Stockport Managed Care Annual Report 07- 08 Including Summary

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Stockport Managed Care Annual Report 07- 08 Including Summary Powered By Docstoc
					                                                  Stockport Managed Care
                                                    Annual Report 07- 08
                                          Including Summary Financial Statements

N.B. Plans pictured above are subject to planning approval
Chair & Chief Officer Statement

This is a report of the first year of operation for Stockport Managed Care (SMC). This innovative new organisation has much development
ahead in terms of realising the potential for clinical leadership on service improvement.

The company, led by its member practices, is tasked with designing service improvements which realise better value for commissioners and
better quality of care for patients.

The company in its first year has established structures and teams to enable this work to commence. A central team of professional staff is now
in place to work in partnership with clinicians to develop proposals for service improvement, along with the implementation teams to change
systems on the ground, train professionals in new techniques and support patients through these new services.

A number of new services have been introduced or piloted in Stockport due to the efforts of this new company – in particular in primary care,
extending the range of what services are offered in practices.

The PCT will hold the company to account for real service improvements and outcomes in the future and will actively monitor and review the
performance of this new company.

The company has managed resources well in its first year, but in very close partnership with the PCT. The overall indicative budget was
underspent and incentive funds not fully deployed.

The company is well supported by its membership and significant work is underway to strengthen members involvement and ability to get
changes and improvements through quickly.

SMC has a partner organisation Stockport Health Enterprise which has also been in operation for its first year. This company is established for
the development of estates and infrastructure in Stockport. The financial statements will therefore reflect the performance of the two

The Board is fully committed to the future of Stockport Managed Care and would like to see this develop from strength to strength with the
support of Stockport PCT.

Dr Ranjit Gill                                     Mrs Alison Tonge
Chair                                              Chief Officer

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Statement of Purpose

Stockport PCT came into existence on the 1st April 2001. Building on the general role of PCTs, Stockport PCT’s Board and the Professional
Executive Committee (PEC) in consultation with staff have agreed 5 over-arching priorities for 3 years: These are:

       −   To improve public health
       −   To narrow health inequalities
       −   To improve the quality of health services specifically in mental health, long term conditions and older people
       −   To improve access to health services
       −   To promote best value

Located in the North West, the PCT has co-terminus borders with Stockport Metropolitan Borough Council, and shares boundaries with
Manchester, Tameside & Glossop, Central & Eastern Cheshire, and Derbyshire County PCTs. Stockport PCT serves a population of 295,000.
The age-profile of the borough closely reflects the national profile, although there are greater variations at locality level. The 2001 census
showed Stockport to be less diverse than the national average (9.1%) with only 4.3% of residents identifying themselves as being Black and
Minority Ethnic (BME) heritage.

There are 54 GP practices, 22% of these being single handed. The PCT has a ratio of 0.68 GPs per 1,000 residents. The PCT has divided
Stockport into 4 localities.

Stockport Managed Care (SMC) is an Industrial Providence Society, set up by the 54 GP practices in Stockport with the agreement of the PCT.
Its aim is to assist General Practices to ensure world class healthcare is provided in the most appropriate setting by improving the
commissioning of health services and providing clinical & management training, to continuously improve patient care pathways.

Stockport Managed Care was established in April 2007. The company’s purpose is to commission care, improve health, manage resources and
improve skills, services and quality in primary care. It is set up therefore to manage Practice Based Commissioning with members that choose
to join. As such, members join the society, elect a Board and agree the overall purpose and direction of the organisation. Practices in Stockport
are therefore allocated, in proportion to list size, a number of membership places. Practices can join the company voluntarily and leave
whenever they wish providing there is due notice. Currently the company has a 100% sign up rate with the practices in Stockport.

The company is therefore only given life and purpose by the membership. Members when joining the society complete a membership
application which is also a binding agreement on the practice to abide by the rules of the society. These rules include:

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       −   attendance at training events
       −   keeping within the practice managed budgets
       −   using prescribed and accredited pathways and protocols
       −   developing standardised patient management systems

all of which are evidence based and aim to improve care and cost effectiveness.

In turn the society offers risk management on certain corporately managed budgets such as non-elective/emergency care and specialised
services. The company also sets up training, provides information systems, guidance and support to both clinicians and management staff.
Influence is greater for practices joining together in this way giving a greater voice for primary care in the strategic planning of the local health

The company is therefore accountable to its membership, but is also accountable to the Primary Care Trust (PCT). Members joining this
company have, in effect, asked the PCT to work with the company on their behalf in administering practice based commissioning. The PCT
and the company have agreed a three year contract which gives clear requirements for delivery through PBC of the PCT/PBC strategic plan.
The company has an opportunity to build strategic partnering agreements with a range of organisations which are selected where the
partnership can add value to both parties and in particular that there is a significant contribution to the company's business objectives.

