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UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
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Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome 3 Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction 5 2.1 Priorities for improvement 6 2.1.1 Progress against 2024/25 priorities 6 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports 8 2.2 Priorities for improvement for 2025/26 28 2.3 Statements of assurance from the Board 47 2.3.1 Review of services 47 2.3.2 Participation in national clinical audits and confidential enquiries 47 2.3.3 Recruiting to research 52 2.3.4 Commissioning for Quality and Innovation (CQUIN) payment framework 52 2.3.5 Statements from the Care Quality Commission (CQC) 52 2.3.6 Payment by results 53 2.3.7 Data quality 54 2.3.8 Data Security and Protection Toolkit (DSPT) 54 2.4 Overview of Quality Performance 55 2.4.1 Single Oversight Framework 55 2.4.2 Reporting against core indicators for 2024/25 55 2.4.3 Learning from deaths 67 2.4.4 Seven-day hospital services 70 2.4.5 Freedom to Speak Up 72 2.4.6 Rota gaps 74 2.4.7 Duty of Candour 76 Part 3: Other information 3.1 Our commitment to safety 77 3.2 Our commitment to improving the experience of the people who use our services 81 3.3 Our commitment to improve the quality of our patients’ environment 83 3.4 Our commitment to sustainability and the environment 85 3.5 Our commitment to staff 89 3.6 Our commitment to education and training 91 3.7 Our commitment to clinical research 98 3.8 Our commitment to technology 102 3.9 Conclusion 103 Part 4: Appendices 104 2 QUALITY ACCOUNT Part 1: Statement on quality from the Chief Executive 1.1 Chief Executive’s statement and welcome I am pleased to present this year’s quality account, which reflects our ongoing commitment to delivering safe, effective and compassionate care for our patients. 2024/25 has been a challenging year for UHS and the wider NHS and social care system. We have navigated operational pressures, with increasing numbers of patients who are medically fit but do not have an onward care package in place to be discharged, alongside a rise in winter infections and a record number of attendances to our emergency department. In the face of these challenges, our teams have worked tirelessly to enhance patient outcomes, improve service accessibility and ensure that the care patients receive meets the highest standards. I want to recognise the hard work of our staff in ensuring safety, driving innovation, and adapting to changes. This report highlights successful initiatives that have improved patient care over the past year. It also provides an overview of our quality priorities for 2024/25 and sets out our quality improvement priorities for 2025/26. We are proud to have maintained our focus on quality and achieved most of our objectives, enhancing the experience for those who use our services. Patient experience is an important priority for UHS. In 2024/25 we have successfully recruited approximately 2,000 ‘involved patients’, which will ensure that we co-design our services with those who use them, keeping our focus on our Trust values of patients first, working together and always improving. 2025/26 promises to be an exciting year for patient experience, with the development of the Patient and Family Support Hub, which will integrate voluntary services and ensure equitable access to support services for all. Our long-standing commitment to delivering safe, high-quality care is underpinned by the Fundamentals of Care programme - eight care commitments that patients, families and carers can expect from their care at UHS and these statements have been written in conjunction with patients, relatives and staff. In 2024/25 the programme has made significant progress in embedding Fundamentals of Care into our organisational culture. This has been achieved through developing understanding with newly registered professionals in our preceptorship programme, support worker development opportunities and the ongoing empowerment of staff through leadership development. In 2024/25, we have continued to strengthen our internal quality assurance programmes by aligning the clinical accreditation scheme with the CQC single assessment methodology. We are collaborating with other internal programmes - such as infection control, Patient-Led Assessments of the Care 3 QUALITY ACCOUNT Environment (PLACE) and friends and family feedback - to triangulate data and enhance oversight of key quality metrics, including patient safety, effectiveness, patient experience, and outcomes. This approach provides us with valuable intelligence to help us uphold our Trust values. 2024/25 marked one year of Patient Safety Incident Response Framework (PSIRF) implementation at UHS which has helped develop ‘just and learning’ culture across the organisation. Safety awareness has increased through our education programmes that have achieved good attendance and feedback. This coming year we will continue to build on the work that has been undertaken as part of implementation of the national safety standards for invasive procedures (NATSSIPS) 2. We continue to collaborate with our partners and develop our work as an integral organisation in the integrated health and social care system, building on trusted relationships across organisational boundaries are essential in improving health outcomes for our whole population. I want to recognise the amazing dedication of our staff in maintaining the safety of both colleagues and patients, fostering innovation, and adapting to evolving circumstances. Throughout this year, our teams across all services have strengthened their collaboration with our partners. As we continue to advance towards an integrated health and social care system, these trusted relationships are proving essential in our ability to respond effectively. To the best of my knowledge, the information contained in this document accurately reflects our performance, provides a true account of the quality of the health care services we provide, and where we have succeeded and exceed in delivery on our plans. David French Chief Executive Officer 26 June 2025 4 QUALITY ACCOUNT Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction Despite it being an extremely challenging year and unprecedented demand in the emergency department during 2024/25, the Trust maintained a strong focus on quality assurance. This was undertaken through established programmes and clinical leadership oversight of key safety and patient experience indicators, including falls, pressure ulcers, and venous thromboembolisms. The Fundamentals of Care initiative continued to be embedded, supported by high-quality peer reviews and weekly matron-led quality walkabouts aligned with CQC domains. The clinical accreditation scheme (CAS) was enhanced with updated documentation reflecting learning from themed walkabouts and aligned with national frameworks. A new governance framework for mortality and morbidity meetings was introduced to improve learning dissemination and escalation. The Trust also opened a Patient and Family Support Hub (P&FSH), advanced volunteer recruitment through a system-wide passporting approach, and began implementing NatSSIPs 2. In response to rising violence against staff, de-escalation training was rolled out, leading to a reduction in physical restraint and violence incidents. The Trust’s commitment to continuous improvement was demonstrated through training over 1,000 staff, outperforming NHS averages in improvement metrics, and achieving measurable service enhancements, including a 5.25% reduction in average length of stay, increased theatre throughput, and expanded use of patient initiated follow up pathways. Every year all NHS hospitals in England must prepare and publish an annual report for the public about the quality of their services. This is called the quality account and makes us at UHS more accountable to our patients and the public which helps drive improvement in the quality of our services. Quality in healthcare is made up of three core dimensions: Patient experience - how patients experience the care they receive Patient safety - keeping patients safe from harm Clinical effectiveness - how successful is the care we provide? 5 QUALITY ACCOUNT The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. This includes: • How well we did against the quality priorities and goals we set ourselves for 2024/25 (last year). • It sets out the priorities we have agreed for 2025/26 (next year), and how we plan to achieve them. • The information we are required by law to provide so that people can see how the quality of our services compares to those provided by other NHS trusts. Additional information about our progress and achievements in key areas of quality delivery. Stakeholder and external assurance statements, including statements from our Council of Governors, Hampshire and Isle of Wight Integrated Care Board and Southampton County Council’s Health Overview and Scrutiny Committee. 2.1 Priorities for improvement This section reflects on the 2024/25 quality improvement priorities at UHS and outlines our quality improvement priorities for 2025/26. 2.1.1 Progress against 2024/25 priorities Last year, we upheld our commitment to delivering the highest standard of care, influenced by various national, regional, local, and trust-wide factors. Throughout the year, we encountered unprecedented demand on our services, contending with challenges related to operational, capacity, patient flow, infection prevention, and safety. Despite these difficulties, we were confident in our ability to maintain our focus on quality priorities. Our teams worked diligently to achieve their goals under these challenging circumstances. We are proud to present our accomplishments and how our successes have continued to enhance the quality of services we provide to those who rely on us. 6 QUALITY ACCOUNT Overview of success Core dimension Patient experience Patient safety Clinical effectiveness Quality priority Progress Exploring the provision of a support centre for people using our services. Creating a behaviour framework behind our values, bringing them to life to improve our patient and staff experience. Volunteering - a new focus. Achieved On hold Achieved Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm. We will ensure that Fundamentals of Care (FoC) are provided to all our patients in collaboration with our patients, their family, and their carers. Improving our morbidity and mortality (M&M) meetings. Achieved Achieved Achieved Develop the Trust’s approach to reducing the impact of health inequalities (HIs). Help develop a UHS quality management system approach. Achieved Achieved 7 QUALITY ACCOUNT 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports Quality Improvement Priority One: Exploring the provision of a support centre for people using our services (year one) Why was this a priority? UHS is a regional centre for many disease types, but we recognise there is inequality in provision of support facilities in the Trust for all our patients and their friends and families regardless of their clinical conditions. While cancer patients have access to designated centres such as The Maggie’s Centre and Macmillan facilities, other disease types have no comparable options despite often having enhanced needs. Patients who are nearing the end of their life are frequently spending their final days in bays with other patients as side rooms are prioritised for isolation purposes, and there are few areas available that can accommodate a hospital bed for patients to have time with their family away from their clinical setting. Apart from the UHS Patient Support Hub, there are no designated spaces that are accessible for patients, families, or carers, often resulting in staff offices and education rooms being inappropriately repurposed to meet their needs. Growing feedback from complaints and Friends and Family Test (FFT) responses emphasis our inability to provide patients, carers and their families access to spaces for respite and support. In addition, a recent UHS carers survey indicated that while we recognise that being a carer can sometimes be demanding both physically and emotionally, there are no designated areas for them to have their own personal needs met. Creating a bespoke support facility at UHS would help to address these needs and would be the first facility of its kind in an acute trust in England. What have we achieved? Estate has been identified. Work has started to repurpose the underutilised Macmillan Centre into a generic non-disease specific Patient and Family Support Hub. This agreement made through the Trust Investment Group was to end the current agreement with the Macmillan charity and to approach Southampton Hospitals Charity to support a refurbishment and further investment into the hub (for example funding a carers shower provision). Key areas identified for further development • Major grant request submitted to Southampton Hospitals Charity due to go to Charity Trustee Board in March 2025. • Recruitment of a band 7 mnager role (appointed in January 2025 and starting 31 March 2025); • Rebranding and merging (of current Patient Support Hub) started in February 2025. 8 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? Once the Patient and Family Support Hub is launched there will be a constant drive for patient and service user involvement, co-designing the space, there will be surveys on before and after, end of life quality of care will improve Progress metrics • Reduction in adverse event reporting that a patient died in an open bay. • Carers survey improvement. • P&FSH FFT results. Quality Improvement Two: Creating a behavior framework behind our values, bringing them to life to improve our staff and patient experience Creating a behaviour framework behind our Trust Values to bring them to life in our everyday work and interactions is still very much a priority. However, the work has been paused to ensure it aligns to the development of the new Trust strategy, both these pieces of work need to be produced side by side. It is anticipated the work on the behaviour framework will commence alongside the development of the overall Trust strategy and timelines for launch and embedding will move to 2025/26. 9 QUALITY ACCOUNT Quality Improvement Priority Three: Volunteering Why was this a priority? To value the contribution our volunteers make to our organisation, we wanted to improve the onboarding process to provide more guidance and support for our volunteer colleagues, and to work with them more closely to build in flexibility and be more creative in the kind of roles and support they could offer. What have we achieved? • We worked with our systems partners to complete a successful bid through Volunteering for Health (VfH) and have plans to develop a unified and standardised approach of volunteer recruitment using a passporting system. • Our key relationship is with the Hampshire and Isle of Wight Voluntary Community and Social Enterprise (VCSE) sector Health and Care Alliance (HIVCA) and it has allowed us to further explore a more system-wide approach, with a view to sharing resources, ideas, and opportunities both internally and outside the organisation on a regular basis. • We have worked with HIVCA and fostered a collaborative learning environment, aiming to streamline and standardise the volunteer onboarding processes over the coming year. • We have built upon current onboarding and training processes and are particularly developing the enhanced care training for our volunteers to support their awareness of working alongside patients who have mental health issues, dementia, delirium, learning disabilities and autism. • We are working with information governance leads to consider how the Trust’s internal policies can create equitable opportunities for a range of volunteers, to support them in accessing limited patient records, to allow them to document the interactions that they have with patients in support of the provision of collaborative holistic care. • We have begun to develop a new “ABC” approach to offering our volunteering roles, codesigning new roles for volunteers, and providing a flexible ‘responsive volunteering’ process that can support the organisational pressures as they arise and dovetailing the offer from our experience of care teams. • We have started to build relationships with the NHS care responder volunteer’s service looking at how they can enhance our existing offering provided by our responder volunteers. Key areas identified for further development • We have more scope to develop a more robust support process for volunteers during their placements through building better relationships between the volunteers and their clinical teams. • We will grow our volunteering hub space in spring 2025, to offer a more effective space for volunteers to access practical and welfare support from voluntary services, giving them a clear base and point of contact. • Working with HIVCA in the system-wide partnership, we will continue to explore the VfH funding and how it can develop the ‘passporting’ system for the volunteers across the network. • As our new Patient and Family Support Hub becomes established, we will work with the NHS responders and our existing responder volunteers to ensure a more extensive five to seven day/ week service (including evenings). 10 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? The key metrics for measuring these outcomes will come from: • Our responder volunteer statistics through the Patient and Family Support Hub. • Our outcomes associated with the HIVCA partnership and the VfH bid i.e. progress with a passporting system including potential recruitment of a post to develop and establish this new system. Progress metrics • Year one funding from the VfH bid was received by the partnership to develop the partnership with the HIVCA support meetings every six to eight weeks. • The system-wide volunteer onboarding and passporting system has not yet been established but will continue to progress with the partnership. • We will have developed a responsive volunteer network, available five days a week with an established support system in place. • We are an open and inclusive recruiter of volunteers and monitor the equality, diversity and inclusivity of the volunteers we recruit, seeing a more diverse range of volunteers that begins to more accurately represent our local community. What our patients/relatives/carers tell us 11 QUALITY ACCOUNT 12 QUALITY ACCOUNT Quality Improvement Priority Four: Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm ADULTS AND PAEDIATRICS Why was this a priority? The recognition, assessment, and escalation of a deteriorating patient either adult or child are a key element of our trust-wide patient safety and quality strategy with the aim of improving clinical outcomes for acutely ill patients. How rapidly we respond to patient deterioration both in and out of hours is a key determinant of patient and quality outcomes. What have we achieved? Five new starters have successfully completed their supernumerary period. The critical care outreach team (CCOT) resumed its 24/7 service on 16 December 2024. Recruitment for the final vacancies was completed in December 2024, with both new recruits scheduled to commence their roles by 31 March 2025. An education task and finish group has been established, which has conducted a gap analysis with all education leads and reviewed both internal and external training resources. Standards are currently under revision. The medical education and simulation team is testing the Acute Life-threatening Events-Recognition and Treatment (ALERT) course, which includes resident doctors and junior nurses. Initial feedback was presented to the deteriorating patient group on 25 September 2024. The Trust’s acute deterioration education day continues to review feedback and evaluations for study days. The acuity surveillance pilot was successful, and the CCOT is now formally implementing this initiative. Monthly acuity reports are generated at the Trust, division, care group, and ward levels, or through bespoke reporting. These reports incorporate various metrics, including National Early Warning Score 2 (NEWS2) and National Paediatric Early Warning Score (NPEWS) activations, Call 4 Concern activations, a 24-hour overview of NEWS2 activations, cardiac arrest calls, CCOT activations and reasons for referral, and unplanned admissions to the intensive care unit (ICU). Quarterly data on cardiac arrests, Treatment Escalation Plans (TEP), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) are presented to the resuscitation committee and the deteriorating patient group (DPG). Challenges persist in collecting robust sepsis data. UHS is participating in the national Martha’s Rule pilot programme, with Call 4 Concern implemented in March 2024 and all activations reported on Ulysses. A task and finish group has been established to explore patient wellness questions, which is a fixed agenda item at the DPG. The bi-monthly DPG has been established, with increasing medical engagement, and regular reports are submitted to the patient safety and quality committee (PSSG). Key areas identified for further development • Further roll out of Martha’s rule UHS-wide including Call 4 Concern. • Gain feedback from divisional governance teams regarding incidents to ensure learning is identified and appropriate action plans are devised and implemented. Collaboration with maternity and neonatal services. • Development of acuity dashboard. • Medium- and long-term service development commenced including workforce planning. 13 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? • Bimonthly deteriorating patient group meetings to review current trends and themes, implementation of appropriate actions and evaluation of actions. • Biannual review of deteriorating patient group terms of reference. • Quarterly report to patient safety steering group. • Yearly assurance report – Trust quality committee. Progress metrics • Patient observation compliance data. • NEWS2 and NPEWS activations and data analysis. • Analysis of all unplanned admwissions to ICU from ward areas – adult and paediatric for themes to inform education and practice. • Adult and paediatric ICU stepdown data. • Adult critical care outreach team activity and outcome data. • Adult and paediatric cardiac arrest and outcomes data. • Adult TEP & DNACPR data. • Complaints and adverse event reports related to failure to rescue and failure to escalate. • Percentage of patients diagnosed with sepsis within the emergency department receiving appropriate antibiotics within one hour of sepsis diagnosis. • Analysis of adult and paediatric Call 4 Concern data, action plan developed, implemented, and adjusted in response to themes. • Analysis of patient/service user feedback on Call 4 Concern service. • Analysis of staff feedback on Call 4 Concern service. Volunteers and quality patient safety partners helped to promote the Call 4 Concern work 14 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Why was this a priority? Patient Experience - Fundamentals of Care (FoC) was established as a priority in 2024/25 due to evidence that post COVID we had not yet returned to a less task-focussed and more patientfocussed level of care. The priority was developed to create a foundation and structure to tackle these care standards of care and to challenge practices, in response to patient and relative feedback. What have we achieved? Since commencing in late 2023 the following has been achieved: • We have established the FoC project board and this group continues to meet every three months to provide an overall project view, share successes and opportunities for learning, discuss the workstreams continuing under the eight standards and to escalate challenges through a formal governance structure (through quality committee and QGSG). • We have had one quality patient safety partner (QPSP) on the project board since conception. Subsequent events have involved two other QPSPs and have broadened the ‘patient voice’. • Each of the standards has a lead who oversees a multi-professional working group with clinical team representation. Some groups have chosen to pair due to links in their primary and secondary project drivers and actions. Matron involvement is driving the patient facing team involvement. • The project board is minuted, with an action tracker. The board is attended by the corporate nursing team and is supported by our deputy chief nurse, chaired by our head of patient experience. It is also supported by our chief nursing informatics officer, members of the transformation team and communications. • There is a FoC project manager in place who has worked with the transformation team to create a project plan in collaboration with workstream leads, a communications plan and drive forward key initiatives including business intelligence and the development of a clinical quality dashboard so we can measure the impact of the FoC. • Enhancing leadership and role modelling of the FoC has been a key focus through leadership in practice study days. These sessions, held three times annually, target leaders across the organisation to address and challenge behaviours related to the FoC. Incorporating the patient voice, these study days are grounded in real patient stories and involve the practical application of skills using simulated patients. 