Browse site A to Z

Search results

Go To Advanced Search

Functional magnetic resonance imaging (MRI) brain scan - patient information

Description: This factsheet explains what a functional magnetic resonance imaging (MRI) brain scan is and what to expect at your appointment.
Url: /Media/UHS-website-2019/Patientinformation/Scansandx-rays/Functional-magnetic-resonance-imaging-MRI-brain-scan-4021-PIL.pdf

Papers Trust Board - 15 July 2025

Description: Agenda Trust Board – Open Session Date 15/07/2025 Time 9:00 - 13:00 Location Conference Room, Heartbeat Education Centre Ch
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-15-July-2025.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.pdf

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

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2019/20 incorporating the quality account 2019/20 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Page 4 ©2020 University Hospital Southampton NHS Foundation Trust Page 5 TABLE OF CONTENTS Overview and performance report Welcome from our chair A word from the chief executive Overview of the Trust Statement of purpose and activities History of UHS Our executive team structure Structure of our services Our vision and values Our priorities, key issues and risks Voluntary disclosures Equality, diversity and inclusion 92 8 9 Environmental sustainability and climate chan ge 95 Quality account 10 Chief executive welcome 101 10 11 Annual accounts 12 Statement from the Chief financial officer 183 13 Independent Auditors report 185 14 Foreword to accounts 192 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 18 How we monitor performance 19 Overview of performance of UHS 18 Regulatory body ratings 19 Environmental matters 23 Social, community, anti-bribery and human rights issues 23 Accountability report Members of the Trust Board 25 Trust Board purpose and structure 30 Board meeting attendance record 2018/19 31 Well-led framework 32 Finance and investment committee 34 Quality committee 33 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 37 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 38 Disclosures 38 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 41 Annual remuneration statement 51 Remuneration and appointments committee 54 Governors’ nomination committee 57 Staffing report 61 Staff survey results 65 Trade union facility time 68 Statement of chief executive’s responsibilities as the accounting officer 72 Annual governance statement 73 Page 6 OVERVIEW AND PERFORMANCE REPORT Page 7 OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2019/20 was another challenging year for University Hospital Southampton NHS Foundation Trust (UHS). Demand for our services continued to rise rapidly, partly because of the ageing of the population we are here to serve and partly because of challenges in the external environment, but also because of our ability to offer exciting innovations for a range of conditions. As a result, we were not always able to offer treatment as rapidly as we wished. A major challenge towards the end of the year was the need to prepare the Trust for the COVID-19 pandemic, resulting in the need to re-engineer services on an unprecedented scale. The response of UHS staff to these challenges has, from start to finish, been magnificent. We saw major innovation in improved patient pathways to accommodate rising demand, and the creativity of colleagues in readying the Trust for COVID-19 was truly breath-taking in its scope and energy. UHS has had a long record of effective financial management. By constantly seeking operational innovation and better value for money in procurement, the Trust has been able to generate the funds necessary to make a number of capital investments which will provide huge patient benefit in future. There has been rapid progress in our major project to refurbish and extend our general intensive care unit. Our £2.2m investment in our new urology unit was completed this year; it will transform our patients’ experiences. We have continued wherever possible to work with partners and we are delighted that work on the £5m Maggie’s Centre has started. Quite apart from the need to navigate our way through the COVID-19 crisis and into the world beyond it, the Trust needs to prepare to play its full role in the Hampshire and Isle of Wight healthcare system as it develops in a way consistent with the NHS Long Term Plan. The responsibility for this falls of course to the Trust Board and I believe that even after having had more change on the Board this year than for some time, we continue to have a strong and committed leadership team. Following the retirement of Caroline Marshall, our long-serving chief operating officer, in September 2019 we welcomed Joe Teape into the position. Joe had not been at the Trust long before we were thrust into the COVID-19 pandemic and got to grips with it impressively rapidly. During the year we said farewell to three non-executive directors (NEDs); Catherine Mason who left us to become chair of Solent Healthcare, Mike Sadler our clinical NED and Simon Porter. After a series of rigorous selection processes, we were delighted to welcome Dave Bennett, Dr Tim Peachey and Keith Evans as replacements. Simon had been both deputy chair and senior independent director (SID) and on his departure Jenni Douglas-Todd succeeded him in both roles. The work of the Board is supported, stimulated and, quite correctly, challenged by the Council of Governors (COG) whose enthusiasm is of huge value to the proper governance of UHS. All of the elections to the COG were competitive, in some cases by a multiplicity of candidates. Unfortunately, one of those vacancies resulted from the death of Edward Osmond. Although Edward had only recently been elected as a governor, he had shown huge commitment to the role and I am sure would have gone on to make a major contribution to UHS. We welcomed nine new governors and one new young governor. I look forward to working with them and all the other governors as we move through and beyond the COVID-19 world. Peter Hollins Chair Page 8 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive My first full year as chief executive officer of UHS has been exciting, inspiring, and extremely rewarding but not, as you would expect, without a considerable degree of challenge! The pressures on the NHS have been well publicised as we strive to provide the highest possible standard of care at a time when demand for our services escalates rapidly. At the same time, at UHS we need to play our full part in working out how we shape and deliver the health and care provision for our community into the future. During the year we have done a great deal of work on how we turn our vision for the Trust, world-class care for everyone, into what happens on the front line every day. While the vision may be new it is built firmly on our long-standing values; patients first, working together, and always improving, which together describe who we are as an organisation. These values were central to the development of our new clinical and corporate strategy which sets out an exciting future for UHS over the coming decade. It includes how we will deliver the safest care, delivering the best outcomes, as well as how we will focus on improving the health of our population, supporting both health and wellbeing. The values also provided the basis for our CQC rating of ‘Good’ awarded during the year as were some other fantastic accolades. These included a prestigious British Medical Journal award for improving care for older patients with the development of our frailty unit and activity hub. Our women’s and maternity care at the Princess Anne Hospital was named as being among the best in the world. In addition, we adopted prehabilitation for cancer patients, a pioneering service. There are countless other examples of innovation which have sprung from the creativity and innovative spirit at UHS. Some of these have involved better outcomes for patients, some an improved patient experience and others simply lower the cost of doing things, liberating money which we can then invest in improving other services. I’d like to thank every one of our staff for creating the spirit of UHS which means that the extraordinary happens every day. The world of health and social care is changing dramatically and we continue to be integral to the Hampshire and Isle of Wight Sustainability and Transformation Partnership (STP). UHS will have a leading part to play in ensuring that, with our partners, we forge a pattern for the provision of healthcare across the local system and beyond, delivering the highest possible standards of care on an enduring basis. As we entered 2020, we began preparing to face COVID-19, the largest pandemic we have seen. Some areas of the hospital are truly unrecognisable as we have adapted to the fight against this virus. The loss of life as a result of COVID-19 has been utterly devastating and it has, I am sure, touched us all personally. It has also challenged the health and wellbeing of all our staff, but particularly our frontline staff, in a unique way. I am not sure whether I am prouder of the spirit with which our staff have responded to the challenge or of the fact that they made us by common consent one of the best prepared trusts in the country. Finally, I’d like to recognise the acts of kindness I see throughout the Trust on a daily basis. It is one of the things that has struck me the most as I have got to know this organisation and the people within it. I watch how they support one another through challenging times, how they support patients and visitors in their own time and in work time, and how they go above and beyond every day for the people they’re caring for. Every day they make me hugely privileged to lead this amazing organisation. Paula Head Chief executive officer Page 9 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and postgraduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 12,000 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2019/20 was £912m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). Page 10 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Executive team structure as at 31/03/2020 Page 11 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Page 12 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: Patients first Patients and families will be at the heart of what we do and their experience within the hospital, and their perception of the Trust, will be our measure of success. Working together Our clinical teams will provide services to patients and are crucial to our success. We have launched a leadership strategy that ensures our clinical management teams are engaged in the day-today management and governance of the Trust. Always improving Our growing reputation in research and development and our approach to education and training will continue to incorporate new ideas, technologies and greater efficiencies in the services we provide Page 13 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our goals 1. Improving patient journeys (system focus, integration) We will: • Write a strategic plan for integrated ‘front door; services to address capacity and demand mismatch and enable flow • Secure influence in primary care by establishing the hospital’s role in supporting primary care networks • Promote value-based healthcare, particularly: Introduce ‘advanced decision making’ • Redesign services to provide timely safe care and meet constitutional access trajectories • Deliver priorities relevant to UHS in the first year of the long-term plan including commissioning and long-term changes 2. Delivering value-based health and care We will: • Deliver the Trust financial plan and maximise any national funding • Prepare UHS for the new NHS financial regime • Deliver the Trust Quality Improvement plan to improve safety/experience and outcomes • Build capability for change by embedding quality improvement, innovation and transformation at a leadership level • Deliver the Cost Improvement Plan (CIP) without compromising on quality 3. Supporting health lives (prevention, wellbeing inequalities, outcomes and experience) We will: • Improve staff health and wellbeing • Improve population health, maximising the impact of UHS touch points • Develop an early warning tool to identify any deterioration in quality 4. Building an expert and inclusive workforce (diversity, engagement, leadership) We will: • Close the staffing supply gap in priority groups/services to provide high quality and timely care • Manage overall workforce cost to meet CIP challenge • Measure improvement in staff engagement by increasing participation in staff survey • Increase representation of diverse groups in leadership and decision making • Improve the staff engagement score 5. Being agile in meeting people’s needs (organisational elegance/design/flexibility) We will: • Reset organisational structure as necessary, responding to changes outlined in the NHS long-term plan • Leverage digital capability to support patient empowerment and self-care • Measure staff user satisfaction with the Trust IT systems and use this to support the digital strategy • Be agile in flexing resources, responding to fluctuating demand • Secure strategic influence by establishing UHS role in the transition from STP to ICS 6. Leading edge research, education and innovation (research and outcomes) We will: • Identify the capacity constraints to expand research and plan to address • Identify priority areas without a research base and set strategy • Improve quality and breadth of education and training programme Page 14 OVERVIEW AND PERFORMANCE REPORT The novel coronavirus (COVID-19) will continue to have a significant impact on public health, morbidity and mortality if adequate prevention and control is not in place. The Trust put rapid and robust arrangements in place early on to prepare for the potential surge in COVID-19 patients. As the government now announces the easing of the lockdown restrictions, the COVID-19 challenge continues to unfold and still represents a very significant future risk to the organization. Our response and mitigations will continue to evolve through 2020/21. Further details on our response to the COVID-19 challenge are in included in the Annual Governance Statement on page 73.. Key issues and risks 1. Inability to develop partnerships and redesign services innovatively renders the Trust unable to meet the expectations of the NHS long-term plan, our strategic plan, and sustainable elective and non-elective pathways. UHS continues to actively develop partnerships across the region and work within the Integrated Care System whilst promoting value-based healthcare and delivering priorities relevant to UHS in the first year of the longterm plan. 2. Failure to deliver regulatory requirements results in license breach and loss of local control with an enforced change in leadership, impacting on Goals 1 to 6. UHS continues to monitor progress against NHSI Performance framework at committee and Board level and build capability for change by embedding quality improvement, innovation and transformation at a leadership level. 3. Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme. A robust cost improvement programme is in place, continuously monitored through governance processes with a focus on delivery of the Trust’s financial plan. 4. Reduced access to resources compromises the quality of services. We will implement the Trust Quality Improvement plan to improve safety/ experience and outcomes. 5. Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care. To mitigate this risk, we will continue to develop initiatives to improve staff health and wellbeing with proactive recruitment and retention initiatives in place. Staff engagement is monitored through staff survey and leadership and development training in place. 