The company is not accountable for contracting with health care providers this is the responsibility of the PCT. The company therefore has
clear and transparent arrangements for the development of ideas, investment cases and specification of service. The final contracting is,
however, separate which will ensure probity is maintained for the benefit of all parties. The company has a detailed scheme of delegation and
rigorous business case process. The company can approve investment to be earmarked for a business case up to a value of £250K. The final
procurement of this however will remain with the PCT who will progress the procurement quickly provided all due diligence has been completed
by the company. This due diligence partly addresses the questions and concerns of the PCT relating to choice, contestability and value for

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Key Aims

The main objectives of the society are to promote and improve public health in Stockport and enhance the quality and efficiency of health and
social care services for persons residing or working in Stockport, in particular by:

       −   involving General Practitioners more closely in the design and commissioning of health and social care services

       −   reinvesting any savings or surpluses generated from practice based commissioning into patient care, health improvement and
           improved healthcare facilities

       −   developing and enabling innovation in healthcare services to improve the efficiency and effectiveness of patient care

       −   scrutinising care pathways and the method of delivery of services by the various providers to make them more cost effective and
           convenient for patients and

       −   to share knowledge, educate and promote best practice in the commissioning of health and social care services

Improving Patient Care

The company has reviewed a range of services in 2007-08 including School Nursing, Podiatry, Salaried Dental, Tier 2, Community
Nursing and Health Visiting Services. These reviews were aimed at assessing the opportunities to improve services through looking at best
practice and clinical evidence on outcomes for patients and cost effectiveness.

Recommendations were formulated by the company for improvements to services which involved changes in models of care and level of
investment. These improvements have been included in the PCT strategic and operational plan.

Realising Savings for Investment

The company works with members to release savings from hospital and prescribing budgets for reinvestment into new primary care and
community based services. In 2007-08 the following areas were focused on:

       −   Reductions of admissions into hospital for patients with ‘Acute’ episodes of chronic illness is a key priority – for example heart
           disease, diabetes, Chronic Obstructive Pulmonary Disease (COPD)

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       −   Members are supported with patient management plans, systems and new services to better support these patients and prevent
           unnecessary admission when a community based programme of care is possible
       −   Reductions in outpatient appointments in the hospital where these can be conducted either in practices or in new CATs services
       −   Follow ups from first outpatient or Accident & Emergency attendance to be reduced using primary care based alternatives
       −   Effective use of resources policies further developed and followed will reduce the number of inappropriate treatments referred
       −   Prescribing lower cost drugs from agreed formulary will release budget savings to the company to reinvest in local services /
           healthcare provision

Developing our Infrastructure

The company has invested in its management structure and appointed staff to the following areas:
      − Service Improvement
      − Education & Training
      − Business & Communications
      − Data Analysis

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Contents Page

  Our Board & Members                                                  Page 8

  Operating and Financial Review                                       Page 11

  Looking Ahead                                                        Page 18

  Financial Information                                                Page 20


     i.     Register of Interest Table                                 Page 25
     ii.    List of Shareholders                                       Page 26
     iii.   Financial Statements – Principals of Accounting Policies   Page 28
     iv.    Notes to the Financial Statements                          Page 29

                                                                                 Page 7 of 30
Our Board & Members

Our Board

The business of the organisation is managed by the Board which is comprised of 10 members as follows:

The Chair is Dr Ranjit Gill, a GP at Stockport Medical Group in Edgeley.

                     Alison Tonge                                                                Terry Dafter
                     The Chief Officer of the organisation is                                    Due to the importance of close working with
                     Alison Tonge, the Lead Director for Practice                                Stockport Metropolitan Borough Council, a
                     Based Commissioning at Stockport PCT,                                       representative of Social Services is also
                     namely the Director of Finance &                                            present on the Board, Mr. Terry Dafter,
                     Estates/Deputy Chief Executive.                                             Deputy Director of Adult Services.

                     Dr Vicci Owen-Smith                                                           James Dunlop
                     Due to the importance of public health in                                     1 non-executive lay member has also been
                     realising the company’s objectives, the                                       appointed by the above Board members to
                     Deputy Director of Public Health, Dr Vicci                                    provide an independent perspective, Mr.
                     Owen-Smith is the second Stockport PCT                                        James Dunlop.
                     officer that sits on the SMC Board.

                                                                                                          Page 8 of 30
6 General Practitioners, drawn from the four localities in the Stockport PCT area represent the members of the organisation. These are:
                                                                                                 Dr Greg Carter
                         Dr John Adams                                                           From Marple Medical Practice, Greg acts as a
                         A GP at Cheadle Medical Practice,                                       Board sponsor on clinical areas relating to
                         John leads on issues relating to                                        birth and children and also supports the
                         research and development for the                                        communications department at a strategic
                         company.                                                                level. He is also the GP clinical lead for the
                                                                                                 development and implementation of Clinical
                                                                                                 Assessment and Treatment Services (CATS).

