nhs westminster annual report

NHS WestminsterAnnual Reportwww.westminster.nhs.uk

CONTENTS

Foreword 4

About us 7

Our performance 8

Our strategic five-year plan 14

1. Reducing health inequalities 18

2. Adding years to life 20

3. Building a choice of quality healthcare 22

4. Adding life to years 23

5. Promoting healthy lifestyles 25

Directorate Reviews 28

1. Service Development 30

2. Public Health 36

3. Nursing and Quality 38

4. Finance and Performance Management 40

5. Human Resources and Corporate Affairs 44

Our Board 46

1. Members’ interests 50

Annual Accounts 54

We changed our name from Westminster Primary Care

Trust to NHS Westminster. This reflects our key role as

commissioners, that is strategic buyers, of healthcare.

Our aim is to focus local services as much on maintaining

healthy lifestyles and preventing ill health as they do on

treating sickness.

Our community service providers (including more than 34 different types of

healthcare workers from physiotherapists to nurses) are separating from us and

forming a new organisation with their counterparts in Kensington and Chelsea

and Hammersmith and Fulham. This will be known as Central London Community

Healthcare and will have enhanced freedom to determine its own future.

This will allow us to focus on our commissioning role.

FOreWOrd Welcome to the 2008/09 NhS WeStmiNSter ANNuAl report

This report outlines how the NHS in Westminster has been

working to improve the health and healthcare of Westminster

residents during the year.

we lAuNCHeD A Five-yeAR £94M iNveStMeNt PRogRAMMe, to CReAte New HeAltH CeNtReS, PRoviDe MoRe DeNtiStS AND iNCReASe tHe NuMBeR oF NuRSeS.

A year of improvement

residents are waiting less time than ever for hospital appointments, finding their doctors’ surgeries are open longer and being better supported in leading healthier lives.

sectionone

www.westminster.nhs.ukNhS WeStmiNSter ANNuAl report 08/09

5

Health services for our community

We spent over £390 million on health services for

our residents. They are able to be treated in some

of the country’s top performing hospitals. We’ve also

reduced treatment waiting times. Mental health

services have continued to expand with investment

in community care and psychological therapies,

as well as in hospitals.

Throughout the past year we have also been

working to bring more healthcare services closer to

home, and to improve patient choice. Our investment

in community services ensures there are now more

nurses and therapists available locally. We have also

worked with local GPs to extend opening hours.

One of the highlights of the year was Health Minister

Lord darzi launching our innovative community-based

cardiovascular disease prevention programme. Healthy

Hearts and Minds identifies residents with a more

than one-in-five chance of developing cardiovascular

disease. Patients are then offered health advice from

a community team of cardiologists, nurses, dieticians

and physiotherapists to help them reduce the risk of

having a heart attack or stroke.

Our programme of polysystems, across Westminster,

aims to provide a broad range of health and wellbeing

services for local communities – they are likely to

include district nurses and physiotherapists as well as

GP services. Improvements are also planned in dental

care, with two new practices expected in 2009.

In the past year we have had great success with

a proactive stop smoking campaign, which was

targeted at areas with the highest numbers of

smokers. As a result there was a 60% increase

in the uptake of smoking cessation advice at

pharmacies where personal help is given.

We listened

We are working alongside our partners to develop

health services that meet the needs of local people,

and we encourage them to help us develop services

that are relevant, easy to access and that make

a real difference in maintaining health.

£94mwill be spent over the next

four years to create new

health centres, provide

more dentists and increase

the number of nurses

£15.5m is what we’ve saved in

2008/09 to invest in our

major health improvement

programme

£390mwas spent on healthcare

for Westminster residents

in 2008/09

50%More than 50% of

Westminster GPs now

offer appointments outside

normal working hours

we Met tHe New 18 week tARget FRoM gP ReFeRRAl to tReAtMeNt. 78% oF PAtieNtS ARe Now BeiNg SeeN witHiN 12 weekS.

MoRe tHAN HAlF oF loCAl gPS Now oFFeR APPoiNtMeNtS outSiDe NoRMAl woRkiNg HouRS.

weStMiNSteR HAS MoRe PHARMACieS tHAN ANywHeRe elSe iN tHe CouNtRy.

Looking ahead

NHS Westminster has developed a strategic plan

looking forward to 2013. This includes measures

that will tell us if we’ve achieved our goals.

Most importantly we are working to reduce health

inequalities in Westminster. Further on in this report

you will find more information on our plans and

strategic goals.

Our financial performance has been strong and we

have ended the year with a surplus of £15.5 million

– which means we can invest in a major health

improvement programme.

Our staff have again rated us as one of the top

health employers in the country. We thank them for

their commitment and hard work that makes all our

achievements possible.

We look forward to the next year when we plan to

achieve real and lasting health benefits for everyone

who uses the NHS in Westminster.

Joe hegartyChair

Dr Dennis AbadiCEC Chair

michael ScottChief Executive

we SPoke to MoRe tHAN 1,600 PeoPle ABout tHeiR FutuRe viSioN oF HeAltHCARe. tHey exPReSSeD CoNCeRN ABout HeAltHCARe ASSoCiAteD iNFeCtioNS AND CANCeR wAitiNg tiMeS. we ARe ACtiNg oN tHoSe CoNCeRNS.

Health Minister Lord Darzi with Chief Executive Michael Scott, Chair Joe Hegarty and Public Health Consultant Dr Adrian Brown.

NhS WeStmiNSter ANNuAl report 08/09 www.westminster.nhs.uk

7

Where are we based?

We have been based in the heart of

Westminster for the last six years and

are responsible for funding all

the health services across

the borough.

We share our boundaries

with the City of Westminster,

extending to regent’s Park in

the north, Queens Park in the

west and Covent Garden in the

east. Our southern boundary follows

the north bank of the river Thames.

What we do

We spend over £433 million each year

making sure people in Westminster

have the best of health and the best

of healthcare.

Planned changes across the NHS

in Westminster reflect our big

three priorities:

• choice - we will provide quality

information so you can choose

how and where you receive

your healthcare

• care closer to home - we are

providing care closer to your home

and linked to other services

• health - we all need to think about

healthier lifestyles and we want to

support you to achieve yours

AbOuT uS: WhAt iS NhS WeStmiNSter?

NHS Westminster is not a new organisation; it is the new

name for Westminster Primary Care Trust. The name reflects

our new focus as buyers of healthcare services rather than

providers of healthcare.

90.07% £390m Commissioning of healthcare

£160m Maternity, general, Acute, A&e

£72m Mental health

£43m Community health services

£40m gP services

£26m Prescribing costs

£14m Dental services

£10m learning difficulties

£25m other contractual services

Who we listen to and who we

work for

We exist to improve the health and

wellbeing of our local residents. So we

listen closely to what you have to say.

We ask for your feedback through

surveys, meetings, events and so on.

Check www.westminster.nhs.uk for

upcoming events, or call freephone

0800 587 8818.

What we spend your money on:

•Familydoctors

•Dentists,opticiansandpharmacies

•Communityservices

•Hospitalcare

•Promotinghealthyliving

•Mentalhealth

9.93% £43m Property and other corporate costs

Bayswater Road

Marylebone Road

Park Road

Wellington Road

Abbey Road

Lisson Grove

Maida Vale

Oxford Street

Piccad

illy

Oxford Street

Grosvenor Street

Knightsbridge

Kensington Road

Street

Sloane

Birdcage Walk

Grosvenor Road

Vauxhall Bridge Road

Victoria Street

Buc

king

ham

Pal

ace

Roa

d

The M

all

Strand

Vict

oria

Edgware Road

Park Lane

Regent S

treet

Baker S

treetGloucester Terrace

HYDE PARK

REGENT’SPARK

our performANce

This is a snapshot of our performance over the last year.

Care Quality Commission Annual Health Check – at a glance

3 Our rating improved from “Fair” to “Good” – this means we delivered

good quality services

3 We are in the top 20% of trusts in London

3 For the second year in a row we were rated “Good” for our

use of resources – which means we spend your money wisely

3 Our substance misuse service was rated as excellent

3 An in-depth review of urgent care put Westminster in the

best Performing category

We were found to have improved services in: mental health, particularly crisis

resolution services; helping pregnant women to give up smoking; improving

access to genito-urinary clinics within 48 hours; chronic disease management;

and helping people with long term conditions remain at home longer through

support from community matrons.

(The Care Quality Commission released its findings for 2007/08 in October

2008. Findings for 2008/09 were not released in time for this report.)

Top 20%We are in the top 20%

of trusts in London, in

terms of performance

7 We met the 18 week

target seven months

ahead of schedule

Top 5We are in the top 5 for

urgent and emergency

care in London

excellentOur substance misuse

service was rated as

excellent by the Annual

Health Check

Jake Johnson with the Fit Squad


9

NHS Westminster – the local leader

World Class Commissioning is a new, ground-breaking

approach to commissioning. It is designed to help

primary care trusts arrange for better services more

closely matched to local needs. This will result in

better quality care, improved health and wellbeing,

and a reduction in health inequalities across

the community.

Like every primary care trust, we were assessed

for our commissioning skills in three areas:

• Health outcomes – our priorities for health

improvements for local residents, including life

expectancy and health inequalities

• Organisational competencies – our knowledge,

skills, behaviours and characteristics that will

make our organisation world class

• Governance – our arrangements for managing

the organisation in the most effective way

possible. This includes developing areas such

as strategic, financial and organisational planning,

as well as the board’s controls and processes

NHS Westminster gained the top rating for our

strategy, vision and objectives. This included the

level of board ownership of our strategy, and the

consistency of our financial plan to deliver on it.

Getting treated faster –

exceeding the 18 week target

We not only met but exceeded the national target

for local patients to be treated within a maximum of

18 weeks. Figures from the department of Health

showed we met the target in May 2008, seven

months ahead of schedule.

by March 2009, 98% of patients who did not

require admission to hospital received treatment

within 18 weeks (ahead of the national target of

95%). 94% of patients who required a planned

admission to hospital were also treated within

18 weeks (ahead of the national target of 90%).

We are also speaking to private providers who can

meet NHS standards and prices – to provide more

choice for patients.

Urgent and emergency care

We were rated as one of the top five performers

in London for urgent and emergency care in the

Care Quality Commission report published in

September 2008.

The Care Quality Commission released a major review

covering all urgent and emergency services. For the

first time, this looked at how the whole system works.

It included all the major aspects of care, including

Accident & emergency, ambulance services, out-of-

hours GP services, NHS direct, urgent care provided

by GPs, and urgent care centres including walk-in

centres and minor injuries units.

The report gave us high scores for:

• public satisfaction with phone access

to GP surgeries

• the response time for GP out-of-hours services

to start telephone assessments of patients

• systems in place to ensure quality and safety

in GP out-of-hours services

• facilities for people with disabilities and systems

to protect vulnerable children and adults

unfortunately, we received lower scores for:

• Accident & emergency attendance for conditions

that could be treated in other settings

• patient satisfaction with GP opening times

We have already improved our GP opening times

and are working on bringing care closer to home,

which will improve the opportunities for patients to

receive care faster and more conveniently.

meetiNg our tArgetSExisting national targets

We were assessed against 17 existing national targets. We achieved 13, under achieved one and failed two.

One target was not assessed.

target rating

People with diabetes to be offered screening for the early detection of diabetic retinopathy Achieved

Maintain a maximum wait of 26 weeks for in-patients Achieved

Maintain a maximum wait of 13 weeks for an outpatient appointment Achieved

Maintain a maximum waiting time of two months from urgent referral to treatment for

all cancers

Achieved

All ambulance trusts to respond to 75% of category A calls within eight minutes Achieved

All ambulance trusts to respond to 95% of category A calls within 19 minutes after

the request has been made for transport

Achieved

All ambulance trusts to respond to 95% of category b calls within 19 minutes under achieved

Maintain delayed transfers of care at a minimal level Achieved

Maintain a maximum waiting time of one month from diagnosis to treatment for all cancers Achieved

every hospital appointment to be booked for the convenience of the patient, making it

easier for patients and their GPs to choose a hospital and consultant that best meets their

needs. Patients should be able to choose from at least four health care providers for

planned hospital care

Failed

Guaranteed access to a primary care professional within 24 hours and to a primary care

doctor within 48 hours

Failed

Improve life outcomes of adults and children with mental health problems by ensuring that

all patients who need them have access to crisis resolution services and a comprehensive

child and adolescent mental health service

Achieved

update practice-based registers so that patients with coronary heart disease and diabetes,

and the majority of patients at high risk of coronary heart disease, continue to receive

appropriate advice and treatment in line with national service framework standards

Achieved

Maintain a two week maximum wait from urgent GP referral to first outpatient appointment

for all urgent suspected cancer referrals

Achieved

Maintain the four hour maximum wait in A&e from arrival to admission, transfer or discharge Achieved

Maintain a three month maximum wait for revascularisation Achieved


11

New national targets

The government’s new national targets are goals for the entire NHS. These aim to improve the health of the

population of england.

