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Disclosure for consent

Description: The DOLS regulations were enacted to ensure that incapacitated adults are not deprived of their liberty by NHS Trusts.
Url: /HealthProfessionals/Clinical-law-updates/Disclosureforconsent.aspx

Engaging for increased research participation - full report

Description: Engaging for increased research participation Public and healthcare professionals' perceptions For further information contact: Chris Stock Head of R&D communications
Url: /Media/Southampton-Clinical-Research/Marketresearch/Engaging-for-increased-research-participation-full-report-v2.pdf

Lynch syndrome - patient information

Description: This leaflet contains information about Lynch syndrome.
Url: /Media/UHS-website-2019/Patientinformation/Genetics/Lynch-syndrome-1431-PIL.pdf

Leg artery bypass (fem-pop bypass) - patient information

Description: Information about an arterial bypass (also known as a fem-pop bypass) - an operation to create a new route for blood to getinto the leg.
Url: /Media/UHS-website-2019/Patientinformation/Cardiovascular-and-thoracic/Leg-artery-bypass-fem-pop-bypass-1659-PIL.pdf

DH IVIg approved indications full guidance July 2011

Description: DH INFORMATION READER BOX Policy HR / Workforce Management Planning / Clinical Performance Document Purpose Gateway Reference Title Author Publication Date Target Audience Estates Commissioning IM & T Finance Social Care / Partnership Best Practice Guidance 16290 ROCR Ref: ROCR approval applied for Clinical guidelines for immunoglobulin use: update to second edition Department of Health 01 Aug 2011 PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs , Medical Directors, Directors of Finance, GPs, Communications Leads, Emergency Care Leads, Chief Pharmacists Circulation List #VALUE! Description The Clinical Guidelines for Immunoglobulin Use were implemented in 2008. The Guidelines were developed utilising an evidence review and extensive consultations. This Update fulfills the commitment to undertake a biennial review from 2009. The Second Edition Guidelines remain in place and this Update should be used in conjunction with them. Cross Ref Superseded Docs Action Required Timing Contact Details Clinical Guidelines for Immunoglobulin Use (Second Edition) N/A N/A N/A Tina Lee Blood Safety & Supply Team Room 30 Wellington House 133-155 Waterloo Road London SE1 8UG 020 7972 4750 0 For Recipient's Use Clinical guidelines for IMMUNOGLOBULIN Use seCOND eDITION UPDATe second edition Update Working Group Dr Jennie Wimperis Consultant Haematologist, Norfolk and Norwich NHS Trust Dr Michael Lunn Consultant Neurologist, National Hospital for Neurology and Neurosurgery Dr Alison Jones Consultant Immunologist, Great Ormond Street Hospital Dr Richard Herriot Consultant Immunologist, NHS Grampian Dr Philip Wood Consultant Immunologist, Leeds Teaching Hospitals NHS Trust Dr Denise O'shaughnessy Blood Policy, Department of Health Mr Malcolm Qualie Pharmaceutical Advisor Department of Health CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Contents ...................................................................................... 2 eXeCUTIVe sUMMARY ....................................................................... 6 Selection criteria for appropriate use of immunoglobulin .................................. 6 Efficacy outcomes to assess treatment success ........................................... 6 Modification of existing indications and inclusion of new indications .................... 7 Commissioning of immunoglobulin ........................................................... 7 INTRODUCTION ................................................................................ 8 Insights from the National Immunoglobulin Database ..................................... 8 CONTeNTs Changes to the colour-coded prioritisation employed in the Demand Management Programme ...................................................................... 8 Automatic assignment of Red and Blue prioritisation ................................. 9 Grey indications ............................................................................. 9 Reclassification of diseases .............................................................. 10 11 12 12 13 14 14 14 15 16 18 26 27 27 Introduction of specific selection and outcome criteria in the Demand .................................................................... Definitions of duration of immunoglobulin treatment ..................................... Recommended dosing of immunoglobulin ................................................ Ideal body weight-adjusted dosing of immunoglobulin .................................. Western Australia pilot study ............................................................. Hospital Corporation of America ........................................................ The Ohio State University Medical Centre, Columbus, Ohio ........................ Infusion rates for intravenous immunoglobulin ............................................ Subcutaneous administration ............................................................... sUMMARY TABLes .......................................................................... sUMMARY Of GReY INDICATIONs ...................................................... Removed from Grey ........................................................................... INDICATIONs fOR WHICH IVIG Is NOT ReCOMMeNDeD .......................... Management Programme CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Replacement pages IMMUNOLOGY HAeMATOLOGY ............................................................................... .............................................................................. 29 35 Primary immunodeficiencies (replacing relevant content on pages 28-29) Coagulation factor inhibitors (replacing relevant content on pages 32-33) Haemolytic disease of the foetus and newborn (replacing relevant content on pages 32-33) Immune thrombocytopenic purpura (replacing relevant content on pages 34-35) NeUROLOGY ................................................................................. 40 Introduction (replacing relevant content on page 41) Chronic inflammatory demyelinating polyradiculoneuropathy (replacing relevant content on page 41) Inflammatory myopathies (replacing relevant content on page 42) TRANsPLANTATION ........................................................................ 43 Antibody Incompatible Transplant (AIT) (replacing relevant content on page 65) Antibody-Mediated Rejection (AMR) (replacing relevant content on page 65) Viral pneumonitis (replacing relevant content on page 65) CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Summary table of conditions for which intravenous immunoglobulin use is appropriate Condition Primary and secondary antibody deficiency states Primary immunodeficiencies Thymoma with immunodeficiency HSCT in primary immunodeficiencies Specific antibody deficiency Secondary antibody deficiency (any cause) Haematology Acquired red cell aplasia Alloimmune thrombocytopenia (foeto-maternal/neonatal) Autoimmune haemolytic anaemia Coagulation factor inhibitors (alloantibodies and autoantibodies) Haemolytic disease of the newborn Haemophagocytic syndrome Immune thrombocytopenic purpura (acute and persistent, excluding chronic*) Post-transfusion purpura Neurology Chronic inflammatory demyelinating polyradiculoneuropathy** Guillain-Barr? syndrome Inflammatory myopathies Myasthenia gravis (including Lambert-Eaton myasthenic syndrome) Multifocal motor neuropathy Paraprotein-associated demyelinating neuropathy (IgM, IgG or IgA) Rasmussen syndrome Stiff person syndrome short duration Long duration continued * Chronic immune thrombocytopenic purpura is a grey indication ** The disease should be life-threatening to allow database entry as red CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Summary table of conditions for which intravenous immunoglobulin use is appropriate continued Condition Others Autoimmune congenital heart block Autoimmune uveitis Immunobullous diseases Kawasaki disease Necrotising (PVL-associated) staphylococcal sepsis Severe or recurrent Clostridium difficile colitis Staphylococcal or streptococcal toxic shock syndrome Toxic epidermal necrolysis, Stevens Johnson syndrome Transplantation (solid organ) short duration Long duration CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use eXeCUTIVe sUMMARY The Clinical Guidelines for Immunoglobulin Use were implemented in 2008. The Guidelines were developed utilising an evidence review and extensive consultations with clinicians and other stakeholders. This update fulfils the commitment made in the Second Edition to undertake a biennial review from 2009. The Second Edition Guidelines remain in place and this update should be used in conjunction with the Second Edition. This update did not review all of the Second Edition Guidelines content, but limited its focus to three key areas: defining selection criteria for appropriate use; efficacy outcomes to assess treatment success; and reassignment of existing indications /inclusion of new indications. should be fulfilled if immunoglobulin is to be used, including particular disease characteristics, disease severity and any requirement for other treatments to have been demonstrably unsuccessful before immunoglobulin is considered. This reflects the approach taken by the National Blood Authority in Australia in defining appropriate prescribing of immunoglobulin. efficacy outcomes to assess treatment success The Guidelines did not include efficacy tracking of immunoglobulin treatment, although Immunoglobulin Assessment Panels (IAP) were encouraged to request parameters by which efficacy could be assessed. This update provides efficacy outcomes to be measured in all indications (except primary immunodeficiencies), and it is expected that all Grey indications will have efficacy parameters defined and monitored on a case by case basis. Efficacy outcomes are expected to play an important role in the IAP decision-making process for patients in whom continuation of immunoglobulin treatment is requested beyond the short- and long-term durations defined in this update. This change reflects the wider change of focus in the NHS to patient outcomes, as presented in The NHS Outcomes Framework. selection criteria for appropriate use of immunoglobulin The Guidelines did not provide explicit selection criteria for the appropriate use of immunoglobulin. Review of data in the National Immunoglobulin Database showed a considerable volume of immunoglobulin was used in patients for whom no specific diagnosis was provided. Clearly, this was less than optimal and caused concern among commissioners. This update provides criteria that CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Modification of existing indications and inclusion of new indications Changes to existing indications required proponents to submit new evidence to the Update Working Group for review. However, allocation of diseases to Red, Blue or Grey did not solely depend on the level of evidence presented, but included expert clinical advice and the availability of effective alternative therapies or treatment approaches. The British Transplantation Society made a strong case to change certain defined transplant cases to Blue, despite limited high-quality evidence for some of the clinical scenarios and the Update Working Group accepted the Society's view. For complex regional pain syndrome, although randomised evidence from a small study showed benefit, this was regarded by the Update Working Group as an emerging indication for refractory cases; a number of important questions concerning optimal treatment doses and duration of treatment remain unanswered. Therefore, this disease has been added to the Grey list. It remains the responsibility of the local IAP to decide with the PCT (or specialised commissioning group) if treatment with immunoglobulin is appropriate on a case by case basis. Other Grey indications have been updated and others, for which there was little or no prescribing recorded in the database, deleted. Grey indications are now listed as immune-mediated disorders with limited evidence of immunoglobulin efficacy, or presumed immune-mediated disorders with little or no evidence of efficacy. Review of Red and Blue indications identified a number of disease entities with the same underlying pathophysiology that were listed separately; these are now grouped together under single disease headings. Commissioning of immunoglobulin Ensuring immunoglobulin prescribing is consistent with the evidence-base and restricted to those patients for whom there are no alternative treatments and for those most likely to benefit is the central aim of these guidelines. But from a commissioner's viewpoint, cost-effectiveness and affordability play an important role in their discussions with IAPs regarding prescribing. The commissioning aspects of this guideline update are included in a separate document and this should be reviewed to understand the requirements of commissioners around immunoglobulin prescribing, in particular regarding National Immunoglobulin Database entry and treatment duration. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use INTRODUCTION This update of the Department of Health's (DH) immunoglobulin guidelines fulfils the commitment made in the Second Edition to undertake a biennial review from 2009. This review was informed by changes in the clinical evidence base for immunoglobulin, the findings of the National Immunoglobulin Database (Reference number ROCR/ OR/0221), and a change of focus in the NHS to patient outcomes, as presented in The NHS Outcomes Framework. The DH has consulted widely in this review and the changes have been discussed at length with clinicians and commissioners involved in the demand management of immunoglobulin. National Immunoglobulin Database was launched on 2nd June 2008. These documents and the National Immunoglobulin Database are accessible through the immunoglobulin website www.ivig.org.uk. The first data review from the National Immunoglobulin Database, published in January 2010, contained data on immunoglobulin prescribing in 5119 patients, and offered a unique, detailed view of prescribing practice of immunoglobulin in England as well as providing, for the first time, a baseline of immunoglobulin use. This was a major step forward in establishing the Demand Management Programme and, in particular, gave insights into the appropriate use of this treatment across all indications. Generally, the data demonstrated appropriate and controlled prescribing of immunoglobulin for a wide range of conditions, most of which was evidence based. The review also identified a number of issues regarding the Demand Management Programme, which are addressed in this guideline update. Insights from the National Immunoglobulin Database The DH's Demand Management Programme for Immunoglobulin was a key output from the 2006 review that assessed the opportunities available to secure the supply of immunoglobulin. The review recommended two complementary work streams, one based on securing supply and the other giving structure to the process of fulfilling demand (the Demand Management Programme). The Demand Management Programme was fully launched in late May 2008, when DH published the Second Edition of `Clinical Guidelines for Immunoglobulin Use' and the `Demand Management Plan for Immunoglobulin Use' (Gateway reference 10012 and 10013). The Changes to the colour-coded prioritisation employed in the Demand Management Programme Automatic assignment of Red and Blue prioritisation The Demand Management Programme introduced colour coding to reflect the prioritisation of immunoglobulin treatment CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use in times of shortage, based on the availability of alternative treatments and strength of clinical evidence. The database review showed many cases for which diseases were mis-assigned to an incorrect prioritisation. In particular, there were many cases of misassignment of diseases to Red and Blue. `Red' indicates conditions for which treatment is considered the highest priority because of a risk to life without treatment. The intention remains that Trusts will protect supply for these high-priority diseases in times of immunoglobulin shortage, particularly for patients with primary immunodeficiencies. To ensure accurate prioritisation assignment, the database will now automatically assign the colour coding upon patient entry on the basis of patient characteristics. The Immunoglobulin Assessment Panels (IAP) at Trusts should continue to manage local demand for immunoglobulin; in times of shortage, local panels should continue to identify Red indications as those of most clinical need. The database will automatically assign diseases to `Blue', but prescribing of immunoglobulin in Blue indications will continue to require prior approval of the IAP . because the disease is rare. Approval from both the local IAP and the Primary Care Trust (PCT) (or specialised commissioning group) is required for immunoglobulin treatment. As previously specified in the Demand Management Plan for Immunoglobulin Use, treatment should be considered on a caseby-case basis, and prioritised against other competing demands for immunoglobulin, especially in times of shortage. It is not possible or desirable to list every disease that could potentially be prescribed immunoglobulin. In cases of `unlisted' diseases, it is important to restate that those not listed in the guidelines are to be considered as Grey. The database review showed a considerable volume of immunoglobulin prescribed without a specific diagnosis being provided. Even if the disease is unlisted, the diagnosis and agreed efficacy criteria are to be recorded in the database. Grey indications are now listed as immune-mediated disorders with limited evidence of immunoglobulin efficacy, or presumed immune-mediated disorders with little or no evidence of efficacy. It is accepted that the lack of an evidence base may reflect the rarity of these diseases; it remains the responsibility of the local IAP to decide with the PCT (or specialised commissioning group) if treatment with immunoglobulin is appropriate on a caseby case basis. Grey indications `Grey' indications are those diseases for which the evidence is weak, in many cases 10 CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Reclassification of diseases 1. Grey to Blue The database review identified two of the top 10 immunoglobulin-using indications as Grey (secondary antibody deficiencies and antibody-mediated rejection following solid organ transplantation). In many Trusts, commissioners have permitted pre-approval of immunoglobulin use for these indications despite the limited evidence base. Therefore, these indications were reviewed in detail and the evidence base was reassessed. Secondary antibody deficiencies were identi- Acquired von Willebrand disease has now been included with acquired haemophilia, in the general disease grouping of `Coagulation factor inhibitors', which is listed under appropriate use of immunoglobulin. Immunoglobulin use carries selection criteria, including that these rare and severe bleeding disorders are managed in a comprehensive care centre for haemophilia. Polymyositis and Inclusion body myositis have now been grouped with dermatomyositis under the general disease grouping of inflammatory myopathies, with strict selection criteria. Post-transfusion hyperhaemolysis has now been fied by a number of stakeholders as a key area for revision. In the previous edition, they were listed under immunosuppressive pharmacotherapy, and separately under some of the haematological malignancies such as CLL, without listing other mature B-cell malignancies such as non-Hodgkin's lymphoma. These have been revised into a single indication. The outcome of this review is that use of immunoglobulin for these indications is appropriate and is now listed as Blue (see replacement page 30). Antibody-mediated rejection following solid grouped under the more general heading of haemolytic anaemia. SLE with secondary immunocytopenias should be considered under the relevant immune cytopenia. 2. Blue to Red Specific antibody deficiency, as a recognised primary antibody deficiency disorder, has been reclassified as a Red indication (for those cases where immunoglobulin replacement therapy is required). Haemolytic disease of the newborn has been organ transplantation and antibody-incompatible transplantation were reviewed, and a single grouping of `Transplantation (solid organ)' has been introduced and listed as Blue. updated to reflect recommendations in NICE clinical guideline 98 on neonatal jaundice [1]. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use 11 Introduction of specific selection and outcome criteria in the Demand Management Programme Selection criteria The database review also raised an important issue over patient diagnosis ? a considerable volume of immunoglobulin was used in patients in which there was no specific diagnosis listed (13% of total recorded immunoglobulin use). Clearly, this was less than optimal and caused concern among commissioners. In addition, this showed that improvements were required before the database was sufficiently robust to be able to link to payments by use. Further feedback from commissioners indicated widespread approval of the system used in Australia, with each indication for immunoglobulin carrying specific selection criteria for use, in particular, the need to use immunoglobulin as second- or third-line treatment in diseases for which there are a number of alternative treatment options. This approach, with selection criteria for each approved indication for immunoglobulin, has now been adopted in this guideline update. The need to employ selection criteria before prescribing will largely remove the need for panel decisions on prescribing, reducing the burden on IAPs and increasing focus on assessing patient outcome. Efficacy outcomes The database was not successful in the capture of data regarding the efficacy of immunoglobulin. Panels were encouraged to request up to three parameters by which efficacy could be determined in each patient [e.g., platelet count in patients with immune thrombocytopenic purpura (ITP)]. The purpose of this exercise was both to obtain preliminary data about efficacy in various conditions (fully accepting that lack of diagnostic criteria and other issues would make this a very crude analysis) and to provide feedback to individual Panels about the quality of their decision making. For example, if Panels repeatedly approved indications prioritised as Grey by the Demand Management Programme and the treatment was largely ineffective, review of these findings would improve IAP decision making. The decision has been taken to introduce efficacy outcomes for most indications. Monitoring of efficacy outcomes by commissioners may result in withholding payments to Trusts if efficacy outcomes have not been recorded in the database. Efficacy outcomes are expected to play an important role in the decision-making process of IAPs in cases in which continuation of immunoglobulin treatment is requested beyond the short- and long-term durations defined in the next section. 1 CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Definitions of duration of immunoglobulin treatment The definitions of short-term and longterm treatment durations are refined in this update, with each approved indication for immunoglobulin now approved on the basis of short-term (3 months) and long-term (3 months) treatment needs. The definitions of duration of treatment are included in the table below. IAPs and commissioners together will make decisions on treatment extensions. short-term treatment Three prescribed doses of up to 2 g/kg, given at appropriate clinical intervals 3 months The treatment episode ends at 3 months. The National Immunoglobulin Database will record treatment re-initiation as a new treatment episode based on a new panel decision. It is expected that the IAP decision will be influenced by the outcome measures recorded on the database. 3 months Treatment reviews should be conducted annually. The National Immunoglobulin Database will record treatment re-initiation as a new treatment episode based on a new panel decision. It is expected that the IAP decision will be influenced by the outcome measures recorded on the database.