                         Dr Jaweeda Idoo                                                         Dr Ranjit Gill
                         Jaweeda is a GP at The Alvanley                                         As a Board member Ranjit provides
                         Practice and is the Board sponsor for                                   leadership on issues relating to pathway
                         Long Term Conditions and Medicines                                      development and implementation.

                         Dr Ash Patel
                         Ash is a GP at Bramhall Park Medical                                    Dr Andrew Johnson
                         Centre & SMC Vice Chair. His areas                                      A GP at Marple Cottage Surgery, Andy
                         of interest include training and                                        acts as the SMC Board champion for
                         development and early intervention                                      Cancer and End of Life.

                                                                                                              Page 9 of 30

Remuneration Committee

This year the Board has established a Remuneration Committee which advises the Board on the terms and conditions of employment of its
Board members and Senior Officers.

Clinical Service Redesign & Quality Standards Board

This Board has been established to oversee three important strands of work that require significant clinical engagement across the health
       − Agreement on Pathways and Service models for Elective and Urgent Care
       − Agreement on policies for Effective Use of Resources (scope of treatments funded and referred)
       − Agreement on Quality improvement targets for Stockport NHS Foundation Trust

Business Case Panel

This panel operates as a sub-committee to both SMC and PEC (for SPCT). The panel is tasked with providing detailed technical / professional
support to commissioning leads in developing commissioning business cases for changes to services in Stockport. The panel follows a
detailed due diligence process and provides SMC with a monthly report and recommendations for consideration in approving such business
cases. The panel works within a process agreed whereby any cases of £250k or above would be advised for consideration to the PEC.

Involving the Public

The Board meetings of SMC are not held in public but, in order to be open and transparent, will make the minutes of the Board meetings
available should they be requested. This will be subject to any personal or practice identifiable data being removed from the minutes prior to

Our Members

Membership to the organisation is open to any General Practitioner, allied health professional working in, or an employee of, a GP Practice on
the Performer List, who completes a membership application and who is nominated in writing by a GP Practice on the Performer List.

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Any GP Practice may nominate persons to be members of the Society in the following proportions:
      − a Practice with a single GP principal may nominate 1 member only
      − a Practice with a patient list of more than one but less than or equal to 5,500 may nominate 2 members
      − a Practice with a patient list more than 5,500 but less than or equal to 10,000 may nominate 3 members
      − a Practice with a patient list more than 10,000 and up to 15,000 may nominate 4 members.

Shares have been issued accordingly. A total of 110 shares were issued in 2007-08. All shares remain unpaid.

Operating & Financial Review

This section details SMC’s performance against the 07-08 Accountability Agreement and details the following:

       −   Delivery to date
       −   Development to date
       −   Risks and Issues

Delivery Plan – Performance to date

The company holds monthly Board meetings and bi-monthly Locality meetings with GP members and other stakeholders. These meetings
steer the overall business of the company.

The PCT has identified a range of improvements required in long term conditions management, use of resources and planned and emergency
care. These ‘outcomes’ have been targeted over the three year period 2007 to 2010. Changes are required to both services, pathways and
referral management to enable these outcomes to be delivered.
The PCT has identified dedicated management to delivery of the overall economy delivery plan. A number of these initiatives have been
allocated as accountable to SMC with associated management resources. This management resource is now part of a Service Level
Agreement between the PCT and SMC. These initiatives are allocated to SMC due to the necessity for clinical leadership, engagement in PBC
referral management and in agreement to invest PBC savings arising from these. These initiatives are monitored and discussed in detail by
SMC each week with the managers concerned.

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There is still some degree of crossover due to the close working nature of these two organisations and their common agenda but these are
slowly being unravelled as the work progresses.
The implementation of the communications strategy should define these boundaries more clearly as one of the key tasks identified is for a core
descriptor document for SMC to be developed that includes a description of its relationship with the PCT. This will form the basis of all
communication for 08-09 ensuring consistency of the company’s key messages.

SMC and PEC operate a joint business case approval panel. Regular reports regarding this meeting are presented to the SMC Board.

Use of Indicative Resources
The Company is responsible for demonstrating effective use of resources through improved patient management and referral systems. This
use of resources is measured through an indicative budget and a series of efficiency targets. It does not represent the actual funding available
to the Company under the Accountability Agreement through the PCT.

Summary of Performance against Budget
The budget statement shows a surplus of £ 731k against a breakeven budget. The majority of this is due to below budgeted payments to the
Practices for the various incentive schemes especially Direct Listing payments. Savings were also realised in the training budget as the
Training Manager didn’t start until towards the end of the year. There were also savings due to delays in occupying the premises on the 7th floor
of Regent’s House. The refurbishment, fixtures and fittings for the 7th floor have been capitalised and therefore the costs do not appear in the
2007-08 statements, the assets will be depreciated over the coming years.
The surplus has been carried forwards to 2008-09 and is budgeted to be spent during the year.