We were assessed against 13 targets. We achieved eight and under achieved five.

target rating

Achieve year on year reductions in MrSA levels, expanding to cover other healthcare

associated infections as data from mandatory surveillance becomes available

Achieved

Improve the quality of life and independence of vulnerable older people by increasing

the proportion being supported to live in their own home by 2008

Achieved

Increase the participation of problem drug users in drug treatment programmes by 2008;

and increase year on year the proportion of users successfully sustaining or completing

treatment programmes

Achieved

reduce health inequalities by 2010 Achieved

Secure sustained national improvements in NHS patient experience by 2008 Achieved

Halt the rise in obesity among children by 2010, as part of a broader strategy to tackle

obesity in the population as a whole

Achieved

ensure that by 2008 nobody waits more than 18 weeks from GP referral to

hospital treatment

Achieved

Improve health outcomes for people with long term conditions by offering a personalised

care plan for vulnerable people most at risk; and reduce emergency bed days by 2008

through improved care in primary care and community settings for people with long

term conditions

Achieved

reduce adult smoking rates by 2010 under

achieved

reduce the under-18 conception rate by 2010, as part of a broader strategy to improve

sexual health

under

achieved

Substantially reduce mortality rates from suicide and undetermined injury by 2010 under

achieved

Substantially reduce mortality rates from cancer by 2010 under

achieved

Substantially reduce mortality rates from heart disease, stroke and related diseases

by 2010

under

achieved

NHS WeSTMINSTer – iNVeStiNg iN better heAlth

A five-year investment programme of £94 million is already

changing healthcare in Westminster for the better. We spent

more than £23 million on this programme in 2008/09.

For NHS Westminster to achieve its ambitious goals and see a measurable improvement in health there must be a change in how we work and how we deliver care.

In 2008/09 our major investments included:

• £2.5 million to reduce health inequalities – including £400,000 on

transforming community nursing in Westminster

• £1.4 million to add years to life – including £700,000 on cardiovascular

disease prevention and cardiac rehabilitation

• £6.6 million to build a choice of quality healthcare – including £1 million to

ensure a maximum waiting time for patients of 12 weeks for planned care;

£1.4 million to increase the number of staff working at the Gordon and

St Charles Hospitals for Westminster residents receiving in-patient mental

health care; £1 million to ensure GP premises for Westminster residents are

of the standards required; and investments of up to half a million pounds in

individual practice-based GP commissioning clusters

• £2.7 million to add life to years – including £770,000 invested in a community

cardiac team

• £1.2 million to promote healthy lifestyles – including more than £400,000 in

addressing obesity in children and adults and more than £200,000 in our stop

smoking service

92%rated their overall experience of using

Westminster’s community health services

as excellent or good

92% said they were seen on time or within

a given time frame

ASk youR PAtieNtS week 2008 SuRvey ReSultS


13

Looking forward

Our investment programme for 2009/10 includes

£3.8 million in mental health services, £3.6 million in

primary care facilities and more than £6 million in

developing Westminster’s first community health

hubs or ‘polysystems’.

A new GP-led health centre will bring care closer

to home and to make it easier to see a GP

in Westminster.

The extra GP services at Queens Park will make it

easier to see a GP in Westminster. The new family

doctor drop-in services will be open for everyone

who lives, works or visits Westminster from 8am to

8pm, seven days a week. The new services will be in

addition to existing GP services and will make it

easier for everyone to see a doctor or nurse quickly,

at a convenient time. Patients can book an

appointment or simply turn up – without having

to face long, and sometimes worrying, waits.

Why polysystems?

residents said that they want to be able to see

a GP and access more health services more easily

– especially during weekends and evenings and

without having to take time off work.

What is a polysystem?

A polysystem is a health system that provides

a wide range of health and wellbeing services to

a local community, closer to home. Our polysystems

will have a central services “hub” and a network of

linked GP practices. The “hub” will be in a building

similar to a large health centre but will offer a far

wider range of services. In addition to GP services,

there will be services such as district nursing, health

visiting and physiotherapy. There will also be

specialist services such as outpatient clinics and

associated diagnostics services (like X-ray), and

health and wellbeing services such as managing

weight and how to stop smoking.

A team from NHS Westminster beat 50 others

to win in the Primary Care category, at the

Involvement to Impact Awards 2008. during

Ask Your Patients week, we used online and

paper questionnaires, and encouraged teenagers

to take part by using video booths. We spoke to

more than 2,200 people and turned their feedback

into action.

66% said they had seen the healthcare

professional’s Id

83% said they felt confident with

hygiene standards

98%had high satisfaction (‘excellent’

or ‘Good’) with a pilot community

blood-clotting prevention service

to bring care closer to home

Emily Savin and Simon Hope from NHS Westminster with Westminster residents at a polysystem consultation.

You told us… we listened

www.westminster.nhs.uk

OUR STRATEgiC FivE-YEAR plAN

Our STrATeGIC PLAN SeTS OuT our ViSioN from NoW to 2013

In partnership with our practice-based commissioning clusters,

over the next five years we will work with Westminster City

Council, a range of healthcare providers and other local

partners, to lead local healthcare improvements.

Five years – five strategic objectives

To achieve our vision, we have set five strategic goals:

1. 0 reducing health inequalities

2. 0 Adding years to life

3. 0 building a choice of quality healthcare

4. 0 Adding life to years

5. 0 Promoting healthy lifestyles

10 health outcomes

NHS Westminster has put in place 10 health outcomes that will show if our

strategy has succeeded. These are to:

1. 0 reduce overall health inequalities, including reducing the size of the gap in

life expectancy between the most affluent and those on the lowest incomes.

We intend to reduce this by 10% by 2012 measured according to the

nationally recognised Index of Multiple deprivation (IMd) score.

2. 0 Increase the overall average number of years people in Westminster are

expected to live.

3. 0 Achieve 98% coverage of children under five who complete both doses

of the mumps, measles and rubella (MMr) vaccine by 2013. Westminster

and London are below the national target of 95% (required for herd

immunity which protects those unable to be vaccinated due to medical

contraindications). The capital therefore is at risk of a measles epidemic.

4. 0 Increase the proportion of women aged 53 to 64 who are screened every

three years for breast cancer. The proportion of Westminster women who

take these regular tests is substantially below the national average.

5. 0 reduce the number of people who die from heart disease. This is the single

biggest cause of premature death in Westminster and the main reason why

people on lower incomes die younger than more affluent people.

sectiontwo


17

6. 0 reduce the number of people who die from

diseases related to breathing and circulation,

such as bronchitis, emphysema and other

diseases of the lungs. This is the second

biggest contributor to why people on lower

incomes die younger. The biggest cause of

these diseases is smoking and we aim to

reduce the level of smoking in young people

and adults to 10% of the population by 2013.

7. 0 Cut the rate of Clostridium difficile (known as

C-diff) in patients who go into hospital. C-diff

is a healthcare acquired infection to which older

people are particularly susceptible. Hospital

infection control is a key priority both for us and

Westminster residents.

8. 0 reduce the numbers of people who are

admitted to hospital because of harm caused

by alcohol. There is growing concern about how

many people need hospital care because of the

effects of alcohol consumption.

9.0 reduce the proportion of primary school-aged

children who are recorded as being obese. There

is growing concern about the rates of childhood

obesity, which rises sharply between starting

primary school and secondary school.

10. Increase the numbers of people with mental

health problems who receive psychological

therapies. The proportion of Westminster’s

population with mental health problems is

relatively high and not everybody is getting

the help and treatment they need.

Who we work with

Our key partners include Westminster City Council,

Imperial College Healthcare NHS Trust, Chelsea and

Westminster Hospitals NHS Foundation Trust,

university College London Hospital NHS Foundation

Trust, Central and North West London NHS Foundation

Trust, Central London Community Healthcare,

neighbouring primary care trusts, i.e. Kensington and

Chelsea, Hammersmith and Fulham, brent and

Camden, NHS London, London Ambulance Service,

Metropolitan Police, Voluntary Action Westminster,

black and Minority ethnic Health Forum, the Carers

Network, Westminster Local Involvement Network

(LINk) and other organisations in the voluntary sector.

We set these four targets after consultation and

engagement with local residents:

• reduce the proportion of our population that

smokes from around a quarter where it is now,

to one adult in ten or less.

• Measure the experience that patients and users

actually have of the NHS, so we know how

patients really feel about NHS services. We will

involve patients and their families, who will help

us make real and tangible improvements.

• reduce the level of MrSA infection in hospital.

• everyone who is diagnosed by their GP as

potentially having cancer beginning their treatment

within 31 days. by 2013 we want all patients who

have a full diagnosis of cancer to have begun their

treatment within nine days or less.

Our local targets

A Westminster resident at the Westminster Health Debate.

Our STrATeGIC FIVe-YeAr PLAN 1. reDuciNg heAlth iNequAlitieS

Overall the health of people living in Westminster is good.

However, people on different incomes and from different

backgrounds have very different levels of health. We are

working to narrow these gaps, including gaps between the

wealthiest and those on the lowest incomes, between men

and women and between different ethnic groups.

12.7 yrsThere are significant differences

in life expectancy between

Westminster’s wards with a gap

of up to 12.7 years for men and

12.6 years for women

x2 People living in the most deprived

areas of Westminster experience

twice the rate of coronary heart

disease and death from stroke,

as those living in the least

deprived areas

x6 Type 2 diabetes is up to six times

more common in people of South

Asian descent and up to three times

more common in those of African

and Caribbean descent than in the

general population

DiFFeReNCeS iN HeAltH

NHS Westminster, with City Partnership colleagues, has developed a five-year strategy to address health inequalities. It includes tackling the causes, reducing the impact, and improving the health of all Westminster residents.

Healthy Futures

This project takes an innovative approach to breaking the cycle of declining

health among residents who find it hard to access mainstream services and

opportunities. The project includes:

healthy people: Health MOTs are available at community centres.

These support residents in choosing healthy lifestyles, including stopping

smoking, increasing physical activity and healthy eating.

Above left: Lord Darzi and Dr Adrian Brown, Consultant in Public Health at the launch of Healthy Hearts and Minds

Above right: Marina, who attended our Understanding Health Improvement course, part of our Health Trainers programme.


19

Local GP practices and NHS Westminster took part

in the national catch-up programme for all children

aged 13 months to 18 years. It was successful, with

the number taking the first dose of the MMr

vaccination increasing by 10% to 89%.

We are nearing the 95% recommended by the

World Health Organization (WHO) to ensure

protection for the whole community (including those

unable to have the vaccine for medical reasons).

The number of children getting the second dose of

MMr more than doubled during the programme.

67% of children have now had the vaccine.

Measles, Mumps and Rubella (MMR) catch-up campaign

healthy homes: environmental health officers

carry out home health improvement in people’s

homes. They identify people who can get help

with home adaptations, fuel poverty and winter

warmth payments.

health trainers: This is an accredited scheme that

trains local people to provide key health messages

within their community. This includes giving information

and advice on the services available locally.

Healthy Hearts and Minds

In January 2009 Health Minister Lord darzi launched

an innovative community-based cardiovascular

disease prevention programme in Westminster –

Healthy Hearts and Minds. This is designed to tackle

the biggest killers and causes of premature death,

heart disease and stroke.

