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Mental health and wellbeing support when you have a heart condition - patient information

Description: This factsheet contains a list of useful mental health and wellbeing support services and resources for people living with a heart
Url: /Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Mental-health-and-wellbeing-support-when-you-have-a-heart-condition-4012-PIL.pdf

Managing pain after surgery

Description: pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 1 Managing pain after your surgery This
Url: /Media/UHS-website-2019/Docs/Services/Pain/Managing-pain-after-surgery.pdf

Welcome to the TAVI clinic - patient information

Description: Information about transcatheter aortic valve implantation (TAVI) - a procedure to replace a faulty aortic (heart) valve via a thin plastic tube.
Url: /Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Welcome-to-the-TAVI-clinic-3352-PIL.pdf

Going home after your stay at the major trauma centre - patient information

Description: This factsheet gives you useful information about returning home after your stay at the trauma centre.
Url: /Media/UHS-website-2019/Patientinformation/Major-Trauma-Centre/Going-home-after-your-stay-at-the-major-trauma-centre-3124-PIL.pdf

Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.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 Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2025 University Hospital Southampton NHS Foundation Trust Contents Welcome from our Chair and Chief Executive 7 Performance report 9 Introduction from the Chief Executive 10 Overview 11 Principal risks to our strategy and objectives 16 Performance overview 17 Performance analysis 22 Quality priorities 29 Financial performance 33 Sustainability 33 Social, community, anti-bribery and human rights issues 34 Events since the end of the financial year 35 Overseas operations 35 Equality in service delivery 35 Going concern 41 Accountability report 42 Directors’ report 43 Remuneration report 69 Staff report 82 Counter fraud 98 Code of governance for NHS provider trusts 98 NHS System Oversight Framework 99 Statement of the chief executive officer’s responsibilities as the accounting officer of UHS 100 Annual Governance Statement 102 Scope of responsibility 102 The purpose of the system of internal control 102 Risk management and control within the Trust 102 Review of economy, efficiency and effectiveness of the use of resources 116 Quality account 119 Part 1: Statement on quality from the Chief Executive 120 Part 2: Priorities for improvement and statements of assurance from the Board 122 Part 3: Other information 194 5 Annual accounts 241 Statement from the Chief Financial Officer 242 Auditor’s report including certificate 244 Foreword to the accounts 251 Statement of Comprehensive Income 252 Statement of Financial Position 253 Statement of Changes in Taxpayers’ Equity 254 Statement of Cash Flows 256 Notes to the accounts 257 6 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) has experienced another challenging year, with increased demand for the Trust’s services, a more restrictive financial environment, and changes in terms of the organisation of the NHS in England. Despite the challenges faced by the Trust during 2024/25, we can feel incredibly proud of the achievements of our 13,000 staff, who went above and beyond to deliver for our patients and the communities we serve. Particular highlights include: • In the top 15 in the country against government targets for elective recovery performance with 127% of activity compared with 2019/20. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including long-waiting patients on referral to treatment pathways, diagnostics and cancer performance. • Delivery of £85.3m of savings through our cost improvement programme – the highest ever amount by the Trust. We continue to be one of the best performing trusts in England in many areas. The Trust’s elective recovery performance places it as one of the best performing trusts in England. As a result, we have seen the number of long-waiting patients fall to one patient waiting over 78 weeks and to 21 patients waiting over 65 weeks – in many instances these delays were due to a national lack of corneal transplant tissue. This is despite an increase in the number of patients being referred to the Trust for treatment. Our performance against key cancer metrics has seen an improvement in commencing treatment of cancer within 62 days to 81% by March 2025, against the NHS England average for 2024/25 of 70.5%. Similarly, the Trust performed in the range of 88%-96% during the year against the target of patients commencing treatment within 31 days of diagnosis. There has been significant demand for non-elective care throughout the year, which has placed significant demands on the Trust’s emergency department. There were frequently more than 400 attendances per day and the Trust saw an average of 13,100 patients per month (2023/24: 12,700). As a result of this increased demand, coupled with issues with flow through the hospital and a high incidence of seasonal illnesses during the winter, UHS’s performance against the four-hour emergency department target has steadily declined over the course of 2024/25. The Trust also recorded a lower than expected death rate via the Summary Hospital-level Mortality Indicator (SHMI) and was one of 12 trusts in England out of 119 with lower than expected death outcomes. The Trust reported a deficit of £7m at year-end, which represents a significant achievement given the financial pressures we have experienced, such as significant demand for services above block contract levels, pay award pressures, and inflation. The Trust also saw its productivity improve during the year and delivered its highest ever performance under its cost improvement programme. 