6. Lack of inclusion and diversity results in the failure to get the best from every individual. UHS has an equality, diversity and inclusion strategy, with established Trust networks and inclusive talent management programmes. Page 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Page 16 OVERVIEW AND PERFORMANCE REPORT Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. Audit andrisk committee Finance and Investment committee Quality Committee People & Organisational Development Committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. Page 17 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The format of the monthly report follows our six strategic goals: • Improve patient journeys • Value-based health and care • Healthy lives • An expert and inclusive workforce • Being agile in meeting people’s needs • Leading edge research, education and innovation The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section has several KPIs that are relevant to the key risk of delivering the national access target. Some of the KPIs are: • Number of attendances • Time to initial assessment • Delayed transfers of care • Non-elective length of stay The Activity and Flow sections have several KPIs that are relevant to the key risk of capacity and occupancy. Some of the KPIs are: • Length of stay • New referrals • Number of attendances • Bed occupancy The Staffing (HR) section has several KPIs that are relevant to the key risk of Staffing. Some of the KPIs are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk Page 18 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against, including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2020/21 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Overview of performance Improving patient journeys 2019/20 was a challenging year in which we made only modest progress against some objectives to ‘Improve Patient Journeys’, and deteriorated in performance against others. • Inpatient length of stay remained stable but didn’t reduce as significantly as we had intended. The percentage of bed days used due to ‘Delayed Transfers of Care’ to other settings increased to nearly twice the national target. This, combined with growth in non-elective admissions (2.8% YTD excluding M12), resulted in occupancy rates which often exceeded our target, and an increase in patients cared for as ‘outliers’ away from their own speciality wards. • Emergency Access Performance (patients spending less than four hours in the emergency department) remained below both the national and local targets, though performance did show modest improvement during the year. There has been a further substantial increase in the volume of emergency department attendances. • The number of ‘elective’ patients waiting for treatment, the percentage of patients waiting within 18 weeks, and also the waiting time for first outpatient appointments, deteriorated significantly during the year. This has, in part, been impacted upon by reduced availability of clinical capacity due to staff concerns about the impact of new pension/tax regulations. There are, however, good indications that service changes are being implemented to increase consultation capacity in an efficient way as we had aimed to. There has been a substantial increase in consultations provided through ‘non-face-to-face’ routes, and a small decrease in the number of more traditional face-to-face consultations. • Urgent GP referrals for suspected cancer seen within two weeks saw a substantial and sustained improvement compared to the previous year, exceeding that target. • Performance against treatment within 62 days measures also demonstrated modest improvement during the year. Significant improvement in cancer performance continues to be required in order for UHS to deliver the national targets for timeliness of treatment. Page 19 OVERVIEW AND PERFORMANCE REPORT Delivering value-based healthcare • Complaints about UHS care have remained low, with the percentage of complaints ‘closed’ within 35 days above target for the first 11 months of 2019/2020. • Pleasingly, the availability of nursing care to our inpatients (expressed as care hours per patient per day) has increased progressively through the year from 8.6 to 8.9. An active overseas nursing recruitment and induction process has supplemented domestic recruitment and training. • The Trust has formed a 50/50 joint venture company with Hampshire Hospitals NHS Foundation Trust called Wessex NHS Procurement Limited (WPL). From 1 December 2019, WPL is providing procurement, supply chain and materials management services to the Trust. The objectives of this innovative partnership include the consolidation of supplies purchases for both Trusts (combined revenue £1.4bn) to leverage better prices from suppliers and increased productivity through the elimination of previously duplicated procurement activity. Supporting healthy lives • There was very good performance on the Hospital Standardised Mortality Ratio. The standard is 100 and we are consistently below this (83 in December, results are reported nationally retrospectively). This measure includes all patients in England with the same condition and compares those who have died with those that have survived. Being below 100 is a strong indicator of good care. • We continue to receive feedback, which is largely positive, through the national ‘Friends and Family’ survey for both our inpatient and maternity care. • The Board monitors a range of quality indicators. Of these, exceeding the target number of patients infected with clostridium difficile by six is of some concern, we are pleased that the number of severe/moderate medication errors has been maintained well below our target level, and following an increase in the number of Serious Incidents Requiring Investigation (SIRI) that were reported to Board in the early part of the year both the number of SIRIs has reduced and the timeliness of investigation has significantly improved. • Staff sickness levels were on target through the summer months, but significantly in excess of this through the winter months. As a whole, this is a cause for some concern. Building an expert and inclusive workforce • Very pleasingly, nursing vacancies were reduced significantly during the year, from 18% to 15%. Though still a challenge, this supports increases in the treatment capacity we can make available in the Trust, in our ability to open additional bed capacity to reduce our inpatient occupancy rates, and increases the care hours provided per patient per day. • Turnover rates have been in excess of our target throughout the year and there has also been a reduction in the percentage of staff who would recommend UHS as a place to work, though we remain above our target of 76%. The percentage of non-medical appraisals taking place within 12 months remains below target and is declining. • We have made steady progress this year towards our target of 15% of staff at Band 7 and above being from Black and Minority Ethnic backgrounds by 2023 (above 9% in March 2020). Being agile in meeting people’s needs • 2019/2020 has seen further progress in the implementation of digital tools that enable patients and clinicians to review and discuss patient specific clinical information in new ways, for example, large increases in usage of ‘My Medical Record’ and ‘digi-rounds’, modest further progress in electronic requesting and acknowledgement of tests, and stable usage of other tools. Page 20 OVERVIEW AND PERFORMANCE REPORT Leading edge research, education and innovation • The majority of recruitment targets have been achieved during 2019/20. • In Q4 UHS ranked 13th for contract commercial study recruitment, which is the same position achieved in the previous year and thus did not achieve our target of Top 10, with a constraint on pharmacy research capacity being a contributing factor. • The proportion of commercial studies closing in the 2019/20 financial year on time and to recruitment target ended the year below the 80% target at 68%, though the year-end target for the proportion of non-commercial studies closing on time and to recruitment target was exceeded at 88% compared to 80% target. Details of UHS performance can be found in the Integrated Performance report which is available in the Trust Board papers section of our website www.uhs.nhs.uk. UHS performance is scrutinised by the Board on a monthly basis. Paula Head, chief executive officer 22 June 2020 Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2019/20 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2020. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. The Trust was on track to deliver a use of resources score of ‘2’. However, as a direct result of COVID-19 our staff were unable to take their full complement of annual leave. The Trust was required Page 21 OVERVIEW AND PERFORMANCE REPORT to allow for this additional cost, which was an unfunded cost pressure allowable by NHS Improvement. This had the impact of moving the distance from financial plan score to a ‘4’ and subsequently the overall use of resources score to a ‘3’. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 Year 3 3 2 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 4 4 1 1 1 1 1 2 1 2 3 3 Care Quality Commission ratings: Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. All sites and services across the organisation are now rated as ‘good’ in the effective and caring domains, with Southampton General Hospital rated as ‘outstanding’ in these areas. The Well-Led section of this report provides further details of the inspectors’ findings. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Page 22 OVERVIEW AND PERFORMANCE REPORT Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital, we undertake a wide range of activities and use a large amount of resources. We are committed to environmental sustainability and consider it as part of the business culture. We continue to invest in energy saving initiatives and staff awareness campaigns that focus on promoting sustainability. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on pages 86 and 95 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter-fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors, and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud, and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the Foundation Trust. No political donations have been made. The Trust has no overseas branches. Page 23 OVERVIEW AND PERFORMANCE REPORT Page 24 ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Biography Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, in hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. David joined the Trust in February 2016 and served as interim chief executive officer from April to September 2018. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Declarations Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint-venture company owned 50/50 by UHSFT and Prime plc; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel; Director of Wessex NHS Procurement Limited (WPL), a joint venture company owned 50/50 by UHSFT and Hampshire Hospitals NHS Foundation Trust (from December 2019) Husband is a consultant surgeon at UHS; Daughter is a midwife at UHS (from March 2019) Dr Derek Sandeman Joe Teape Medical director Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional Director of UHS Pharmacy Limited, endocrine service. Throughout his career he has had a wholly-owned subsidiary of extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Joe joined the Trust as chief operating officer in December Nil 2019. Previously he was deputy chief executive and director of operations of a large health board in Wales which managed integrated services across three counties including four district general hospitals as well as mental health, learning disability and community services. Prior to this, Joe worked in director roles across finance and strategy within provider acute trusts across the south west of England. Joe is passionate about providing leadership and support for all staff, whatever their profession, and contributing to excellent patient care. He is committed to open and ongoing engagement with the general public and often uses social media to engage with colleagues and with those who have an interest in healthcare. Page 25 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Dr Tim Peachey Non-executive director David Bennett Non-executive director Biography Declarations Peter graduated in chemistry from Hertford College, Chair of CLIC Sargent Cancer Care Oxford. Joining Imperial Chemical Industries in 1973, for Children (a company limited by he undertook a series of increasingly senior roles in guarantee) (until December 2019); marketing and then general management. Following Council member of University of three years in the Netherlands as general manager of Southampton ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non- executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non- executive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Tim qualified as a doctor from Kings College Hospital Director, TP Medcon Ltd; Clinical School of Medicine in 1983. For nearly 20 years, he Safety Officer, Block Solutions Ltd; worked as a consultant anaesthetist at the Royal Free Non-executive director and Quality Hospital in London, specialising in pancreatic cancer Committee chair, Isle of Wight NHS surgery, liver surgery and liver transplantation. He also Trust developed an interest in medical leadership and management and has held positions such as clinical director, divisional director and medical director at the Royal Free. In 2012, Tim moved into full-time management as chief executive of Barnet and Chase Farm Hospitals NHS Trust until its acquisition by the Royal Free. He then worked as the London associate medical director at the NHS Trust Development Authority before moving to Barts Health NHS Trust as improvement director and subsequently became deputy chief executive. Tim now holds two NHS non-executive posts. In addition to his role at University Hospital Southampton, Tim also serves on the board for Isle of Wight NHS Trust as deputy chair. He is a practicing mediator specialising in the healthcare sector. He also consults for companies in the medical information technology industry. Dave graduated in chemistry from the University of Director, Davox Consulting Limited; Southampton before entering management consulting, Non-executive director, Faculty of becoming a partner in Accenture’s strategy practice. Leadership and Medical In 2003 he joined Exel Logistics (later bought by DHL), Management (from November managing the company’s healthcare business across 2019); Director Royal College of Europe and the Middle East. During this time, he General Practitioners (RCGP) established NHS Supply Chain, a UK organisation Enterprises Ltd and RGCP responsible for procuring and delivering medical Conferences Ltd (from November consumables for the NHS in England, as well as sourcing 2019) capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016. He chaired the Trust’s quality committee. Page 26 ACCOUNTABILITY REPORT Board member Name Title Jenni DouglasTodd Senior independent director/deputy chair (from 01/02/2020) Biography Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two and a half years as a resident twinning adviser for the UK, based in Turkey to help set up a law enforcement complaints system before taking up the role of chief executive of the county’s police authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. Declarations Independent chair, Dorset Integrated Care System. Managing director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Nonexecutive director, Hampshire Cricket Board; Trustee, NACRO; Member of English Cricket Board’s Regulatory Committee. Professor Non-executive Cyrus director Cooper In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the General Dental Council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He’s also vicedean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. Director and professor of rheumatology, Medical Research Council (MRC) Lifecourse Epidemiology Unit; Vice-D
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-and-quality-account-2019-202.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2020/21. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Over 50% of UHS services are paid for by CCGs and approximately 48% by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The 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 Opthalmology Theatres and Anaesthetics Division B Division C Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/2021 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these describes a number ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research and innovation in Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century, including an estates masterplan. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, added to the risks facing the Trust. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these from page 167 of the quality report. The board of directors also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance against this measure is now 12% worse than one year ago, at 66%. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.pdf

