement on 2008/09. Although there was a four per cent increase in demand over this period, there was a significant decrease in the numbers of four-hour A&E breaches in the same period. January and February proved to be difficult months for the whole of South East Coast, with the added impact of the bad weather and Norovirus. Performance for quarter four at Medway NHS Foundation Trust dipped below 98 per cent to approximately 97.5 per cent. However, overall, performance at Medway NHS Foundation Trust for 2009/10 exceeded 98 per cent and performance for the local health economy (including the minor injuries units at Sheppey Hospital and Sittingbourne Memorial Hospital) was approximately 99 per cent. Improvements in 2009/10 In 2009/10, working closely with our colleagues at Medway NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust, and Medway Community Healthcare, we achieved a number of improvements both to manage capacity and to ensure that patients receive the best possible service when they come into hospital for emergency treatment. We:
funded a multi-disciplinary Acute Hospital Dementia Liaison Team (provided by KMPT) to improve care within the hospital for inpatients with dementia and facilitate discharge worked with the hospital and Medway Community Healthcare to clarify best care for paediatric patients with specific conditions improved communications to patients about alternatives to A&E, through a multi-media campaign including radio, web and newspaper advertisements, posters at railways stations and on buses, and 50,000 information cards
In addition:
refurbishment of the Children’s Emergency Department was completed leadership development programme for senior sisters and senior doctors in the A&E department developed and implemented 37
The delivery plan includes a number of initiatives for 2010/11 to avoid unnecessary A&E attendances and acute admissions. These include:
development of a plan covering care management and admission avoidance for people with a high rate of re-admission.
an innovative pilot scheme under which MedOCC manages the care of patients who call an ambulance but are assessed by South East Coast Ambulance Service staff as not needing A&E treatment. Ambulance staff discuss the needs of the patient with MedOCC who arrange the right treatment (such as a home visit by the respiratory team)
the introduction by South East Coast Ambulance Service of paramedic practitioners in Medway to assess the needs of patients and signpost them to alternatives to A&E where appropriate.
development, by a whole system falls group, of a multi-agency proactive and responsive service for patients at risk of falling, to improve prevention and management of falls in older people.
a review by a whole system delayed transfer of care group of systems and processes in use locally, in order to minimise delay in patient transfers and discharges, and maximise admission avoidance.
development of a whole system capacity model to help shape and inform future demand and capacity requirements within urgent care.
Primary angioplasty This new service for patients suffering the most severe form of heart attack as a consequence of a complete blockage in an artery, started for patients from Kent and Medway in April 2010. Angioplasty is a procedure to unblock an artery carrying blood to the heart. Under local anaesthetic, a small balloon is inserted via an artery in the groin or arm and guided to the blockage. It is offered at William Harvey Hospital in Ashford and is expected to save lives and reduce disability.
7. Learning disability In 2009/10 we:
successfully transferred lead responsibility for the commissioning of social support for people with learning disabilities to Medway Council, as recommended in the Government’s White Paper, Valuing People Now widened the number of GP practices providing annual physical health checks to people with a learning disability in Medway, with more than 38
two-thirds of practices now part of the scheme ensured that the commissioning of highly specialised mental health services and NHS placements was strengthened as part of a Kent and Medway-wide scheme completed a self-assessment of the way in which people with a learning disability are supported in mainstream health services agreed funding for a specialist nurse at Medway Maritime Hospital
In 2009/10 we plan to:
appoint a specialist manager to advise all areas of commissioning on how to ensure that people with a learning disability receive healthcare that is as good as the population as a whole work with Medway Council to improve the specialist team which supports people with a learning disability work with Kent and Medway NHS and Social Care Partnership Trust to improve mental health services for people with a learning disability start work on ensuring that all aspects of key NHS communications are accessible to people with a learning disability
8. 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 hosts the directorate which commissions adult mental health services for the whole of Kent and Medway, which has a population of over 1.6million. During 2009/10, its focus was on developing a vision and strategy for improving mental health and wellbeing in Kent and Medway, which will be published in summer 2010 and will form the framework for mental health commissioning until 2015. A suicide prevention strategy is also being developed as part of the wider work carried out by mental health commissioners on behalf of Kent and Medway. In 2009/10, following a competitive tender process, Oxleas Mental Health Foundation Trust was awarded the contract to provide mental health services in adult prisons (including HM Young Offenders Institute, Rochester) across Kent and Medway, with effect from 1 April 2010. In Medway, as in wider Kent, our main focus is on recovery, wellbeing and inclusion for people with mental health needs. In 2009/10 we:
developed a local pathway for depression with service users and clinicians, now published on the Map of Medicine website. This will ensure that service users in Medway are signposted or referred to the 39
most appropriate service for them improved care for people having a mental health crisis, by increasing Crisis Resolution and Home Treatment to a 24 hour service carried out detailed work on the current and future needs of people in Medway and Swale as part of the review and redesign of inpatient and community services agreed funding for A&E liaison nurses to improve care for people with mental health needs in A&E at Medway Maritime Hospital brought in three new posts within the medicine management team of Kent and Medway NHS and Social Care Partnership (KMPT) to work closely with inpatient and community teams and GPs, to ensure patients are getting the most beneficial medication funded a community specialist mental health service to support GPs, midwives and health visitors in early detection of mental health issues in new mothers and mothers-to-be and provide care which enables women to stay at home wherever possible established a community eating disorder service to provide early intervention and recruited a clinical nurse specialist and a family therapist funded a pilot police custody suite diversion and court liaison scheme at Gillingham police station. This service offers offenders access to mental health and/or learning disability assessment by a psychiatric nurse and opportunity for diversion from the criminal justice system where appropriate
In 2010/11 we plan to:
employ a mental health promotion specialist and roll out mental health first aid training to relevant groups, to promote mental health and wellbeing and lessen stigma and discrimination invest in local services for people with Adult Attention Deficit Hyperactivity Disorder and Asperger’s continue the review and redesign of both adult inpatient and community mental health services to ensure that access and treatment for patients are clear for both those using and those referring to services as well as ensuring that services are being delivered in the best way possible and focus on recovery develop a Personality Disorder Strategy to ensure robust delivery of appropriate services further develop the A&E liaison service
9. 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 wellbeing, so they stay as well and as independent as possible. For all long term conditions, we will continue to develop personalised care planning, 40
improving the care we give to people and helping them to better manage their own conditions. In 2009/10 we:
worked with GP practices across Medway on improving their heart failure registers piloted a seven day service for people having transient ischaemic attacks (TIAs, also known as mini-strokes) offered targeted lung health checks in the community to identify people with respiratory disease launched local guidelines for the management of chronic obstructive pulmonary disease (COPD) to the GP community began a review of community neurological rehabilitation to improve multi disciplinary care for people with long term neurological conditions started a local insulin pump therapy service for children and young people worked together on the local pathway for diabetes
In 2010/11 we plan to:
raise awareness of coronary heart disease (CHD) within Medway in line with the British Heart Foundation campaign set up a Medway Community Arrhythmia Service (for people with an irregular heartbeat which increases the risk of stroke) pilot a project to increase collaborative working between CHD services begin implementing the new national COPD and Asthma strategy work with GPs, MedOCC, the ambulance service and the community respiratory team to reduce emergency admissions to hospital review care for interstitial lung and neurological respiratory diseases offer TYSABRI infusions to people with multiple sclerosis at Medway Maritime Hospital look at developing specialist neurology nurse clinics in the community continue to educate patients, public and healthcare professionals about the prevention and management of diabetes look at how the current services can most effectively manage the increasing number of people living with diabetes
Local Area Agreement on supporting people with long-term conditions Supporting people with a long-term condition to be independent and in control of their condition is a Local Area Agreement target (see p12). The measurement for 2009/10 will be calculated from responses to the GP Patient Survey during the six months from 1 October 2009 to 31 March 2010, which were still being analysed at time of going to print. In the six months from 1 April to 30 September 2009, 84 per cent of patients with a long-term condition said that their doctor or nurse gave them information about things they might do to manage their health problem and 18 per cent said their doctor or nurse gave them a written document about their discussions. 41
Wheelchairs 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 clear the waiting list. In 2009/10 we carried out a full review of the service jointly with KMPT, patients and carers. This resulted in improvements to the way the service works which reduced the time patients wait for assessment and provision of a wheelchair. As part of the 2010/11 contract, KMPT have agreed that no one will wait more than 15 days for an assessment and, if a wheelchair is needed, the waiting time will be between 15 and 65 days depending on the complexity of the chair. This is a dramatic improvement and we will be monitoring the service carefully to ensure these standards are achieved. We are also working with other Kent primary care trusts and our stakeholders to make further improvements and expect to undertake a Kent-wide tender for the wheelchair service with a new service starting in 2011/12.
10. Older people NHS Medway and Medway Council have developed a joint health and social care commissioning strategy to support a more strategic and joined-up approach to commissioning services for older people in Medway. It sets out clearly, and in one place, our joint key commissioning intentions – intentions that have been developed from analysis of local needs with local stakeholders, including older people themselves and their carers. In 2009/10 we:
developed a joint Medway Carers Strategy jointly secured £207,000 funding from the Department of Health to establish the Dementia Advisor Service. funded additional mental health clinical support to better meet the mental health needs of older people. commissioned a dementia crisis support team to provide home treatment for people with dementia who are experiencing physical problems. commissioned an Acute Hospital Dementia Liaison Team to work in Medway Maritime Hospital to provide rapid assessment and help with care planning for people with cognitive impairment. 42
established good links with black and minority ethnic communities and developed an information sharing programme.
In 2010/11, we plan to build on this and:
review services for people with dementia and their carers and consult about different options for the future develop more services for people in their own homes. develop services for older people at risk of falling further develop the Dementia Advisor Service develop intermediate care and rehabilitation services to enable older people to retain their independence
NHS continuing healthcare and NHS funded nursing care 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, as opposed to social 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 2009/10 was £106.30 a week. NHS Medway’s Continuing and Funded Nursing Care Team in 2009/10:
received the following new requests for assessment for eligibility for NHS continuing healthcare for the period April 2009 – March 2010.