15 QUALITY ACCOUNT • As part of the patient hygiene working group, we have undertaken surveys using volunteer support, of patients and staff in the clinical decision unit (CDU), acute medical unit (AMU3), trauma assessment unit (TAU) and Macmillan acute oncology service (MAOS) in relation to their experiences of patient hygiene care and the impact of the trial patient hygiene packs. • Existing surveys, PALS interactions, complaints, adverse event reports (AER), Friends and Family Test (FFT) are followed up and reviewed by senior managers accordingly. These inform the FoC workstream through the head of patient experience. • Since conception, sharing the patient perspective and reflecting what patients would like to hear from us has been key. The posters around the organisation on our care commitments and resources on staffnet and the virtual learning environment (VLE) for staff, support this. These resources include: o Resources developed by each group to share during the monthly focussed trolley dashes. o Videos developed by staff for staff, to improve awareness of some key facts about each of the eight standards. Staff on Bassett ward engaging patients with dementia in crafting activities • Strong presence of the FoC throughout education as it has been mapped to the health care support worker (HCSW) induction, is included on preceptorship for all staff groups, has been presented to some university students at the University of Portsmouth and is embedded in lots of local training and development initiatives. The head of patient experience delivers many sessions across the organisation and beyond. Head of patient experience engaging with clinical staff in cardiovascular and thoracics on how to assess the FoC in their area 16 QUALITY ACCOUNT • The What Matters To Me (WMTM) project was trialled in some clinical areas from October 2024 (F7 and G7). Due to challenges in engaging the volunteer support to maintain this project it has temporarily been halted. The boards have an agreed template, agreed by a QPSP, and based upon feedback from staff and patients. The values of this project are echoed in local projects we have seen. • The FoC is being reviewed in conjunction with matron walkabout and the clinical accreditation scheme (CAS). Starting in February 2025, a new monthly focus is being established, with five core questions associated with a FoC standard and five specialist questions associated with that topic. This is forming past of ward benchmarking with a new self-assessment tool being implemented. Key areas identified for further development • Clinical representation in these working groups is to be re-established/built upon to support further engagement in the clinical areas/teams. • Continuing to establish links and support in child health, maternity and outpatients to ensure a bespoke but collaborative roll out of FoC. • To continue strong patient engagement and involvement, linking with involved patients where required with the support of our existing FFT results, the national inpatient and urgent and emergency (U&E) care surveys. • Resources to continue to grow to create a repository of information for staff and develop their knowledge around the FoC and to support each other in challenging behaviours and practices. • Employ interim project manager to maintain the project and support new ones whilst the current project manager is on maternity leave, focusing on establishing the dataset to evidence the FoC. • Strengthen the recruitment of volunteers for WMTM through the successful bid to Volunteering for Health (VfH) through the recruitment and investment in a volunteer coordinator, as part of a partnership with other organisations in Hampshire and Isle Of Wight (HIOW), including the charity sectors. • Successful implementation and evaluation of WMTM boards across key areas in organisation, with full volunteer support for the obtaining of photographs of the patients from themselves/ families to maintain that person-centred focus. How will ongoing improvements be measured and monitored? Improvements will be measured and monitored through FFT feedback, feedback from selfassessment tools and ongoing surveillance of the clinical quality dashboard. Progress metrics Reduction in clinical Iincidents: We’ve seen a decrease in the number and severity of incidents related to the FoC across inpatient settings. A key theme in early 2024 involved patients reporting being asked to urinate in incontinence pads. Six adverse event reports (AERs) were recorded in Q1, with none reported in Q3, indicating improvement. Reduction in complaints: While we don’t yet tag complaints specifically to FoC, we’ve observed a decline in ‘patient care’ complaints - from 14.67% in Q1 to 13.91% in Q3. We’re also exploring refinements in complaint categorisation to better align with FoC themes. 17 QUALITY ACCOUNT Increase in compliments: Patient and family feedback is gathered through various channels. For example, our urgent and emergency care survey showed an overall satisfaction score of 7.68/10. Improved oerformance against metrics: Throughout 2024, we’ve redesigned our improvement metrics in collaboration with clinical teams. These are now reflected in the clinical quality dashboard, supported by a comprehensive data dictionary developed by our project manager. 18 QUALITY ACCOUNT Quality Improvement Priority Six: Improving our morbidity and mortality (M&M) meetings Why was this a priority? The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents. It supports our processes for learning and improving patient safety and clinical effectiveness and replaces the old serious incident framework. An important element of the PSIRF is the focus on strengthening the processes for local learning through M&M meetings. M&M meetings (or clinical review meetings) have a central function in supporting our services to achieve and maintain high standards of care. They allow us to review the quality of the care that is being provided to our patients and learn lessons from outcomes. They are multi-disciplinary meetings which provide a safe place for learning, for supporting comprehensive conversations and ensuring governance standards are met. They allow us to identify any opportunities for improvement and are an important opportunity for education. They also provide opportunities for senior staff to model appropriate professional behaviour and engage the significant expertise of clinicians at the point of care. There is also a growing trend in M&M meetings to identify how resilience within complex systems enables good outcomes in the face of the kind of challenges and uncertainties which we are experiencing, and which are inherent within healthcare delivery. What have we achieved? The medical advisor for patient safety is leading efforts on morbidity and mortality (M&M) meetings. A comprehensive framework for M&M meetings at UHS has been developed, establishing expectations for a safe learning environment that is multiprofessional and multi-disciplinary, with a systematic meeting structure and agenda focused on learning, governance integration, and patient-centred care. This framework is supported by a handbook, resources, and education for M&M leads. A dedicated Teams channel has been created to provide resources for M&M leads. An M&M workshop was held as part of the WHO Patient Safety Day on 12 September 2024, focusing on creating strong learning environments, maintaining patient centrality, and learning from palliative care. The workshop was attended by 20 M&M leads and governance representatives. Additionally, 20 M&M leads attended a study day on 23 January 2025, covering topics such as human factors and systems thinking, PSIRF, keeping the patient central, appreciative inquiry in M&M, creating strong learning environments, managing difficult behaviour, and expanding the scope of M&M beyond mortality. The study day was well received, and another is planned for early April. Regular meetings are held with M&M leads and the medical patient safety advisor to provide support and identify areas needing assistance. An electronic M&M recording system was developed and trialed to capture and evidence outcomes, but it is no longer supported by the Trust, prompting the investigation of alternatives. A clear escalation process from M&M meetings to the existing governance structure has been established, with actions recorded. M&M meeting outcomes are now a standing agenda item in governance meetings. 19 QUALITY ACCOUNT UHS - 6 key principles of M&M Safety A safe space for learning. A meeting atmosphere that is conductive to open discussion with a focus on ‘Just and Learning Culture’ and an emphasis on understanding the systems factors, not focusing on individuals. Multiprofessional and Multi-disciplinary Ensuring active participation across staff groups and different disciplines. Meeting Framework Systematic agenda selection process, structured meeting format and objective analysis of data, including consideration of systems factors, and human factors and ergonomics. Learning Focus Comprehesive discussions to generate actionable learning and system improvement. Using an appreciative inquiry approach to emphasise and learn from the every day, as well as where things can go wrong. Governance Hospital-wide system to record outcomes, lessons learned, and dissemination of recommendations to ensure action and learning. Supporting our integrated approach to quality across the organisation. Folow up to ensure actions are completed. Clear pathways for central reporting and escalation of concerns. Patient Centred Keeping the patient and the family central to the learning. Ensuring that the patient voice is heard when learning from events. Completing feedback and duty of candour to help build trust. Training as part of the WHO World Patient Safety Day: Discussing how to create psychological safety in meetings 20 QUALITY ACCOUNT Key areas identified for further development • Development of electronic recording process that can be used for all M&M meetings. • Need to develop stronger links and greater support from local governance. How will ongoing improvements be measured and monitored? Regular review of M&M meetings with the M&M leads to ensure that: • M&M meetings are represented by the multi-disciplinary. • Terms of reference are in place. • Incorporating mortality data. • Using a recording app (when available). • Outcomes are linked to actions and governance processes. Progress metrics The electronic recording system is not currently supported so we cannot measure this (and it makes it hard to audit actions and escalations as these would be audited via this). Survey of clinical staff (163 replies) and their view on M&M. Key findings: • 73% staff feel UHS views the meetings as important. • 75% that their department views these as important. • 60% that they are fit for purpose. • 75% that they make a difference to patient safety. • 80% agree that systems factors are considered. • 35% felt they were well supported by local governance. 21 QUALITY ACCOUNT Quality Improvement Priority Seven: Develop the Trust’s approach to reducing the impact of health inequalities (HIs) (year one) Why was this a priority? The causes of health inequalities are complex, but research has shown that the main drivers of health inequalities are social determinants; the environments people live in, access to employment and the kind of start they had in life. Inequalities are also driven by the ways in which health services are designed and delivered, and by the quality of clinical care received. The NHS plays an important role in both mitigating against the wider determinants and in reducing healthcare-based inequalities. As well as a moral and social responsibility, NHS trusts have a legal duty to consider health inequalities. A new requirement from NHS England asks that trusts describe the extent to which they have exercised its functions consistently with NHS England’s views set out in the statement on information on inequalities. Addressing health and care inequalities is a core focus of the CQC’s 2021 strategy. To reinforce this commitment, the CQC has outlined five equality objectives aimed at tackling disparities in health outcomes. They have made it clear that action will be taken where care falls short for particular groups. Providers are expected to proactively identify, engage with, and respond to individuals who face barriers to accessing care or experience poorer outcomes. These efforts will be reflected in the CQC’s assessment frameworks. Failure to address health inequalities also carries a significant financial burden for NHS trusts. Estimates suggest these disparities cost the NHS around £5.5 billion each year. Eliminating health inequalities could potentially reduce the volume of treatments provided by the NHS by up to 15%, easing pressure on services and resources. What have we achieved? Governance A health inequalities board has been convened, chaired by the chief medical officer and attended by representation across UHS, patient partners, public health teams from the local councils and the population health team within the integrated care board. The board has set some initial objectives. These will be delivered through five areas of focus, each with a dedicated sponsoring director and a detailed delivery plan. These areas of focus are: • Clinical priorities. • Data and measurement. • Enabling the organisation. • Communications and engagement. • Strategy and approach. Clinical priorities Three clinical priorities have been set, based on national guidance on services where there is greatest health inequalities impact. The public health leadership from the local councils and integrated care board were involved in this prioritisation to ensure that we chose areas with high prevalence locally, and where it was felt an acute trust can have greatest impact. Priorities set are tobacco dependency, hypertension and obesity. 22 QUALITY ACCOUNT Tobacco dependency In Southampton, smoking rates are higher than the national average. It is estimated that one in six Southampton deaths are attributable to smoking (JSNA, 2021). 70% of our lung cancer patients and 86% of our COPD patient deaths are directly attributable to smoking. People who smoke are 36% more likely to be admitted to hospital than non-smokers and have poorer treatment outcomes including reduced response to treatments, prolonged recovery and increased risk of complications, across many areas including surgery, cancer and cardiovascular disease (Royal College of Physicians, 2020). This leads to increased length of stay, higher rates of emergency department attendance and greater pressure upon outpatient clinics due to smoking-related comorbidities. We have been focusing on improving identification of those who have been admitted who smoke, increasing the delivery of very brief advice to all patients who smoke and increasing referral to tobacco dependency services on the ward for those who do not opt out. We’ve been reviewing our data to understand how we are supporting those most at risk of being impacted by health inequalities. Obesity In 2022 to 2023, 29.5% of adults in Southampton were estimated to be living with obesity, above the national average. Southampton has one of the highest childhood obesity rates in the county. There are a large number of conditions linked with obesity, including cardiovascular disease, hypertension and liver disease. There is a multi-disciplinary service provided at UHS for children which provides excellent outcomes, reversing clinical impacts such as hypertension and type two diabetes. This programme seeks to identify opportunities to collaborate with our system to prevent the increasing levels of childhood obesity, reflecting the national focus on left shift and prevention. Adult obesity services are in review across our system. Hypertension Hypertension is amongst the leading causes of death in Southampton and Hampshire. High blood pressure causes threat to life expectancy linked with stroke, vision loss, heart failure, heart attack, kidney disease/failure. Hypertension identification and control have both been a challenge across Hampshire and Isle of Wight. Although hypertension treatment is delivered in primary care, there are actions we are taking as a trust to support this important priority. This includes: • As the largest employer in the city we have the opportunity to improve health by supporting our staff. We are developing materials to support our staff to understand the importance of blood pressure monitoring and approach to accessing help with high blood pressure. We hope this knowledge will extend to families, communities and how we support our patients. • Support people to ‘wait well’ whilst on our waiting list, with improved guidance on controlling and monitoring blood pressure while waiting for surgery, reducing the number of cancelled procedures due to high blood pressure. • Consider how improved data sharing on blood pressure readings between UHS and GPs can support onward support for hypertension. 23 QUALITY ACCOUNT w Data and measurement Several positive steps have been taken in measuring and understanding health inequalities within our services. These have been: • Building new dashboard that enables us to assess whether access to our services in equitable related to IMD decile, age, gender and ethnicity. • Assessment of equitable delivery of smoking cessation services. • Assessing the acute impact of hypertension control. • Collaborating with the Integrated care board on producing the data required for national reporting guidelines. Enabling the organisation We wish to support staff across our organisation to understand health inequalities, to recognise them within services, to access to tools to enable service change and to have routes to escalate issues. We have appointed a health inequalities officer who will be a key link to support services to achieve this. We have begun developing training that will be available across the organisation. We have also established escalation routes for raising concerns related to health inequalities. Communications and engagement There have been a number of excellent case studies communicated during this year through existing communications channels such as the Connect magazine. HELIXR, a pioneering programme that supports vulnerable patients with chronic liver disease through the introduction of peer support workers, attracted news coverage and was featured on the BBC and ITV Meridian in March. We have been attending events across Southampton including Pride and the Black Business and Arts Festival to show our support and to connect with our communities. We’ve been reaching out to grow the number and diversity of our involved patients, aiming to reflect the diversity of our population in our feedback and helping us to better serve the needs of our community. Strategy and approach We have worked on establishing this approach to delivering health inequalities over the year, which is now seeing results in progress in all prioritised areas for improvement. We have taken discussions to our Trust Board to establish how we will move this important work forward in years to come. We have also reflected on how population health, prevention and health inequalities will feature in our developing updates to our trust and clinical strategies. Key areas identified for further development There are detailed delivery plans for all of our priority areas over the next year, which will enable us to keep driving towards our aims. Highlights from these plans include: • Designing and publishing health inequalities training for all staff. • Creating an internal staff campaign, recognising the impact of health inequalities within our people and providing advice. • Establishing a health inequalities operational group who receive escalations of health inequalities issues and assess trust-wide implications and support improvements. • Delivery of planned improvements within our three prioritised clinical specialties. • Connecting with our communities and engagement leads across our city, improving our insights into the local drivers of health inequalities and identifying improvement opportunities. • Reviewing our use of QEIAs for change and decision making. 24 QUALITY ACCOUNT • Development of Trust and clinical strategies with making impact on health inequalities included. • Making use of the data sets we have built to drive change within our services and measure our impact. How will ongoing improvements be measured and monitored? We have clear objectives against all priorities with delivery timelines. We will continue to assess our progress in delivering against these. The dashboards that have been built will enable us to measure change over time, demonstrating where we have been able to impact on the equality of access to services. We will continue to work with our patients to gain feedback on how well we have met their needs while under our care. Progress metrics During 2024/25, we significantly advanced data capabilities to measure health inequalities across UHS services. We now track outpatient and inpatient waiting lists, discharges, and emergency department performance by age, gender, ethnicity, and Index of Multiple Deprivation - enabling long-term impact assessment. Staff access to this data will also be monitored. While some planned measures were successfully implemented, others remain in progress and will continue into year two (2025/26) of this quality priority. As part of our hypertension programme, we aimed to reduce theatre cancellations and non-elective admissions. Pathway improvements are underway and will be implemented in 2025/26, supported by expanded data sources. Combined with the Hampshire and Isle of Wight Intergrated Care Board’s (HIOW ICB) cardiovascular disease (CVD)-focused ‘signature move’ in primary care, these efforts are expected to reduce non-elective admissions. HIOW ICB data for 2024/25 shows: • ~95 CVD-related ED attendances/month • ~420 non-elective admitted episodes of care/month • ~2,340 bed days/month Our tobacoo quit rates continue to be better than expected nationally. Throughout the year, the health inequalities board reviewed case studies from eight services, showcasing impactful improvement work. These have been documented to support organisational learning. 25 QUALITY ACCOUNT Quality Improvement Priority Eight: Develop a UHS quality management system approach (year one) Why was this a priority? In April 2023, NHS Improving Patient Care Together (IMPACT) was launched to support all NHS organisations, systems, and providers at every level (including NHS England) to have the skills and techniques to deliver continuous improvement. NHS IMPACT’s five components form the basis of all evidence-based improvement methods and underpin a systematic approach to continuous improvement: • Building a shared purpose and vision. • Investing in people and culture. • Developing leadership behaviours. • Building improvement capability and capacity. • Embedding improvement into management systems and processes. Taking a more integrated quality approach is also a key component of our ‘always improving’, clinical effectiveness and Trust strategies in support of our ‘outstanding patient outcomes, safety and experience’ strategic pillar. To establish our current position, the Trust undertook a self-assessment to gauge its organisational maturity against the IMPACT framework and identified ‘embedding improvement into management systems and processes’ as an area of opportunity to improve and employ best practice. It was also a recommendation from the Thirlwall Inquiry that organisations focus on their ability to triangulate different quality indicators to build
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

(Refusing) Consent for surgery

Description: Two recent cases with similar facts have resulted in different outcomes.
