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University Hospital Southampton NHS Foundation Trust Constitution

Description: Read our constitution here.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/University-Hospital-Southampton-NHS-Foundation-Trust-Constitution.pdf

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2024 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 37 Directors’ report 38 Remuneration report 62 Staff report 75 Annual governance statement 95 Quality account 111 Statement on quality from the chief executive 112 Priorities for improvement and statements of assurance from the board 115 Other information 180 Annual accounts 207 Statement from the chief financial officer 208 Auditor’s report 210 Foreword to the accounts 217 Statement of Comprehensive Income 218 Statement of Financial Position 219 Statement of Changes in Taxpayers’ Equity 220 Statement of Cash Flows 221 Notes to the accounts 222 5 Welcome from the Chair and Chief Executive Officer This has been another busy and undoubtedly challenging year across the NHS and UK health and social care system, and much of what has impacted the national picture has been reflected in the operational focuses and patient and people priorities for University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) over the last year. Meeting and continuing to overcome the challenges we have faced has required an organisation-wide team effort, and looking back at the successes we feel incredibly proud of the achievements of our 13,000 staff. Particular highlights include: • In the top ten in the country (7th) against government targets for elective recovery performance with 118% of activity compared with 2019. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including Emergency Department access, long-waiting patients on Referral to Treatment pathways, Diagnostics and Cancer performance. • Significant investment in new capacity through building new wards and theatres and refurbishing existing areas of the hospital. • Delivery of our highest ever Cost Improvement Programme saving. These achievements place us among the best performing trusts in England in several areas and are even more remarkable against a backdrop of continued periods of industrial action and increasing demand for our services, with many people coming to us with higher levels of acuity than ever before. The Trust’s performance in terms of elective recovery places it as one of the best-performing trusts in England and demonstrates the impact of the Trust’s decision to invest in additional capacity in prior years by building new wards and theatres. The Trust’s Emergency Department performance in respect of its four-hour waiting target at the end of March 2024 has attracted additional capital funding as part of an incentive scheme. Some of this funding will be used to increase the department’s same-day emergency care capacity during 2024/25. From a financial perspective, balancing the complexities of today’s challenges alongside the need to protect and ensure the long-term stability and quality of our service provision, has required the Board to take a number of considered and crucial efficiency improvement actions this year. Whilst challenging, the Trust has seen significant progress in delivering on both its forecasted finance position for 2023/24 and productivity targets. Achieving long-term financial stability is key to us continuing to invest in much needed upgrades and improvements to the parts of our estate that are ageing, and to developing new state-of-the-art facilities and infrastructure that increases our capabilities and capacity into the future. In the last year parts of the hospital have been transformed, with the opening of new wards, theatres and a skybridge to link the estate. Construction of a sterile services and aseptics facility has begun at Adanac Park and the expansion of our neonatal department, where we treat and care for some of our most vulnerable babies and their families, is underway. The development of a new aseptic facility at Adanac Park will have capacity to serve other hospitals within the region and is a significant opportunity for improved system-wide working. 6 We have also worked with our people to design spaces where they can rest, relax and recharge - including a new wellbeing hub and rooftop garden on the Princess Anne Hospital site. In addition, 40 staff rooms across the site have been refurbished thanks to funding from Southampton Hospitals Charity. During the year, the Trust worked to establish the Southampton Hospitals Charity as a separate charitable company to improve its ability to both raise and spend funds. This process completed on 1 April 2024. Work was carried out to refurbish a children’s ward during the year in partnership with the charity. Our people are our greatest asset, and we are pleased to see improvements from the annual staff survey in several areas - such as how people can work more flexibly, access to learning and development and improved satisfaction in support from line managers. We recognise the pressures and demands that come with working in this environment and will continue to ensure everyone working here feels heard, encouraged and supported when raising concerns. At UHS, every opportunity is taken to recognise and celebrate the incredible things our people do here every day, including the return of our in-person annual awards ceremony, monthly staff recognition events and the first ever ‘We Are UHS Week’. These occasions are an important reminder that, even when faced with challenges, there is so much to be proud of and celebrate across the whole Trust. Working together, both within the Trust and across organisational boundaries, remains one of our core values. The partnership between UHS and the University of Southampton is as strong as it has ever been, with more than 250,000 individuals having now taken part in research studies in Southampton. As the lead partner member for Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board, we are proactively working with other trusts and healthcare providers in the region to improve the health of the community we serve. In addition, the Trust has continued to work in partnership with other providers across the system to build a shared elective orthopaedic hub in Winchester. It is anticipated that the health and social care system will continue to be a challenging environment in 2024/25. We recognise that many of the big challenges we face can only be solved in partnership with wider local partners, and we are committed to actively playing our part in delivering system-wide solutions. Equally, we will continue to focus on improving whatever is within our internal control, and to work collaboratively with our people to ensure our patients’ experience, safety and outcomes remain central to our decision-making and the actions of everyone at UHS. Jenni Douglas-Todd Chair 19 July 2024 David French Chief Executive Officer 19 July 2024 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer As with 2022/23, this was another challenging year with continued increasing demand for the Trust’s resources and the need to balance this with the need to deliver quality patient care and at the same time maintain a sustainable financial position. Demand for non-elective care continued to increase with an average of 375 attendances per day to our main Emergency Department. In addition, the number of patients on the 18-week Referral to Treatment pathway rose to 58,000. Patients having no clinical criteria to reside in hospital, but unable to be discharged due to the lack of funded care in a more suitable location, posed and continues to pose a significant challenge for the Trust. The number of patients within this category was as high as 270 at times and was consistently higher throughout the year when compared to 2022/23. Despite this the Trust continued to perform well when compared to other comparable organisations, achieving some of the best Emergency Department and elective recovery fund performance in England. The Trust’s financial position continued to be difficult, which required some difficult decisions in respect of spending controls and controls on recruitment. The Trust focused in particular on controlling spending on temporary and agency staff, but in view of the overall workforce numbers compared to the 2023/24 plan, further controls were implemented in respect of substantive recruitment. Due to the additional controls and the Trust’s best delivery to date on its Cost Improvement Programme (£63.4m), the Trust achieved an end of year deficit of £4.5m, compared to the deficit of £26m anticipated in its 2023/24 plan. 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 £1.3 billion in 2023/24. It is based on the coast in south east 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 nearly four 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 155,000 inpatients and day patients, including about 70,000 emergency admissions sees over 750,000 people at outpatient appointments deals with around 150,000 cases in our emergency department 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 54% is paid for by NHS England and 43% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). 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 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. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings 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 Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Division B Division C Division D Surgery Critical Care Opthalmology Theatres and Anaesthetics 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 The Trust’s values describe how things are done 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. These 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 its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims 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 2023/24 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Increasing the number of reported Shared Decision-Making conversations. • Increasing the number of specialities reporting outcomes that matter to patients. • Rolling out the Patient Safety Incident Reporting Framework across the Trust. • Working with patients as partners to improve patient satisfaction. • Treating patients according to need but aiming for no patient to wait, other than through patient choice, more than 65 weeks for treatment. • Delivering national metrics for site set-up time to target for clinical research studies. • Improving the Trust’s position against peers. • Delivering year three of the Trust’s research and innovation investment plan. • Developing the five-year research and development strategy implementation plan and delivery of the first year. • Strengthening and broadening the partnership between the Trust and the University of Southampton. • Supporting delivery of the Trust’s workforce plan for 2023/24. • Reducing turnover and sickness absence rates. • Increasing overall participation in the NHS staff survey and maintaining overall staff engagement score. • Increasing the proportion of appraisals completed. • Delivering the first year objectives of the Inclusion and Belonging strategy. • Working in partnership with acute trusts to agree and implement the acute services strategy. • Producing and embedding an internal framework for network development. • Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. • Working with system partners to open a surgical elective hub. • For the Trust to be seen as an ‘anchor institution’ in the local area. • Delivering the Trust’s financial plan for 2023/24. • Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. • Delivery of the Always Improving strategy priorities. • Delivering the Trust’s capital programme in full. • Entering into a new energy performance contract and delivering the first year of the Public Sector Decarbonisation Scheme. Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. 14 At the end of 2023/24, the Trust had met the objectives set as follows: Corporate Ambition Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Totals Number of Objectives 5 5 5 5 5 25 Achieved in full 4 3 2 3 2 14 Partially achieved 1 2 2 1 3 9 Not achieved 0 0 1 1 0 2 Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Delivery of quality priorities in Shared Decision-Making and the roll out of the Patient Safety Incident Response Framework. • Achieving the Trust’s 65-week waiter glide path. • Successful delivery of a number of research and development priorities, including work with the University of Southampton. • Maintaining sickness absence and turnover well below the targets set at the beginning of the year, and successfully delivering the first year of the Trust’s Inclusion and Belonging strategy. • Delivery of the Trust’s full available capital budget and completion of the first year of the Trust’s decarbonisation scheme. 15 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 2023/24 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 or carers with a highquality 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 does not take full advantage of its 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 its patients. • 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, 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 and digital strategies and in transformation initiatives. • 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 2023/24, the Trust saw continued increased demand for its services, particularly in the Emergency Department In addition, the number of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of appropriate care packages was higher than anticipated and spiked during winter, which significantly impacted patient flow through the hospital and required the Trust to engage additional temporary staff. The number of patients in this category peaked at 270 during the winter. There were particular challenges in respect of those patients with a primary mental health care need who would be better cared for in a more suitable alternative setting. 