1 Footnote

1. Safe and Financially Effective (SaFE) Epsom & St Helier University Hospitals NHS Trust Text 15 September 2011 1 Footnote SOURCE: Source

2. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier

3. Introduction • Healthcare for London, published in July 2007, illustrated a compelling case for change in health and healthcare services across London. Four years on, the case for change is as powerful as ever. • London’s NHS faces pressure from increasing demand for healthcare: • a growing and ageing population; • changing patterns of disease and health; • innovations in medical technology; and • changing public expectations. • which alongside the slowdown in funding growth for the NHS poses a significant challenge to the overall affordability of London’s healthcare system. • In 2009, NHS London undertook detailed modelling that showed that on a ‘do nothing’ basis, by 2016/17, there would be a £4.4billion funding shortfall for commissioners in London on a recurrent basis over a 9-year period, to be addressed by tariff pricing (£2.4bn) and commissioning levers (£2.0bn). Analysis also demonstrated additional pressure of up to £1.9bn on acute providers from activity changes. • Implementing Healthcare for London proposed an approach, underpinned by financial analysis, that achieved both clinical sustainability and financial viability for PCTs in London. But major service reconfiguration and/or organisational changes would be necessary to deliver viable Trusts capable of achieving FT status. • The NHS in London is running out of time to undertake these changes in order to achieve a viable provider landscape. Although London’s integrated plan for 2011/12 and beyond reflected an updated commissioner model, in many cases PCT Clusters’ plans fail to reveal the scale of changes needed, partly because of the complex policy and political environment within which the NHS operates. • Therefore, SaFE provides a simulation based on standardised modelling of financial, quality and safety issues. It is consistent across London and determines whether the 18 acute NHS Trusts in London can achieve FT status by 2014, taking into account current cost and income trajectories, quality requirements and potential productivity improvements. • Following discussions with NHS leadership and Secretary of State, a number of workstreams have been developed to take this work forward, central to which is a dialogue with each Trust Board regarding its response to the challenges and opportunities presented by the analysis. This will inform the development of detailed milestones to be included in finalised TFAs.

4. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier

5. Approach: We estimated Trusts’ financial position to 2014/15 in 5 steps Establish 10/11 baseline • Used Trusts’ underlying position in 10/11 (net of non-recurrent income and costs) as baseline • Forecasted income until 2014/15 based on 3 factors: • Net clinical activity growth based on commissioner plans • underlying demand growth assumptions (range 1.9%-5.0%) • demand management net of reinvestment (range 1.1%-8.9%) • Price reduction of -1.5% per year across both PbR and non-PbR clinical income • Forecast of non-clinical income (R&D, education and training) based on NHS London teams’ view • Modelling excludes all potential future reconfigurations and service changes Estimate income changes by 14/15 Estimate cost changes by 14/15 • Estimated change in cost as a result of changes in activity (assuming cost scales 70-80% with increase in activity and 55-65% with decrease in activity)1 • Added expected PFI cost development based on DH schedules • Added non-activity-related operating expenses, assuming increases with inflation • Estimated opportunity to reduce cost by closing productivity gap vs. benchmark peers: • Peers selected considering Trusts’ academic/non-academic status, size and single/multi-site status where relevant • Peers with bottom quartile quality excluded (HSMR used as proxy for quality) • 2 levels of potential savings modelled: • 1) Close gap vs. peer at upper quartile productivity threshold, assuming the peer reduces costs by 2% p.a. • 2) Close gap vs ‘average of top 3 peers’, assuming the peers reduce cost by 2% p.a. • To avoid assuming unsustainable nursing cost reductions, we set a “floor” of 8 nurse hours per patient bed day • Set a cap of 20% reduction on the total cost base over 4 years as the maximum sustainable improvement • Ensured Trusts met minimum medical resource standards for key specialties (Obstetrics and Emergency services) • Inflated the cost base net of all other changes by 2.5% p.a. • Used Trusts’ 2011/12 plans as short term forecast and re-profiled demand management and productivity improvement of the 4-year period accordingly • Modelled impact of community services component of merged acute and community Trusts (assuming 3% surplus) Develop year-by-year forecasts Evaluate financial outlook • Assessed Trusts’ viability based on whether they achieve 1% underlying net surplus position in 2014/15 • For Trusts that would achieve 1% net surplus by 2014/15 if it were not for the 20% cap, the forecast period has been extended to check if the target can be achieved given more time 1 Cost scaling assumptions modelledat level of detailed cost categories, reflecting differences in proportions of fixed and variable costs