Healthy Hearts and Minds identifies the residents

with a more than one in five chance of developing

cardiovascular disease. It will help them to make

lifestyle changes to reduce their chances of having

a heart attack or stroke.

Patients recruited to the programme are offered

one-to-one assessments and health advice from

a team of cardiologists, nurses, dieticians and

physiotherapists. In regular sessions at community

venues they will be able take part in supervised

exercise classes, workshops on healthy eating,

diabetes, blood pressure management and how

to stop smoking.

Improving access to psychological therapies

We have expanded our cognitive behavioural therapy

workers from 5 to 11 (funding we won through the

department of Health).

We will also support people with mental health

problems to return to work or stay in their jobs.

These new services will help reduce health

inequalities and regenerate Westminster by:

• ensuring that people who need access to primary

care mental health services for anxiety and

depression receive them rapidly

• helping people to stay in work or return to work

and supporting those who have recently been

made redundant

• creating jobs for local people in both the NHS

and the voluntary sector, through investment in

the local economy

BY 2013 WE Will

• Reduceoverallhealthinequalities

• Increaseaveragenumberofyearspeoplein

Westminster are expected to live

• Increaseproportionofchildrenunderfivewho

get both doses of the MMr vaccine

Our STrATeGIC FIVe-YeAr PLAN 2. ADDiNg yeArS to life

Preventable ill health and disease is one of the major causes

of premature death in Westminster.

We will change this by working to prevent ill health, diagnosing disease much earlier and giving people more rapid access to specialist centres of excellence. This will give many more Westminster residents a better chance of living longer.

Cancer

In Westminster, cancer accounts for 33% of premature deaths in men and 41%

of those in women. The main causes of premature cancer death in men are lung

and bowel cancer. In women they are

breast, bowel and lung cancer.

We are working to ensure that people

use cancer screening programmes

(cervical, breast and bowel), promoting

healthy lifestyles, and we are improving access to cancer treatment services. This

means that people who develop cancer receive treatment as early as possible.

After talking with local residents, we have set ourselves local cancer targets:

• everyone who is diagnosed by their GP as potentially having cancer should

begin their treatment within 31 days

• by 2012 we want all patients who have cancer to have begun their treatment

within nine days or less of their diagnosis

eARly CHeCk uP iS tHe MoSt iMPoRtANt tHiNg, BeCAuSe PReveNtioN iS BetteR tHAN CuRe!Mr Kasim, Harrow Road

3 daysOne woman in Westminster

is diagnosed with cancer

every three days.

1 in 8For every eight women

diagnosed with breast

cancer, one will be spared

a mastectomy.

90%90 per cent of care

currently delivered at

hospital outpatient

departments will be

delivered by the new

community cardiac team.

170,000”NHS Westminster sets

a gold standard for the

prevention of heart attack

and stroke, which kills

170,000 people every year

in the uK.” Health Minister

Lord darzi


21

MyAction

MyAction is a new and rapidly growing programme

in heart disease prevention. It integrates the care

of patients with cardiovascular disease (and their

families) and those at high risk of developing

atherosclerotic disease, within a convenient local

community setting.

In Westminster, we will provide the programme

to around 1,500 families each year, in seven

community centres.

Community Cardiac Team

This year we commissioned a new service to move

the care of patients with cardiovascular disease into

the community. We plan to integrate it with MyAction

and our new polysystems.

The services will be consultant-led with a range of

new specialist nurse posts. It will be a one-stop shop

for diagnostics and patient clinical management

plans. It will also move patients out of hospitals and

into the community. because they are run by clinical

specialists, patients will have world class expertise

closer to home.

BY 2013 WE Will

• Increasetheproportionof54-to64-year-

old women who are screened every three

years for breast cancer

• Reducethenumberofpeoplewhodie

from heart disease – the single biggest

cause of premature death in Westminster

and the main reason poorer people die

younger than wealthier people

HeARt DiSeASe AND StRoke ARe tHe BiggeSt CoNtRiButiNg FACtoRS to tHe HeAltH iNeQuAlitieS tHAt exiSt BetweeN RiCH AND PooR, Not oNly iN weStMiNSteR witH itS DiveRSe PoPulAtioN, But ACRoSS tHe uk.

Our STrATeGIC FIVe-YeAr PLAN 3. builDiNg A choice of quAlity heAlthcAre

The NHS now allows all patients to be treated at any hospital

of their choice. We’re working to ensure residents are aware

of their right to choose the care that is best for them.

Since december 2008, more than half the GP practices in Westminster offer patients longer opening times. This includes before 8.00am, after 6.30pm in the evening and on Saturday mornings. We are now planning extra GP services which will open from 8.00am to 8.00pm, seven days a week.

We’ve commissioned a GP-led health centre which should help patients see GPs and get primary care services when they need them – patients had told us that they found it difficult to see a GP at a convenient time.

The launch of our practice nursing scheme funds more nursing hours – giving

more appointment choices for patients wanting to see a practice nurse.

Local residents also told us that more dental surgeries were needed to give

them easy access to NHS dental care. We are making major improvements

to dental care with two new practices opening in 2009.

both new surgeries will be offering

longer opening hours and services for

patients with disabilities and phobias.

It is planned that the new surgeries

will cover 3,000 new patients by 2010

and that this will increase to 5,000 by

March 2011.

We have enough dentists for all

Westminster residents to register and

receive NHS dental care.

For a list of dentists accepting new patients and clear guidance on charges

visit www.westminster.nhs.uk, call freephone 0800 587 8818 or email

[email protected].

gp-led

heath centres

•open8amto8pm,

7 days a week

•GPappointments

•walk-inservices

•forregisteredand

non-registered

patients

we StARteD oFFeRiNg A lAte NigHt weDNeSDAy SuRgeRy uNtil 8PM AND A SAtuRDAy MoRNiNg oPeNiNg. ouR FiRSt week wAS Fully BookeD! ouR PAtieNtS HAve welCoMeD tHe New, CoNveNieNt tiMeS. Mandy Walsh, Practice Manager at Bayswater Medical Centre in Craven Road, W2


23

Our STrATeGIC FIVe-YeAr PLAN 4. ADDiNg life to yeArS

Many people live with illness for a significant part of their lives.

We are working to improve the quality of their life, as well

as their lifespan, by tailoring care to their particular needs,

preferences and expectations. Where possible, we also aim

to keep patients out of hospital.

Care pathways

In 2008/09, we redesigned care pathways for clinical areas including

musculoskeletal services, dermatology, gynaecology and ear nose and throat.

The new pathways mean more services will be available in the community, as

most of these services are currently provided in hospital. We are working to have

care closer to home wherever possible.

A wide range of local clinicians have been involved in developing the new pathways,

including GPs, hospital consultants, nurses and physiotherapists. Local people were

also asked their opinions and provided ideas and feedback into the project.

The new pathways will be commissioned during 2009 and patients will be able

to have specialist care at a clinic close to their home.

Closer to home

More health services are being provided at or near the home than ever before

and people in Westminster have better access to high quality care. This particularly

helps people with long-term conditions such as asthma and diabetes to stay

healthy and independent for as long as possible.

NHS Westminster will also be funding more staff to work in the community with

increased community nursing, therapists and services to support people with

mental health problems.

Audrey Lewis, Clinical Lead for Healthy Choices/Obesity

A new team has been formed to help patients

who have suffered a stroke to leave hospital earlier.

When they return home, they are supported by an

expert team taking hospital level care into

the community.

Patients have welcomed a new community blood

clotting prevention service which gives them the

opportunity to be treated locally – or at home if they

are unable to make it to the local clinics.

Learning disabilities

NHS Westminster was praised by a national

independent inquiry for good practice in providing

health services for people with learning disabilities.

(The Independent Inquiry into Access to Healthcare

for People with Learning disabilities cited the Trust’s

work in their report released on 29 July 2008.)

NHS Westminster has developed a unique service in

conjunction with local GPs. This was developed after

listening to local people with learning disabilities and

their carers, who said that better access to health

services was needed.

People with learning disabilities now get to see

their GP at least once a year for a health check –

which includes everything from diet to sexual health

and foot care. They then develop an individual

health action plan, with their GP.

Since the new service started, blood pressure

recordings have doubled from 41% to 82.5%.

These health checks have also given us vital public

health information that we use to improve other

services such as dentistry, sexual health and weight

management for people with learning disabilities.

Since the health checks started, referrals have

increased almost tenfold.

Expert patients programme

This is a free, six week course giving you the

confidence, skills and knowledge to manage

your condition better, and reduce its impact on

your daily life. Courses are led by tutors living

with long term conditions themselves.

Call our Patient Advice and Liaison Service

(PALS) Freephone 0800 587 8818 or check

our website www.westminster.nhs.uk for

more information.

£3.6m £3.6m will be spent over three years

in community nursing services

£260,000 £260,000 in a new community-

based assessment and treatment

service for elderly patients

£540,000 £540,000 in a community-based

podiatry service which will start in

2009. More than 2,000 Westminster

residents told us what they wanted

from their local podiatry service

i HAve A HeAltH ACtioN PlAN. it’S ABout HeAltHy eAtiNg AND exeRCiSe. HeAltH ACtioN PlANS ARe veRy iMPoRtANt iF you HAve A HeAltH PRoBleM. Patricia, Learning Disability Partnership Board member

we HAve DouBleD tHe tAke-uP oF RoutiNe HeAltH teStS FoR PeoPle witH leARNiNg DiSABilitieS.

Matthew Morris and Dr Tom Mtandabar at a Health Check


25

Our STrATeGIC FIVe-YeAr PLAN 5. promotiNg heAlthy lifeStyleS

London welcomes the world to its Olympic Games in three

years time, and we see our preparations for the Olympics as

a major opportunity to promote the need for us all to make

lifestyle changes that will improve our health and wellbeing.

Preventing illness is one of our major priorities. It includes raising awareness of,

as well as supporting, healthy lifestyles. There are six lifestyle areas we are

concentrating on:

1. Healthy eating

2. Physical activity

3. Smoking

4. Sexual health

5. Substance misuse

6. Mental health and wellbeing

KickStart – from strength to strength

Kickstart helps children and families in Westminster adopt a healthier

lifestyle. It’s a free 12-week after-school programme for children

above their ideal weight, who are aged 7-12, and their families.

Family-focused and hands on, the sessions are interactive and packed

with exciting activities including street dance, football and cooking.

The programme, which has been running since 2006, has helped over 60

children and their parents lead healthier lives. It uses behavioural change

strategies, healthy eating education and physical activity to help children and

families get healthier.

Drop in to Weigh In

In Westminster local schemes give support to residents to make healthy lifestyle and

food choices. Over 500 people have joined our ‘drop in to Weigh In’ scheme and lost

hundreds of kilos.

Our dieticians set up the free weight management service, to help people lose

weight and increase their knowledge and understanding of healthy eating principles

and a healthy lifestyle.

Supporting people to stop smoking

The Westminster Stop Smoking Service has helped just over

10,000 people quit smoking from 1 April 2003 – 31 March 2009.

kiCkStARt HAS BeeN gReAt Not juSt FoR My SoN, But FoR tHe wHole FAMily.Westminster Dad, Moifak Dib

kiDS ARe HeAltHieR wHeN tHeiR HoMeS ARe SMokeFRee.

This year we focussed on the areas with the heaviest

smokers: Westbourne Park, Queens Park, Church

Street, Harrow road, Warwick, Tachbrook, Churchill

and Vincent Square. Local pharmacies saw a

60% increase in referrals where one-on-one help

was available.

We have also been working to keep Westminster

homes “Smokefree”. We know second hand smoke

can cause cancer. So, we want to give families

in Westminster a reason to stop smoking around

their children. Our Smokefree project includes

a community-led programme of education, a social

marketing campaign, health promotion and a referral

to a stop smoking service if required.

Promoting Sexual Health

We aim to reduce the levels of HIV and other

sexually transmitted diseases, particularly in those

people under 25. We are adding to our sexual health

services and commissioning more community projects

to engage with young people around sexual health.

A significant element of this programme is our

chlamydia screening programme.