7 Despite the introduction of strict controls in early 2024, the Trust exceeded its target for workforce numbers during 2024/25 by 373 whole-time-equivalents. However, a significant proportion of this number was due to assumed reductions in the number of staff required to manage patients with no clinical criteria to reside in the hospital and patients with a primary mental health need not materialising. Instead, the number of both categories of patient continued to rise during the year, placing additional strain on the Trust’s capacity and reducing flow through the hospital as patients are unable to move in a timely way from the emergency department, to wards and then to discharge due to lack of capacity. Higher levels of staff absence during the winter months coupled with high levels of seasonal illness and consequent demand on the emergency department also necessitated the opening and staffing of surge capacity. Indeed, demand on the emergency department was so great during the year that surge capacity was required even outside of the typically busier winter period. Our people remain our greatest asset. Without our staff, the Trust would not be able to deliver for the communities we serve. We were pleased to see the results from the 2024 Staff Survey, which placed UHS above the benchmarking group across all the key people themes. In particular, there have been improvements in relation to satisfaction with immediate managers, flexible working opportunities, and staff recommending UHS as a place to work. UHS has also continued with its staff room refurbishment programme and made significant improvements to the prayer facilities for Muslim staff, patients, students and community members in our chapel, all funded by Southampton Hospitals Charity. We expect 2025/26 to be even more challenging than 2024/25. The Trust has already had to take some difficult decisions in terms of its workforce numbers, prioritisation for capital expenditure, and services. We will be expected to continue to maintain quality of patient care and experience and to deliver the required levels of performance whilst at the same time having to make significant reductions in its expenditure to deliver a balanced budget. Many of the challenges faced by the Trust – in common with other providers – can only be addressed by working in partnership with wider local partners, such as other healthcare providers, local authorities and charities to deliver system-wide solutions. At the same time, we recognise that there is more that we can do internally to ensure that our internal processes deliver in the most effective and efficient manner. We would like to express our heartfelt thanks to our amazing staff, who have gone and continue to go above and beyond to put our patients first and deliver world class care. Jenni Douglas-Todd Chair David French Chief Executive Officer 8 PERFORMANCE REPORT OVERVIEW AND PERFORMANCE Performance report Introduction from the Chief Executive Officer This was another challenging year for the Trust, continuing the trend seen in previous years of increasing demand which must be balanced with the need to deliver quality patient care whilst maintaining a sustainable financial position. The Trust saw even higher demand for non-elective care than in recent years with attendances at the emergency department being as high as 400 per day and the Trust having to open and staff surge capacity for a significant proportion of the year, including outside of the typically more strained winter period. The trend of increasing numbers of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of funded care in a more appropriate venue, continued, as did the increasing number of patients presenting with a primary mental health need. This placed significant pressure on the Trust’s resources due to the impact on flow through the hospital and the need to engage additional members of staff to manage these patients – in some instances this requires as many as four members of staff, usually via a specialist agency, for each patient as well as, potentially, additional security resource. Despite the challenges, the Trust continued to perform well when compared to other comparable organisations, achieving some of the best elective recovery performance in England at 127% compared to 2019/20 levels. The Trust implemented spending and recruitment controls in early 2024, which it continued to operate under during 2024/25, in order to manage its difficult financial position. However, the Trust ended the year above its plan in terms of workforce numbers, although a significant proportion of this amount was due to the increasing number of patients having no criteria to reside and mental health patients. The Trust achieved its highest ever delivery on its cost improvement programme with £85.3m of savings, and achieved an overall end of year deficit of £7m. 10 OVERVIEW AND PERFORMANCE Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of £1.5 billion in 2024/25. It is based on the coast in southeast England and provides services to people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 166,000 inpatients and day patients, including about 75,000 emergency admissions sees over 770,000 people at outpatient appointments deals with around 155,000 cases in its emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care, and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton, it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff, it acts as a community midwifery hub. • Lymington New Forest Hospital – a community hospital located in Lymington managed by Hampshire and Isle of Wight Healthcare NHS Foundation Trust. UHS manages surgical services at the hospital. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. 