                                                                                                                Page 12 of 30
Page 13 of 30
                 Performance & Use of Resources
                 The data presented details SMC’s performance against its key indicators up to March 2008.
                                                                                                                                                                                                                       Base        Actual
Efficiency Plan Action Area                      Apr-07       May-07          Jun-07            Jul-07         Aug-07         Sep-07       Oct-07        Nov-07          Dec-07        Jan-08      Feb-08   Mar-08    Apr06-       Apr07-
                                                                                                                                                                                                                      Mar07        Mar08
Admission charging policy          -80%          -11.5%        -5.6%           -6.1%            -14.5%          -11.5%        -8.2%         -8.3%         -8.3%           -8.5%        -7.9%        -8.2%   -6.5%      1126         1052
Ambulatory Care (LTC) & PARR
                                   -10%          -0.6%         +1.6%           -0.6%            +3.5%           +5.3%         +5.5%        +5.3%          +4.3%           +5.1%        +4.8%        +3.7%   +3.0%      4180         4307
unscheduled care
Obstetrics Triage                  -9%           -10.0%        -13.1%         -13.8%            -12.8%          -10.4%        -9.5%        -10.2%         -10.0%          -8.6%        -9.8%        -9.1%   -8.3%      3881         3560
Primary Care DVT                   -58%          -33.3%        -10.0%          +6.3%            -5.0%           -9.1%         -10.0%       -13.5%         -8.3%           -6.6%        -0.1%        +1.9%   +3.3%       120          124
Care and Utilisation /EUR          -85%         +17.0%         +4.8%           -1.1%            +0.8%           -0.8%         -3.0%         -1.1%         +1.6%           +3.9%        +5.2%        +5.5%   +3.6%       880          912
ICAT's deflection target           -22%          -10.0%        -11.9%         -14.1%            -10.0%          -8.8%         -9.6%         -7.1%         -4.6%           -3.6%        -3.2%        -0.7%   -0.3%      24673        24602
Alcohol intervention               -50%          +5.7%        +29.4%          +34.5%            +28.1%         +15.4%         +9.8%        +8.0%          +8.4%          +14.4%        +12.2%      +10.8%   +8.5%       801          869
A&E follow ups                     -59%          -11.2%        +6.5%           +8.9%            +8.4%          +10.5%         +7.8%        +10.1%        +10.8%          +10.2%        +8.7%        +7.5%   +6.2%      1987         2110
Low Cost Statin Prescribing        -27%          -23.6%        -23.3%         -23.2%            -23.3%          -23.3%        -23.1%       -23.9%         -24.3%         -24.2%        -24.0%      -23.6%   -23.3%   £4,627,682   £3,547,188

Efficiency Plan Action Area                    Performance measure (All for identified SPCT Practices)                                                      Comment

Admission charging policy         % Change on 2 year base ACP Emergency Spells SFT                                             Below previous year
Ambulatory Care (LTC) & PARR
                                  % Change on 1 year base ACS & PARR Spells                                                    Above last year but initiative to manage not in place
unscheduled care
Obstetrics Triage                 % Change on 2 year base N12 Obstetric Spells SFT                                             Below previous year

Primary Care DVT                  % Change on 2 year base DVT Spells, All PODs All Trusts                                      Series volatile due to low levels of activity
                                  Measured are surgical treatments for: Tonsils, OME , Varicose veins,
Care and Utilisation /EUR         Caesars(elective), reversal of sterilization, circumcision, incontinence (Where operation    Higher than previous year but based on restricted definition
                                  not normal "M" types on bladder/ureter/urethra) % Change on 2 year base.
                                  All OP GP referred 1st OP atts vs 2006/7 in qualifying Specialties i.e. 100, 101,
ICAT's deflection target                                                                                                       Very slightly below previous year
                                  110,120,140,330 & 502
Alcohol intervention              Alcohol mentions in A&E atts Complaints/Diagnoses fields vs 2006/7 SFT                       Series volatile and subject to changes in recording during year
                                                                                                                               Patient not clinician driven (consultant initiated follow ups 13%
A&E follow ups                    A&E Atts shown as follow-up vs 2006/7
                                                                                                                               down on previous year)
                                  Effect of switch to lowcost Statin prescribing at constant prices and overall volume of
Low Cost Statin Prescribing                                                                                                    Consistently good performance in year
                                  Statin prescribing

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Development Plan: Performance to Date

District Nursing and Active Case Management
A review update was provided to the February 2008 SMC Board meeting with the final review anticipated by April. The final structures,
investments and service specification will be agreed and subsequently commissioned.

End of Life and Palliative Care
The service review and strategy was presented to SMC Board in March 2008. As this subject is also one of the 8 clinical pathways reviews
being undertaken across Stockport, the final reports and business case for investments, although completed, have been delayed. This is in
order to fit with the timetable of events leading up to the development of the PCT strategy.