BY 2013 WE Will

•Havelessprimaryschool-agedchildren

recorded as being obese – obesity levels for

children rise sharply between starting primary

school and beginning secondary school

•Havelesspeopleadmittedtohospital

because of harm caused by alcohol. There

is growing concern about how many people

need hospital care because of the effects

of alcohol consumption

it iS vAluABle to See tHe DietiCiANS eACH week AND i eNjoy MeetiNg otHeR PeoPle At tHe SeSSioN FoR eNCouRAgeMeNt AND SuPPoRt AND AM FeeliNg HeAltHieR AS A ReSult. Now i Feel gooD ABout MySelF AND AM lookiNg FoRwARD to loSiNg MoRe iN 2009. David Fearn

4 Smokers are four times more likely

to quit with NHS support

24% of under-25s would not tell their

previous sexual partners that they

had chlamydia

500 More than 500 people have joined

our drop in to Weigh in scheme


27

i HAve FouND it AN exCelleNt wAy oF loSiNg weigHt AS it iS RelAxiNg AND tHeRe iS No PReSSuRe. i tHiNk oF it AS HeAltHy eAtiNg, Not DietiNg. i MADe CHANgeS to My eAtiNg wHiCH HAS MADe A ReAl DiFFeReNCe AND i Now Feel BetteR, i go tHe gyM AND CAN RuN to tHe BuS. tHe FACt it’S FRee iS AN ADDeD iNCeNtive.Brenda Smith, Drop in to Weigh In participant

A Queens Park resident signing up to Smokefree Homes.

www.westminster.nhs.uk

DiRECTORATE REviEWS

dIreCTOrATe reVIeWS 1. SerVice DeVelopmeNt

Key achievements in 2008/09

Strategic and Joint Commissioning

• We invested £1 million to reduce waiting times for planned care – and since

July 2008, 95% of patients are now seen within 18 weeks

• We redesigned care pathways to move more clinical services away from

hospitals into the community to give patients care closer to home

• We helped GP Practices review the services they offer to make them more

accessible and convenient – with quicker and more proactive care.

• We developed an electrocardiogram reporting service, a falls prevention clinic

and an anticoagulation service

• based on an assessment of health needs in Westminster,

we developed new, three year commissioning strategies, that

bear in mind the needs of users, carers and the wider community

• We received “beacon” status for our joint strategic

commissioning, which means we have been recognised as

delivering best practice, from the IdeA programme on behalf

of the department for Communities and Local Government.

We plan to share our experiences in 2009/10

• We developed a procurement policy and a procurement competition dispute

resolution procedure for dealing with issues raised around individual tenders

• Major re-commissioning programmes have been implemented or are in

progress and include: the integration of drug and alcohol services; access to

psychological therapies; new supported housing for people with learning

disabilities; improved access to wheelchair services; and an overhaul of the

chlamydia screening programme

we ARe CReAtiNg joBS FoR loCAl PeoPle By eNCouRAgiNg ouR ReSiDeNtS to tRAiN AS PSyCHologiCAl tHeRAPy woRkeRS.

sectionthree


31

• We are reviewing our contract portfolio to make

services more personalised and to give new

guidance on community health service and mental

health contracting

Mental Health

• We invested an extra £1.4 million to improve the

quality of care at the mental health in-patient

wards at Gordon Hospital and the St Charles’

Mental Health unit, including putting more staff

on the wards

• We secured additional investment to improve

access to psychological therapies by employing

14 low and high intensity, locally based, cognitive

behavioural therapy workers. This means that

more people get help for depression and anxiety

when they need it

• We commissioned a user-led website,

Go4mentalhealth.com which was conceived,

implemented, led and maintained by service users,

employs a website manager and a trained

volunteer team. More than 200 people have

visited the site each month since April 2008

• Westminster Forum, our local mental health user

group, organised three Open Forum events and

a user-led conference

Learning Disabilities

• We increased investment in learning disability

services to support young people moving from

children’s to adult’s services, and the resettlement

of people from NHS campuses

tHe Big PlAN outliNeS tHe joiNt CoMMiSSioNiNg StRAtegy FoR PeoPle witH leARNiNg DiSABilitieS oveR tHe Next tHRee yeARS. it CAN Be DowNloADeD FRoM tHe weStMiNSteR City CouNCil weBSite At: www.weStMiNSteR.gov.uk/wlDP/tHeBigPlAN

• As part of the local housing strategy for people

with learning disabilities, seven new flats with on

site support have been opened. We are working

with Westminster City Council to develop more

• Our locally enhanced service, to ensure people

with learning disabilities receive an annual health

assessment and health action plan, has been

acknowledged by the department of Health

as an example of best practice

• We have invested in oral hygiene, healthy living,

health and fitness projects – and a liaison post

at St Mary’s Hospital

• The Learning disability Partnership board

had elections for positions that included video

campaign addresses on the website. Over 100

people voted

Older People and Physical Disabilities

• A pilot scheme to support early discharge of

stroke patients from hospital has been set up.

This involves providing specialist multidisciplinary

stroke rehabilitation and care in the home setting.

The team includes home support, physiotherapy

and voluntary sector services, providing return to

work support, re-training, vocational rehabilitation

and so on

• Two hub projects, strategically attached to older

peoples’ housing units, provide drop-in centres for

patients over 50 years of age – allowing them

access to a range of services that help them stay

well and independent at home

• A new memory assessment service has been

commissioned as part of the development of

Chelsea and Westminster Hospital NHS

Foundation Trust opened a new state-of-the-art

HIV and sexual health centre in the heart of Soho

in March 2009. 56 dean Street, which replaced

the Trust’s Victoria Clinic at the South Westminster

Centre, has been designed to be welcoming and

friendly, with a social, rather than clinical, feel. It

provides a full range of HIV and sexual health

services and is even open during the evenings and

on Saturdays. It has proved popular with patients

- 23% more people used services at 56 dean

Street in the 4 months from 2 March - 31 July

compared with the same period last year at the

Victoria Clinic.

New sexual health centre at 56 Dean Street


33

a dementia strategy. This service will ensure good

quality diagnosis and intervention for all, with easy,

direct access to services

• A survey was introduced to obtain patient

feedback on their experience of using major

home adaptations and community equipment. It is

influencing the way local services are developed

• At the Physical disabilities and Sensory Needs

Strategy stakeholder event, the aims and priorities

of the strategy for the next three years were agreed

by service users, carers and group members

HIV and Sexual Health

• We commissioned a range of services to screen

15-24 year olds in Westminster for chlamydia

which included screening in sexual health centres,

GP and pharmacy services, outreach in community

and social services, the www.check-kit.org.uk

website and marketing campaigns

• We currently have the third largest HIV positive

population in London. So, in partnership with

Westminster City Council, we carried out an HIV

needs assessment to ensure we have the right

services in place by April 2010. We’re aiming to

make HIV testing more accessible – in primary

care, out-patient services, and community and

social venues; provide support to people at times

of need, such as when they are first diagnosed,

start treatment, are entering a new relationship

or have children; and continue to have services in

place to meet people’s needs around housing,

welfare benefits and debt advice

Substance Misuse

• We are on target to increase by 3% the numbers

of drug users receiving treatment

• An additional three hostels offering services were

established in 2008/09

• We have commissioned two new services to

improve the general health and well being of

substance misusers

• A joint pilot project to develop a comprehensive

package of testing and support in Westminster to

offer dry blood spot testing was successful. It will

be mainstreamed in 2009/2010 and focus on

improving pathways into secondary care for

substance mis-users who test positive for

hepatitis C and HIV

• We increased the provision and availability of

alcohol services in Accident and emergency

(A&e), which increased the number of referrals

from 848 in 2007/08 to 956 in 2008/09

Blood Borne Viruses

• From just two testing sessions in 2007/08 the

service has expanded to coverage across the city

five days a week in 2008/09. Over 500 patients

have been tested for blood borne viruses

• The project has been endorsed by the National

Treatment Agency as an example of best practice

in terms of harm reduction

16 to 24-yeAR-olDS iN weSt loNDoN CAN get A FRee CHlAMyDiA teSt FRoM www.CHeCk-kit.oRg.uk

Alcohol and Accident & Emergency

• We commission two posts based in Accident

& emergency who offer brief interventions and

referrals into specialist alcohol services in their

borough of residence. The service is embedded as

part of the core staff team which is part of the

reason it has been successful

Dentistry

• We have designed a new, quality focused, service

specification to procure two new dental practices

• Working with our current practices, we’ve

increased provision and improved access to

already established practices

• We have implemented a communication strategy

to give local people information about good oral

health and where to find services

• We’ve also funded digital signage in 11 local

practices to inform patients about their

entitlement to care, costs and to promote oral

health. The digital screens will also display other

healthcare messages and we aim to install the

same equipment in further practices

Community Pharmacy

With the Community Pharmacy Advisor, we have

commissioned a range of new services to be

delivered through local pharmacies. These include:

• stop smoking services

• flu vaccinations

• chlamydia screenings

• medicine usage reviews

• emergency hormonal contraception

• minor ailments

• supervised consumption and needle exchange

Following the 2007/08 pilot, this year we

implemented the flu vaccination service in pharmacies

and increased the numbers of patients vaccinated

there from 412 to 946 – an increase of over 100%.


35

Eye Care

On 1 August, we rolled out the national contract

across 70 NHS practices. As part of this, 19 opticians

now provide home-based services. We are developing

a needs assessment to inform future commissioning

decisions for eye care services for local people.

General Practice

We have been working with GPs to improve access

to services, both in primary care and for specialist

referrals. We recently awarded a contract for a new

GP-led health centres. Our aim is to increase the

range of services that patients can receive from their

GPs. So we have funded practices to:

• implement Choose and book, which allows

patients real choice in where they obtain

secondary care (most practices have now

implemented this system)

• open longer – over 50% now have more sessions

at the weekend or open later for at least some

evenings during the week

• offer chlamydia screening

• increase coverage of flu vaccination

• provide a greater range of minor surgery

• develop anticoagulation services

NHS Westminster has introduced a system to measure

practice performance, including the range of services

available at each GP surgery. The results will be shared

with the public through NHS Westminster’s website.

This will give patients information on practices in their

area, and to help them choose where they would like to

register. A similar scheme will be introduced for dentists.

91 We have 91 pharmacists working

in Westminster

2,283,360 In 2008/09 we filled over

2.2 million prescriptions

50% More than 50% of

Westminster GPs now

offer appointments outside

normal working hours

2. public heAlth

We aim to lead the development and implementation of

programmes to improve the health and wellbeing of the

local population and to reduce health inequalities.


• The Westminster Health debate, where 1,600 local people contributed to the

development of our strategic plan

• The 2006/07 Public Health report, which identified the health inequalities

that exist in Westminster, and the development on behalf of the Westminster

City Partnership of a joint strategy to tackle these health inequalities

• Our joint strategic needs assessment, developed in partnership with Westminster

City Council, which aims to build a shared view of Westminster and ensure that

our services meet the needs of our population, now and in the future

• The Westminster Smoke Free Homes Project, which encourages local people

to keep their homes smoke free, reduces exposure of children to second hand

smoke, and supports people to quit smoking

• The launch of the Healthy Hearts and Minds Programme, a community-based

cardiovascular disease prevention and treatment programme

• The implementation of our new diabetes service,

which has enabled more people to receive high

quality care closer to where they live (our model is

now recommended by Healthcare for London for

how to improve diabetes services across the capital)

• Our Health Trainer Programme, which supports

people living in Westminster’s most deprived

areas to choose healthier lifestyles and to access

health and social care services

• The black, Minority and ethnic (bMe) Health

Forum’s Good Practices for Access and Wellbeing

programme for GPs and dental practices

• National recognition for our Ask Your Patients Week

Programme, which won the Primary Care Category

of the Involvement to Impact Awards 2008

• Safer management of controlled drugs in

Westminster resulting from the sharing of

intelligence with external agencies

Key findings from the Westminster

Health Debate

Health care services in Westminster generally

have a good quality but there was felt to be

“room for improvement”. A need for increased

dental and mental health services was identified

as well as more flexibility from GP surgeries.

There is also a call to reduce waiting times.

Westminster residents are aware of core health

services. but, there is much less known about

specialist services.

General lifestyle was seen to be the main

barrier to healthy living.