11 OVERVIEW AND PERFORMANCE Trust services are supported by clinical income, of which 53% is paid for by NHS England and 44% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health, and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Ophthalmology Theatres and Anaesthetics Division B Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Division C Women and Newborn Maternity Child Health Clinical Support 12 Division D Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust headquarters division OVERVIEW AND PERFORMANCE Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 13 OVERVIEW AND PERFORMANCE Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • experience and safety By 2025 we will strengthen our national reputation for outstanding • patient outcomes, experience and safety, providing high quality care • and treatment across an extensive range of services from foetal medicine, through all life stages and conditions, to end-of-life care. Pioneering research and • innovation We will continue to be a leading • teaching hospital with a growing, reputable and innovative research • and development portfolio that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • Supporting and nurturing our people through a culture that values • diversity and builds knowledge and skills to ensure everyone reaches their full potential. We must provide • rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and • collaboration We will deliver our services with • partners through clinical networks, collaboration and integration across geographical and organisational • boundaries. • We will monitor clinical outcomes, safety and experience of our patients regularly to ensure they are amongst the best in the UK and the world. We will reduce harm, learning from all incidents through our proactive patient safety culture. We will ensure all patients and relatives have a positive experience of our care, as a result of the environment created by our people and our facilities. We will recruit and enable people to deliver pioneering research in Southampton. We will optimise access to clinical research studies for our patients. We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. We will recruit and develop enough people with the right knowledge and skills to meet the needs of our patients. We will provide satisfying and fulfilling roles, growing our talent through development and opportunity for progression. We will empower our people, embracing diversity and embedding compassion, inclusion and equity of opportunity. We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated Care System. We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 14 OVERVIEW AND PERFORMANCE Foundations for the future • We will deliver best value to the taxpayer as a financially Making our enabling infrastructure efficient and sustainable organisation. (finance, digital, estate) fit for • We will support patient self-management and seamless the future to support a leading care across organisational boundaries through our university teaching hospital in the ambitious digital programme, including real time data 21st century and recognising our reporting, to inform our care. responsibility as a major employer • We will expand and improve our estate, increasing in the community of Southampton capacity where needed and providing modern facilities and our role in broader for our patients and our people. environmental sustainability. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2024/25 these objectives included: Outstanding patient Establishing an integrated approach to quality management. outcomes, experience Treating patients according to need but aiming to meet the target of zero and safety 65-week waiters by the end of September 2024, and continued reduction of longer waiters. Reducing length of stay across elective and non-elective pathways. Improving patient experience and outcomes through continued implementation of the Fundamentals of Care programme. Pioneering research and innovation Delivering year four of the research and innovation investment plan. Delivering year two of the five-year research and development strategy implementation plan for research for impact. World class people Delivering a workforce plan for the Trust for 2024/25 which is safe, sustainable and affordable. Delivering targeted improvements in staff experience, engagement and culture. Sustaining turnover at less than 13% and maintaining sickness absence at under 4%. Integrated networks In partnership with acute trusts working directly with priority areas to and collaboration progress joint network strategies. Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. Foundations for the future Delivering a stretching financial plan for 2024/25, including identifying what needs to be true to recover a sustainable financial position and exit the Recovery Support Programme. Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. Delivering the aims of the 2024/25 transformation programmes and always improving strategic priorities. Delivering the prioritised 2024/25 capital programme and setting a prioritised capital programme for 2025/26. Completing year two of the Public Sector Decarbonisation Scheme. 15 OVERVIEW AND PERFORMANCE Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. At the end of 2024/25, the Trust had met the objectives set as follows: Corporate Ambition Number of Green Amber Red objectives Outstanding patient outcomes, 4 3 1 0 safety and experience Pioneering research and innovation 2 2 0 0 World class people 3 2 0 0 Integrated networks and collaboration 2 0 2 0 Foundations for the future 5 2 2 1 Totals 16 8 6 2 Note: Green: achieved in full Amber: partially achieved Red: not achieved Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Reduction in the number of patients waiting over 65 weeks, with only 21 waiting over 65 weeks. • Reduction in the length of stay by 5.25% through successful delivery of the inpatient flow transformation programme. • Implementation of the Fundamentals of Care programme. • Successful delivery of year four of the research and innovation investment plan. • Reducing staff turnover to 10.1% at year end and achieving a staff absence rate below 4%. • Progress in developing the identified priority clinical networks. • Successful delivery of the Trust’s 2024/25 capital programme. Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2024/25 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust does not take full advantage of its position as a leading university teaching hospital with a growing, reputable and innovative research and development portfolio, attracting the best 16 OVERVIEW AND PERFORMANCE staff and efficiently delivering the best possible treatments and care for its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme; NHS England imposing additional controls/ undertakings; and a reducing cash balance, impacting the Trust’s ability to invest in line with its capital plan, estates and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. As in previous years, demand for services continued to increase, especially for emergency (nonelective) care. The winter months in particular saw both high levels of demand and above average levels of staff absence due to seasonal illnesses. The Trust consistently experienced high numbers of patients having no clinical criteria to reside in hospital, but who could not be discharged due to a lack of appropriate care packages. This results in a lack of flow through the hospital and also requires additional staff to be engaged due to the need to open surge capacity. In addition, the Trust continued to experience significant challenges from patients with a primary mental health care need for whom there were insufficient spaces available in a more suitable alternative setting. Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive, and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. 17 OVERVIEW AND PERFORMANCE The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust experienced high demand for its services, continuing the trend from previous years. Demand in the emergency department in particular was significant, with attendances growing by 3.2% compared to 2023/24. This situation has resulted in a gradual decline in the Trust’s performance against the target of 95% patients spending less than four hours in the main emergency department. The number of patients having no clinical criteria to reside continued to impact flow within the hospital. The number of patients having no clinical criteria to reside was frequently above 250 at any one time during the year. The Trust experienced an increase in the number of referrals with the number of patients on a waiting list under the 18-week referral to treatment pathway rising from approximately 59,000 to 62,000 by the end of the year. Quality and compliance The Trust’s elective recovery performance was one of the best in England at 127% compared to 2019/20. The Trust continued to monitor the quality of care delivered throughout 2024/25 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. The roll out of the Trust’s Fundamentals of Care initiative continued. High-quality peer reviews were consistently conducted, with a key focus on weekly matron-led quality walkabouts – both during and outside of standard hours – centred around the five CQC domains: safe, effective, responsive, caring, and well-led. Additionally, focused matron walkabouts were introduced to address specific themes related to patient safety and Fundamentals of Care standards, such as medication safety and infection prevention. These initiatives have been instrumental in identifying areas for improvement and promoting the sharing of best practices across teams. The Trust’s clinical accreditation scheme (CAS) builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing on-site visits. The clinical areas were supported by the CAS team from an initial contact meeting and walkabout through to outcome panel. Patient representatives were included in these review teams. CAS paperwork was reviewed to reflect the learning points from themed Matron’s walkabouts, aligning it to the CQC single assessment framework and the UHS Fundamentals of Care programme to ensure a robust ward accreditation. Learning was shared at the clinical leaders’ group and via reports. 18 OVERVIEW AND PERFORMANCE A framework was developed to govern Mortality and Morbidity meetings at the Trust, setting expectations for the content and format of these meetings. In addition, further work was carried out to ensure that the output from these meetings was shared more widely and that there is a clear escalation process. The Trust opened a patient and family support hub, repurposing the Macmillan Centre into a generic non-disease specific facility. The Trust worked with system partners to develop a unified and standardised approach to volunteer recruitment using a passporting system. The Trust commenced its implementation of the National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). Violence, abuse and aggression against staff continued to rise. The Trust took action over the course of the year to support its teams, including through roll out of de-escalation training. This has had a positive impact and has reduced the requirement for physical restraint and has reduced the number of incidences of physical violence against staff. However, the level of violence and aggression directed at staff by patients and other members of the public continues to be an area of concern for the Trust. The Trust continued to build its always improving culture and