* Long-term treatment *The primary immunodeficiencies are exempt from funding termination at 1 year. Recommended dosing of immunoglobulin The Second Edition of the Clinical Guidelines did not provide specific dosing recommendations; it is widely accepted that the standard immunomodulatory dose of 2 g/kg is usually divided into five daily infusions of 0.4 g/kg, although some physicians prefer to use two daily doses of 1 g/kg each. The database infusion records were incomplete and, therefore, it was not possible to fully interpret the data and decipher the dosing that had been used. This update to the guidelines now provides specific dosing recommendations for each of the conditions for which prescribing is regarded as appropriate. Immunoglobulin users are expected to record the dosing employed in the national database. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use 1 An ongoing issue for diseases that require long-term immunoglobulin treatment is that once responsiveness to intravenous immunoglobulin (IVIg) is proven for a patient using standard immunomodulatory dosing, the `maintenance' dosing required to maintain the therapeutic response is not well characterised. In this update, the dosing recommendations for some neurological indications include `time to relapse' as the interval between doses. This approach is supported by recent evidence from The Oxford Programme for Immunomodulatory Immunoglobulin Therapy, which was set up to review multifocal motor neuropathy (MMN) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) treatment with immunoglobulin. In view of the uncertainty of both remission and disease progression in CIDP and MMN, The Oxford Programme reviewed the dose and infusion frequency of patients on a regular basis and showed that increasing the infusion interval proved successful in some patients and resulted in treatment discontinuation [2]. The study also indicated that the precise dose and infusion interval to keep each patient asymptomatic was not predictable, but the authors suggested a rough guide: patients in whom responses last 20% more than IBW, prescribers should consider using adjusted-bodyweight dosing of immunoglobulin. Infusion rates for intravenous immunoglobulin Initial intravenous infusion rates are low, and if well tolerated, the rate of administration may be increased, as specified in the products' Summary of Product Characteristics (SPC). For certain products, the SPC indicates that if the higher rate is tolerated, the rate may be further increased in primary immunodeficiency (PID) patients to the maximum infusion rate. Higher infusion rates may lead to improved convenience for patients and may reduce nursing time and the need for hospital resources. Infusion rates for each of the licensed immunoglobulins are provided in the table below. Immunoglobulin should be administered according to the manufacturers' recommendations. The table below gives the infusion rates, and the infusion time at maximum infusion rate of 1 g/kg dose in a 70 kg person. Infusion rates Infusion time of 0 g in minutes at max. rate 100 250 500 640 125 200 125 241 83 Product Baxter Kiovig BPL Gammaplex BPL Vigam Biotest Intratect CsL Privigen Grifols flebogamma Grifols flebogamma 10 Octapharma Octagam Octapharma Octagam 10 Initial 0.5 mL/kg/h for 30 mins 0.01?0.02 mL/kg/min for 15 mins 0.01?0.02 mL/kg/min for 30 mins 1.4 mL/kg/h for 30 mins 0.3 mL/kg/h 0.01?0.02 mL/kg/min for 30 mins 0.01 mL/kg/min for 30 mins 1 mL/kg/h for 30 mins 0.01?0.02 ml/kg/min for 30 mins Maximum 6 mL/kg/h (8 ml/kg/h in PID) 0.04?0.08 mL/kg/min 0.04 mL/kg/min (max. 3mL/min) 1.9 mL/kg/h 4.8 mL/kg/h (7.2 mL/kg/h in PID) 0.1 mL/kg/min 0.08 mL/kg/min 5 mL/kg/h 0.12 ml/kg/min 1 CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use subcutaneous administration Subcutaneous immunoglobulin (SCIg) as replacement therapy for primary immune deficiency disease and as immunomodulatory therapy for some autoimmune diseases, including peripheral neuropathies, can be a safe, effective, and convenient alternative to intravenous therapy. Subcutaneous administration can offer advantages that may be important for many patients [3]. Although SCIg is typically administered weekly by infusion pump, administration by a rapid push technique may provide a greater degree of convenience, and recent evidence suggests it is a safe and effective method. Seventy-four patients with primary immune deficiency disease received an average SCIg dose of 32 g/month split into an average of three times per week. Volume per site ranged from 3 to 20 mL, typically administered over 5?20 min. Mean serum IgG levels did not differ significantly compared with those receiving infusion and only two patients discontinued therapy because of an adverse event [4]. Recent evidence suggests that individualising the dosage based on measured serum IgG levels and the clinical response is preferable to using mean pharmacokinetic parameters [5]. Findings from the Oxford Self Infusion at Home Programme for CIDP and MMN also suggest that the dose of immunoglobulin and the serum IgG trough level are individual to each patient [2]. Recommendation Prescribers should consider the comparative advantages of intravenous and subcutaneous administration for individual patients requiring immunoglobulin treatment where this is clinically appropriate. Table. Subcutaneous immunoglobulin products licensed in the UK CSL Vivaglobin Baxter Subcuvia Octapharma Gammanorm BPL Subgam CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use 1 RefeReNCes 1. NICE clinical guideline 98. Neonatal Jaundice. Nice, 2010. 2. Lucas M, Hugh-Jones K, Welby A, et al. Immunomodulatory therapy to achieve maximum efficacy: doses, monitoring, compliance, and self-infusion at home. J Clin Immunol 2010;30 Suppl 1:S84?9. 3. Berger M. Subcutaneous immunoglobulin replacement in primary immunodeficiencies. Clin Immunol 2004;112:1?7. 4. Shapiro R. Subcutaneous immunoglobulin therapy by rapid push is preferred to infusion by pump: a retrospective analysis. J Clin Immunol 2010;30:301?7. 5. Berger M, Rojavin M, Kiessling P, Zenker O. Pharmacokinetics of subcutaneous immunoglobulin and their use in dosing of replacement therapy in patients with primary immunodeficiencies. Clin Immunol 2011;139:133?41. 1 sUMMARY TABLes PRIMARY AND seCONDARY ANTIBODY DefICIeNCY sTATes selection criteria A specific PID diagnosis must be established by a clinical immunologist Outcome measures are not required Condition s L Outcomes for review Dosing Initiate at 0.4?0.6 g/kg/month; dose requirements may increase and should be based on clinical outcome Initiate at 0.4?0.6 g/kg/month; dose requirements may increase and should be based on clinical outcome Initiate at 0.4?0.6 g/kg/month; dose requirements may increase and should be based on clinical outcome Initiate at 0.4?0.6 g/kg/month; dose requirements may increase and should be based on clinical outcome Primary immunodeficiencies (associated with significant antibody defects) Profound B cell depletion and/or significant antibody deficiency Outcome measures are not required Thymoma with immunodeficiency HSCT in primary immunodeficiencies PID patients undergoing HSCT Outcome measures are not required CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Specific antibody deficiency Approval by a clinical immunologist, AND Severe, persistent, opportunistic or recurrent bacterial infections despite continuous oral antibiotic therapy for 3 months, AND Documented failure of serum antibody response to unconjugated pneumococcal or other polysaccharide vaccine challenge Underlying cause of hypogammaglobulinaemia cannot be reversed or reversal is contraindicated; OR Hypogammaglobulinaemia associated with NHL, CLL, MM or other relevant B-cell malignancy confirmed by haematologist; AND ? Recurrent or severe bacterial infection despite continuous oral antibiotic therapy for 3 months ? IgG 1 dose required if thrombocytopenia persists Clinical suspicion in antenatal or neonatal setting based on clinical and laboratory features: Thrombocytopenia or spontaneous haemorrhage in the foetus; OR Thrombocytopenia with or without haemorrhage in the neonate; OR Unexplained foetal death in a previous pregnancy and the presence of maternal platelet-specific allo-antibodies that are known or suspected to cause this condition (most commonly HPA-1a or HPA-5b) Symptomatic or severe anaemia (Hb 15, acute rising Any significant clearance of C. diff. creatinine and/or signs/symptoms Duration of hospital in-patient stay of colitis) not responding to oral vancomycin 125 mg qds, highdosage oral vancomycin +/- iv metronidazole 500 mg tds is recommended; the addition of oral rifampicin (300 mg bd) or IVIg may be considered. If multiple recurrences, especially if evidence of malnutrition, wasting etc., consider IVIg Severe or recurrent Clostridium difficile colitis 0.4 g/kg, one dose, and consider repeating continued Other selection criteria Diagnosis of streptococcal or staphylococcal TSS, preferably with isolation of organism; AND Failure to achieve rapid improvement with antibiotic therapy and other supportive measures; AND Life-threatening Diagnosis by a dermatologist; AND Involved body surface area > 10%; AND When other treatments are contraindicated; OR The condition is life-threatening Resolution of the disease 2 g/kg, preferably as a single dose, or divided over 3 consecutive days Improvement of FBC, ALK, CPK Reduction in hospital inpatient stay Survival (yes/no) 2 g/kg as a single dose continued Outcomes for review Dosing Condition s L Staphylococcal or streptococcal toxic shock syndrome Toxic epidermal necrolysis, Stevens Johnson syndrome Transplantation (solid organ) AIT Up to 2 g/kg to be repeated as per DSA, in renal desensitisation at 0.1 g/kg for 8?12 doses AMR Up to 2 g/kg to be repeated for 2?3 doses Viral pneumonitis 0.5 g/kg for 5 days CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Antibody Incompatible Transplant AIT and AMR* (AIT) Renal Patients in whom renal, heart or Type of renal transplant lung transplant is prevented HLA class DSA because of antibodies Rejection episodes Patient survival Antibody Mediated Rejection Graft survival (AMR) Renal function = eGFR (MDRD) Patients experiencing steroid Cardiothoracic resistant rejection or where other DSA therapies are contraindicated after Patient survival renal, heart and/or lung transplant Length of ITU and hospital stay Graft function (heart = ejection Viral pneumonitis fraction; lung = spirometry) Patients experiencing viral pneumonitis following heart and/or Viral pneumonitis* lung transplant (viruses to include Cardiothoracic HSV, VZV, CMV, RSV, but excluding Virus type influenza virus) Reversal of radiological infiltrates Length of hospital stay Survival *These parameters will be reviewed after one year, at which time specific outcome criteria will be formulated. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use sUMMARY Of GReY INDICATIONs Grey indications are those diseases for which the evidence is weak, in many cases because the disease is rare. Approval from both the local IAP and the PCT is required for immunoglobulin treatment. In cases of `unlisted' diseases, those not listed in the guidelines are to be considered as Grey. Even if the disease is unlisted, the diagnosis and locally agreed efficacy criteria are to be recorded in the database. Immune-mediated disorders with limited evidence of immunoglobulin efficacy Acute disseminated encephalomyelitis (if high-dose steroids have failed) Autoimmune encephalitis (including NMDA and VGKC antibodies, among others) Catastrophic antiphospholipid syndrome Cerebral infarction with antiphospholipid antibodies Chronic ITP Complex regional pain syndrome CNS vasculitis Intractable childhood epilepsy Neuromyotonia Opsoclonus Myoclonus Post-exposure prophylaxis for viral or pathogenic infection if intramuscular injection is contraindicated, or treatment when hyperimmune immunoglobulins are unavailable Pyoderma gangrenosum Systemic juvenile idiopathic arthritis Systemic vasculitides and ANCA disorders Urticaria (severe, intractable) Presumed immune-mediated disorders with little or no evidence of efficacy Acquired red cell aplasia NOT due to parvovirus B19 Acute idiopathic dysautonomia Aplastic anaemia/pancytopenia Atopic dermatitis/eczema Autoimmune neutropenia Chronic facial pain Diabetic proximal neuropathy Haemolytic uraemic syndrome PANDAS Paraneoplastic disorders that are known not to be B- or T-cell mediated POEMS SLE without secondary immunocytopenias (including juvenile) CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Removed from Grey: ? Secondary antibody deficiencies INDICATIONs fOR WHICH IVIG Is NOT ReCOMMeNDeD (now Blue) ? Acquired vWd (now Blue) ? Post-transfusion hyperhaemolysis (now with haemolytic anaemia) ? Graft versus host disease (delete) ? SLE with secondary immunocytopenias (included in the relevant cytopenias) ? Infection following BMT or HSCT (included in Blue) ? Polymyositis (now Blue) ? Transplantation indications (now Blue) ? Immunodeficiency secondary to paediatric HIV infection ? Autologous BMT ? Adrenoleukodystrophy ? Alzheimer's disease ? Amyotrophic lateral sclerosis ? Chronic fatigue syndrome ? Critical illness neuropathy ? Multiple sclerosis ? Rheumatoid arthritis ? Neonatal sepsis (prevention or treatment) ? Sepsis in the intensive care unit not related to specific toxins or C. difficile ? Asthma ? Graves' ophthalmopathy ? IVF failure ? Recurrent spontaneous pregnancy loss CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Next section contains the replacement pages of second edition CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use Update for pages 28?30 IMMUNOLOGY Primary immunodeficiency disorders (associated with significant antibody defects) Antibody deficiencies may arise as primary disorders with a known or suspected genetic basis or secondary to a variety of other diseases, drugs and environmental or iatrogenic factors. They may occur in isolation or in association with defects in other effector components of the immune system (combined defects). Significant primary antibody deficiencies collectively account for the majority of primary immunodeficiency syndromes encountered in clinical practice [1,2]. The hallmark clinical presentation is recurrent or persistent bacterial infection, but these disorders are also associated with a heterogeneous variety of other infectious and non-infectious complications and with a high incidence of chronic, structural tissue damage, particularly in the respiratory tract. Clinical recognition of primary antibody deficiency is frequently delayed with consequent acute and chronic ill health, diminished Common Common variable immunodeficiency group (CVID) X-linked agammaglobulinaemia quality of life, and decreased life expectancy. Primary antibody deficiency can present at any age. Taken together, the primary antibody deficiency disorders account for at least half of all primary immunodeficiency syndromes. For some conditions, internationally-agreed diagnostic criteria have been established [3], but in other disorders formal case-definition criteria are lacking. The evidence base for current practice in the recognition, diagnosis and management of antibody deficiency has recently been reviewed [4]. Disorders which generally require immunoglobulin replacement as a central component of their management are presented below. Diagnosis, particularly of primary deficiencies, is frequently delayed or overlooked [1,5]. Many patients present with established structural tissue damage, especially in the lungs, which is essentially irreversible even with optimal treatment. Diagnostic aims are to a) identify, or exclude, significant antibody deficiency, b) differentiate primary from secondary disease and c) delineate, where possible, a precise diagnosis. Less common Germinal centre class switch recombination defects (`Hyper-IgM syndromes') Other primary antibody deficiency (XLA) (including unclassifiable disorders) Combined immunodeficiencies (including severe combined immunodeficiency (SCID) and unclassifiable disorders) 0 CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use The goals of management are to prevent complications or retard their progression, optimise quality of life, working capacity and life expectancy and, in children, ensure optimal growth and development [6]. Replacement therapy with polyclonal human normal immunoglobulin is the cornerstone of management for significant primary antibody deficiency disorders. No viable alternatives exist to this essential, basic component of treatment, particularly in the context of severe, persistent or recurrent bacterial infections. For most patients, replacement therapy is a lifelong requirement. Existing formulations replace deficient IgG only and are given by either intravenous or subcutaneous infusion in a hospital setting or, increasingly, within domestically-based programmes. Subcutaneous and intravenous preparations are therapeutically equivalent [7]. All preparations carry risks of adverse, infusion-related reactions and both real (hepatitis C) and theoretical (vCJD) risks of transmissible disease. Replacement therapy increases life expectancy and reduces the frequency and severity of infections, antibiotic usage and hospital admissions [4]; however, patients remain susceptible to sporadic breakthrough infections [8]. Optimal dosing and target levels for IgG are not known but higher doses are more effective than low-dose regimens in reducing infection rates and risk of chronic tissue damage. However, even apparently adequate treatment may fail to completely retard progression of established disease complications such as bronchiectasis [9]. Replacement therapy is frequently targeted at achieving a sustained or pre-infusion trough serum IgG level within the normal range (6?16 g/L). There is evidence that improved outcomes, particularly in respect of respiratory infection, are associated with higher serum IgG levels up to at least 10 g/L [10]. Dosage should generally be initiated at 0.4?0.6 g/kg/month, but individual patients may require higher doses in the long term. The goal of therapy in individual cases should be to improve clinical outcome rather than achieve a minimum target level of serum IgG [11]. Dose requirements are commonly increased in the context of secondary structural tissue damage (especially in the respiratory tract) or co-existent chronic inflammatory conditions. Risk assessments for ongoing therapy with immunoglobulin should be carried out regularly (including the need to continue with active treatment). Recommendation Replacement immunoglobulin therapy in patients with significant, symptomatic primary defects of antibody production or function should be tailored to individual patient outcomes with the minimum aim of maintaining serum IgG levels within the age-related normal range (grade B recommendation, level IIb evidence). CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use 1 Other specific Disorders Thymoma with immunodeficiency (Good's Syndrome) Good's syndrome is a complex CVID-like condition where thymoma is found in association with profound B cell lymphopenia and quantitative or functional antibody deficiency. Infection frequencies correlate better with numerical B-cell depletion than with hypogammaglobulinemia. Thymectomy rarely results in normalisation of immunoglobulin levels and the syndrome may therefore constitute, and be classified as, a primary rather than secondary defect and, in respect of any antibody deficiency, be treated as for other primary antibody defects [2,12]. diagnosis is established. Pre-existing infection in the high-risk situation of a combined primary immunodeficiency reduces the chances of a successful outcome from a haemopoietic stem cell transplant. Treatment with immunoglobulin should be continued following transplantation until reconstitution of B cells and antibody production has been achieved. In some cases, prolonged immunoglobulin replacement therapy is required. Recommendation Immunoglobulin replacement therapy should be considered an important adjunct to haemopoietic stem cell transplantation in the management of some primary immunodeficiency disorders. Duration of treatment should be based on individual reconstitution of B-cell function post-transplantation (grade C recommendation, level III evidence). Recommendation Immunoglobulin replacement is recommended for patients with thymoma associated with profound B-cell depletion and/or significant antibody deficiency (grade C recommendation, level III evidence). specific antibody deficiency Specific antibody deficiency is characterised by an inability to mount adequate humoral responses to polysaccharide antigens, with otherwise normal immunoglobulins [13]. Robust case definition is currently hampered by a lack of consensus on in-vitro diagnostic criteria. Consequently, uniform recommendations for treatment are yet to be developed. Most cases appear to have a relatively mild clinical phenotype (encompassing mainly respiratory infections) which Combined immunodeficiencies requiring haemopoietic stem cell transplantation In this group of disorders, including Severe Combined Immunodeficiency and occurring predominantly in children, immunoglobulin therapy is required as a central measure to protect against infection and should be implemented as soon as possible after the CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use can be managed with prophylactic antibiotics and acute treatment of breakthrough infections. Immunoglobulin replacement is reserved for those cases where prophylactic antibiotics fail to control either the frequency or severity of breakthrough infections. Recommendation Immunoglobulin replacement therapy may be required in a proportion of infants with prolonged physiological delay of native immunoglobulin production. Where required, the planned duration of therapy should be defined prior to initiation of active treatment (grade C recommendation, level III evidence). Recommendation Immunoglobulin replacement therapy is recommended in specific antibody deficiency in cases of failure of prophylactic antibiotic treatment where severe, persistent, opportunistic or recurrent breakthrough infections are encountered (grade C recommendation, level III evidence). secondary antibody deficiency Secondary antibody defects are found in a wide range of circumstances (in association with drugs, malignant disease, chronic infections, protein-losing states, systemic inflammatory diseases, trauma and iatrogenic factors such as splenectomy). Infections associated with low measured antibody levels appear to be relatively uncommon in secondary deficiencies, with the exceptions of hypogammaglobulinaemia linked with haematological malignant disease, occasional cases of drug-associated deficiency and rare cases of nephrotic syndrome [15]. Dosage and treatment duration are important factors in drug-associated deficiencies. The deficit may, or may not, be reversible on cessation of therapy. The selection criteria for IVIg to treat hypogammaglobulinaemia linked with haematological malignancy includes the requirement to document failure of serum antibody response to Transient hypogammaglobulinaemia of infancy Hypogammaglobulinaemia in young children is often transient, reflecting delayed maturation of the immune system. In the majority of such children, immunoglobulin levels normalise by the age of around 4 years, but in a minority this can be delayed until 11 or 12 years of age. Most of these children are affected by frequent, minor infections, which can be managed with early, acute antibiotic usage or antibiotic prophylaxis [14]. However, in a small minority, infections are more severe and cannot be controlled or prevented with antibiotics alone. In such circumstances, immunoglobulin replacement is required until normalisation of endogenous antibody production. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use unconjugated pneumococcal or other polysaccharide vaccine challenge. Although this may sound onerous from a practical point of view, the intention is simply to ensure that a patient's response to polysaccharide vaccination is included as a component of the evaluation for IVIg therapy. For example, if a patient received pneumococcal polysaccharide vaccine 3 months previously and their specific antibody levels are low, it would seem reasonable to prescribe immunoglobulin. However, if the patient was vaccinated many years previously, it would be reasonable to vaccinate again and assess the functional antibody response before immunoglobulin was prescribed. Recommendation Immunoglobulin replacement therapy is recommended in secondary antibody deficiency if the underlying cause of hypogammaglobulinaemia cannot be reversed or reversal is contraindicated, or is associated with B-cell malignancy where severe infections with encapsulated bacteria are persistent despite prophylactic antibiotic therapy (grade C recommendation, level III evidence). RefeReNCes 1. Eadles-Perner A-M, Gathmann B, Knerr V, et al. The European internet-based patient and research database for primary immunodeficiencies: results 2004-06. Clin Exp Immunol 2007;177:306?12. 2. Geha RS, Notarangelo LD, Casanova JL, et al. for the International Union of Immunological Societies Primary Immunodeficiency Diseases Classification Committee. Primary immunodeficiency diseases: an update from the International Union of Immunological Societies Primary Immunodeficiency Diseases Classification Committee. J Allergy Clin Immunol 2007;120:776?94. 3. Conley ME, Notarangelo LD, Etzioni A. Diagnostic criteria for primary immunodeficiencies. Clin Immunol 1999;93:190?7. 4. Wood P, Stanworth S, Burton J, et al. Recognition, clinical diagnosis and management of patients with primary antibody deficiencies: a systematic review. Clin Exp Immunol 2007;149:410?23. 5. Seymour B, Miles J, Haeney MR. Primary antibody deficiency and diagnostic delay. J Clin Pathol 2005;58:546?7. 6. Folds JD, Schmitz JL. Clinical and laboratory assessment of immunity. J Allergy Clin Immunol 2003;111(Suppl. 2):S702?11. 7. Chapel HM, Spickett GP, Ericson D, et al. The comparison of the efficacy and safety of intravenous versus subcutaneous immunoglobulin therapy. J Clin Immunol 2000;20:94?100. 8. Pettit SJ, Bourne H, Spickett GP. Survey of infection in patients receiving antibody replacement treatment for immune deficiency. J Clin Pathol 2002;55:577?80. CLINICAL GUIDeLINes fOR IMMUNOGLOBULIN Use 9. Kainulainen L, Varpula M, Liippo K, et al. Pulmonary abnormalities in patients with primary hypogammaglobulinemia. J Allerg