There was broad agreement that people need

to take responsibility for their own actions,

however NHS Westminster can help by

promoting healthy lifestyle services.


37

Stephen, who attended our Understanding Health Improvement course.

Health training

“I work for a charity that deals with the older Asian

community. Health is something that we deal with and

health and nutrition is of particular importance. I will

use what I have learnt of this course to inform people

of the impact of food on health.” Adbul Kalum

“I am interested in anything that is designed to keep

you fit and well. I will use this information to talk to the

children that I work with and hopefully take the next

level of this course.” Mary Amayo

3. NurSiNg AND quAlity

We aim to provide nursing advice to the Board, ensure that

vulnerable adults and children are protected, and that our

nurses are fit to practice.


• Continued to implement the community nursing programme with an

investment of £3.6 million over the next two years

• Strengthened clinical practice by employing nurses with teaching skills

• Created clinical leads for end of life care, long term conditions, urgent care,

access and medical technology, self care and health inequalities

• Took part in the productive ward scheme in Garside Nursing Home and the

rehabilitation unit at Athlone House with real improvements for patients and staff

• Worked with children’s services on the integration agenda including the family

recovery project

• delivered the national cervical cancer immunisation programme for young girls

• recruited two GPs to provide four sessions a week on safeguarding children

to support General Practices in Westminster

• Continued to raise the safeguarding agenda, making it everyone’s responsibility

• Achieved compliance for all 24 core standards for better Health, as both

a commissioner and provider of healthcare services

• delivered a research governance audit and we now submit all projects for

monitoring and onto national research registers

• data quality send from NHS Westminster to the National Patient Safety

Agency met 100% accuracy

• Actions to prevent incidents occurring and minimising actions had greater

data quality

• Greater number of incidents with ‘no harm’ outcomes reported

• 13% increase in numbers of incidents reported on 2005/06

• All incidents involving patients reported effectively via the National Patient

Safety Agency reporting and learning mechanism

• Improvement in staff skills to de-escalate conflict situations


39

Our investment in community nursing

We are recruiting over 80 extra staff, ranging

from health care support workers, assistant

administrators to district nurses. This will

increase the quality of patient care and the

ability to look after more patients in the

community to deliver care closer to people’s

homes within Westminster.

“community nursing will be transformed under this programme to bring the most specialised hospital level care out to patients in their own homes. We will aim to recruit a number of the new staff from the Westminster area to build up community links and knowledge. this investment supports the theme of bringing care out of hospital and closer to people’s home which is a major aim of NhS Westminster and healthcare for london” Chief executive Michael Scott

4. fiNANce AND performANce mANAgemeNt

This year, we spent over £390 million on services for

our residents.

We also had a revenue surplus of £15.5m for 2008/09, achieving financial

balance for the seventh consecutive year. The surplus is £3.0m above the

planned £12.5m and remains within the local surplus target range of £14.7m

to £15.9m set by NHS London.

Funding our goals

during 2008/09 NHS Westminster has invested an extra £10m in support of

the five strategic goals which best reflect the health needs of our population.

This includes:

• funding 115 individual schemes ranging in value from £0.02m to £1.42m

• a further £20m has been set aside for strategic goals in 2009/10

• an action plan is being developed to prioritise investment schemes and ensure

they deliver the intended health and quality improvements whilst achieving

value for money


• Supporting provider services to separate from NHS Westminster

• Continuing to support and develop our practice-based commissioning clusters

• Preparing the organisation and systems to operate under International

Financial reporting Standards (IFrS) from 2009/10

• Providing significant financial and informatics support to the world class

commissioning submission and associated strategic plan

• delivering annual accounts within the national faster closure timetable

• developing a new information strategy for 2009-14

• Significant progress on information governance agenda

• Implementing GP referrals information service

• Continuing to roll out IT network improvements across NHS Westminster

and primary care services in Westminster


41

Looking to the future

The financial prospects for NHS Westminster show

a continuing surplus. This allows us to support both

our five-year Commissioning Strategy Plan and the

Healthcare for London programme. We have reported

to our board that the biggest risk to our plans during

this period is our capacity to deliver on our ambitious

investment programme. The final two years are likely

to be much more financially challenging and a savings

programme of at least £5m is being developed to

ensure NHS Westminster has the funds required to

invest in the future.

Annual Health Check

The Care Quality Commission’s (previously the

Healthcare Commission) Annual Health Check seeks

to establish whether an organisation is getting the

basics right and is making and sustaining progress.

Trusts are assessed in five areas and an overall

rating determined for:

• use of resources (focussing on how well finances

are managed)

• quality of services (which includes whether we are

meeting standards and targets set by Government)

ratings are excellent, Good, Fair or Weak.

The Care Quality Commission released its findings for

2007/08 in October 2008. Findings for 2008/09

were not released in time for inclusion in this report.

For 2007/08, NHS Westminster again scored

“Good” for use of resources, and we also scored

“Good” for quality of services – an improvement

on “Fair” in previous years.

Use of Resources

The Annual Health Check looked for evidence of

positive outcomes from our use of resources and

processes in terms of economy, efficiency and

effectiveness. It covered the following themes:

• Managing finances – How effectively does NHS

Westminster manage its finances to deliver value

for money?

• Governing the business – How well does NHS

Westminster govern itself; ensure value for money

in the services it delivers and commissions; and

delivers better outcomes for local people?

• Managing resources – How well does NHS

Westminster achieve value for money in relation

to a wider definition of resources, including

natural resources, people and assets

The Annual Health Check interim review for use of

resources in 2008/9 classed us as good. The final

rating will be confirmed in October 2009.

Declaration of Core Standards

One of the five components of the Care Quality

Commission’s, Annual Health Check is the

“Core Standards for better Health”.

This sets out 24 standards as a minimum level of

service NHS Westminster should provide to ensure

our services are safe and of an acceptable quality.

We assessed and rated our performance against the

core standards and declared compliance as both

a buyer and provider of healthcare.

Meeting our targets

NHS Westminster is required to meet five financial and administrative duties to ensure that public funds are

used appropriately.

Duties our performance in 2008/09 Duty met?

1 Meet revenue resources limit NHS Westminster has a surplus of £15.53 million against a revenue resource limit of £428.51 million

Yes

2 Meet capital resource limit We underspent by £0.04 million on a capital resource limit of £1.43 million

Yes

3 Meet cash limit (revenue and capital) with no unplanned borrowing at year end

No variance against the cash limit Yes

4 Full cost recovery of directly provided services £0.91 million underspend Yes

5 To meet the better Practice Code by paying 95% of non-NHS creditors within 30 days of the invoice date

NHS Westminster achieved 91.7% (on volume) and 93.1% (on value) which are lower than 2007/08 due to the impact of operating two financial systems for commissioning/provider split. An action plan is in place to improve performance in 2009/10

No

Information Governance

Information governance risks are management actions and are included in the corporate objectives

document that incorporates the board Assurance Framework, and our risk register.

There were no breaches of information governance which met the criteria outlined for serious untoward

incidents. All incidents are shown below.

Summary of other personal data incidents 2008-09

Dh category Nature of incident total

I Loss of inadequately protected electronic equipment devices

or paper documents from secured NHS premises

0

II Loss of inadequately protected electronic equipment devices

or paper documents from outside secured NHS premises

5

III Insecure disposal of inadequately protected electronic equipment,

devices or paper documents

0

IV unauthorised disclosure 7

V Other – Patient notes not available for consultation 13


5. humAN reSourceS AND corporAte AffAirS


• Supporting and preparing our provider services and commissioning services

to be fit for their future including the Strengthening Commissioning

programme and World Class Commissioning audit process

• engaging and supporting staff through the processes of significant

organisational change

• Keeping our sickness absence rate at 3.26% which is well below our

target of 5%

• Keeping our staff turnover rate at a reasonable level of 19.65% full time

employed at a time of significant organisational change

• Assisting in the recruitment of a significant number of key new nursing

positions – an example of our extra investment in district nursing

• relocating the Occupational Health Service to a new site with a view to

providing increased services for the wellbeing of staff

• Supporting staff through sickness to improve their health and wellbeing

through our Occupational Health department

• Increasing the number of cases handled by our Patient Advice and Liaison

Service (PALS) by 21%

StAFF RAteD uS iN tHe toP 20% oF PRiMARy CARe tRuStS iN 15 AReAS oF woRk iN tHe 2008 NAtioNAl NHS StAFF SuRvey.


45

Annual Staff Survey

For the fifth year running, our staff told us that NHS

Westminster is well-run, well-managed and a good

place to work.

We were particularly pleased to be rated second

of all trusts in the country for having a high majority

of staff who would recommend the organisation as

a great place to work.

Key areas in which NHS Westminster is in the top

20% of primary care trusts nationally;

• staff feeling satisfied with the quality of care they

are able to deliver

• staff agreeing that their role makes a difference

to patients

• quality of job design

• perceptions of effective action from employer

towards violence and harassment

• fairness and effectiveness of procedures for

reporting errors, near misses or incidents

NHS Westminster also scored a higher than our

average percentage for staff receiving job relevant

training, learning or development. This maintains our

strong performance from last year’s survey.

Challenges and opportunities of the year ahead

To support our staff in facing the challenges

of working in a new and more market-oriented

environment, we are developing:

• a board development programme

• a Talent Management Strategy to develop NHS

Westminster’s ability to identify and manage

talented staff rising through the ranks

• project management and leadership skills

• a range of commissioning capabilities including

database management and monitoring skills,

procurement, risk analysis, predictive modelling

and contract management

• effective induction and appraisal systems

We are also developing a range of skills such as

management, leadership, IT and business planning,

as well as looking at new approaches of working

with patients to improve their experience of using

our services.

Staff group Total

Administration and estates 392

Healthcare assistants and other support staff 106

Medical and dental 43

Nursing, midwifery and health visiting learners 5

Nursing, midwifery and health visiting staff 343

Other 7

Scientific, therapeutic and technical staff (including allied health professionals) 220

grand Total 1116

OUR BOARD

our boArD

Nicholas Woolf Non-Executive Director

Marian Harrington* Co-Opted Board Member

Marek Stepniak Non-Executive Director

Brigitta lock** Co-Opted Board Member

David Hawker* Co-Opted Board Member

Joe Hegarty Chair

Catherine longworth Vice Chair

Michael Scott Chief Executive

Dr Dennis Abadi PEC/CEC Chair

Jeff Deane Executive Director

Dr Margaret guy Executive Director

Ann Duncan Executive Director

Dr Sheila D’Souza Non-Executive Director

Andrew Whitley Non-Executive Director

Councillor Ed Argar* Co-Opted Board Member

* Co-opted member (Westminster City Council)** Co-opted member (Patient Public Involvement Forum)

sectionfour


49

Board membership 2008/09

NHS Westminster non-executive directors Catherine

Longworth, Sheila d’Souza and Andrew Whitley have

been re-appointed in the past year.

Catherine Longworth is Vice-Chair of the board

and has been a non-executive director at NHS

Westminster since 2002, Sheila d’Souza since

2005 and Andrew Whitley since 2002.

In the last year david Hawker and brigitta Lock left

the board and we thank them for all their hard work

and commitment.

We have been joined by Councillor ed Argar and

Marian Harrington (Co-Opted Members, Westminster

City Council). Councillor Argar is the Cabinet Member

for Health and Adult Social Care. Marian is currently

responsible for the care management service and

commissioning and developing services for older

and disabled people in Westminster.

Throughout the year our board members have taken

part in a wide range of seminars and training.

Changes in our Commissioning

Executive Committee

The Professional executive Committee (PeC)

was dissolved on 31 december 2008 and the

Commissioning executive Committee (CeC) began

on 1 January 2009.

The change in membership of the Commissioning

executive Committee reflects the need for a more

formal commissioning relationship between NHS

Westminster and the practice-based commissioning

consortia.

The chairs of each practice-based commissioning

cluster/consortium will be full members of the

Commissioning executive Committee. They will be

tasked with leading, or at least contributing to, the

strategic commissioning decisions of NHS Westminster.

They will also bring their local commissioning plans

to the Commissioning executive Committee for

discussion and endorsement.