6. There are a number of potential downsides that have not been included in this analysis and that would make Trusts’ prospects of financial viability lower Assumption / approach in this work Potential downside • Costs scaled at 70-80% with increases in activity, and 55-65% with decreases • Some Trust operating plans imply higher scaling with increases and lower / no scaling with decreases Scaling Cost inflation • 2.5%pa cost inflation assumed on all cost categories (based on the average cost inflation assumed in operating plans 2011/12) • An alternative scenario with additional 1%pt unfunded cost inflation has been modelled • Potential higher cost inflation through pay drift and other cost pressures Tariff uplift & price changes • Additional price pressures from new tariff rules (e.g. emergency readmissions) • Potential income caps imposed by commissioners if demand not contained • -1.5%pa price reduction per year, across both PbR and non-PbR clinical income PFI & other capex • Only includes agreed PFI and capex programmes (+ known requirements for immediate sustainability in 2 cases) • Trusts with aging estates may need major capex programmes beyond current plans SOURCE: SaFE modelling assumptions

7. We have limited the potential savings that can be achieved to 20% over the 4-year period, which is at the very top end of savings seen internationally We have set an upper limit on the total cost savings that can be achieved over 4 years… …based on not having seen evidence of higher levels of cost savings sustained over a long period Examples of hospital cost reduction programmes % reduction in total cost base, CAGR Time-frame • The ‘20% cap’ translates to: • 20% of total cost base over 4 years • 5.4% annual cost reduction on total cost base • 24% of variable and semi-variable costs over 4 years • 6.6% annual cost reduction on variable and semi-variable costs US private hospital 2-3 years ~5 Germany private hospital 4-5 years 4-5 Portugal private hospital 2-3 years 4-5 Germany public hospital ~4 3-4 years Sweden public hospital ~2 years ~4 The highest levels of productivity savings have only been achieved in the private sector

8. Costs to ensure minimum standards of emergency and maternity care included • Early involvement of senior doctors in assessment and management of acutely ill patients improves health outcomes • Significant variation between clinical staffing levels on weekdays compared to weekends. In London’s hospitals consultant cover at weekends is only half of what it is during the week, which means that patients admitted to hospital at weekends face a significantly increased risk of death. In London, the risk is in excess of 10%, meaning that there will be more than 500 deaths per year that need not have occurred • Clinicians have developed a series of minimum standards for on-call 24/7 rotas, together with appropriate 24/7 consultant cover for A&E departments and for anaesthetics • Estimated cost of implementing these across the 18 Trusts: £64m (2014/15) Emergency care Maternity care • Royal College guidance emphasises the importance of midwives, 1:1 care during labour and increased presence of consultant obstetricians on labour wards. • London's maternity services do not perform uniformly well, with unacceptable inequalities in outcomes • Due to concerns about the rate of maternal deaths in the capital - 19.3 deaths per 100,000 maternity episodes in 18 months - a review commissioned by NHS London into 34 deaths showed 26 had avoidable factors, some of which may have contributed to the outcome • Estimated cost impact of recommended minimum standards for appropriate staffing levels of consultant obstetricians across the 18 Trusts: £6m (2014/15)

9. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier

10. Forecast underlying I&E 2010/11 to 2014/15 2010/11-11/12 (Trust Operating Plans) EPSOM & ST HELIER Units: £m Income Costs 2010/11– 14/15 2010/11– 14/15 4 2 0 19 6 34 16 19 0 1 48 22 8 18 1 0 Net surplus 2014/15: -£15m (-5.2%)2 Net impact from volume changes = -£13m 334 328 313 298 Under-lying demand Demand manage-ment Other oper- atingincome1 Non oper-atingincome Impact of net change in activity PFI Other oper-atingex-penses Non-oper-atingex-penses Pro-duc-tivity Impact of new quality standards Income 2010/11 Tariff uplift Income 2014/15 Cost 2010/11 Cost inflation Cost 2014/15 Note: All figures are nominal (i.e. the effects of inflation are included in the future years). Cost inflation is applied after the effects of net changes in activity and productivity. 1 Includes R&D, education, private patient, etc. 2 Underlying net surplus modelled under DH Control Totals adjusted for non-recurrent items. 9 SOURCE: Trust Operating Plans 2011/12; Modelled impact of commissioning plans; Benchmark productivity targets

11. Forecast financial position 2010/11 to 2014/15 Matching ’peer at top quartile threshold’ (+2% with cap) Matching ’average of top 3 peers’ (+2% with cap) -5.2% -1.8% -6.2% -4.9% -4.8% -1.5% 0.2% 0.7% 0.8% 2.5% EPSOM & ST HELIER Units: £m, % Underlying net surplus (in year), 2010/11 – 14/15 0 -5.9 -5.0 Lines may overlap. EBITDA and net surplus shown for matching ‘peer at top quartile threshold’ (+2% with cap) -10.0 -14.5 -15.1 -15.4 -15.0 -19.3 -20.0 2011/12 operating plan (underlying) 2010/11 (underlying) 2012/13 forecast 2013/14 forecast 2014/15 forecast Underlying EBITDA % of income Underlying net surplus % of income SOURCE: 2011 Trust Operating Plan (Apr 2011); 2010/11 Trust draft accounts (Apr 2011); PCT Commissioning Plans (Apr 2011); Update to Monitor’s financial assumptions (April 2011). 10

12. Benchmark analysis on cost saving opportunities Modelled scenarios on next page EPSOM & ST HELIER Units: £m, % Cost savings (2010/11 – 14/15) Forecast underlying net surplus (2014/15) % CAGR £m % £m Required savings to achieve 1% surplus by 2014/15 7.0 84.3 3.0 1.0 Matching ’peer at top quartile threshold’ (+2% no cap) 7.5 89.4 8.5 2.9 Matching ’peer at top quartile threshold’ (+2% with cap) 5.4 66.9 -15.4 -5.2 Matching ’average of top 3 peers’ (+2% no cap) 8.5 100.3 19.8 6.7 Matching ’average of top 3 peers’ (+2% with cap) 5.4 66.9 -15.4 -5.2 NOTE: Benchmarks are based on current (2009/10) performance, so targets are increased 2%pt per annum to simulate the peer group continuing to improve over the period 2011/12 to 2014/15 (note that although benchmarks are based on 2009/10 performance, the 2%pt is not added for 2010/11 year because the baseline costs on which the savings are applied are 2010/11, so already includes the change for this year) 11 SOURCE: FIMS 09/10, Annual Reports 09/10 , HES 09/10, ERIC 09/10, Trust operating plan 2011/12 (for 10/11 underlying position)

