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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 Par
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.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 Pa
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Pa
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-22-23-6.pdf

Annual-report-24-25-final

Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Pa
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.pdf

Annual-report-and-quality-account-2019-20

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Found
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-and-quality-account-2019-202.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Par
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.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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Annual-report-2017-18

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

Annual report 15-16

Description: University Hospital Southampton NHS Foundation Trust Annual report and accounts 2015/16 incorporating the quality account 2015/16 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2016 University Hospital Southampton NHS Foundation Trust TABLE OF CONTENTS Performance report Statement from the chief executive 7 Statement of purpose and activities 8 History of UHS 8 Key issues and risks 9 Going concern disclosure 9 Performance reporting 10 Regulatory body ratings 14 Environmental matters 14 Social, community and human rights issues 15 Accountability report Directors’ report 17 Introducing the Board of Directors 20 The people 21 Audit and assurance committee 25 Disclosures 28 Council of Governors 33 Annual remuneration statement 40 Appointment and remuneration committee 43 Governors’ nomination committee 45 Staffing data 50 Regulatory ratings 57 Statement of chief executive’s responsibilities as the accounting officer 59 Annual governance statement 60 Voluntary disclosures 69 Quality account and report 2015/16 Chief executive’s welcome 121 Overview of University Hospital Southampton NHS Foundation Trust 122 Activity levels during 2015/16 122 Our 2015/16 priorities for improving quality 123 Our 2015/16 priorities for outcomes and clinical effectiveness 124 Our 2015/16 priorities for patient experience 126 Our 2015/16 priorities for patient safety 129 Never events 130 Our quality priorities for 2016/17 130 Participation in national clinical audits and confidential enquiries 131 Participation in clinical research 133 Data quality 133 Review of services 134 Registration with the Care Quality Commission (CQC) 136 Our standard core indicators of quality 139 Overview of performance 146 Further information about our Trust 150 Conclusion 153 Responses to our quality account 154 Statement of directors’ responsibilities 160 Independent auditor’s report 161 Annual accounts Statement from the chief financial officer 79 Foreward to the accounts 81 Independent auditor’s report 82 Financial statements 87 FTC summarisation schedules for UHS NHS Foundation Trust 118 Appendix Appendix A – pulse KPI’s 165 Appendix B – national clinical audit activity 166 Appendix C – local clinical audit activity 167 Appendix D – patient improvement framework 2016/17 175 Appendix E – glossary of acronyms 176 5 Statement from the chief executive 2015/16 has been a challenging year for University Hospital Southampton (UHS) but we are proud of the achievements we have made. In order to meet the needs of the population, we have seen 706,931 patients (total inpatients and outpatients), which is over 25,000 more patients than in the previous year. You’ll find a more detailed breakdown of activity on page 11. Overall, patients were happy with the care that we gave them, with 96%* likely to recommend UHS. We have worked hard to maintain and improve the quality of our services. In particular, we are pleased that our Hospital Standardised Mortality Rate (HSMR) is now below nationally expected levels. You can find more detail on this within the quality account section of this report. We are very aware that healthcare is a ‘risky business’ and that, internationally, healthcare is not as safe as it could be. In order to address this it is crucial that we encourage a safety conscious culture, including the reporting and analysis of all incidents and untoward events. In February 2016 the NHS published a ‘transparency league’ designed to assess how open and transparent NHS organisations are with regards to errors. We were pleased to be ranked as ‘good’ in this assessment. Patient waiting times is another important aspect of quality – whether that be waiting at home for a cancer diagnosis or elective surgery, or waiting in the emergency department for treatment or an inpatient bed. Throughout the year we met the national standards for cancer treatment, diagnostics and elective care, but we did not meet the four hour emergency access standard. We have, however, improved our performance compared to 2014/15, and we are committed to improving this performance in 2016/17. Feedback from our staff is important to us and is another important indicator of quality. The most recent staff Friends and Family Test indicated that 90% of our staff would recommend us as a place to be treated, and 76% as a place to work. Whilst we still have work to do, these figures are significantly better than the national average, and the highest that we have ever achieved. Other highlights of the year include being selected for two national initiatives: 1. to be one of the early implementers for the seven