The practice-based commissioning chairs will be

making healthcare commissioning decisions on

behalf of their clusters/consortia, as well as the

populations they serve. They will therefore be

mandated to disseminate these decisions back

to their constituent practices. Practice-based

commissioning cluster chairs will also be mandated

to make decisions on behalf of their practice-based

commissioning clusters/consortia.

Professional Executive

Committee Members

dr Maher Shakarchi***

Sangita Patel

Meredith Gamble

dr derek Chase ***

dr Mike Cornell ***

dr Nazeer Ahmed ***

Tera Younger

Paul Jenkins

Marian Harrington*

dr dennis Abadi (Chair)

Jeff deane

Margaret Guy

Ann duncan

Michael Scott

Commissioning Executive

Committee Members

dr derek Chase ***

dr Nazeer Ahmed ***

dr Matthew Johnson***

dr Jonathan Fluxman***

dr Jonathan Munday***

Tera Younger

Paul Jenkins

Marian Harrington*

dr dennis Abadi (Chair)

Karen broughton

Jeff deane

Margaret Guy

Ann duncan

Michael Scott

* Co-opted member (Westminster City Council)*** Practice-based commissioning cluster representative

memberS’ iNtereStS

All board, Professional executive Committee and Commissioning executive

Committee members of NHS Westminster are required, on appointment,

to subscribe to a Code of Conduct. As part of this, they should declare any

conflict of interest that arises in the course of conducting NHS business.

They are required to declare:

• directorships

• Ownerships or part ownerships of private businesses or consultancies likely

to or seeking to do business with the NHS

• Significant shareholdings in organisations likely or possibly seeking to do

business with the NHS

• details of any position of authority in any body, including a charity or voluntary

body, in the field of health and social care

• details of any connection with a voluntary or other body contracting

for NHS services

• details of fees received from public bodies or other organisations

Westminster LINk is your chance to have a say

on how health and social care services are

provided in Westminster. The LINk is independent,

run by local volunteers and open to everyone:

you can take part whether you’re an individual

or part of a group.

[email protected] 020 7535 0492

Westminster LINk, c/o VAW, 37 Chapel St,

London, NW1 5dP

www.westminsterlink.org.uk

Westminster local involvement Network (liNk)

Catherine Longworth at The Rainbow Centre


51

during 2008-09 the following interests were declared:

dr dennis

AbadiChair PEC*, CEC** GP Principal St John’s Wood Medical Practice under

contract with NHS Westminster. director/Shareholder

General Healthcare provision, a company set up in 2006

to provide health services in the community. Fees from

GMS GP Contract, additional enhanced services, rent and

rates reimbursement from NHS Westminster

dr Nazeer

AhmedMember PEC*, CEC** No outside interests declared

Councillor

edward ArgarCo-opted Board Member Cabinet Member, Health and Adult Social Care,

Westminster City Council. Vice-Chair London Councils

Health and Social Care Forum. employed by Mouchel

Contracting with various NHS bodies. Allowance paid by

Westminster City Council and also by London Councils

Karen

broughtonDirector of Human Resources and Corporate Affairs, Senior Management Team

No outside interests declared

dr derek

ChaseMember PEC*, Member CEC**

director, Central London Healthcare Ltd. director/

part-owner/shareholder, Central Healthcare Provider Ltd.

Chairman, Central London Healthcare Ltd. Fees from

Central London Healthcare Ltd and Central Healthcare

Provider Limited

Jeff deane Director of Finance and Performance, Senior Management Team, Member PEC*, CEC**

director Allington Healthcare Ltd. A company providing

residential care to elderly people

dr Sheila

d’SouzaNon-Executive No outside interests declared

Ann duncan Director of Nursing and Quality, Senior Management Team, Member PEC*, CEC**

No outside interests declared

dr Jonathan

FluxmanMember CEC** delegated representative on CeC to dr Nazeer Ahmed

Meredith

GambleMember PEC* No outside interests declared

dr Margaret Guy Director of Public Health /Medical Director, Senior Management Team, Member PEC*, CEC**

General board Member, Faculty of Public Health. Member

of Healthcare delivery Working Group, diabetes uK

Marian

HarringtonMember PEC*, CEC**, Co-opted Board Member

Strategic director, Adult & Community Services

Westminster City Council. Salary Westminster

City Council

Joe Hegarty Chair, Non-Executive director Manor House (Marylebone) Ltd, a company

established to purchase the freehold of Mr Hegarty’s

home. Chair of Governors, St Vincent’s Catholic

Primary School

Paul Jenkins Director of Service Development, Senior Management Team, Member PEC*, CEC**

Chair, rugby House

dr Matthew

JohnsonMember CEC** Owner, small private medical practice providing treatment

and testing for persons with drug related problems.

No NHS work planned

brigitta Lock Co-opted Board Member Co-owner and Trustee of a family charity trust,

Member of LINk

Catherine

LongworthVice Chair, Non-Executive Trustee, dolphin Square Charitable Foundation,

Francis Holland School Trust

dr Jonathan

MundayMember CEC** Chairman Victoria GPs LLP. President, Hammersmith

division St John’s Ambulance. GMS Locum Fees PCT

Sangita Patel Member PEC* No outside interests declared

Michael Scott* Chief Executive, Senior Management Team, Member PEC*, CEC**

Governor, Quintin Kynaston School

dr Maher

SharkachiMember PEC* PeC Practice-based commissioning Cluster representative,

board Member, Victoria Commissioning Consortium

Marek Stepniak Non-Executive director, Stepniak & Partners, Governor North West

London NHS Foundation Trust, Non executive director

CWL Community Services. Advisor and consultant to

Perot Systems Corporation

Andrew Whitley Non-Executive Interim Chair, City West Homes (paid role). retainer,

richmond Fellowship

Nicholas Woolf Non-Executive director, derby Homes Limited, Concilian Group. Trustee,

Princess Alice Hospice, beating bowel Cancer and barts

& The London Charity

Tera Younger Member PEC*, CEC** Owner, TY Consultancy

* The PeC was dissolved on 31 december 2008.**The Commissioning executive Committee superseded PeC on 1 January 2009.


ANNUAl ACCOUNTS

FINANCIAL STATeMeNTS 2008/09

Foreword to the Accounts

These accounts for the year ended 31 March 2009 have been prepared by Westminster PCT under section 98 (2) of the National Health Service Act 1977 (as amended by section 24 (2), schedule 2 of the National Health Service and Community Care Act 1990) in the form which the Secretary of State has, with the approval of the Treasury, directed.

Westminster PCT was established with effect from 1 April 2002.

dIreCTOr’S STATeMeNT

Statement of the Chief Executive’s responsibilities as the Accountable Officer of the Primary Care Trust

The Secretary of State has directed 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 authority;

• the expenditure and income of the authority has been applied to the purpose 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.

Chief executive

date 09.06.09

sectionfive


57

STATeMeNT OF dIreCTOrS’ reSPONSIbILITIeS IN reSPeCT OF THe ACCOuNTS

The directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the organisation and the net operating cost, recognised gains and losses and cash flows for the year. In preparing these accounts, directors are required to:

• apply on a consistent basis accounting policies laid down by the Secretary of State with the

approval of the Treasury;

• make judgements and estimates which are reasonable and prudent;

• state whether applicable accounting standards have been followed, subject to any material

departures disclosed and explained in the accounts.

The directors are responsible for keeping proper accounting records which disclose with

reasonable accuracy at any time the financial position of the organisation and to enable them

to ensure that the accounts comply with requirements outlined in the above mentioned direction

of the Secretary of State. They are also responsible for safeguarding the assets of the health

authority and hence for taking reasonable steps for the prevention of fraud and other irregularities.

The directors confirm to the best of their knowledge and belief they have complied with the

above requirements in preparing the financial statements.

by order of the board.

Chief executive

date 09.06.09

director of Finance

date 09.06.09

STATeMeNT OF INTerNAL CONTrOL

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.

I am accountable to the Chair of the Trust and to the Chief executive of the Strategic Health

Authority. The Chief executive is regularly performance managed through twice yearly

performance appraisals undertaken by the Trust Chair and, at the year end, the Chief executive

of the Strategic Health Authority formally records his/her comments on NHS Westminster

Chief executive’s performance. Westminster Primary Care Trust also undergoes a quarterly

performance review process with the Strategic Health Authority, involving NHS Westminster

Chief executive and other PCT executive directors.

I have constructed systems and processes to ensure effective working with partner organisations.

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:

i. identify and prioritise the risks to the achievement of the organisation’s policies,

aims and objectives

ii. 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 Westminster Primary Care Trust for the year

ended 31 March 2009 and up to the date of approval of the annual report and accounts.

Capacity to Handle Risk

NHS Westminster has in place a risk management strategy that is reviewed annually.

The director of Nursing and Quality has delegated responsibility for managing the strategic

development and implementation of organisational risk management and controls assurance.

The director of Nursing and Quality has overall responsibility for clinical risk management and

this includes being the Lead director, in 2008/09, for the work on risk Assessment.

The risk management agenda is led at directorate level by clinical governance facilitators who

are provided with training. The Trust learns from good practice through clinical supervision and

reflective practice, individual and peer reviews, performance management, continuing professional

development programmes, clinical audit and application of evidence-based practice.


59

The Risk and Control Framework

The system of internal control is based on an ongoing risk management process which combines the following elements:

• the identification and treatment of principal risks to the achievement of the

organisation’s objectives;

• the identification of risks through the comparison of Trust practice against external

standards such as Standards for better Health, Clinical Negligence Scheme for Trusts,

risk Pooling Scheme for Trusts and National Frameworks; and

• the analysis, recording and learning from untoward occurrences or near misses.

The Trust’s risk Assessment Tool ensures a consistent approach is taken to the evaluation and monitoring of risk, in terms of the assessment of likelihood and consequence. The board, Audit Committee and the Clinical Governance Assurance Committee are responsible for reviewing action plans, providing scrutiny and monitoring their implementation for risks with a significant and high rating.

The risk Management Strategy clearly states that risk management is the responsibility of all employees. All staff are provided with risk management training at induction. Clinical governance facilitators act as local risk management leads. All staff are able to identify risks through incident reports and risk assessments.

The board Assurance Framework is based on the four corporate and 37 principal objectives underpinning them for 2008/09 as identified in the Westminster Primary Care Trust’s business Plan. The risks to achieving these objectives have been identified and there are action plans and improvements underway accordingly.

The Framework identifies the effectiveness of the operation of the key controls to manage the risks identified and the assurance provider for those controls. Gaps in control and gaps in assurance have been identified and prioritised and include major incident and flu pandemic planning, the achievement of breast cancer screening targets, chlamydia screening, targets to reduce healthcare-associated infections in acute hospital activity, meeting the 18 week referral to treatment target (including the robust scrutiny of patient data), the monitoring of independent contractor performance and meeting the decontamination standard requirements. The board requires the development and implementation of action plans for gaps identified but not presently being addressed, and monitors the development of these action plans.

The partnership mechanisms described previously are used to explore potential risks which may impact upon other organisations and public stakeholders. Additionally, there are also many cross organisation fora which exist to support this approach.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the regulations.

Control measures are in place to ensure that all the organisation’s obligations under equality,

diversity and human rights legislation are complied with.

Review of Effectiveness

As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control.

My review is informed in a number of ways. The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the board 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.

My review is also informed by a regular performance reporting on targets and objectives to the Trust board, internal and external audits including the use of resources, Healthcare Commission Annual Healthcheck and other reviews, the Commissioning Strategy Plan, Operating Plan and Local delivery Plans, Health and Safety executive inspections, and Patient and Staff Surveys. The performance improvement plan is driven by both the Healthcare Commission Annual Healthcheck and NHS London’s quality and outcome framework.

The Trust is fully compliant with the core standards for better health.

The Head of Internal Audit Opinion’s review awarded overall significant assurance for the sound system of internal control, with 3 out of 10 objectives achieving limited assurances. These relate to occupational health, dental contracts and practice-based commissioning. It must be noted that action plans are in place to improve these risks identified in the review.

I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the Professional executive Committee, the Audit Committee and the Clinical Governance Assurance Committee. A plan to address weaknesses and ensure continuous improvement of the system is in place and includes:

• the implementation of action plans arising from Corporate Objectives/board Assurance Framework;

• increasing the number of significant principal risks monitored by the Audit and Clinical

Governance Assurance Committees.