13. EPSOM & ST HELIER Identified cost saving opportunities Units: £m, % Cost saving opportunity (before adding 2% per year or 20% cap) Matching average of top 3 peers (Sherwood, County Durham, Northumbria) Matching peer at top quartile threshold (Bournemouth) Current Top quartile on each metric operating cost 10/11 Category 69 86 26 39 57 9 48 334 0 -22 (-32%) -37 (-44%) -9 (-34%) 0 (0%)4 8 (15%) -3 (-38%) n/a -63 -19% -5.1% 0 -20 (-29%) -32 (-37%) -4 (-14%) -1 (-2%) -15 (-27%) -3 (-34%) n/a -74 -22% -6.1% -2 -17 (-25%) -37 (-43%) -9 (-36%) -11 (-28%) -13 (-23%) -3 (-37%) n/a -93 -28% -7.8% ALOS1 Medical pay Nurses pay2 ST&T pay Non-clinical pay Clinical supplies Other variable costs3 Fixed costs5 Total6 Savings (% of total costs) Savings (4-year CAGR) 1 Bed day opportunity estimated at £150/day. Note that ALOS is assumed to stay at current rate or move to target, whichever is shorter. Impact on costs is apportioned to other cost categories in the model (Medical – 10%, Nursing – 52%, ST&T – 13%, Non-clinical – 9%, Clinical supplies – 16%) 2 Nursing WTE level capped at minimum of 8 nurse hours per occupied bed day 3 Other variable costs include catering, cleaning and laundry 4 Increase in costs capped to zero 5 Fixed costs include estate and establishment costs, and non-operating costs (PDC, interest, depreciation, etc.) 6 Total Trust expense used to arrive at net surplus 12 SOURCE: FIMS 09/10, Annual Reports 09/10 , HES 09/10, ERIC 09/10, Trust operating plan 2011/12 (for 10/11 underlying position)

14. EPSOM & ST HELIER Cost savings breakdown Peer at top quartile threshold Average of top 3 peers Top quartile on each metric Category Metric ratio Units Trust Casemix adjusted average length of stay2 Medical WTE per £1m clinical income Medical pay per medical WTE Nurse WTE per 1,000 bed days Nursing pay per nurse WTE ST&T WTE per 1,000 spells ST&T pay per ST&T WTE Non-clinical WTE per 1,000 bed days Non-clinical pay per non-clinical WTE Clinical supply costs per £1,000 clinical income Laundry cost per bed day Cleaning costs per bed day Catering costs per patient per bed day ALOS1 Days WTE £k WTE £k WTE £k WTE £k £ £ £ £ 4.8 2.5 100.4 6.4 46.0 4.8 53.7 4.5 29.3 215.5 5.1 18.6 11.3 5.7 1.8 93.0 5.0 31.9 3.8 44.3 4.5 33.1 246.8 3.5 12.7 5.5 5.5 2.1 84.0 5.4 32.6 5.9 36.5 3.7 42.9 157.4 4.0 12.4 6.7 4.5 2.1 91.8 5.2 30.8 4.8 33.1 3.5 26.7 166.5 3.4 13.4 5.4 Medical pay Nurses pay ST&T pay Non-clinical pay Clinical supplies Other variable costs Note: All figures are from 2009/10 1 Bed day opportunity estimated at £150/day. Reapportioned to other cost categories in the model (Medical – 10%, Nursing – 52%, ST&T – 13%, Non-clinical – 9%, Clinical supplies – 16%) 2 Adjusted for differences in HRG mix, specialties and elective / non-elective inpatients. Daycases excluded from analysis SOURCE: FIMS 09/10, Annual Reports 09/10 , HES 09/10, ERIC 09/10 13

15. Trusts were placed into four categories – Epsom & St Helier was not viable under any tested scenario Categories Definition Viable if improving productivity to “top quartile peer” level At least 1% surplus achievable if (capped) Top Quartile productivity delivered 1 Viable if improving productivity to “top 3 peer” level (Capped) Top 3 peer productivity required to secure 1%+ surplus 2 Become viable after an extended period 3 Significant productivity opportunity constrained by cap, meaning that longer period required to reach 1%+ surplus (or productivity performance exceeding the capped level) • Either: • Productivity opportunity not sufficient to deliver 1% surplus even without capping • Or: • Significant productivity opportunity constrained by cap, but not sufficient to reach 1%+ surplus even over extended period – therefore would need immediate productivity performance exceeding the capped level Not viable under any tested scenario 4 Epsom & St Helier

16. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier

17. Even before corrective action, change is necessary to secure delivery of the £1.2bn productivity opportunity identified Additional centrally-led initiatives that can help Trusts capture savings Building blocks required to reach high productivity Five cross-cutting actions we want to take to embed changes System leadership Political, clinical and managerial leadership to create a compelling narrative and explain need for change • Develop a compelling narrative explaining the need for unprecedented change in quality and operational efficiency • Establish graduated performance regime of support and incentives for Trusts, including the possibility of failure. This should link support of deficits and financing of debt to changes in operating model and productivity • Invest in leadership development and capability-building for Boards and clinical leaders to equip them to drive change • Develop more detailed information for Trusts to identify the right productivity opportunities, including supporting them to use SLR/PLICs to drive efficiencies and require Trusts to provide operational data that is sufficiently detailed to assess progress against productivity requirement • Productivity support programme for Trusts to help Trusts build the skills of clinical and managerial leaders and share best practice, including driving the roll-out of Lean methodology • Support one or more organisations to become a “model hospital” • Drive a transformation in nursing, including: • creating targeted incentives for nursesto work in deprived areas and/or ‘failing’ Trusts; • establishingnursing banks across a network of Trusts; and • benchmarking nurse staffing mix • Consolidate or outsource clinical support such as pathology • London-wide support for radical action on non-clinical back office and estates • Increase the leverage and scope of the London Procurement Programme, including building on existing work for improving medicines management Incentives Incentives in place to drive high performance at the system, organisation, team and individual level Internal leadership Strong Board-level and clinical leadership to drive productivity Information Timely and accurate information that provides insight into performance and productivity relevant to peers Tools & Skills Well-defined tools and the skills and capabilities to use them • Success of all actions and initiatives is predicated on Trusts having right leadership talent in place – with indications that the system does not currently have this. Four options, which could be linked to the performance/ failure regime, might address this: • Mergers and Acquisitions to extend management capability of effective boards • Academic Health Science Systems (AHSS) to raise reputation and clinical leadership of Trusts through networks • Private sector operators to bring in additional leadership • Heavily incentivise top team posts to attract best talent from UK and abroad 16

18. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier 17

19. Discussion points • Does the Trust recognise the challenges signalled by the SaFE analysis? • What are the Trust’s productivity opportunities? • What is the Trust’s plan for maximising the productivity opportunities? • What other strategic options could be implemented beyond productivity? • On what does the Trust need help? 18

20. Agenda 1 Introduction 2 Methodology 3 Conclusions for Epsom & St Helier (from Phase 1) 4 Supporting London Acute Productivity Gain 5 Discussion Points • Appendix • Peer Groups • Medical Oncosts for Epsom & St Helier