day service standards for emergency and inpatient services, and 2. to be one of the pilots for supporting staff health and wellbeing. Both of these initiatives are an important part of our journey towards becoming a higher quality provider of healthcare and an exemplary employer. Following extensive consultation, we also launched our new vision ‘Forward’ which can be found at www.uhs.nhs.uk/AboutTheTrust/Ourvision. Our Trust chair, John Trewby, left the Trust at the end of March 2016 when his second term of office came to an end. John has been an exceptional leader and over the last eight years he has steered UHS to achieve great things in some truly difficult circumstances. Under his leadership we achieved foundation status in 2011, developed as a clinical academic centre with a growing reputation for research, and have gained an outstanding reputation for the excellence and outcomes of our clinical services. I would like to take this opportunity to thank him for his commitment to UHS and welcome his successor, Peter Hollins, to the role. Finally, we continued to invest in our buildings and equipment. This included the creation of a new main entrance opened in May 2016, and ongoing major investment into radiological equipment. We also expanded our emergency department to create an ambulance assessment area and, in March 2016, chancellor George Osborne announced that the government will invest £2m in a new £4.8m children’s emergency and trauma department for our Southampton Children’s Hospital. Fiona Dalton Chief executive *figure based on April 2016 survey 7 Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 650,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to more than three million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 10,500 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the time of over 1,000 volunteers. Our turnover in 2015/16 was £693m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Fourteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the regulator, Monitor. 8 Key issues and risks that could affect achievement of our objectives There are three key issues that could affect our ability to achieve our objectives, these are: 1. Failure to deliver the four hour emergency department target, which impacts both patient experience and safety. There is a recovery action plan in place which has been formally reviewed by our commissioners. The main focus for 2016/17 is working with partners to reduce delayed transfers in care, improving the numbers of discharges that occur before midday and improving processes for emergency patients between the ED and inpatient teams. 2. Capacity and occupancy, which impacts on patient flow and timeliness of care. Increased risk in 2016/17 through unplanned transfers in service by other local providers and support for emergency flows. We have mitigated this by minimising the bed closures refurbishment programme, focusing on seven day service, improving patient flow (such as home before lunch), developing a hospital without walls, investing in a capital programme to improve capacity (surgical robot, hybrid theatres and minor ops rooms) and reducing length of stay. 3. Staffing, plans are in place for both recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: - continuing to recruit from overseas - working with universities to increase student nurses - developing band 4 posts and apprentices - rolling out a new, consistently branded, ‘Think UHS’ recruitment campaign - enhancing overseas fellows posts - reviewing all junior rotas in light of the new contract - using flexible and temporary staff when needed - creating different roles linked to our research agenda - reviewing training and education to enhance retention Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. 9 Performance reporting Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. This begins with the monthly Trust Board meeting where the executive directors of the Trust will present a high level summary to the chairman and non-executive directors, as well as providing greater detail on key performance changes, risks and issues. Below this are a number of executive sub-committees attended by a subset of executive and non-executive directors. These are the audit and assurance committee, the strategy and finance committee and the quality and performance committee. These committees will review performance and issues in greater depth, feeding back to Trust Board as appropriate. In addition, there are regular Trust Board study sessions which focus on specific individual issues with the entire Board present. The Trust executive committee (TEC) meets monthly and is made up of the executive board members and the divisional management teams. Performance and service issues are discussed with greater granularity at this meeting. Finally, there are regular performance meetings between the operational management team, led by the chief operating officer, and the division and care group management teams. These meetings focus on the individual patient and service pathways and developing the detailed plans for improvement. Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The monthly report features the following sections: • Executive digest – a textual update on the previous month’s performance across the Trust written by the director of transformation and improvement • Pulse KPIs – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months (see appendix A) • Performance • Activity • Capacity • Emergency department (ED) • Referral to Treatment (RTT, or 18 Weeks) • Cancer waiting times • Finance • Patient experience • Patient safety • Outcomes • Staffing (HR) and estates • Education and training • Research and development This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. 