16 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 Trust continued to experience high demand for its services, especially in the Emergency Department, with average demand during the year being around 375 patients presenting per day in the main adult and children’s emergency department. In addition, the Trust experienced a significant impact on flow within the hospital due to a high number of patients having no clinical criteria to reside in hospital but unable to be discharged. This number was as high as 270 at times during winter: an increase of around 50 patients when compared to the prior year. The Trust also saw an increase in the number of referrals with the number of patients on a waiting list under the 18-week Referral to Treatment pathway rising from approximately 55,000 to 58,000 by the end of the year. In common with other trusts, the ongoing industrial action also impacted the Trust’s ability to provide urgent care and deliver on its elective recovery programme. Quality and compliance Despite the challenges, the Trust’s Emergency Department performance was one of the highest in England in March 2024, which resulted in additional capital funding being awarded. In addition, the Trust’s elective recovery performance was one of the best in England at 118% compared to 2019. The Trust continued to monitor the quality of care delivered throughout 2023/24 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. Quality peer reviews were carried out, most significantly through Matron-led Quality Walkabouts every week in and out of hours focusing on the five key CQC questions – safe, effective, responsive, caring, and well-led. The Trust’s Clinical Accreditation Scheme builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing onsite visits. Patient representatives were included in these review teams. Learning was shared at the Clinical Leaders’ Group and via quarterly reports. The Trust was an active partner in a South-East accreditation network, offering advice and a steer to providers who are just setting up or looking to develop their own scheme, and extended that advice and support to other providers in England. 17 On 15 May 2023, the CQC inspected the maternity and midwifery service at Princess Anne Hospital as part of their national maternity inspection programme. The inspection report was published 11 August 2023, and the Trust retained its overall rating of ‘good’. This year UHS introduced its Fundamentals of Care (FOC) initiative. Whilst this is not a new concept, there were concerns that missed fundamental care had been amplified during the COVID- 19 pandemic. This initiative aims to empower and educate staff at all levels to ensure fundamental care is at the heart of what the Trust does. The Trust completed its transition to the Patient Safety Incident Response Framework (PSIRF) and collaborated with the ICB to develop a PSIRF plan and policy to underpin the change. The Trust implemented the requirements in respect of ‘Martha’s Rule’ where patients, relatives and carers have a legal right to a rapid review by a critical care outreach team during an acute deterioration episode in and out of hours. The Trust continued its focus on infection prevention and control, responding rapidly to rises in infection over the winter, and successfully flexing initiatives and innovations to achieve successful management in a responsive manner. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of further quality improvement projects. This included improvements across theatres, inpatient flow and outpatient programmes. During the year, average length of stay was reduced by 1.64%, day theatre cancellations were reduced by 200, and 42,350 patients were placed onto Patient Initiated Follow Up (PIFU) pathways. Further information can be found in the Quality Account. Partnerships The Trust works within the Hampshire and Isle of Wight Integrated Care System, and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 18 Workforce The Trust’s key areas of focus during 2023/24 were in respect of increasing the substantive workforce whilst also reducing reliance on bank and agency usage, and reducing staff turnover and sickness. 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 331 whole-time equivalents above its plan for 2023/24. The Trust was successful in reducing staff turnover from 13.5% in 2022/23 to 11.4%, achieving the local target of . Cancer Waiting Times - 2 Week Wait Performance Cancer Waiting Times - 2 Week Wait Performance 100% 90% 80% 70% 60% 50% 40% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance % standard met The national target was for 96% of patients to commence treatment within 31 days of diagnosis. In March 2024, the Trust achieved 92% and performed in the range of 86%-94% throughout the year. The Trust has continued to make progress against the target for treatment of cancer within 62 days of an urgent GP referral, improving performance from 64% in April 2023 to 76% in March 2024 (NHS average: 69%). First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performanceUHS vs. NHSE average Cancer waiting times 31 day RTT performance UHS vs. NHSE average 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% Apr-23 May-23 Jun-2 3 Jul-2 3 Aug-23 Sep-2 3 Oct-23 Nov-2 3 Dec-23 Jan-24 Feb-2 4 Mar-24 Performance NHS Average 27 Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average % standard met 1 00% 80% 60% 40% 20% 0% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance NHS Average 28 Quality priorities Priorities for improvement 2023/24 Last year the Trust continued its ambition to deliver the highest quality care shaped by a range of national, regional, local, and Trust-wide factors. During the year the Trust continued to experience unprecedented demand on its services, with flow, capacity, infection prevention and safety all presenting challenges. However, the Trust was confident in its ability to keep a focus on its quality priorities, and its teams worked hard to achieve their goals even in these difficult circumstances. Priorities are aligned to the three core dimensions of quality: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care provided? Out of the six priories set, the Trust achieved five and partially achieved one. Overview of success Quality Priority One Improving care for people with learning disabilities and autistic (LDA) people across the Trust. Supporting staff delivering this care. Outcome against goals: achieved Key achievements: • LDA working group reestablished. • Development of an improvement plan using the NHS Learning Disability Improvement standards. • The LDA team has moved to the virtual enhanced care group in Division B where operational and governance support, leadership, and peer support/learning opportunities has been strengthened. • Sensory Boxes have been introduced for all clinical areas, funded by the Hampshire and Isle of Wight (HIOW) Integrated care board (ICB). These boxes include noise cancelling headphones, fidget toys, communication books and visual cards to support patients and wards. • Recruited additional Learning Disability Champions. • Established links with the parent carer forum (PCF) for the local area and are now attending regular events. A representative from the PCF sits on the LDA working group. The LDA team are working with the Trust lead for patient experience to develop this aspect of the LDA workplan over the next year. Quality Priority Two Supporting patients, service users and staff to overcome their tobacco dependence via a smoking cessation programme. Outcome against goals: achieved Key achievements: • Package of support available to patients who may be smokers and who need to be supported not to smoke during their treatment. • Fully trained team of tobacco advisors working in the hospital and an advisor working in the outpatient setting supporting the patients once they have returned home. • Devised the IT changes the Trust would like to implement to improve its service and referral process. • Recruited 30 smoke-free champions. • Successfully supported 1,131 patients with a self-confirmed quit rate of 45.6% at 28 days. • Supported 109 outpatients who have successfully achieved a 60% quit rate. • On track to achieve the goal to go smoke-free by April 2024 including the removal of smoking shelters. 29 Quality Priority Three Ensure carers are fully supported, involved, and valued across all our services by developing the carers support service across the Trust in partnership with Southampton Hospitals. Outcome against goals: partially achieved Key achievements: • Carers now have a more comprehensive package of concessions and vouchers to help support their cared-for person (e.g. free parking available onsite for blue badge owners is now available). • Listening events were held to put patients at the centre of transforming the way we deliver care is delivered, enabling their voices to improve the quality of care and outcomes for all. • Developed joint working with local partners (e.g. Children’s Society and No Limits to support young carers). Not yet achieved: • The ‘pathway to support, has not yet been developed. Work is ongoing to develop a new strategy. • A charity-funded carers’ support worker has not yet been appointed. • The carers’ training package has not yet been relaunched. Quality Priority Four Put patients at the centre of transforming the way care is delivered, enabling their voices to improve the quality of care and outcomes for all. Outcome against goals: achieved Key achievements: • Work has continued to work across corporate and divisional services to embed patients and carers into quality and service improvement, creating new patient groups (e.g. Mesh Support Group). • Successfully developed our engagement with various local communities, working to ensure that a range of care experiences are considered ( e.g. there is now a Gypsy, Roma, and Irish Traveller community health liaison officer to ensure that these communities are engaged with and brought into work to improve the inclusivity of our services). • Attending multiple public engagement opportunities (Young Carers’ Festival, Mela, University Freshers’ Fayres, Carers’ Listening Lunch, Hoglands Park Play Day, visits to local temples and ‘Love Where You Live’). • Youth and Young Adult Ambassador involvement has increased, including attendance toat meetings of the Council of Governors, and supporting hospital projects. • A Celebration of Carers Week and Volunteers Week were run. • The Trust has analysed its reported outcome measures to identify health inequalities in its services. This information has been used to set a new quality priority for 2024/25. • An SMS friends and family test text survey has been introduced to improve the response rate on patient feedback from the Emergency Department. In the first three months following the survey launch, responses increased from 24 to 424. 30 Quality Priority Five To develop the Trust’s clinical effectiveness process, connecting to the Trust’s Always Improving approach to measuring, understanding, and using outcomes to improve patient care. Outcome against goals: achieved Key achievements: • The Trust has developed its clinical effectiveness process across the Trust with involvement of informatics, governance and management teams, clinical effectiveness leads as well as reporting committees. • Patient representation onhas been included in the clinical assurance meeting for effectiveness and outcomes (CAMEO) to ensure conversations focus on what matters to patients. • The CAMEO template has been changed to focus discussions on areas the specialty is proud of (strong or improving outcomes), areas for improvement (poorly benchmarked or worsening outcomes) and planned actions. • The Trust encourages the use of run and/or statistical process control charts along with benchmarking where available. • Details of NICE and quality standards and national and regional reviews are included to cover breadth of clinical effectiveness. • How the clinical effectiveness team works has been reorganised, aligning each of them to each division giving a named link which helps to deepen understanding and improve links with governance and improvement activities locally. • Working with informatics to establish a core set of clinical outcome measures which are meaningful to patients, which can be reported centrally (starting with surgical specialities). • Starting to develop an education strategy and platform to support staff with a number of tools used in clinical effectiveness as well as clarity on where and how to record and evidence audit and service improvement. • A revised strategy has been drafted. Quality Priority Six Developing a culture where all clinical staff have a basic knowledge of diabetes. Outcome against goals: achieved Key achievements: • Launch of the ‘Start with the Diabasics’ Initiative, designed to help give diabetes visibility across UHS. • Delivered an extensive education programme to clinical staff across the professions and bands, including the introduction of some e-learning and a Diabasics introductory video has been shown at all trust staff inductions since July 2023. • Supported the development of 45 diabetes link nurses, resulting in all ward areas now having a named diabetes link nurse. • Improved triage for referrals. • Established processes for ‘lessons learned’. • Developed IT solutions to improvingimprove alerts and guidance. • A ‘Ketone Wednesdays’ initiative has been created in response to overuse of blood ketone testing (estimated waste cost of £100,000 per year). • The Trust’s lead diabetes specialist nurse and the Diabasics Initiative were both shortlisted for National Quality in the Care Diabetes Awards (October 2023). • The Diabasics Initiative was mentioned as a case study on the Diabetes UK charity website as an example of good practice that could be reproduced elsewhere. 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 2024/25, in the Trust’s Quality Account for 2023/24. 