Url: /HealthProfessionals/Clinical-law-updates/Refusing-Consent-for-surgery.aspx

Papers Trust Board - 7 January 2025

Description: Date Time Location Chair Observing Agenda Trust Board – Open Session 07/01/2025 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Fatemeh Jenabi, Specialty Registrar (shadowing Joe Teape) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 5 November 2024 9:15 Approve the minutes of the previous meeting held on 5 November 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 Dave Bennett, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 Tim Peachey, Chair including Maternity and Neonatal Safety 2024-25 Quarter 2 Report 5.4 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 Break 10:35 5.7 Finance Report for Month 8 10:45 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 ICB Finance Report for Month 8 10:55 Receive and discuss the report Sponsor: David French, Chief Executive Officer 5.9 People Report for Month 8 11:05 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Freedom to Speak Up Report 11:15 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.11 Guardian of Safe Working Hours Quarterly Report 11:25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 5.12 Learning from Deaths 2024-25 Quarter 2 Report 11:35 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendees: Natasha Watts, Deputy Chief Nursing Officer/Jenny Milner, Associate Director of Patient Experience 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report 11:45 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Lead Infection Control Director/Julie Brooks, Deputy Director of Infection Prevention & Control 5.14 Annual Medicines Management 2023-24 Report 11:55 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist 5.15 Annual Ward Staffing Nursing Establishment Review 2024 12:05 Discuss and approve the review Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Rosemary Chable, Head of Nursing for Education, Practice and Staffing Page 2 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:15 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Annual Assurance for the NHS England Core Standards for Emergency 12:25 Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Joe Teape, Chief Operating Officer Attendees: John Mcgonigle, Emergency Planning & Resilience Manager/ Danielle Sinclair, Deputy Emergency Planner 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 March 2025 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 7 January 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB Finance Report for Month 8 5.9 People Report for Month 8 5.10 Freedom to Speak Up Report 5.11 Guardian of Safe Working Hours Quarterly Report 5.12 Learning from Deaths 2024-25 Quarter 2 Report 5.13 Infection Prevention Control 2024-25 Quarter 2 Report 5.14 Annual Medicines Management 2023-24 Report 5.15 Annual Ward Staffing Nursing Establishment Review 2024 7.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPPR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3a, 3b 1b 1c All 1b, 3a 1a, 3a, 5b, 5c Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 3x3 9 4x4 16 Open (Technology & Innovation) 3x3 9 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4 x3 12 4x3 12 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 3x5 15 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x3 6 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x x x Minutes Trust Board – Open Session Date 05/11/2024 Time 9:00 – 11:30 Location The Ark Conference Centre, HHFT/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 5.1) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Ali Keen, Head of Cancer Nursing (AK) (item 4.11) Kelly Kent, Head of Strategy and Partnerships (KK) (item 5.1) 4 governors (observing) 2 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since September 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 10 September 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 10 September 2024. 3. Matters Arising and Summary of Agreed Actions In respect of action 1175, it was noted that there had been an increase in the number of incidents of delays in giving of medication or pain relief, missed symptoms, and insufficient staffing numbers. However, in part the increase in numbers of incidents was considered to be due to efforts to encourage reporting of such incidents, and the situation had improved more recently. It was agreed to close this action. Page 1 It was noted that there were no other matters arising or overdue actions. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: • The committee reviewed the lessons learned from the 2023/24 annual accounts, and noted that the issues encountered should be resolved in time for the 2024/25 accounts due, largely, to the implementation of a new finance system. • The committee also received a report in respect of the risk of impersonation fraud for bank/agency staff and the procedures that had been put in place to mitigate this risk. 4.2 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The committee had reviewed the Finance Report for Month 6 (item 4.7) and discussed the Trust’s re-commitment to its 2024/25 plan in support of its request for deficit support funding from NHS England. • The position in respect of cash was challenging and the committee discussed what the Trust should do in the final quarter of 2024/25. It was noted that the rules on when and how much cash support could be requested were somewhat unclear. • The committee discussed a potential expansion of the activities of UHS Pharmacy Limited, although it was subsequently noted that the specific potential opportunity had since failed to materialise. • The committee also discussed the Trust’s financial recovery programme. 4.3 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 21 October 2024, the content of which was noted. It was further noted that: • The Trust had been below its plan in terms of whole-time-equivalent (WTE) numbers, although this position would change from October 2024 onward due to the onboarding of newly qualified nurses and the failure of the Integrated Care System transformation plans to deliver in terms of reduction in patients having no criteria to reside and mental health support. • The committee noted the cumulative impact on staff of having to balance staff numbers, performance, and patient experience. • Whilst noting that the annual appraisal rate remained low, it was suspected that more appraisals than recorded had taken place, but that these had not been recorded on the Electronic Staff Record. 4.4 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to present the Committee Chair’s Report in respect of the meeting held on 14 October 2024, the content of which was noted. It was further noted that: Page 2 • Patients’ access to a rehabilitation and recovery service during and after intensive care unit (ICU) admission was limited due to a lack of service provision. The Trust was non-compliant with national guidance in this area. • Due to resource constraints the Trust was unable to systematically roll out the National Safety Standards for Invasive Procedures (NatSSIPS) 2. However, it was noted that a solution to this issue was being considered. • There had been no significant improvement in terms of the Trust’s system partners in respect of supporting the Trust with mental health admissions. • The committee also reviewed the Maternity and Neonatal Safety Report, based on data available at September 2024, and including the NHS Resolution Maternity Incentive Scheme Year 6 progress update, the local response to the Care Quality Commission’s National Report Review of Maternity Services in England 2022-2024, and the Antenatal and Newborn Screening Annual Report 2023/24. 4.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • Whilst the commitment in the Autumn Statement to additional funding for the NHS was welcomed, it was unclear at this stage what this additional funding will mean in practice and how it would be allocated. • There had been recent media coverage of the Trust’s ongoing dispute with its porters following a press release by the UNITE union. • Arbitration proceedings were expected to commence in respect of a long- running dispute with BAM Construction relating to the construction of the east wing annex building. • Significant changes in employment legislation were anticipated between now and 2026, although, due to the nature of employment conditions in the NHS, it was not anticipated that these changes would have a significant impact on the Trust. • The new combined community provider, Hampshire and Isle of Wight Healthcare NHS Foundation Trust was launched on 1 October 2024. • A meeting had been held with the now independent hospital charity to discuss priorities over the medium term. • The national NHS staff survey had launched on 20 September 2024 and would run until 28 November 2024. It was noted that the participation rate thus far had been below that seen in previous years. • The Trust’s quality and patient safety partners programme had won the ‘Patient Involvement in Safety’ award at the Health Service Journal’s Patient Safety Awards on 16 September 2024. • There was a concern that the Government’s intended 10-Year Plan for the NHS, which was expected to redirect focus on prevention and community healthcare, could result in an immediate loss of funding for acute providers, i.e. before the longer-term preventative measures had had an opportunity to take effect. 4.6 Performance KPI Report for Month 6 Joe Teape was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s overall performance was good compared to other teaching hospitals. In August 2024, the Trust was first for its 65-week wait performance, and second for the 60-day cancer metric. Page 3 • The month of October was proving to be challenging with increased bed occupancy and surge capacity having to be opened. Type 1 Emergency Department attendance was over 400 per day. • Whilst there had been improvements in the length of stay, the impact of this had largely been negated by the high demand being experienced. • The ‘W-45’ initiative was to be implemented at the end of November 2024, whereby ambulances would automatically hand over patients to emergency departments after 45 minutes. It was noted that this policy would potentially put strain the relationship between the Emergency Department and the South Central Ambulance Service (SCAS). • It was noted that there were potential issues with the data presented in terms of the number of virtual appointments and use of MyMedicalRecord. The Board discussed the high levels of attendance in the Emergency Department. It was noted that: • The Trust’s winter plans did not assume 400 attendances per day. • Attendances were typically of higher acuity, and did not appear to be as a result of patients being unable to access GP services. • The Trust had a number of projects underway in order to direct patients to alternative routes into the hospital, such as through the Same-Day Emergency Care service. • The importance of ensuring the wellbeing of staff during such a period of sustained demand was also noted. • In addition, the Trust had requested funding for GPs in the Emergency Department as had occurred in previous years as a means of reducing demand on the Emergency Department. Action: Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. 4.7 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had received additional funding in respect of 2023/24 Elective Recovery Fund (ERF) performance, funding for industrial action costs, and deficit support funding from NHS England. As a result, the Trust had recorded a year-to-date deficit of £8m, a variance of -£4.7m against plan. • The Trust’s underlying deficit continued to be £5-6m per month. • The Trust had 200-220 patients with no criteria to reside at any one time, and expected reductions in mental health demand had not been realised due to non-delivery of system programmes. • The Trust had also undertaken £17m of unpaid activity in the first half of 2024/25. • The Trust had recorded 130% ERF performance in month and 128% year-to- date. It also continued to maintain low bank and agency use, and had delivered £32m of Cost Improvement Programme benefits. • There was significant financial pressure throughout the NHS in England. 4.8 ICB Finance Report for Month 6 Ian Howard was invited to present the ICB Finance Report for Month 6, the content of which was noted. It was further noted that: • The report tabled to the meeting had been prepared by the Hampshire and Isle of Wight Integrated Care Board (ICB) for all providers in the system. Page 4 • The system’s 2024/25 plan targeted a deficit of £70m. • During the first half of 2024/25, the system had received £55m in deficit support funding from NHS England and a surplus of £20m would be required during the second half of the year in order to be able to meet its 2024/25 target. • Meeting the 2024/25 target would likely be challenging. • The system had yet to see any significant benefit from the six transformation programmes. • It was noted that the ICB report would benefit from additional information in respect of workforce and equality, diversity and inclusion. 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment Ian Howard was invited to present the paper ‘Recovery Support Programme (RSP) Undertakings – Self-Assessment’, the content of which was noted. It was further noted that: • In June 2024, the Trust, along with all other organisations in the Hampshire and Isle of Wight Integrated Care System (ICS) under the Recovery Support Programme had submitted a self-assessment in respect of the undertakings entered into in 2023. NHS England had provided feedback in respect of these self-assessments in August 2024. • All providers had been asked to provide a further self-assessment, which would then be incorporated into a system-wide response in January 2025. • The evidence supplied by the Trust in support of its self-assessment indicated significant engagement by the Trust’s Board with the organisation’s undertakings under the RSP as well as progress against these undertakings since the previous submission. • Factors such as the number of patients having no criteria to reside and other matters beyond the Trust’s control remained a concern in terms of the Trust’s ability to fully meet the undertakings. • The action plans for the ICS transformation programmes should be included as part of the Trust’s response to the request for a self-assessment. Decision Having discussed the proposed response by the Trust, the Board agreed the proposed self-assessment, and authorised David French and Ian Howard to submit it to the Hampshire and Isle of Wight Integrated Care Board, subject to there being no material changes prior to submission. 4.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The Trust was currently under its 2024/25 plan by 249 whole-time-equivalents (WTE). However, this situation was expected to change in October 2024 due to the impact of onboarding of newly qualified nurses and midwives, and also due to non-delivery of ICS transformation programmes in non-criteria to reside and mental health, which assumed a reduction of 167 WTE. • The Trust benchmarked well in terms of its sickness absence rate and turnover. • The Trust had plans to transfer recording of appraisals from the Electronic Staff Record to the Visual Learning Environment platform, which was considered to be more ‘user friendly’ and was therefore expected to improve recorded appraisal numbers. Page 5 • The Trust was in active negotiations with Unison in respect of the Band 2/3 pay dispute. • The People and Organisational Development Committee was to examine the overall workforce picture in more detail. 4.11 Cancer Patient Experience Survey Results 2023 Ali Keen was invited to present the Cancer Patient Experience Survey Results 2023, the content of which was noted. It was further noted that: • The survey involved 132 trusts, and had a 58% response rate at UHS (1,064 patients). • At the Trust 15 out of 59 questions scored above the expected range, which indicated that the Trust was a positive outlier when compared to trusts of a similar size and demographic. • Patients with longer-term health conditions and women tended to have worse experiences than other groups. • The care by and quality of staff at the Trust were rated highly. • There were opportunities for improvement in some areas such as administration and communication around appointments. 5. STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review Martin De Sousa and Kelly Kent were invited to present the Corporate Objectives 2024/25 Quarter 2 review, the content of which was noted. It was further noted that: • The report now incorporated a forecast for the end of year. • The overall picture was positive with 12 objectives shown as ‘green’, two as ‘amber’, and two as ‘red’. • The main areas of risk in terms of the objectives concerned the deliverability of a stretching financial plan. • The completion of year two of the Public Sector Decarbonisation Scheme was also at risk due to the state of steam duct tunnels, which required substantial remediation ahead of work commencing on the low temperature hot water system. 5.2 Board Assurance Framework (BAF) Update Craig Machell was invited to present the Board Assurance Framework Update, the content of which was noted. It was further noted that: • In September and October 2024, the Board’s committees had reviewed the BAF risks assigned to them, and the Audit and Risk Committee had reviewed the entire BAF. • As a result of these reviews, it had been agreed to increase the risk rating for Risk 1c (Infection Prevention Control) and to extend the target date. In addition, the target dates for all risks were to be reviewed to ensure that they were realistic. • The Board agenda now included an annex, which indicated where papers were linked to a BAF risk and the impact of any decision by the Board on the Trust’s achievement of its target risk rating. Furthermore, Board papers now Page 6 had a clear link to any relevant BAF risk included as part of the new cover sheet. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors’ (CoG) Meeting 23 October 2024 The Chair provided an overview of the meeting of the Council of Governors held on 23 October 2024. It was noted that the meeting had addressed the following matters: • Attendance at Council of Governors meetings • Appointment of a member of the Governors’ Nomination Committee • Planning for the Governors’ strategy session in December 2024 • Membership engagement • Feedback from the Working Groups • The external auditor’s report on the Annual Accounts In addition, on 31 October 2024, the Council of Governors had met with the Hampshire and Isle of Wight ICB to discuss future plans for the system and opportunities for collaboration between providers. 6.2 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7. Any other business There was no other business. 8. Note the date of the next meeting: 7 January 2025 9. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025 Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 05/11/2024 4.6 Performance KPI Report for Month 6 1181. MyMedicalRecord (MMR) Teape, Joe 07/01/2025 Completed Explanation action item Joe Teape agreed to investigate the data in respect of virtual appointment and MyMedicalRecord numbers presented for Month 6. Update: The issue was related to the MMR – drop-in logins in month and the increase in the previous month which was noted in the Month 6 report, as oncology had been added to the system and all patients notified in that month driving a surge in logins. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • • For month 7, the Trust had reported an in-month deficit of £4.5m and a £12.5m year-to-date deficit. The Trust was £9.2m behind plan. The non-delivery of system-wide transformation programmes represented approximately half of the overall deficit. The recent pay awards resulted in an additional £2m cost pressure. Elective Recovery performance was 125%, which was lower than previously due to operational challenges in October 2024, high levels of annual leave, and the performance achieved in October 2019 on which in-month performance was based. The Trust’s workforce numbers were beginning to increase as anticipated as newly qualified staff members were onboarded. The ongoing discussions with Unison in respect of the Band 2/3 pay dispute would likely lead to additional one-off costs as well as recurring costs if any pay increase were agreed. It was expected that the Trust would be below the NHS England minimum cash holding during Quarter 4. It was forecast that the Trust would deliver £67.7m of CIP for 2024/25 against £84.9m of identified schemes. The Trust’s Always Improving programme had succeeded in delivering a 3.6% reduction in length of stay. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Not applicable. Any Other Matters: • The committee received a quarterly update from Estates, Facilities and Capital Development. • The committee supported the Trust’s bid for external funding in support of the Southampton Elective Hub. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Finance & Investment Committee Meeting Date: 16 December 2024 Key Messages: • • • • The Trust’s financial position remains difficult despite significant levels of savings being delivered in areas such as patient flow, theatres, and outpatients. The main contributor to the Trust’s deficit continues to be non-delivery of system-wide transformation programmes, especially those concerning patients having no criteria to reside. The Trust was forecasting to achieve c.£67m of its cost improvement programme target for 2024/25, a shortfall of £17m against the identified opportunities. However, much of the unachieved amount assumed delivery of system transformation programmes. The Trust’s cash balance was initially expected to fall below the NHS England minimum holding level during Quarter 4. However, the Trust has received £12m of additional cash, which now means that the Trust’s cash balance should not fall below minimum required levels until Quarter 1 of 2025/26. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust’s in-month deficit was £5.7m and a year-to-date deficit of £18.2m, £14.8m behind plan year-to-date. • The Trust has carried out £21m of unfunded activity during the year. • The Trust continues to benchmark well in terms of value for money, and continues to apply measures to ensure financial grip and governance with strong controls in place. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • The risk rating for Risk 5a has been increased from 15 to 20 due to the deteriorating cash balance and the ongoing financial pressures. Any Other Matters: • The committee reviewed the outputs of the review of non-pay expenditure carried out by Deloitte. • The committee supported the outline strategy for a possible private patient unit. • The committee gave its support in principle for the Trust to bid for £1.75m of funding in support of the Trust’s Same-Day Emergency Care service. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.2 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: People & Organisational Development Committee Meeting Date: 13 December 2024 Key Messages: • • • • • The Trust’s substantive workforce grew by 7 whole-time-equivalents (WTE) during November 2024 in line with forecast. However, an adjustment has also been made to the substantive numbers being reported due to the status of a hosted network (the CRN), which expanded following a TUPE transfer of staff. The rate of bank staff usage had increased in November 2024 due to the need to open surge capacity. This was expected to continue during the remainder of the year. Reduction in bank benefit has been assumed though, commencing in January linked to NQNs exiting supernumerary periods. The non-delivery of system-wide transformation programmes continues to pose a significant risk to the Trust’s delivery of its 2024/25 workforce plan. A Mutually Agreed Resignation Scheme (MARS) has been approved by NHS England, which was expected to deliver a reduction in workforce of c.20 WTE by March 2025. The Trust was forecasting a total workforce of 13,464 WTE at the end of the year – broadly flat compared with the end of 2023/24. Increases in substantive workforce has been forecasted during December and January. Due to the volatility of predicting start dates during the Christmas period, a reforecast may take place in January. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust is above its 2024/25 workforce plan by 77 WTE due to a combination of the planned increases in substantive staff as newly qualified employees are onboarded, and the assumed reduction in workforce requirements due to delivery of system-wide transformation programmes. • The system-wide transformation programmes assumed a reduction in workforce of 218 WTE. Non-delivery of these programmes therefore poses a significant risk to the Trust’s achievement of its overall 2024/25 workforce plan. • The Trust’s sickness absence rate was 3.3% against the target of 3.9%, and turnover was lower than expected. • The response rate to the Staff Survey was low compared to the national average. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 3a, 3b and 3c have been updated, following discussions with the respective Executive Director(s). • The financial situation and uncertainty in respect of the NHS long-term workforce plan poses a significant underlying risk, and it was suggested that increasing the rating of risk 3c should be considered to reflect this. Any Other Matters: • A detailed update was provided in respect of the ongoing industrial dispute with the porters and in respect of the Band 2/3 pay dispute. Page 1 of 2 • The need to manage ongoing industrial disputes was impacting the Trust’s People team’s capacity to make progress on other areas, such as those relating to transformation. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda item 5.3 Committee Chair’s Report to the Trust Board of Directors 7 January 2025 Committee: Quality Committee Meeting Date: 25 November 2024 Key Messages: • • • • • • • There had been seven never events reported during 2024/25. There had been a decrease in the number of category 2 pressure ulcers, which was possibly due to increased training rates. Three prostate patients had been lost to follow up, and there were concerns in respect of capacity within the prostate service. Overall, the Quality Indicators show a system under pressure. There were also concerns in respect of cardiac surgery services due to staffing levels and culture within the team, which had led to cancellations and increased waiting lists. The PALS/complaints service had had 2,135 interactions during Quarter 2. The top themes related to clinical treatment, patient care, and communication. The number of Inquests was increasing, which was putting pressure on services. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.12 Learning from Deaths 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial Medium • Whilst the overall death rate had increased, this was in line with national trends. The Trust was performing well, and was one of 13 trusts scoring below the expected figure. • A mobile application to share the outputs of mortality and morbidity meetings was being reviewed. • The lack of available side rooms was leading to an increasing number of patients dying on wards rather than in a private environment. 5.13 Infection Prevention and Control 2024-25 Quarter 2 Report Assurance Rating: Risk Rating: Substantial High • The Trust was expected to miss most bacteraemia targets for 2024/25. • The Trust was mid-table compared with other teaching hospitals. • The rate of MRSA had increased to 4-5 cases per annum from 2020 onwards, compared with 0-2 per annum between 2015 and 2020. • An audit of hand washing had raised concerns about the compliance rate. • The loss of experienced staff since the COVID-19 pandemic was considered to be a significant contributor to the decline in performance. Any Other Matters: The committee reviewed the Maternity and Neonatal Safety 2024-25 Quarter 2 Report and noted the following: • Caesarean section rates remained high. • The Trust’s post-partum haemorrhage rate remained above the national expectations, but no key themes had been identified following review of this matter. • In a review of third- and fourth-degree tears, no key themes had been identified. • One maternal death was under investigation. Page 1 of 43 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 43 Agenda Item 4.6 Report to the Quality Committee, 25 November 2024 Title: Sponsor: Author: Purpose Maternity and Neonatal Safety 2024-25 Quarter 2 Report Gail Byrne, Chief Nursing Officer Alison Millman, Quality Assurance and Safety Midwifery Matron Jessica Bown, Quality Assurance and Safety Midwifery Matron Hannah Mallon, Quality Assurance and Safety Neonatal Matron Marie Cann, Maternity and Neonatal Safety Lead Emma Northover, Director of Midwifery (Re)Assurance Approval Ratification Information x x x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks Foundations for the and collaboration future x Executive Summary: NHS Resolution (NHSR) requires that the Maternity & Neonatal (MatNeo) service reports to our Trust Quality Committee each time it meets. This Quarter 2 (Q2) 24-25 MatNeo services safety report will continue to be adapted and responsive to safety concerns or issues within our service providing assurance around safety improvements impacting our families, services, and staff. The information provided is for assurance and reassurance, whilst meeting the requirements of NHSR Maternity Incentive Scheme (MIS)Year 6 and highlights the safety improvement work and learning from all aspects of the services. We ask members to continue to support the MatNeo Services and provide monitoring and scrutiny as required. Contents: This report provides an update in relation to the following areas for Quarter 2 2024/25: 1. Perinatal Quality Surveillance – Maternity & Neonatal Dashboard (Appendix 1) 1.1. Scheduled Caesarean Section Capacity 1.2. Post Partum Haemorrhage (PPHs) 1.3. Episiotomy 1.4. 3rd and 4th degree tears 1.5. ITU transfers 1.6. Apgars 500ms (43.58%) NMPA target is 1500mls (5.8%) NMPA target is 35% Global majority booked CoC Model – Q2 compliance 19.5%, National target is > 35% The most vulnerable families are still supported by our Needing Extra Support Teams (NEST) and as we progress workstreams around future workforce plans, the service aspires to develop new and more sustainable CoC models of care. To give assurance we monitor and audit outcomes to ensure that groups most likely to be offered a CoC model are not showing as exceptions in our data or when clinically reviewing adverse outcomes. 1.9 FFT recommenders as % of responders Current compliance: 83.9% of responders would recommend our service. This has fallen slightly from Q1 (87.4%). As mentioned in the previous Committee report, the % of responders who would recommend our postnatal ward dropped to 67% in September 2024. This was escalated to the inpatient matrons and an improvement plan focusing on two areas has been developed (Appendix 2). These areas are: • Partner or someone else involved in service users care being allowed to stay with them as much as the service user wanted during their stay in hospital. • After the birth, ensure that women and birthing people are given the opportunity to ask any questions they may have about their labour and birth. 1.10 Maternity Opel 4 Diverts There has been an increase in the number of occasions when the Maternity Service has moved through escalation and ultimately declared OPEL 4. There are escalation processes and policies in place that aim to ensure appropriate decision making and the safety of our families and workforce. This issue has been widely monitored through Birthrate Plus reporting and reviewed within safety incident investigations and is on our Risk Register (Risk 259 High Red). As per the Trust’s PSIRF plan, harm tools are completed for each Opel 4 exceeding 24 hours to review the wider impact and harm associated with the service being on
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Papers Trust Board - 5 November 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 05/11/2024 9:00 - 11:30 The Ark Conference Centre, HHFT/Microsoft Teams Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Minutes of Previous Meeting held on 10 September 2024 Approve the minutes of the previous meeting held on 10 September 2024 3 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 4 QUALITY, PERFORMANCE and FINANCE 9:10 Quality includes: clinical effectiveness, patient safety, and patient experience 4.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans, Chair 4.2 Briefing from the Chair of the Finance and Investment Committee Dave Bennett, Chair 4.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood, Chair 4.4 Briefing from the Chair of the Quality Committee Tim Peachey, Chair 4.5 Chief Executive Officer's Report 9:25 Receive and note the report Sponsor: David French, Chief Executive Officer 4.6 Performance KPI Report for Month 6 9:35 Review and discuss the report Sponsor: David French, Chief Executive Officer 4.7 Finance Report for Month 6 9:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.8 ICB Finance Report for Month 6 10:10 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 4.9 Recovery Support Programme (RSP) Undertakings - Self Assessment 10:20 Review and discuss the self-assessment Sponsor: David French, Chief Executive Officer 4.10 10:30 People Report for Month 6 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 4.11 Cancer Patient Experience Survey Results 2023 10:45 To receive and discuss the results Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Ali Keen, Head of Cancer Nursing 5 STRATEGY and BUSINESS PLANNING 5.1 Corporate Objectives 2024-25 Quarter 2 Review 11:00 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendees: Martin De Sousa, Director of Strategy and Partnerships/Kelly Kent, Head of Strategy and Partnerships 5.2 Board Assurance Framework (BAF) Update 11:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from the Council of Governors' (CoG) Meeting 23 October 2024 11:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 6.2 Register of Seals and Chair's Actions Report 11:20 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7 Any other business 11:25 Raise any relevant or urgent matters that are not on the agenda Page 2 8 Note the date of the next meeting: 7 January 2025 9 Items circulated to the Board for reading 9.1 CRN: Wessex 2024-25 Q2 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. Page 3 Agenda links to the Board Assurance Framework (BAF) 5 November 2024 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Appetite (Category) Minimal (Safety) Cautious (Experience) Minimal (Safety) Open (Technology & Innovation) Open (workforce) Open (workforce) Open (workforce) Cautious (Effectiveness) Cautious (Finance) Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) Current risk rating 4x5 20 3x3 9 4x4 16 3x3 9 4x5 20 4 x3 12 4x3 12 3x3 9 3x5 15 4x5 20 3x4 12 2x3 6 Target risk rating 4 x 2 Apr 6 27 3 x 2 Mar 6 26 2 x 3 Apr 6 27 3 x 2 Mar 6 25 4 x 3 Mar 12 26 4 x 2 Mar 8 27 3 x 2 Mar 6 25 3 x 2 Apr 6 25 3 x 3 Apr 9 25 4 x 2 Apr 8 27 3 x 2 Apr 6 27 2 x 2 Dec 4 24 Agenda links to the BAF No Item 4.6 Performance KPI Report for Month 6 4.7 Finance Report for Month 6 4.8 ICB Finance Report for Month 6 4.9 Recovery Support Programme (RSP) Undertakings – Self Assessment 4.10 People Report for Month 6 4.11 Cancer Patient Experience Survey Results 5.1 Corporate Objectives 2024-25 Quarter 2 Review Linked BAF risk(s) 1a, 1b, 1c 5a 5a 5a 3a, 3b, 3c 1b All Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x Minutes Trust Board – Open Session Date Time 10/09/2024 9:00 – 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Diana Eccles, NED (DE) (9:00-10:00 and 12:00-13:00) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) Alison Tattersall, NED (AT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Jane Fisher, Head of Health and Safety Services (JF) (item 7.2) Danielle Honey, Named Nurse for Safeguarding Children (DH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DHu) (item 5.10) Duncan Linning-Karp, Deputy Chief Operating Officer (DLK) (item 5.5) Corinne Miller, Named Nurse for Safeguarding Adults (CMi) (item 5.13) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.11) Jessica Bown, Midwifery Quality Assurance and Safety Matron (shadowing Gail Byrne) 1 member of the public (item 2) 5 governors (observing) 1 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) (from 10:00-12:00) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. 2. Patient Story Allan Peters was invited to relate his experience as a cancer patient, who had been diagnosed with stage 4 lymphoma, and, in particular, his experience of CAR-T cell therapy, which had been successful, with no reappearance of the cancer for more than a year. It was noted that the patient had had a positive experience with staff, and, when he collapsed, had been impressed by the reaction of a student nurse. Page 1 3. Minutes of the Previous Meeting held on 25 July 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 25 July 2024. 4. Matters Arising and Summary of Agreed Actions It was noted that action 1165 could be closed, and the relevant paper had been updated with the correct information. There were no other matters arising or actions overdue. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee had reviewed the Finance Report for Month 4 (item 5.7), noting that whilst the Trust was slightly off-plan, it was maintaining its trajectory in terms of an improved position. • The Trust was making progress in terms of its Always Improving programme with some reduction in length of stay. • There were a number of risks to the Trust’s achievement of its 2024/25 plan, including costs incurred from industrial action, insufficient funding for the pay award, and non-delivery of system transformation programmes. The Trust was also delivering £10m of unpaid activity. • The committee received a report from Estates, noting that there had been an improvement in the Trust’s ability to recruit staff. 5.2 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 21 August 2024. It was noted that: • The committee had reviewed the People Report for Month 4 (item 5.9), noting that the Trust was below its target workforce level, although there had been an increase in use of bank staff due to the holiday period. The Trust was benefitting by £1.5m a month from these savings in staff numbers. • It was expected that the Trust would go above its planned staff numbers in September 2024 due to factors such as higher than assumed numbers of patients having no criteria to reside. • The committee received an update on violence and aggression in the context of the recent riots. 5.3 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 19 August 2024. It was noted that: • The committee reviewed the Trust’s main quality indicators and noted that the indicators in respect of infection prevention were of concern. However, there had been a reduction in Emergency Department waiting times. • The Trust’s progress in implementing the measures under ‘Martha’s Rule’ was noted. • The committee received the annual medical safety report and reviewed consultant job planning. • There had been difficulties with porting over documents to a new IT system in Ophthalmology. Page 2 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The 2024/25 pay award for Agenda for Change staff was due to be paid in October. In addition, the Government had made an offer to junior doctors, which appeared likely to be acceptable. There were concerns about the extent to which these pay awards would be fully funded. • The Trust had been formally notified of a collective pay grievance for healthcare support workers, which potentially impacted over 1,000 staff and was for up to six years of back pay. • The civil unrest in late July 2024 had had a significant impact on staff, especially from those from black and minority ethnic communities. • The New Hospitals programme had been paused, and the situation regarding the proposed new hospital near Basingstoke was unclear. Separately, the ‘Save Winchester Action Group’ had written to board members of the Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) expressing concerns about the proposed downgrade of Winchester hospital. • The Care Quality Commission had published its adult inpatient survey for 2023, which showed a deterioration in people’s experiences since 2020. • The Trust’s aseptic unit had received a positive audit report and had been assessed as being ‘low risk’. • An inspection of the Trust’s mortuary arrangements had been carried out by the Human Tissue Authority in August 2024. The outcome was awaited. • The NHS’s long-term plan process had commenced, with an expected emphasis on digital and moving away from hospitals to focus on the community and prevention. • The report by Lord Darzi on the NHS had been published. This indicated a variation in both quality of and access to NHS services across the country. • A workshop was scheduled in October 2024 regarding violence and aggression, with the focus now being on there needing to be a limit on what the Trust will tolerate and there being consequences, including exclusion of individuals. 5.5 Patient Safety and Quality of Care in Pressured Services Joe Teape was invited to present the paper ‘Patient Safety and Quality of Care in Pressured Services’, the content of which was noted. It was further noted that: • NHS England had sent all integrated care boards, integrated care partnerships, regional directors and NHS trusts and foundation trusts a letter on 26 June 2024 regarding urgent and emergency care, and requiring boards to assure themselves that the Trust is doing all it can to provide alternatives to Emergency Department attendance and admission, and to maximise in- hospital flow. • The Trust chose to queue patients in the Emergency Department, rather than in ambulances in order to be able to release ambulances. It was considered that this approach was safer than having patients remain in ambulances. • The Trust was able to provide good assurance based on its performance against the standards. • The HIOW ICB was proposing to introduce an initiative to reduce ambulance delays whereby patients would be released to the Emergency Department after 45 minutes. Page 3 5.6 Performance KPI Report for Month 4 Joe Teape was invited to present the Performance KPI Report for Month 4, the content of which was noted. It was further noted that: • The Trust was in the top quartile for seven out of nine measures. Of those where the Trust was below top quartile, one was 78-week waits due to the shortage of corneal transplant material, and the other was the 31-day standard, although improvement was expected. • The Trust was aiming to reduce its 65-week waiters to single digits by the end of September 2024. • There had been an increase in the relative mortality rate, the causes of which were being investigated. • The Trust had not had to open surge capacity. • Ward D4 had been closed for deep-cleaning to tackle candida auris. In terms of the spotlight on waiting lists, it was noted that: • The Trust’s waiting list had increased slightly in year by c.1,500, although the growth was in outpatients waits, not patients waiting for a procedure. • There was an opportunity to triage referrals, with use of advice and guidance for General Practitioners in particular. However, it was noted that GPs were not obliged to accept advice and guidance as an alternative to a referral, and the expected industrial action by GPs was seen as a risk. • The Trust had been successful in stabilising its waiting list, it would now be necessary to reduce it from c.60k to c.40k in order to meet the 18-week Referral To Treatment standard. Action: Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 5.7 Finance Report for Month 4 Ian Howard was invited to present the Finance Report for Month 4, the content of which was noted. It was further noted that: • The Trust had recorded an in-month deficit of £3.9m and £16.9m year-to-date. The monthly position continued to improve month-on-month, and the Trust’s cost base remained relatively stable. • The Trust’s Elective Recovery performance would be key to achievement of its 2024/25 plan. There remained significant uncertainties in respect of the costs of industrial action, pay award funding, payments for 2023/24 Elective Recovery Funding (ERF), and 2024/25 ERF. • The reasons for the Trust’s variance to plan were largely driven by costs of industrial action, pay awards, unidentified Cost Improvement Programme (CIP), and non-delivery of system mental health and non-criteria to reside programmes. • Identification of CIP and pay controls were working well, and the Trust had delivered 126% ERF performance. • The Trust was anticipating a deficit of £3.8m and 128.5% ERF performance in Month 5. 5.8 Break 5.9 People Report for Month 4 Steve Harris was invited to present the People Report for Month 4, the content of which was noted. It was further noted that: Page 4 • At the end of July 2024, the Trust was 288 Whole Time Equivalents (WTE) below its overall workforce plan. However, over the following months a significant increase in workforce numbers was expected due, largely, to the onboarding of newly-qualified nurses. • The Trust’s plan was predicated on the delivery of system programmes to reduce the number of patients having no criteria to reside and mental health patients. The assumed improvements in mental health patient numbers represented approximately 160 WTE. • There was a dispute with the Trust’s porters, with Unite threatening industrial action. 5.10 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • The previous year had been a difficult one for foundation year doctors due to the industrial action and associated press around this. • Changes in the structure of doctors’ postings and training had resulted in a loss of the previously firm structure and had generated uncertainty for those impacted. It was necessary to ensure that F1 and F2 doctors felt part of the UHS family. • Improvements in the induction process for F1 doctors were required. A twoweek shadowing period had been received positively. 5.11 Learning from Deaths 2024-25 Quarter 1 Report Jenny Milner was invited to present the Learning from Deaths report for Quarter 1 of 2024/25, the content of which was noted. It was further noted that: • Nationally, the Trust continues to benchmark lower than the expected death rates. • The morbidity and mortality reviews process required refining, as sharing of learning could be inconsistent as was the quality of reviews. A mobile application was being developed to help share learnings. • A recurrent theme had emerged via incident reporting in respect of out-ofhours paediatric palliative care advice and support, as no out-of-hours service had been commissioned. • There had been an increase in the number of complaints relating to the location of the death due to a lack of side rooms. Similarly, there was a lack of private spaces to have sensitive conversations. • A palliative care box had been trialled on Ward D3. Use of charity funding was being considered to enable this to be rolled out elsewhere. 5.12 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Paul Grundy was invited to present the Medical Appraisal and Revalidation Annual Report, the content of which was noted. It was further noted that: • The report was intended to enable the Trust to provide assurance that its professional standards processes meet the requirements of the Medical Profession (Responsible Officers) Regulations 2010 and related guidance. Page 5 • This was the second year of using a portal as part of the appraisals process, which had resulted in an improved user experience. • Compliance rates had continued to improve, and there was a good process in place to remind individuals to complete their appraisals. • There had been an increase in the number of appraisers and these were wellrated. Decision: Having reviewed the Annual Report, the Board approved the Statement of Compliance tabled to the meeting, and authorised either the Chair or Chief Executive Officer to sign the Statement on behalf of the Trust. 5.13 Safeguarding Annual Report 2023-24 Corinne Miller and Danielle Honey were invited to present the Safeguarding Annual Report for 2023/24, the content of which was noted. It was further noted that: • There had been a continued increase in activity across most services, and there had been a sustained increase in the number of Deprivation of Liberty Safeguards (DoLS) applications across the Trust along with requests for support with complex Mental Capacity Act case management. • The year had been challenging due to a loss of key staff. • The Trust had undertaken work to update its policies and Level 3 Safeguarding Adult Training had been rolled out via the Virtual Learning Environment (VLE). • A key area of work had been to review the pathway for adults with local authorities. The response from local partners remained challenging due, largely, to budgetary constraints at these other organisations. • The Trust’s children’s safeguarding team had carried out the self-assessment audit required by section 11 of the Children Act 2004, which highlighted no areas of specific concern or gaps. There had been an 28% increase in referrals as well as an increase in the level of complexity. • The adult safeguarding team had won the ‘UHS Champions Team of the Year’ award. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant Executive Director(s) since the BAF was last presented to the Board, with an extensive review having been carried out in December 2023 and in April 2024. • Following review by the Finance and Investment Committee in August 2024, risk 5c had been modified to better reflect the Trust’s estates-related risks. • The NHS was designing a dynamic risk assessment framework. • Work was ongoing to compare the Care Quality Commission’s Well-Led framework with the Trust’s BAF, and to identify any gaps. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Health and Safety Annual Report 2023-24 Jane Fisher was invited to present the Health and Safety Annual Report for 2023/24, the content of which was noted. It was further noted that: • There continued to be a number of incidents of late reporting of work-related absence, although steps were being taken to streamline the process and to make reporting easier. • There had been a number of losses in staff over the year, which had impacted the FFP3 mask-fitting team in particular. • Improved training had been made available through the Virtual Learning Environment, and health and safety training received was now listed as a skill on staff members’ HealthRoster profile. • Thirty-nine incidents had been reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). • The main causes of injuries were as a result of collisions, slips, trips and falls, sharps, and incidents of violence and aggression. With the exception of the latter, these incidents were generally accidents or a result of human error, with nursing and healthcare assistants being the most likely groups to be injured. 7.3 People and Organisational Development Committee Terms of Reference It was noted that the People and Organisational Development Committee had reviewed its terms of reference at its meeting held on 21 August 2024. Decision: Following discussion, it was further noted that whilst the committee had proposed no changes to the terms of reference, it was agreed that the terms of reference should include specific reference to the CQC’s quality statements given the emphasis within the CQC’s latest framework on equality, diversity and inclusion related matters. 8. Any other business There was no other business. 9. Note the date of the next meeting: 5 November 2024 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. Page 7 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 8 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 06/06/2024 5.6 Performance KPI Report for Month 1 1152. Digital Teape, Joe Explanation action item JT agreed to include Digital as an agenda item at a future Trust Board Study Session. 27/02/2025 Pending Update: Item tentatively scheduled for TBSS on 27/02/2025. Trust Board – Open Session 25/07/2024 5.4 Briefing from the Chair of the Quality Committee (Oral) 1163. Impact of technology Machell, Craig 27/02/2025 Pending Explanation action item Craig Machell agreed to add an item covering the impact of technology over the next 5-10 years to a future Trust Board Study Session agenda. Update: Item tentatively scheduled for 27/02/25 Study Session. Trust Board – Open Session 10/09/2024 5.6 Performance KPI Report for Month 4 1175. 'Red flag' staffing incidents Byrne, Gail Explanation action item Gail Byrne agreed to look into the increase in ‘red flag’ staffing incidents in July 2024. 05/11/2024 Pending Page 1 of 1 Agenda item 4.1 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Audit and Risk Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed the year end process for 2023/24, and associated ‘lessons learned’. Many of the issues encountered ought to be mitigated by the introduction of a new finance system, together with a ‘rehearsal’ of the year end accounts process to be carried out early in 2025. • The Trust’s National Cost Collection submission for 2024 went well with no validation errors requiring re-submission and data quality was good. Whilst the output will be presented to the Finance and Investment Committee, initial indications were that the Trust was more efficient than the average. • The committee received an update on the Procurement Act 2023 and the potential impact on the Trust. It was noted that the additional reporting requirements had been delayed until February 2025 due to issues with the digital reporting platform development. • The committee received updates in respect of Information Governance and Legal. • The committee received an update on Data Quality, including work ongoing to review cancer waiting times data. • A report on a local proactive exercise in respect of Bank/Agency staff identity fraud showed that whilst the Trust was following the majority of the recommendations to reduce the risk of this type of fraud, current practice could be improved. The committee agreed with the report. 