drive on quality improvement by training over 1,000 staff, remaining 3% above the NHS average for all improvement focussed staff survey questions and winning an award for patient involvement in improvement and safety. This enabled improvements across theatre, inpatient flow and outpatient programmes. In 2024/25, average length of stay was reduced by 5.25%, an additional 1,230 patients were treated in theatres, and 7% of patients were placed onto patient initiated follow up (PIFU) outpatient pathways. Partnerships Further information can be found in the quality account. The Trust works within the Hampshire and Isle of Wight Integrated Care System and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 19 OVERVIEW AND PERFORMANCE Workforce The Trust’s key area of focus during 2024/25 was to maintain a flat workforce level in order to meet the Trust’s 2024/25 workforce plan. In addition, the Trust sought to reduce reliance on bank and agency staff. The Trust ended the year above its workforce plan by 373 whole-timeequivalents. A significant proportion of the expected reduction in staff numbers had been linked to expected delivery of reductions in the number of patients having no criteria to reside and mental health patients through system-wide transformation programmes. However, these reductions did not materialise. In addition, due to the significant demand on the Trust’s services, it was necessary to open and staff surge capacity. This was exacerbated by high levels of staff absence due to illness during the winter months. The Trust was successful in reducing staff turnover to 10.1%, achieving the local target of 75% of staff in each area has received training, including neonatal medical team. • Trolley dashes. • Train the trainer. Progress metrics Audit of compliance: • Has it been undertaken for the appropriate babies? • Was the frequency of observation undertaken correctly? • Was the score accurately calculated? • Did escalation take place if required? • Was the response to escalation appropriate? 157 QUALITY ACCOUNT Quality Improvement Priority Four: Implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) 2 at UHS Core dimension Patient safety Rationale of selection The new National Safety Standards for Invasive Procedures (NatSSIPs 2) represent the progression of the original NatSSIPs. The key aim to standardise, harmonise and educate (SHE) across organisations and procedural teams remains central to the NatSSIPs purpose. Critical changes include bolstered organisational standards and proportionate checks that recognise different levels of risk during major and minor invasive procedures, and the adaptions to processes that may be necessary in lifethreatening situations. This standardisation, harmonisation and education goals are set out in the table below. Standardise Harmonise Educate Organisational Sequential (‘The NatSSIPs Eight’) Safety behaviours, processs, policies, insight, involvement and performance measures across organisations and specialities. Expected behaviour, safety standards, checklists and format across invasive specialities. Across groups of hospitals. Across IT systems. Reduce variation across specialities. Commit to safety education, human factors expertise and systems thinking. Create a safety infrastructure, leadership understanding and training in cultural change. Teach and train in team behaviours, human factors, systems thinking learning / co-production with patients. Investigations into the increase of never events in 2023 and 2024 has identified that the majority of these had contributing factors related to stop points for safety. The key learning identified: Thematic analysis of never events Surgical mark not visible/clear Not listening to patient concerns Change in surgical plan and lack of documentaion Lack of time out if concerns are raised Lack of triangulated checks Ability to speak up concerns Swab, sharp and instrument count process Implant checks not triangulating patent details Inexperienced staff with lack of familiarity of processs Lack of induction training in stop points Distractions during stop point checks 158 QUALITY ACCOUNT All these factors will be addressed through NatSSIPs2 implementation. Safer invasive procedures is to be included as a local quality indicator by the ICB within the 2025/26 national contract. Key aims • Establish a NatSSIPs oversight committee. • Set up an invasive procedures committee. • Establish the following workstreams: o Audit of stops point for safety in theatres and for minor procedures in outpatient and ward areas o Multi-disciplinary safety walkabouts o VLE and induction workstream • Education: recruitment of medical education led to set up simulation-based MDT training. • Patient involvement. • NatSSIPs eight and communications. • Stop points for safety staff resources. Progress metrics • Increase in the completion of VLE stop points training. • Develop and implement a programme to deliver non-technical skills to the MDT. • All areas with a never event in the last two years have an up to date audit and action plan for compliance with NatSSIPs2. 