31 Financial performance The Trust delivered a deficit of £4.5m from a revenue position of over £1.3bn, following receipt of £24.6m one-off cash support from NHS England. UHS started the year with an underlying deficit as a result of a number of cost pressures, notably demand for services being above block contract levels and the cost of national pay awards being above funded levels. The Trust has also continued to face a number of pressures, including high numbers of patients who no longer meet the criteria to reside in the hospital, and high demand for patients with a primary mental health need. In 2023/24, the Trust delivered a record savings level of £63.4m (5%) across a range of programmes. Trust operating income rose by £107m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Trust operating expenses rose by £89m, incorporating funded inflationary costs as well as costs relating to the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investment of over £75m, including investment in new wards, theatres, decarbonisation, digital infrastructure, neonatal expansion and backlog maintenance. Trust cash and cash equivalents finished the year at £79m, a reduction of £24m from the previous year due to the operating loss and capital investment outlined above. Whilst liquidity remained strong in 2023/24 supported by NHS England cash support, the underlying financial deficit means it is likely to decline further in 2024/25. The Trust is continuing to monitor its cash position closely and is considering whether additional cash support may be required in 2024/25. Sustainability The Trust recognises that everyone has a part to play in responding to the climate crisis. In March 2022, the Trust agreed its own green plan in response to the challenge of the NHS becoming the world’s first health service to reach carbon net zero. Now in its third year, the plan identifies the Trust’s key areas of focus and its ambitions and has seen progress across all areas of the plan. The plan sets out the scale of the challenge, the Trust’s commitment to reducing the impact on the environment and the steps to be taken across the following categories: • Estates and facilities • Clinical and medicines • Digital transformation • Supply chain and procurement • Travel and transport • Waste and resources • Food and nutrition • Adaptation • Biodiversity • Wider sustainability The Trust continues to progress through its green plan and has completed the ‘Greener NHS’ reporting tool for several quarters, which has demonstrated good progress. In addition, the Trust is planning to launch its ‘Our Sustainable UHS’ app for staff, which will give tips on sustainability and create personalised travel plans, including identifying potential contacts for car sharing. In addition, the Trust is considering proposals to implement additional solar power, smart metering and expanding the use of LED lighting. 32 In 2022/23, the Trust was successful in bidding for £29.4m of funding through the Public Sector DeCarbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. During the year the Trust successfully bid for £823k in National Energy Efficiency Funding which has been used to upgrade the lighting at Princess Anne Hospital. Social, community, anti-bribery and human rights issues The Trust recognises its responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK). These rights include: • right to life • right not to be subjected to inhuman or degrading treatment or punishment • right to liberty and freedom • right to respect for privacy and family life. These are reflected in the duty, set out in the NHS Constitution, to each and every individual that the NHS serves, to respect their human rights and the individual’s right to be treated with dignity and respect. The Trust is committed to ensuring it fully takes into account all aspects of human rights in its work. An equality impact assessment is completed for each Trust policy. For patients, the Trust’s safeguarding policies protect and support the right to live in safety, free from abuse and neglect and other policies and standards are designed to optimise privacy and dignity in all aspects of patient care. Feedback from patients and the review of complaints, concerns, claims, incidents and audit help to monitor how the Trust is achieving these objectives. The Trust’s green plan, approved by the board of directors in March 2022, recognises the Trust’s broader role and responsibility to address the issues of climate change, air pollution, waste and environmental decline present to the city of Southampton and the impact that these issues have on the health and wellbeing of the local population served. Although the Modern Slavery Act 2015 does not apply to the Trust, its green plan sets out an ambition to stop modern slavery. The Trust is also committed to maintaining an honest and open culture within the Trust; ensuring all concerns involving potential fraud, bribery and corruption are identified and rigorously investigated. The Trust has a Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Raising Concerns (Whistleblowing) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. Anti-bribery is part of the Trust’s work to counter fraud. This work is overseen by the Audit and Risk Committee, which receives regular reports from the local counter fraud specialist on the effectiveness of these policies through its monitoring and reviews, providing recommendations for improvement, as well as an annual report from the freedom to speak up guardian. You can read more about the work of the Audit and Risk Committee and the Trust’s approach to counter fraud in the Accountability Report. Events since the end of the financial year There have been no important events since the end of the financial year affecting the Trust. Overseas operations The Trust does not have any overseas operations. 33 Equality in service delivery NHS trusts have an essential role in tackling health inequalities, both as part of the services they provide, but also through work with the wider system. By working with those in integrated care systems, local authorities and third sector organisations, the Trust can have a significant impact on the health of the local population. The national focus on health inequalities is growing. This comes with new legal duties around reporting information and expectations to report on improvement programmes. In September 2023, a health inequalities steering group was initiated, under the leadership of the Chief Medical Officer, with representation from clinical, operational, transformation, patient experience, research, organisational development and culture, informatics, public health and the Integrated Care Board. The group focused on scoping future priorities aligned to national guidelines, contractual obligations and priorities, regional priorities, feedback from clinical teams and patients, understanding where action is already being taken, and what the data is showing. Overall, the group
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Standing Financial Instructions

Description: These Standing Financial Instructions (SFIs) are issued for the regulation of the conduct of Trust members and officers in relation to all financial matters with which they are concerned.
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Finance/StandingFinancialInstructions.pdf

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2022 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 36 Directors’ report 37 Remuneration report 59 Staff report 72 Annual governance statement 94 Quality report 105 Statement on quality from the chief executive 106 Priorities for improvement and statements of assurance from the board 109 Other information 182 Annual accounts 210 Statement from the chief financial officer 211 Auditor’s report 212 Auditor’s report including audit certificate 218 Foreword to the accounts 220 Statement of Comprehensive Income 221 Statement of Financial Position 222 Statement of Changes in Taxpayers’ Equity 223 Statement of Cash Flows 224 Notes to the accounts 225 5 Welcome from our chair and chief executive As we emerged from the most severe phase of the COVID-19 pandemic, 2021/22 was another challenging year for everyone at University Hospital Southampton NHS Foundation Trust (UHS). It was also a year on which we can look back with pride at what we achieved together in unprecedented circumstances. Amongst many notable achievements over the past twelve months, we have: • Led on globally ground-breaking research trials to inform the country’s COVID-19 vaccine booster strategy, including the world’s first COVID-19 vaccine booster study of mixed schedules. • Successfully managed infection prevention and control, putting us amongst the best in the country for minimising nosocomial spread. This was against a backdrop of, at times, R-rates in our local community that were amongst the highest in the country. • Published new strategies for digital and sustainability, which respectively set out how we are revolutionising our technical capability to meet changing patient needs and responding to the growing threat posed by climate change as part of the NHS-wide commitment to reaching carbon net zero by 2045. The pandemic also highlighted the vital importance of our staff’s wellbeing so we could continue to meet the needs of the most vulnerable and sick within our community and beyond. In response, we launched and have sustained a comprehensive programme of support to help our staff recognise and address the physical and emotional burden of the last two years. In financial terms, the Trust achieved its forecast breakeven position in 2021/22 on a turnover of £1.15 billion. Our strong, long-term financial performance meant we could continue investing in the capacity and condition of our estate. During the last year we have welcomed patients into our new ophthalmology outpatients area, expanded the majors area of our emergency department, built Hamwic House for treating cancer patients and opened four new operating theatres. Our ambition remains to increase capacity and improve facilities so that we can meet rising demand for our services, treating more people in improved settings than ever before. The momentum we are building is informed and driven by our five-year strategic plan, which describes our collective ambitions on our journey to becoming a world-class organisation. Our successes over the last twelve months were set against a backdrop of exceptional pressure on our services, unlike anything we have seen before. Like most hospital trusts, the lifting of COVID-19 restrictions in the wider community saw significant increases in attendances at our emergency department and increased referrals for treatments including surgery and cancer care. Everyone at UHS is working hard to restore services and bring waiting times down, although there are headwinds impacting our elective recovery. As we write this report, we have more than 200 patients in the hospital who no longer need our care but are waiting for discharge, either to a care home or to their own home with domiciliary care packages. Like many sectors, our local authority partners are struggling to buy or directly provide the capacity that is needed due primarily to workforce shortages. On occasion, the number of patients stranded in our hospitals means we have had to cancel scheduled surgery patients due to a lack of beds. Despite this, we are making good progress on recovering our elective performance, for example the number of elective surgery procedures in May 2022 was over 8% higher than in May 2019, prior to the COVID-19 pandemic. 6 Looking back over the year, our achievements would not have been possible without every single one of our 13,000 staff, who have gone above and beyond to put patients first. As a Trust Board we recognise that our people are our greatest asset. The results of this year’s NHS annual staff survey are encouraging, with the percentage of staff recommending UHS as a place to work being the sixth highest across all NHS trusts in England. However, we know we can do even better and our new people strategy will help us achieve this by introducing programmes which enable our people to thrive, excel and belong in a diverse and inclusive environment. We ended the year by saying farewell to Peter Hollins, who completed his second and final term as chair on 31 March 2022. In the six years of his leadership, the Trust has undergone a huge transformation to the benefit of both patients and staff. Peter has been a trusted and respected colleague whose outstanding leadership has set UHS on course to be a world-class organisation with world-class people delivering worldclass care. We welcome the formation of the Hampshire and Isle of Wight integrated care system on 1 July 2022, which will facilitate increased integration and collaboration across health and social care partners. We look forward to continuing strong relationships with all our partners as we work to develop an NHS of which all the communities we serve can be proud. Jane Bailey Interim Chair June 2022 David French Chief Executive Officer June 2022 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive 2021/22 is the second year that the ways in which the Trust has worked, and the performance it has achieved, have been strongly influenced the COVID-19 pandemic. Our circumstances varied significantly through the year, however, by March 2022: • COVID-19 related restrictions had been removed across the wider community, but remained necessary within healthcare settings; • a combination of partial immunity and improved treatments had reduced the numbers of patients experiencing the most severe symptoms of COVID-19, but the total numbers of people being infected remained very high; and • the numbers of patients attending, or being referred to, healthcare services for other conditions had returned to pre-pandemic levels or higher. Our challenges and priorities have varied through the year in a similar manner, and have included: • providing sufficient urgent care capacity for patients with COVID-19 alongside those with other illnesses or injuries; • running our services with significantly increased levels of COVID-19 related absence amongst our staff, as infection rates have increased in the wider community; and • increasing the numbers of elective treatments provided, back to pre-pandemic levels and higher, to start to reduce patient waiting times and reverse the increases in waiting list sizes caused by COVID-19. Our performance this year has often been impacted by the adversity of the circumstances. We have not always been able to achieve the targets established prior to the pandemic, nor to deliver the standard of service that we would aspire to for our patients. The Trust is proud to have performed well in comparison to other hospital trusts across many performance measures, however, I would like to thank our patients for their understanding and patience, and all our staff for their resilience, commitment and dedication to care for patients and their colleagues. As we begin to emerge from the pandemic, and consider the year ahead, we look forward to working with patients, hospital colleagues, and partners across health and social care to: • continue the recovery from the impacts of the COVID-19 pandemic; • improve our performance against key measures, continuing to perform well in comparison with other hospitals and moving closer to the national targets; and • continue to adapt and improve services such that the outcomes and results achieved for patients will be better than ever before. 