UHS AR 22-23-6

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

Annual report 2021-2022

Description: 2021/22 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2021/22 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2022 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 36 Directors’ report 37 Remuneration report 59 Staff report 72 Annual governance statement 94 Quality report 105 Statement on quality from the chief executive 106 Priorities for improvement and statements of assurance from the board 109 Other information 182 Annual accounts 210 Statement from the chief financial officer 211 Auditor’s report 212 Auditor’s report including audit certificate 218 Foreword to the accounts 220 Statement of Comprehensive Income 221 Statement of Financial Position 222 Statement of Changes in Taxpayers’ Equity 223 Statement of Cash Flows 224 Notes to the accounts 225 5 Welcome from our chair and chief executive As we emerged from the most severe phase of the COVID-19 pandemic, 2021/22 was another challenging year for everyone at University Hospital Southampton NHS Foundation Trust (UHS). It was also a year on which we can look back with pride at what we achieved together in unprecedented circumstances. Amongst many notable achievements over the past twelve months, we have: • Led on globally ground-breaking research trials to inform the country’s COVID-19 vaccine booster strategy, including the world’s first COVID-19 vaccine booster study of mixed schedules. • Successfully managed infection prevention and control, putting us amongst the best in the country for minimising nosocomial spread. This was against a backdrop of, at times, R-rates in our local community that were amongst the highest in the country. • Published new strategies for digital and sustainability, which respectively set out how we are revolutionising our technical capability to meet changing patient needs and responding to the growing threat posed by climate change as part of the NHS-wide commitment to reaching carbon net zero by 2045. The pandemic also highlighted the vital importance of our staff’s wellbeing so we could continue to meet the needs of the most vulnerable and sick within our community and beyond. In response, we launched and have sustained a comprehensive programme of support to help our staff recognise and address the physical and emotional burden of the last two years. In financial terms, the Trust achieved its forecast breakeven position in 2021/22 on a turnover of £1.15 billion. Our strong, long-term financial performance meant we could continue investing in the capacity and condition of our estate. During the last year we have welcomed patients into our new ophthalmology outpatients area, expanded the majors area of our emergency department, built Hamwic House for treating cancer patients and opened four new operating theatres. Our ambition remains to increase capacity and improve facilities so that we can meet rising demand for our services, treating more people in improved settings than ever before. The momentum we are building is informed and driven by our five-year strategic plan, which describes our collective ambitions on our journey to becoming a world-class organisation. Our successes over the last twelve months were set against a backdrop of exceptional pressure on our services, unlike anything we have seen before. Like most hospital trusts, the lifting of COVID-19 restrictions in the wider community saw significant increases in attendances at our emergency department and increased referrals for treatments including surgery and cancer care. Everyone at UHS is working hard to restore services and bring waiting times down, although there are headwinds impacting our elective recovery. As we write this report, we have more than 200 patients in the hospital who no longer need our care but are waiting for discharge, either to a care home or to their own home with domiciliary care packages. Like many sectors, our local authority partners are struggling to buy or directly provide the capacity that is needed due primarily to workforce shortages. On occasion, the number of patients stranded in our hospitals means we have had to cancel scheduled surgery patients due to a lack of beds. Despite this, we are making good progress on recovering our elective performance, for example the number of elective surgery procedures in May 2022 was over 8% higher than in May 2019, prior to the COVID-19 pandemic. 6 Looking back over the year, our achievements would not have been possible without every single one of our 13,000 staff, who have gone above and beyond to put patients first. As a Trust Board we recognise that our people are our greatest asset. The results of this year’s NHS annual staff survey are encouraging, with the percentage of staff recommending UHS as a place to work being the sixth highest across all NHS trusts in England. However, we know we can do even better and our new people strategy will help us achieve this by introducing programmes which enable our people to thrive, excel and belong in a diverse and inclusive environment. We ended the year by saying farewell to Peter Hollins, who completed his second and final term as chair on 31 March 2022. In the six years of his leadership, the Trust has undergone a huge transformation to the benefit of both patients and staff. Peter has been a trusted and respected colleague whose outstanding leadership has set UHS on course to be a world-class organisation with world-class people delivering worldclass care. We welcome the formation of the Hampshire and Isle of Wight integrated care system on 1 July 2022, which will facilitate increased integration and collaboration across health and social care partners. We look forward to continuing strong relationships with all our partners as we work to develop an NHS of which all the communities we serve can be proud. Jane Bailey Interim Chair June 2022 David French Chief Executive Officer June 2022 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive 2021/22 is the second year that the ways in which the Trust has worked, and the performance it has achieved, have been strongly influenced the COVID-19 pandemic. Our circumstances varied significantly through the year, however, by March 2022: • COVID-19 related restrictions had been removed across the wider community, but remained necessary within healthcare settings; • a combination of partial immunity and improved treatments had reduced the numbers of patients experiencing the most severe symptoms of COVID-19, but the total numbers of people being infected remained very high; and • the numbers of patients attending, or being referred to, healthcare services for other conditions had returned to pre-pandemic levels or higher. Our challenges and priorities have varied through the year in a similar manner, and have included: • providing sufficient urgent care capacity for patients with COVID-19 alongside those with other illnesses or injuries; • running our services with significantly increased levels of COVID-19 related absence amongst our staff, as infection rates have increased in the wider community; and • increasing the numbers of elective treatments provided, back to pre-pandemic levels and higher, to start to reduce patient waiting times and reverse the increases in waiting list sizes caused by COVID-19. Our performance this year has often been impacted by the adversity of the circumstances. We have not always been able to achieve the targets established prior to the pandemic, nor to deliver the standard of service that we would aspire to for our patients. The Trust is proud to have performed well in comparison to other hospital trusts across many performance measures, however, I would like to thank our patients for their understanding and patience, and all our staff for their resilience, commitment and dedication to care for patients and their colleagues. As we begin to emerge from the pandemic, and consider the year ahead, we look forward to working with patients, hospital colleagues, and partners across health and social care to: • continue the recovery from the impacts of the COVID-19 pandemic; • improve our performance against key measures, continuing to perform well in comparison with other hospitals and moving closer to the national targets; and • continue to adapt and improve services such that the outcomes and results achieved for patients will be better than ever before. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2021/22. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volumes as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The NHS patient services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Just under half of the Trust’s NHS patient services are paid for by CCGs and just over half are paid for by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology 11 Trust Headquarters Division Always Improving Central Operations Clinical Outcomes Commercial Development Communications Contracting Corporate Affairs Data and Analytics Education and Workforce Estates, Facilities and Capital Development Finance Health and Safety Human Resources Informatics Medical Examinerss Service Occupational Health Organisational Development Quality Patient Safety Planning and Productivity Procurement and Supply Research and Development Safeguarding Strategy and Partnerships The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2021/22 these objectives included: • Recovery restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Implementing the ‘Always Improving’ strategy • Delivering the first year of the research and investment plan • Restoring a full research portfolio and preparing for future growth • Delivering joint research and innovation infrastructure with UoS and Wessex partners • Increasing our people capacity (recruitment, retention, education) • Great place to work including focus on wellbeing • Building an inclusive and compassionate culture • Working in partnership with the integrated care system and primary care networks • Integrated networks and collaboration • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2021/22 were that: • It would have insufficient capacity to respond to emergency demand, reduce waiting lists for planned activity and provide diagnostics results in avoidable harm to patients • It would not be able to provide service users with a safe, high quality experience of care and positive patient outcomes • It would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection • It would not secure the required ongoing investment to support our pioneering research and innovation, driving clinical services of the future 14 • It would not realise the full benefits of being a University teaching hospital through working with regional partners to accelerate research, innovation and adoption; increasing the number of studies initiated and the patients recruited to participate in these studies and the delivery of new treatments and treatments that would not otherwise be available to patients • It would not be able to increase the UHS workforce to meet current and planned service requirements through recruitment to vacancies and maintaining annual staff turnover below 12% and develop a longerterm workforce plan linked to the delivery of the Trust’s corporate strategy • It would not develop a diverse, compassionate and inclusive workforce, providing a more positive staff experience for all staff • It would not create a sustainable and innovative education and development response to meet the current and future workforce needs • It would not implement effective models to deliver integrated and networked care, resulting in suboptimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • It would be unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (CDEL). • It would not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. • It would fail to introduce and implement new technology and expand the use of existing technology to transform our delivery of care through the funding and delivery of the digital strategy. • It would fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, have added to the risks facing the Trust. This risk has continued into 2021/22 and has been coupled with increases in referrals for cancer and increased attendances to our emergency department and non-elective activity. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52, 78 and 104 weeks has increased significantly. While there was a significant reduction in the number of patients waiting over 104 weeks in 2021/22, with the Trust expecting that no patients will be waiting more than 104 weeks by July 2022, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by future waves of the COVID-19, a continuation of the sustained demand for urgent non-elective activity and an ongoing number of referrals, often requiring more complex treatment due to delays in people visiting their GPs for the first time and presenting with more advanced disease. The Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk and continues to make use of independent capacity for cardiac surgery. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2021/22 (described in the Estates section below), the Trust also committed expenditure in 2021/22 to open further wards and operating theatres during 2022/23 and 2023/24. These initiatives will contribute to further improvements in elective waiting times in coming years. 15 Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2021/22. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of an award-winning COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). While the Trust continued to perform well overall, the Trust exceeded its annual threshold for Clostridium difficile infections and there was one MRSA bacteraemia during March 2022, the only such event in 2021/22. The Trust continued to develop its proactive patient safety culture during 2021/22 with changes to the way in which patient safety incidents are investigated and the launch of its Always Improving strategy and transformation initiatives in theatre efficiency, patient flow and outpatients. Reporting and investigation of incidents continued during 2021/22. The Trust continues to prepare for the implementation of the new patient safety incident response framework in June 2022/23. Partnerships – During 2021/22, the Trust and its partners continued to work together to discharge patients safely, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop the regional COVID-19 saliva testing programme for local schools, hospitals and other employers. The new arrangements for integrated care systems will be implemented in July 2022. This is expected to reinvigorate work with partners at a system, place and provider level in Hampshire and Isle of Wight. The Trust is already part of an acute provider collaborative with other acute trusts in Hampshire and the Isle of Wight and is progressing a number of projects including the development of an elective hub at Winchester Hospital, diagnostics, pathology, endoscopy and imaging networks. The Trust also continued to progress research activity and opportunities with the University of Southampton and Wessex health partners. Workforce – The Trust continued to recruit nurses from overseas and through targeted recruitment campaigns during 2021/22 meaning that the number of nursing vacancies has remained relatively stable. Vacancies in other areas have increased reflecting a more competitive job market, particularly for lower band roles. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. Staff turnover remained above the 12% target during 2021/22 and retention is a key element of the people strategy. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2021/22 we have also focused on supporting our staff to respond to the COVID-19 pandemic and operational pressures by providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2021/22 including opening a new ophthalmology outpatient area, expansion of the majors area of the emergency department and four new operating theatres. These were part of £65 million of capital expenditure in 2021/22 that also included equipment, digital and the backlog maintenance programme. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these in part three of the quality account. The board of directors has also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. 16 The Trust and its partners also been successful in securing external funding including one of only four successful NHSX awards to test the concept of federated trusted research environments with its Wessex health partners and core funding of £10.5 million for the National Institute for Health and Care Research (NIHR) Southampton Clinical Research Facility (CRF) for the period between September 2022 and August 2027. Sustainable financial model –The Trust achieved its forecast breakeven position in 2021/22. Income was more predictable in 2021/22 as block contract arrangements remained in place in response to the COVID-19 pandemic and ensured that costs were covered, however, funding from the elective recovery fund, particularly, in the first half of 2021/22 introduced a degree of income volatility as did changes to the framework for the elective recovery fund half way through the year. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. The financial outlook across the NHS looks extremely challenging going into 2022/23 due to the reductions in non-recurrent funding and efficiency targets. The Trust currently has an underlying deficit, with pressures on energy prices and drugs cost growth within block contract arrangements, which had been supported with non-recurrent funding in previous years. While specific funding has been provided to address inflationary pressures there is a risk that inflation could exceed this funding and raw material and supply shortages could also impact on costs. Performance overview The Trust monitors a very wide range of key performance indicators within its departments, divisions, directorates and executive committee. Assurance for our board of directors and executive committee includes an integrated performance report which is reviewed monthly and contains a variety of indicators intended to provide assurance regarding implementation of our strategy and that the care we provide is safe, caring, effective, responsive and wellled. The integrated performance report also includes a monthly ‘spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, any performance concerns and requests from the board of directors. Assurance for our council of governors includes a quarterly Chief executive’s performance report, which includes a range of non-financial and financial performance information. 17 Performance analysis COVID-19 Impacts In 2021/22, the most prominent impacts of COVID-19 have been in relation to occupancy of inpatient beds by patients with a COVID-19 diagnosis and increased levels of staff sickness absence associated with COVID-19, in addition to normal levels of absence due to other causes. The impact of COVID-19 has varied significantly through the year, linked primarily to the prevalence of the disease within the wider community. In comparison to 2020/21: • bed occupancy (all types) did not reach the same exceptional peaks, however, it exceeded 50 patients between August 2021 and March 2022 and reached an average of 83 in March 2022; • the number of patients requiring treatment in intensive care and high care were much reduced, though still significant; • fewer patients were admitted requiring hospital treatment for COVID-19 alone, and greater numbers were admitted requiring treatment for other medical conditions who were also infected with COVID-19 at the same time; • staff sickness absence levels were typically higher, particularly in the second half of the year when national restrictions had been removed and COVID-19 infections in the community increased – the sickness absence rate (from all causes) peaked at 6% in March 2022 All bed types Intensive care/higher care beds 18 Staff sickness absence Emergency access through our emergency department Following a reduction during the first year of the pandemic, the numbers of patients who presented to receive care at our emergency department increased exponentially in 2021/22. Attendance levels exceeded the higher levels seen prior to the pandemic by approximately 10%. All patients presenting to the emergency department This exceptional increase in the clinical demand upon our department has had a significant adverse impact upon the timeliness of care, particularly for those patients who have a less urgent condition. The department has also continued to deliver services separately for those patients who have respiratory symptoms and those who do not, and to implement additional infection control measures. Emergency access performance is measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department. The national target of 95% was not achieved and the Trust experienced a large deterioration in our own performance to 64% (main ED/Type 1 attendances) by March 2022. Our performance compared favourably with other acute trusts in England despite this, however. 19 Emergency access four hour performance The number and duration of any ambulance handover delays are another important performance indicator. Ensuring that ambulance staff can ‘hand over’ the patients they convey to our emergency department without delay is important because this releases the staff and their vehicle to meet the needs of other medical emergencies in the community. We are very proud to have an exceptionally good record in this regard, working with colleagues in ambulance services to transfer arriving patients into our emergency department and the care of our staff even when the hospital is already fully occupied. 20 Elective Waiting times Demand 2021/22 has seen a continuation of the trend of increasing elective referrals, following a major reduction which occurred at the start of the COVID-19 pandemic. Referral rates to our services are now typically at, or above, the levels seen before the pandemic. Feedback from clinicians is that they are also seeing more patients with advanced disease than they would normally, because of delays in referral to the service/diagnosis. Accepted referrals The number of patients referred to hospital with suspected cancer increased exceptionally during 2021/22; the number of patients seen for a first consultant-led appointment was 27% higher than in 2020/21 and 18% higher than in 2019/20. Performance remained below the national target of 93% throughout the year, with a deterioration to 74% in December 2021 prior to a recovery to 90% in March 2022. Our performance also declined in comparison with other acute trusts in England. Most of the patients who waited longer than two weeks for their first appointment were within our breast service, which sees a very large number of referrals for suspected cancer and experienced a 22% increase in the number of patients seen compared to 2019/20. Additional consultants who specialise in breast cancer have now been recruited and performance in this service returned to target in April 2022. 