6.2 Board Assurance Framework (BAF) Level of Assurance: Substantial • All risks had been reviewed with the relevant executive director(s). • It is intended that agenda items at Board meetings will be more clearly linked to the BAF risks. • In addition, division-level ‘BAFs’ are under consideration to provide a clearer idea of overall risk at the divisional level to bridge the gap between the operational risk register and Board-level BAF. • 90% of operational risks had been reviewed, an indicator of wellembedded risk management within the organisation. The Trust’s Fraud, Bribery & Corruption Annual Report 2023/24 highlighted no particular areas of concern. The committee reviewed the performance of the Trust’s internal and external auditors. In addition, the committee held a discussion with the external auditors without management present. Substantial Assurance Reasonable Assurance There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 2 of 2 Agenda item 4.2 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Finance and Investment Committee Meeting Date: 21 October 2024 Key Messages: • • • • • • The Trust has received significant additional cash in October 2024 through deficit support funding and additional payments for 2023/24 ERF performance. The Trust’s financial position remains challenging with a year-to-date deficit of £8m. The Always Improving programme continues to make progress, but will need to go further and faster. The Trust’s data centre arrangements remain a risk and design work is ongoing in respect of a solution. The risk associated with cyber incidents also remains high. The committee supported a business case for possible expansion of UHS Pharmacy Limited and recommends it to the Board. The committee reviewed the proposed financial recovery plan and recommends to the Board its submission to the ICB. The main risk to the achievement of the Trust’s 2024/25 plan remains the need for the ICS transformation programmes to deliver. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 6 Level of Assurance: Substantial • The Trust has received £11.2m of deficit support funding as well as £6.5m of additional funding in respect of 2023/24 Elective Recovery performance. • The year-to-date deficit is c.£8m, with an underlying deficit of c.£6m per month. • The Trust’s monthly income remains strong and ERF performance in September 2024 was 130%. However, costs are gradually increasing, and further investigation is required into pay expenditure. • The full amount of 2024/25 CIP has now been identified. • The most significant risk to the Trust’s achievement of its 2024/25 plan remains delivery of the system transformation programmes. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Directors. • Risk 5a will be reassessed following the Trust’s self-assessment against the Recovery Support Programme undertakings to ensure that the risk rating and target are appropriate. • A new scoring framework is being developed to improve consistency in the rating of risks. Any Other Matters: The additional cash received in October 2024 means that it is now likely that the Trust will not need additional cash until February 2025, whereas this was previously expected to be the case in November 2024. The Trust has in place effective controls to monitor its cash position, and a regular report on cash will be provided to the Finance and Investment Committee. Page 1 of 2 Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 2 of 2 Agenda item 4.3 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: People and Organisational Development Committee Meeting Date: 21 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust remains below its plan in terms of workforce numbers. However, from October 2024 onward, this position is expected to change. • The risk of non-delivery of ICS transformation programmes is significant. The Trust has assumed a significant reduction in workforce based on delivery of these schemes. • The committee examined the progress against actions designed to improve the lives of resident doctors. It was noted in particular that there was an issue with a lack of availability of office/desk space. • The Trust had been notified that Unite was commencing a ballot of its members commencing on 21 October 2024 as part of the ongoing dispute with porters. 5.11 People Report for Month 6 Level of Assurance: Substantial • The Trust was 249 WTE below its plan. However, this position was expected to change significantly with the onboarding of newly qualified nurses etc. in the autumn. • In addition, the Trust’s plan assumed that the ICS transformation programmes would begin to deliver significant reductions from October 2024 onward. • Turnover and sickness remain below target at 11.1% and 3.6% respectively. Bank and agency rates also remain low. • Appraisal rates remain low at 73%. The Trust was considering a move away from the current ESR system in order to make the appraisal process easier. The Trust had held constructive discussions with Unison as part of the Band 2/3 pay dispute. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.4 Committee Chair’s Report to the Trust Board of Directors 5 November 2024 Committee: Quality Committee Meeting Date: 14 October 2024 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The Trust was making good progress against its 2024/25 Quality Priorities. • There were concerns regarding the consistency of approach to infection prevention and control in the Trust. Action plans were being produced and the ‘Fundamentals of Care’ programme is also intended to address many of these concerns. • A never event due to wrong site surgery had been recorded. This is the fifth never event reported during 2024. • The closure of Ward D4 had not been effective in eradicating the candida auris infection with four new cases reported. • There was insufficient resource to roll out National Safety Standard for Invasive Procedures (NatSSIPS) 2 in a comprehensive and systematic manner. • In its review of mental health work, the committee noted the following top three risks: lengths of wait for onward care; parity of esteem for patients; and the level of support from local mental health trusts. 6.2 Board Assurance Framework Level of Assurance: Reasonable • Risks 1a, 1b, 1c and 4a have been updated, following discussions with the respective Executive Directors. • It was agreed that the likelihood of achieving the target risk level for risk 1c (infection prevention and control) by April 2025 should be reviewed. • Staffing remains the main concern for the Trust’s Maternity services. • The possibility of support from Salisbury NHS FT to manage the increasing number of caesarean sections was being explored. Substantial Assurance Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Page 1 of 1 Agenda item 4.5 Report to the Trust Board of Directors, 5 November 2024 Title: Sponsor: Author: Purpose Chief Executive Officer’s Report David French, Chief Executive Officer Craig Machell, Associate Director of Corporate Affairs (Re)Assurance Approval Ratification Information x Strategic Theme Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future x x x x Executive Summary: The CEO’s Report this month covers the following matters: • Autumn Statement • Portering Dispute • BAM Dispute • Change NHS • Review into the Operational Effectiveness of the Care Quality Commission • Proposed Legislative Changes • New Hospital Programme – Hampshire Together • Hampshire and Isle of Wight Healthcare • Charity Priorities • Staff Survey • National Patient Safety Award Contents: Chief Executive Officer’s Report Risk(s): N/A Equality Impact Consideration: YES / NO / N/A Chief Executive Officer’s Report Autumn Statement On 30 October 2024, the Chancellor of the Exchequer presented her Autumn Statement. The statement was said to be based on the principles of restoring economic stability and increasing investment. A summary can be found from NHS Providers website: autumn-budget-2024-on-the-day-briefing.pdf The statement set out measures to raise an additional £40bn in taxation. This includes an increase in employer’s national insurance contributions by 1.2% to 15% from April 2025, increases in the rates of capital gains tax, changes to inheritance tax, abolition of the nondomicile tax regime, increased stamp duty on second homes, an increase in the rate of the windfall tax on energy companies, and removal of the VAT exemption for private schools. The Chancellor said that she would reduce wasteful spending and has set a 2% productivity savings target for all departments. The Government will publish its ten-year plan for the NHS in Spring 2025 and re-committed to reducing waiting times to 18 weeks by delivering on its manifesto commitment for 40,000 extra hospital appointments each week. The key announcements for health and care include: • Day-to-day spending for the Department of Health and Social Care will increase by £22.6bn from 2023/24 to 2025/26. This is a two-year average real terms NHS growth rate of 4% – the highest since 2010 (excluding the years affected by the COVID-19 pandemic). • Capital spending will increase by £3.1bn in 2025/26 (compared to 2023/24 outturn) – rising to £13.6bn. This is a two-year average real terms growth rate of 10.9%, although it is still lower than the overall value of the maintenance backlog (£13.8bn). This includes £1.5bn for new surgical hubs and diagnostics scanners, and £1bn towards backlog maintenance. There remains some uncertainty regarding the implications of the additional revenue funding and whether any of the funding announced will provide in-year relief in addition to values already confirmed as part of pay award and Elective Recovery Framework funding. Overall, the commitment to additional capital and revenue investment to the NHS is extremely welcome. We will assess the implications for HIOW ICS and to UHS over the coming weeks and months. The national proposed rise in the minimum wage to £12.21 in April 2025 will exceed the current lowest level within the NHS of £12.08. The national staff council will be working with NHS unions to review the implication of this and how it is addressed at a national level. Portering Dispute The Trust has been formally notified by UNITE the union that it has initiated a strike ballot of its members employed within the portering department at University Hospital Southampton. The ballot commenced on 21 October and will run until 11 November 2024. UNITE is balloting members on a range of issues including conduct, culture and working conditions. Prior to the ballot, and having been made aware of staff concerns, the Trust commissioned an independent external review, seeking views of all the portering department. The ballot has attracted media coverage from the BBC and some other local sources, and the Trust provided a response to the issues raised. The Trust is in active discussions with UNITE and local portering representatives to address the issues being raised and will continue to work constructively to resolve the dispute. Page 2 of 6 Meanwhile, the Trust is actively considering plans to ensure patient services and safety are maintained in the event a strike takes place. This will include enacting the Trust’s business continuity processes through the hospital incident management structure. The Board will be kept informed as plans are finalised and on conclusion of the ballot. BAM Dispute While the Trust was proceeding with the development of the east wing annex, concerns were raised by external structural engineers over the capacity of the existing building to cope with the expected additional weight the development would put on the existing structure. In 2022, the Trust raised a formal issue with BAM, the principal contractor of the existing east wing annex building. Over the last two years the Trust, with the support of DAC Beachcroft, has been trying to get BAM’s representatives to the mediation table to resolve the issues raised on the building. In September 2024, the decision was taken to commence arbitration proceedings against BAM Construction over the inability to agree to a mediator or mediation date. The Trust continues to work closely with DAC Beachcroft during this process, aiming for completion in early 2025. Change NHS On 21 October 2024, the Department for Health and Social Care launched an online portal for individuals to share their views, experiences and ideas to assist in the development of the Government’s 10 Year Health Plan. Staff and members of the public have been asked to: • Give their views on the NHS and health and care. • Tell the Government what they feel is working well and what needs improving. • Share their experiences. • Post their ideas for improving health and care in the future. More information can be found at: Change NHS: help build a health service fit for the future GOV.UK Review into the Operational Effectiveness of the Care Quality Commission On 15 October 2024, the Government published an independent report by Dr Penny Dash, who had been commissioned in May 2024 to review the operational effectiveness of the Care Quality Commission (CQC). The review heard from over 300 people from across the health and care sectors and within the CQC, and analysed the CQC’s performance data. The review found significant failings in the internal workings of the CQC, which have led to a substantial loss of credibility, a deterioration in the CQC’s ability to identify poor performance and support a drive to improve quality. The review summarised these failings as follows: • Poor operational performance – there has been a stark reduction in activity compared with 2019. • Significant challenges with the provider portal and regulatory platform. • Delays in producing reports and poor-quality reports. • Loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement. • Concerns around the single assessment framework and its application. • Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections to calculate a current rating. • There are opportunities to improve the CQC’s assessment of local authority Health and Care Act 2022 duties. • ICS assessments are in early stages of development with a number of concerns shared. • The CQC could do more to support improvements in quality across the health and care sector. • There are opportunities to improve the sponsorship relationship between the CQC and the Department of Health and Social Care. Page 3 of 6 The full report can be read at: Review into the operational effectiveness of the Care Quality Commission: full report - GOV.UK Proposed Legislative Changes The Government has proposed a number of significant reforms to employment legislation through its Employment Rights Bill. These changes include: • From 2026, employees will have immediate entitlement to paternity leave, unpaid parental leave, and bereavement leave from the first day of employment. Protections for pregnant women and mothers will also be strengthened. • ‘Exploitative’ zero-hours contracts will be banned, giving workers the right to move to guaranteed hours contracts after a 12-week reference period.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-5-November-2024.pdf

Papers Trust Board - 9 September 2025

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 09/09/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd David French, Tim Peachey 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 15 July 2025 9:15 Approve the minutes of the previous meeting held on 15 July 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance and Investment Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:25 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:30 including Maternity and Neonatal Safety 2025-26 Quarter 1 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:35 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 4 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.6 UHS Operating Plan 2025-26 and Board Assurance Statement 10:30 Receive and approve the Plan Sponsor: Andy Hyett, Chief Operating Officer Attendee: Duncan Linning-Karp, Deputy Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 4 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICS Operational Delivery Report for Month 4 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 11:10 People Report for Month 4 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Learning from Deaths 2025-26 Quarter 1 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Annual Complaints Report 2024-25 11:30 Receive and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.13 11:40 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance Receive and note the Annual Report. Approve the Statement of Compliance. Sponsor: Paul Grundy, Chief Medical Officer 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 11:50 Receive and discuss the report and strategy Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Corinne Miller, Named Nurse for Safeguarding Adults/ Dannielle Honey, Named Nurse for Safeguarding Children 6 STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update 12:05 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 16 July 2025 12:20 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 People and Organisational Development Committee Terms of Reference 12:30 Review and approve Sponsor: Steve Harris, Chief People Officer 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 11 November 2025 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Quarter 1 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 9 September 2025 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 4 5.6 Operating Plan October 2025 – September 2026 5.8 Finance Report for Month 4 5.9 ICS Operational Delivery Report for Month 4 5.10 People Report for Month 4 5.11 Learning from Deaths 2025-26 Quarter 1 Report 5.12 Annual Complaints Report 2024-25 5.13 Medical Appraisal and Revalidation Annual Report including Board Statement of Compliance 5.14 Safeguarding Annual Report 2024-25 and Strategy 2025-26 1a, 1b, 1c 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b, 3b 1b, 3b 3b, 3c 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date Time 15/07/2025 9:00 – 13:00 Location Chair Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd (JD-T) Present Gail Byrne, Chief Nursing Officer (GB) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Duncan Linning-Karp, Interim Chief Operating Officer (DL-K) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (shadowing CM) Julie Brooks, Deputy Director of Infection Prevention and Control) (JB) (item 5.12) Phil Bunting, Director of Operational Finance (PB) (item 7.2) Martin De Sousa, Director of Strategy and Partnerships (MDeS) (item 6.1) Christopher Kipps, Clinical Director of R&D (CK) (item 6.2) Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian (CMb) (item 5.11) Laura Purandare, Deputy Director of R&D (LP) (item 6.2) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.12) Karen Underwood, Director of R&D (KU) (item 6.2) 1 members of the public (item 2) 4 governors (observing) 3 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. 2. Patient Story Verity Elbro-White was invited to present her experience of the birth of her second child at Princess Anne Hospital. The mother was diabetic, and the pregnancy was complex. It was noted that: Page 1 • Both the community midwife and diabetic team had been excellent. The midwife had advised that the patient go to hospital because she was feeling unwell, following which she underwent a caesarean section. • The patient felt valued and listened to, with the care patient-centred. • The surgical and neonatal intensive care teams were also excellent and compassionate. • Attention was also paid to family members. 3. Minutes of the Previous Meeting held on 13 May 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 13 May 2025. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. It was noted that action 1247 could be closed. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 9 June 2025, the content of which was noted. It was further noted that: • There had been a delay in the production of the Trust’s Annual Report and Accounts due to issues with reconciling information from the Trust’s ledgers into the accounts. NHS England had been notified, and it had been agreed that the Trust would submit its accounts by 21 July 2025. • The committee had reviewed the internal auditor’s report for 2024/25 and noted that out of the six reviews undertaken during the year, the results were good overall. • The committee received an update from the Trust’s external auditor and noted that it was necessary for the Trust to simplify its processes in order to prevent a repeat of the delay in producing end-of-year accounts. 5.2 Briefing from the Chair of the Finance and Investment Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 2 June 2025 and 23 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the Finance Reports for Month 1 and Month 2 (item 5.8), noting that the Trust’s reported deficit remained in line with its plan. • The Trust’s underlying deficit remained at c.£7m per month. • The committee reviewed the Trust’s Cost Improvement Programme, noting that the Trust was targeting £110m of savings for 2025/26. It was further noted that even with full delivery of the Trust’s workforce plans, there would still be a shortfall. • The committee received an update on the contracting process for 2025/26, noting that there was a risk that there would be £20-30m of unfunded activity during the year based on the current position. • The committee also continued to monitor the Trust’s cash position. Page 2 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Report in respect of the meeting held on 25 June 2025, the content of which was noted. It was further noted that: • The committee reviewed the People Report for Month 2 (item 5.10), noting that the Trust was on track in terms of its plan to reduce its workforce by c.700 and had received more than 220 applications under the Mutually Agreed Resignation Scheme. • The committee received an update on organisational change and the support being given to staff on managing change. • An update was provided in respect of the Trust’s education programmes, noting that there was a risk due to a lack of resource. • The committee would be reviewing the recently published 10-Year Plan in detail, particularly in terms of the organisational development elements and the plan’s implications for the Trust. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 2 June 2025 and to provide an update following the meeting held on 14 July 2025, the content of which was noted. It was further noted that: • There had been a further never event, although no harm had resulted. • The committee received a report on pressure ulcers and noted some concerns with respect to the regular turning of patients. • An update on the Fundamentals of Care programme was received and it was noted that improvement in general standards was limited in the absence of sufficient staff. • The committee noted an update in respect of job planning and that this provided good assurance of the process. • The committee reviewed the Maternity and Neonatal Safety Report for Quarter 4 and confirmed that there was nothing requiring escalation to the Board. Tim Peachey was invited to present the Maternity and Neonatal Workforce Report, the content of which was noted. It was further noted that: • The Trust expected to be compliant with the requirements of the NHS Resolution Maternity Incentive Scheme for 2025/26. • Although the Birthrate Plus assessment indicated a reduction in the birth rate, the acuity was, however, higher. • According to assessment, the Trust was approximately nine midwives below the required level. However, there was a plan in place to address this shortfall using the existing workforce. • There was a national shortage of neonatal nurses, although the Trust was attempting to address this issue through its in-house training programme. • In terms of the obstetrics workforce, there remained an issue with the number of trainees. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Trust had opened a new Neonatal ICU facility on 11 July 2025 as part of its work to improve the quality of the environment in the department. • The Government had published its 10-Year Health Plan for the NHS in England, which was based on reforming the NHS through three shifts: hospitals to community; analogue to digital; and sickness to prevention. Page 3 • NHS England had published the NHS Oversight Framework for 2025/26 under which organisations would be segmented based on their performance against a range of metrics. Whilst the Trust was one of the best performing trusts, the impact of a financial override and being in the Recovery Support Programme meant that the Trust would be placed in segment 5, the lowest category of performance. • Whilst the NHS waiting list nationally had fallen, the Trust’s waiting list has continued to grow. This was partially due to the impact of the cap on elective funding which had caused the Trust to cease outsourcing some procedures on the basis that it was not financially viable. • Notification had been received from the British Medical Association that resident doctors would embark on a five-day strike commencing on 25 July 2025. There was a risk of industrial action by other staffing groups, as both the Royal College of Nursing and Unite were conducting consultative ballots in respect of the 2025/26 pay award and other matters. 5.6 Performance KPI Report for Month 2 Duncan Linning-Karp was invited to present the Performance KPI Report for Month 2, the content of which was noted. It was further noted that: • In the spotlight on Referral To Treatment, despite the Trust treating more patients, its waiting list had grown by 1%. Certain services accounted for much of this growth, with other services seeing flat or reducing waiting lists. The increase had also been driven by the decision to cease outsourcing some specialities due to the impact of the elective recovery funding cap. • There were three ways to address the increasing size of the waiting list: refusing referrals, validation, and treating more. The ‘patient choice’ agenda made refusing out-of-area referrals difficult. • The Trust’s performance across the constitutional standards indicated that the Trust was operating in a challenging environment and was delivering at activity levels far in excess of pre-COVID-19 levels. • Attendances at the Emergency Department remained high, averaging 433 attendances per day across March, April and May 2025. The Trust’s performance against the four-hour standard was 56.2%, a reduction of 4.5% compared to April 2025. • There had also been a reported increase in the number of Category 2 Pressure Ulcers (per 1,000 bed days) to 0.37 in May 2025, above the target of 0.3. • The Trust continued to benchmark in the top quartile when compared to peer teaching organisations against the national cancer performance targets. • Pressure on flow had caused an increase in overnight ward moves. 