10 How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will serve a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. We will build on this knowledge by meeting and working with other trusts around the country and the world in order to share learning and build the best patient pathways and most efficient uses of resources possible. Detailed analysis and explanation of the development and performance of UHS Over the past four years we have seen significant increases in all types of activity. Some of this is due to an increase in the range of specialist services we offer, becoming a major trauma centre and the building of the helipad, but much of it is due to the increased and aging population in Southampton and the surrounding area. The graphs below demonstrate this increase in activity. UHS Growth in Activity - 2012/13 to 2015/16 600000 500000 400000 300000 200000 100000 2012/13 2013/14 2014/15 2015/16 0 Inpatient Spells (inc day cases) Outpatient Appointments ED Attendances (type 1) Referrals 2012/13 Inpatient spells (inc day cases 133,712 Outpatient appointments 447,122 ED attendance (type 1 & 2) 115,917 Referrals 165,597 2013/14 138,868 493,471 115,660 181,761 2014/15 144,934 536,949 111,297 182,402 2015/16 145,524 561,407 113,569 190,170 Increase 2012/13 to 2015/16 8.8% 25.6% -2.0& 14.8% In order to manage these increasing pressures we have focused our attention on the flow through the hospital. Our adult midday bed occupancy decreased by 4.3% in 2015/16 (to the end of February) compared to the same period in 2014/15, allowing the Trust greater flexibility when dealing with periods of high demand. This is reflected in the reduction in the number of red and black alerts issued in 2015/16. 11 The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls. In 2014/15 a black alert was recorded 91 times at the twice daily bed meetings. In 2015/16 this was reduced to seven. A central pillar of this change has been the stabilisation of Length of Stay (LoS) despite the increased number of patients requiring a complex package of care after their discharge. These patients can often have their discharges delayed while beds in community care homes are found and supporting community care packages are arranged. The chart below demonstrates the change in LoS for elective and non-elective (emergency) patients over the past four years. Rolling 12-Month Average Length of Stay - Elective and Non-Elective 6.50 6.00 5.50 5.00 4.50 4.00 3.50 R-12 Non-Elective LoS R-12 Elective LoS 3.00 2015/16 saw an increased focus on discharging patients earlier in the day and at the weekend. This will remain a major focus for the Trust in 2016/17. Each of the above metrics will have an impact on the Trust’s performance against the three primary nationally reported targets for Referral to Treatment (RTT, or 18 Weeks) performance, emergency department performance and cancer waiting times performance. Referral to Treatment (18 Weeks) performance At the start of 2015/16 there were three targets the Trust was responsible for delivering: 1. Incomplete Pathways – 92% of all patients on an 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month. 2. Admitted Stops – 90% of all patients requiring an inpatient treatment should receive this treatment within 18 weeks of referral. 3. Non-Admitted Stops – 95% of all patients either receiving treatment in an outpatient setting or discharged without requiring treatment should have their pathway stopped within 18 weeks of referral. The government announced that, from July 2015 onwards, only the achievement of the Incomplete Pathways target would be required. This change allowed trusts to treat greater numbers of long-waiting patients each month. UHS met all three targets in quarter 1 of 2015/16 and continued to meet the Incomplete Pathways target throughout the rest of the year. 12 This continuing good performance should be set against the aforementioned rise in patient referrals, which highlights the increased demands being placed on the Trust. It is only due to the increased efficiency shown by the Trust’s inpatient and outpatient services that it has been possible to meet these targets on an ongoing basis. Emergency department (ED) performance We have failed to meet the national target of 95% of all ED attendances being treated and either admitted or discharged within four hours of arrival in any month in 2015/16. However, this has been a challenging target nationwide with the winter period providing the worst performance the NHS in England has ever recorded. Against this, the year on year improvement seen at UHS is good progress. There are three types of ED that can be included in these figures: Type 1 A consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Type 2 A consultant led single specialty accident and emergency service (e.g. ophthalmology, dental) with designated accommodation for the reception of patients. Type 3 Other type of A&E/minor injury units (MIUs)/Walk-in Centres, primarily designed for the receiving of accident and emergency patients. A type 3 department may be doctor led or nurse led. It may be co-located with a major ED or sited in the community. A defining characteristic of a service qualifying as a type 3 department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. UHS has a type 1 and a type 2 (ophthalmology) department. The Trust also had a type 3 (MIU) department