Maternity Matters
A strategy review update is due in 2008 and forms part of local clinical pathways reviews.

Cancer Strategy
The cancer strategy has been developed and agreed by the local Joint Strategy Group and will be presented to PCT and SMC groups in the
Summer 08. Work on new cancer pathways covering referral through to treatment and ‘living with cancer’ is advancing slower than expected
partly due to the ambitious timetable and need for clinical engagement.

Work has begun regarding the implementation of 2 week waits on Choose & Book and will be completed by end of June 08.

Tier 2 and Clinical Assessment and Treatment Services
In November 2007, an evaluation of the locally provided Tier 2 services for Orthopaedics, Urology, Gynaecology, General Surgery and
Dermatology was undertaken. The review highlighted a number of recommendations to improve the services including the need for: business
processes re-design, improved diagnostic support, a detailed review of the workforce, funding and capacity and improved accommodation. A
project was then launched to tackle all of the recommendations and aims to complete the improvement work by December 2008.

Work on the mobilisation of the national independent sector Clinical Assessment and Treatment Services (CATS) contract continued and the
service is anticipated to go live in early 2009. In order to develop local CATS a detailed service specification was developed and will be used to
measure the improvements in the Tier 2 services and to commission CATS from another provider to complement the current provision. The
service from the third provider is projected to go live by the end of 2008.

                                                                                                                Page 15 of 30
Clinical Pathways
The development of clinical pathways in association with primary and secondary care colleagues continued throughout the year with a common
format for such pathways being agreed to ensure consistency.

Training and Education
An outline training strategy has been drafted under the leadership of the newly appointed Performance & Education Manager.

Following a successful tender, Staniforth Communications have been appointed in February 08 to facilitate improved communications with GP
members under the guidance of the newly appointed Business & Communications Manager for SMC.

Locality Development
Four new managers are now in place to support 4 Associate Directors covering each of the localities (Cheadle& Bramhall, Heatons & Tame
Valley, Stepping Hill & Victoria and Marple & Werneth) and to work closely with the GP members as well as leading on cross cutting
modernisation change, pathway implementation, performance improvement and improved communications.

Dedicated Public Health Teams have also been established to support each locality and the work will be coordinated through a new Public
Health Locality Manager (to be appointed).

During February a full engagement session was held with each of the localities on the strategic priorities for the health economy and for that
locality. Key messages from members are being fed into future service improvement proposals. An innovation fund for each locality has been
proposed to enable service change to move forward at a more rapid pace under the governance of each locality team. Ideas are being sought
to develop up into small business cases.

Progress to date:

       −   Innovation fund and locality governance including a business case template has been agreed.
       −   Locality meetings are taking place on a quarterly basis, with further engagement from practices being encouraged. The Chair
           positions for the Locality meetings are currently being filled

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Development of St Thomas
Stockport PCT with Stockport Managed Care & Stockport Health Enterprises is a national demonstrator site for the government Community
Hospital Concept initiative.
This new concept drawing together traditionally delivered with new innovative ideas, partnerships, community involvement concept and
systems will develop the synergies of service delivery, innovation & technology and building space utilisation.
The following services will be provided:
       −   St Thomas’s Community Venture provides care out of hospital, in a purpose built facility, in an area of high need, offering responsive
           flexible care. Services offered in this initiative include
       −   a diagnostic and treatment centre for surgical care speeding up access to hospital operations or providing simple procedures and
           assessments in the community
       −   a responsive Early Intervention Service for Acute Chronic Illness, and Long Term conditions centre including tele medicine, open till
           11pm at night when needed.
       −   New extended care Primary Care services operating till 8pm at night, and an extended Pharmacy service.
       −   Psychological therapies – establishing a centre for cognitive behavioural training
       −   Healthy living centre including health advice, specialist weight management service, childrens centre services, healthy hearts
       −   Health enterprise centre to support training, innovation and learning, employment and fledging business’s focused on social and
           health benefit.
       −   Close working between local people, health, social care, education and regeneration agencies will ensure this initiative is a success

The project will be delivered via the NHS P21 procurement process project managed by Stockport Health Enterprises Community Interest
Company Ltd, a GP owned social enterprise company in conjunction with Stockport Managed Care & Stockport PCT.

Management capacity
Only one vacancy existed at the end of March 2008 (Assistant Director of Finance & Performance – Practice Based Commissioning).

                                                                                                                Page 17 of 30
Risk Issues
It should be noted that the targets outlined at the start of this year were stretch targets. During 07-08 SMC have not had a fully dedicated
management resource but plans are underway to have this actioned for the start of the new financial year.