Url: /Media/SUHTExtranet/TrustMedicinesFormulary/Forms/DH-IVIg-approved-indications-Full-Guidance-July-2011.pdf

Papers Trust Board - 30 January 2020

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 30/01/2020 9:00 - 11:45 Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH Peter Hollins David Bennett 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Minutes of Previous Meeting held on 9 January 2020 3 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the Minutes, and to agree on the status of any actions assigned at the previous meeting. 4 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 4.1 Staff Story 9:15 To receive feedback from patients, carers, or other stakeholders about their experience of the Trust's services. 4.2 Briefing from Chair of Quality Committee for review (Oral) 9:30 Tim Peachey, Non-Executive Director 4.3 Briefing from Chair of Audit and Risk Committee for review (Oral) 9:35 Simon Porter, SID/Non-Executive Director 4.4 Briefing from Chair of Strategy & Finance Committee for review (Oral) 9:40 Jane Bailey, Non-Executive Director 4.5 Integrated Performance Report for Month 9 review 9:45 To review the Trust's performance as reported in the Integrated Performance Report and the Quarterly Patient Safety Report. Sponsor: Jane Hayward, Director of Transformation & Improvement 4.6 Finance Report for Month 9 for review 10:30 Sponsor: David French, Chief Financial Officer 5 STRATEGY and BUSINESS PLANNING 5.1 Change Champions for decision 10:40 Sponsor: Gail Byrne, Director of Nursing & Organisational Development Attendees: Tristan Chapman, Director of Improvement & Partnerships, David Young, Head of Leadership Development and Change Champions 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Feedback from Council of Governors' meeting 23 January 2020 (Oral) 11:00 Sponsor: Peter Hollins, Trust Chair 6.2 Register of Seals, and Chair's Actions for ratification 11:05 In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Delegation. Sponsor: Peter Hollins, Trust Chair 6.3 Board Assurance Framework 2019-20 Quarter 3 Report and Next Steps for 11:10 review To receive the Quarter 3 report on the Board Assurance Framework and update on Risk Appetite and Principal Risks for 2020/21 Sponsor: Paula Head, Chief Executive Attendee: Audley Charles, Interim Company Secretary 6.4 Board Committee Terms of Reference - Current Position for review (Oral) 11:30 Sponsor: Peter Hollins, Trust Chair Attendee: Audley Charles, Interim Company Secretary 7 Any other Business 11:40 To raise any relevant or urgent matters that are not on the agenda 8 To note the date of the next meeting: 26 March 2020, in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH 9 Exclusion of press, public, and others The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted.” 10 Items circulated to the Board for reading 31 December 2019 Press Release: Liver expert says alcohol withdrawal symptoms ‘to blame’ for workplace anxiety 17 January 2020 Press Release: Senior doctor says perfect school attendance for children with chronic conditions “unfair and unrealistic” Page 2 10.1 11 11:45 12 12:00 13 13:15 20 January 2020 Press Release: Southampton surgeons showcase state-of-the-art surgical robot 22 January 2020 Press Release: Researchers find drug used widely to treat eye condition has “no benefit” Guardian of Safe Working Hours Quarter Report Sponsor: Derek Sandeman, Medical Director Follow-up discussion with governors Clinical Visit Lunch Page 3 2 Minutes of Previous Meeting held on 9 January 2020 1 Trust Board Minutes Open Session 9 January 2020 Date Time Location Chair Present Attendees Apologies Minutes Minutes Trust Board – Open Session 09/01/2020 9:00 - 10:54 Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH Peter Hollins (PTH) Jane Bailey (JB) Non-Executive Director (NED) Gail Byrne (GB) Director of Nursing & Organisational Development Cyrus Cooper (CC) NED Jenni Douglas-Todd (JD-T) Senior Independent Director/NED Keith Evans (KE) NED Designate Simon Porter (SP) /NED Paula Head (PH) Chief Executive David French (DAF) Chief Financial Officer Jane Hayward (JH) Director of Transformation & Improvement Joe Teape (JT) Chief Operating Officer *Steve Harris (SH) Director of Human Resources *Audley Charles (AC) Interim Company Secretary & Associate Director of Corporate Affairs *Duncan Linning-Karp (DL-K) Divisional Director of Operations 3 Governors 2 Members of staff *Denotes non-voting member/attendee David Bennett, NED Derek Sandeman, Medical Director Tracey Burt, PA to Trust Chair and CEO 1 Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed members and attendees, including Keith Evans, NED Designate. He noted that that was the first Trust Board JD-T had attended as Deputy Chair/SID. There were no interests declared in relation to items on the agenda. 2 Minutes of Previous Meeting held on 28 November 2019 The minutes were confirmed as an accurate record subject to the following updates/amendments:- • DL-K and JMcA to be denoted as non-voting attendees. • PTH advised that as the Trust Board minutes for 28.11.2019 had only just been re-issued, any subsequent observations would be accepted by email. RESOLVED: The minutes were approved as an accurate recored subject to the changes indicated. 3 Matters Arising and Summary of Agreed Actions The Action log was reviewed and updated as follows: • Annual Litigation & Insurance Review – Action 116. An update would be taken to the March Quality Committee and to Board on the 26th March 2020. • Patient Mis-identification – Action 117. This would be taken to the April Quality Committee and an update provided to the Board on the 30th April 2020. • Research and Development Strategy – Action 118. A tentative date had been scheduled for this to be discussed at a Board Study Session. • Shared Research and Development Mission – Action 119. A meeting between the Vice Chancellor and Chair of Council of the University of Southampton, PTH and PH had been arranged for the 14th February. • Staff suffering violence – Action 127. SH advised that he had met the staff (and their managers) who had presented at the Trust Board. On reflection he felt that whilst there was a range of relevant policies/procedures in the organisation, they did not link together well. The issue would be reviewed at the People Committee which was due to operate from February 2020 under the chairmanship of JD-T. An update would be given at the April Board. ACTION: SH/GB to update the April Board. • Patient experience and waiting times – Action 130. JH advised that information on cancer waiting times would be provided to the Board on the 30th January. ACTION: JH to update Board on the 30th January. 4 QUALITY, PERFORMANCE and FINANCE 4.1 Patient Story A patient and her husband shared their experience of the Trust’s services following her diagnosis with ovarian cancer in March 2019. They praised the nursing staff but expressed disappointment about communication and the service provided by the physios. They also mentioned expensive car parking, poor food, the lack of empathy/support provided by stoma nurses and being given the wrong medication. PTH thanked them for attending and sharing their experience. Page 2 ACTION: GB to advise the couple of actions taken in relation to their observations. 4.2 Briefing from Chair of Strategy & Finance Committee for review Jane Bailey, Non-Executive Director, summarised the items discussed at the Strategy & Finance Committee held on the 6th January and highlighted the following:- • whole system updates had been discussed and the impacts they would have on the Trust’s future capacity and resourcing. • the current financial position and the Cost Improvement Programme had been considered. It had been a challenging month but the papers and issues were clear and there was nothing specifically that needed to be flagged to the Board. • the forecast outturn had been considered and would be discussed during the Closed Board. 4.3 Integrated Performance Report for Month 8 for review JH, Director of Transformation and Improvemnt, introduced the report. Improving patient journeys • JD-T asked whether anything had been done differently to support administrative staff who had to contact patients regarding the cancellation of operations. PH advised that matrons had been providing support to admin teams and patients having their operations cancelled on the day of surgery were being contacted/seen by senior staff. • PTH noted that it had been a difficult period for delayed transfers of care and asked whether the Trust could encourage other organisations to do more. PH advised that this was a national issue and whilst additional funding had been provided by government, it was not sufficient to match demand. Local councils had been trying different things but lack of staffing was a key issue for many care providers. JT advised that there had been between 80 and 100 delayed transfers of care during the period and whilst some issues were within the gift of UHS, there were also capacity and external factors and all aspects of the process needed to be speeded up. ACTION: JH advised that delayed transfers of care would be discussed at a Quality Committee. • PTH asked what was driving referral to treatment time performance and where the Trust would be if demand had not increased in the way it had. JH advised that there had been some quite successful programmes to reduce demand this year but the greatest difference had been the Trust’s inability to deliver additional outpatient clinics and theatre lists. Page 3 She noted that West Hants CCG had been doing work on intial triage to reduce demand. Key Performance Indicators (KPI) report PTH suggested that the icons were removed as they were not adding value. This was agreed. (IPJ1-L) Non elective LOS - it was noted that the line was very flat and that this was one of the Trust’s most important metrics. (IPJ16-N) %Patients on an open 18 week pathway - the impact this wait had on patients was a concern. (HL1-N) Cumulative Clostridium difficile - the increase in numbers was noted. GB advised that this was due to increased testing because of the norovirus outbreak, rather than higher levels of C. difficule being present. (HL12) Crude Mortality Rate – PTH noted the sharp increase and asked whether this should be a matter of concern.. TP advised that this metric was particularly sensitive to coding issues. (HL14-L) Maternity FFT negative score – the score was noted and GB suggested that there was some fatigue with the collection of data. The Trust would be working with a new survey supplier. (HL15-L) Staff Sickness Absence - it was noted that this was increasing and that other workforce metrics were not being met. (LE7-L) NIHR CRF/BRC publications year on year growth – JB noted the decline and the impact this might have on the Trust obtaining the next BRC research grant. CC advised that an advisory panel would be coming to the Trust on January 22nd and would provide an indication of the likely bid success. Estates – DAF noted the drop off in these graphs and advised that a new Head of Maintenance had recently started work at the Trust. KE asked which were the most important KPIs and this was debated briefly. RESOLVED: The Board noted the report. 