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 2021/22. It is based on the coast in south east 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 in the top ten nationally for research study volumes as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver 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 offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The NHS patient services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Just under half of the Trust’s NHS patient services are paid for by CCGs and just over half are paid for by NHS England. We provide these 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 Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. 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 11 Trust Headquarters Division Always Improving Central Operations Clinical Outcomes Commercial Development Communications Contracting Corporate Affairs Data and Analytics Education and Workforce Estates, Facilities and Capital Development Finance Health and Safety Human Resources Informatics Medical Examinerss Service Occupational Health Organisational Development Quality Patient Safety Planning and Productivity Procurement and Supply Research and Development Safeguarding Strategy and Partnerships The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. 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 continue on its journey 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 tax payer 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 2021/22 these objectives included: • Recovery restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Implementing the ‘Always Improving’ strategy • Delivering the first year of the research and investment plan • Restoring a full research portfolio and preparing for future growth • Delivering joint research and innovation infrastructure with UoS and Wessex partners • Increasing our people capacity (recruitment, retention, education) • Great place to work including focus on wellbeing • Building an inclusive and compassionate culture • Working in partnership with the integrated care system and primary care networks • Integrated networks and collaboration • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) 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 of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors 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 2021/22 were that: • It would have insufficient capacity to respond to emergency demand, reduce waiting lists for planned activity and provide diagnostics results in avoidable harm to patients • It would not be able to provide service users with a safe, high quality experience of care and positive patient outcomes • It 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 • It would not secure the required ongoing investment to support our pioneering research and innovation, driving clinical services of the future 14 • It would not realise the full benefits of being a University teaching hospital through working with regional partners to accelerate research, innovation and adoption; increasing the number of studies initiated and the patients recruited to participate in these studies and the delivery of new treatments and treatments that would not otherwise be available to patients • It would not be able to increase the UHS workforce to meet current and planned service requirements through recruitment to vacancies and maintaining annual staff turnover below 12% and develop a longerterm workforce plan linked to the delivery of the Trust’s corporate strategy • It would not develop a diverse, compassionate and inclusive workforce, providing a more positive staff experience for all staff • It would not create a sustainable and innovative education and development response to meet the current and future workforce needs • It would not implement effective models to deliver integrated and networked care, resulting in suboptimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • It would be unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (CDEL). • It would not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. • It would fail to introduce and implement new technology and expand the use of existing technology to transform our delivery of care through the funding and delivery of the digital strategy. • It would fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, have added to the risks facing the Trust. This risk has continued into 2021/22 and has been coupled with increases in referrals for cancer and increased attendances to our emergency department and non-elective activity. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52, 78 and 104 weeks has increased significantly. While there was a significant reduction in the number of patients waiting over 104 weeks in 2021/22, with the Trust expecting that no patients will be waiting more than 104 weeks by July 2022, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by future waves of the COVID-19, a continuation of the sustained demand for urgent non-elective activity and an ongoing number of referrals, often requiring more complex treatment due to delays in people visiting their GPs for the first time and presenting with more advanced disease. The Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk and continues to make use of independent capacity for cardiac surgery. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2021/22 (described in the Estates section below), the Trust also committed expenditure in 2021/22 to open further wards and operating theatres during 2022/23 and 2023/24. These initiatives will contribute to further improvements in elective waiting times in coming years. 15 Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2021/22. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of an award-winning COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). While the Trust continued to perform well overall, the Trust exceeded its annual threshold for Clostridium difficile infections and there was one MRSA bacteraemia during March 2022, the only such event in 2021/22. The Trust continued to develop its proactive patient safety culture during 2021/22 with changes to the way in which patient safety incidents are investigated and the launch of its Always Improving strategy and transformation initiatives in theatre efficiency, patient flow and outpatients. Reporting and investigation of incidents continued during 2021/22. The Trust continues to prepare for the implementation of the new patient safety incident response framework in June 2022/23. Partnerships – During 2021/22, the Trust and its partners continued to work together to discharge patients safely, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop the regional COVID-19 saliva testing programme for local schools, hospitals and other employers. The new arrangements for integrated care systems will be implemented in July 2022. This is expected to reinvigorate work with partners at a system, place and provider level in Hampshire and Isle of Wight. The Trust is already part of an acute provider collaborative with other acute trusts in Hampshire and the Isle of Wight and is progressing a number of projects including the development of an elective hub at Winchester Hospital, diagnostics, pathology, endoscopy and imaging networks. The Trust also continued to progress research activity and opportunities with the University of Southampton and Wessex health partners. Workforce – The Trust continued to recruit nurses from overseas and through targeted recruitment campaigns during 2021/22 meaning that the number of nursing vacancies has remained relatively stable. Vacancies in other areas have increased reflecting a more competitive job market, particularly for lower band roles. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. Staff turnover remained above the 12% target during 2021/22 and retention is a key element of the people strategy. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2021/22 we have also focused on supporting our staff to respond to the COVID-19 pandemic and operational pressures by providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2021/22 including opening a new ophthalmology outpatient area, expansion of the majors area of the emergency department and four new operating theatres. These were part of £65 million of capital expenditure in 2021/22 that also included equipment, digital and the backlog maintenance programme. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these in part three of the quality account. The board of directors has also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. 16 The Trust and its partners also been successful in securing external funding including one of only four successful NHSX awards to test the concept of federated trusted research environments with its Wessex health partners and core funding of £10.5 million for the National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility (CRF) for the period between September 2022 and August 2027. Sustainable financial model –The Trust achieved its forecast breakeven position in 2021/22. Income was more predictable in 2021/22 as block contract arrangements remained in place in response to the COVID-19 pandemic and ensured that costs were covered, however, funding from the elective recovery fund, particularly, in the first half of 2021/22 introduced a degree of income volatility as did changes to the framework for the elective recovery fund half way through the year. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. The financial outlook across the NHS looks extremely challenging going into 2022/23 due to the reductions in non-recurrent funding and efficiency targets. The Trust currently has an underlying deficit, with pressures on energy prices and drugs cost growth within block contract arrangements, which had been supported with non-recurrent funding in previous years. While specific funding has been provided to address inflationary pressures there is a risk that inflation could exceed this funding and raw material and supply shortages could also impact on costs. Performance overview The Trust monitors a very wide range of key performance indicators within its departments, divisions, directorates and executive committee. Assurance for our board of directors and executive committee includes an integrated performance report which is reviewed monthly and contains a variety of indicators intended to provide assurance regarding implementation of our strategy and that the care we provide is safe, caring, effective, responsive and wellled. The integrated performance report also includes a monthly ‘spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, any performance concerns and requests from the board of directors. Assurance for our council of governors includes a quarterly Chief executive’s performance report, which includes a range of non-financial and financial performance information. 17 Performance analysis COVID-19 Impacts In 2021/22, the most prominent impacts of COVID-19 have been in relation to occupancy of inpatient beds by patients with a COVID-19 diagnosis and increased levels of staff sickness absence associated with COVID-19, in addition to normal levels of absence due to other causes. The impact of COVID-19 has varied significantly through the year, linked primarily to the prevalence of the disease within the wider community. In comparison to 2020/21: • bed occupancy (all types) did not reach the same exceptional peaks, however, it exceeded 50 patients between August 2021 and March 2022 and reached an average of 83 in March 2022; • the number of patients requiring treatment in intensive care and high care were much reduced, though still significant; • fewer patients were admitted requiring hospital treatment for COVID-19 alone, and greater numbers were admitted requiring treatment for other medical conditions who were also infected with COVID-19 at the same time; • staff sickness absence levels were typically higher, particularly in the second half of the year when national restrictions had been removed and COVID-19 infections in the community increased – the sickness absence rate (from all causes) peaked at 6% in March 2022 All bed types Intensive care/higher care beds 18 Staff sickness absence Emergency access through our emergency department Following a reduction during the first year of the pandemic, the numbers of patients who presented to receive care at our emergency department increased exponentially in 2021/22. Attendance levels exceeded the higher levels seen prior to the pandemic by approximately 10%. All patients presenting to the emergency department This exceptional increase in the clinical demand upon our department has had a significant adverse impact upon the timeliness of care, particularly for those patients who have a less urgent condition. The department has also continued to deliver services separately for those patients who have respiratory symptoms and those who do not, and to implement additional infection control measures. Emergency access performance is measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department. The national target of 95% was not achieved and the Trust experienced a large deterioration in our own performance to 64% (main ED/Type 1 attendances) by March 2022. Our performance compared favourably with other acute trusts in England despite this, however. 19 Emergency access four hour performance The number and duration of any ambulance handover delays are another important performance indicator. Ensuring that ambulance staff can ‘hand over’ the patients they convey to our emergency department without delay is important because this releases the staff and their vehicle to meet the needs of other medical emergencies in the community. We are very proud to have an exceptionally good record in this regard, working with colleagues in ambulance services to transfer arriving patients into our emergency department and the care of our staff even when the hospital is already fully occupied. 20 Elective Waiting times Demand 2021/22 has seen a continuation of the trend of increasing elective referrals, following a major reduction which occurred at the start of the COVID-19 pandemic. Referral rates to our services are now typically at, or above, the levels seen before the pandemic. Feedback from clinicians is that they are also seeing more patients with advanced disease than they would normally, because of delays in referral to the service/diagnosis. Accepted referrals The number of patients referred to hospital with suspected cancer increased exceptionally during 2021/22; the number of patients seen for a first consultant-led appointment was 27% higher than in 2020/21 and 18% higher than in 2019/20. Performance remained below the national target of 93% throughout the year, with a deterioration to 74% in December 2021 prior to a recovery to 90% in March 2022. Our performance also declined in comparison with other acute trusts in England. Most of the patients who waited longer than two weeks for their first appointment were within our breast service, which sees a very large number of referrals for suspected cancer and experienced a 22% increase in the number of patients seen compared to 2019/20. Additional consultants who specialise in breast cancer have now been recruited and performance in this service returned to target in April 2022. 