Number of applications received 379
Number assessed as eligible for NHS continuing healthcare 275
Number assessed as not eligible or referred to an alternative service 104
undertook over 1600 assessments as part of the NHS continuing and funded nursing care process. focused on the full implementation of the revised Department of Health Framework for NHS continuing healthcare and NHS funded nursing care (July 2009). in conjunction with colleagues from Medway Council social care, provided training to over 148 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. continued working with the NHS South East Coast procurement hub on regional commissioning arrangements with care providers to ensure 43
quality, needs-focused, placements.
value
for
money,
care
packages
and
In 2010/11, we plan to:
assist partners in health and social care to ensure that the requirements of the Department of Health national framework for children’s continuing care, due for release in 2010, are implemented and that transition from children’s to adult services is seamless continue training health and social care staff to ensure that people who may be eligible for NHS continuing healthcare are referred for an assessment further develop partnership working with Medway Council to ensure a seamless approach by health and social care continue to develop person centred care packages and placements, ensuring that patients have choice over how and where their needs are met
11. End of life care End of life care offers support and palliative treatment for both patients and their families through the last phase of life and into bereavement. Our main focus for end of life care in 2009/10 was building on previous work to widen the scope of palliative care services to non-cancer patients and developing our local end of life care strategy. In 2010/11 we will undertake major service redesign to develop more robust and effective care and support for individuals, their carers and families in a more joined-up approach with our partners. This will allow more people to die at home with more support for their carers and families. The emphasis will be on improving access and quality of care to individuals approaching end of life and their carers, to ensure improved outcomes. We will be implementing our strategy jointly with Medway Council which will allow us to deliver the national and local pledges which are: developing a rapid response crisis service for those entering a rapid state of decline allowing more patients to die at home, if they so wish, by enhancing the capacity of night sitting services and home support services improving access to home care and night nursing services delivering an End of Life Care Register improving access to bereavement services continuing to educate clinicians and the public on end of life care issues training clinicians on end of life care tools such as Gold Standards Framework and the Liverpool Care Pathway. developing integration with the council which will allow us to utilise our resources more effectively and deliver joined-up care and support 44
Medway Community Healthcare Medway Community Healthcare, hosted by NHS Medway, is responsible for providing community health services to patients across Medway. In line with national guidance on Transforming Community Services, issued by the Department of Health, Medway Community Healthcare continues to work towards becoming a separate organisation, independent of NHS Medway. Medway Community Healthcare has a separate Board, which remains accountable to the main NHS Medway Board until formal separation of the organisations, which it is anticipated will be completed by April 2011.
Healthcare services for local people Medway Community Healthcare provides a wide range of high quality community health services for Medway residents; from health visitors and district nurses to speech and language therapists and out of hours and urgent care.
Children’s services Children’s services are delivered by: three integrated teams of health visitors and speech and language therapists an integrated children’s therapy team which cares for children with complex and special needs a youth offending team in partnership with police officers, social workers, probation and education staff the young parents’ integrated team, which supports teenage parents the child and adolescent support team which focuses on emotional well-being Achievements in 2009/10:
the Early Support Programme was successfully developed to offer support for the families of very young children diagnosed with disabilities, by integrating health visitors into the children’s therapy team as a pilot project. Funding has been secured for 2010/11 the Family Nurse Partnership Programme has been running since July 2009, supporting young mothers (under 19 years) and their children until the child is two years old the health visiting service is now rolling out the national Healthy Child Programme, which sets the standards of service that every family should expect to receive from pregnancy through to when their child is five years old. In addition to all the core visits to families, the health visiting teams will offer additional support to those who need it 45
the Children’s Therapy Team continued to provide services across Medway at a variety of sites while plans for a permanent hub for the service are developed
Plans for 2010/2011:
progress the project to develop the service for children with disabilities in Medway, including working in partnership with parents and other users to design how the service will look in the future health visitors and midwives will support the infant feeding strategy and the roll out of the UNICEF Baby Friendly programme across Medway to support new mothers in breastfeeding their babies
Adult services Community healthcare services for adults are delivered by:
St Bartholomew’s Hospital, Rochester, a nurse-led rehabilitation centre providing rehabilitation care and treatment, which helps patients of all ages recovering from a variety of illnesses or injuries, ranging from a stroke to a motorcycle accident, return to living independently the Walter Brice Rehabilitation Centre, Hoo, 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 a physiotherapist, rehabilitation nurse and occupational therapist six integrated health and social care teams offering care, support and advice for people in their own homes, including district nurses, care managers, social workers, occupational therapists and physiotherapists the rapid response team, which provides intensive short-term health and social care support to people recovering from an illness or injury a community equipment service which supplies beds, hoists, walking aids and similar equipment to patients being cared for at home a 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, and conditions such as multiple sclerosis, Parkinson’s disease, motor neurone disease, dementia or head and neck cancer the dietetics team which provides advice and support to individual patients with special dietary needs and people with conditions such as diabetes and heart disease, as well as information and training for healthcare professionals an orthopaedic clinical assessment service, which consists of an orthopaedic physician (a GP with a special interest in orthopaedic conditions); consultant physiotherapist; orthopaedic physiotherapy 46
practitioners; extended scope practitioners in physiotherapy; occupational therapy and podiatry. The team will assess patients to diagnose problems and can arrange x-rays and magnetic resonance imaging (MRI) or give injections if necessary. Conditions treated by the team include hip, knee, shoulder and other joint problems, arthritis, lower back pain a physiotherapy team, which provides clinics as a number of venues across Medway for physiotherapy assessments, treatments and advice for adults with musculo skeletal problems. Conditions seen may be caused by injury, overuse or be age related and include low back pain, joint problems, whiplash, broken bones and rheumatoid arthritis. Treatments include manipulation, exercise programmes, group education session and electrotherapy - including ultrasound and TENS and acupuncture a podiatry service offering 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 independent a phlebotomy (blood taking) team, which runs sessions at Rainham, Lordswood, Parkwood and Twydall an advanced clinical assessment team of advanced clinical practitioners who support people in their own homes and care homes. The support and care provided by team helps patients avoid going into hospital or a nursing home before they need to and also supports them to return home from hospital as soon as they are able to
Achievements in 2009/10:
closer working established by the advanced clinical assessment team with the Medway On Call Care (MedOCC) urgent care team provides patients with more tailored care pilot of an outpatients clinic, at St Bartholomew’s Hospital, to provide intravenous Venofer (iron) medication for patients with chronic renal disease new Macmillan oncology care co-ordinator now in post to help ensure that patients with cancer receive the support and care they need ensured 100 per cent of patients were cared for in same sex environments
Patient comment “The podiatrist was so very kind and helpful and the treatment was provided with the utmost care.”
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Plans for 2010/2011:
establishing a dietetics nutritional support team, which will focus on patients being fed by tube and those who are malnourished, to provide greater support for malnourished patients and improve health outcomes, help reduce hospital admissions and reduce inappropriate prescribing of nutritional supplements further developments for community equipment loan service (CELS) including further extending opening hours;; publication of an equipment catalogue for use by prescribers; the implementation of a new electronic system to enhance record-keeping; a new bed maintenance and servicing contract with a third party supplier; and further reduction in waiting times with 97% of all equipment requests, including special orders, provided to patients within seven days. In May 2010, the service relocated to new premises with better storage and access enhancing the combined working of the orthopaedic clinical assessment service and the physiotherapy team to streamline the care provided to patients reviewing the service provided for patients with long term neurological conditions including the rehabilitation care provided to patients attending the Walter Brice Rehabilitation Centre
Specialist services Specialist community healthcare services delivered by Medway Community Healthcare are:
DentaLine, the out-of-hours emergency dental service for Medway and Kent a community dental service, which provides dental care for vulnerable people and those with special needs in Medway and West Kent, as well as oral health promotion work in schools and care homes Darland House in Gillingham – a 40 bed 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. The hospice team includes Macmillan nurses who provide care for people in their own homes and a specialist team of palliative care social workers who offer psychosocial and family support the community respiratory team, which provides assessment, breathing tests, rehabilitation, advice and support to people in Medway and Swale with chronic lung disease a community cardiology team and heart failure team which carries out both non-urgent tests for diagnosing heart conditions and offers rehabilitation support, including exercise classes the stroke service, which cares for everyone registered with a Medway or Swale GP who has had a recent stroke 48
a specialist diabetes service which gives advice and support to adults with diabetes and the professionals caring for them the tissue viability service, which offers wound care for people with chronic wounds or recovering from surgery or an injury plus advice and support the falls prevention team, which offers older people who have fallen a full assessment and works with them to prevent a recurrence.
Achievements in 2009/10:
the development of a dedicated dining room at Darland House. This has improved the eating environment of those residents who are able to use it and choose to do so. It also means staff have more time to spend with patients who are not able to eat in the dining room, resulting in an improved nutritional intake in 2009, the Friends of Wisdom Hospice purchased a newly built house adjacent to the hospice building, to provide accommodation for people visiting their friends and relatives in the hospice Darland House and Wisdom Hospice ensured 100per cent of patients were cared for in same sex environments, and achieved excellent ratings for all aspects of privacy and dignity in care the diabetes team introduced a new X-pert education programme for newly diagnosed diabetes patients to help them understand and better manage their diabetes the stroke team was again accredited as a Practice Development Unit with Bournemouth University, in recognition of their continued good practice and high quality service. The team also piloted a TIA (transient ischaemic attack) service, available seven days a week, which provides specialised care to those patients at risk of a stroke the falls service now takes direct referrals from the South East Coast Ambulance Service (SECAmb) meaning patients who have fallen and been seen by SECAmb can be referred directly for assessment and care the Wisdom Hospice team has been working with clinicians in other services to extend the admission rights onto the wards at the hospice; the cardiology service can now admit patients into the hospice where the patient and family feel it would be beneficial.
Plans for 2010/2011:
Darland House plans to open a shop, based within the house, to provide everyday goods for residents and visitors and an opportunity for residents to work in the shop the day hospice service at the Wisdom Hospice will be expanded giving more people a chance to benefit; a dedicated package of care will be designed for each patient to ensure they receive the most they can from the service. In 2010, the house at the Wisdom Hospice, purchased by the Friends of the Wisdom, will be opened to visitors the cardiology team will take on more staff to offer the new arrhythmia 49
service, diagnosing and treating patients with arrhythmia - an abnormal alteration in rhythm of the heartbeat the TIA (transient ischaemic attack) service provided by members of the stroke team based at Medway Maritime Hospital will be extended from five days a week to seven days a week; thus ensuring that at the weekend patients with a suspected TIA will be treated quicker.