4.4 Staff Strategy 6-month Progress Report for review The report was presented by SH, Director of Human Resources and the following points were highlighted:- • in Spring 2018 the Trust had agreed a five-year Staff Strategy which now needed to be refreshed to align with new UHS goals, the clinical strategy and to meet the requirements of the National NHSI People Plan. Page 4 • the staff sickness absence rate was still below the National average but had increased and was an indication of the pressure staff were under. • appraisal rates had dropped but the Trust was working to improve the quality of appraisals. • there had been significant strides made in the recruitment of overseas nurses which had helped to reduce agency spend. Following national advice from the BMA regarding pensions, UHS had written to all consultants providing contractual assurance. PH suggested a pragmatic approach as staff reviewed their work/life balance and advised that other solutions to demand/capacity issues would be needed. GB advised that because of demand/capacity issues and the opening of more areas, registered nurses had been moved around the Trust. They were now spread more thinly which may result in the need for extended agency use. She also advised that the running of a kindness and civility campaign across the Trust was being considered. There was also to be a calendar of events to celebrate nursing. JD-T advised that the new People Committee would meet for the first time in February. Terms of Reference would be signed off and the Committee name confirmed. JB asked whether any themes relating to low staff morale had been picked up through the staff survey. SH advised that the HR Business Partners had run some sessions with staff in areas identified and the Change Champions had also picked up on hot spots. CC noted the growing strain on medical train and suggested that this should be monitored. RESOLVED: The Board noted the report. 4.5 Finance Report for Month 8 for review The Finance Report for Month 8 (November) was presented by DAF, Chief Financial Officer. It had been expected that the month would be profitable as winter pressures had not set in and most staff were at work but a surplus of £0.6m was delivered against a planned surplus of £3.1m. This was largely due to the impact of norovirus which meant that significant elective capacity was lost, as beds were occupied by nonelective patients. The Trust was also unable to admit new patients to empty beds due to infection being present in bays. The other significant factor was CIP delivery which was £3.1m against a plan of £3.7m. The CIP plan had required length of stay reductions which would have enabled cost savings through bed closures. The engagement of PwC to support the Trust’s ‘Always Improving - Inpatients’ programme would help with length of stay improvements during the coming months. Page 5 Year to date the Trust had a £4.4m surplus excluding PSF and a £7m surplus including PSF which was within £0.1m of Plan. DAF was confident that the Trust would achieve the Q3 surplus plan which would trigger Q3 PSF of £3.8m. It was unlikely, however, to achieve the Q4 plan which would require an £11m surplus. The forecast year end surplus was £2-5m which represented a £12-15m downside. The four key factors affecting the Trust’s financial out-turn for the year were:- • the length of the norovirus outbreak and the impact of flu. • the impact of high non-elective activity off-setting profitable elective capacity. • CIP, in particular, length of stay reductions. • the outcome of negotiations with CCGs who were challenging coding and counting. RESOLVED: The Board noted the report. 5 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 5.1 Amendments to the Trust's Constitution for approval The paper was presented by PTH. Board members were advised that there was an error on page 3, section 1.1 which should state that were 6 voting Executive Directors, including the CEO. Change to Section 4.2: Composition of the Board of Directors Following discussion the Remuneration and Appointment Committee had approved the appointment of a new Executive Director. A Director of People, who would be a voting member of the Board, would be appointed and the recruitment process was underway. It was therefore proposed that the Trust’s Constitution be amended to read that the Board of Directors would comprise:- 4.2 The Trust’s Board of Directors is to comprise; 4.2.1 A non-executive chair 4.2.2 Not less than five or more than seven each of executive and nonexecutive directors 4.2.3 The numbers of executive and non-executives shall be equal 4.2.4. The Chairman has a casting vote in the event of a tie Change to Sections 13.1 and 13.6: Arrangements for the appointment of the Lead Governor and Deputy Lead Governor The Constitution did not state how those appointments should be made and the arrangement outlined on page 3 of the paper was proposed for adoption. Page 6 RESOLVED: The Board approved the proposed amendments to the Trust’s Constitution. 5.2 Register of Seals, and Chair's Actions for ratification DAF suggested that the fee agreed with PricewaterhouseCoopers be removed from the Trust’s records, so that it was not subject to FoI requests as it was commercially sensitive. RESOLVED: The Board approved the removal. 6 Any other Business Thanks • Steve Erskine, Chair, Hampshire Hospitals had spent Christmas Day at UHS with his mother and had thanked staff for the “terrific treatment” she had received. • PTH noted that that was the last formal Board meeting that SP would attend as a NED. He thanked him for all his work on the Board and for his contributions to the Strategy and Finance Commmittee and the Audit Committee. Register of Interests • JD-T asked for an amendment to be made to the register. 7 To note the date of the next meeting: 30 January 2020, in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH There being no further business the meeting was closed at 10.54 hrs Page 7 3 Matters Arising and Summary of Agreed Actions 1 List of Action Items List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 31/10/2019 4.3 Briefing from Chair of Audit and Risk Committee for review (Oral) 116. Annual Litigation & Insurance Review Charles, Audley Peachey, Tim 26/03/2020 Pending Explanation action item TP to ensure nature of claims against the Trust is picked up through the Quality Committee and provide a periodic summary to Board. Acknowledged at the November Board and the Interim Company Secretary to discuss with Tim Peachey a Formal Report to be presented to the March Quality Committee, after which the Chair will update the Board in his briefing. An update will be brought to the March Board after the Annual Business Cycle for the Quality Committee has been approved. Trust Board – Open Session 31/10/2019 4.5 Integrated Performance Report for Month 6 for review 117. Patient Mis-identification Byrne, Gail Peachey, Tim 30/04/2020 Pending Explanation action item The Quality Committee to review progress on eliminating the possibility of patient mis-identification in 6 months' time and feed back to the Board. This to be incorporated into the Quality Committee agenda for 27/04/19, with an update to Board. Trust Board – Open Session 31/10/2019 4.5 Integrated Performance Report for Month 6 for review 118. Research and Development Strategy Hollins, Peter Sandeman, Derek Explanation action item Identify an opportunity to discuss R&D strategy during a Board Study Session. Item tentatively scheduled for the April Board Study Session. 07/04/2020 Pending Page 1 of 3 Trust Board – Open Session 31/10/2019 4.5 Integrated Performance Report for Month 6 for review 119. Shared Research and Development Mission Head, Paula Explanation action item Arrange a joint meeting of the UHS and UOS Boards. Meeting arranged for 14 February 2020. 30/01/2020 Pending Trust Board – Open Session 28/11/2019 3 Matters Arising and Summary of Agreed Actions 127. Staff Stories - Staff members suffering violence Byrne, Gail Harris, Steve 30/04/2020 Pending Explanation action item SH to consider the need for a specific procedure as part of his review until resolved and GB to inform staff members involved of the outcome. This issue would be reviewed at the People Committee which was due to operate from February 2020 under the chairmanship of JD-T. An update would be given at the April Board. Explanation Harris, Steve SH has now met with the staff members, and also held a separate meeting with the line manager and the matron from the area. The meetings were productive. In summary it is concluded that there need to be revision to existing policy and practice, and an increase in the existing support provided to staff, particularly when injured at work through violence. The areas identified were: • Ensuring compassionate and fair application of trust policy (particularly sickness) when colleagues are injured in the line of duty • Increasing the levels of support and deploying these rapidly for those who are physically injured, and ensuring metal injury is prevented or supported if this occurs • Increasing support and awareness of PTSD • Formalising a fast tacking programme to ensure staff can receive clinical treatment at UHS, and potentially other NHS organisations, in a timely way to help support them back to work sooner. • Rapid application of temporary injury allowances where appropriate. Page 2 of 3 Trust Board – Open Session 28/11/2019 4.5 Integrated Performance Report for Month 7 for review 130. Patient Experience and Waiting Times Hayward, Jane 30/01/2020 Pending Explanation action item The Board requested that positive assurance in relation to patient experience and waiting times be provided in the opening narrative of the next reports. JH advised that information on cancer waitiing times would be provided to the Board on 30th January 2020. Trust Board – Open Session 09/01/2020 4.1 Patient Story 145. Patient Story Byrne, Gail Explanation action item GB to advise the couple of actions taken in relation to their observations. 30/01/2020 Pending Trust Board – Open Session 09/01/2020 4.3 Integrated Performance Report for Month 8 for review 146. Improving Patient Journeys Hayward, Jane 30/01/2020 Explanation action item JH advised that delayed transfers of care would be discussed at the Quality Committee. Update: The Complex Discharge Quarter Report will be reviewed at the Quality Committee on 27 January 2020. Pending Page 3 of 3 Report to the Trust Board of Directors dated Thursday, 30 January 2020 Title: Integrated Performance Report 2019/20 Month 9 Category Quality, Performance, and Finance Agenda item 4.5 Sponsor Director of Transformation and Improvement Author Trust Performance Manager Provenance Classification The Integrated Performance Report is reviewed monthly by the Board of directors This Report is unclassified. Purpose and The paper is presented for REVIEW. recommendation Relevant strategic  Goal 1: Improving goals patient journeys.  Goal 4: Building an expert and inclusive workforce.  Goal 2: Delivering value-based health and care.  Goal 5: Being agile in meeting people’s needs.  Goal 3: Supporting healthy lives.  