159 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Core dimension Patient safety Rationale of selection The term Fundamentals of Care (FoC) describes the eight standards that staff across the Trust have committed to in collaboration with the patient, to support the physical and emotional needs of patients’, relatives, and carers. This is not a new concept, it underpins the core values of what it means to be a healthcare professional, to truly ‘care’ and will build upon our achievements in year one. Operational challenges have led the workforce to become more task-focused and less personfocused, taking away from that personalised care experience but we are committed to changing that culture, following our Trust value, patients first. The FoC exemplifies how the interdisciplinary team connects and builds relationships with our patients, getting to know them and what matters to them as a person, not just as a patient, supporting and encouraging independence and rehabilitation from the beginning of their hospital stay. These activities are the essentials of our daily living such as personal hygiene, skin care, oral hygiene, toileting, eating and drinking, and mobilising. Communication is also essential and includes both listening and hearing patients, understanding what is important to them using communication tools they need, coming to shared decisions with patients about their care and recognising the diversity of our population, embracing accessibility for those with people with learning disabilities, sight/hearing loss or other disabilities, or if English may not be their primary language. In addition, the FoC encourages us as healthcare professionals to consider the whole person, support cultural, spiritual, mental health, emotional wellbeing and dignity needs of people we care for and those that matter to them. We know here at UHS that not everyone experiences this level of care, but we acknowledge the need to change the rhetoric from ‘we are busy’ to ‘we are never too busy to care’ empowering and educating our staff at all levels to challenge the ‘we have not got time’ rhetoric and ensure fundamental care is at the heart of what we do at UHS. Thus improving, patient care and experience. Key aims We will grow the multi-disciplinary engagement and involvement in workstreams that embrace the FoC and encourage person centred to care. We will continue to pursue the digitalisation of the Friends and Family Test (FFT), using this data and the national inpatient and urgent and emergency care survey as a baseline, while linking with involved patients where required with to encourage feedback on the FoC. We will listen to the voice of our patients, their relatives, and carers to make sure their stories and experiences are heard by our workforce to encourage the organisation wide change. We will ensure the FoC will has clear and measurable improvement metrics as part of a live clinical quality dashboard that will afford ward managers and senior leaders, the opportunity to monitor, review and report on to FoC in their areas. 160 QUALITY ACCOUNT We will embed the FoC into the matron walkabout and CAS processes, supported by consistent evaluation metrics that ask the patients about their experiences and encourage clinical areas to continually assess and evaluate the FoC in their areas through a self-assessment tool. We will enhance the availability of existing resources on our virtual learning environment (VLE) in collaboration with our patient partners for all staff groups and embed the FoC into training across the organisation, to improve the knowledge, skills and awareness ensuring the delivery of quality care. We will continue to test and evaluate the What Matters To Me project, growing our volunteer role to support staff in finding out what is important to the patient and using their personalised board to remind staff of the ‘person’ they are caring for. We will continue to establish project links in child health, maternity and outpatients to ensure a bespoke, but collaborative roll out of FoC, considering how these different care environments may impact care. Progress metrics • Patient hygiene: we will see an improvement in the number of patients who report having their personal care needs met, particularly within their first 24 hours coming through emergency admission routes. • Skin integrity: we will support the reduction in incidences of avoidable pressure ulcers across the organisation. • Communication: we see an increase in the number of people accessing our interpreting services and a reduction in complaints related to interpretation. • Pain: we will see an improvement in patients reporting that their pain was well controlled when coming through the emergency department. • Mouthcare: we will see a positive uptake in the implementation of the new mouthcare assessment tool and an improvement in patients reporting that their oral hygiene needs have been met. • Nutrition and hydration: we will see an increase in patients reporting they are being offered adequate food and drink provisions throughout their hospital stay, including access to equipment for those with conditions or disabilities that impact their ability to do so independently. • Bowel and bladder care: we will see improved assessment of bowel and bladder habits through increased documentation using the Inpatient Noting system. • Enhancing safe movement: we will support a reduction in the incidence of high harm falls and high harm falls that have preventable causes. • Infection prevention: we will see a reduction in nosocomial infections through increased hand hygiene standards and more effective cleaning of equipment. 