Urgent care Medway On Call Care (MedOCC) provides a service for people needing urgent GP and nurse appointments. MedOCC never closes but is open 24/7, every day of the year. Residents of Medway and visitors to the area can access MedOCC when GP surgeries are closed during the evenings, at weekends and on Bank Holidays. In addition, MedOCC will also see patients during the day Monday to Friday if they need an urgent appointment which their own surgery cannot provide. In these cases, their surgery refers them. Most patients who get in touch with MedOCC need urgent care. Others contact the service because they have not registered with a GP locally. Out-of-hours, MedOCC also dispenses urgently required prescribed by its GPs, such as pain relief and antibiotics.
medication
Achievements in 2009/10:
more than 45,000 patients were seen at one of MedOCC’s clinics, at Quayside House, Chatham, Rochester Healthy Living Centre and alongside A&E at Medway Maritime Hospital, Gillingham; a further 30,000 patients received telephone advice and around 10,000 patients received a home visit the extended MedOCC team introduced a service offering care for patients suffering from suspected Deep Vein Thrombosis ( a blood clot blocking circulation to the legs), and Cellulitis (a severe skin infection of the arms and legs), arranging assessment, ultrasounds and prescribing appropriate treatments MedOCC became only the third out-of-hours service in England to make use of the new Summary Care Record system. This enables MedOCC doctors and nurses, with patients’ consent, to access a brief summary of their GP record, if it has been created (see p31 for more details about the system)
Plans for 2010/2011:
to develop a new referral system so MedOCC can arrange for patients to go into St Bartholomew’s Hospital, rather than Medway Maritime Hospital, if they need very short term nursing care 50
Patient comment “I thought you should know how grateful I was to have concerns taken seriously and acted upon directly - from the very kind man who took my details to the professional care and attention from the doctor and the reception staff who directed me to the late night pharmacy.”
Productive Series, releasing time to care Medway Community Healthcare is implementing the Productive Series, a national programme which engages all teams in improving quality and productivity, with the aim of releasing more time to care. This continues the successful work carried out introducing the Productive Ward Programme at St Bartholomew’s Hospital. During 2010/2011, this programme will be rolled out across clinical services.
Single sex accommodation and privacy and dignity In January 2009, the Department of Health commenced an intensive drive to virtually eliminate mixed sex accommodation for patients. Within Medway Community Healthcare, a number of projects were developed to achieve our target. These included new doors, blinds and signs at Wisdom Hospice; new bed curtains and signs at St Bartholomew’s Hospital, and cubicle curtains and signs in outpatient physiotherapy. The Privacy and Dignity Policy has been revised to incorporate the escalation process if a case of mixing occurs. Medway Community Healthcare are pleased to confirm that mixed sex accommodation has been virtually eliminated in all our in-patient areas. Within Medway Community Healthcare, peer to peer reviews (by other healthcare organisations) were successfully conducted during 2009/10 to assess privacy and dignity and single sex accommodation in all inpatient areas. These reviews found outstanding standards of privacy and dignity at all three inpatient sites (St Bartholomew’s Hospital, Darland House and Wisdom Hospice). This was confirmed by focus groups held at each site in June 2009 which demonstrated excellent inpatient satisfaction on privacy and dignity. Wisdom Hospice and Darland House received 100 per cent satisfaction ratings. The staff at Darland House make privacy and dignity a priority and together they have created a culture which revolves around the routine of the patients and their needs. Staff have been involved in the national Dignity in Care Campaign and are a Department of Health ”showcase”, a collection of good practice examples that show how to promote or enhance dignity in various care settings and what a difference this can make to patients. 51
Safeguarding children The Children Act 2004 2 places a duty on health organisations to safeguard the welfare of all children. Medway Community Healthcare is committed to protecting children and has in place a safeguarding children team who provide professional safeguarding and child protection advice and support to staff whose work brings them into contact with children and adults who are parents or carers, however minimal. Working in partnership the team are members of: Medway Safeguarding Children’s Board sub-groups. Multi Agency Risk Assessment Conference (High level domestic abuse cases) Children’s Trust Child Death Process Achievements in 2009/10:
provision of child protection training as part of a multi-agency programme supervision to 100 per cent of staff who have children subject to a child protection plan on their caseload. supervision sessions run monthly for children’s services. a series of workshops to address national guidance and issues from Serious Case Reviews. a Service Level Agreement with NHS Medway to provide support on all aspects of safeguarding to the commissioners developed a new style of health visitor record in conjunction with the integrated children’s teams.
Plans for 2010/11:
to recruit and appoint a specialist nurse to raise awareness of domestic abuse and its impact on children. promotion of safer sleeping for all babies
Safeguarding adults Medway Community Healthcare is committed to ensuring that adults live free from abuse. To support staff, safeguarding adult training has been redesigned to allow not only an understanding of the theory but also to have the opportunity to discuss issues related to patient care during clinical supervision. To raise awareness of abuse, each service area has a designated safeguarding link who is able to reinforce the importance of prompt recognition of and action on abuse with colleagues. The link representative 2
Children Act 2004 section 11. London HMSO
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also ensures that staff are aware of the support available to them from the safeguarding adults team. The Mental Capacity Act (2005) is legislation which affects the care delivered by all staff; it is mandatory for all clinical staff to attend basic awareness training. Staff at St Bartholomew’s Hospital, the Wisdom Hospice and Darland House have regular contact with the safeguarding adult team to ensure that patients are not unlawfully deprived of their liberty and care is delivered in their best interests. The safeguarding adult team work in collaboration with council colleagues to ensure that joint procedures are followed and that lessons learnt are implemented robustly.
Infection control Medway Community Healthcare aims to provide care in environments that ensure the prevention of infection. All staff with patient contact are required to attend annual infection control and hand hygiene training, while non clinical staff have two yearly training. Robust cleaning schedules are displayed in all areas identifying what is cleaned and how frequently. We have moved to single use instruments in most areas and are part of a move to a centralised sterile supplies provision in podiatry. We monitor cleaning standards and the environment, staff compliance with hand hygiene, and other clinical procedures, through a comprehensive audit programme. Patient experience surveys seek assurance from patients that they feel cared for in clean and appropriate environments as well as asking if the clinical staff were seen to wash their hands or use alcohol gel. Over the last year we have actively promoted the cleanyourhands and Essential Steps national campaigns. The infection control team have also worked to support nursing care homes in all aspects of infection control. The homes have representation on the infection control link practitioner network. There are very few incidents of MRSA or Clostridium difficile within services. Any occurrence is investigated, appropriate action taken and lessons learnt.
Medway Community Healthcare Patient Environment Action Team Assessments (PEAT) 2010 PEAT is an annual assessment of inpatient healthcare sites with more than ten beds which aims to ensure improvements are made in the non-clinical aspects of patient care, such as cleanliness, food and infection control. Assessments are carried out by NHS staff (nurses, matrons, doctors, catering and domestic service managers, executive and non-executive directors, 53
dieticians and estates directors). Patients, patient representatives and members of the public are also part of this assessment process. The assessment results help to highlight areas for improvement and share best practice across healthcare organisations in England. The results for Medway Community Healthcare for 2010 are:
Site Name Darland House Nursing Home St Bartholomew's Hospital Wisdom Hospice
Environment Food Score Score Good Acceptable Excellent
Excellent Excellent Excellent
Privacy & Dignity Score Excellent Excellent Excellent
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Our staff NHS Medway has 1,614 staff. Of these, 1,238 work within Medway Community Healthcare. The remaining 376 (311 full time equivalents) work in the commissioning arm of the organisation. Sickness absence In 2009/10, the average sickness absence rate for Medway Community Healthcare was 4.7 per cent, which is a reduction on the previous year. The sickness absence rate for staff in the commissioning arm was approximately 3 per cent. On average, there were 9.3 days of sickness absence for each full time equivalent post at NHS Medway (including Medway Community Healthcare) from January to December 2009. More than a quarter of staff had no sickness absence. The average for NHS organisations in England as a whole was 9.8 days.
Equal opportunities NHS Medway, including Medway Community Healthcare, believes that every employee should be treated with equal respect and dignity. We value the rich diversity and creative potential of people with differing backgrounds and abilities and encourage a culture of equal opportunities in which personal success depends on personal merit and performance. We are fully committed to a programme of action to ensure the promotion of equal opportunity for all and the elimination of discrimination in all aspects of employment. Our policy on equal opportunities and disabled employees is set out in our Equality and Diversity in Employment Policy which covers staff in both the commissioning arm of the organisation and Medway Community Healthcare, and which complies with current law and codes of practice. Staff engagement and development – Medway Community Healthcare During 2009/10, a major focus for Medway Community Healthcare engagement with staff continued to be around Transforming Community Services, including the future organisational form of Medway Community Healthcare. Members of the Medway Community Healthcare executive team attended almost 50 separate team meetings, ran a series of staff drop-in sessions, launched a newsletter, Talk, which concentrates on issues related to Transforming Community Services, and set up a system to enable staff with concerns to ask questions anonymously via the intranet. 55
Medway Community Healthcare also produced its first stand alone workforce plan with contributions from every service, covering what the current and future workforce will need to equip them to deliver high quality care for all. In 2009/10 we:
launched the Medway Community Healthcare leadership forum with an event led by Professor Michael West from Aston University, who demonstrated that effective outcome-based appraisals and teamwork result in better outcomes for patients. We redesigned our approach to appraisal, ensuring clearer guidance and support for managers and staff launched induction for managers and a manager’s passport, to ensure that all new managers in Medway Community Healthcare are equipped with the skills and knowledge they need to be effective saw the first cohort of band 1-4 staff start the new Foundation degree for administrative and clerical staff working in health and social care launched a Medway Community Healthcare equality and diversity steering group and achieved equality and diversity training for more than 53 per cent of staff, helping to embed equality and diversity across the organisation announced our commitment to achieving the Investors in People award established our own Joint Staff Forum to work with trade unions and staff representatives continued substantially to improve the Electronic Staff Record to help the organisation understand the demographics of the workforce continued to embed a learning management system which links to the Electronic Staff Record for more robust management and reporting addressed musculo skeletal and back problems, major causes of sickness absence, by launching a fast track physio pilot. It is being used not only by staff absent from work but also as a preventative service to enable other staff with long standing problems to stay at work were one of only three organisations in the South East Coast region to win a bid for Social Partnership funding. We have used it to train in-house mediators to help resolve disputes in the workplace that might otherwise become formalised
In 2010/11 we plan to:
hold lunchtime health and wellbeing events for staff to have health checks and seek advice from clinical and non clinical specialists on health and wellbeing services host events to acknowledge staff who have worked continuously in the NHS for more than 25 years hold an inaugural staff conference to celebrate the successes, achievements and contribution made by individuals and teams in Medway Community Healthcare to the residents, patients and carers of the Medway towns 56
launch an updated Single Equality Scheme, following consultation and engagement with staff and various local community groups
Our main focus in workforce planning will be to build on service workforce plans, and ensure skill mix provides high quality, best value, services that meet patient expectations. The Electronic Staff Record team will implement the national Position Based Access Control (PBAC) project, which through ESR employee positions, will give users the access they need to IT programmes in the course of their work, whilst ensuring that risks are properly managed to meet data protection and patient rights. Voluntary Services Medway Community Healthcare hosts the Voluntary Services department for Kent and Medway. There are approximately 1,200 volunteers in 173 placement areas within the Voluntary Services department. NHS volunteers contributed a total of 109,393 hours in 2009/10 - an increase of 14,393 hours on the previous year. Our volunteers offer their time to support and complement the Medway and Kent areas and ultimately benefit the patient experience. They make a considerable contribution to services such as advocacy and campaigning work, the development of community awareness, and supporting community initiatives, engaging patient and public involvement. The department has been involved with many new projects, most significantly providing more than 50 volunteers to support the Macmillan Cancer Care Unit at Medway Maritime Hospital. NHS Medway is working towards offering an accredited training programme to support the new volunteer breast-feeding helpers. Voluntary Services is supporting both the NHS stop smoking service and the MEND programme, which are run by Medway’s public health directorate. In 2010/11, opportunities for specific and unique training for NHS Medway volunteers are being developed alongside the HR learning and development team to benefit and enhance volunteers’ skills and experiences. With the current economic climate, demand for volunteers is continually increasing. The voluntary services department looks forward to identifying and meeting this demand. Staff engagement and development - NHS Medway In 2009/10 we:
carried out the first staff survey focusing just on NHS Medway commissioning staff, and held an inaugural event “NHS Medway – Our Message” for all commissioning staff 57
balloted staff about a new approach to staff engagement, and set up a new Staff Engagement Group as a result, with representatives from all directorates launched lunchtime healthy walking sessions, making it easier for staff to become healthier, in line with A Better Medway offered equality and diversity training to all staff, launched an equality and diversity steering group, and started a series of lunchtime celebrations of cultural and religious festivals revised induction for commissioning staff encouraged band 1-4 staff to start a Foundation degree continued our progress towards Investors in People status
In 2010/11 we plan to:
re-establish quarterly staff briefings with the Chief Executive offer World Class Commissioning masterclasses and lunchtime learning to all staff launch a new health and wellbeing group for staff which will organise events in response to staff demand and develop a staff health and wellbeing strategy refresh the intranet hold a further commissioning staff conference and launch an award scheme to celebrate staff achievements achieve Investors in People status by November 2010 develop a World Class Commissioning leadership pathway for managers substantially improve the Electronic Staff Record to help the organisation understand the demographics of the workforce, and enable updating of records by managers and staff
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.nhsba.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. Details of the scheme’s valuation are available in NHS Medway’s Annual Accounts, published separately.