The Audit Committee provides the board with an independent and objective view of arrangements for internal financial control within the PCT, ensuring the Internal Audit service complies with mandatory auditing standards including the review of all fundamental financial systems.

executive directors have managed and reviewed their principal risks through the business

Planning process, the Performance Improvement Plan and their contribution to development

of the board Assurance Framework.

Signed on behalf of the board

Chief executive

date: 09.06.09


61

INdePeNdeNT AudITOr’S rePOrT to the Director’S of the boArD of WeStmiNSter primAry cAre truSt

Opinion on the financial statements

I have audited the financial statements of Westminster PCT for the year ended 31 March 2009

under the Audit Commission Act 1998. The financial statements comprise the Operating Cost

Statement, the balance Sheet, the Cashflow Statement, the Statement of Total recognised

Gains and Losses and the related notes. These financial statements have been prepared in

accordance with the accounting policies directed by the Secretary of State with the consent of

the Treasury as relevant to the National Health Service set out within them. I have also audited

the information in the remuneration report that is described as having been audited.

This report is made solely to the board of directors of Westminster PCT in accordance with Part II

of the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 36 of the

Statement of responsibilities of Auditors and of Audited bodies prepared by the Audit Commission.

Respective responsibilities of Directors and auditor

The directors’ responsibilities for preparing the financial statements in accordance with

directions made by the Secretary of State are set out in the Statement of directors’ responsibilities.

The Chief executive’s responsibility, as Accountable Officer, for ensuring the regularity of financial

transactions is set out in the Statement of the Chief executive’s responsibilities.

My responsibility is to audit the financial statements in accordance with relevant legal and

regulatory requirements and International Standards on Auditing (uK and Ireland).

I report to you my opinion as to whether the financial statements give a true and fair view in

accordance with the accounting policies directed by the Secretary of State as being relevant to

the National Health Service in england. I report whether the financial statements and the part

of the remuneration report to be audited have been properly prepared in accordance with the

accounting policies directed by the Secretary of State as being relevant to the National Health

Service in england. I report to you whether, in my opinion, the information which comprises the

‘General Introduction’, ‘Annual Health Check’, ‘use of resources’ and ‘Meeting our Targets’ sections in the commentary on ‘Financial and Performance Management’ in the Annual report

is consistent with the financial statements. I also report whether in all material respects the

expenditure and income have been applied to the purposes intended by Parliament and the

financial transactions conform to the authorities which govern them.

I review whether the directors’ Statement on Internal Control reflects compliance with the

department of Health’s requirements, set out in ‘Guidance on Completing the Statement

on Internal Control 2008/09’, issued on 25 February 2009. I report if it does not meet the

requirements specified by the department of Health or if the statement is misleading or

inconsistent with other information I am aware of from my audit of the financial statements.

I am not required to consider, nor have I considered, whether the directors’ Statement on

Internal Control covers all risks and controls. Neither am I required to form an opinion on the

effectiveness of the PCT’s corporate governance procedures or its risk and control procedures.

I read the other information contained in the Annual report and consider whether it is consistent

with the audited financial statements. This other information comprises the Annual report,

except for the ‘General Introduction’, ‘Annual Health Check’, ‘use of resources’ and ‘Meeting

our Targets’ sections of the commentary on ‘Financial and Performance Management’, and the

unaudited part of the remuneration report. I consider the implications for my report if I become

aware of any apparent misstatements or material inconsistencies with the financial statements.

My responsibilities do not extend to any other information.

Basis of audit opinion

I conducted my audit in accordance with the Audit Commission Act 1998, the Code of Audit

Practice issued by the Audit Commission and International Standards on Auditing (uK and

Ireland) issued by the Auditing Practices board. An audit includes examination, on a test basis,

of evidence relevant to the amounts and disclosures in the financial statements and the part

of the remuneration report to be audited. It also includes an assessment of the significant

estimates and judgments made by the directors in the preparation of the financial statements,

and of whether the accounting policies are appropriate to the PCT’s circumstances,

consistently applied and adequately disclosed.

I planned and performed my audit so as to obtain all the information and explanations which

I considered necessary in order to provide me with sufficient evidence to give reasonable

assurance that:

• the financial statements are free from material misstatement, whether caused by fraud

or other irregularity or error;

• the financial statements and the part of the remuneration report to be audited have been

properly prepared; and

• in all material respects the expenditure and income have been applied to the purposes

intended by Parliament and the financial transactions conform to the authorities which

govern them.

In forming my opinion I also evaluated the overall adequacy of the presentation of information

in the financial statements and the part of the remuneration report to be audited.

Opinion

In my opinion:

• the financial statements give a true and fair view, in accordance with the accounting policies

directed by the Secretary of State as being relevant to the National Health Service in england,

of the state of the Westminster PCT’s affairs as at 31 March 2009 and of its net operating

costs for the year then ended;

• the part of the remuneration report to be audited has been properly prepared in accordance

with the accounting policies directed by the Secretary of State as being relevant to the

National Health Service in england;


63

• in all material respects the expenditure and income have been applied to the purposes

intended by Parliament and the financial transactions conform to the authorities which

govern them; and

• information which comprises the ‘General Introduction’, ‘Annual Health Check’,

‘use of resources’ and ‘Meeting our Targets’ sections of the commentary on ‘Financial and

Performance Management’ in the Annual report is consistent with the financial statements.

Conclusion on arrangements for securing economy, efficiency and effectiveness

in the use of resources

Directors’ responsibilities

The directors are responsible for putting in place proper arrangements to secure economy,

efficiency and effectiveness in the PCT’s use of resources, to ensure proper stewardship and

governance and regularly to review the adequacy and effectiveness of these arrangements.

Auditor’s responsibilities

I am required by the Audit Commission Act 1998 to be satisfied that proper arrangements

have been made by the PCT for securing economy, efficiency and effectiveness in its use of

resources. The Code of Audit Practice issued by the Audit Commission requires me to report

to you my conclusion in relation to proper arrangements, having regard to the use of resources

Guidance issued by the Audit Commission. I report if significant matters have come to my

attention which prevent me from concluding that the PCT has made such proper arrangements.

I am not required to consider, nor have I considered, whether all aspects of the PCT’s arrangements

for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

Conclusion

I have undertaken my audit in accordance with the Code of Audit Practice and having regard

to the use of resources Guidance published by the Audit Commission in May 2008 and

updated in February 2009, I am satisfied that, in all significant respects, Westminster PCT

made proper arrangements to secure economy, efficiency and effectiveness in its use of

resources for the year ended 31 March 2009.

Certificate

I certify that I have completed the audit of the accounts in accordance with the requirements of

the Audit Commission Act 1998 and the Code of Audit Practice issued by the Audit Commission.

Michael Haworth-Maden

district Auditor

Audit Commission

1st Floor, Millbank Tower

Millbank , London SW1P 4HQ

June 2009

operAtiNg coSt StAtemeNt FOr THe YeAr eNded 31 MArCH 2009commissioning

2008/09 £000

2007/08

£000

Gross operating costs 397,632 374,306

Less: Miscellaneous income (10,284) (7,712)

Commissioning net operating costs 387,348 366,594

provider

Gross operating costs 36,320 30,326

Less: Miscellaneous income (9,352) (5,910)

Provider Net operating costs 26,968 24,416

Net operating costs before interest 414,316 391,010

Interest receivable 0 0

Interest payable 147 23

Net operating cost for the financial year 414,463 391,033

StAtemeNt of recogNiSeD gAiNS AND loSSeS FOr THe YeAr eNded 31 MArCH 2009

2008/09 £000

2007/08

£000

Fixed asset impairment losses 0 0

unrealised surplus / (deficit) on fixed asset

revaluations/indexation (7,740) 3,991

Increase in the donated asset reserve and government

grant reserve due to receipt of donated and government

granted assets 0 0

Additions / (reductions) in the General Fund due to the

transfer of assets from/(to) NHS bodies and the

department of Health 0 0

Additions / (reductions) in “other reserves” 0 0

recognised gains and losses for the financial year (7,740) 3,991

Prior period adjustment – other 0 0

gains and losses recognised in the financial year (7,740) 3,991


65

bAlANce Sheet AS At 31 MArCH 200931 march 2009

£000

31 March 2008

£000

fixed assets

Intangible assets 150 81

Tangible assets 54,095 61,278

Investments 0 0

Financial assets 0 –

54,245 61,359

current assets

Stocks and work in progress 0 75

debtors 6,790 5,582

Other financial assets 0 –

Cash at bank and in hand 10 38

total current assets 6,800 5,695

Creditors: Amounts falling due within one year (26,049) (26,784)

Other financial liabilities falling due within one year 0 –

Net current assets / (liabilities) (19,249) (21,089)

total assets less current liabilities 34,996 40,270

Creditors: Amounts falling due after more than one year (2,570) (255)

Other financial liabilities falling due after more than one year 0 –

Provisions for liabilities and charges (14,979) (16,225)

total assets employed 17,447 23,790

financed by: taxpayers equity

General fund 0 0

revaluation reserve 2,961 1,485

Other reserves 0 0

total taxpayers equity 17,447 23,790

The financial statements were approved by the board

on 9th June 2009 and signed on its behalf by:

Chief executive

cASh floW StAtemeNt FOr THe YeAr eNded 31 MArCH 2009

2008/09 £000

2007/08

£000

operating activities Net cash outflow from operating activities (415,092) (391,566)

Servicing of finance and returns on investment:

Interest paid 0 0

Interest received 0 0

Interest element of finance leases (147) 0

Net cash inflow/(outflow) from servicing of finance and returns on investment (147) 0

capital expenditure

Payments to acquire intangible assets (90) (24)

receipts from sale of intangible assets 0 0

Payments to acquire tangible fixed assets (2,071) (1,150)

receipts from sale of tangible fixed assets 0 0

Payments to acquire fixed asset investments – 0

receipts from sale of fixed asset investments – 0

Payments to acquire financial instruments 0 0

receipts from sale of financial instruments 0 0

Net cash inflow/(outflow) from capital expenditure (2,161) (1,174)

Net cash inflow/(outflow) before financing and management of liquid resources (417,400) (392,740)

management of liquid resources

(Purchase) of other current asset investments – 0

Sale of other current asset investments – 0

Net cash inflow/(outflow) from management of liquid resources 0 0

Net cash inflow/(outflow) before financing (417,400) (392,740)

financing

Net Parliamentary Funding 417,372 392,795

Other capital receipts surrendered 0 0

Capital grants received 0 0

Capital element of finance lease rental payments 0 (23)

Cash transfers (to)/from other NHS bodies 0 0

Net cash inflow/(outflow) from financing 417,372 392,772

increase/(decrease) in cash (28) 32


67

Note 2. financial performance targets Note 2.1 revenue resource limit

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

2008/09 £000

2007/08

£000

Total net operating cost for the financial year 414,463 391,033

Less: Non-discretionary expenditure 1,488 1,107

operating costs less non-discretionary expenditure 412,975 389,926

Final revenue resource Limit for year 428,509 401,801

under/(over) spend against revenue resource limit 15,534 11,875

Note 2.2. capital resource limitThe PCT is required to keep within its Capital resource Limit

Gross Capital expenditure 1,389 1,960

Add: Loss in respect of disposals of donated assets 0 0

Less: Net book value of assets disposed of 0 0

Less: Capital grants 0 0

Less: donations 0 0

charge Against the capital resource limit 1,389 1,960

capital resource limit 1,429 3,151

(over) / under spend against capital resource limit 40 1,191

Note 2.3. provider full cost recovery dutyThe PCT is required to recover full costs in relation to its provider functions.

The performance for 2008/09 is as follows:

Provider gross operating cost* 36,320 30,326

Less: Miscellaneous income relating to provider functions (9,352) (5,910)

Net operating cost 26,968 24,416

Less: Costs met from PCT’s own allocation (27,879) (24,802)

under / (over) recovery of costs (911) (386)

*Costs do not include an allocation for corporate overheads.