21 Performance following ‘Two week wait’ urgent referral for suspected cancer 22 Activity The number of UHS hospital appointments, diagnostic tests and elective admissions all increased significantly during 2021/22. The number of appointments undertaken, and diagnostic tests performed, exceeded activity levels in both 2019/20 and 2020/21. The number of elective and day case admissions increased significantly compared to 2020/21 (the first year of the pandemic) yet remained approximately 10% below the levels achieved between April 2019 and February 2020 (prior to COVID-19). There were a wide range of factors influencing these activity levels, and the lower levels of admitted activity specifically, including: • the availability of beds for the admission of elective patients after emergency patients with COVID-19 and other conditions had been accommodated; • the availability of staff to deliver elective care, during periods of increased COVID-19 bed occupancy, and during periods of increased staff absence related to COVID-19; • additional infection prevention measures which were maintained, particularly within inpatient treatment settings where risks of COVID-19 transmission are otherwise increased. Most of the activity has been delivered within NHS hospitals in 2021/22 (local independent sector hospitals were used to replace NHS elective capacity in 2020/21), and we have recruited additional staff and invested in an additional ward, theatres and outpatient rooms in order to be able increase our treatment activity. The graphs below show 2021/22 activity levels as a percentage of those achieved prior to the COVID-19 pandemic. Elective admissions (including day case) 23 Outpatient attendances Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. At the end of March 2022, 20% of patients were waiting more than six weeks to receive their investigation. This is a significant improvement compared to 28% of patients waiting more than six weeks at the end of March 2021, yet still significantly worse than the national target (1%) and UHS performance prior to pandemic. At the end of March 2022, the total waiting list size (including patients waiting less than six weeks) had increased by 14% compared to March 2021 and was 34% larger than before the pandemic. These trends reflect a combination of large reductions in diagnostic activity in the first year of the pandemic, followed by record levels of diagnostic tests being performed during 2021/22 (7% higher than before the pandemic) combined with very high levels of referrals for diagnostic testing over the same period. 24 The tests with largest numbers of longer waiting patients are non-obstetric ultrasound, peripheral neurophysiology, MRI and CT. Initiatives to improve performance include the recruitment of additional staff in the relevant professions and investment in additional equipment, in the context of NHS forecasts that diagnostic demand will continue to increase over the longer term. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 25 Referral to Treatment Our waiting list from referral to treatment increased in size by 27% (9,768 patients) during 2021/22 and is now 36% larger than before the pandemic. Both referrals and hospital activity declined steeply at the start of the pandemic, but referral levels increased more quickly than hospital activity following this. The rate at which the waiting list is increasing has however reduced in the most recent six months. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance has deteriorated from 80% immediately before the pandemic, to 68% at the end of March 2022. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with, and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 26 The fact that some patients wait significantly longer than the 18 week target is a particular concern. In 2020/21 NHS England targeted the stabilisation of the numbers of patients waiting more than 52 weeks and the elimination of waiting times more than 104 weeks (except when patients choose to wait longer). The percentage of patients waiting more than 52 weeks at UHS reduced from 9% to 4%. The number of patients waiting more than 104 weeks reduced, from a maximum of 171, to 59 at the end of March 2022 (of whom only five were wishing to proceed with treatment at that time). The patients who typically wait longest for treatment continue to be those who require admission for surgical procedures in specialities such as ear nose and throat, orthopaedics and oral surgery. The Trust opened four additional operating theatres during 2020/21 and is working in collaboration with partners in the Hampshire and Isle of Wight integrated care system to implement further elective recovery plans. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 27 Cancer Waiting Times The timeliness of urgent services for patients with suspected cancer has unfortunately declined during 2021/22. The Trust continues to perform well in comparison with the teaching hospitals that we benchmark with and deliver a similar range of services, however. We have faced a range of challenges including: • a large increase in the number of new patients referred for investigation; • delays in the onward referral (for specialist investigation or treatment) of patients from other trusts which have also experienced increases in referrals; • the need to provide capacity to investigate and treat the full range of other conditions, alongside those patients with suspected cancer; and • an increase in the complexity of treatment required by new and existing patients, potentially because of delays in referral or treatment during the first year of the pandemic The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. UHS exceeded this level of performance in April 2021 but has not done so since then, performance deteriorated to 66% in January 2022 before recovering somewhat to 72% by March 2022. Treatment for Cancer within 62 days of an urgent GP referral to hospital The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients. Trust performance has been very variable in 2021/22, ranging from 89% to 98% in individual months. Likewise, performance has ranged from below average in some months, to amongst the best in the group of teaching hospitals that we benchmark with. 28 First definitive treatment for cancer within 31 days of a decision to treat A range of initiatives are being pursued to maintain and improve the timeliness of our cancer services including: • changes to some of the processes for the referral and initial assessment of patients with suspected cancer, for example the inclusion of high quality photographs within referrals for suspected skin cancer; • projects to refine processes and procedures for the investigation of suspected gynaecological and urological cancers; • an operating services improvement programme designed to improve the flow of patients, and the numbers of patients treated, through our existing theatre facilities; and • staffing level increases and recruitment to clinical roles in specialities where the increases in demand require this. Quality priorities The Trust set four quality priorities in 2021/22, which were aimed at ensuring we continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the second year of the COVID-19 pandemic, by limiting the number of priorities to four. We also acknowledged the risk that the delivery of our priorities could be disrupted by the ongoing pandemic and that we needed to be flexible in adapting the priorities to changing circumstances. The Trust set the following four priorities: 1. Introduction of midwifery continuity of carer for women at risk of complications in pregnancy. 2. To support staff wellbeing and recovery. 3. Managing risks to patients delayed for treatment and restoring elective programmes. 4. Reducing healthcare associated infection (HCAI) 29 The Trust achieved three of the quality priorities and partially achieved one priority. In relation to midwifery continuity of carer, the Trust’s performance exceeded the ambition that had been set by NHS England in 2020/21 following its national review of maternity services in 2015 as shown below. NHS England ambition set in 2020/21 35% of women will be booked to receive care in a continuity of carer team 35% of black and minority ethnic women booked to receive care in a continuity of carer team 35% of women living in an IMD-1 area (most deprived areas measured using indices of deprivation) Percentage achieved 41.7% 75% 80% The Trust continued to introduce programmes, interventions and wider support offerings to promote staff wellbeing and recovery in 2021/22. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. More information about staff health and wellbeing is included in the staff report below. The Trust only partially achieved the priority relating to managing the risks to patients delayed for treatment and restoring elective programmes. The Trust’s performance against elective waiting time standards are described in more detail above. While the Trust focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency, we continue to recognise the impact of delays on people’s quality of life and, at times, outcomes. COVID-19 remained a key area of focus for the Trust in 2021/22 in terms of infection prevention. The Trust implemented a number of awareness campaigns, including its award-winning COVID ZERO campaign, and strategies to reduce in-hospital transmission of COVID-19 and kept these under review throughout the year. The chart below shows the trend of hospital-onset cases of COVID-19, which has broadly followed local and national prevalence of the virus, and the Trust’s performance compared very favourably with its local and national peers. 30 The table below provides an overview of the Trust’s performance against national and other infection prevention standards and limits to minimise infections, the majority of which have been achieved by the Trust. Category National Objectives: MRSA bacteraemia Clostridium difficile infection E coli Bacteraemia End of year RAG Action /Comment R One MRSA bloodstream infection attributable to UHS 2021/22 in March 2022. R 74 cases against a threshold of 64 for the year. G 138 cases in 2021/22 against a threshold of 151. Klebsiella Bacteraemia A 64 cases in 2021/22 against a threshold of 64. Pseudomonas Bacteraemia MSSA G 30 cases in 2021/22 against a threshold of 34. 43 cases in 2021/22 after 48 hours in hospital. Other: Hospital onset, healthcare associated COVID-19 103 hospital-onset probable healthcareassociated cases in 2021/22. 125 hospital onset definite healthcare associated cases in 2021/22. Prudent antibiotic Antimicrobial prescribing Stewardship G The standard contract requirement for reduction in antibiotic usage for 2021/22 was waived, as in 2020/21. Had it been applied as anticipated, the Trust would very likely have met this. Provide Assurance of Infection G The annual infection prevention audit assurance of Prevention Practice programme was reinstated in April 2021 for basic infection Standards the monitoring and assurance of infection prevention prevention and control practices but practice: subsequently suspended in September 2021. You can find more information about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2022/23, in the Trust’s quality account for 2021/22, incorporated in the Trust’s annual report and accounts. 31 Financial performance The Trust delivered a surplus of £0.048 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England and NHS Improvement, su
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/Annual-report-2021-2022.pdf