Workforce planning NHS Medway has a leadership, developmental and assurance role in workforce planning and education commissioning across the health community. We recognise that to achieve the vision set out in our Strategic Commissioning Plan, the whole healthcare system in Medway needs to have 58
the right workforce, with the right skills, at the right time, in the right place and at the right cost. Over 70 per cent of all NHS expenditure is on staff. In the current economic climate it is even more essential that workforce plans are comprehensive and integrated with financial plans. In 2009/10 we:
worked with all our main provider organisations to ensure that they are developing workforce and education plans to support future service delivery provided training in workforce planning for staff across the local health community as well as organising training in data modelling for workforce managers across Kent and Medway produced a local health community workforce and education plan that summarises the future anticipated workforce changes in the next three to five years
In 2010/11 we plan to:
continue to provide leadership in workforce planning and education commissioning across the local health community work with our neighbouring primary care trusts and social care partners to align and integrate workforce planning and education commissioning develop a programme of activities and events to strengthen workforce planning capabilities across organisations contribute to the development of a framework for managing large scale workforce change across Kent and Medway
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How we deal with complaints NHS Medway and Medway Community Healthcare work hard to ensure errors or accidents do not happen. However, sometimes mistakes are made, and in these cases we follow the principles of good practice with regard to remedying the problem. This means: 1. Getting it right NHS Medway and Medway Community Healthcare put an emphasis on acknowledging complaints quickly and putting right what went wrong. We aim to consider all relevant factors when deciding the appropriate remedy and ensure fairness for the complainant and, where appropriate, for others as well. 2. Being customer focused We apologise for any errors made and explain the causes to those involved. We work with those involved to devise and implement solutions. 3. Being open and accountable We explain 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. 4. 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. 5. Putting things right NHS Medway and Medway Community Healthcare work with those who are aggrieved to determine what would be an appropriate outcome, whether this is an apology, explanation or compensation. 6. Seeking continuous improvement We seek to use the lessons learned from complaints to ensure that service is improved as a result. Complaints are reported to the NHS Medway Board and Medway Community Healthcare Board, and service directors receive quarterly reports of complaints received, including trend analysis. These reports also go to the Clinical Governance and Clinical Risk Groups. Making experiences count In April 2009, the NHS introduced a new complaints procedure, Making Experiences Count. The new focus is on patient involvement and patient choice, to try and resolve concerns as quickly as possible and to the patient’s satisfaction. Complaints to the commissioning arm of NHS Medway Complaints received by NHS Medway include concerns about the commissioning or funding of NHS services or procedures in Medway and concerns regarding NHS initiatives, such as Summary Care Records. Patients 60
who are not happy with the service they received from independent practitioners (GPs, dentists, pharmacists and optometrists) can also choose to complain to NHS Medway rather than directly to the individual or practice involved. People can choose what form they want the response to their complaint to take (such as a meeting, a letter or a phone call) and the timescale in which the investigations should be completed and a response sent. In 2009/10, there were 171 formal complaints and 110 informal complaints to NHS Medway. Any complainants who are not satisfied with the local response can ask the Parliamentary and Health Service Ombudsman to get involved. In 2009/10, two NHS Medway complaints were passed to the ombudsman. Complaints continue to be reported, anonymously, to clinical groups to ensure issues are fed back and addressed appropriately. A Lessons Learnt Group has been established to record and share learning from complaints, so that care is improved for the future. Complaints staff have been out on health road shows, as part of the Customer Care Team, to publicise the new complaints procedure and advise patients how to take complaints forward. Complaints to Medway Community Healthcare A new procedure for managing complaints was introduced at the start of the year to reflect the guidance issued by the Department of Health “Listening, Responding, Improving - A guide to better customer care” (2009). It also aims to meet the “Principles of Good Complaint Handling” (2009) laid down by the Parliamentary and Health Service Ombudsman and outlines a new approach for Medway Community Healthcare to listening, responding and learning from experiences of care. During 2009/10, 438 compliments were recorded centrally by the customer care department. It is likely even more were received but not forwarded. A total of 246 complaints were received. Of these, 32 were verbal complaints and were closed within 24 hours, and 31 were joint complaints coordinated by Medway NHS Foundation Trust. When patients asked to meet directly with services to discuss their complaint, this was arranged. Four complaints were passed to the ombudsman and were closed with no further action required.
PALS Throughout 2009/10, NHS Medway’s Patient Advice and Liaison Service (PALS) continued to support patients by assisting them with advice and answering queries. The service received 1,360 enquiries during 2009/10. In addition to offering advice and support via e-mail, letter and telephone, PALS has been out as part of the Customer Care team, visiting shopping centres, healthy living centres and sheltered accommodation to advertise the services available to the public and offer on-the-spot help and support. 61
Our environmental impact At NHS Medway we strive constantly to reduce our carbon footprint and our general environmental impact. All new buildings run with efficient systems and have sensor operated lights which activate when someone enters a room we have replaced most of the outdated boilers in our buildings with costeffective energy conservation systemsSt Bartholomew’s Hospital, Rochester, 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 £4,000-6,000 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 o Car share o Use public transport o Plan journeys to best effect o Embrace flexible working o Use video / telephone conference facilities o Cycle or walk we have introduced recycling at all sites which a majority of staff have embraced although we could still do more a Microfibre cleaning system has been introduced in community clinics, reducing the need to use chemicals as well as the risk of infection In 2010, we were accepted on the Carbon Management Programme, run by the Carbon Trust, which will assist us in developing plans to reduce our carbon footprint by around 25 per cent over the next five years. We have formed a carbon management team with representatives from all NHS Medway directorates to implement further carbon reductions. How we do 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, with buildings being assessed on an annual basis. The aim is to achieve a ‘D’ rating or above. To date, NHS Medway has achieved 6 ‘D’ and above ratings, two ‘E’, failing by a small figure and one ‘G’ for which an investigation is being undertaken. Given the age of most of the estate these certificates are very positive and will assist in achieving our ultimate goal in carbon reduction. In 2009 for all sites we used:
4,391,569 KwH of electricity at a cost of £197,933 4,929,744 KwH of gas at a cost of £158,438
This was an increase on 2008, because of the increasing property portfolio of NHS Medway. We swapped our utility provider for one with a cheaper tariff. 62
In 2009 across all sites, including Medway Community Healthcare, NHS Medway produced a total of approximately 420 tonnes of waste, which cost ÂŁ80,000 to dispose of. This included 72 tonnes of recycled waste, at a collection cost of ÂŁ9,200. This indicates the importance of recycling in not only reducing our carbon footprint and making us more sustainable, but also in making cost savings.
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NHS Medway Board The board sets the strategy and direction of NHS Medway, monitors its performance and makes financial and policy decisions. Non Executive Directors Chairman: Denise Harker (since 1 January 2010) Trevor Cooper Glyn Griffiths David Mayes (since 1 March 2010) Marcus Sherwood-Jenkins (until 31 March 2010) Chairman of the Audit Committee Jane Bastow (until 31 March 2010) Azhar Mahmood (until 31 March 2010) Stephen Gee (since 1 March 2010) Graham Mayes (since 1 April 2010) – Chairman of the Audit, Assurance and Risk committee Gillian Wells (since 1 April 2010) Saba Sadiq (since 1 April 2010) Changes during 2009/10 Eddie Anderson was Chairman until 30 September 2009. David Griffiths was Interim Chairman from 1 October - 31 December 2009. Executive Directors Marion Dinwoodie, Chief Executive Dr Alison Barnett, Director of Public Health Jonathan Bates, Director of Finance and Assurance Malvinder Raval, Professional Advisory Committee Chair (until 31 December 2009 ) Dr Peter Green, Professional Advisory Committee Chair (since 1 January 2010) Dr Gill Fargher, Professional Advisory Committee Other members of the executive team Pippa Barber, Director of Clinical Performance / Executive Nurse Fay Brown, Interim Director of Integrated Commissioning (until 31 March 2010) Helen Buckingham, Director of Commissioning and Performance Natalie Davies, Company Secretary Dr Peter Green, Medical Director (became an Executive Director when appointed Professional Advisory Committee chair on 1 January 2010) Wendy Head, Director of Organisational Development and Workforce Planning Lauretta Kavanagh, Director of Commissioning for Mental Health and Substance Misuse, Kent and Medway Martin Riley, Managing Director of Medway Community Healthcare 64
Practice Based Commissioning locality clinical leads Rochester and Strood: Dr Christopher Markwick (until 31 March 2010) Dr Dudley Hubbard (from 8 June 2010) Chatham: Dr Nathan Nathan Gillingham and Rainham: Dr Subramaniyam Selvan
Membership of major committees Professional Advisory Committee Chair: Malvinder Raval (until 31 January 2010) Dr Peter Green, Professional Advisory Committee (since 20 January 2010) Dr Gill Fargher, GP Dr Nathan Nathan, GP (as PBC lead) Dr Subramaniyam Selvan, GP (as PBC lead) Dr Chid Balachander, GP Dr Olurotimi Adesanya, dentist (since 1 June 2010) Mary Kirk, Cardiology Nurse Consultant Kath Plumbe, Consultant Physiotherapist (until 31 July 2009) Richard Redmond, Interim Assistant Director of Social Care, Medway Council (until 20 November 2009) David Quirke-Thornton, Assistant Director Adult Services, Medway Council (since 23 November 2009) Dr Chau Shum, GP Sue Whiting, Clinical Nurse Lead (until 31 July 2009) Marion Dinwoodie, NHS Medway Chief Executive Pippa Barber, Director of Clinical Performance / Executive Nurse 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 Audit, Assurance and Risk Committee Graham Mayes, Chairman Stephen Gee Saba Sadiq Trevor Cooper Remuneration Committee The members of the Remuneration Committee are all the non executive directors of NHS Medway. The committee is chaired by the NHS Medway Chairman. The NHS Medway Board holds six meetings a year in public at NHS Medway‘s HQ at Fifty Pembroke Court, Chatham. The Board is supported by a number of sub committees chaired by non executive directors.