Looking Ahead

SMC has a detailed Business Plan outlining the specific initiatives it will pursue in 2008-09. These initiatives link intrinsically to the 2008-09
Accountability Agreement signed off by both SMC and Stockport PCT in April 2008:

Main objectives
      − Redesign Primary Care Long Term Conditions
      − Community Audiology Service
      − Restructure Medicines Management
      − Development of Primary Care Facing Diagnostics
      − Mobilisation and development of Tier 2/CATs/IS CATs
      − Reduce Outpatient Appointments
      − St Thomas Diagnostic & Treatment Centre
      − Termination of Pregnancy Pathway
      − Assisted Conception Pathway
      − Reduce Follow Ups
      − Weight Management Pathway
      − End of Life Pathways
      − Stroke Pathway Development
      − Cancer Pathway Improvement
      − Early Intervention Service
      − Maternity Pathway Development

Supporting initiatives
      − Locality Development
      − Practice & Members support
      − Develop & implement Communications Strategy

                                                                                                                Page 18 of 30
       −   Establish corporate governance systems
       −   Pathway development and implementation/Map of Medicine
       −   Referral Management, Business Process Redesign, LEAN Working
       −   Commission services and develop pathways in order to deliver year1 of new Urgent Care Strategy
       −   Roll out Health Inequalities Strategy and Locality working
       −   Develop & implement Training & Development Strategy

To assist in realising the above SMC with Stockport PCT and Stockport Foundation Trust has lead a 6 month review entitled ‘Working together
for better health’. The review has looked at how health services are delivered now and recommends how they can be improved. It will inform
strategic commissioning priorities for 2008 / 2009 and beyond.

The programme adopts a similar process to the Darzi review, listening to the public and involving the opinion of health staff, but focuses purely
on the specific needs of the Stockport area. As such, it is the first PCT in the North West to do so.

The review focuses on improving care in five general areas:
       − improving patient experience and quality
       − enhancing the overall health and well being of people
       − addressing health inequalities
       − ensuring best value
       − improving access to services

Areas of care assessed include maternity and newborn care, staying healthy, children’s, urgent care, planned care, sexual health, long term
conditions, end of life care and mental health. Each of the above has produced 5 top recommendations which will be progressed in 2008-09.

                                                                                                                Page 19 of 30
Financial Statements of the Company


Stockport Managed Care Commissioning Ltd (SMC) was established in April 2007. The legal entity of SMC is an Industrial Provident Society
and it is registered with the Financial Services Authority (FSA). SMC has charitable status for tax purposes. Rules for SMC have been
submitted to the FSA and these set out the governance of the Society. Under these Rules the Financial Statements of SMC must be filed with
the FSA within 7 months of the year end after being approved by the AGM which must be held within 6 months of the year end.

Stockport Health Enterprises (SHE) is a subsidiary of Stockport Managed Care the Financial Statements are therefore shown for the Society
and for the consolidated company including SHE.

Stockport Health Enterprises is a community interest company whose business activities include the developing, equipping, maintaining and
operating premises and facilities for health and social services.

Accountability Agreement

SMC is funded by Stockport Primary Care Trust (SPCT) the terms of this funding are set out in the Annual Accountability Agreement. The
Accountability Agreement is an agreement between Stockport Primary Care Trust and Stockport Managed Care that sets out the
responsibilities and accountability of SMC to SPCT. The Agreement is reviewed and signed annually when new targets, areas of development
and budgets are set.

The PCT has engaged SMC to further develop Practice Based Commissioning in Stockport and in particular to focus on Training, Education,
Communication, Innovation and Improving Performance and Value for Money. The agreement comprises of

       −   Accountability & Governance
       −   A Service Improvement Plan which governs the Incentive Scheme and Practice Development Plans
       −   Financial Governance arrangements between the PCT and SMC

The primary objectives of setting up SMC is to enable better engagement of clinicians with Practice Based Commissioning.

                                                                                                            Page 20 of 30
The improvement targets are driven from national and local priorities the 6 priority areas are:-

       −   Reducing Health Inequalities
       −   Health Improvement
       −   Improving Access
       −   Improving Productivity and Value for Money
       −   Improving Mental Health
       −   Developing Long Term Condition and Older People care

The Accountability Agreement sets out the Management Service Level Agreement from SPCT to SMC and the funding for these services.

Management Services Agreement

The Management Services Agreement is in place to ensure that SPCT provides adequate management support to enable SMC to fulfil their
requirements in terms of efficient and effective commissioning. The agreement identifies how the aims will be delivered and the budgeted costs.
SMC staff remain employees of SPCT and are therefore governed by SPCT’s terms & conditions and HR policies. There is a management
charge paid to the PCT to cover the costs of these staff.

Stockport Health Enterprises

Stockport Health Enterprises has a services agreement with SPCT and works in works in partnership with the PCT to achieve the PCT’s
Strategic Estates Investment Plan.