Goal 6: Creating leading-edge research, education, and innovation. Assurance framework links • BAF01 – 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 nonelective pathways • BAF02 – Failure to deliver regulatory requirements causes the Trust to breach the terms of its Provider Licence leading to a loss of local leadership due to an enforced change in Board and Executive composition, impacting on Goals 1 to 6 • BAF03 – Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme • BAF04 – Reduced access to resources compromises the quality of services • BAF05 – Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care • BAF06 – Lack of capacity and agility renders the Trust unable to respond to the changing operating environment, causing a failure to provide contracted services • BAF07 – Poor staff wellbeing and engagement leads to an inability to deliver safe and timely care • BAF08 – Lack of inclusion and diversity results in the failure to get the best from every individual • BAF09 – Failure to respond with the necessary organisational changes in design and operation renders the Trust unable to remain a competent NHS Provider • BAF10 – Inability to offer translational research renders the Trust unable to maintain its cutting-edge teaching hospital status Impact n/a assessments Other standards n/a affected Integrated KPI Board Report Digest Improving patient Journeys December was a challenging month for UHS across both the elective and non-elective pathways. While the norovirus outbreak from November largely abated, we continued to spend a significant number of days on Black Alert and a high number of elective cancellations. Non elective length of stay increased slightly from 6.38 in November to 6.41 in December. This is the second month in a row we have had an increase following a reducing trend for the previous 38 months. Delayed transfers of care increased in December to 7.3% against a target of 3.5% which is the highest figure since definition changes made in August 2018. Although we are not achieving the percentage target year to date we have delivered 1067 more complex discharges when compared to last year reflecting the additional complexity and volume of patients we are treating. We have continued to work closely with system partners and we are working together to ensure we have additional capacity in the winter months. The wider system has put in 15 additional beds, as well as a home care service, and UHS opened the first tranche of winter beds at Princess Anne (a 26 bedded medical ward, a net increase of 14 beds). The COO team have stated to work with the Integrated Discharge Bureau to improve the escalation framework for DTOCs, and are also convening a summit with the system to look at what more can be done, including how risk is more appropriately spread across the system at times of heightened pressure. Adult bed occupancy has been consistently higher this autumn compared to last autumn at around 94%. Adult bed occupancy last year was 86.4%, this year it was 93.2% in December. We have had a 7.8% growth in emergency attendances and a 3.4% increase in non-elective spells (year to date) accounting for the additional inpatients this summer. The Always Improving Inpatients project started in late November with a plan to reduce LOS by 12% by March 2020. Teams have been engaging in the project well. This is being rolled out in phases so will not deliver a 12% reduction overall in LOS but will be focused on key areas. While early anecdotal reports have been positive, we are not expecting data showing any improvements until February. ED performance improved in December from the low of November. For the month, type 1 performance in December was 76.3% and we ranked 3rd of 8 Major Trauma Centre peers (8th being worst). Local delivery system performance was at 86.6% in December against a local target of 90.0%. The key issues remain the same, poor bed flow (particularly for medicine and medicine for older people) and internal processing and capacity within the Emergency Department. A new clinically led action plan is being developed with the department and will be ready by the end of January. While performance obviously remains important, the current overcrowding within the department, patient experience and outcomes are the driving factor in our improvements. The key improvements focus on: • Internal processing and standardisation within the Emergency Department • Pull from receiving specialties (including developing new pathways, e.g. for #NOF) • The potential to expand SDEC • A longer term strategy on the future of the Emergency Department, including the estates (and the Emergency Village) • What more the system can do to reduce attendances and improve discharges • Mental Health • GP streaming As part of the budget setting process we are also looking at what additional investment the Emergency Department needs and how this will support both performance and safety. The percentage of patients on an open Referral to treatment pathway (waiting list) who have waited less than 18 weeks in December is at 79.5%. Patients waiting over 18 weeks increased by 337. The overall waiting list increased in size by 87 patients over December. Capacity in OPs and theatres was reduced due to December bank holidays. Neurology, Ophthalmology and ENT all had increased volume of > 18 week waits in the referral category, these are patients who have not yet been seen. Ophthalmology, dermatology and colorectal all had increased numbers of patients in the still on pathway category (these patients have been seen but not yet had a definitive treatment) and gynaecology, urology and ENT all increased their number of > 18 week patients waiting for surgery. 52 week breaches • In December 22 patients had not received a definitive treatment within 52 weeks. • The main areas of concern remain ENT, benign urology and paediatric orthopaedics. There are specific plans in place for these specialties whilst other care groups with lower volumes are carefully tracking all long waiting patients. Work is ongoing to improve pathways across all RTT areas and a range of plans are in development as part of our plans for 2020-21. Some examples of these include:- Neurology. • In January the team commenced a 200 day rapid improvement project with the aim of reducing patients requiring Outpatient appointment by up to 28% per annum. • If achieved, assuming referrals do not increase, this would balance demand and capacity it would not however reduce the backlog, further plans would need to be developed for this. Ophthalmology • There is additional capacity via an insourcing model at Lymington hospital from February 2020, delivering 1,400 additional outpatient appointments. • There will be a new consultant in eye casualty from March 2020 adding additional 219 clinic slots per annum and 252 cataract operating slots. ENT • We are planning to operate on 75 long waiting patients by the end of March either in the private sector or by the use of an insourcing company. This would remove the long waiting benign work which is displaced due to the high ENT cancer demand. • There are ongoing discussions with CCGs about stopping some referrals to UHS for benign ENT work which would then take place at alternative locations. Urology • In January the team are undertaking benign long waiting kidney stone work in the private sector; It is expected to remove 14 longer waiting benign patients from the waiting list. • There is space in the newly developed urology day unit, with the appointment of an Associate specialist for kidney stone work this should treat an additional 32 patients from the waiting list by the end of March. The ENT & Ophthalmology operating work streams are being supported by additional NHSI funding which was secured in December. Gynaecology • The gynaecology theatres have been refurbished this winter, the re-opening has been delayed due to validation of the air handling system. The service will continue to use theatre K in the meantime and will maintain access to theatre k when gynaecology are back and operating in their own footprint. • UHSFT has access to one theatre at Southampton treatment centre, the service has been asked to review their use of the STC and are due to report back with actions against all of their 52 week breach risk in light of this additional capacity being made available. Paediatric Orthopaedics. • All patients at risk of not being treated within 52 weeks now have dates for surgery. • A sustainable plan for paediatric trauma is required and will form part of the overall discussion around theatre capacity. Diagnostics 6 week diagnostic performance did not achieve the target at 2.51% against a target of 80%). Of those found to have moderate or high alcohol dependence 86% were given relevant advice or a referral to specialist services in December, this performance is stable not achieving the target 90% (last achieved December 2018). Of those found to smoke who were given advice or offered medication performance in December was 96%, above the target 90%. Building an expert and inclusive workforce This month staffing remains amber overall because some key targets have been missed for staff turnover and appraisals. A small increase in CHPPD can be attributed to a decrease in patient numbers due to the Christmas period and the amount of nursing hours remaining stable. Rolling sickness absence rates are continuing to increase and are now over 0.16% over the target of 3.4% a, underpinned by a higher rate of sickness absence during the summer compared to 2018. Reporting of sickness will transition to statistical control process from February. UHS has seen improvements in rates of employment for BAME Band 7+ to 9%. Additionally, the position for the following is stable: statutory and mandatory training compliance (with 7 of 12 measures meeting target). In UHS ward-based areas, total nursing staff vacancies have increased by 0.69% since last month Registered nurse vacancies in ward-based areas have again decreased this month (by -0.63% since last month) and is below the target of 15%. These changes are due to 24 Overseas nurses having acquired their PINs and promotion of RNs, however there have also been staff lost due to relocation of staff and reduction in contracted hours mainly following return from maternity leave, . The total CHPPD rate in the Southampton General has increased from last month to RN 5.7 (previously 5.6), HCA 3.5 (previously 3.4) overall 9.2 (previously 9.0).The CHPPD for ward based areas (excluding Critical care units) in in the Trust has increased from last month to RN 4.2 (previously 4.1) HCA 3.5 (previously 3.5) overall 7.7 (previously 7.6). Being agile in meeting people’s needs Estates helpdesk requests completed on time did not achieve target in December (10th month in a row), currently at 77.2%. Unresolved help desk requests remain below target, in December we had 838 against a target 85% in November at 92.8%. Since introducing eQuest requesting in theatres in SGH we have seen a surge in histo requests being placed directly. In total the number of specimens being acknowledged is increasing. UHS patient logins to My Medical Record dropped significantly in December. Cumulative patient registrations is at 21,727. The plan is to increase to 100,000 registrations by the end of this year. At the current rate of increase this will not be achieved. Mr Dave Berry, Chair of the MyMR steering group, will review this and a new MyMR strategy is being developed. Leading edge research, education and innovation In Q3 2019/20 UHS was ranked 9th for non-weighted and 6th for weighted CRN recruitment against a target of being in the top 10 and top 5 respectively. Whilst we are still meeting target for non-weighted recruitment in terms of ranking our performance against our NIHR CRN target is significantly down, largely due to one large musculoskeletal study (5k participants) unlikely to hit target but also impacted by capacity constraints within clinical trials pharmacy. Our weighted recruitment is currently not meeting target, and again is also down against our NIHR CRN target which reflects in part that many of our more complex interventional clinical trials have been impacted by the capacity constraints within clinical trials pharmacy (see below for how these have been addressed) In Q3 UHS are currently ranked 13th for contract commercial study recruitment, which whilst an improvement against previous recent performance (up from 16th), is still not meeting our target of being in the top 10, so we will continue our specific focus on improving our commercial performance. Comparative CRN recruitment performance by specialty was on target in Q3 2019/20 with 52% specialties ranking as predicted (in the top 5 or top 10 based on prior performance). Proportion of commercial studies closing in 18/19 FY on time and to recruitment target ended the year below the 80% target at 71%, however this was an improvement on the 17/18 performance of 57%. In Q3 2019/20 this metric is currently at 65%, and