2008/09 £000

2007/08

£000

employee benefits 0 0

0 0

retirements due to ill-health during 2008/09 there was one early retirement from the PCT agreed on the grounds of

ill-health (2007/08: 2). The estimated additional pension liabilities of this ill-health retirement

(calculated on an average basis and borne by the NHS Pension Scheme) will be £2k

(2007/08: £32k).

management costs

Management costs (£000s) 9,081 8,206

Weighted population (Number) 256,602 256,602

management cost per head of weighted population (£) 35.39 31.98

the pct measures its management costs according to the definitions provided by the Department of health

better payment practice codebetter Payment Practice Code – measure of compliance

2008/09 number

2008/09 £000

2007/08

number

2007/08

£000

Non-NhS creditors

Total bills paid in the year 24,284 77,407 21,152 47,494

Total bills paid within target 22,273 72,089 19,973 45,936

Percentage of bills paid within target 91.72% 93.13% 94.43% 96.72%

NhS creditors

Total bills paid in the year 3,019 294,419 2,808 247,406

Total bills paid within target 2,776 287,206 2,680 246,161

Percentage of bills paid within target 91.95% 97.55% 95.44% 99.50%

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.


69

Note 20. Related Party Transactions

Westminster Primary Care Trust is a body corporate established by order of the Secretary of

State for Health.

related party transactions between the PCT and board Members and members of key

management were:

payments to related party 08/09 £

payments to related party 07/08 £

dr Chase (Cavendish Health Centre

and Kings College*)

1,871,658 1,801,911

dr N Ahmed (Queens Park Health Centre) 249,367 216,402

dr Abadi (dr S Charkin & Partners –

St John’s Wood Medical Centre)

1,267,873 1,065,121

dr M Cornell (dr M Cornell & Partners) 192,836 918,534

dr M Shakarchi (dr V Muir & Partner –

belgrave Medical Centre)

444,478 785,336

Other senior manager related party interests are:

*£924,848 relates to Kings College and £946,810 relates to Cavendish Health Centre.

London Central & West unscheduled Care Collaborative (dr M Cornell is a director)

£1,790,763 - Payment for unscheduled GP cover for Westminster practices and accident

& emergency. dr. Cornell also received £16,302 for the completion of GP appraisals.

Westminster City Council (d Hawker – deputy Chief executive & director of Children Services

(to July 2008), M Harrington Head of Care Management Service) £41,865k for the provision

of social services and payments in respect of joint working in 2008/09 (2007/08 £24,839k).

The department of Health is regarded as a related party. during the year Westminster Primary

Care Trust has had a significant number of material transactions with the department, and with

other entities for which the department is regarded as the parent department. The entities

with transactions greater than 1% of Westminster Primary Care Trust’s net operating cost for

the financial year are listed below:

• Imperial College Healthcare NHS Trust, provision of acute healthcare services, £98,704k,

formerly St Mary’s NHS Trust, provision of acute healthcare services (2006/07 £107,857k)

• Hammersmith Hospitals NHS Trust, provision of acute healthcare services (2006/07 £9,752k)

• Central & North West London Mental Health NHS Foundation Trust, provision of mental

healthcare services £53,389k (2007/08 £49,166k)

• Chelsea & Westminster NHS Foundation Trust, provision of acute healthcare services

£16,284k (2007/08 £15,068k)

• university College London Hospital NHS Foundation Trust, provision of acute healthcare

services £16,102k (2007/08 £12,508K)

• Hillingdon PCT, provision of acute and community healthcare services through shared

commissioning £12,080k (2007/08 £12,055k)

• London Ambulance Service NHS Trust, provision of acute healthcare services £10,415k

(2007/08 £7,271k)

• royal Free Hampstead NHS Trust, provision of acute healthcare services £5,089k

(07/08 £3,935k)

• Guy’s and St Thomas’ NHS Foundation Trust, provision of acute healthcare services

£8,775k (2007/08 £7,260k)

The PCT has not received revenue or capital payments from any charitable funds, apart from

the charitable funds hosted by North West London Hospitals Trust. Net receipts for 2008/09

were £32k. (In 2007/08 there were net receipts of £3k).


71

remuNerAtioN report 2008/09

This report has been prepared in accordance with the directors’ remuneration regulations 2002.

Membership of the remuneration and Terms of Services Committee:

Nicholas Woolf Non executive director (Chair)

marek Stepniak Non executive director

Sheila D’Souza Non executive director

catherine longworth Non executive director

Joe hegarty (in an advisory capacity)

Andrew Whitley (receives papers)

Karen broughton director of Human resources – Secretary

Role of the Remuneration and Terms of Services Committee and Statement of Policy on the

Remuneration of Senior Managers

The Committee advises the board on appropriate remuneration and terms of service for the Chief executive

and Trust directors. The Committee monitors and evaluates the performance of the Chief executive,

directors and individual officer members of the Professional executive Committee – having proper regard

to the PCT’s circumstances and performance and to the provisions of any national arrangements for such

members and staff where appropriate.

The Committee reports the basis for its recommendations to the board which uses the Committee’s report

as the basis for its decisions on remuneration. However, the board remains accountable for taking final

decisions on the remuneration and terms of service for the Chief executive and Trust directors.

For directors’ pay increases, the following factors are considered:

• current national market rates of comparable director posts;

• the individual performance of directors;

• internal comparators;

• changes to director portfolios;

• NHS pay awards for other staff groups;

• any national guidance relating to maximum pay bill increases;

• significant recruitment and/or retention issues; and

• financial position of the PCT.

Performance measurement

directors’ performance is appraised on an annual basis by the Chief executive. The Chief executive’s

performance is appraised on an annual basis by the Chief executive of the Strategic Health Authority,

now called NHS London.

Summary and explanation of policy on duration of contracts, and notice periods and

termination payments

Senior managers are permanent employees of the PCT, and in the event of redundancy, they are subject

to standard NHS severance packages.

CEC and Non-Executive unexpired contract dates

contract end date

Non-executive

Joe Hegarty – (Chair) 31 January 2011

Catherine Longworth –

(Vice Chair)

31 March 2013

Sheila d’Souza 31 March 2013

Marek Stepniak 31 March 2010

Andrew Whitley 31 March 2013

Nicholas Woolf 31 March 2010

pec members (the pec was dissolved on 31 Dec 08)

dr dennis Abadi –

(PeC Chair)

31 december 2008

dr Nazeer Ahmed 31 december 2008

dr derek Chase 31 december 2008

dr Mike Cornell 30 September 2008

Jeff deane*

Ann duncan *

Meredith Gamble 31 december 2008

Margaret Guy*

Marian Harrington *

Paul Jenkins *

Sangita Patel 31 december 2008

Michael Scott*

dr Maher Sharkachi 31 december 2008

Tera Younger 31 december 2008

* These people retain tenure in the PeC as long as

they remain in post.

contract end date

cec (commissioning executive committee, superseded pec on 1/01/2009)

dr dennis Abadi –

(CeC Chair)

01 January 2011

Karen broughton*

dr derek Chase 31 March 2009

Jeff deane*

Ann duncan *

Margaret Guy*

Marian Harrington *

dr Nazeer Ahmed

Paul Jenkins *

dr Matthew Johnson 01 January 2011

dr Jonathan Fluxman 31 March 2009

dr Jonathan Munday 01 January 2011

Michael Scott* 01 January 2011

Tera Younger 13 January 2011

* These people retain tenure in the CeC as long as

they remain in post.


73

Senior Managers’ remuneration

2008-09 2007-08

Name and title Salary (bands of

£5,000)

other remuneration

(bands of £5,000)

benefits in kind

(bands of £100)

Salary (bands of £5,000)

Other remuneration

(bands of £5,000)

benefits in kind

(bands of £100)

£000 £000 £00 £000 £000 £00

d Abadi –

PeC/CeC Chair

35-40 0 0 30-35 0 0

K broughton – director

of Human resources

70-75 0 0 65-70 0 0

J deane –

director of Finance

& Performance Mgmt

95-100 0 0 95-100 0 0

A duncan – director

of Nursing and Quality

70-75 0 0 60-65 0 0

M Gamble – Clinical

PeC Member1

5-10 60-65 0 5-10 60-65 0

J Gannon – director

of Primary Care2

0 50-55 0 85-90 0 0

M Guy – director of

Public Health/

Medical director

155-160 0 0 160-165 0 0

L Hamlyn –

Chief executive3

0 0 0 105-110 0 0

J Hegarty –

Chair – Non executive

30-35 0 0 30-35 0 0

P Jenkins – director of

Service development

100-105 0 0 95-100 0 0

C Longworth –

Non executive

5-10 0 0 5-10 0 0

T Mali – Clinical

PeC Member4

0 0 0 5-10 40-45 0

S Patel –

Clinical PeC Member5

0-5 35-40 0 0-5 20-25 0

M Scott –

Chief executive6

130-135 0 0 0 0 0

S d’Souza –

Non executive

5-10 0 0 5-10 0 0

1. up to 31/12/20082. left 1/09/20083. left 11/01/20084. left 30/03/085. from 31/12/20086. from 28/03/2008

2008-09 2007-08

Name and title Salary (bands of

£5,000)

other remuneration

(bands of £5,000)

benefits in kind

(bands of £100)

Salary (bands of £5,000)

Other remuneration

(bands of £5,000)

benefits in kind

(bands of £100)

£000 £000 £00 £000 £000 £00

M Stepniak –

Non executive

5-10 0 0 5-10 0 0

A Whitley –

Non executive

5-10 0 0 5-10 0 0

N Woolf – Audit

Committee Chair

& Non-executive

10-15 0 0 10-15 0 0

T Younger –

Lay CeC Member

0-5 0 0 0 0 0

• Marian Harrington – CeC Member for Westminster City Council – her remuneration is a recharge

therefore excluded

• Tera Younger – Lay CeC Member – received a nominal amount of £16.05 per meeting up to

december 2008

• dr N Ahmed, dr derek Chase, dr Michael Cornell and dr Maher Sharkachi are practice-based

commissioning cluster representatives who receive locum cover only

• Councillor ed Argar, Marian Harrington and brigitta Lock are co-opted board members who are unpaid


75

Pension entitlements

Name and title real increase

in pension at age 60 (bands of

£2,500)

lump sum at age 60 related to

real increase in

pension (bands of

£2,500)

total accrued

pension at age 60 at 31 march

2009 (bands of

£5,000)

cash equivalent

transfer Value at

31 march 2009

Cash

equivalent

Transfer

Value at

31 March

2008

real

increase in

in Cash

equivalent

Transfer

Value

2007/08 £000 £000 £000 £000 £000

d Abadi – CeC Chair 0-2.5 5-7.5 40-45 686 506 168

K broughton – director

of Human resources

5-7.5 17.5-20 15-20 221 130 88

J deane –

director of Finance

& Performance Mgmt

0-2.5 5-7.5 40-45 860 637 207

A duncan –

Chief Nurse

2.5-5 12.5-15 20-25 421 284 130

J Gannon – director

of Primary Care

2.5-5 7.5-10 20-25 344 231 36

L Hamlyn –

Chief executive

0 0 0 0 963 215

M Gamble –

Clinical PeC Member

0-2.5 0-2.5 5-10 113 83 28

M Guy – director

of Public Health/

Medical director

10-12.5 32.5-35 50-55 1,173 1,085 61

P Jenkins – director of

Service development

0-2.5 0-2.5 20-25 395 312 76

T Mali –

Clinical PeC Member

0 0 0 0 103 n/a

S Patel – Clinical

PeC Member

0-2.5 0-2.5 10-15 216 163 49

M Scott –

Chief executive

0-2.5 2.5-5 0-5 33 0 33

real increase in Cash equivalent Transfer Value is the comparison of the inflated values at 31 March 2008 with the actual values at 31 March 2009.

As Non-executive members have elected not to receive pensionable remuneration, there are no entries in respect of pensions

for Non-executive members.

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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 member’s accrued benefits and any contingent spouse’s pension payable from the scheme.

A CeTV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme.

The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.

The CeTV figures and 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 of Faculty of Actuaries.

Real Increase in CETV

This reflects the increase in CeTV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of period.

If you would like this document in large print or another format, please email [email protected] or call freephone 0800 587 8818.

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