until July 2014. Due to the nature of the activity at the MIU, the transfer of this department to another provider reduced UHS performance against the four hour target by approximately 3%. When comparing performance over the long term, it is important to factor this change in. ED performance reduced fractionally in quarters 1 and 2 of 2015/16 compared to 2014/15, despite the loss of the MIU activity. In quarter 3, when the comparative activity was the same, performance improved by 4.7%. This was due in part to the improvements in hospital flow outlined earlier, and also linked to improvements in the operational performance of the department itself. While performance fell by 1.2% in quarter 4 of 2015/16 compared to the same time the previous year, this must be set against an increase in activity of over 3,000 additional ED attendances (12.1%). The graph below shows UHS performance against the four hour target over the past four years. Year-On-Year ED Performance by Quarter 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% Cancer waiting times 82.00% 80.00% 78.00% 76.00% Q1 Q2 Q3 Q4 2012/13 2013/14 2014/15 2015/16 13 There are 10 separate cancer waiting times measures that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2015/16 (to the end of February) the Trust met all 10 of these measures, an improvement on 2014/15 when one target was failed. This performance against the targets should be set against the significant rise in activity seen on the cancer pathways. The three central targets are the percentage of two week wait urgent suspected cancer patients seen within two weeks of their referral, which saw a rise in demand of 13% in 2015/16, the percentage of these patients diagnosed with cancer treated within 62-days of their referral (for which demand increased by 20.1%) and the number of all patients treated within 31 days of an agreed treatment plan being put in place (for which demand rose by 14.2%). The chart below shows the rise in demand for UHS cancer services over the past five years. 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - UHS Growth in Activity - 2012/13 to 2015/16 Two Week Waits 62-Day Target Patients 31-Day Target Patients 2011/12 2012/13 2013/14 2014/15 2015/16* * 2015/16 data covers April to February only These targets are a leading priority for the Trust and will be the focus of in depth work in 2016/17, especially given the ongoing increases in demand for these services. Regulatory body ratings In the last quarter of 2015/16 Monitor rated UHS ‘2’ for our financial sustainability risk rating (1 being the most serious risk and 4 the lowest risk) and ‘green’ for our governance risk rating, which means that no governance concern is evident and no formal investigation is being undertaken. More details can be found on page 57. The Care Quality Commission (CQC) gave us an overall rating of ‘requires improvement’ as at December 2014. You can see the full report by visiting www.uhs.nhs.uk or www.cqc.org.uk. Environmental matters A number of projects were undertaken in 2015/16 to reduce our impact on the environment. We installed a large anaerobic digester which will provide renewable energy by naturally breaking down waste and turning it into fuel. We have also replaced one of our combined heat and power engines so that we can generate more of our own electricity on site and get the benefit of free heating that is a by-product of running a large gas engine. 14 In conjunction with these two developments we have implemented a range of measures to ensure that we are using energy more efficiently. For example, we are now ensuring that large water pumps are only running when needed and we are in the process of replacing old fluorescent lighting with more efficient LED systems. More information can be found within the environmental sustainability and climate change section of this report. Social, community and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. 15 Directors’ report Composition of the Board The Board is currently comprised as follows: Non-executive directors: Peter Hollins, chair Simon Porter, senior independent director Professor Iain Cameron Lynne Lockyer Dr David Price Dr Mike Sadler Jenni Douglas Todd Executive directors: Fiona Dalton, chief executive Gail Byrne, director of nursing and organisational development Jane Hayward, director of transformation and improvement Dr Derek Sandeman, medical director Dr Caroline Marshall, chief operating officer David French, chief financial officer Name John Trewby Lena Samuels Judy Gillow Dr Michael Marsh Mike Murphy Alastair Matthews Gail Byrne Dr Derek Sandeman Position Chairman Non-executive director Director of nursing and organisational development Medical director Director of strategy Director of finance and deputy chief executive Director of nursing and organisational development Medical director Paul Goddard Acting director of finance David French Chief financial officer Note Left the organisation on 31 March 2016 Left the organisation on 29 February 2016 Left the organisation on 30 September 2015 Left the organisation on 31 May 2015 Left the organisation on 31 December 2015 Left the organisation on 1 November 2015 Commenced from within the organisation on 1 October 2015 Commenced from within the organisation on 1 June 2015 Acting director from 23 October 2015 to 2 February 2016 Joined the organisation on 3 February 2016 It should be noted that the size of the Board has been reduced to seven non-executive directors (including the chair) and six executive directors. This decision was agreed by our appointments and remuneration committee on 25 August 2015. Each director confirms that at the time the annual report and accounts is approved: • so far as the director is aware, there is no relevant audit information of which the NHS foundation trust’s auditor is unaware • the director has taken all the steps they ought to have taken as director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust’s auditor is aware of that information. 