Having a total hip replacement - patient information

Description: This leaflet contains important information about having a total hip replacement.
Url: /Media/UHS-website-2019/Patientinformation/Muscles,jointsandbones/Having-a-total-hip-replacement-4038-PIL.pdf

Headache - patient information

Description: Patient information factsheet Headache More than 10 million people in the UK get headaches regularly,
Url: /Media/UHS-website-2019/Patientinformation/Generalmedicine/Headache-1361-PIL.pdf

Papers Trust Board - 13 January 2026

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 13/01/2026 9:00 - 13:00 Conference Room, Heartbeat Education Centre Jenni Douglas-Todd Diana Eccles 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 11 November 2025 9:15 Approve the minutes of the previous meeting held on 11 November 2025 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Finance, Investment & Cash Committee 9:20 David Liverseidge, Chair 5.2 Briefing from the Chair of the People and Organisational Development 9:30 Committee Jane Harwood, Chair 5.3 Briefing from the Chair of the Quality Committee 9:40 including Maternity and Neonatal Safety 2025-26 Quarter 2 Report Tim Peachey, Chair 5.4 Chief Executive Officer's Report 9:50 Receive and note the report Sponsor: David French, Chief Executive Officer 5.5 Performance KPI Report for Month 8 10:20 Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer 5.6 11:00 5.7 11:15 5.8 11:25 5.9 11:30 5.10 11:45 5.11 11:55 5.12 12:05 5.13 12:15 6 6.1 12:25 7 12:35 8 Break Finance Report for Month 8 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer ICB System Report for Month 8 Receive and discuss the report Sponsor: Ian Howard, Chief Financial Officer People Report for Month 8 Review and discuss the report Sponsor: Steve Harris, Chief People Officer Learning from Deaths 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience Infection Prevention and Control 2025-26 Quarter 2 Report Review and discuss the report Sponsor: Natasha Watts, Acting Chief Nursing Officer Attendees: Julian Sutton, Clinical Lead, Department of Infection/Julie Brooks, Deputy Director of Infection Prevention and Control Medicines Management Annual Report 2024-25 Receive and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: James Allen, Chief Pharmacist Annual Ward Staffing Nursing Establishment Review 2025 Discuss and approve the review Sponsor: Natasha Watts, Acting Chief Nursing Officer CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Review and discuss the report Sponsor: Andy Hyett, Chief Operating Officer Attendee: John Mcgonigle, Emergency Planning & Resilience Manager Any other business Raise any relevant or urgent matters that are not on the agenda Note the date of the next meeting: 10 March 2026 Page 2 9 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 10 Follow-up discussion with governors 12:45 Page 3 Agenda links to the Board Assurance Framework (BAF) 13 January 2026 – Open Session Overview of the BAF Risk 1a: Lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. 1b: Due to the current challenges, we fail to provide patients and their families / carers with a high-quality experience of care and positive patient outcomes. 1c: We do not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. 2a: We do not take full advantage of our position as a leading University teaching hospital with a growing, reputable, and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for our patients. 3a: We are unable to meet current and planned service requirements due to the unavailability of staff to fulfil key roles. 3b: We fail to develop a diverse, compassionate, and inclusive workforce, providing a more positive staff experience for all staff. 3c: We fail to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. 4a: We do not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. 5a: We are unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme, NHS England imposing additional controls/undertakings, and a reducing cash balance impacting the Trust’s ability to invest in line with its capital plan, estates/digital strategies, and in transformation initiatives. 5b: We do not adequately maintain, improve and develop our estate to deliver our clinical services and increase capacity. 5c: Our digital technology or infrastructure fails to the extent that it impacts our ability to deliver care effectively and safely within the organisation, 5d: We fail to prioritise green initiatives to deliver a trajectory that will reduce our direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. Agenda links to the BAF No Item Linked BAF risk(s) 5.5 Performance KPI Report for Month 8 5.7 Finance Report for Month 8 5.8 ICB System Report for Month 8 5.9 People Report for Month 8 5.10 Learning from Deaths 2025-26 Quarter 2 Report 5.11 Infection Prevention and Control 2025-26 Quarter 2 Report 5.12 Medicines Management Annual Report 2024-25 5.13 Annual Ward Staffing Nursing Establishment Review 2025 6.1 Annual Assurance for the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 1a, 1b, 1c 5a 5a 3a, 3b, 3c 1b 1c 1b 1b, 3a 1b Appetite (Category) Minimal (Safety) Current risk rating 4x5 20 Cautious (Experience) Minimal (Safety) 4x4 16 4x4 16 Open (Technology & Innovation) 3x4 12 Open (workforce) Open (workforce) Open (workforce) 4x5 20 4x3 12 4x4 16 Cautious (Effectiveness) 3x3 9 Cautious (Finance) 5x5 25 Target risk rating 4 x 2 Apr 6 27 3 x 2 Apr 6 27 2 x 3 Apr 6 27 3 x 2 Mar 6 27 4 x 3 Mar 12 30 4 x 2 Mar 8 30 3 x 2 Mar 6 29 3 x 2 Dec 6 25 3 x 3 Apr 9 30 Cautious (Effectiveness) Open (Technology & Innovation) Open (Technology & Innovation) 4x5 20 3x4 12 2x4 8 4 x 2 Apr 8 30 3 x 2 Apr 6 27 2 x 2 Dec 4 27 Does this item facilitate movement towards or away from the intended target risk score and appetite? Towards Away Neither x x x x x x x x x Minutes Trust Board – Open Session Date 11/11/2025 Time 9:00 – 13:00 Location Conference Room, Heartbeat Education Centre Chair Jenni Douglas-Todd (JD-T) Present Diana Eccles, NED (DE) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Andy Hyett, Chief Operating Officer (AH) David Liverseidge, NED (DL) Tim Peachey, NED (TP) Alison Tattersall, NED (AT) Natasha Watts, Acting Chief Nursing Officer (NW) In attendance Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.2) Martin de Sousa, Director of Strategy and Partnerships (MdS) (item 6.1) Lucinda Hood, Head of Medical Directorate (LH) (item 5.13) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 5.12) Vickie Purdie, Head of Patient Safety (VP) (item 7.3) Kate Pryde, Clinical Director for Improvement and Clinical Effectiveness (KP) (item 5.13) Scott Spencer, Health and Safety Advisor (SS) (item 7.3) 4 governors (observing) 2 members of staff (observing) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that no apologies had been received. The Chair provided an overview of meetings she had held and events that she had attended since the previous Board meeting. 2. Patient Story Item deferred to the next meeting. 3. Minutes of the Previous Meeting held on 9 September 2025 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 9 September 2025, subject to a minor correction at 5.10. Page 1 4. Matters Arising and Summary of Agreed Actions The matters arising and actions were noted. • Actions 1281, 1283 and 1284 were closed. • Action 1282 was to be addressed through item 5.6 below. • In respect of action 1285, the Quality Committee would monitor progress on complaints response times. 5. QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee Keith Evans was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • In terms of the internal audit reports, which had been received by the committee, whilst there were a number of points for the Trust to address, no areas of significant concern had been identified. • There was a focus on ‘imposter fraud’ whereby individuals who had turned up to carry out a shift were not who they claimed to be. Whilst there had been no reported incidents at the Trust, the Trust had implemented controls at the ward level, which would be subject to testing during 2025/26. 5.2 Briefing from the Chair of the Finance, Investment & Cash Committee David Liverseidge was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • In September 2025, the Trust had reported that it was in line with its Financial Recovery Plan. Of the £110m Cost Improvement Programme (CIP) target, 76% had been fully developed. • The committee had reviewed the Finance Report for Month 6 (item 5.8), noting that the Trust had reported an in-month deficit of £5.4m, which was in line with the Financial Recovery Plan. • The committee had expressed concern that 17% of the CIP target was not fully developed and that the Trust was £2.5m off-track in terms of delivery of the target at Month 6. • Whilst progress had been made in terms of addressing patients with no criteria to reside and mental health patients, this remained an area of concern. • The committee considered the NHS England Medium Term Planning Framework, noting that the first submission by the Trust was due prior to Christmas 2025. 5.3 Briefing from the Chair of the People and Organisational Development Committee Jane Harwood was invited to present the Committee Chair’s Reports in respect of the meetings held on 22 September and 3 November 2025, the contents of which were noted. It was further noted that: • There continued to be little improvement in terms of the number of patients with no criteria to reside or mental health patients, which impacted staffing numbers. • The Trust was adopting a harder line in respect of its approach to violence and aggression, which included a greater willingness to exclude individuals. • The current participation rate in the Staff Survey was lower than the national average, which was likely indicative of staff morale and engagement. Page 2 • The Trust’s workforce numbers remained above plan, with limited options available to address this issue, especially in the absence of funding for restructuring costs. 5.4 Briefing from the Chair of the Quality Committee Tim Peachey was invited to present the Committee Chair’s Report in respect of the meeting held on 13 October 2025, the content of which was noted. It was further noted that: • The committee received an update in respect of mental health patients, noting that although there were significant issues in the Emergency Department, the whole pathway for these patients remained a problem. • The committee carried out a six-monthly review of the Trust’s progress against its Quality Priorities, noting that good progress had been made on four of the six priorities and two were slightly behind. 5.5 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • NHS England had published the Medium Term Planning Framework, which was intended to encourage organisations to think beyond a 12-month time horizon and to progress the NHS 10-Year Plan. The Trust was expected to provide its first submission prior to Christmas 2025, but the detailed planning assumptions had yet to be received from NHS England. It was noted that a more detailed report on the Medium Term Planning Framework was to be received as part of the closed session of the meeting. • The Strategic Commissioning Framework had been published by NHS England, which provided welcome clarifications about the future role of integrated care boards. • The Trust had been placed into Tier 1 for both Urgent and Emergency Care and for Elective performance. There was a national expectation that trusts would have no patients waiting over 65 weeks for elective care by 21 December 2025. Where organisations had more than 100 such patients at the end of October 2025, they had been placed into Tier 1. The Trust was taking steps, including mutual aid, to attempt to address the number of long waiters, but there was insufficient capacity in the system. • Resident doctors were due to strike for a further five-day period commencing on 14 November 2025, having rejected the Government’s latest offer to resolve the ongoing dispute with the British Medical Association. • The Hampshire and Isle of Wight Integrated Care Board and NHS England South East Region had carried out a visit to the Trust’s paediatric hearing services in May 2025. The report, received in October 2025, had been positive about the service. • The Trust and the University of Southampton had been awarded £16.3m by the National Institute for Health and Care Research. The Trust was one of only four organisations out of 15 applications to receive an award. • The NHS Business Services Authority had announced the award of a £1.2bn contract to Infosys to deliver a new and enhanced workforce management system for the NHS to replace the existing Electronic Staff Record system. The 2030 target date for implementation was considered ambitious. Further details would be considered by the People and Organisational Development Committee when available. Page 3 5.6 Performance KPI Report for Month 6 Andy Hyett was invited to present the ‘spotlight’ report in respect of Diagnostics, the content of which was noted. It was further noted that: • Diagnostics performance was a key element of the pathway, as delays in diagnosis had a consequential impact on the overall length of pathways such as those for cancer and patients on a Referral To Treatment pathway. • Although there were some concerns with Diagnostics in the Trust, the Trust, generally, performed better than other organisations. The Board discussed the matters raised in the Diagnostics ‘spotlight’. This discussion is summarised below: • There had been a long-standing issue with waiting times for cystoscopy due to insufficient capacity. However, a plan was being developed to improve the situation, although it was considered appropriate that the plan should also address broader issues with urology as a whole. • There was concern regarding the availability of magnetic resonance imaging (MRI) scanners, particularly as two scanners were