we anticipate a further improvement by year end, with an ambition that we will meet the 80% target. Proportion of non-commercial studies closing on time and to recruitment target in Q3 is currently at 65% and again we anticipate that this will improve significantly by year end, such that Wessex will meet its 80% target. Clinical study set up and recruitment (in particular for the commercial portfolio) has been impacted by capacity constraints across the research infrastructure and by pressures within the clinical services, in particular with regards to pharmacy capacity to set up and deliver clinical trials. Capacity constraints within clinical trials pharmacy have been addressed in the longer term by a business case to double staffing levels, which was approved by TIG in November 2020 and the initial round of recruitment has recruited additional pharmacy staff due to start in the new year. In the shorter term the clinical trials pharmacy team have been working closely with the R&D office to streamline processes, and work together against a prioritised pipeline of studies in set up. The year to date NIHR CRF & BRC publications in 2019/2020 is 329 currently (14.5% less than same time last year), related to a loss of clinical academic staff. This is a major concern for our next BRC and CRF applications and actions are currently in progress that will require Trust support in due course. Integrated KPI Board Report covering up to Dec 2019 Executive Sponsor - Jane Hayward, Director of Transformation Jane.Hayward@uhs.nhs.uk Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line Percentiles Control Chart Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). A line percentiles chart is used to represent the distribution of a variable. The 50th percentile shows the median value, we also show the 5th, 25th (lower quartile), 75th (upper quartile) and 95th centiles. A control chart shows movement of a variable in relation to it's control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from it's target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving it's target. 2 December 2019 Improve Patient Journeys IPJ1-L Non Elective LOS Rolling 12 months IPJ2-N Delayed transfers of care (CQC Calculation) Oct Nov Dec Jan Feb Mar Apr May Jun Jul 7.5 6.70 6.0 8.96% 7.1% 5.26% Aug Sep Oct Nov Dec Monthly Target 6.41 =21days) 231.62 204.36 177.10 162 77.44 IPJ4 Outliers weekday (am) census average 50.48 22 23.51 196 IPJ10-N UHS Total (includes SGH all types and lymington until Jul 19) Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec QTD 88.8% 90% 80% 76.3% 77.3% 695% 3 3 5 9 7 9 7 7 6 6 5 4 72.4% 53 91.29% 83.4% 75.48% 90.7% 90.7% 78.3% 78.94% IPJ11- Local Delivery System L/N . 94.33% 88.2% 82.14% 92.9% 86.6% 86.87% Q Target 95% 95% L = 90% N = 95% IPJ12 Same Day Emergency Care (SDEC) 70 IPJ13-N Time to initial assessment 95th Centile UHS Total - 55 40 Awaiting national data definition - - 42 IPJ14-N Time to treatment Percentiles UHS Total IPJ15-N Total time spent in ED Total Percentiles UHS Mean, 1:34 50th, 1:21 Mean, 2:44 50th, 2:41 90th, 3:24 =92% 79.51% 34605 30633 - 0.5 5 9 10 8 9 10 6 8 3 6 5 7 8 6 IPJ21 The national average for this metric in November was 79.36% with UHS ranked 106th out of 155 organisations. IPJ22NL 62 day cancer wait performance 88.0% 76.5% 72.6% N=> 76.2% 90% L=> N = 23 L= 1 of 74% 77% 170.5 1 of 13 tumour sites achieved 62 day target in July. IPJ23NL 31 day cancer wait performance 97.1% 93.3% 89.5% N=> 96% N=70 88.05% L=> L=58 of 879 88% 95% IPJ24-N Urgent GP referrals seen in 2 weeks 96.8% 91.2% 85.6% 83.0% 97.5% => 93% 0 of 1544 97% 12 of 13 tumour sites achieved 2 week target in July. IPJ25 Snapshot of waits > 104 days 72 29 28 46 28 37 28 26 33 38 41 55 52 41 - - - 100% IPJ26 28 Day Faster Diagnosis 79% => 95% 231 of 1484 78% 70% IPJ26 - this KPI is being shadow monitored by UHS in preparation for national submissions beginning April 2020. There is no update this month 6 December 2019 1.30 Value Based Health and Care MMoonntthhllyy Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target YTD YTD Target VB4-L Complaints per 1000 units 0.22 0.00 - 0.29 100% VB5-L % Complaints closed within 35 days 20% VB6 Urgent cancer referrals and Breast Symptoms referrals VB7 Number of first cancer treatments (i.e. 31 day activity) VB8 Total ED Attendances 40% 2,000 1,300 500 200 12,000 9,000 1704 1658 388 373 11967 10868 86% 70% Month QTD -46 +79 YTD +233 -2.7% +2.3% +1.7% +15 +9 +32 +4.0% +1.2% +1.1% +1099 +2505 +7371 +10.1% +7.9% +7.8% VB8: Lymington MIU removed. VB9 Non-elective Spells 6,700 6660 +273 +335 +1916 (incl. CDU) 5,000 6387 +4.3% +1.7% +3.4% 7 December 2019 VB10 Face to Face OPA Value Based Health and Care Monthly 65,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target YTD YTD Target 51669 -4142 +3410 - 45,000 47527 -8.0% +0.9% - VB10/VB11: This currently excludes mymedical record contacts. VB11 8,500 Non-Face to Face OPA 5,000 7513 +347 +3225 +3225 7166 +4.8% +6.9% +6.9% 9.5 Total nursing staff all inpatient 9.1 VB12 areas - Care hours per patient day (CHPPD) 8.0 9.2 - The total CHPPD rate in the Southampton General has increased from last month to RN 5.7 (previously 5.6), HCA 3.5 (previously 3.4) overall 9.2 (previously 9.0).The CHPPD for ward based areas (excluding Critical care units) in in the Trust has increased from last month to RN 4.2 (previously 4.1) HCA 3.5 (previously 3.5) overall 7.7 (previously 7.6) 100 62 VB13 Red Flag staffing incidents 50 28 - 0 8 December 2019 Supporting Healthy Lives Monthly Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target YTD YTD Target HL1-N Cumulative Clostridium difficile HL2 Number of pressure ulcers causing 2 moderate/severe harm 0 HL2 KPI commenced in April 2019, no historic data available HL3-N Medication Errors (severe/Moderate) 1 HL4 Serious Incidents Requiring Investigation (SIRI) 4 HL5-L Number of overdue SIRIs 6 30 6 49 49 =35% 100% HL7-N Neonatal admission temperature within range rate 40% HL8-N Bronchopulmonary Displasia (BPD) rate 100% 57% 80% 0% > =80% =20% =20% 80% > 90% > 90% 11 December 2019 EW1-L Staff - Turnover - Rolling 12-months An Expert and Inclusive Workforce Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly Target 13.83% 13.22% 12.60% 13.0% 13.6% 92% =76% 30% 9.0% - 12 December 2019 Being Agile in Meeting People's Needs Estates Monthly Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target 2500 1771 1724 - R-3M - BA1-L Number of Help desk requests and percentage completed on time 1000 100% 85% 81.0% 77.2% > 85% 77.3% 50% 1500 Reactive Maintenance BA2-L Unresolved help desk requests 1000 750 838 85% 82.5% - - 222 > 95% 98.2% 97.3% 13 December 2019 BA6 Monthly average unavailable toilets (%) Oct 1% Being Agile in Meeting People's Needs Monthly YTD Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target Target 0.53% 0.47% 0.51% 0.32% 0.80% 1.00% 0.49% 0% BA6 - This KPI is intended to be a proxy of the impact of maintenance work that is not completed on patients and staff. 9,000 BA7 Number of computers 8,000 7,000 4.0 7899 7971 8144 8181 BA8 Average age of computers (years) 3.5 3.9 3.9 3.0 95% BA9-L Percentage specimens requested through eQUEST - rolling 3M 89.3% 3.9 3.8 4.0 > =95% - 85% 95% BA10L Percentage specimens available for acknowledgment through eQUEST - rolling 3M 85% 200,000 BA11 digiRounds patient records accessed 100,000 0 91.4% 47,681 > =95% - 151,538 14 December 2019 Being Agile in Meeting People's Needs Monthly Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target eQuest Results Alerts Sent 20,000 BA12 Decision support notifications (email alerts) 10,000 0 20000 8693 BA13 Medxnote 10000 BA14 InfoQlik (Daily) Activity BA15 Sap BI (Daily) Activity 0 50 23.2 0 50 31.8 8430 29.8 27.4 0 44,800 BA16 My Medical Record - Cumulative UHS patient registrations 22,400 0 10,000 BA17 My Medical Record - UHS patient logins 0 1,697 718 21,727 2,447 15 December 2019 Leading Edge Research, Education and Innovation Comparative CRN Recruitment Performance Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec LE1-L Non-weighted 8 7 7 10 9 YTD YTD Target - Top 10 LE2-L Weighted 2 2 3 - Top 5 5 6 LE3-L Contract commercial 12 13 - Top 10 13 16 15 LE4-L Comparative CRN Recruitment performance by clinical specialty 42% 50% 58% 44% 52% 52% 50% Proportion of studies closing in FY on 75% 71% 59% 68% 65% LE5-L time and to recruitment target - 65% 80.00% commercial Proportion of studies closing in FY on LE6-L time and to recruitment target - 50% 46% 56% 65% 65% 65% 80.00% non-commercial 16 December 2019 Leading Edge Research, Education and Innovation Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec LE7-L NIHR CRF & BRC publications Year on year growth 581 385 246 137 Quality of practice experience for LE8-N doctors in training (annual report with quarterly qualitative updates) Minor Risk 100 78 LE9 Number of Apprenticeship Starts 0 Minor Risk 30 Minor Risk 12 Minor Risk 28 Minor Risk YTD Target No risk - 17 Quarterly Patient Safety Report Sep 19 – Nov 19 • The NHS Patient Safety Strategy. Safer culture, safer systems, safer patients was released in July 2019. Link to document: NHS safety strategy. UHS is developing our own UHS patient safety strategy planned launch April 2020. A safety culture workshop was held in early December. • One Never Event was reported in this quarter. Discussions are ongoing with NHSE regarding the categorisation of a miss placed NG tube in a paediatric patient. • There were 12 new SIRI cases and 1 Never event reported to SISG and 1 infection prevention SIRI During this period we report 1 new ophthalmology SIRI • The trust has meet the 95% target for VTE assessments since October 2019 • Work is continues to develop guidance to standardise the definition of harm for patients on RTT or cancer pathways who are waiting for treatment outside of agreed national standards, a paper has gone to Quality committee to approve process. • RCA’s completed for 12 hour trolley breeches in ED (these are predominately mental health patients) are now being clinically reviewed to ensure there are no clinical, patient safety or safeguarding concerns and that learning is identified where relevant. • In relation to lying and standing blood pressure (BP) – Safetrack has been further support completion based on staff feedback by enforcing an antisocial hours logic and providing a 3 minute capture option. Reports available at local level for clinical leaders to monitor compliance. Education ongoing for lying and standing BPs including Health care assistant competencies. • The pharmacy team have redesigned how they measure medicines reconciliation to ensure it captures all eligible patients and matches the updated national definition. The focused review of areas where rates are significantly lower than target has identified three key areas (child health, oncology and women’s health). An action plan is being developed to resolve the shortfall in these areas. • Southampton City CCG have funded a Acute Kidney Injury (AKI) nurse led follow up clinic as one of their 2019/2020 QUIPP. This is already supporting a reduction in readmissions and improve safety netting for those with AKI stage 2 and 3. Work is ongoing to make this service business as usual and widen out to include West Hampshire CCG patients. • Incident report rates have continued to remain greater than the 35 per 100 bed days. Which is line with a positive reporting culture. • Full time Falls lead in post until April 2020 Current focuses are QI development for the CQUIN and falls policy, review of the falls policy, especially head injury guidance and management, and Trust wide education development. • In the first week of October UHS took part in a national NHSI audit to check the skin of every adult and child inpatient over 3 days. Results have been submitted to NHSI. • UHS held a workshop to review the concept of adopting the principle of a patient safety zone in November. Patient safety zone • Year to date we have had 4 deaths following high harm falls (1 Div A, 2 div B and 1 Div D) • An in depth review of the increased incidence of pressure damage in CICU has demonstrated that this is reflective of the co-morbidities and acuity of the patients and not poor practice. • 4 cases ar
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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
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