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Note on committee structure: on 24 March 2010, the NHS Medway Board agreed to set up a new Audit, Assurance and Risk committee, (combining the functions of the former Audit and Risk Management committees) a new Human Resources steering group and a new Finance committee. Key Board Committees
NHS Medway Board and Committee Structure 2009/10
Management Groups Chief Exec Authority
PCT Board
Provider Board
Chief Executive Authority
Remuneration & TOS Strategic Change Programme Board
WCC Project Group
Investment Decision Support Group
Choosing Health Planned Care Urgent Care
Quality
Mental Health Strategic commissioning Board.
Audit
PAC
Joint Commissionin g Board
Clinical
Executive Team
Accreditation
Medicines Management
Privacy and Dignity Group
Operational Risk Group
HR steering Group
Quality Development Group
Standards for Better Health
Clinical Effectiveness
M FT Clinical Review
ICDC
Non NHS Providers
SUI ops groups
KMPT Quality Review Group
PBC Operational Group
Fire Health and safety Emergency Planning Information Governance
Diabetes
Cancer
Practice Based Commissioning
Patient Safety
Primary Care
Coronary Heart Disease
Risk Management
Policy Group MCH Clinical Quality Group Prisons
Renal Services Stroke Childress Services Joint Commissioning Board Older Peoples services Maternity Matters Substance Misuse End of Life Long Term Conditions Dementia
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Ethnicity and Diversity advisory group
NHS MEDWAY PERFORMANCE 2009/10 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. Indicator 18 week referral to treatment times - reported waits for admitted elective care 18 week referral to treatment times - reported waits for non admitted elective care Direct access audiology waiting times Access to genito-urinary medicine (GUM) clinics within 48 hours
Performance 2009/10
90.00%
94.35%
Target achieved and sustained
98.13%
Target achieved and sustained
100%
Target achieved and sustained
95.00%
100.00%
100.00%
99.89% Quarters 1 to 3 GP Patient Survey Able to see a doctor fairly quickly 77%
Access to primary care - patient reported measures
91%
Able to book ahead for an appointment 69% Satisfaction with opening hours 75%
Access to primary dental services
Comment
Target 2009/10
165,864
Year to date Dec 09 166,768
Performance within allowed tolerance target achieved This is a three part indicator based on aggregated results from the four quarterly GP Patient Surveys. PCTs are expected to perform well across three themes (fast access, booking ahead and satisfaction with opening hours) to achieve the overall indicator. For 2009/10 this will be measured as the number of patients seen in the 24 month period ending 31 March 2010. Final figures for 2009/10 will be published at the end of June.
67
All-age all cause mortality (AAACM) rate per 100,000 – female
2009 510.50
No update available
All-age all cause mortality (AAACM) rate per 100,000 - male
2009 702.10
No update available
All cancers: one month diagnosis (Decision to treat) to treatment
96.00%
98.8%
31-day standard for subsequent cancer treatments (surgery and drug treatment (chemotherapy). All treatments to start within 31 days of patient being added to the waiting list for that treatment.
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 treatment.
Drug 98% Surgery 94%
94%
Data for 2009 will be published in December 2010 Data for 2009 will be published in December 2010 Target achieved
Drug 99.5% Surgery 97.7%
96.9%
Target achieved
The expansion of the standard to incorporate radiotherapy treatment is required to be achieved by December 2010 in the Cancer Reform Strategy. South East Coast SHA have set interim stretch targets to be achieved and the PCT seems to be achieving but we are aware that not all providers are fully submitting this data yet. Therefore there may be a dip in performance as more data is submitted. Target achieved
All cancers: two month GP urgent referral to treatment
85.00%
88.7%
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Extended 62-day cancer treatment targets. Percentage of patients who receive a first definitive 90.00% treatment for cancer within 62 days of an urgent referral from the national screening programme
100%
Extended 62-day cancer treatment targets. Percentage of patients No who receive a first definitive standard treatment for cancer within 62 days set of a consultant decision to upgrade their priority status.
100%
All cancers: two week wait to be seen by a specialist
95.5%
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) Breast cancer screening for women aged 53 to 70 years
93%
93%
Quarter 4 90.2%
>= 70%
2008/09 80.7%
Ambulance Trust - Category A calls meeting 8 minute standard from call connect
75%
76.3%
Ambulance Trust - Category A calls meeting 19 minute standard
95%
98.2%
Target achieved
The standard for first treatment from consultant upgrade has not been set as there have been insufficient numbers for the robust calculation of an operational standard
Target achieved
Target starts from December 2009
Information for 2009/10 not yet available This is the performance of the South East Coast Ambulance Trust (SECAmb). Achievement of Category A targets and performance on Category B reflects the high levels of effort and commitment from everyone in the Trust.
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Ambulance Trust - Category B calls meeting 19 minute standard
Cervical screening for women aged 25 to 64 years – the number of women aged 25 to 49 who have received cervical screening in the last 3.5 years, and the number of women aged 50 to 64 who have received cervical screening in the last 5 years
95%
93.4%
< 3.5 years Q1 70.7% Not Q2 70.6% available Q3 69.8% < 5 years 80%
Q1 81.8% Q2 81.5% Q3 81.0%
Childhood obesity - measured in Year R (Reception)
9% (88% coverage)
2008/09 11.7% (88.2% coverage)
Childhood obesity - Measured in Year 6
19% (88% coverage)
2008/09 19.4% (89.6% coverage)
Chlamydia prevalence (screening) percentage of population aged 15 to 24 screened or tested for Chlamydia
25.00%
23.7%
This is the performance of the South East Coast Ambulance Trust (SECAmb). Achievement of Category A targets and performance on Category B reflects the high levels of effort and commitment from everyone in the Trust. No standard has been set as yet
Target achieved
More children were measured than in 2007/08.The rate of obesity increased compared to 2007/08 when it was 8.0% More children were measured than in 2007/08. The rate of obesity dropped compared to 2007/08 when it was 20.4% This is a significant increase on 2008/09 when 14.9% of the relevant population was screened. It is also higher than national performance for 2009/10 of 22.1%. The positive rate in Medway (an indication of whether screening 70
is targeted correctly) is 6.9% compared to 6.0% nationally
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) Commissioning of Crisis Resolution / Home Treatment Services
Target achieved 3 as at 3 31/03/2010
Target achieved
3 as at 3 31/03/2010
Target exceeded
3 as at 4 31/03/2010
Target exceeded
3 as at 4 31/03/2010
Target achieved 473
494
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Target achieved
Commissioning of Early Intervention in Psychosis services
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Data quality on ethnic group
85%
2008/09 85.47%
Delayed transfers of care
<3.5%
Qtr 1 22 Qtr 2 20 Qtr 3 22 (these are numbers of patients whose care was delayed â&#x20AC;&#x201C; the percentage as a proportion of the adult population of Medway will be calculated when Quarter 4 date is available)
Diabetic retinopathy screening percentage of diabetes patients identified by the practices who have been offered digital retinopathy in the last 12 months (less exclusions)
100.00%
Forecast 100.7%
32 Target achieved This has been affected by the high number of delayed transfers of care reported by the Kent and Medway NHS and Social Care Partnership Trust. The causes of delayed transfers of care in acute and community settings are being reviewed by the urgent care strategic commissioning programme. This is the number of people with diabetes offered screening in the previous 12 months as at the end of March 2010 divided by the number of people identified by the practices in the PCT at the end of December 2009. People who choose to opt out of screening or will not benefit from the offer of screening are excluded. The performance is over 100% as the number of excluded people at each quarter will change and will impact the overall performance.
72
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
83
No update available
Target exceeded 1175
1949
570
962
Incidence of C Diff (Commissioner) includes hospital and community acquired infections for NHS Medway registered population
131
82
Inpatients waiting longer than the 26 week standard
0.00%
0%
2009 3.7
NHS Medway commissioning staff 3.61
636
Jan 10 806
NHS staff survey based measures of job satisfaction Number of drug users recorded as being in effective treatment
Outpatients waiting longer than the 13 week standard Patients waiting longer than three months (13 weeks) for revascularisation Prevalence of breastfeeding at 6-8 weeks (totally or partially breastfed) of infants due a 6-8 weeks check Percentage of infants with a Breastfeeding status recorded at the time of their 6-8 weeks check
Selected questions from the relevant primary care survey will be used to calculate an overall score for this indicator.