out-of-action. It was noted that the current set-up in terms of MRI scanners was not fit for the longer term and a strategy for the future needed to be developed. • There was a disparity between capacity and demand in respect of the neurophysiology service, as this service had previously relied on outsourcing. • Generally, activity was increasing, but overall performance appeared to be declining. There was also the additional financial challenge that Diagnostics was funded under a ‘block’ contract arrangement which did not fully take into account the demand for these services. • There were concerns about the electrical supply capacity at the Southampton General Hospital site and the ability of the Trust to expand its Diagnostic capacity with this limitation. It was considered that a better longer-term model would be for scanners at local community diagnostics centres. Actions Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Andy Hyett agreed to develop a long-term solution to the neurophysiology service. Andy Hyett was invited to present the Performance KPI Report for Month 6, the content of which was noted. It was further noted that: • The Trust’s Emergency Department had recorded performance of 67.6% against the four-hour standard during September 2025. The department remained busy with c.450 patients and 120 ambulance attendances per day. • There had been some initial performance impacts with the roll out of the MIYA system in the Emergency Department, but this appeared to have now been addressed with performance up to previous levels. • A number of initiatives were being introduced into the Emergency Department in order to improve performance. These included the layout of the service, pathway re-designs, having General Practitioners in the department, and arranging with non-urgent patients to attend at a scheduled time rather than waiting in the department. Page 4 • In October 2025, the Trust had recorded 363 patients waiting over 65 weeks on a Referral To Treatment pathway against a national target of no such patients by the end of December 2025. • The Trust was making use of the independent sector, weekend working, and was requesting capacity from other providers to address the number of patients waiting over 65 weeks. • The planned industrial action by resident doctors posed a challenge, noting that the national expectation was that trusts maintain 95% of their capacity during this period. It was noted that, in contrast to previous instances of industrial action, resident doctors were apparently less forthcoming in terms of whether they intended to participate in the industrial action. • The Trust continued to report one of the lowest Hospital Standardised Mortality Rates in England. • The Trust’s cancer performance, based on a BBC article, was 21 out of 121 trusts. It was noted that whilst the number of patients being referred on a cancer pathway had increased significantly, the number of patients diagnosed with cancer had not materially changed. • There appeared to have been an increase in the number of pressure ulcers and ‘red flag’ incidents. Work was ongoing to address the findings of the pressure ulcer audit which had been presented to the Quality Committee on 2 June 2025. • The number of patients having no criteria to reside and mental health patients remained high. Actions Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. 5.7 Break 5.8 Finance Report for Month 6 Ian Howard was invited to present the Finance Report for Month 6, the content of which was noted. It was further noted that: • The Trust had submitted its Financial Recovery Plan to NHS England in August 2025, which committed to an additional £23m improvement in the Trust’s financial position to deliver a full-year position of a £54.9m deficit. In the absence of these additional improvements, the Trust had been forecasting a year-end position of a £78m deficit. The revised target was subject to a number of assumptions, including the need for demand management and improvements in non-criteria to reside and mental health patient numbers. • There were a number of risks to the achievement of the Financial Recovery Plan, including whether there would be improvements in mental health and non-criteria to reside and/or steps taken to manage demand, high levels of activity, and whether it would be possible to reduce the workforce and close theatres. The need for the Trust to focus on achieving the 65-week wait target in particular could impact the Trust’s ability to close capacity. • The Trust had reported an in-month deficit of £5.4m (£30.8m year-to-date), which was in line with the trajectory set out in the Financial Recovery Plan. The Trust’s underlying deficit had seen some marginal improvement during the period. • The Trust’s cash position remains an area of significant concern. Cash requests had been made to NHS England, but the latest request for November 2025 had been rejected. It was therefore likely that the Trust would need to manage its supplier payments in accordance with its available cash. Page 5 5.9 ICS System Report for Month 6 Ian Howard was invited to present the ICS System Report for Month 6, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care System had reported a year- to-date deficit of £48m. • A significant improvement in the run-rate would be required for the system to be able to deliver its 2025/26 plan. • The system was one of the worst in England in terms of the number of beds occupied by patients having no criteria to reside with approximately 23% of beds being occupied by such patients compared with a national average of 12%. • The system was also below plan in terms of its targets for access to General Practitioners and targets relating to mental health patients. It was noted that the performance in these areas had a consequential impact on the Trust’s performance in areas such as urgent and emergency care performance. 5.10 People Report for Month 6 Steve Harris was invited to present the People Report for Month 6, the content of which was noted. It was further noted that: • The overall workforce fell by 73 whole-time-equivalents (WTE) during September 2025 and was reported as being 54 WTE above the Trust’s 2025/26 plan. The reduction in workforce had been driven through a combination of the impact of the recruitment controls, mutually agreed resignation scheme (MARS) leavers, and a significant drop in use of temporary staff during the month. • On 15 October 2025, the Trust had heard the collective grievance brought by the Royal College of Nursing in respect of the removal of enhanced NHS Professionals rates. It was decided not to reverse the decision in order to maintain equity with the rest of the workforce and consistency across other local providers. A number of actions had been agreed following the hearing. • Sickness rates had increased to 3.8%, although the Trust still benchmarked well against peers. • There were concerns about the potential impact of influenza during the winter period and therefore the Trust was taking a number of actions to promote vaccination of staff. The Trust was currently third in terms of uptake in the Region. • The level of participation in the national Staff Survey remained a challenge with only 32% of staff having completed the survey compared with a national average of 38%. It was considered likely that the recent difficult decisions taken and the impact on staff was impacting staff experience and engagement. • The People and Organisational Development Committee would be examining statutory and mandatory training levels together with the latest proposed national changes. Page 6 5.11 NHSE Audit and review of 'Developing Workforce Safeguards' including UHS Self-Assessment Return Natasha Watts was invited to present the NHS England audit and review of ‘Developing Workforce Safeguards’ (2018), including the Trust’s Self-Assessment Return, the content of which was noted. It was further noted that: • ‘Developing Workforce Safeguards’ was published in October 2018 and included a range of standards to assure safe staffing across the workforce. NHS England had initiated an audit, review and improvement plan amidst concern about a national reduction in compliance. • The Trust had submitted a self-assessment as part of this NHS England review. This assessment showed that the Trust continued to comply with the majority of the standards. • The audit exercise has been used as an opportunity to identify opportunities for improvement. Twelve recommendations have been developed, of which nine were assessed as ‘green’ and three as ‘amber’. 5.12 Guardian of Safe Working Hours Quarterly Report and Update on 10-Point Plan Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report and Update on the 10-Point Plan, the content of which was noted. It was further noted that: • Resident doctors were due to strike for five days from 14 November 2025. This would be the thirteenth strike in recent years. It was noted that, in addition to pay, the dispute also concerned working conditions and the shortage of posts and consequent risk to resident doctors of unemployment. • The Trust had performed a self-assessment against the 10-Point Plan and it was noted that the majority of the plan’s contents had been considered by the Trust for some time. There were also a number of dependencies on the part of NHS England in areas such as lead employer models. • A national review of statutory and mandatory training was expected to enable portability of training records to facilitate staff moving between NHS organisations. • There had been significant improvements in respect of gaps in rotas. 5.13 Annual Clinical Outcomes Summary Luci Hood and Kate Pryde were invited to present the Annual Clinical Outcomes Summary Report, the content of which was noted. It was further noted that: • The paper provided an overview of the clinical outcomes reviewed by the Clinical Assurance Meeting for Effectiveness and Outcomes (CAMEO) over the 12-month period to September 2025. • The majority of specialities provide reports to CAMEO, although outcome data can be more difficult in some areas to capture than in others. • The outcomes reviewed by the CAMEO and outputs from this body were also influencing the development of the Trust’s clinical strategy. • The strains on the capacity of services posed a risk to clinical outcomes. Page 7 • There was potential that a ‘quality’ override could form part of the NHS Oversight Framework in the future, operating in a similar manner to the ‘financial’ override by limiting the segmentations available to an organisation. 6. STRATEGY and BUSINESS PLANNING 6.1 Corporate Objectives 2025-26 Quarter 2 Review Martin De Sousa was invited to present the review of Corporate Objectives 2025/26 for the second quarter, the content of which was noted. It was further noted that: • Of the 12 objectives agreed for 2025/26, six were rated ‘green’, four were ‘amber’ and two were ‘red’. • The ‘red’ rated risks were that relating to the Trust’s financial performance and that relating to the Trust’s achievement of its workforce plan for 2025/26. 6.2 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework update, the content of which was noted. It was further noted that: • BDO had completed its audit of the Trust’s risk maturity and had presented its report to the Audit and Risk Committee on 13 October 2025. The audit had highlighted a number of strengths including the Board Assurance Framework, risk definition, and use of risk in decision-making. In terms of opportunities for improvement, the audit report suggested some improvements in articulation of operational risks and use of ‘SMART’ methodology for actions. • The Board Assurance Framework had been reviewed by relevant executive directors and committees since it was last presented to the Board. There had been no changes to the ratings or target dates. 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors’ (COG) Meeting 28 October 2025 The Chair presented a summary of the Council of Governors’ meeting held on 28 October 2025. It was noted that the meeting had considered the following matters: • Chief Executive Officer’s Performance Report • Governor attendance at Council of Governors’ meetings • Review of the Council of Governors’ Expenses Reimbursement Protocol • Appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025 • Membership engagement • Feedback from the Governors’ Nomination Committee It was noted that the Trust’s work on violence and aggression received particular attention from the Governors. 7.2 Register of Seals and Chair’s Action Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Page 8 It was further noted that one further item had been sealed on 7 November: Deed of Guarantee between University Hospital Southampton NHS Foundation Trust (Guarantor) and CHG-Meridian UK Limited (Beneficiary) regarding the payment and due performance obligations of UHS Estates Limited (UEL) under the Guaranteed Contract and specifically the Stryker Power Tools delivered to UEL under the pre-contract open build period with CHG. Seal number 307 on 7 November 2025. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’ and to the additional document referred to above. 7.3 Health and Safety Services Annual Report 2024-25 Spencer Scott was invited to present the Health and Safety Services Annual Report 2024/25, the content of which was noted. It was further noted that: • The number of incidents reportable pursuant to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) had increased substantially to 68 such incidents compared to 39 in 2023/24. The majority of these incidents related to moving and handling or exposure to infectious diseases. • There was a concern that there had been a reduction in the number of health and safety related reports and escalations whilst at the same time the number of RIDDORs had increased. • Four areas of concern were highlighted: Entonox surveillance of maternity staff, display screen equipment compliance, the Southampton General Hospital loading bay, and workplace temperatures during the summer. 