21. Teaching Bold indicates London non-FTs Grey indicates exclusions due to bottom quartile HSMR Peer groups Ordered alphabetically Non-teaching Large Medium Small Included: Barts and The London Brighton and Sussex Bristol (FT) Cambridge (FT) Chelsea and Westminster (FT) Coventry and Warwickshire Guy's and St Thomas‘(FT) Imperial King's College (FT) Leeds Leicester Newcastle Upon Tyne (FT) Norfolk and Norwich (FT) North Staffordshire Nottingham Oxford Radcliffe Plymouth Royal Devon and Exeter (FT) Royal Free Hampstead Royal Liverpool and Broadgreen Sheffield (FT) Southampton St George's University College London (FT) Excluded: Birmingham (FT) Central Manchester (FT) Derby (FT) Hull and East Yorkshire Single site Single site South Manchester (FT) Southend (FT) St Helens and Knowsley Taunton and Somerset (FT) Whipps Cross Wirral (FT) York (FT) Excluded: Basildon and Thurrock (FT) Dudley Group (FT) Northampton General Royal Wolverhampton Due to small number of ‘large non-teaching Trust’, Trusts in this peer group have been benchmarked against all non-teaching Trusts irrespective of size. Additional ‘large’ Trusts included: East Kent1 (FT) Gloucestershire (FT) Heart of England (FT) North Bristol Portsmouth SLHT South Tees (FT) Excluded: Pennine Acute Included: Frimley Park (FT) Great Western (FT) Ipswich Luton and Dunstable (FT) Medway (FT) Royal Surrey County (FT) Royal United Bath Salford Royal (FT) Salisbury (FT) South Devon Healthcare (FT) Included: Airedale Basingstoke and North Hampshire (FT) Bedford Burton (FT) Chesterfield Royal (FT) Countess of Chester (FT) Croydon Dartford and Gravesham Dorset County (FT) Ealing East Cheshire Gateshead (FT) Harrogate and District (FT) Hereford Hinchingbrooke Homerton (FT) James Paget (FT) Kingston Lewisham Milton Keynes (FT) Newham Northern Devon Poole (FT) Princess Alexandra Queen Elizabeth King's-Lynn South Tyneside (FT) Walsall West Middlesex West Suffolk Weston Area Whittington Excluded: Barnsley (FT) George Eliot Kettering General (FT) Mid Cheshire (FT) North Middlesex Rotherham (FT) Royal Bolton (FT) Surrey and Sussex Tameside (FT) Yeovil District (FT) Peer selection • Peers selected considering trust’s: • Academic/non-academic status • Size • Single/multi-site status where relevant • Other peer characteristics not found to have as statistically relevant impact on performance Multi site Included: Ashford and St Peter's Aintree (FT) Barnet and Chase Farm BHRT Blackpool, Fylde & Wyre (FT) Bradford (FT) Calderdale and Huddersfield (FT) Colchester (FT) County Durham and Darlington (FT) Epsom and St Helier Heatherwood and Wexham Park (FT) Lancashire (FT) Maidstone and Tunbridge Wells Mid Essex Services Morecambe Bay Northern Lincolnshire and Goole (FT) Northumbria (FT) NWLH Peterborough and Stamford (FT) Royal Berkshire Royal Bournemouth and Christchurch (FT) Royal Cornwall Sandwell and West Birmingham Sherwood Forest (FT) Stockport (FT) West Hertfordshire Worcestershire Wrightington, Wigan and Leigh (FT) Excluded: Buckinghamshire Doncaster and Bassetlaw (FT) East and North Hertfordshire East Lancashire East Sussex Mid Yorkshire North Cumbria North Tees and Hartlepool (FT) Shrewsbury and Telford Sunderland (FT) United Lincolnshire Western Sussex Multi site Included: Hillingdon (FT) Mid Staffordshire (FT) Trafford Warrington (FT) Winchester and Eastleigh Excluded: Scarborough South Warwickshire (FT) Southport 1 East Kent not included in analysis due to gaps in data

22. Impact of new service standards in emergency services and obstetrics, 11/12 & 14/15 Epsom & St Helier Emergency care services 14/15 Maternity Emergency care services 11/12 Maternity Total Paediatrics A&E Anaesthetics General medicine General surgery Obstetrics Total Paediatrics A&E Anaesthetics General medicine General surgery Obstetrics Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional1 consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional Cost £m Additional1 consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Additional consultants (WTE) Trust Trust Note: For general medicine and general surgery secretarial costs are included in the cost 1 Additional consultants estimated based combination of WTE and PA analysis, assuming £110k per WTE in 11/12 11.5 22.2 7.7 63.4 4.4 4.3 15.0 - 39.3 17.7 3.6 5.7 0.0 0.5 1.7 7.6 0.4 1.6 0.2 0.8 1.3 2.1 0.8 2.4 0.3 11.1 1.3 2.7 ESH ESH 1 Additional consultants estimated based combination of WTE and PA analysis, assuming £121k per WTE in 14/15 • Sources • Numbers of consultants required based on: • Paediatrics : consultant delivered service and 24 hour EWTD compliant rota • A&E: <80,000 attendances = 10; 80,000 – 100,000 = 12; 100,000+ = 14 • Anaesthetics: 11 for each of surgery and obstetrics • General medicine and general surgery: numbers necessary to achieve 12/7 in line with AES standards • Current numbers of consultants based: • Medicine and surgery, Trust reported for AES project • Other specialities, NHS Hospital and Community Health Services (HCHS) : Medical and dental staff by SHA, Organisation, Specialty and Grade, 2009