21 Performance following ‘Two week wait’ urgent referral for suspected cancer 22 Activity The number of UHS hospital appointments, diagnostic tests and elective admissions all increased significantly during 2021/22. The number of appointments undertaken, and diagnostic tests performed, exceeded activity levels in both 2019/20 and 2020/21. The number of elective and day case admissions increased significantly compared to 2020/21 (the first year of the pandemic) yet remained approximately 10% below the levels achieved between April 2019 and February 2020 (prior to COVID-19). There were a wide range of factors influencing these activity levels, and the lower levels of admitted activity specifically, including: • the availability of beds for the admission of elective patients after emergency patients with COVID-19 and other conditions had been accommodated; • the availability of staff to deliver elective care, during periods of increased COVID-19 bed occupancy, and during periods of increased staff absence related to COVID-19; • additional infection prevention measures which were maintained, particularly within inpatient treatment settings where risks of COVID-19 transmission are otherwise increased. Most of the activity has been delivered within NHS hospitals in 2021/22 (local independent sector hospitals were used to replace NHS elective capacity in 2020/21), and we have recruited additional staff and invested in an additional ward, theatres and outpatient rooms in order to be able increase our treatment activity. The graphs below show 2021/22 activity levels as a percentage of those achieved prior to the COVID-19 pandemic. Elective admissions (including day case) 23 Outpatient attendances Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. At the end of March 2022, 20% of patients were waiting more than six weeks to receive their investigation. This is a significant improvement compared to 28% of patients waiting more than six weeks at the end of March 2021, yet still significantly worse than the national target (1%) and UHS performance prior to pandemic. At the end of March 2022, the total waiting list size (including patients waiting less than six weeks) had increased by 14% compared to March 2021 and was 34% larger than before the pandemic. These trends reflect a combination of large reductions in diagnostic activity in the first year of the pandemic, followed by record levels of diagnostic tests being performed during 2021/22 (7% higher than before the pandemic) combined with very high levels of referrals for diagnostic testing over the same period. 24 The tests with largest numbers of longer waiting patients are non-obstetric ultrasound, peripheral neurophysiology, MRI and CT. Initiatives to improve performance include the recruitment of additional staff in the relevant professions and investment in additional equipment, in the context of NHS forecasts that diagnostic demand will continue to increase over the longer term. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 25 Referral to Treatment Our waiting list from referral to treatment increased in size by 27% (9,768 patients) during 2021/22 and is now 36% larger than before the pandemic. Both referrals and hospital activity declined steeply at the start of the pandemic, but referral levels increased more quickly than hospital activity following this. The rate at which the waiting list is increasing has however reduced in the most recent six months. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance has deteriorated from 80% immediately before the pandemic, to 68% at the end of March 2022. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with, and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 26 The fact that some patients wait significantly longer than the 18 week target is a particular concern. In 2020/21 NHS England targeted the stabilisation of the numbers of patients waiting more than 52 weeks and the elimination of waiting times more than 104 weeks (except when patients choose to wait longer). The percentage of patients waiting more than 52 weeks at UHS reduced from 9% to 4%. The number of patients waiting more than 104 weeks reduced, from a maximum of 171, to 59 at the end of March 2022 (of whom only five were wishing to proceed with treatment at that time). The patients who typically wait longest for treatment continue to be those who require admission for surgical procedures in specialities such as ear nose and throat, orthopaedics and oral surgery. The Trust opened four additional operating theatres during 2020/21 and is working in collaboration with partners in the Hampshire and Isle of Wight integrated care system to implement further elective recovery plans. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 27 Cancer Waiting Times The timeliness of urgent services for patients with suspected cancer has unfortunately declined during 2021/22. The Trust continues to perform well in comparison with the teaching hospitals that we benchmark with and deliver a similar range of services, however. We have faced a range of challenges including: • a large increase in the number of new patients referred for investigation; • delays in the onward referral (for specialist investigation or treatment) of patients from other trusts which have also experienced increases in referrals; • the need to provide capacity to investigate and treat the full range of other conditions, alongside those patients with suspected cancer; and • an increase in the complexity of treatment required by new and existing patients, potentially because of delays in referral or treatment during the first year of the pandemic The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. UHS exceeded this level of performance in April 2021 but has not done so since then, performance deteriorated to 66% in January 2022 before recovering somewhat to 72% by March 2022. Treatment for Cancer within 62 days of an urgent GP referral to hospital The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients. Trust performance has been very variable in 2021/22, ranging from 89% to 98% in individual months. Likewise, performance has ranged from below average in some months, to amongst the best in the group of teaching hospitals that we benchmark with. 28 First definitive treatment for cancer within 31 days of a decision to treat A range of initiatives are being pursued to maintain and improve the timeliness of our cancer services including: • changes to some of the processes for the referral and initial assessment of patients with suspected cancer, for example the inclusion of high quality photographs within referrals for suspected skin cancer; • projects to refine processes and procedures for the investigation of suspected gynaecological and urological cancers; • an operating services improvement programme designed to improve the flow of patients, and the numbers of patients treated, through our existing theatre facilities; and • staffing level increases and recruitment to clinical roles in specialities where the increases in demand require this. Quality priorities The Trust set four quality priorities in 2021/22, which were aimed at ensuring we 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. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the second year of the COVID-19 pandemic, by limiting the number of priorities to four. We also acknowledged the risk that the delivery of our priorities could be disrupted by the ongoing pandemic and that we needed to be flexible in adapting the priorities to changing circumstances. The Trust set the following four priorities: 1. Introduction of midwifery continuity of carer for women at risk of complications in pregnancy. 2. To support staff wellbeing and recovery. 3. Managing risks to patients delayed for treatment and restoring elective programmes. 4. Reducing healthcare associated infection (HCAI) 29 The Trust achieved three of the quality priorities and partially achieved one priority. In relation to midwifery continuity of carer, the Trust’s performance exceeded the ambition that had been set by NHS England in 2020/21 following its national review of maternity services in 2015 as shown below. NHS England ambition set in 2020/21 35% of women will be booked to receive care in a continuity of carer team 35% of black and minority ethnic women booked to receive care in a continuity of carer team 35% of women living in an IMD-1 area (most deprived areas measured using indices of deprivation) Percentage achieved 41.7% 75% 80% The Trust continued to introduce programmes, interventions and wider support offerings to promote staff wellbeing and recovery in 2021/22. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. More information about staff health and wellbeing is included in the staff report below. The Trust only partially achieved the priority relating to managing the risks to patients delayed for treatment and restoring elective programmes. The Trust’s performance against elective waiting time standards are described in more detail above. While the Trust focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency, we continue to recognise the impact of delays on people’s quality of life and, at times, outcomes. COVID-19 remained a key area of focus for the Trust in 2021/22 in terms of infection prevention. The Trust implemented a number of awareness campaigns, including its award-winning COVID ZERO campaign, and strategies to reduce in-hospital transmission of COVID-19 and kept these under review throughout the year. The chart below shows the trend of hospital-onset cases of COVID-19, which has broadly followed local and national prevalence of the virus, and the Trust’s performance compared very favourably with its local and national peers. 30 The table below provides an overview of the Trust’s performance against national and other infection prevention standards and limits to minimise infections, the majority of which have been achieved by the Trust. Category National Objectives: MRSA bacteraemia Clostridium difficile infection E coli Bacteraemia End of year RAG Action /Comment R One MRSA bloodstream infection attributable to UHS 2021/22 in March 2022. R 74 cases against a threshold of 64 for the year. G 138 cases in 2021/22 against a threshold of 151. Klebsiella Bacteraemia A 64 cases in 2021/22 against a threshold of 64. Pseudomonas Bacteraemia MSSA G 30 cases in 2021/22 against a threshold of 34. 43 cases in 2021/22 after 48 hours in hospital. Other: Hospital onset, healthcare associated COVID-19 103 hospital-onset probable healthcareassociated cases in 2021/22. 125 hospital onset definite healthcare associated cases in 2021/22. Prudent antibiotic Antimicrobial prescribing Stewardship G The standard contract requirement for reduction in antibiotic usage for 2021/22 was waived, as in 2020/21. Had it been applied as anticipated, the Trust would very likely have met this. Provide Assurance of Infection G The annual infection prevention audit assurance of Prevention Practice programme was reinstated in April 2021 for basic infection Standards the monitoring and assurance of infection prevention prevention and control practices but practice: subsequently suspended in September 2021. You can find more information about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2022/23, in the Trust’s quality account for 2021/22, incorporated in the Trust’s annual report and accounts. 31 Financial performance The Trust delivered a surplus of £0.048 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England and NHS Improvement, su
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

Papers Council of Governors 20 July 2022

Description: Agenda attachments 1 CoG Agenda - 20.07.2022.docx Date Time Location Chair Agenda Council of Governors 20/07/2022 14:00 - 15:30 Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 27 April 2022 4 Matters Arising/Summary of Agreed Actions 14:04 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gail Byrne, Chief Nursing Officer 5.2 Strategic Objectives (Oral) 14:26 Review and feedback on the Strategic Objectives Sponsor: David French, Chief Executive Officer Attendee: Christine McGrath, Director of Strategy and Partnerships 6 Governance 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 14:41 • Approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment • Approve the recommendation to defer the appointment of a deputy chair to the meeting on 19 October 2022 following a recommendation made by the newly appointed chair Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.2 Amendments to the Constitution 14:51 Approve the proposed amendments to the Trust’s constitution Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.3 Appointment of Lead Governor 14:56 Note the proposal to appoint the Lead Governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:01 Receive the report Sponsor: David French, Chief Executive Officer Attendee: Karen Burwell, Communications and Marketing Manager 7.2 Feedback from Governors' Nomination Committee 15:06 Chair: Jenni Douglas-Todd, Trust Chair 7.3 Feedback from Strategy and Finance Working Group 15:09 Chair: Tim Waldron 7.4 Feedback from Patient and Staff Experience Working Group 15:12 Chair: Forkanul Quader 7.5 Feedback from Membership and Engagement Working Group 15:15 Chair: Bob Purkiss 8 Review of Meeting 15:18 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any other business 15:23 Raise any relevant or urgent matters that are not on the agenda 10 Date of next meeting: 19 October 2022 15:28 Note the date of the next meeting 11 Resolution regarding the press, public and others 15:29 Agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Council of Governors, 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 Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 3 Minutes of Previous Meeting 1 3 COG Minutes Draft - 27.04.2022 final.pdf Minutes - Council of Governors (CoG) Date Time Location Chair Present In attendance Apologies 27 April 2022 14.00-16.00 Microsoft Teams Jane Bailey, Interim Chair Jane Bailey, Interim Chair Dr Diane Bray, Appointed, Solent University Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Helen Eggleton, Appointed, NHS Hampshire, Southampton and Isle of Wight CCG Harry Hellier, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff Councillor Alexis McEvoy, Appointed, Hampshire County Council Robert Purkiss, Elected, Rest of England and Wales (until item 6.4) Forkanul Quader, Elected, Southampton City Catherine Rushworth, Elected, Isle of Wight Councillor Rob Stead, Appointed, Southampton City Council (until item 6.5) Werner Struss, Elected, Medical Practitioners and Dental Staff Amanda Turner, Elected, Non-Clinical and Support Staff Quintin van Wyk, Elected, Rest of England and Wales Sam Dolton, Events and Membership Officer Karen Flaherty, Associate Director of Corporate Affairs Ian Howard, Chief Financial Officer (for items 5.1 and 5.2) David French, Chief Executive Officer (for item 5.3) Tim Peachey, Non-Executive Director (NED) Karen Russell, Council of Governors’ Business Manager Asa Thorpe, Associate Director – Commercial (for item 5.2) Theresa Airiemiokhale, Elected, Southampton City Katherine Barbour, Elected, Southampton City Professor Mandy Fader, Appointed, University of Southampton Tim Waldron, Elected, Southampton City JB DB ND HE HH KL AM RP FQ CR RS WS AT QvW SD KF IH DAF TP KR ATh TA KBa MF TW 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and, in particular, WS who was attending a meeting of the CoG for the first time since becoming a governor. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 26 January 2022 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted. The review of the CoG’s 1 composition had been considered by the CoG Membership and Engagement Working Group at its most recent meeting and a progress update would be provided later in the meeting. 5 Strategy, Quality and Performance 5.1 Operational Plan 2022/23 IH, who was attending the meeting to present this item, advised that the operational plan for 2022/23 had also been presented to the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The purpose of the paper was to inform the CoG about aspects of the Trust’s operating environment and plan for 2022/23. The following areas were summarised: • the Trust’s income for 2022/23 was broadly level with 2021/22 and the expectation was that 104% of the 2019/20 levels of elective activity would be delivered with this level of funding, through increased efficiency improvement valued at £33 million; • there were planned operating deficits across the NHS and the Trust’s deficit of £19.5 million was attributable to factors outside of its control, including costs associated with COVID-19, increased energy prices and general inflationary pressures; and • there were plans for continued recruitment and retention to increase employed staff by a further 478 full-time equivalent staff, to be funded through planned reductions in the use of bank and agency staff hours. In response to questions raised IH confirmed: • the Trust’s specialities with the patients waiting longest (over 18 months and two years) were: o trauma and orthopaedics, where procedures were of lower clinical priority and had been deferred for that reason; and o ear, nose and throat, where activity had reduced because of infection prevention and control measures related to aerosol generating procedures; and • although recruitment to fill vacancies was continuing there was no funding for new posts, however, additional investment in staffing would be required in 2023/24 and 2024/25 to meet the expected increase in elective activity to reduce waiting lists further. 5.2 Non-NHS Activity This item had also been discussed by the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The Trust’s private patient income for 2021/22 was forecast to be approximately £6.4 million, which represented just under 0.7% of the Trust’s overall income. The growth in activity had been due to more complex patients being treated, whilst maintaining the prioritisation of clinically urgent procedures in the context of the unprecedented pressure on core NHS services. Private patient activity was expected to remain at similar levels for at least the next six months. The income from non-NHS activity, including private patient activity, was reinvested into NHS services and to support further innovation and activity. Non-NHS income was also derived from the following: • the commercialisation of Trust-derived intellectual property with an expected forecast of at least £140,000 in 2022/23; • the co-development of innovative medical technology, for which the income forecast was £150,000 for 2022/23; and • advertising income from the electronic screens located in patient areas 2 around the hospitals. Details of a range of the innovative therapies, treatments and projects being developed by the Trust were shared with governors. Decisions: • The CoG confirmed that it was satisfied that the Trust’s non-NHS activity would not significantly interfere with its principal purpose, which was to provide goods and services for the health service in England, or the performance of its other functions. • The CoG authorised the Trust Chair to inform the board of directors (Board) of its decision. 5.3 Chief Executive Officer’s Performance Report DAF joined the meeting to present the performance report and provided an update since the period of December 2021 to February 2022 covered by the report. He highlighted that: • March and April 2022 had been very challenging for the NHS nationally due to the high levels of COVID-19 among patients in hospital for other reasons, and in norovirus reflecting the prevalence of these viruses in the community; • the Trust’s staff absence rates had increased to 6% at times from approximately 3% normally due to staff having COVID-19 or self-isolating; • there were consistently 180 patients in the hospitals who were medically optimised for discharge (MOFD), however, continuing levels of staff absence in community and domiciliary care services and in care homes were leading to delays in discharge for patients needing further support following discharge or with longer-term care needs; • attendances in the emergency department were increasingly high and the Trust’s emergency access performance had been impacted negatively by the number of attendances, including the Trust’s approach to ambulance handovers, which resulted in fewer ambulances queuing but more patients in the department; • the volume of non-elective urgent activity and the number of patients MOFD had regrettably led to the cancellation of elective activity, which had both a practical and emotional impact on those patients whose surgery was delayed; • cases of COVID-19 and norovirus in the Trust had dropped substantially in the previous two weeks and the focus had moved to delivering the Trust’s programme of elective activity; • the number of patients waiting over 104 weeks had reduced to five by the end of March 2022 and the Trust was confident that this would be zero by July 2022; • the Trust had increased both physical and workforce capacity through investment over the previous few years, however there was still insufficient capacity, and this was being addressed through the creation of clinical networks with partners and improvement programmes in theatres, outpatients and patient flow through the hospitals; and • recruitment and retention of staff was more difficult in an increasingly competitive employment market, however, in the NHS staff survey 2021, the Trust had scored highly among staff recommending it to care for family and friends (fifth in its peer group) and recommending it as a place to work (seventh in its peer group). In response to a question from CR, DAF confirmed that the Trust did offer incentive payments to staff who worked additional shifts, however, substantive recruitment 3 was the solution to ensure a good work life balance and overall wellbeing for staff. In response to a query from FQ regarding the expected performance of the Trust in six months’ time, DAF agreed it was difficult to predict however, he hoped that there would significantly fewer cases of COVID-19 and elective activity would return to levels achieve previously and the Trust could deliver comparative performance in the top quartile. The next few years would be very difficult for the NHS generally as it reduced waiting times and the number of patients waiting. While the Trust’s plans to reduce waiting lists were achievable, capacity would continue to be an issue for the Trust. The number of patients who were MOFD would have a bearing on this so the Trust would continue to work closely with health and social care partners to facilitate the timely discharge of patients. The plans to open a new elective hub at Winchester Hospital within the next 18 months would also provide additional capacity and clinical, managerial and finance teams at the trusts involved were committed to making this work. In response to a question from RP, DAF advised that the maternity friends and family test score had improved substantially in January and February 2022 as a result of an improvement plan put in place in the antenatal ward, and progress had been closely monitored by the Board. The response time for complaints had been increased from 35 to 55 days to recognise the demands upon clinical staff during the latest wave of the COVID-19 pandemic. There had also been a number of changes to personnel within the patient advice and liaison service (PALS) as staff had moved into other roles in the Trust. 5.4 Draft Quality Report and Annual Report Timetable NHS England and NHS Improvement (NHSE/I) had published the timetable for the 2021/22 annual report and accounts and associated guidance. While this had removed the requirements to produce a separate quality report, the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still applied requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the CoG for comment by the end of April 2022. The Trust had taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document by the submission deadline of 22 June 2022. However, due to the additional work required to complete the value for money external audit, the quality accounts were to be published as a separate document by 30 June 2022. The annual report and accounts would be published after they had been laid before Parliament, which was expected to occur at the beginning of September 2022. The timing of the meeting of the CoG at which the final annual report and accounts (including the quality accounts) and the external auditors’ report were to be presented would be later than usual to allow for these to be laid before Parliament as this would normally take place in July. An update would be provided to the CoG in a closed session of its meeting in July 2022 to mitigate the impact of this delay. The date of the annual members’ meeting would be finalised at a later date to ensure that the annual report and accounts were laid before Parliament before the annual members’ meeting took place. Governors had been invited to provide comments or feedback on the draft quality accounts for 2021/22 by 29 April 2022 and the formal response to the consultation from the CoG would be co-ordinated by RP as Lead Governor. 4 6 Governance 6.1 Non-Executive Director Reappointment The first three year term of office as a NED for Dave Bennett was to come to an end on 14 July 2022. NEDs were eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a NED, the CoG should consider: • the outcome of the NED’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. The most recent appraisal of Dave Bennett was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that Dave Bennett’s performance as a NED continued to be effective and demonstrated his commitment to the role and that he would have no hesitation in recommending Dave Bennett for reappointment to the role. Since his original appointment, Dave had ceased his commercial consultancy business, Davox Consulting Ltd, and had been appointed to the following NED/trustee roles: • Chairman, Royal College of General Practitioners (RCGP) Enterprises Ltd • Chairman, RCGP Conferences Ltd • NED, Faculty of Leadership and Medical Management (FMLM) • Director, FMLM Applied Ltd • Director/Trustee and Chair, YMCA Fairthorne Group. Dave had indicated his willingness to be reappointed for a further three year term and confirmed that he continued to have the time to commit to the role. The Governors’ Nomination Committee (GNC) had met on 26 April 2022 and had agreed to recommend that the CoG approve the reappointment without any need for process of open competition. Decision: The CoG approved Dave Bennett’s reappointment as a NED for a second three year term commencing on 15 July 2022 on the same terms and conditions as his current appointment. 6.2 Review Terms of Reference – Council of Governors and Working Groups The terms of reference for the Council of Governors and its working groups should be reviewed regularly, and at least once annually, to ensure that these reflected the purpose and activities of the CoG and each of the working groups. The terms of reference for the GNC were reviewed by the CoG at its meeting in October 2021 and so were not presented for review at this meeting. The terms of reference for the CoG’s working groups had been reviewed by the relevant working group prior to submission to the CoG. Minor changes were proposed to reflect changes to practice and strategies since the terms of reference were last reviewed. Decision: The CoG approved the revised terms of reference for the: • CoG; • CoG Membership and Engagement Working Group; • CoG Patient and Staff Experience Working Group; and • CoG Strategy and Finance Working Group 5 6.3 Council of Governors’ Election 2022 A number of vacancies within the CoG would arise on 1 October 2022 as current governors reached the end of their terms of office, following agreement of the CoG to fill existing vacancies at the scheduled election in 2022 and as a result of proposed changes to the composition of the CoG taking effect from 1 October 2022. Elections would take place in the following areas of the public constituency and classes of the staff constituency: • Isle of Wight - one vacancy; • Southampton City - five vacancies; • New Forest, Eastleigh and Test Valley - three vacancies for a term of three years and one vacancy with a remaining term of office of one year; • Rest of England and Wales - one vacancy with a remaining term of office of two years; • Non-clinical and support staff class - one vacancy; • Nursing and Midwifery staff class - one vacancy; As a result of the proposed changes to the composition of the CoG taking effect from 1 October 2022, a vacancy that would have arisen in the Rest of England and Wales public constituency would not be filled as the number of governors representing this constituency was to be reduced by one. The timetable for the elections had been prepared in accordance with the guidance specified in the model election rules. The elections would be conducted by an independent election service provider acting as the returning officer on behalf of the Trust. Four election service providers had been invited to provide a quote and three quotes had been received. A meeting had been held with each of the three providers on 27 April 2022 and a decision on which to appoint would be made by 29 April 2022. 