17 There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. Trust Board declarations of interest John Trewby Council member University of Southampton; chair Exelis Defence Ltd; associate of Group 4 Securicor. Peter Hollins Partner in the Jubilee Film Partnership; chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee). Lena Samuels Shareholder and director, 37 Patshull Road NW5 Limited; magistrate of Southampton Bench; member of staff at BBC; shareholder and director of Wessex Creative Media Ltd; chair of Pylewell Park Cricket Club; trustee Cultural Development Trust; prospective Labour Party parliamentary candidate for the New Forest West constituency (until 7 May 2015); communications and development specialist advisor for the Hampshire Cultural Trust (from 4 May 2015) Iain Cameron Dean of Faculty of Medicine and Member of University Executive Board, University of Southampton; board member of Wessex Academic Health Science Network; director (chair) of Medical Schools Council; director of Medical Schools Council Assessment; director of UK Clinical Aptitude Test; trustee of Wessex Medical Trust; joint chair of University Hospital Southampton/University of Southampton Joint Research Strategy Board; joint chair, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Southampton Executive Board. Simon Porter Independent member of audit committee Amicus Horizon (until 21 October 2015); Former partner in Ernst & Young LLP; non-executive director and chair of audit committee, Radian Group; non-executive director and chair of audit committee, Octavia Housing. Lynne Lockyer Board member/trustee of the Brendoncare Foundation. David Price Public member of Network Rail Ltd (until 30 June 2015); chair of RTL Materials Ltd; chair of Telesoft Technologies Ltd; chair of Optitune Plc; chair of Symetrica Ltd; member of Advisory Board, Silverstream Technologies BV; treasurer, University of Southampton. Michael Sadler GP specialist advisor for the Care Quality Commission; external clinical associate for PricewaterhouseCoopers. Fiona Dalton Trustee of Gingerbread, the national charity for one-parent families (until 31 December 2015). Judy Gillow Trustee of Naomi House Children’s Hospice, Winchester (until 31 August 2015); trustee of Enham House Disability Charity, Andover. Gail Byrne Husband is a consultant surgeon in the Trust; trustee of Naomi House Children’s Hospice (from 1 January 2016). 18 Caroline Marshall Nothing to declare Jane Hayward Father is mental health act manager, Southern Foundation Trust (voluntary position), member of Mental Health Act Committee, Southern Foundation Trust (voluntary position), member of Assessment Committee for Clinical Excellence Awards (lay member), a UHS Simulated Patient (voluntary position), Lay member on Medical School undergraduate interview panels (until 31 December 2015); Mother is a UHS Simulated Patient (voluntary position). Michael Marsh Married to Sarah Marsh, who works within Specialised Commissioning of NHS Commissioning Board; selfemployed Medico Legal Expert on ad hoc basis independently to solicitors, Medical Defence Union (MDU) and NHS Litigation Authority. Derek Sandeman Nothing to declare. Alastair Matthews Non-executive director of NHS Innovations South East Ltd. Paul Goddard Partner works for the Trust as projects officer within the contracting department and previously PA to the director of research and development. David French Non-executive director and chair of audit and risk committee, Sentinel Housing Association; governor and chair of audit committee, South Wilts Grammar School for Girls; chair of Hampshire & Isle of Wight NHS Counter Fraud Board. Mike Murphy Parent governor, Mountbatten School, Romsey. 19 Introducing the Board of Directors Trust Board The Board is made up of the chair, six non-executive directors and six executive directors including the chief executive. Together they bring a wide range of skills and experience to the Trust, such that the board achieves balance and completeness at the highest level. The non-executive directors, including the chair, are people who live or work in the local area and have shown a genuine interest in helping to improve the health of local people. The non-executive directors are determined by the Board to be independent in both character and judgement. The chair, executive directors and non-executive directors have declared any business interests that they have. The Board is satisfied that no conflicts of interest are indicated in any external involvement. The register of Board members’ interests is updated at least annually and is maintained by the company secretary and associate director of corporate affairs. It is available for public inspection from the company secretary and associate director of corporate affairs. The ‘reservation of powers to the Board and delegation of powers policy’ sets out the business to be conducted by the Board, or by one of its committees. Any enquiries should be made to: company secretary and associate director of corporate affairs, Trust Headquarters, Mailpoint 18, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD or telephone 023 8120 