161 QUALITY ACCOUNT Quality Improvement Priority Six: Develop the Trusts’ approach to reducing the impact of health inequalities (HIs) (year two) Core dimension Clinical effectiveness Rationale of selection Tackling health inequalities is a key priority for the NHS. At UHS we have been working to have an impact on health inequalities for several years. In 2024/25 we formalised these efforts with a governing board, chaired by our chief medical officer and with a clear programme of improvement based on recognised priorities. This formed the basis of our quality priority in 2024/25. This year’s quality priority is a continuation of the work that started in 2024/25. We intend to continue to grow our understanding and actions as an organisation, improving the equity of access, outcomes and experience of our services across our community. Key aims We are continuing our health inequalities board, with focus on five priorities: enabling our organisation, data and measurement, clinical service priorities, communication and engagement and strategy and approach. Each of these priorities have aligned directors to oversee improvement and a detailed delivery plan. Key priorities and expected outcomes from each of these are listed below: Enabling the organisation • Developing supporting structures: set up governance so that teams who identify health inequality related issues know where they can go for help, so that we can understand frequently arising challenges and notice when a problem raised might be affecting other of the hospital too. This will aid improvement, learning from issues identified and escalation of issues that cannot be resolved locally • Capability building: develop training for our staff to understand health inequalities, identify them within services and access tools to make improvement. • Delivery of the health inequalities officer role: grow knowledge of the health inequalities officer role across the organisation and utilise this role to share knowledge, training and support improvements. Data and measurement • Continue to develop our understanding of inequalities in access across outpatients and diagnostics, inpatients, theatres and the emergency department. • Enable the measurement of improvement in areas recognised as clinical priorities. • Enable completion of national reporting. Clinical priorities • Improve services and support for patients and staff with obesity (children and adults). • Improve identification and control of hypertension. • Improve services and support for patients and staff who smoke. 162 QUALITY ACCOUNT Communication and engagement • Adopt health inequalities into leadership and decision making. • Learning from our communities and our staff. • Communicating improvements internally and externally. • Staff support campaign. Strategy and approach • Overseeing and agreeing UHS approach and strategy for HIs. • Overseeing annual delivery against priorities. • Aligning programme resource. • Maintaining collaborative working with public health and Integrated care board teams and other local healthcare providers. • Keeping up to date with national recommendations and expectations, sharing this knowledge with our organisation. • Overseeing trust-wide improvement and health inequalities maturity. Progress metrics • Increasing numbers of staff trained. • Numbers of health inequalities issues reported (expected to increase through understanding before reducing due to improvement work). • Case studies shared of successful improvement projects. • Increased involvement and collaboration with patients and public on improvement. • Increased use of QEIA templates in decision making. • Demonstration of improved access to care for obesity, tobacco dependency and hypertension. 163 QUALITY ACCOUNT 2.3 Statements of assurance from the Board This section includes mandatory statements about the quality of services that we provide relating to the financial year 2024/25. This information is common to all quality accounts and can be used to compare our performance with that of other organisations. The statements are designed to provide assurance that the board of directors has reviewed and engaged in crosscutting initiatives which link strongly to quality improvement. 2.3.1 Review of services During 2024/25 UHS provided and/or sub-contracted 118 relevant health services (from total Trust activity by specialty cumulative 2024/25 contractual report). UHS has reviewed all the data available to them on the quality of care in all these relevant health services. The income generated by the relevant health services reviewed in 2024/25 represents 100% of the total income generated from the provision of relevant health services by UHS for 2024/25. 2.3.2 Participation in national clinical audits and confidential enquiries The UHS clinical audit programme was developed in support of the Trust’s vision by putting patients first, working together and always improving. This leads on to a specific strategy for clinical outcomes, to ensure robust and measurable processes are in place to plan locally and participate strategically. Healthcare Quality Improvement Partnership (HQIP) produces a National Clinical Audit & Enquiries Directory which identifies those national audits which are included in the NHS England Quality Account List 2024/25, those audits which are part of National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP audits are commissioned and managed on behalf of NHS England by HQIP. These collect and analyse data supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, NCAPOP audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for patients. The audits listed on the NCAPOP are ‘must-do’ national audits. The quality accounts national clinical audit list includes audits which we regard as ‘best practice’ to participate in (in addition to those from the NCAPOP) and for that reason we always include these in our corporate audit plans as a priority where they are relevant to our Trust. UHS has a strong history for completing clinical audits. The clinical effectiveness team has a robust approach to governing and supporting the completion. We’ve opened discussions with senior clinical leadership within Hampshire and Isle of Wight Integrated Care Board regarding the current challenges with contributing to and using the outputs of national audits. Benchmarked data resulting from national audits provides strong guidance on areas of excellence and improvement, however completion can be challenging in its compl
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-24-25-final.pdf

Quality account 24-25 final

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