5.7 Break 5.8 Finance Report for Month 2 Ian Howard was invited to present the Finance Report for Month 2, the content of which was noted. It was further noted that: • The Trust had reported an in-month deficit of £3.8m, which was consistent with the Trust’s annual plan. The underlying monthly deficit remained at £7.2m. • There had been a number of ‘one-offs’ during the month which had reduced the underlying deficit to meet the planned level of deficit. The Trust continued to target recurrent savings. • Whilst the Trust remained on an improving trajectory, there was some concern regarding the pace of improvement. Page 4 • The Trust was involved in a number of contractual disputes in respect of currently unfunded or insufficiently funded services. • The Trust’s cash position remained an area of concern and continued to be closely monitored. The Trust had five operating days of expenditure, although this was supported in month by holding c.£13m of payments. There remained a significant risk that the Trust’s cash balance would reduce to close to zero in the first half of 2025/26. 5.9 ICS Operational Delivery Report for Month 2 Ian Howard was invited the present the ICS Operational Delivery Report for Month 2, the content of which was noted. It was further noted that: • The previous ICB Finance Report had been expanded to now include operational and performance information across the system. • The Hampshire and Isle of Wight Integrated Care System had reported that it was on plan for Month 2 with a reported deficit year-to-date of £18.25m against a planned deficit of £18.3m. • All organisations in the system would receive deficit support funding for Quarter 1 and Quarter 2. Whilst there was no clear national picture, it was believed that other organisations were in a similar position. • The South East region’s plan for 2025/26 was for a deficit of £95m at Month 2. 5.10 People Report for Month 2 Steve Harris was invited to present the People Report for Month 2, the content of which was noted. It was further noted that: • In May 2025, the workforce grew by 19 whole-time-equivalents (WTE), although was still below plan by 107 WTE. In addition, in June 2025, there had been a reduction in the overall workforce size of 99 WTE driven by the closure of surge capacity and higher turnover during the month. • There had been a freeze on hiring for administrative and clerical roles since March 2025 and only 70% of clinical leavers were being replaced. However, patient demand was not reducing. • The Trust had carried out a divisional restructure, reducing its clinical divisions from four to three. • Even full delivery of the Trust’s Cost Improvement Programme workforce reduction schemes would still produce a shortfall in terms of the Trust’s achievement of its 2025/26 plan. Whilst the Trust was currently on plan in terms of its workforce numbers, it was expected that it would deviate from this later in the year. • The Trust had accepted 42 applications under the Mutually Agreed Resignation Scheme and a number of others were under consideration. The majority of accepted applicants were from clinical administration teams, • The Trust was carrying out work to benchmark its temporary pay rates against others. • Transparency about the changes was key to mitigate against the anxiety in the workforce. A number of engagement activities were taking place, including regular ‘Talk To David’ sessions. • An Equality and Quality Impact Assessment process was in place and was undertaken in respect of decisions. The impact of decisions would be monitored through the Quality Governance Steering Group. It was also Page 5 necessary to ensure that there was a strategic view of decisions rather than just individual cases. The Board discussed the controls on recruitment. The content of the discussion is summarised below: • It was questioned whether a complete freeze on non-clinical recruitment could be sustained for the full year, and that shortages in administrative staff were already having an impact. It was noted that there had already been restrictions on recruitment for these staff groups during the previous year. • It was noted that decisions made by providers in isolation could impact other providers. However, chief medical officers across the system had agreed to discuss plans collectively. 5.11 Freedom to Speak Up Report Christine Mbabazi was invited to present the Freedom to Speak Up Report, the content of which was noted. It was further noted that: • The Trust had received 37 Freedom to Speak Up cases between December 2024 and June 2025, compared to 64 cases during the same period in 2023/24. There had also been a lower number of patient safety and health and safety reports. • Although there had been fewer reports via Freedom To Speak Up, there were other routes for raising concerns and Freedom To Speak Up was meant to provide a route where other options were unavailable or not possible. • It had been reported that the National Guardian Office function was to be abolished. The Board discussed the report, the key points from which are summarised below: • The Freedom to Speak Up framework was designed to facilitate reporting of patient safety related concerns. However, there had been few such reports through this route, with the mechanism being used more as a conventional ‘speak up’ method to report matters such as bullying and harassment. • Moreover, it was not clear whether the lack of such reports via Freedom to Speak Up was an indicator whether the more conventional reporting mechanisms were working effectively and hence there was no requirement to use Freedom to Speak Up. • It was agreed that it would be helpful to have data from the other means of reporting patient safety concerns included in the report in order to provide greater assurance. Action Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. 5.12 Infection Prevention and Control 2024-25 Annual Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control 2024/25 Annual Report, the content of which was noted. It was further noted that: Page 6 • The Trust had exceeded the threshold for Clostridioides Difficile and Methicillin-resistant Staphylococcus aureus (MRSA) cases during the year. However, the Trust had been successful in improving antimicrobial stewardship by 1%. • There had been a surge in respiratory infections in early 2025, which the Trust had managed well due to the use of its rapid testing diagnostic tool. The Trust had also successfully mitigated outbreaks of norovirus. • The measures taken to prevent the spread of Candida auris had been successful with only four acquisitions since September 2024. • Only 59% of areas had achieved the accreditation scheme standard, but there were actions in place to address this and improve standards as well as support through the Fundamentals of Care programme. 5.13 Guardian of Safe Working Hours Quarterly Report Paul Grundy was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There was a resident doctor vacancy rate of 8%, which was good compared with others. • Exception reports had decreased since the winter months. 711 exception reports had been received over the past 12 months, an average of 59 per month. • The People and Organisational Development Committee would continue to receive updates in respect of work being carried out to improve the lives of resident doctors. • The main challenge in terms of steps required to improve working conditions remained the Trust’s estate and the limited options for providing office space. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 1 Review Martin de Sousa and Kelly Kent were invited to present the Corporate Objectives 2025/26 Quarter 1 Review, the content of which was noted. It was further noted that: • Twelve objectives had been agreed for 2025/26. • The Trust was on track with 75% of objectives recorded as ‘green’ and the balance being ‘amber’. • The main risks to achieving the Trust’s objectives related to availability of people and financial constraints. 6.2 Research and Development Plan 2025-26 Karen Underwood and Chris Kipps were invited to present the Research and Development Plan 2025/26, the content of which was noted. It was further noted that: • 2024/25 had been a challenging year, but despite this there had been a number of significant successes. These included an award to host a new Commercial Research Delivery Centre, launch of the South Central Regional Page 7 Research Delivery Network, and securing funding for a secure data environment. • There remained challenges in terms of available capacity to set up and deliver studies. • Key Performance Indicators were to be focused on national priorities. • The plan for 2025/26 would focus on efficiency and working regionally. • The Trust had increased the size of its commercial portfolio. However, there needed to be a balance with non-commercial studies to support the Trust’s wider strategy. Decision Having considered the proposed Research and Development Plan for 2025/26, the Board approved the plan. 6.3 Board Assurance Framework (BAF) Update and Risk Appetite Statement Lauren Anderson was invited to present the Board Assurance Framework (BAF) Update, the content of which was noted. It was further noted that: • All risks had been reviewed by the relevant executive(s) and by the Board’s committees since the Board Assurance Framework was last presented to the Board. • The risk ratings had been increased for three risks. This was broadly due to the tension between the Trust’s finances and increasing demand. As a result, 60% of BAF risks were now at the ‘critical’ level. • The risk descriptions indicated crossover in terms of mitigations, demonstrating a holistic approach to risk management. Lauren Anderson was invited to present the Trust’s Risk Appetite Statement, the content of which was noted. It was further noted that: • The Trust’s Risk Appetite Statement had been updated following the Trust Board Study Session held on 3 June 2025. • Due to the current environment, the Trust was required to tolerate a higher level of risk. • The main changes in terms of risk appetite were to reflect the need to make decisions that might adversely impact patient experience and a lower appetite for financial risk. Decision: The Board agreed the Risk Appetite Statement tabled to the meeting. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Review of Standing Financial Instructions 2025 Ian Howard was invited to present the review of the Standing Financial Instructions, the content of which was noted. It was further noted that: • There were two main changes proposed: an additional section on employee expenses and reducing non-pay approval limits for certain bands. • The Standing Financial Instructions had been benchmarked against others to address differences of approach. • The proposed changes had been reviewed and supported by the Audit and Risk Committee at its meeting held on 9 June 2025. Decision: The Board approved the proposed changes to the Standing Financial Instructions tabled to the meeting. 8. Any other business There was no other business. 9. Note the date of the next meeting: 9 September 2025 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 13/05/2025 - 5.6 Performance KPI Report for Month 12 1246. Virtual outpatients appointments Linning-Karp, Duncan 09/09/2025 Pending Explanation action item Duncan Linning-Karp agreed to investigate why the number of virtual outpatients appointments had reduced. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 13/01/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 1 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • • • The committee reviewed the Finance Report for Month 3, noting that the Trust had reported a £4.5m in-month deficit. This was £1.1m above the plan submitted to NHS England. The Trust’s underlying deficit was £6.5m in month and income had been lower than expected. Whilst the Trust’s financial trajectory was improving, it was not improving at the rate required to deliver the plan. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received additional cash from the ICB during the month. However, the Trust expected to record a negative cash balance in December 2025. Accordingly, the Trust was investigating further measures to manage its cash position. There was also a risk due to any unfunded elements of the pay award and additional costs due to industrial action. The committee reviewed the Trust’s CIP performance, noting that whilst the Trust was close to full achievement, there had been fewer recurrent schemes delivered than anticipated with a greater proportion of savings being delivered through non-recurrent savings. The committee received an update in respect of the Trust’s productivity, noting that this would be one of the metrics to be included in the new NHS Oversight Framework. The committee received an update regarding the Outpatient Transformation Programme. The committee reviewed Wessex NHS Procurement Limited’s performance, including its delivery of CIP. The committee received the quarterly UHS Digital report. The committee received an update on the proposed Hampshire and Isle of Wight elective hub and on a possible Urgent Treatment Centre at Southampton General Hospital. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: Finance and Investment Committee Meeting Date: 2 September 2025 Key Messages: • • • • • • The committee reviewed the Finance Report for Month 4 (see below). The committee reviewed and discussed a draft of the Trust’s Financial Recovery Plan, which was to be reviewed by the Board on 9 September 2025. The committee requested some clarifications and proposed some additions to ensure that long-term implications were understood. These changes would be incorporated into the paper to go to the Board. Suggestions for further action were also raised, but some of these had been discounted due to the impact on operations and detriment to the short-term position. The committee received an update in respect of the Trust’s cash position, noting that the Trust had received cash advances in June and July and that the ICB had agreed to provide additional cash in August and September. In addition, the process for requesting cash support from NHS England had now been published, although this would likely require some adjustments to the Trust’s governance to establish a ‘cash committee’ – it was considered appropriate to review the terms of reference for the Finance and Investment Committee and possibly to separate out the cash monitoring activities. It was further noted that NHS England had published guidance which suggested that trusts should have a minimum of four days’ operating expenditure in cash. The committee supported the submission of a request for cash support from NHS England, noting that the consequences of not receiving such support would be extremely serious (see also BAF review below). The committee received an update in respect of ongoing and recent contracting disputes, noting that a number of significant disputes had been closed and two remain in dispute and have been escalated. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.8 Finance Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The Trust had recorded a year-to-date deficit of £19.5m, which was £5.8m above its 2025/26 plan. • There had not been the one-off benefits seen in previous months during Month 4, which meant that the Trust’s position had worsened. However, its underlying month-on-month deficit was improving with £6.5m being recorded in month (previous months had been c.£7m). • The Trust had also received less income than anticipated from areas such as the Channel Islands, genomics, pathology, and CAR(T). There was also a risk that the Trust would not be fully paid for its over performance in terms of elective work, but this was being pursued with the relevant commissioners. • The Trust was also above its workforce plan by 55 whole-timeequivalents and the unfunded element of the pay award amounted to £2.4m per annum, of which £1.4m related to the training and Page 1 of 2 Any Other Matters: education contract and the balance being as a result of the settlement not accurately reflecting the Trust’s staffing mix. • However, the Trust was on track in terms of its CIP delivery, albeit there had been higher non-recurrent delivery than expected. 6.1 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • Risks 5a, 5b and 5c have been updated, following discussions with the respective Executive Director(s). • It had been agreed to increase the rating of risk 5a from 20 to 25 on the basis that the Trust did not, currently, have an agreement for the provision of cash support, and that the Trust was reliant on third parties to resolve many of the underlying issues. It was also noted that the need to reduce activity and spending now would likely require increased expenditure in future years in order to recover the Trust’s position. • It was agreed that the target risk ratings should be amended to show a rating of 20 at April 2026 and 15 at April 2027. The committee noted new guidance in respect of strengthening financial management and supporting delivery in 2025/26. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 21 July 2025 Key Messages: • • • • • • • The committee reviewed the People Report for Month 3 and noted that the size of the workforce had reduced during June 2025. There had been 110 whole-time-equivalent (WTE) staff who left during the month and the Trust was phasing new starters. In addition, the Trust had been able to close surge capacity and was closing wards, which had led to a reduction in bank staff use. Based on the forecast, the Trust expected to be c.350 WTE short of its 2025/26 plan based on the delivery of the ‘green’ and ‘amber’ rated CIP programmes. The Trust continued to experience increased demand and there had been an increase in the number of patients having no criteria to reside. In addition, new resident doctors and newly qualified nurses would impact the Trust’s workforce numbers and the forecast made no assumptions regarding industrial action. The committee noted that administrative and clerical staff had been hardest hit by the recruitment restrictions over the past two years, which was causing difficulties in some areas. The committee discussed the potential intake of newly qualified nurses, noting the difficulty of balancing the Trust’s short-term concerns of needing to reduce its workforce with the longer term need for qualified staff. The committee received an update on the organisational change activities underway, including the proposed divisional restructure and MARS programme. The committee received an update in respect of the planned industrial action by resident doctors. The committee reviewed the National Education and Training Survey for 2024, which covered all staff in training posts in the NHS. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee reviewed five draft Equality and Quality Impact Assessments relating to the measures required to deliver the Trust’s 2025/26 plan. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 1 of 2 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 9 September 2025 Committee: People and Organisational Development Committee Meeting Date: 1 September 2025 Key Messages: • • • • • • The committee reviewed the People Report for Month 4 (see below). The committee noted the recent announcement by the Government of a ‘graduate guarantee’ for nurses. It was noted that, prior to this announcement, the Trust had decided to increase the level of offers to newly qualified nurses, but to phase start dates in line with predicted turnover and anticipated vacancies in nursing posts. The committee noted that there were significant challenges across the organisation with staff impacted by multiple factors, including: increased car parking rates, building work requiring temporary relocation of 300-400 car park users to Adanac (Park and Ride), a reduction in enhanced bank rates back to standard Agenda for Change levels, and a decision to no longer offer free tea and coffee in theatres for staff (in line with other areas of the Trust). This coupled with the ongoing financial environment and workforce controls would impact staff engagement and satisfaction with the Staff Survey due to launch at the end of September 2025. The committee also expressed its concern for staff – particularly those from overseas – in view of the recent political climate regarding immigration. The committee reviewed the workforce related elements of the Trust’s proposed recovery plan, noting that the Trust was dependent on a number of material assumptions in order to be able to meet its 2025/26 plan. These included: availability of funding for further restructuring, reductions in mental health and no criteria to reside numbers, and reduction in overall activity levels. The committee received an update in respect of the industrial action undertaken by resident doctors in July 2025 and noted that about one third of staff eligible took part in the strike and that most clinical activity continued. It was also noted that F1 doctors were to be balloted separately by the BMA with the focus more on pay and availability of training places. The Trust has been required to produce a selfassessment of ten actions relating to doctors’ working conditions and to determine how to achieve these actions which will be presented to committee and to Board through the update by the Guardian of Safe Working at UHS. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.10 People Report for Month 4 Assurance Rating: Risk Rating: Substantial High • The overall workforce had increased by 10 whole-time-equivalents (WTE) in July 2025. Whilst the substantive workforce had decreased by 18 WTE, increased numbers of mental health cases, coupled with industrial action, had led to an increase in use of temporary staff. • Accordingly, the Trust was above the NHSE 2025/26 workforce plan by 55 WTE. • 65 applications under the Mutual Agreed Resignation Scheme (MARS) had been approved with all successful applicants due to leave Page 1 of 2 Any Other Matters: by the end of November 2025. This would deliver a recurrent saving of £2.2m based on the whole-year saving, albeit at a one-off cost of £1.1m, which meant that it was broadly cost neutral for 2025/26. • The Trust completed its divisional restructure on 1 July 2025, which was expected to deliver a saving of £700k and 12 WTE 7.2 People and Organisational Assurance Rating: Risk Rating: Development Committee Terms N/A N/A of Reference • The committee reviewed its terms of reference and recommended that the Board approve the updated terms of reference. • Only one minor change was proposed – to remove reference to the Charitable Funds Committee on the basis that this committee no longer existed. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that
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Annual-report-2017-18

Description: ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2018 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Statement from the chairman and chief executive 7 Statement of purpose and activities 8 History of UHS 8 Structure of executive team 9 Structure of our services 10 Our vision and values 11 Priorities, key issues and risks 12 Going concern disclosure 15 Performance report 15 Regulatory body ratings 22 Environmental matters 23 Social, community and human rights issues 24 Accountability report Directors’ report – the Trust Board 26 Well-led framework 32 Audit and risk committee 32 Disclosures 35 Council of Governors 43 Annual remuneration statement 52 Remuneration and appointments committee 55 Governors’ nomination committee 57 Staffing report 61 Responding to the staff annual attitude survey 66 Statement of chief executive’s responsibilities as the accounting officer 71 Annual governance statement 72 Review of economy, efficiency and effectiveness of the use of resources 79 Equality, diversity and inclusion 83 Environmental sustainability and climate change 85 Southampton Hospital Charity 89 Developments in informatics 90 Leading research into better care 90 Investing for the future 91 Quality account and report Chief executive’s welcome 139 Our approach to quality assurance 141 Our commitment to safety 142 Our commitment to staff 143 Our commitment to education and training 145 Our commitment to technology to support quality 146 Our commitment to the Care Quality Commission 147 Review of quality performance 149 Progress against 2017/18 priorities 157 Clinical research 149 Review of services 150 CQUIN payment framework 150 Data quality 151 Clinical audits and confidential enquiries 152 Seven day hospital services 153 Learning from deaths 154 Priorities for improvement 2018/19 175 Conclusion 191 Responses to our quality account 192 Statement of directors’ responsibilities 198 Independent auditor’s report 199 Appendix Appendix one Quality improvement framework 2018/19 203 Appendix two Quality performance data 204 Appendix three CQUIN data 211 Appendix four Clinical audit and confidential enquiries data 214 Appendix five Registration with the Care Quality Commission 216 Appendix six Glossary of acronyms 217 Annual accounts Statement from the chief financial officer 93 Foreward to the accounts 94 Independent auditor’s report 95 Financial statements 101 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT A word from the chairman and chief executive Staff at UHS achieved some amazing things in 2017/18, a year in which the Trust faced the huge challenge of continuing to deal with rapidly rising demand for our services at a time when, like many hospitals, we were already under great pressure. Perhaps the most obvious achievement was that the Care Quality Commission (CQC) rated UHS as good for the quality of care which it provides overall and outstanding for leadership. It is no coincidence that the results from our latest NHS staff survey were so positive. We were particularly pleased that our response rate had increased and that UHS staff rated us the fourth best nationally for staff recommending the hospital as a place to work or receive care. We are also the seventh best nationally for staff engagement and results show that our staff feel able to contribute fully towards improvements. However, it’s truly in times of adversity, such as that we experienced over the winter period, that you see teamwork and commitment shine through. On several occasions we supported our neighbouring hospitals by providing care to their patients. We were also immensely proud of the way our staff pulled together during the days of thick snow with many staying on site overnight to ensure we had enough staff to care for our patients. Others stayed to look after stranded patients who were unable to get home. Staff with 4x4 vehicles collected colleagues for work and drove patients home. It was a monumental and incredibly uplifting effort from all. Our staff have indeed continued to strive tirelessly to provide both the quality of care and the speed of access to treatment to which we aspire. We are confident that we have done the former but the rapid increase in patient numbers has at times made it difficult to achieve the latter. We are determined to improve our performance to achieve the standards our patients expect. We are encouraged by the terrific results we achieve in the NHS Friends and Family test, with patients overwhelmingly recommending UHS as a place to have their hospital care. As the result of achieving our financial target for 2016/17 we became eligible for additional national cash incentive payments, which meant that in 2017/18 we were able to commit to the biggest capital investment programme the Trust has ever seen. As part of this programme we were able to address some of the areas of our estate that were highlighted as requiring improvement in a previous CQC report. We are delighted to say that we have again delivered our financial target for 2017/18 and will as a result be able to sustain a high rate of investment in upgrading our hospitals. We have also recently been able to start work on a £5m project to build a new Children’s Emergency Department as the result of generous support from the public for Southampton Hospital Charity and our partnership with the Murray Parish Trust without which the project would have been impossible. It will transform the environment in which our young patients are treated. Sadly at the end of the year we waved goodbye to Fiona Dalton, our chief executive for the last four years, who took the opportunity of a lifetime to live and work in Vancouver where she will lead a major Canadian healthcare group. Fiona was a remarkable chief executive, both immensely liked and admired throughout UHS and she left with the goodwill and best wishes of everyone. Peter Hollins David French Chairman Interim chief executive officer 7 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,454 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2017/18 was more than £810m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 8 OVERVIEW AND PERFORMANCE REPORT The way we’re structured Structure of the executive team Associate director of corporate affairs Amanda Lowe Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive (interim) David French Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer (interim) Paul Goddard Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security; communications Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 9 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our services are split into five divisions and within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 10 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 11 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 12 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 13 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2018/19. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 14 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 30. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 72. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 15 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2017/18 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Executive digest – update on the previous month’s performance written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months • Safe • Effective • Caring • Activity • Emergency department (ED) • Referral to treatment (RTT/18 weeks) • Cancer waiting times • Flow • Staffing (HR) • Education and training • Research and development • Estates This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. The emergency department, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 16 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS Trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2017/18 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust now has a model hospital steering group which identifies potential improvement projects from the data and reports to transformation board. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2015/16 to 2017/18 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases Outpatient appointments 2015/16 2016/17 2017/18 ED attendances (type one) Referrals Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 2017/18 154,224 624,083 102,547 208,872 Increase 15/16 to 17/18 5.6% 10.9% 7.7% 8.9% 17 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven and in 2017/18 this increased again to twenty. The chart below shows red and black alerts logged during 2017/18. 50 Number of AM and PM alerts 40 30 20 10 0 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Red alerts Black alerts Contributing to this change has been an increase in length of stay (LoS) for elective patients linked to a more complex case mix and an increase in day cases. The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2017/18. UHS delayed transfers of care 2017/18 Percentage of bed days lost 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Mar 2017 April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 18 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS met the target in quarter one of 2017/18 but did not meet the target for the rest of the year. Achievement of this target in 2017/18 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. We have identified a reporting issue at our satellite outpatient clinics in Salisbury and are investigating the impact on referral to treatment reporting. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and, in August 2017 we also took over the operation of Lymington Minor Injuries Unit and opened the Urgent Care Hub at Southampton General in October 2017. All three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard remains at 95% but a national recovery trajectory was agreed as: Patients should be treated and either admitted or discharged within four hours of arrival 85% achievement target set for April 17 90% achievement target in or before September 2017 95% achievement target by March 2018. How did we do? December 2017 was an extremely challenging month for emergency patients for the whole Hampshire and Isle of Wight area. UHS saw an increase in patients admitted to the Trust with influenza and, alongside our own bed pressures, we took ambulance diverts from other hospitals in order to maintain patient safety across Hampshire. Our Trust received formal letters of thanks from local commissioners and providers for the part we played during this difficult period. 19 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year. National 4 hour access target – UHS performance 100% 95% 89.4% 90% 85% 80% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 87.1% 83.2% 82.1% 82.5% 75% April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Cancer waiting times There are ten separate cancer waiting times measures (below) that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2017/18 the Trust met six of these measures. Number Measures Achieved 1 a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive 8 treatment for all cancers 2 a maximum 31-day wait for subsequent treatment where the treatment is surgery 8 3 a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 3 4 a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen 3 5 a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive 8 treatment for all cancers 6 a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment 3 for cancer 7 a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the 3 priority of the patient (all cancers) 8 a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms 3 9 a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, 8 even if cancer is not initially suspected 10 A maximum 31-day wait (urgent GP referral to treatment) for first treatment for rarer cancers 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 5.2% in 2017/18. The chart overleaf shows the rise in demand for UHS cancer services over the past three years. 20 OVERVIEW AND PERFORMANCE REPORT UHS growth in cancer actvity – 2015/16 to 2017/18 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 62 day target patients 2015/16 2016/17 2017/18 31 day target patients For staffing performance, please refer to page 61. For financial performance please see page 93. David French Interim chief executive officer 24 May 2018 21 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2017/18 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2018. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 2 1 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Good Outstanding Requires improvement Outstanding 22 OVERVIEW AND PERFORMANCE REPORT The CQC inspected all key questions in four of the eight core services of surgery, critical care, end of life care and outpatient and diagnostic imaging and noted the Trust had a stable leadership team in place since their last inspection. The previous inspection in 2015 had found safety of medicine and maternity services, along with responsiveness of urgent and emergency care and children’s services ‘required improvement’. At the 2017 inspection the following observation was made: ‘At this inspection we saw significant improvement across the areas we inspected. There were improvements in surgery, critical care, end of life care and outpatients. Critical care is rated overall as ‘Outstanding’, with surgery, end of life care, and outpatients and diagnostic imaging as ‘Good’ overall. These services had been rated requires improvement in 2015. The improvements were in line with the trust’s improvement plan and had been assisted by the trust board and executive leadership team’ Professor Sir Mike Richards Chief Inspector of Hospitals Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 85 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 23 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 24 FR STAND BODY ACCOUNTABILITY REPORT Directors’ report – the Trust Board Board member Name Title Fiona Dalton Chief executive (until March 2018) David French Interim chief executive (chief financial officer until March 2018) Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT. David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT; Member of Solent Acute Alliance Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice (until 10 February Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is mental health act manager, Southern Foundation Trust (voluntary position) (until 31 August 2017), member of assessment committee for Clinical Excellence Awards South and Public Health England (lay member) (until January 2018), a UHSFT simulated patient (voluntary position); Mother is a UHSFT simulated patient (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Daughter-in-law employed at UHSFT as medical support to department of innovation (from January 2017 – December 2017) Daughter is in an administration role at UHS (from July 2017) 26 ACCOUNTABILITY REPORT Board member Name Title Biography Declarations Paul Goddard Interim chief financial officer (from April 2018) Paul joined the Trust in June 2007 as assistant director of finance and become the deputy director in December 2012. Paul has spent over 25 years in NHS finance having worked in many different organisations. A fellow of the Association of Chartered Certified Accountants, Paul became interim chief financial officer at UHS from April 2018. Serves as a director of the Trust’s wholly owned subsidiary company, UHS Pharmacy Limited. Sits on the Southampton Hospital Charity committee. Non-executive directors Peter Hollins Simon Porter Chair Senior independent director and deputy chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council member of University of Southampton Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Former partner in Ernst & Young LLP; Non-executive director and chair of audit committee, Radian Group; Non-executive director and chair of audit committee, Octavia Housing Dr Mike Sadler Non-executive director Mike joined UHS as a clinical non-executive director in September 2014, from a similar position at an NHS foundation trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. External clinical associate for PricewaterhouseCoopers; Member of the Advisory Board for xim (from 1 May) Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. 27 ACCOUNTABILITY REPORT Board member Name Title Jenni Non-executive Douglas- director Todd Biography
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2017-181.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
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The Flange FITS Guide for optimal comfort, efficiency and milk yield

Description: THE FLANGE FITS™ GUIDE for optimal comfort, efficiency and milk yield a results-based method for pumping Feel Intensity Tempo Supply SIDE VIEW PARENT’S VIEW ©Copyright Babies in Common 2023 Jeanette Mesite Frem, IBCLC. Reproduction permitted with attribution. April 2023. Best Fit • only nipple pulled into tunnel • sides of nipple touch walls of tunnel • nipple moves a little bit back and forth in tunnel • milk sprays during pumping • best to pump 15-20 minutes (both sides at same time) • feels like nothing or a gentle tug Too Large Much Too Large • might hurt • might get less milk or more drips than sprays • nipple might move side to side in tunnel • pumping might take a long time • more chance for nipple swelling and damage • areola goes into tunnel and can swell • outdated recommendations will indicate this as best fit; newer clinical evidence finds this too large babiesincommon.com Feel of the flange (size, shape, material) Which flange size, shape or material is the most comfortable (but also gets out the most milk)? Often, a flange that is closest to the actual size of the nipple feels best (and gets the most milk out). Start by measuring how wide the tip of each nipple is (left can be different than right). 1. Gently touch/tug the nipple to help it stick out a bit. 2. Use a tool with centimeters (cm) or millimeters (mm). Start with 0 next to one edge of the nipple tip. The tool does not need to touch the nipple. 3. Turn on the pump on a low vacuum/intensity level and try pumping with 2 or 3 hard plastic flange sizes: one a little smaller than the nipple, one about the same size, and one a little bigger than the nipple. • Best fit or optimal fit: The sides of the nipple touch the sides of the flange tunnel and the nipple gently glides a little bit back and forth. It should also be comfortable and milk should come out easily. • Too small: The nipple will not move easily in the tunnel and less/no milk comes out. • Too large: It may hurt, make the nipple get bigger than it usually is (swollen) and less milk comes out. A thin layer of coconut oil or nipple balm on the bend of the flange can increase comfort. Pumping should feel good and get plenty of milk out! Intensity of the pump (vacuum pressure/pull) How strongly does the pump pull on the nipple? The intensity of the pull of the nipple into the flange tunnel depends on the pump. Not all pumps are the same. Not all pumping parents need a strong pull when pumping. Once milk starts spraying and there is complete comfort, stay on that vacuum level and play with the pump cycle speed. Increase the intensity of the pull during the pumping session if it is comfortable and you see more milk sprays. Pumping should be comfortable from start to finish – it should not be something to "tolerate". Nipples should feel good when the pumping session is done. The size of the nipple (width) should be about the same as before pumping (but the nipple may be longer after pumping). Tempo of the pump (cycle speed, rhythm, vibration) What is the best tempo of the pump? The one that helps the most milk come out. The tempo is not only the speed, or cycle, but also the rhythm. Some pumps have simple tempos and others have options. Think of tempo like music for dance. Some tempos are faster, slower, or a combination of fast and slow. See what works best for your body with the pump you have. Some pumps have more of a pull-release rhythm and others have more of a vibration. Helpful Tips: • Start on the fastest tempo and after milk is coming out for 20-30 seconds, change to a slower tempo – more sprays should come out. • If sprays stop at some point during the pumping session, change the tempo back to faster for 1-2 minutes and then back to slower again. There are people who stay on a faster tempo the entire pumping session—play with the tempo to discover what works best to get the most milk out but with comfort. Some parents may need to find a different pump that works better for their body. A pumping session ideally would last 15-20 minutes. Supply of milk (drips, dribbles; strong sprays are ideal) How much milk should someone get when pumping? The answer depends on many factors but the goal is to see sprays of milk during pumping. Drips and dribbles are fine for part of a pumping session but, ideally, sprays would be seen/heard for most of the pumping session. Helpful Tips: • Many people find they get the most milk when they have the best flange fit. They may also get the same amount or more milk in a shorter amount of time when pumping than with flanges that are too large. • Hands-on pumping during pumping and hand expression of milk after pumping can help get more milk out. • The left breast may make more or less milk than the right • It's normal to get more milk in the morning hours. If you want to make more milk overall, it's best to seek out help from a lactation professional who specializes in pumping and milk supply. What about silicone flanges and inserts? For parents who wish to get more milk during pump sessions but who want to try silicone inserts or silicone flanges, it is best to try hard plastic flanges first to find the ideal size for each nipple. Then try silicone flanges and/or inserts and see how the comfort and amount of milk pumped compares to using the best fitting hard flange. Many people find that they get more milk with a hard flange that is the optimal size, and they are completely comfortable. Need help? Find a lactation professional who has experience observing pumping sessions with varied flange options. They can do an in-person or video meeting to help find the optimal flange size for you. If you have questions or want help finding someone near you who can help with flange fitting, email jeanette@babiesincommon.com. The Flange FITS™ Guide by Jeanette Mesite Frem MHS, IBCLC, RLC, CCE. Reproduction and distribution permitted with attribution. No editing or cropping permitted. Editing Assistance: Nikki Lee, RN, BSN, MS, IBCLC, RLC, CCE & the Washington State Dept of Health WIC Program. Stephanie Audette Connor, graphic designer. areola nipple tip Measure nipple tip before pumping to estimate which flange sizes to try. 1cm = 10mm. Flange sizes are in mm. page 2/2 | v.2, 4/2023
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Papers Trust Board - 10 March 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 10/03/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Steve Peacock 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 13 January 2026 9:15 Approve the minutes of the previous meeting held on 13 January 2026 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee 9:20 Ian Howard, Chief Financial Officer, for Chair 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee 9:25 David Liverseidge, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee 9:35 including Interim Maternity and Neonatal Safety Report Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 10 10:10 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.7 Break 10:40 5.8 Finance Report for Month 10 10:55 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.9 ICB System Report for Month 10 11:05 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.10 People Report for Month 10 11:10 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.11 Freedom to Speak Up Report 11:20 Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.12 11:35 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Review and discuss the report and update Sponsor: Paul Grundy, Chief Medical Officer Attendee: Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant 6 STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 3 Update 11:50 Review and feedback on the corporate objectives Sponsor: David French, Chief Executive Officer Attendee: Martin de Sousa, Director of Strategy and Partnerships 6.2 Board Assurance Framework (BAF) Update 12:00 Review and discuss the update Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 29 January 2026 12:15 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 7.2 Register of Seals and Chair's Actions Report 12:20 Receive and ratify the report In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 7.3 Audit and Risk Committee Terms of Reference 12:25 Review and approve the Terms of Reference Sponsor: Ian Howard, Chief Financial Officer, for Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.4 Quality Committee Terms of Reference 12:30 Review and approve the Terms of Reference Sponsor: Tim Peachey, Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7.5 Remuneration and Appointment Committee Terms of Reference 12:35 Review and approve the Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 8 Any other business 12:40 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 14 May 2026 10 Items circulated to the Board for reading 10.1 South Central Regional Research Delivery Network (SC RRDN) 2025-26 Q3 Performance Report Note the report Sponsor: Paul Grundy, Chief Medical Officer 11 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 12 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 10 March 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.6 Performance KPI Report for Month 10 5.8 Finance Report for Month 10 5.9 ICB System Report for Month 10 5.10 People Report for Month 10 5.11 Freedom to Speak Up Report 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan 1a, 1b, 1c 5a 5a 3a, 3b, 3c 3b 3b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 4x4 16 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x Minutes Trust Board – Open Session Date Time Location Chair 13/01/2026 9:00 – 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd (JD-T) Present Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Non-Executive Director (NED) (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director and Deputy Chair (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) James Allen, Chief Pharmacist (JA) (item 5.12) Julie Brooks, Deputy Director of Infection Prevention and Control (JB) (item 5.11) Blue Cunningham, Patient Engagement & Involvement Officer (item 2) John Mcgonigle, Emergency Planning & Resilience Manager (JMc) (item 6.1) Jenny Milner, Associate Director of Patient Experience (JM) (item 5.10) Julian Sutton, Clinical Lead, Department of Infection (JS) (item 5.11) 4 governors (observing) 5 members of staff (observing) 2 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Blue Cunningham was invited to present the Patient Story on behalf of Jade […], whose nine-year-old daughter, Lucy, had had a bowel resection at the Trust. It was noted that: • Lucy was a very structured child, who relied heavily on planning and knowing outcomes as well as having sensitivities to lots of different sensory inputs. Page 1 • In their treatment of Lucy, staff paid particular attention to Lucy’s needs and adapted their behaviour and took the time to make Lucy’s stay in hospital as comfortable as possible. • This Patient Story clearly demonstrated the Trusts’ values and the time taken in the handling of Lucy by staff likely saved time and effort in the long run by not distressing the patient and then having to manage this situation. 3. Minutes of the Previous Meeting held on 11 November 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 11 November 2025, subject to reassigning action 1296 to James Allen. 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Action 1293: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. • Action 1294: this formed part of a larger piece of work, which would be addressed through the planning cycle. The action could be closed. • Action 1295: a solution had been developed, but the Trust was waiting on a third party to be able to implement the solution. The action could be closed. • Action 1296 was addressed as part of item 5.12 below. It was explained that the metric was based on day cases and national statistics and was intended to show usage levels of the most critical antibiotics. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 24 November and 15 December 2025, the contents of which were noted. It was further noted that: • The Trust had reported an in-month deficit of c.£5m and, at the end of November 2025, had reported a year-to-date deficit of £40m. • The committee had received an update in respect of the Trust’s theatres improvement plans, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee had received a report on the Trust’s productivity based on the national framework and noted that further work was required to understand the metrics behind the national framework. • The committee had reviewed the Trust’s cash position and supported a proposal to request further cash support for January 2026. • The committee noted that whilst the Trust’s transformation plans were ambitious, they were nonetheless grounded in reality. • In its review of the proposed capital plans for 2026/27-2029/30, the committee noted the challenge of having to balance the Trust’s allocation of Capital Departmental Expenditure Limit (CDEL) with the cash available to the Trust. • The committee reviewed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. It was noted that the assumed reductions in patients with no criteria to reside and mental health Page 2 patients were those reasonably considered to be within the Trust’s control rather than reductions which were dependent on third parties. • The committee supported a proposal for transforming the Southern Counties Pathology network. 5.2 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 21 November and 15 December 2025, the contents of which were noted. It was further noted that: • Whilst there had been reductions in the size of the substantive workforce, this had been offset by an increase in temporary staff due to a combination of demand, sickness absence, patients with no criteria to reside, and mental health patients. • The committee noted changes with respect to statutory and mandatory training, which would facilitate ‘passporting’ between NHS organisations. • The committee received an update in respect of the Trust’s Inclusion and Belonging strategy, noting that progress had been slower than anticipated due to available resource. It was further noted that the external political environment had also created additional challenges in this area. • The committee received an update regarding the Trust’s refreshed approach to violence and aggression, noting a greater willingness to take action against violent/abusive patients and members of the public. It was further noted that the communications accompanying the new approach would be key. • The committee reviewed the Trust’s performance against the ten-point plan for resident doctors, noting that the Trust was, subject to a few exceptions, in a good position. • Whilst the results of the Staff Survey were still under an embargo, early indications were that the participation rate was lower than hoped for. • The Trust’s seasonal vaccination campaign had been successful with over 50% of staff having been vaccinated against influenza. 