6829. Senior independent director The role of senior independent director has been established and, until 31 March 2016, was held by Peter Hollins, a non-executive director. The senior independent director role provides a channel through which foundation trust members and governors are able to express concerns, other than the normal route of the chair or chief executive. Appointments Non-executive directors are appointed via open advertisement in accordance with the ‘Appointment of a foundation trust non-executive director good practice guide’ procedure adopted by the Trust. The process is managed through the governors’ nomination committee, a sub-committee of the Council of Governors. This committee also determines the remuneration and terms and conditions of the non-executive directors. For further details on the appointment of non-executive directors please see page 45. Development of the Board The Board held monthly study sessions during 2015/16 where strategic issues, along with emerging issues, were discussed. Meetings of the Board The Board meets once a month in public. Additional private meetings with only the board, and associated employees of the Trust making presentations to the board in attendance, are held as required. Other committees of the Board include: appointment and remuneration committee; audit and assurance committee, strategy and finance committee; quality and performance committee and charitable funds committee. Generally the other committees of the board meet monthly with the exception of the audit and assurance committee, which meets five times a year and the appointments and remuneration committee which meets every other month. The frequency of the meetings is set out in each committee’s terms of reference. These terms of reference are reviewed at least annually. 20 The performance of individual Board members is reviewed as set out on page 44 of this report. Engagement with Council of Governors The Trust Board engages with the Council of Governors through the chair and senior independent director. Non-executive and executive directors engage with sub-groups of the council where these are related to their portfolios. Board members meet regularly with governors and have an open invitation to attend formal Council of Governor meetings. The people Non-executive directors John Trewby, chair to 31 March 2016 John joined the Trust on 1 April 2008, bringing with him a wealth of leadership experience after a distinguished career in the Navy where he rose to the rank of rear admiral and became the first chief executive of the Naval Bases and Supply Agency. After 36 years in the Navy, John joined the defence company British Aerospace (latterly BAE Systems) where he was their chief naval advisor for eight years. He is an associate of Group4Securicor and chair of Exelis Defence Ltd. He is a fellow of the Royal Academy of Engineering; sitting on its proactive membership committee and in 2009 chaired a study into “ICT for the UK’s Future”. He is currently chairing a study on wind turbines. He is a council member of the University of Southampton. Professor Iain Cameron Iain Cameron is a professor of obstetrics and gynaecology and dean of the Faculty of Medicine at the University of Southampton. After graduating in medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in Edinburgh, Melbourne and Cambridge. He held the regius chair of obstetrics and gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology and investigation of the impact of the maternal environment on early pregnancy. Iain is chair of the Medical Schools Council; a member of the UK Clinical Research Collaboration board; the National Institute for Health Research advisory board; the Health Education England medical advisory group; and the Wessex Academic Health Science Network delivery board. Peter Hollins Peter Hollins graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. Lynne Lockyer Lynne’s background is in human resource management and strategic management. She became a nonexecutive director for Southampton and South West Hampshire in 1996 and the vice chair in 2000. She was chair of Eastleigh and Test Valley South PCT from its inception in 2002 until its disestablishment in 2006. She has taken many roles in the local health economy including being a member of Hampshire’s Local Area Agreement Board and nationally was a member of the NHS Confederation Council and the National NHS Leaders Steering Group. She was until recently a course director at the University of Portsmouth and is now an organisation development consultant. She is a trustee of the Brendoncare Foundation. 21 Simon Porter Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director and co-chair of the audit and assurance committee from 1 June 2011. He has chaired the quality and performance committee since it was established in January 2014. He also holds non-executive board positions in the social housing sector. Dr David Price David is a former chief executive of a FTSE-250 company with broad experience within the electronics, chemical, aerospace, defence, marine, and nuclear industries. He has a successful track record of developing highly complex companies in international markets. He is currently non-executive chairman of Symetrica Ltd, Telesoft Technologies Ltd, RTL Materials Ltd and Optitune Plc. He is treasurer of the University of Southampton and a member of the advisory board of Silverstream Technologies BV. David is a chartered engineer and chartered scientist. He has a degree in electronic engineering, a PhD from University College London and, in 