The business of Stockport Health Enterprises shall be to promote and improve public health, well-being and social care in Stockport by:

       −   providing high quality and functionally fit for purpose accommodation, facilities and services thereby promoting choice and
           competition amongst providers
       −   promoting, developing, equipping, maintaining and operating premises and facilities for health, well being and social care services
       −   seeking out new sources of finance and innovative partnerships and structures to fund health, well being and social care premises
       −   providing or procuring a cost-effective and efficient estates and facilities management service for health, well being and social care
           facilities, either on its own account, or in partnership with other organisations

                                                                                                                 Page 21 of 30
Annual Assurance

The PCT requires an Annual Assurance Statement from Internal Audit based upon an independent review of governance, financial control, risk
and delivery arrangements. This review has been completed for 2007-08 and a final report has been produced.

Financial Summary

The Financial Statements for the Year Ended 31st March 2008 show a surplus of £ 735K (Consolidated), £ 731k (Society). The majority of this
is due to an under spend on the incentive schemes especially Direct Listings. Other savings are due to delays in setting up the company and
moving to the new premises. The Refurbishment of the 7th floor and accompanying furniture has been capitalised and will be depreciated over
ten and five years respectively thus increasing the surplus for 2007-08.

The surplus has been carried forwards to 2008-09 and is budgeted to be spent during the year.

For the first year of operation Stockport Health Enterprises profit before taxation for the year ended 31 March 2008 was £6,433 which was in
line with expectations. SHE’s operating activities during the financial year were working towards completing the original business case (OBC)
for the St Thomas development and project managing the Heald Green and Woodley developments on behalf of Stockport PCT.

Principals of Accounting Policies

The accounts have been prepared under the historical cost convention.

The consolidated financial statements consist of Stockport Managed Care Commissioning Ltd and it’s subsidiary Stockport Health Enterprises

Revenue from the rental of premises is recognised evenly over the period to which the charges relate.

Revenue from project management services is recognised based on the percentage of completion method. The stage of completion is
estimated on a consumption basis as determined by the proportion of costs incurred relative to the estimated total contract costs.

All assets are stated at cost. Items with a cost exceeding five thousand pounds are capitalised. Refurbishment of the premises is depreciated
over ten years, furniture and equipment is depreciated over five years. Depreciation is charged from the first month after completion.

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  i.    Register of Interests

                                Page 27 of 30
      ii.   List of Members

 Stockport Managed Care – List of Shareholders April 2007 – March 2008

NO.    NAME OF SHAREHOLDER                      PRACTICE           NO.   NAME OF SHAREHOLDER                PRACTICE
 1    Dr Ashwin Patel               Bramhall Park Medical Centre   21    Dr Susan Mary Jenkins    Bramhall Park Medical Centre
 2    Dr Ranjit Singh Gill          Stockport Medical Group        22    Dr Sasha Johari          Park View Group Practice
 3    Dr Jaweeda Idoo               The Alvanley Family Practice   23    Dr Stephen F Levy        Beech House Medical Practice
 4    Dr Gregory John Carter        Marple Medical Practice        24    Dr Karen McEwan          Park View Group Pracitice
 5    Dr John Adams                 Cheadle Medical Practice       25    Dr Helen Hewetson        Marple Medical Practice
 6    Alison Tonge                  n/a                            26    Dr Janice Allister       Brinnington Health Centre
 7    Dr Vicci Owen-Smith           n/a                            27    Dr Michael Armstrong     Bredbury Medical Centre
 8    Dr Javaid Ali                 Bramhall Health Centre         28    Margaret Arnold          Heaton Norris Health Centre
 9    Dr Philip Allan               Beech House Medical Practice   29    Dr H Azmy                The Surgery Brinnington Road
10    Dr Ameer Aldabbagh            Springfield Surgery            30    Dr Rebecca Baron         Bracondale Medical Centre
11    Dr Alexander Neil Bayes       Bramhall Park Medical Centre   31    Dr Robert Beardsell      Bredbury Medical Centre
12    Dr Alison Buckley             Archways Surgery               32    Dr Tim Billington        Heaton Moor Health Centre
13    Dr Joanna Kathryn Davie       Cheadle Hulme Health Centre    33    Dr David Bostock         Brinnington Health Centre
14    Dr Rosalind Deering           Springfield Surgery            34    Dr Catherine Briggs      Bracondale Medical Centre
15    Dr Ian Dickie                 The Family Surgery             35    Dr Jill Chambers         Eastholme Surgery
16    Dr John Adrian Geary          Bramhall Health Centre         36    Dr Monica Chanda         Woodley Health Centre
17    Dr John Hall                  Marple Medical Practice        37    Dr Stella Cole           South Reddish Medical Centre
18    Dr Stephen Craig Hastings     Cheadle Hulme Health Centre    38    Dr Chris Davies          The Health Centre Smithy Green
19    Dr Kevin Higginbotham-Jones   Offerton Health Centre         39    Dr David Dawson          Heaton Moor Health Centre
20    Dr Najabat Hussain            Park View Group Practice       40    Dr Carolyn Day           Ellesmere Medical Centre