0%
0.03%
0%
0%
Qtr 4 2009/10 49.50%
29.22%
Qtr 4 2009/10 90%
72.42%
Target exceeded Achievement that reflects the effort and commitment of the whole health community on infection control Target achieved Slightly higher than national average of 3.60 but lower than target Target exceeded
16 patients waiting longer than 13 weeks for a first outpatient appointment Target achieved
Improving breastfeeding rates is a priority for NHS Medway Improving breastfeeding rates is a priority for NHS Medway
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Immunisation rate for children aged 1 who have been immunised for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b - All 3 doses
Immunisation rate for children aged 2 who have been completely immunised for Pneumococcal infection (PCV booster)
Immunisation rate for children aged 2 who have been completely immunised for Haemophilus influenza type b, meningitis C (Hib/MenC booster)
Immunisation rate for children aged 2 who have been immunised for measles, mumps and rubella (one dose)
Immunisation rate for children aged 5 who have been immunised for Diphtheria, Tetanus, Polio, Pertussis (4 doses)
95%
Qtr 1 2009/10 96.1% Qtr 2 2009/10 96.4% Qtr 3 2009/10 96.6%
95%
Qtr 1 2009/10 95.2% Qtr 2 2009/10 94.2% Qtr 3 2009/10 93.4%
95%
Qtr 1 2009/1095.8%Qtr 2 2009/1094.7%Qtr 3 2009/1095.0%
92%
Qtr 1 2009/10 95.8% Qtr 2 2009/10 93.5% Qtr 3 2009/10 95.1%
95%
Immunisation rate for children aged 5 who have been immunised for measles, mumps and rubella (2 doses)
95%
Immunisation rate of 90% for human papilloma virus vaccine for girls aged around 12-13 years
90%
Qtr 1 2009/10 92.9% Qtr 2 2009/10 94.4% Qtr 3 2009/10 94.4% Qtr 1 2009/10 88.1% Qtr 2 2009/10 89.7% Qtr 3 2009/10 89.3% No update available at time of print
NHS Medway consistently achieves immunisation rates that are the highest in the South East Coast and usually higher than the national average
To achieve three points for each part of the indicator for the 2008/09 Annual Healthcheck, actual performance had to exceed planned performance
Despite NHS Medway’s recognised high performance, a score of 14 was achieved, where 15 was needed for a rating of “achieved” This resulted in a rating of “under achieved”.
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Immunisation rate for children aged 13 to 18 who have been immunised with a booster dose of tetanus, diphtheria and polio
90%
No update available at time of print
Cancer mortality rate (people aged under 75) rate per 100,000
2009 109.40
2008 124.66
CVD mortality rate per 100,000 (Heart disease, stroke and related diseases in people aged under 75)
2009 79.20
2008 77.1
Quality stroke care - proportion of people who spend at least 90% of their time on a stroke unit
89%by Qtr 4
Q1 60.71% Q2 78.43% Q3 82.8% Q4 63.64%
Quality stroke care - proportion of people who have TIA and are at a higher risk of stroke who are scanned and treated within 24 hours
75% by Qtr 4
Q1 22.22% Q2 81.82% Q3 83.33% Q4 46.15%
Teenage conception rate (number per 1,000 females aged 15-17)
2009 29
2008 44.2
85%
>95%
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) Proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help Total time in A&E: Four hours or less
68.00%
YTD Qtr 2 71.3%
In 2009/10 NHs Medway is again likely be rated as â&#x20AC;&#x153;under achievedâ&#x20AC;? despite its high immunisation rates 2009 figures due to be published in December 2010 2009 figures due to be published in December 2010 The performance in 2007/08 was 69%
This is a marked improvement on 2007/08 when performance was 16% This is an improvement on 2007 when performance was 48.4 girls per 1000 Target exceeded
On course to achieve target
Target achieved 98.00%
98.93%
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Statement of the Chief Executiveâ&#x20AC;&#x2122;s Responsibilities as the accountable officer of the Primary Care Trust The Chief Executive of the NHS has designated that the Chief Executive should be the Accountable Officer to 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.
Signed............ Date......9 June 2010.
. Marion Dinwoodie, Chief Executive
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STATEMENT OF INTERNAL CONTROL 2009/10 1.
Scope of responsibility
The Board is accountable for internal control. As Accountable Officer, and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum. In particular, I am responsible for: o o o o o o
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: o o o o
With local communities through public meetings and the publishing of annual reports and accounts. With patients through the PCT’s Local Involvement Networks (LINks). With the South East Coast Strategic Health Authority through a range of regular meetings and forums. With other partners through the Medway Whole System Delivery Group 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: o o o o
o
Regular reporting to the Board and Professional Advisory Committee (PAC) 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 Committee. 77
o o o o
2.
The Quality Board which incorporates Clinical Governance. 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. The purpose of the system of internal control
The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to: o o
identify and prioritise the risks to the achievement of the organisationâ&#x20AC;&#x2122;s policies, aims and objectives, evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control has been in place in NHS Medway for the year ended 31 March 2010 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: o
o
o o
o
o
There is Board, PAC and Executive Management Team commitment to, and leadership of the 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. This process is supported by both Corporate and Directorate Risk registers. 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 participation and consultation in Risk Management processes. There are risk leads and clinical governance leads in all services which feed into Departmental and Directorate risk registers. 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. 78
o
o o o
o
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 Use of Resources, Information Governance toolkit and the world class commissioning requirements. Where weaknesses are identified, action plans are developed, implemented, 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 and that every care is taken to ensure that key controls put in place to manage risk do not have a detrimental effect on stakeholders. The organisation has a strong control on fraud and has made great progress in embedding effective counter fraud operations in all its processes and procedures. The organisation was awarded a Compound Indicator assessment rating of level 3 (out of a maximum 4) after a successful appeal to the Counter Fraud Service. Training: o All staff have been trained in both physical and environmental risk assessment of their work areas; assessments have been carried out in year which has fed into the risk registers. o All new staff have risk management training as part of their induction to the organisation o 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 organisationâ&#x20AC;&#x2122;s objectives; to evaluate the nature and extent of those risks; and to manage them efficiently, effectively and economically. The PCTâ&#x20AC;&#x2122;s risk management system covers four types of risks and controls: 1. Clinical risks â&#x20AC;&#x201C; Covered by the Quality Board report to the board and risk management committee and recorded in the clinical risk register. Executive 79
accountability for clinical risk management rests with the Managing Director of Provider Services and the Director of Clinical Performance / Executive Nurse. 2. Organisational risks â&#x20AC;&#x201C; Covered by the annual report on risk management and recorded in the Assurance Framework, and Corporate Objectives report. Executive accountability for organisational risks rests ultimately 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) â&#x20AC;&#x201C; 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. Risks in all these areas are recorded in directorate risk registers and feed into the corporate risk register. Using the reports detailed above, and regular performance update reports, these risk areas are monitored regularly by: o o o o
The Board The Audit Committee The Risk Management Committee The Quality Board
Risk management awareness and the purpose of assessment and monitoring of risk are embedded in the activity of the organisation at all levels through: o
o
o o
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 Directorate 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. In line with virtually every PCT commissioner during 2009/10, NHS Medway faced significant financial pressure from an over performing acute provider. Activity anomalies where observed in year through routine performance monitoring. These were escalated to the Board to manage.
Payments for these acute services are based on performance figures and over performance presented a significant financial risk to the organisation. The Board tackled the risk through negotiation and the implementation of a 80
â&#x20AC;&#x153;short stay â&#x20AC;&#x201C; non electiveâ&#x20AC;? patient number audit. These actions resulted in the drafting of a revised contract which includes enhanced spending controls and monitoring processes. This risk is being closely monitored so as to reduce the likelihood of a reoccurrence in the future; performance towards the end of the financial year demonstrates that these actions are having a positive effect. Care Quality Commission For the reporting year 2009/10 the Care Quality Commission adapted its performance self-assessment process for PCTs to a registration process. In December 2009 NHS Medway declared its mid-year performance as fully meeting the core standards for better health with only one standard not being met (C7e: discrimination, equality and diversity). The organisation was assessed during a recent Annual Healthcheck as not having attained an adequate equality and diversity standard and that it had not fully embedded the practices of the Single Equality Scheme (SES) across the whole organisation. The repercussions to failing to meet this objective may be far reaching and include potentially failing to met best practice requirements, loss of staff morale, loss of public confidence and a drop in organisational reputation. To address the risk of not achieving our objective, an Equality and Diversity implementation plan is being implemented and an Equality and Diversity Steering Group created to control these activities. A consultation on the SES is currently taking place and will finish in June 2010. Changes have also been introduced to the Equality Impact Assessment process, significant staff training and drafting of service specifications. In March 2010 NHS Medway was able to register with the Care Quality Commission without any considerations. Information Governance The Information Governance agenda covers a broad spectrum of subjects that ensures the organisation maintains public confidence in our handling of their information; each carries their own individual risks and controls. Within the year three near misses of data loss were identified and swift action taken to investigate the reason for these. The system managed through both a dedicated Information Governance Committee as well as through individual and corporate risk registers. The organisation has developed a comprehensive data flow analysis process which has enabled us to identify potential risks to data security and mitigate them. All data under the direct management of the organisation is tightly monitored and controlled. Advancements across the entire information governance agenda have seen the organisation become a local leader and an organisation to be trusted with 81
handling and using sensitive information correctly. We are continuing to challenge ourselves with a comprehensive work programme which has been devised to further enhance our processes and protocols. Assurance Framework 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. The framework reports both positive and negative controls as well as identifying control gaps; those with significant risk ratings have action plans. A recent internal audit awarded the organisation Significant Assurance for its Assurance Framework. The auditors reported that the Board could place reliance on the Assurance Framework as a tool to monitor progress against corporate objectives To ensure public stakeholder involvement, the Local Involvement Networks (LINks) is kept informed of key risks impacting on service to the public, and the PCT's actions to address them. 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, employerâ&#x20AC;&#x2122;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. The organisation has undertaken risk assessments and has created a Carbon Reduction Delivery Plan in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisationâ&#x20AC;&#x2122;s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. In an effort to achieve control of our physical resources the Board has endorsed the development of a carbon reduction strategy. This demonstrates a real commitment and determination to make best use of every resource available to us. World Class Commissioning (WCC) NHS Medway has also completed its self assessment against the World Class Commissioning requirements and awaits its formal assessment report. Against the outcome requirements, NHS Medway can demonstrate clear improvements in the rate of change in a significant number of outcomes. We are in the top quartile for improvement in our outcomes: o Female health inequalities o Smoking Quitters 82
o o
Influenza vaccinations Diabetes controlled blood sugar
We have increased to 100 per cent of our target number of people receiving a brain scan within 24 hours from having a stroke. The only outcome that we are in the bottom quartile of improvement for is male life expectancy. A significant amount of work has been undertaken to address this. Initiatives include NHS Health Checks targeted by need, smoking groups in manual workers groups and the â&#x20AC;&#x2DC;Better Medwayâ&#x20AC;&#x2122; campaign which targets life style factors including obesity, alcohol and the management of long term conditions. The PCT has self-assessed the governance requirements under WCC in Strategy, Finance and Board as green for the year 2009/10. The PCT has self-assessed 9 out of 11 competencies under WCC as level 3. The two competencies which have not been assessed as level 3 are 7 and 11 both of which have been assessed as level 2. The PCT has showed real progress in year in many areas of the competencies. One example would be in competency 3 where the PCT self assessment improvement from level 1 to level 3. This has been backed up with compelling patient survey results where 80 per cent of those surveyed felt that the PCT was improving the NHS for people like them. Other progress includes the work of the local LINk forum which has become much more involved in assessing, signposting and feeding lessons back into planning. Competency 7 assesses how well the organisation stimulates the market to address health outcomes through a through assessment of provider capacity, alignment with health needs and the creation of effective choice. While the organisation has aligned provider capacity and health needs, we are aware of the need to better understand capability and create better choice for patients locally. The PCT took a significant step forward in year with the appointment of an Assistant Director of Systems Management. A database of provider capacity and capability is being enhanced and the PCT will continue to build on improvements in year in choose and book which reduced slot unavailability by two thirds. Competency 11 is new for this year and assesses the efficiency and effectiveness of spend. The PCT has assessed itself as level 2 for all areas of this competency. Improvements in year have included the assessment of initiatives prior to commencement including prioritisation, value for money and benchmarking. Further work is required to assess the impact of initiatives post implementation and to more effectively feed this learning back into the planning process.