2001, he was awarded an honorary doctorate by Cranfield University for his services to science and engineering. David was made a Commander of the Order of the British Empire (CBE) for his services to industry. Dr Mike Sadler Mike joined us as a clinical non-executive director in September 2014, from a similar position at an NHS Foundation Trust providing mental health, learning disability and community services. He works for the CQC as a specialist adviser in primary care and works as an advisor and consultant on health and social care services. Mike was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. Jenni Douglas Todd – appointed 1 April 2016 Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was head hunted into the civil service, at the Home Office, where she spent four years before being becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two-and-a-half years as a resident twinning adviser for the UK, based in Turkey to help set-up a law enforcement complaints system before taking up the role of chief executive of the county’s Police Authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the general dental council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. 22 Executive directors Fiona Dalton, chief executive Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. Gail Byrne, director of nursing and organisational development Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Jane Hayward, director of transformation and improvement Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Dr Derek Sandeman, medical director Dr Derek Sandeman was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Dr Caroline Marshall, chief operating officer Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care before holding the position of divisional clinical director between 2010 and 2013. Caroline served as interim chief operating officer before being appointed in December 2014. David French, chief financial officer David joined the Trust in February 2016 and leads on finance, estates and commercial development. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Sentinel Housing Association, a Hampshire-based social housing provider. Board effectiveness On the basis of the expertise and experience described above, the Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing and effective Board. The chairman has held no other significant commitments during 2015/16. A register of interests of Board members is outlined within this report and is also available from the associate director 23 of corporate affairs. The effectiveness of the Board of Directors meetings is reviewed at the end of each meeting. Effectiveness of Board sub-committees are monitored through monthly board reports and annual evaluation/review of the terms of reference and work programmes. Schedule of Decisions Reserved to the Board The NHS Foundation Trust Code of Governance requires that there should be a formal schedule of matters specifically reserved for decision by the Board. The Scheme of Delegation shows the ‘top level’ of delegation within the Trust. The Scheme should be read in conjunction with Trust’s Standing Financial Instructions and Standing Orders. A copy of the Schedule of Matters Reserved for the Board can be obtained from the associate director of corporate affairs. Attendance at board meetings in 2015/16 Board Apr member 28 John Trewby chair 3 Peter Hollins SID & 3 deputy chair Iain Cameron NED 5 Lena Samuels NED 3 Simon Porter NED 3 Lynne Lockyer NED 3 David Price NED 3 Mike Sadler NED 3 Fiona Dalton CEO 3 Alastair Matthews finance 3 director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical 3 director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of 3 nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) Caroline Marshall chief 3 operating officer Jane Hayward director 3 of transformation and improvement Mike Murphy director 5 of strategy and business development May 26 May Jun Jul Extra 28 30 28 CS only 3 3 3 3 3 3 3 3 Sept Oct Nov Dec 18 Jan 29 29 24 CS only 28 3 3 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 5 3 3 5 3 3 5 3 3 5 5 5 3 telecon 3 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 3 3 telecon 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 (CS only) n/a 3 3 3 3 n/a n/a 5 5 n/a 5 5 3 3 3 3 3 n/a 3 3 3 3 3 n/a 3 3 3 3 n/a 5 3 3 3 5 3 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 Feb Mar 23 31 3 3 3 3 3 3 5 n/a 3 5 3 3 3 5 3 3 3 3 n/a 3 3 3 3 3 3 3 3 3 5 n/a 24 Audit and assurance committee attendance 2015/16 Board member Simon Porter NED and co-chair Iain Cameron NED and co-chair Peter Hollins NED senior independent director/ deputy chair Lena Samuels NED Lynne Lockyer NED David Price NED Mike Sadler NED Alastair Matthews finance director and deputy CEO (until 1/11/15) Paul Goddard acting director of finance (from 24/10/15 until 2/2/16) David French chief financial officer (from 3/2/16) Michael Marsh medical director (until 31/5/15) Derek Sandeman medical director (from 8/10/15 previously interim from 1/6/15) Judy Gillow director of nursing and organisational development (until 30/9/15) Gail Byrne director of nursing and organisational development (from 1/10/15) May 18 3 3 3 3 3 3 3 3 3 n/a 5 July 20 3 3 3 3 3 3 3 5 n/a 5 3 n/a Oct 19 3 3 3 3 5 3 3 3 n/a 3 3 Jan 18 3 3 3 Mar 21 3 3 3 3 n/a 3 3 3 3 5 3 n/a 3 n/a 3 n/a 3 3 n/a 3 3 Audit and assurance committee Introduction The audit and assurance committee is a non-executive committee of the Trust Board with delegated authority to review the estab
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