5.3 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 24 November 2025, the content of which was noted. It was further noted that: • The committee noted that the Trust’s Complaints service, particularly Patient Advice and Liaison Service (PALS), was fragile. There was a backlog of c.500 emails due to resource constraints. • The committee noted that despite the financial pressure the Trust was under, it had sought to maintain staff numbers to ensure patient safety. A significant proportion of the reduction in staff during the year had been from administrative staffing groups. Whilst the Trust had successfully reduced the size of the clinical administrative workforce, it had not been possible to transform how this service was delivered through technical or other means. Therefore, there was a risk of bottlenecks due to insufficient administrative staff with the high level of demand falling on a smaller number of staff. • NHS England had launched changes to maternity care reporting with additional reporting requirements with the aim of developing national standards and approaches. • The committee had reviewed the Trust’s Maternity and Neonatal Safety report for the second quarter and noted that the Trust had demonstrated compliance with the requirements for the NHS Resolution Maternity Incentive Scheme. Page 3 5.4 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published latest segmentation and league tables under the NHS Oversight Framework for Quarter 2. The Trust had fallen slightly from 48 out of 134 to 51 out of 134. The Trust remained in segment 5 due to being in the Recovery Support Programme. • The number of patients waiting over 65 weeks in October 2025 had resulted in the Trust entering Tier 1 for elective performance. However, since that time, the Trust had successfully reduced the number of patients waiting over 65 weeks to c.80, with a target to reduce this number to nil by the end of March 2026. • The Employment Rights Bill received Royal Assent on 18 December 2025. The Act included a number of changes which would impact the Trust. These changes were to be reviewed in detail by the People and Organisational Development Committee. • During further strike action by resident doctors between 17 December and 22 December 2025, the Trust had met the national target of maintaining 95% of activity. Roughly one-third of resident doctors had taken part in the industrial action, which compared favourably to other trusts – some had reported a participation rate of 80-90%. • University Hospitals Sussex NHS Foundation Trust had been fined in connection with the death of a patient with severe mental health problems who had absconded from a ward at the trust and subsequently committed suicide. This case was pertinent for the Trust given the number of mental health patients currently being cared for at the Trust in the absence of a more appropriate setting. It was noted that the Trust’s policy was clear on the approach to be taken in the event of a similar situation to that faced by University Hospitals Sussex NHS FT. • On 2 January 2026, the Trust had been informed that its endoscopy service had had its accreditation renewed until 1 November 2026 following an annual review by the Royal College of Physicians’ Joint Advisory Group on Gastro- Intestinal Endoscopy. • Alison Tattersall had been appointed as the Trust’s second Nominated Trustee on the board of the Southampton Hospitals Charity. • The Trust’s department of clinical law – a service established to deal with clinical questions relating to regulatory and legal principles within the Trust – had been in existence for 16 years. 5.5 Performance KPI Report for Month 8 Andy Hyett was invited to present the ‘spotlight’ report in respect of Cancer waiting time targets, the content of which was noted. It was further noted that: • There had been an increase in referrals over recent years, but despite this increase, the Trust had maintained performance, particularly in respect of the 28-day faster diagnosis pathway. • Consideration was being given in terms of demographic groups to be targeted in view of the success of the Targeted Lung Health Check programme and its efforts to target particular sections of the population. • The main challenge in terms of improving performance was in terms of diagnostic capacity, including access to magnetic resonance imaging (MRI) and other imaging services. Improving the diagnostics services remained a key priority, including development of a longer-term strategy for imaging. It was noted that MRI and computed tomography (CT) scan capacity in the UK was lower than that in comparable nations such as those in the US and EU. Page 4 • The Trust maintained a good relationship with the Wessex Cancer Alliance, which was an effective route for obtaining additional funding for cancer care. Action Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Andy Hyett was invited to present the Performance KPI Report for Month 8, the content of which was noted. It was further noted that: • The Trust’s overall Referral To Treatment (RTT) waiting list for November 2025 had decreased by 0.9% and the Trust had made significant progress in reducing the number of patients waiting more than 65 weeks. • The number of patients waiting for diagnostics marginally increased, but the Trust had maintained its previous performance with c.80% of patients waiting under six weeks for the fourth month in a row. • The Trust’s performance against the four-hour emergency department target had improved by 5.8% since October 2025, achieving 60.4% in November 2025, which was above its in-year performance plan submitted at the beginning of 2025/26. The Board discussed the Performance KPI Report for Month 8. This discussion is summarised below: • In terms of the Trust’s RTT waiting list, it was forecast that there would be c.60,000 patients on this list by the end of March 2026 with performance against the 18-week target expected to be c.67%. • The Trust’s performance in respect of the number of mental health patients spending over 12 hours in accident and emergency was considered to be reflective of the need to admit mental health patients where there was no more appropriate venue available. This situation also gave rise to increased use of agency staff. A workshop had been held with Hampshire and Isle of Wight Healthcare NHS Foundation Trust (HIOWH) and an action plan had been agreed. It was noted that HIOWH was also experiencing challenges in terms of its ability to discharge patients. • The reduction in the percentage of virtual appointments as a proportion of all outpatient consultations compared to 2024/25 was being looked at. • As of 13 January 2026, there were 295 patients with no criteria to reside – equivalent to 12 wards – at Southampton General Hospital. Work was ongoing to create wards specifically for this cohort of patients. It was noted that Hampshire and Isle of Wight Integrated Care System was ranked 39 out of 42 in terms of its number of patients with no criteria to reside. 5.6 Break 5.7 Finance Report for Month 8 Ian Howard was invited to present the Finance Report for Month 8, the content of which was noted. It was further noted that: • The Trust had reported a £4.9m deficit for Month 8 (£40.8m deficit, year-to- date), which was in line with its Financial Recovery Plan. This in-month deficit had also been maintained for Month 9, with the year-to-date deficit increasing to £45.6m. • The Trust’s underlying deficit remained at c.£6m per month with continued high numbers of patients with no criteria to reside and mental health patients coupled with operational pressures. Page 5 • The Trust had carried out between £20m and £30m of unfunded work during the year and had incurred £10m-15m of costs associated with patients with no criteria to reside and mental health patients. • The Trust expected to deliver £90m of savings under its Cost Improvement Programme against its target of £110m. • The Trust had requested £8.4m of additional cash support for January 2026 and expected to require a further £3m of support in March 2026. 5.8 ICS System Report for Month 8 Ian Howard was invited to present the ICS System Report for Month 8, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £65m, which represented a variance of £36m from plan. It was noted that the Trust was a significant contributor to this variance, but that other organisations were also now reporting variances to plan. • The Trust had achieved the best ambulance handover time performance in the system, but further work was ongoing across the system with South Central Ambulance Service (SCAS) to improve performance. 5.9 People Report for Month 8 Steve Harris was invited to present the People Report for Month 8, the content of which was noted. It was further noted that: • The overall workforce fell marginally during November 2025, with reduction in substantive staff of 52 whole-time-equivalents (WTE) being partially offset by an increase in temporary staff usage due to operational pressures and sickness absence. • The Trust remained above its 2025/26 plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to meet its Financial Recovery Plan, the Trust’s workforce needed to reduce by a further 137 WTE. • Sickness absence continued to increase with 4.2% being reported during November and 4.8% being reported for December 2025. • The 2025 Staff Survey had closed. It was noted that the results were expected to be challenging. • The Trust had hit its target of 58% of staff having been vaccinated against flu, which placed the Trust in the top 15 nationally and second in the South East. • There was a significant amount of work ongoing to refresh the Trust’s approach and policies in respect of violence and aggression, including policy changes, training and communications. 5.10 Learning from Deaths 2025-26 Quarter 2 Report Jenny Milner was invited to present the Learning from Deaths report for the second quarter, the content of which was noted. It was further noted that: • The Trust continued to benchmark well against other organisations. It was one of only 11 trusts nationally with a lower than anticipated mortality rate based on its summary hospital-level mortality indicator (SHMI) score. • The Medical Examiner Service had reviewed a total of 1,078 deaths, of which 36% had occurred at the Trust’s sites. • Patients with learning disabilities remained an area of concern, although progress was being made in this area. The Trust was one of only a few Page 6 organisations to hold separate meetings to discuss deaths of patients with learning disabilities. • The Trust had procured a system to support organisation-wide learning from Morbidity and Mortality outcomes. 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report Julian Sutton and Julie Brooks were invited to present the Infection Prevention and Control report for the second quarter, the content of which was noted. It was further noted that: • For the period covered by the report (July-September 2025), the Trust had exceeded all measures in terms of the annual limits for incidences of bacteraemia. The Trust was in a similar position to other organisations nationally. • There had been two cases of Methicillin-resistant Staphylococcus aureus (MRSA) and 34 cases of Clostridioides difficile (C-diff) during the period. • There had been a focus on invasive device care management (such as cannulas and catheters) and on hand hygiene. • The Trust had successfully managed the Candidozyma auris outbreak, with only three new cases identified since the beginning of 2025, the last of which was identified in April 2025. 5.12 Medicines Management Annual Report 2024-25 James Allen was invited to present the Medicines Management Annual Report 2024/25, the content of which was noted. It was further noted that: • The Trust’s expenditure on medicines during 2024/25 was £215m, a 2% reduction compared to 2023/24 and was on track to spend only £207m during 2025/26. These reductions indicated that the strategy of using less expensive generic and biosimilar medicines had been effective in reducing costs. • The number of approvals for clinical trials and research activity had continued to improve. • The Trust had completed work to decommission nitrous oxide manifolds, which was expected to reduce the Trust’s nitrous oxide emissions by 600,000 litres per year, equivalent to 354 tonnes of carbon dioxide emissions. • An area of focus was the deployment of digital systems. Action Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. 5.13 Ward Staffing Nursing Establishment Review 2025 Natasha Watts was invited to present the Ward Staffing Nursing Establishment Review 2025, the content of which was noted. It was further noted that: • The report set out the results of the ward staffing review undertaken between July and October 2025. • There was a renewed national focus on safe staffing. • Overall, the Trust’s staffing establishments remain appropriate and within recommended guidelines. Page 7 • Continued high levels of enhanced care demand, a significantly more junior workforce, managing additional surge areas, and the impact of financial controls had been highlighted as ongoing challenges. 6. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Jon Mcgonigle was invited to present the Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response, the content of which was noted. It was further noted that: • NHS England required all trusts to complete an annual self-assessment against a number of core standards. In its assessment against 62 applicable core standards, the Trust was fully compliant with 56 and not yet fully compliant with 6 standards. • Of the areas where the Trust was not yet fully compliant, these related primarily to governance maturity, exercising and testing, workforce training consistency, and assurance evidence, rather than the absence of emergency response arrangements. • Since an initial report had been submitted to the Trust Executive Committee in November 2025, the Trust had completed development and approval of the Business Continuity Management System, completed the consultation and adoption of Protective Security and Emergency Lockdown arrangements, and had commenced consultation and system engagement for Evacuation and Shelter. • Training was scheduled to take place between February and May 2026 for on- call staff in charge. It was intended to hold a tabletop exercise during 2027. • It was noted that it had been some time since the Trust had practised a major incident response with other partners. • The Trust was on schedule to embed the ‘protect’ duty under the Terrorism (Protection of Premises) Act 2025 by March 2027. Action John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. 7. Any other business It was noted that the Trust had declared a critical incident on 10/11 December 2025 due to an IT system failure. It was noted that this was Keith Evans’ final formal meeting, as his second threeyear term as a non-executive director was due to expire on 31 January 2026. The Board expressed its thanks to Keith Evans for his service and support. 8. Note the date of the next meeting: 10 March 2026 Page 8 9. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. TB 13/01/26: work had commenced on a broader MRI strategy. This work would be presented to the Quality Committee in due course – the action remained open. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. 16/04/2026 Pending Update: Item deferred to TBSS on 16/04/26. Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 13/01/2026 - 5.5 Performance KPI Report for Month 8 1311. Cancer diagnosis Hyett, Andy 10/03/2026 Pending Explanation action item Andy Hyett agreed to provide Jane Harwood with further data regarding the stage at which cancer was diagnosed by socio-economic group. Trust Board – Open Session 13/01/2026 - 5.12 Medicines Management Annual Report 2024-25 1312. Medicines costs Howard, Ian 10/03/2026 Pending Explanation action item Ian Howard agreed to look at the level of savings achieved in terms of medicines costs and how costs of medicines were budgeted for. Trust Board – Open Session 13/01/2026 - 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1313. Major incident response exercise Mcgonigle, John Hyett, Andy 10/03/2026 Pending Explanation action item John Mcgonigle agreed to look at scheduling a major incident response exercise with other partners involved. Page 2 of 2 Agenda Item 5.1 Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Audit & Risk Committee Meeting Date: 27 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee considered the accounting policies and management judgements in respect of the 2025/26 annual accounts, noting the impact of the review of the Modern Equivalent Asset valuation estimation methodology. This review was to ensure that the valuation reflects specialised assets based on a modern, functionally equivalent facility at an alternative location, rather than simply replicating the current buildings and equipment. • The committee received an update in respect of the work on the Trust’s interim accounts, noting that there had been significant improvements in terms of use and recording of manual adjustments, with an objective of further reducing the use of manual adjustments in future. • The committee noted the work undertaken to address the issues identified in the production of the 2023/24 and 2024/25 accounts. • The committee reviewed the Trust’s compliance with the Code of Governance for NHS Provider Trusts, noting that the Trust was compliant in all areas or had appropriate explanations for areas of non-compliance, of which there were only a few. • The committee received a report on compliance with the Trust’s Standards of Business Conduct Policy, noting that the level of declarations of interest had remained largely static and that further work would be required to review the Trust’s approach in this area. • The committee received updates in respect of the internal audit programme, including the reports in respect of an audit of cyber security and the Trust’s core financial systems. • An update was provided in respect of the work of the counter-fraud team. It was noted that the risk of temporary worker impersonation was a particular area of focus. In addition, the committee noted the work undertaken to review the Trust’s compliance with the Economic Crime and Corporate Transparency Act 2023. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: Substantial N/A • All risks had been reviewed with the relevant executive director(s). • There had been no significant changes in ratings or target dates since the BAF had been last reviewed in October 2025. However, the committee challenged how realistic some of the target dates were on the basis that many of the actions required were reliant on third parties. • The committee suggested that the rating for risk 5c should be reconsidered in view of the increasing cyber risk. • It was noted that the actions from the internal audit on the Trust’s risk management maturity were on track. Page 1 of 2 Any Other Matters: 7.4 Audit and Risk Committee Assurance Rating: Risk Rating: Terms of Reference Substantial N/A • The committee reviewed its Terms of Reference and no changes were proposed. • The committee recommended that the Board approve the revised Terms of Reference. N/A Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 26 January 2026 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee received the Finance Report for Month 9. The Trust had reported an in-month deficit of £4.9m and continued to report in line with the Financial Recovery Plan. The Trust had also delivered £10.3m of savings under the Cost Improvement Programme during the month. The modern equivalent assets review had been completed, which delivered £3m of benefit during the month. • The committee carried out a deep-dive into the Trust’s underlying financial position, noting that there had been £15.8m of one-off adjustments and that the underlying deficit was £61.4m year-to-date. The monthly underlying deficit continued to be c.£6m and therefore the 2025/26 exit position was assessed to be £72m. • The committee received an update on the Trust’s medium term planning submission, noting that it was expected that the Trust would submit a non-compliant plan. There remained a significant gap between the level of performance required under the framework and the available funding and an absence of proposals from Specialised Commissioning. It was noted that the assumptions regarding noncriteria to reside numbers were based on factors within the Trust’s control, rather than those dependent on third parties. • The committee received an update on financial improvement, noting that the Trust was £4m behind its CIP plan for 2025/26, expecting to deliver £88m of savings by year end compared to the £110m target. The Trust was targeting £50m of CIP savings for 2026/27. Based on national data, the Trust had the tenth smallest opportunity for productivity savings. • The committee considered the Trust’s cash position as at 31 December 2025 and the forecast cash position for the remainder of the financial year. The Trust expected to require a further £2.9m of cash support in March 2026, which the committee supported. • The committee received an update in respect of the Trust’s outsourced cleaning and catering services contract. N/A Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Page 1 of 2 Reasonable Assurance Limited Assurance No Assurance Not Applicable There is a series of controls in place, however there are potential risks that may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 10 March 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 23 February 2026 Key Messages: • • • • • • • • • The committee received the Finance Report for Month 10 (see below). The committee received an update in respect of the impact of the fire at Southampton General Hospital on 1 February 2026, including in respect of the actions being taken to restore the lost services and the Trust’s claims under the NHS Resolution Property Expenses Scheme and under its commercial insurance policy. The committee received an update following the submission of the Trust’s medium term plan on 12 February 2026, noting that the Trust’s current proposed deficit made it an outlier. There remained a significant gap between the level of funding available from commissioners and the performance required under the framework. The committee enquired as to the possible route to resolve and supported the view that pricing of activity needed to be set at a level which did not create an increasing deficit as it currently does in critical care areas. Following the external review recommendations, the committee look forward to a deeper dive into the drivers of the increases in the Trust’s cost base over the past 5-6 years as this has increased at a greater rate than activity levels. This is planned for the March 2026 meeting. The committee received an update in respect of the Always Improving programme, noting that the fire had prompted something of a re-think in terms of organisational and system fundamentals. It was noted that there had been changes in the Trust’s risk appetite in terms of management of patients having no criteria to reside and outpatient appointments. Sustaining the improvements in these areas was considered to be a key priority. The committee received a report on the roll out of the MIYA system in the Trust’s emergency department, which went live on 8 October 2025. It was noted that whilst there had been some initial impact on performance during the first weeks, this had been expected, and the issues appeared to have been largely resolved. The system had delivered improvements in clinical management and in terms of data analytics. The committee noted that the Trust had been awarded £39m in capital funding for 2025/26. It was noted that this was a significant amount of funding to be used during the final months of 2025/26 and that work was ongoing to secure this funding through placing of orders and other activity. The committee received an update in respect of the Trust’s proposed tender for car parking services. The committee supported the proposals to obtain mobile endoscopy units to address the loss of the Trust’s endoscopy service in the fire on 1 February 2026. The committee noted proposals in respect of changes to NHS Property Services. Page 1 of 3 Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: 5.8 Finance Report for Month 10 Assurance Rating: Risk Rating: Substantial High • The Trust had submitted a revised forecast to NHS England of a deficit of £49.9m following a request for an ‘art of the possible’ reforecast. The Trust had since received additional funding, which reduced the 2025/26 forecast deficit to c.£45m. • The Trust had reported a year-to-date deficit of £44.8m, with the underlying monthly deficit remaining between £5.5-6m. The Trust expected additional one-offs during the final months, but there was significant risk associated with this. • The Trust was forecasting CIP delivery of £94m for 2025/26, with £78m achieved year-to-date. • Whilst there had been some increase in workforce numbers in December 2025 and January 2026, it was considered normal for this to occur during this period, however this was creating a deviation from the planned workforce numbers. This was explained as the result of the decision taken to address 65- and 52-week waits which had therefore impacted staff numbers. The resulting increased income from additional work had yet to register in the Trust's revenue numbers but was expected in February and March.. 6.2 Board Assurance Framework (BAF) Update Assurance Rating: Risk Rating: N/A • Risk 5a remained the Trust’s highest-rated risk at 25 and the target date for reduction had been extended by six months due to continued uncertainty around the funding available during 2026/27 and the impact of the fire on 1 February 2026. • Risk 5b had been assessed following the fire, but it was considered that whilst there had been significant disruption, the event and subsequent activities had been well-managed and demonstrated the effectiveness of the Trust’s evacuation and business continuity plans. Accordingly, no changes were proposed to the rating. • There had been an increase in the rating of risk 5c, largely due to risks surrounding the age of the Trust’s digital infrastructure and uncertainty regarding the OneEPR programme. The committee reviewed the Trust’s cash position and forecast, and the committee supported the additional request to be submitted in February 2026 for cash support up to a maximum of £10m to be received in April 2026. The trajectory for cash support in 2026/27 was to be reviewed at the March 2026 meeting. Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Page 2 of 3 Limited Assurance No Assurance Not Applicable Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trus
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