6.4 Council of Governors’ Expenses Reimbursement Protocol The CoG expenses reimbursement protocol had been updated and reformatted and additional clarification had been added in a number of areas not previously included in the protocol. The protocol was required to approved by the Board in accordance with the Trust’s constitution. Clarification for governors was requested in relation to: • how costs for printing would be reimbursed; and • whether governors who had been issued with permits for staff car parks could continue to use these when attending CoG meetings at the main hospital site. Actions: KR would review the issue of printing costs and the parking arrangements at the Trust for when meetings resumed in person. 6.5 Consultation Regarding Timings of Council of Governors’ Meetings At the CoG meeting on 22 January 2022, it had been agreed that a survey of governors would be carried out to identify the preferred times of day for CoG meetings with a view to varying the times of future meetings. This followed the resignation of two staff governors who had been unable to regularly attend meetings of the CoG due to work commitments. Ten responses to the survey had been received. There was a slight preference expressed for meetings to be held at regular times, although no overall majority in favour of regular or varied meeting times. Most governors identified meetings held in the mornings or afternoons to be more convenient and meetings held in the 6 evenings were less convenient for most governors. The CoG was asked to consider: • whether they would like to hold some or all CoG meetings in the morning; • whether they would prefer to hold CoG working group meetings in person when meetings in person were able to resume or whether to continue holding these meetings virtually using Teams would be preferable in terms of securing good attendance; and • if CoG working group meetings were held in person would it most convenient to schedule these on the same day as CoG meetings so that all meetings would be held in person on the same day. Some governors felt virtual meetings made it possible for them to attend more regularly as travelling time was not required and it was noted that attendance at meetings had increased since the introduction of virtual meetings. Virtual meetings also had benefits in terms of reducing congestion on the hospital sites and contributed positively to the delivery of the Trust’s green plan. It was more beneficial to hold meetings in person where these could be combined with a visit to an area of the hospital. Decision: The CoG agreed to retain a mix of meetings in the mornings and afternoons and a combination of face-to-face and virtual meetings once face-to-face meetings could resume. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report highlighting that: • since the last CoG meeting in January 2022 there had been regular engagement with members; • in March 2022 members were informed of the appointment of Jenni Douglas-Todd as new chair of the Trust from July 2022; • as demand for hospital services had increased during April 2022 members had been kept up to date with the latest position and how they could assist by sharing messages to ensure that those who need medical treatment used the most appropriate service; • the Connect newsletter was sent in February and April 2022, with the latter edition split into versions for different constituencies for public members and staff and included details of which governors represented their area and an interview with one of the elected governors; • emails had been sent to all members aged 18 to 30 directly inviting them to take part in a study comparing COVID-19 vaccine doses when used as a third dose at the end of January 2022 and to other members asking them to help share information about recruitment to the study; • targeted emails were sent to members under 30 years of age to publicise a University of Southampton study into the kind of voluntary work, community activities and informal work that young people may have been doing during the pandemic; • the Trust advertised a listening event regarding children and young people with a learning disability organised by our patient involvement team for members with a specific interest in children’s services; • in February 2022 an online survey was launched to help shape the future of the Trust’s membership programme and governors who had provided feedback on the survey prior to its launch were thanked for their support; • KR and SD had attended a listening lunch for carers in Southampton earlier in April 2022, which was organised by the experience of care team; • weekly governor updates including a summary of key staff briefing 7 messages continued to be sent; and • since the last CoG meeting on 26 January 2022, 19 new members had joined the Trust. Future plans included: • supporting the upcoming CoG election in four public constituencies and two staff constituencies; • planning and executing a virtual event for members focusing on research at the Trust in May 2022; • taking part in upcoming community events to promote UHS membership and communicate key Trust messages; and • producing an edition of Connect in June 2022. 7.2 Governors’ Nomination Committee Feedback Feedback from the GNC meeting on 26 April 2022 was provided earlier in the meeting. 7.3 Feedback from Strategy and Finance Working Group In the absence of TW, KR advised that the Strategy and Finance Working Group had met on 21 April 2022. Topics considered had included: • the operational plan 2022/23; • an overview of non-NHS activity; • an update on the annual report and accounts; the process of annual self-certification of the Trust's licence conditions; and • a review of the Strategy and Finance Working Group terms of reference. 7.4 Feedback from Patient and Staff Experience Working Group FQ advised that a meeting of the Patient and Staff Experience Working Group had been held on 20 April 2022. This had been a very interesting session with presentations of the Trust’s new people strategy, the results of the NHS staff survey 2021 and the NHS maternity survey 2021 results. A review of the Patient and Staff Experience Working Group terms of reference was also carried out. 7.5 Feedback from Membership and Engagement Working Group RP advised that a meeting of the Membership and Engagement Working Group had been held on 26 April 2022. The following areas had been covered at the meeting: • SD had attended to provide a membership update and feedback on events held since the last meeting and also provide information on future events; • proposals to introduce an appointed governor for students as part of the composition of the CoG; and • a review of the Membership and Engagement Working Group terms of reference. CR was planning to engage with constituents in the Isle of Wight and RP suggested that all governors be supplied with some paper copies of Trust membership application forms for distribution amongst their constituents. Action: SD would provide a supply of Trust membership application forms to KR for distribution to governors. 8 Any Other Business There was no other business. 8 9 Date of Next Meeting – 19 July 2022 To note the date of the next meeting. RP suggested the meeting was held at its usual time of 2pm, immediately following the separate meeting between the governors and NEDs. There being no further business, the meeting concluded. 9 4 Matters Arising/Summary of Agreed Actions 1 4 Summary of Agreed Actions.docx List of action items Agenda item Assigned to 13 July 2022 10:55 Deadline Status Council of Governors 27/04/2022 7.5 Feedback from Membership and Engagement Working Group 687. Issue of a supply of Trust membership forms for distribution by governors Karen Russell 20/07/2022 Complete Explanation action item RP suggested that governors could be issued with a few Trust membership forms for distribution to promote membership. It was agreed that KR would send a supply to each governor. Explanation Russell, Karen A supply of Trust membership forms were issued to governors on 10 May 2022 as agreed. Council of Governors 27/04/2022 6.4 Council of Governors' Expenses Reimbursement Protocol 686. Reimbursement of printing costs and availability of parking Karen Russell 20/07/2022 Complete Explanation action item RP asked whether governors could be reimbursed for printing papers at home. A further query was raised regarding the availability of parking when face to face meetings resumed. Explanation Russell, Karen As part of the UHS Green Plan and wider sustainability, we want to avoid any unnecessary printing and we would also like to avoid any governors having to incur printing costs when printing at home. To facilitate this, at face to face meetings there will be a free wi-fi connection and a paper copy of the agenda only will be provided. Supporting papers will be displayed on the screen in the meeting room where necessary to support the discussion. On any other occasion which governors are attending an interview or other event where paper copies of any information may be required, these can be printed and provided by the Trust on a more cost-effective basis. A full response was circulated to governors on 23 May 2022. 13 July 2022 10:55 With regard to the availability of parking when attending face to face meetings, KR has arranged with Travelwise to cordon off an area of one of the car parks for use by governors when attending CoG meetings and exit car passes will be provided free of charge for use at these meetings. In view of this governor parking permits will no longer be required. KR will circulate details of the car park which should be used in advance of the next face to face meeting. Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Helen Potton/Karen Russell 19/10//2022 Pending Explanation action item A review of the Council of Governors' composition is to be carried out to check that it still remains appropriate. The review was presented to the CoG at the meeting on 21 July 2021. The CoG agreed that volunteers for a task and finish group would be sought to consider the composition of the CoG in more detail. If no volunteers were forthcoming it would be referred to the Membership and Engagement Working Group for further review. Explanation Russell, Karen Following discussions by the Membership and Engagement Working Group, proposals for a change to the composition of the CoG relating to the New Forest, Eastleigh and Test Valley, and Rest of England and Wales constituencies will be presented for approval at the CoG meeting on 20 July 2022. Suggestions regarding young governor representatives were discussed further at the Membership and Engagement Working Group meeting on 27 June 2022. Proposals are to include two young governors as full members of the CoG, one each from the University of Southampton and the UHS Young Adults Group. This will be considered in more detail by a sub group and proposals will then be presented to the CoG. Page 2 5.1 Chief Executive Officer's Performance Report 1 5.1i Report template UHS CoG July 2022.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Jason Teoh, Director of Data and Analytics 20 July 2022 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: Risks: This report provides performance information relating to a broad range of Trust services and activities, there are no specific implications. This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. Page 1 of 1 1 5.1ii Chief Executive's Performance Report Jul 2022 FINAL.docx UHS Council of Governors 20th July 2022 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. This report covers data from the period from March to May 2022, noting that performance in relation to some of the targets is reported further in arrears. Notable features of the period included: • An increase in the number of COVID-19 inpatients through the period as rates of infection increased across the country. There was also a corresponding increase in the number of hospital-acquired COVID-10 infections. • Extremely high volume of attendances to the Emergency Department, averaging 378 patients per day, an 18% increase on the same period the prior year. • A significant number of patients not meeting the criteria to reside (formerly medically optimised for discharge), usually between 180 – 200 patients, continuing to occupy hospital beds, restricting flexibility in our elective programmes. The number has been as high as 229. Such patients are typically waiting for care to be provided in the community to continue their recoveries or meet long term needs in their home setting. • Referral volumes have exceeded pre-pandemic levels, and despite an increase in hospital activity, the RTT waiting list continues to increase. So far in 2022, the waiting list has grown by 10%. • High numbers of referrals have also been seen for patients with suspected cancer, which have impacted our 2 week wait and 62 Day performance. However, for both metrics, we continue to benchmark in the upper quartile of our teaching hospital peers. • A longer-term trend in higher staff sickness absence continues to rise, with an underlying 0.6-1% of absences in any given week being related to COVID-19. Page 1 of 7 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 95.0% ≥ 90.0% Mar 2022 Apr 2022 67.5% 70.4% 76.9% 79.5% May 2022 67.5% 77.3% Attendances to the main (Type 1) Emergency Department (ED) have continued to increase throughout this period, averaging 378 per day (up 18% on the same period the previous year). UHS four-hour performance has deteriorated; however, we continue to benchmark well against other trusts.. In the period of March to May 2022, UHS ranked in the top quartile of the 16 teaching hospitals that we benchmark against (Type 1 attendances). A related, national, issue is ambulance handover times. UHS continues to maintain timeliness in accepting the handover of patients from ambulance staff, despite challenges this may create within our own department on some occasions. We have maintained handover time between March to May 2022 (despite higher attendances). Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Mar 2022 67.7% 46,318 Apr 2022 66.4% 48,458 May 2022 68.1% 49,283 Since December 2021, the number of patients on the RTT waiting list has increased by 10%. Referrals have returned to, and are now exceeding, pre-pandemic levels. This means that despite UHS’s activity having increased, we continue to see growth within the waiting list. However, we have made good progress in reducing the longest waiting patients. At the end of May, we only had 10 patients who had waited over two years for treatment (four of which were patient related delays). By the end of June – in line with the NHS requirements – we will have no patients waiting over two years for treatment, apart for any patient requested delays. Cancer Urgent GP referrals seen in 2 weeks Breast symptomatic patients’ referral seen in 2 weeks Treatment started within 62 days of urgent GP referral Target => 93% => 93% => 85% Mar 2022 90.4% 63.6% 72.3% Apr 2022 87.2% 91.7% 74.7% May 2022 86.9% 100% 69.5% There has been improvement within our two week wait (2WW) capacity, particularly within our Breast service as additional consultants have started and the service has run multiple weekend sessions through 2022. There remain some challenges within the Gynaecology and Head & Neck tumour sites – mainly due to higher referrals and staffing challenges. However, despite these performance issues, we continue to benchmark in the top quartile for performance relative to our teaching hospital peers. As a result of referral and treatment challenges, our 62 day cancer treatment performance has been adversely impacted. This is partly due to higher referral volumes, alongside late tertiary referrals, but also highlights some challenges that we have within existing pathways. We are working with the Wessex Cancer Page 5 of 7 Alliance to review, and optimise, relevant cancer pathways. Despite the challenges, UHS continues to benchmark in the upper quartile compared to our peer teaching hospitals. 5. Finance The Trust has now submitted its annual accounts to NHS England and NHS Improvement for 2021/22 reporting a small surplus of £0.05 million from a revenue position of over £1.2 billion, once items deemed as “below the line”, such as impairments to the valuation of our fixed assets, were removed. This met the national minimum breakeven mandate required for NHS organisations. Supporting this delivery was the achievement of £15 million of efficiencies in year, which, although below previous years’ levels, was a significant achievement given the level of operational pressure. Operating income increased £160 million from the previous financial year with significant funding increases related to the UK Health Security Agency saliva mass testing programme contract and also increases in research and development income due predominantly to COVID-19 vaccine studies. Additionally, NHS income continued to grow both in line with funding settlements and inflationary awards together with service expansions and elective recovery funding. Spend increased in equal measure however, with pay spend increasing by £57 million from the previous year. The trusts capital programme for 2021/22 also closed on plan with delivery in full to capital departmental expenditure limits (CDEL). Spend totalled £65 million, including investment in new theatres, expanding our emergency department and expanding our ophthalmology capacity. The underlying financial position of the trust is however more challenging, with inflationary pressures particularly within energy costs, a continuation of covid spend mainly on staff sickness/absence backfill, and drugs cost growth in excess of block funding levels, all creating financial pressure. The trust has however submitted a breakeven plan for 2022/23 which is predicated on the delivery of cost improvement plans totalling £45m (4%). For April and May the YTD position is a £5m deficit which is £2.2m below planned levels as a deficit had been anticipated in earlier months of the year knowing that traction on the trusts savings programme would take time to establish. The gap to plan is mainly driven by covid costs greater than forecast in addition to slower than anticipated delivery of cost improvement plans. Increased focus is now being applied in this area to ensure financial improvement is delivered and the breakeven plan for the year can be achieved. Capital spend is on plan year-to-date however much of the spend is profiled to later months with wards developments, MRI replacements and theatres expansion all planned for the second half of the year. Page 6 of 7 6. Human Resources Indicator Target Staff FFT - % of staff who agree or strongly agree that they would recommend UHS as a place to work Staff recommending UHS as a place to receive care/treatment => 75.5% => 85.0% Q4 21/22 73.8% National Average (Acute / Acute + Community Trusts) Picker average 58.4% 59.2% 84.9% 66.9% 66.8% The national NHS Staff Survey 2021 opened from September to November 2021 inclusive. Results are sent to individual trusts January to March, with embargo lifted in March 2022. Staff Survey results are now aligned to the NHS People Promise themes. UHS had a response rate of 56.2% (6,985 staff), representing a 6% increase from 2020. UHS scored average or above average on all seven themes. Our aim is to continue to improve, strive to increase our scores where all scores are above average in 2022, and aim for being the “best” scoring wherever possible thereafter Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing Vacancies (Registered Nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Mar 2022 14.3% 4.5% 12.8% Apr 2022 15.8% 4.6% 13.0% May 2022 14.9% 4.7% 13.6% Primarily reasons for sickness included: Covid-related sickness (including long Covid); work-related stress; and MSK. There has also been a recent increase in short-term sicknesses. End. Page 7 of 7 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 1 6.1a Non-Executive Director Reappointment and Appointment of Deputy Chair front sheet v2 updated.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Non-Executive Director Reappointment and Appointment of Deputy Chair 6.1 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: Response to the issue: Implications: Risks: Summary: The first three year term of office as a non-executive director for Tim Peachey will come to an end on 30 September 2022. Non-executive directors are eligible for reappointment for a second three year term subject to reappointment by the Council of Governors. One of the roles of the Governors’ Nomination Committee is to make recommendations to the Council of Governors on the reappointment of non-executive directors. The constitution provides for the appointment of a deputy chair. Jane Bailey is the current deputy chair and has resigned from that role as at the end of July 2022. It is proposed that Tim Peachey is reappointed for a second three year term of office. The attached paper provides details of the outcome of appraisals, changes to commitments and ongoing independence and commitment to the role. In terms of the deputy chair position it is proposed that a recommendation is made to the Council of Governors at their meeting on 19 October 2022. The appointment and reappointment of non-executive directors is one of the statutory responsibilities of the Council of Governors role following recommendation by the Governors’ Nomination Committee. The appointment of the deputy chair is one of the responsibilities of the Council of Governors. 1. Failure to ensure an appropriate balance of executive and independent non-executive directors in accordance with the Trust’s Constitution and The NHS Foundation Trust Code of Governance. 2. Ensuring the appropriate balance of skills and experience among the non-executive directors on the Board. 3. Ensuring the effective functioning of the Board. The Council of Governors is asked to approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment. The Governors’ Nomination Committee will be Page 1 of 2 asked to review the proposed reappointment at its meeting in July 2022 and will provide its recommendation to the Council of Governors. The Council of Governors is asked to approve the recommendation to defer the appointment of a deputy chair to the meeting on 18 October 2022 following a recommendation made by the newly appointed chair. Page 2 of 2 1 6.1b NED Reappointment and Appointment of Deputy Chair paper v2 updated.docx Non-Executive Director Reappointment and Appointment of Deputy Chair 1 Non-Executive Director Reappointment Background In September 2019 the Council of Governors (CoG) appointed Tim Peachey as a nonexecutive director for an initial three year term commencing on 1 October 2019. Nonexecutive directors are eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a non-executive director, the Governors’ Nomination Committee and the CoG should consider: • the outcome of the non-executive director’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. Annual appraisal Tim Peachey has been subject to satisfactory appraisal annually since his appointment in 2019. Governors have had the opportunity to contribute to the appraisal of the non-executive directors each year by providing feedback through the Lead Governor. The most recent appraisal was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that: • following formal performance evaluation, Tim Peachey’s performance as a nonexecutive director continued to be effective and demonstrated his commitment to the role; and • he would have no hesitation in recommending Tim Peachey for reappointment to the role following the appraisal process. Other commitments Since his original appointment, Tim has ceased his role as clinical safety officer of Block Solutions Ltd and taken on the role of Health Advisory Board member at Palantir Technologies UK, Ltd. Tim currently performs the following roles in addition to his role as a NED for the Trust: • Director, TP-Medcon Ltd • Clinical Advisor, Bolt Partners Ltd • Associate - Mediator, Problem Resolution Ltd • Non-Executive Director and Chair of Quality Committee, Isle of Wight NHS Trust • Health Advisory Board member, Palantir Technologies UK, Ltd. Tim has indicated his willingness to be reappointed for a further three year term and confirmed that he continues to have the time to commit to the role. This has been demonstrated through his attendance at meetings, which was considered as part of the appraisal process. 1 Independence Non-executive directors should be independent in character and judgement. Tim Peachey was considered to meet the requirements for independence applicable to a non-executive director on appointment. In his performance as a member of the Board of Directors and Audit and Risk Committee, chair of the Quality Committee and as the non-executive Maternity Safety Champion, Tim has continued to demonstrate his independence and constructive challenge. Since his appointment Tim has been subject to annual fit and proper persons checks and declaration processes applicable to directors to confirm ongoing compliance with the requirements. Recommendation Subject to recommendation by the Governors’ Nomination Committee, the Council of Governors is asked to reappoint Tim Peachey as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment, including the current annual fee of £14,000 as remuneration for the role and the fee of £2,000 for additional chairing responsibilities in respect of the Quality Committee. 2 Appointment of Deputy Chair Background The appointment of the Deputy Chair is made by the Council of Governors. The current postholder, Jane Bailey, has advised that she intends to step down from the role as at the end of July 2022. When considering the appointment of a new Deputy Chair it would be usual for the view of the Chair of the Trust to be taken into consideration and a recommendation for approval be made. Recommendation Following the recent appointment of Jenni Douglas-Todd to the position of Chair of the Trust, it is recommended that a paper would be presented to the Council of Governors on 19 October 2022 with a recommendation in relation to the appointment of a Deputy Chair. 2 6.2 Amendments to the Constitution 1 6.2a Amendments to Constitution - cover sheet v2 updated.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Amendments to Constitution 6.2 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Following a review of the composition of the council of governors of the Trust, the council of governors has agreed to alter the number of governors elected by the areas of the public constituency to ensure that these remain representative of those to whom the Trust provides services. Having reviewed the current areas of the public constituencies and the proportion of patients seen by the Trust from those areas, the following proposed changes have been agreed: • to reduce the number of governors representing the Rest of England by one governor; and • to increase the number of governors representing New Forest, Eastleigh and Test Valley by one governor. The council of governors has also agreed to maintain a representative on the council of governors from local commissioners as an appointed governor, following the transfer of functions from NHS Hampshire, Southampton and Isle of Wight Clinical Commissioning Group to NHS Hampshire and Isle of Wight Integrated Care Board taking effect on 1 July 2022. Other minor changes are proposed to be made to the current constitution identified as part of this review and to correct minor typographical and other errors. These changes include: • to reflect the transfer of functions from Monitor/NHS Improvement to NHS England from 1 July 2022; • to update the model election rules attached at annex 4 to the constitution to those published by NHS Providers in August 2014 (these have not yet been updated to reflect the transfer of functions from Monitor to NHS England, however references to Monitor should be read as referring to NHS England); • to remove appendix 4 to annex 8 as it duplicates provisions in paragraph 25 of the constitution, as amended, and the terms of reference for the governors’ nomination committee; • to remove references to registers in paragraph 35 that are no longer maintained, or required to be maintained, by the Trust; • to all
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Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Chair
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Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament
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Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
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Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25
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