83
5.
Review of effectiveness
As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed in a number of ways. The Director of Finance and Assurance 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 assurance. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. The final position statements contained within the Assurance Framework, external and internal auditors reports on the Assurance Framework and our financial management, our Use of Resources assessment, our information governance toolkit assessment verified by internal audit, clinical audits, good fraud compound indicators and our Annual Healthcheck assessment. It is on these on which reliance has been placed during the year. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control. A plan to address weaknesses and ensure continuous improvement of the system is in place. These plans will be discussed by the following groups who will take responsibility for maintaining and reviewing the effectiveness of the system of internal control: o o o o o o
the Board the Audit Committee Audit, Risk and Quality Committees Executive Management Team Internal Audit Assurance Frameworks, world class commissioning and other selfassessment declaration, the Comprehensive Area Assessment and the Use of Resources scores
Significant internal control issues Issues identified through the Assurance Framework ď&#x201A;ˇ The implementation of both the Children and Young People (CYP) Plan and Child Health Strategy through Childrenâ&#x20AC;&#x2122;s Trust Board has been subject to a number of delays and a lack of focus on the health aspect of strategy resulted in an unbalanced service evolving. To tackle this, a jointly funded post with Medway Council was created with the line management role reporting to the NHS. NHS Medway also took on the role of vice chair of Childrenâ&#x20AC;&#x2122;s Trust Board. 84
The Board gave their approval of Children's plan as well as delegating the authority to manage the development of both programmes to the Children's Trust Board. This has resulted in the creation of a new care pathway and better care for clients. ď&#x201A;ˇ An audit of the complete Stroke pathway was due to be completed during the 2009/10 period. The audit was to be led by the Kent Stroke Network; however, its implementation was delayed leading to an increase risk that an enhanced pathway would not be implemented. The risk of non delivery of this objective has been mitigated by the Director of Clinical Performance/Executive Nurse taking control of the issue. Outcomes have been improving as demonstrated by the achievement of 100% target for brain scan being undertaken within 24 hours for stroke patients. Failure to meet a published standard during the reporting year (2008/09) Non compliance with Core Standard C7e (discrimination) ď&#x201A;ˇ The PCT was not compliant for the assessment year 2007/08 and did not make sufficient changes in 2008/09 to increase this assessment. The areas that did not meet the necessary level to be considered compliant were: o The draft Single Equality Scheme (submitted to the Board in March 2009) was not felt to be robust. o The use of Equality Impact Assessments (a legal duty) in developing new policies, reviewing policies and service design and reorganisation was not wholly reflective of local stakeholders and it was not clear how it addressed adverse impacts. o Not publishing race employment monitoring data. o o The following rectifying actions have been taken to ensure that this Core Standard is met for 2009/10: o A comprehensive recovery plan (with timescales) was produced and comprehensive action plan developed and implemented. o The Trust appointed an equality and diversity lead to coordinate the implementation of the programme. o An equality and diversity advisory group has been created and has executive and non executive representation. o The Equality Impact Assessment has been amended and all staff have been trained on its application. The training, delivered through a leading third party E&D training company, also tackled the Single Equality Scheme and its application within the NHS. o The Trusts personnel data has been improved and a robust data set now exists. A full reporting suite has been developed to enable the production of effective personnel reporting. The draft Single Equality Scheme was agreed by the PCT Board at the beginning of the year and is currently out for consultation. It is envisaged that the final version of the scheme will be adopted in July 2010. 85
Conclusion This statement sets out the control arrangements and the results of assessments carried out relating to the PCT. It also sets out those areas where there have been lapses in internal control My review confirms that NHS Medway has a generally sound system of internal control that supports the achievement of its policies, aims and objectives.
Signed Marion Dinwoodie, Chief Executive Date
9 June 2010
(On behalf of the Board)
86
NHS Medway summary financial statements 2009/10 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. Medway PCT - Annual Accounts 2009/10 OPERATING COST STATEMENT FOR THE PERIOD ENDED 31 March 2010 2009/10 £000
2008/09 £000
Commissioning Employee benefits Other costs Income
15,207 391,547 (28,372)
9,631 332,925 (22,264)
Provider Employee benefits Other costs Income
38,406 16,262 (9,299)
31,742 17,325 (9,987)
PCT net operating costs before interest
423,751
359,372
Investment income Other (Gains)/Losses Finance costs Net operating costs for the financial year
(74) 0 1,397 425,074
(111) 0 1,474 360,735
87
STATEMENT OF FINANCIAL POSITION AS AT 31 March 2010 31 March 2010 £000 Non-current assets: Property, plant and equipment 42,943 Intangible assets 369 Other financial assets 633 Trade and other receivables 2,460 Total non-current assets 46,405
31 March 2009 £000
1 April 2008 £000
48,240 265 559 2,362 51,426
45,618 294 560 2,444 48,916
Non-current assets classified "Held for Sale"
0 11,626 0 0 0 11,626 135
0 10,815 0 0 9 10,824 0
0 15,715 0 0 6 15,721 70
Total current assets
11,761
10,824
15,791
Total assets
58,166
62,250
64,707
(28,039)
(27,414)
(29,371)
(85)
0
0
(890)
(817)
(2,425)
Current assets: Inventories Trade and other receivables Other financial assets Other current assets Cash and cash equivalents
Current liabilities Trade and other payables Other liabilities Provisions
88
Borrowings
(459)
(524)
(29)
Other financial liabilities
0
0
0
Total current liabilities
(29,473)
(28,755)
(31,825)
Trade and other payables Provisions Borrowings Other financial liabilities Other liabilities
(2,460) (1,981) (16,247) 0 0
0 (2,485) (16,742) 0 0
0 (2,114) (17,775) 0 0
Total non-current liabilities Total Assets Employed: FINANCED BY: TAXPAYERS' EQUITY General fund Revaluation reserve Donated asset reserve Government grant reserve Other reserves Total Taxpayers' Equity:
(20,688) 8,005
(19,227) 14,268
(19,889) 12,993
(120) 6,854 1,271 0 0 8,005
1,217 11,500 1,551 0 0 14,268
1,333 10,122 1,538 0 0 12,993
28,693
33,495
32,882
Non-current liabilities
The financial statements were approved by the Board on 9th June 2010 and signed on its behalf by Chief Executive, 9 June 2010 89
Medway PCT - Annual Accounts 2009/10 STATEMENT OF CHANGES IN TAXPAYERS' EQUITY For the year ended 31 March 2010
Changes in taxpayers’ equity for 2009/10 Balance at 1 April 2009 Net operating cost for the year Net gain on revaluation of property, plant, equipment Net gain on revaluation of intangible assets Net gain on revaluation of financial assets Net gain on revaluation of assets held for sale Receipt of donated or government granted assets Movements in other reserves Impairments and reversals Release of reserves to OCS Non-cash charges – cost of capital Transfers between reserves Transfers to/(from) other bodies within the Resource Account Boundary Total recognised income and expense for 2009/10 Net Parliamentary funding Balance at 31 March 2010
Donated Asset Reserve £000 1,551
Govt. Grant Reserve £000 0
Other Reserves
Total Reserves
£000
1,276 0 0 0
12 0 0 0 0
0 0 0 0 0
0 0 0 0
(5,641) 0
(241) (51)
0 0
(281) 0
0 0
0 0
0
£000 14,268 (425,074) 1,288 0 0 0 0 0 (5,882) (51) 340 0 6
(4,646)
(280)
0
0
6,854
1,271
0
0
General Fund
Revaluation Reserve
£000 1,217 (425,074)
£000 11,500
0
0
340 281 6 (424,447) 423,110 (120)
(429,373) 423,110 8,005
90
Medway PCT - Annual Accounts 2009/10 STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 March 2010 2009/10 ÂŁ000
2008/09 ÂŁ000
Cashflow from operating activities Net operating cost before interest Other cash flow adjustments Movements in Working Capital Provisions utilized Interest paid Net cash outflow from operating activities
(423,751) 6,020 2,173 (682) (1,296) (417,536)
(359,372) 2,563 1,139 (1,109) 0 (356,779)
Cash flows from investing activities Payments to purchase property, plant and equipment Payments to purchase intangible assets Proceeds of disposal PPE & intangible assets Purchase of financial investments (LIFT) Sale of financial investments (LIFT) Loans made in respect of LIFT Loans repaid in respect of LIFT Payments for other financial assets Proceeds from disposal of other financial assets Interest received Rental Income Net cash inflow/(outflow) from investing activities Net cash inflow/(outflow) before financing
(5,200) (103) 275 (75) 1 0 0 0 0 74 0 (5,028) (422,564)
(3,058) (83) 69 0 1 0 0 0 0 111 0 (2,960) (359,739)
91
Cash flows from financing activities Net Parliamentary Funding Other capital receipts surrendered Capital grants received Capital element of payments in respect of finance leases, onSoFP PFI and LIFT Cash transfers (to)/from other NHS bodies Net cash inflow/(outflow) from financing Net increase/(decrease) in cash and cash equivalents Cash (and) cash equivalents (and bank overdrafts) at the beginning of the financial year Effect of exchange rate changes on the balance of cash held in foreign currencies Cash (and) cash equivalents (and bank overdrafts) at the end of the financial year
423,110 0 0
359,761 0 0
(555) 0 422,555
0 0 359,761
(9)
22
9
(13)
0
0
0
9
92
Medway Primary Care Trust is a body corporate established by order of the Secretary of State for Health. During the year none of the Department of Health Ministers, trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with Medway PCT. PAC GPs are members of the following practices: The Thorndyke Centre, Rochester Walderslade Village Surgery, Chatham Payments to GPs and Practices are determined by the Board following recommendations made by the PAC. GPs are not in the majority on the Board. The Department of Health is regarded as a related party. During the year Medway PCT 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 (see table)
Related party transactions Balances with related Parties 2009/10 ÂŁ000s Expenditure Debtors Creditors
Income South East Coast Strategic Health Authority Croydon PCT Eastern and Coastal Kent PCT West Kent PCT Dartford and Gravesham NHS Trust East Kent Hospitals University Foundation Trust Guys and St Thomas' Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Kings Healthcare Foundation Trust Maidstone and Tunbridge Wells NHS Trust Medway NHS Foundation Trust Queen Victoria Foundation Trust South London and Maudsley Foundation Trust University College London Foundation Trust Kent County Council Medway Council
528
148
81
89
6,167 18,060
2,445 14,400
3,497 3,175
1,418 91
707
3,620
717
500
0 0
5,419 11,906
593 0
69 0
14 0
27,491 5,451
26 0
2,456 536
2,203 52
15,167 130,226 4,231
25 2,647 35
1,343 7,575 3
0
65
0
0
0
987
0
39
104 3,223
0 0
0 0
0 0
In addition, the PCT has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the NHS Pensions Agency, HM Revenue and Customs, and the NHS Business Services Authority (Prescription Pricing Authority). 93 and Charitable Funds collected by the Medway PCT are invested in the Charitable Funds managed by the Kent Medway NHS and Social Care Partnership Trust.