8. Any other business There was no other business. 9. Note the date of the next meeting: 13 January 2026 10. Items circulated to the Board for reading The item circulated to the Board for reading was noted. There being no further business, the meeting concluded. 11. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 9 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 15/07/2025 - 5.11 Freedom to Speak Up Report 1267. Data Mbabazi, Christine 10/03/2026 Pending Explanation action item Christine Mbabazi to include data from other mechanisms for reporting concerns in future Freedom to Speak Up reports. Trust Board – Open Session 09/09/2025 - 8 Any other business 1286. Organ donation Machell, Craig 03/02/2026 Pending Explanation action item Craig Machell agreed to add organ donation to the agenda of a future Trust Board Study Session. Update: Scheduled for TBSS on 03/02/26. Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1293. MRI scanners and imaging Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to work on and present at either a future Board meeting or Trust Board Study Session the Trust’s longer-term strategy with respect to MRI scanners and imaging. 1294. Cystopscopy/urology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a longer-term plan for cystoscopy/urology and to report back to the Board during Quarter 4. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 11/11/2025 - 5.6 Performance KPI Report for Month 6 1295. Neurophysiology Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to develop a long-term solution to the neurophysiology service. 1296. Watch & Reserve antibiotics usage Hyett, Andy 13/01/2026 Pending Explanation action item Andy Hyett agreed to clarify the basis of the calculation of the ‘Watch & Reserve antibiotics usage per 1,000 adms’ metric. Page 2 of 2 Agenda Item 5.1 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 24 November 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other Matters: • The committee received an update in respect of the Trust’s commercial activities, noting that the Trust had robust systems in place to maximise cost recovery for private patient and overseas visitor income. The Trust’s private patient unit project continued to progress. The Trust was also seeking a partner to manage its parking provision. • The committee received the Finance Report for Month 7. The Trust had reported a £5.1m in-month deficit (£35.9m year-to-date), which was in line with the trajectory contained in the Financial Recovery Plan. The underlying deficit remained flat at £6.4m. Whilst there had been a slight reduction in the number of mental health patients, there were c.240 patients having no criteria to reside at any point during the period. There was an increased level of scrutiny in respect of non-pay expenditure. • The committee reviewed an update on the Trust’s measures for financial improvement, noting that the Trust was forecasting achievement of £85-95m against its target of £110m Cost Improvement Programme delivery for 2025/26. • The committee noted the Trust’s approach and the timelines associated with the Medium Term Planning submission. It was noted that the framework set ambitious financial and performance targets. • The committee received an update in respect of the Trust’s Theatre Experience Programme, noting that there had been a 3% increase in utilisation and a 3% reduction in cancellations. • The committee reviewed the Trust’s productivity, noting that the Trust’s productivity had fallen by 3.3% compared to the prior year due to high-cost growth. • The committee received an update in respect of the Trust’s cash position and forecast and supported a proposal to request further cash support for January 2026. • The committee received an update on Capital Planning for 2026/272029/30. It was noted that it was expected that the Trust would be allocated c.£40m per annum, although there were concerns about the impact of the Trust’s cash position and the ability of the Trust to meet this level of expenditure. N/A N/A Page 1 of 2 Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.1 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: Finance, Investment and Cash Committee Meeting Date: 15 December 2025 Key Messages: • • • • • • The committee received the Finance Report for Month 8 (see below). The committee discussed the Trust’s future transformation programmes, noting that the areas of focus would be: urgent and emergency care, elective care, and automation of administrative processes. The committee was assured that the programmes were felt to be suitably ‘bold and ambitious’ and were grounded in realistic opportunities, rather than ‘blue sky’ ideas. The committee reviewed the draft capital plan for 2026/27 – 2029/30, noting that the Trust had been allocated c.£40m of capital departmental expenditure limit (CDEL) per year. It was noted that the Trust’s cash position could place constraints on the Trust’s capital programme. The opportunity to secure funding from national programmes outside of CDEL should be pursued vigorously. The plan was to be discussed in a Trust Board Study Session prior to submission in February 2026. The committee reviewed, challenged and discussed the Trust’s medium-term plan ahead of the first submission to NHS England on 17 December 2025. The committee provided feedback in respect of the proposed submission noting that some of the assumptions within the 2025/26 plan had not materialised with regard to matters such as reductions in non-criteria to reside numbers and the committee sought assurance that learnings had been applied to the development of the medium-term plan submission. The committee was assured that such assumed reductions within the 2026/27 plan were based purely on actions which were deemed to be within the Trust’s control. The committee suggested some changes with regard to the plan, particularly around growth assumptions in the cost base, and agreed to recommend the revised plan to the Board for approval. It was noted that more detail and reviews would be required prior to the final submission date in February 2026. The committee received an update in respect of the Trust’s cash position and supported a proposal to make a further request for cash support from NHS England for January 2026. The Trust reviewed and supported a proposal for transforming the Southern Counties Pathology network. Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) 5.7 Finance Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The Trust had reported an in-month deficit of £4.9m (£40m year-todate), which was consistent with the Trust’s Financial Recovery Plan. • November 2025 had been a challenging month due to costs associated with industrial action, patients with no criteria to reside and mental health patients. • The Trust had received c.£3m of income out of £6.1m for elective over-performance. • There had been a slight improvement in the Trust’s underlying deficit. Page 1 of 2 Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. No Assurance There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Not Applicable Where assurance is not required and/or relevant. Risk Rating: Low Medium High Not Applicable Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 i) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 21 November 2025 Key Messages: • • • • The committee reviewed the People Report for Month 7 including progress against the workforce plan. During October 2025, the overall workforce grew by 14 whole-time-equivalents (WTE). Although the substantive workforce had reduced by 15 WTE, there had been lowerthan-expected turnover and increased temporary staffing usage due in part to high sickness levels. The Trust remained on track, however, with respect to its Financial Recovery Plan trajectory. There were concerns about the response rate to the Staff Survey, which was below the national average. The Trust’s vaccination campaign for staff had started well with the uptake rate for the flu vaccine amongst staff at 43%. The committee considered the outputs of the review by NHS England of statutory and mandatory training and the implications for UHS. It was noted that a revised framework would facilitate passporting of training between NHS organisations. The Trust was aligned to the Core Skills Training Framework across six out of eleven areas and ten out of eleven areas for the Utilising E-Learning for Health material. The committee received an update in respect of the Trust’s Inclusion and Belonging strategy. It was noted that resource constraints and the impact of the current financial and operational environment on staff morale had impacted progress towards achievement of the objectives set out in the strategy. The committee reviewed the People risks contained within the Trust’s Board Assurance Framework. Assurance: N/A (Reports/Papers reviewed by the Committee also appearing on the Board agenda) Any Other N/A Matters: Assurance Rating: Substantial There is a robust series of suitably designed internal controls in place upon Assurance which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. Reasonable There is a series of controls in place, however there are potential risks that Assurance may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Limited Assurance Controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls. Page 1 of 2 No Assurance Not Applicable Risk Rating: Low Medium High Not Applicable There is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls. Where assurance is not required and/or relevant. Based on the report considered by the committee, there is little or no concern that the Trust will be unable to meet its stated objectives and/or plans. There is some concern that the Trust might not be able to fully meet its stated objectives and/or plans based on the information contained in the report considered by the committee. There is a significant risk that the Trust will not be able to meet its stated objectives and/or plans based on the information contained in the report considered by the committee. Where risk rating is not relevant. Page 2 of 2 Agenda Item 5.2 ii) Committee Chair’s Report to the Trust Board of Directors 13 January 2026 Committee: People & Organisational Development Committee Meeting Date: 15 December 2025 Key Messages: Assurance: (Reports/Papers reviewed by the Committee also appearing on the Board agenda) • The committee reviewed the People Report for Month 8 (see below) including progress against the workforce plan and Financial Recovery Plan. • The committee considered the workforce implications of the Trust’s medium term plan submission, noting that there were a number of national expectations and targets, such as those relating to sickness rates and elimination of agency spend. In addition, the committee noted the risks associated with the plan, including those where the Trust was reliant on progress with respect to non-criteria to reside and mental health numbers. • The committee received an update regarding the Trust’s Violence and Aggression workstream, noting that the Trust had adopted a revised approach to violence, aggression and abuse directed at staff with a greater willingness to take action against violent/abusive patients and members of the public. A violence and aggression board had been established to provide executive oversight and leadership, and the Trust’s policy was being revised. This work would be accompanied by a comprehensive communication plan for both staff and members of the public. • The committee reviewed the Trust’s progress against its objectives for Year 4 of its People Strategy. 5.9 People Report for Month 8 Assurance Rating: Risk Rating: Substantial High • The overall workforce fell during November 2025, with substantive numbers falling by 52 whole-time-equivalents (WTE). However, temporary staffing use had increased during the month due to increased sickness and operational pressures, which offset much of the reduction in substantive numbers. • The Trust was over its original plan by 214 WTE despite a decrease of nearly 400 WTE since 31 March 2025. In order to hit the Trust’s Financial Recovery Plan target, the overall workforce would need to fall by a further 137 WTE (including a 72 WTE reduction in temporary staffing) by the end of March 2026. • A forecast based on the previous year’s temporary staffing usage for the remaining months of the year indicated that the Trust would end the year approximately 500 WTE above the Trust’s 2025/26 plan. • The Trust had submitted a baseline assessment against the 10 Point Plan to improve Resident Doctors’ working lives in August 2025, which indicated that the Trust compared favourably against other organisations in the South East. The main issues concerned space available for doctors to work in and timeliness of reimbursement of course-related expenses. • The Trust was expected to meet a target of 95% of job plans having been signed off prior to 31 March 2026. At the start of December 2025, 55% of job plans had been signed off. Page 1 of 2 Any Other Matters: • Sickness absence had increased in November 2025 to 4.2% in month due to seasonal illnesses. • The staff survey closed on 28 November 2025. The completion rate for the staff survey had been lower t
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2026-Trust-documents/Papers-Trust-Board-13-January-2026.pdf

1 to 10 of 126

Previous 1 2 3 4 5 … Next

Browse site A to Z

Search results

Functional magnetic resonance imaging (MRI) brain scan - patient information

Papers Trust Board - 15 July 2025

Annual-report-2018-19

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

Annual report 20-21

UHS AR 22-23-6

Annual report 2021-2022

Having a total hip replacement - patient information

Headache - patient information

Papers Trust Board - 13 January 2026

Site policies

Contact details

Useful links