                                                                                                 Page 28 of 30
NO.    NAME OF SHAREHOLDER              PRACTICE             NO.   NAME OF SHAREHOLDER               PRACTICE
41    Dr Kevin Dean          Heald Green Health Centre       68    Dr Ian Morgan           Chadsfield Medical Practice
42    Dr Nicholas Devine     Bramhall Park Medical Centre    69    Dr Julia Morrison       Heaton Norris Health Centre
43    Dr Stephen Gaduzo      Cheadle Medical Practice        70    Dr A P Murthy           Heaton Norris Health Centre
44    Dr Mark Gallagher      The Alvanley Family Practice    71    Dr Gnana Murugan        The Family Surgery
45    Dr Abdul Ghafoor       Bents Lane Medical Practice     72    Dr Bonny Needham        Gatley Health Centre
46    Dr David Gilbert       Adshall Road Medical Practice   73    Dr M J Needham          Marple Bridge Surgery
47    Dr Kalwanprit Gill     Dial House Medical Centre       74    Dr Johnathan Owen       Offerton Health Centre
48    Dr Alan Gilman         Brinnington Health Centre       75    Dr Penelope Owen        Heald Green Health Centre
49    Dr David Greenwell     Bredbury Medical Centre         76    Dr Sipra Pal            Vernon Park Surgery
50    Dr Sarah Griffiths     Heald Green Health Centre       77    Dr Graham Parker        Archways Surgery
51    Dr Claire Hayes        Woodley Health Centre           78    Dr Michael Parkinson    Offerton Health Centre
52    Dr P J Hedley          Marple Bridge Surgery           79    Dr Raina Patel          Romiley Health Centre
53    Dr David Herbert       Alvanley Medical Centre         80    Dr Lesley Pontefract    The Family Surgery
54    Dr Joanne Herd         Eastholme Surgery               81    Dr Leonie Price         Stockport Medical Group
55    Dr Lucy Housley        Stockport Medical Group         82    Dr Heather Procter      Lowfield Surgery
56    Dr Thomas Howling      Brinnington Health Centre       83    Dr Geryl Rees           Heaton Mersey Medical Practice
57    Dr Jill Jeffs          Adswood Road Surgery            84    Dr Saqib Rafique        Haider Medical Centre
58    Dr Roderick Lennox     Woodley Health Centre           85    Dr Keith Richardson     The Health Centre Smithy Green
59    Dr Hazem Lloyd         Cedar House                     86    Dr Philip Riley         Beech House Medical Practice
60    Dr Jillian Lowe        Bramhall Health Centre          87    Dr Martin Rodgers       Marple Bridge Surgery
61    Dr Stewart Lund        Dial House Medical Centre       88    Dr Ruth Seabrook        The Health Centre Smithy Green
62    Dr Amanda Large        Heaton Norris Health Centre     89    Dr Iain Semple          Heaton Mersey Medical Practice
63    Dr Emma Leon           Heald Green Health Centre       90    Dr Andrew Shepherd      Heaton Moor Health Centre
64    Dr Brian Lightowler    Dean Lane Medical Centre        91    Dr Alison Shipston      Cheadle Hulme Health Centre
65    Dr Viren Mehta         Cheadle Medical Practice        92    Dr Benjamin Sigmund     South Reddish Medical Centre
66    Gillian Miller         Ellesmere Medical Centre        93    Dr Debra Spreckley      Chadsfield Medical Practice
67    Dr Amarendra Mishra    South Reddish Medical Centre    94    Mr Paul Stevens         The Health Centre Smithy Green

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NO.    NAME OF SHAREHOLDER              PRACTICE             NO.   NAME OF SHAREHOLDER                PRACTICE
95    Mr Johan Taylor        Marple Cottage Surgery          103   Dr Jane Whittaker        Dial House Medical Centre
96    Dr Rachel Tomalin      Cale Green Surgery              104   Dr Alan Wild             Houldsworth Medical Centre
97    Dr Michael Travenen    Shaw Villa Medical Centre       105   Dr Diana Wilks           Bramhall Health Centre
98    Dr M Von Fraunhofer    Heald Green Health Centre       106   Dr Simon Woodworth       Chadsfield Medical Practice
99    Dr Lindsay Webb        Adshall Road Medical Practice   107   Dr Andrew Wright         Heald Green Health Centre
100   Dr Abigail Webster     Ellesmere Medical Centre        108   Dr Jeremy Wynn           Heaton Mersey Medical Practice
101   Dr Keith Wells         Marple Cottage Surgery          109   Dr Melanie Wynn-Jones    Marple Medical Practice
102   Dr Mark White          Adswood Road Surgery            110   Dr Andrew Davison        Gatley Health Centre

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