Better Payment Practice Code Measure of compliance Non-NHS Payables Total Non-NHS Trade Invoices Paid in the Year Total Non-NHS Trade Invoices Paid Within Target Percentage of Non-NHS Trade Invoices Paid Within Target NHS Payables Total NHS Trade Invoices Paid in the Year Total NHS Trade Invoices Paid Within Target Percentage of NHS Trade Invoices Paid Within Target
2009/10 Number
2009/10 £000
2008/09 Number
2008/09 £000
21,898
76,489
18,777
59,448
20,003
69,561
17,564
54,092
93.54%
90.99%
3,405 2,398
202,688 186,864
70.43%
92.19%
91.35%
4,275 2,914 68.16%
90.94%
270,989 248,584 91.73%
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.
PCT Management Costs
2009/10
2008/09
Management costs (£000s) Weighted population (number in units) Management Cost per weighted head of population (£ per head)
9,408 255,109
6,767 246,027
37
28
7.6.2 PCT Commissioning Services Management Costs Management costs (£000s) Weighted population (number in units) Management Cost per weighted head of population (£ per head) 7.6.3 PCT Provider Services Management Costs Management costs (£000s) Provider Services Income (£000s)
2009/10 5,917 255,109 23
2009/10 3,491 55,935
94
External Audit External Auditors are appointed by the Audit Commission. The auditors appointed to the PCT are PKF (UK) LLP. External Audit fees (excluding VAT) for 2009/10 were: ÂŁ Accounts and Governance
123,500
Use of Resources
26,500
Risk based Work
22,000
Total
172,000
No non audit work has been carried out by PKF (UK) LLP for this PCT. Value for Money The audit fees for value for money included: . Use of resources assessment (mandatory) . Risk based work Audit Committee The PCT Audit Committee members during 2009/10 were :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: Jonathan Bates, Director of Finance PKF (UK) LLP, PCT External Auditor South Coast Audit, PCT Internal Auditor and counter fraud specialists 95
2009/10 Remuneration Name and title
Contract
Date of
of service
Leaving
dated
Salary (bands of £5,000) £000
Mrs D Harker Mr D Griffiths * Mr E Anderson Ms J Bastow Mr T Cooper Mr A Mahmood Mr M Sherwood-Jenkins Mr G Griffiths Mr D Mayes Mr S Gee
Chairman (Acting) Chairman Chairman Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director
01.01.10 01.10.09 15.05.02 1.12.06 17.02.03 10.09.02 01.10.06 01.08.07 01.03.10 01.03.10
Ms M Dinwoodie Mr J Bates
Chief Executive Director of Finance Director of Public Health Health Visitor - PEC Chair GP - PEC Member Nurse - PEC Member GP - PEC Member Physiotherapist - PEC Member GP - PEC Member
01.10.06 13.11.06
Dr A Barnett Ms M Raval Dr G Fargher Ms M Kirk Dr N Nathan Ms K Plumbe Dr C Shum
31.12.09 30.09.09 31.03.10 31.03.10 31.03.10
03.03.08 01.04.02 01.09.06 01.05.08 01.05.08
30.09.09
01.04.05 01.09.06
31.07.09
2009-10 Other remuneration (bands of £5,000) £000
5 - 10 0 15 - 20 5 - 10 5 - 10 5 - 10 10 - 15 5 - 10 0-5 0-5 130 135 95 - 100 125 130
Benefits
Salary
2008-09 Other
in kind (bands of £100) £00
(bands of
remuneration
£5,000) £000
(bands of £5,000) £000
in kind (bands of £100) £00
30 - 35 5 - 10 5 - 10 5 - 10 10 - 15 5 - 10
-
-
135 - 140 95 - 100
-
6-7 -
115 - 120
-
-
25 - 30 20 - 25 5 - 10 10 - 15
10 - 15 45 - 50 20 - 25
18 - 19 -
10 - 15 10 - 15
35 - 40 -
29 - 30 23 - 24
6-7
10 - 15 15 - 20 5 - 10 5 - 10
5 - 10 5 - 10 50 - 55 25 - 30
0-5 5 - 10
10 - 15
18 - 19
29 - 30
96
Benefits
Ms S Whiting
Ms P Barber
Ms H Buckingham Mrs C Clements Mrs W Head Ms N Davies
Dr P Green Mr M Riley
Nurse - PEC Member Director of Clinical Performance / Executive Nurse Director of Commissioning and Performance Director of Human Resources Director of OD and Workforce Planning Company Secretary Medical Director and PAC Chair (from February 2010) Director of Provider Development
01.04.05
0-5
10 - 15
-
-
22.10.07
70 - 75
45 - 50
-
-
01.03.09
95 - 100
5 - 10
-
-
10 - 15
85 - 90
-
-
02.11.09 18.02.08
35 - 40 60 - 65
60 - 65
-
-
01.09.07
70 - 75 100 105
50 - 55
-
-
95 - 100
-
-
01.05.07
13.11.06
31.07.09
31.05.09
* Mr Griffiths, whilst Acting Chairman, continued to be paid by his employer, NHS West Kent, who recharged his salary to NHS Medway. Since recharges are not shown on this statement, no costs are shown. Benefits in kind relate to the amount paid by the PCT in respect of expenses claims, which is in excess of the amount nationally agreed by the Inland Revenue Remuneration waived by directors and allowances paid in lieu £0 (2008-09 £0) remuneration was waived by 0 (2008-09 0) directors. £0 (2008-09 £0) of allowances were paid in lieu to 0 (2008-09 0) directors.
97
2009/10 Pension entitlements Real increase in pension at
Name and title
age 60 (bands of £2,500)
Ms M Dinwoodie Mr J Bates Dr A Barnett
Ms P Barber Ms H Buckingham Ms C Clements Ms N Davies Dr P Green Mrs W Head
Mr M Riley
Chief Executive Director of Finance Director of Public Health Director of Clinical Performance / Executive Nurse Director of Commissioning and Performance Director of Human Resources Company Secretary Medical Director Director of OD and Workforce Planning Managing Director of Medway Community Healthcare
Real increase
Total accrued
in lump Sum at
pension at age 60 at 31 March 2010 (bands of £5,000)
aged 60 (bands of £2,500)
Cash
Real increase
Equivalent
in Cash
Transfer
Transfer
Equivalent
contribution to stakeholder
pension at 31 March 2010 (bands of £5,000)
Value at 31 March
Value at 31 March
Transfer Value
pension (rounded to
2010
2009
£000
£000
£000
£000
£
Lump sum
at age 60 related accrued
Cash
Equivalent to
Employer's
nearest £00)
0 - 2.5 0 - 2.5 0 - 2.5
20 - 22.5 7.5 - 10 5 - 7.5
55 - 60 15 - 20 30 - 35
170 - 175 50 - 55 90 - 95
1353 348 593
1342 331 558
11 17 35
-
0 - 2.5
17.5 - 20
15 - 20
55 - 60
316
310
6
-
0 - 2.5 0 - 2.5 0 - 2.5 2.5 - 5
7..5 - 10 2.5 - 5 10 - 12.5 5 - 7.5
15 - 20 20 - 25 05 - 10 50 - 55
55 - 60 60 - 65 25 - 30 150 - 155
267 386 116 958
231 345 101 832
36 41 15 126
-
0 - 2.5
0 - 2.5
0-5
0
6
0
6
-
0 - 2.5
7.5 - 10
15 - 20
55 - 60
290
261
29
-
As Non-Executive members do not receive pensionable remuneration, there are no entries in respect of pensions for Non Executive members.
98
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 pension scheme, not just their service in a senior capacity to which disclosure applies. 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. 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. 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. 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: 99
Basic Pay: A spot rate for the post Additional payments where appropriate An Annual performance bonus scheme A performance bonus was given to the CE and 3 Executive Directors in the last financial year. All Senior Managers are on permanent contracts and the notice periods do not exceed 6 months
Signed â&#x20AC;Śâ&#x20AC;Ś
Chief Executive 9 June 2010
100
Independent Auditors’ report to the Board of Directors of Medway PCT We have examined the summary financial statements for the year ended 31 March 2010 which comprises the Operating Cost Statement, Statement of Financial Position, Statement of Changes in Equity, Statement of Cash Flows, Related Party Transactions, Better Practice Payment Code, Management Costs, Audit costs and Remuneration Report set out on pages 87 to 100. 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 49 of the Statement of Responsibilities of Auditors and of Audited Bodies prepared by the Audit Commission. Respective responsibilities of directors and auditors The directors are responsible for preparing the Annual Report. 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. 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. The other information comprises only pages 4 – 86 and the unaudited part of the Remuneration Report. We conducted our work in accordance with Bulletin 2008/03 “The auditor's statement on the summary financial statement in the United Kingdom” issued by the Auditing Practices Board. Our report on the statutory financial statements describes the basis of our opinion on those financial statements. Opinion In our opinion the summary financial statement is consistent with the statutory financial statements of Medway Primary Care Trust for the year ended 31 March 2010. We have not considered the effects of any events between the date on which we signed our report on the statutory financial statements (11 June 2010) and the date of this statement.
Signature: Name:
Date: 1 July 2010 Robert Grant,Partner on behalf of PKF (UK) LLP, London, UK
Published 1 July 2010 101
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