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Data protection and confidentiality policy

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University Hospitals Southampton NHS Foundation Trust needs to collect and use information about people with whom it deals in order to
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/Media/UHS-website-2019/Docs/Policies/Data-protection-and-confidentiality-policy.pdf

How to perform a breath test for small intestinal bacterial overgrowth (SIBO) at home - patient information

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This factsheet explains what small intestinal bacterial overgrowth (SIBO) is and how to perform a breath test for it at home
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/Media/UHS-website-2019/Patientinformation/Digestionandurinaryhealth/How-to-perform-a-breath-test-for-SIBO-2892-PIL.pdf

Your personal data and your rights - patient information

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As part of your care at University Hospital Southampton we will need to collect information about you. This data is vital
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/Media/UHS-website-2019/Patientinformation/Visitinghospital/Your-personal-data-and-your-rights.pdf

Patient-initiated follow-up (PIFU) for thyroid cancer - patient information

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This factsheet contains a summary of patient-initiated follow-up (PIFU) for thyroid cancer.
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/Media/UHS-website-2019/Patientinformation/Cancercare/Patient-initiated-follow-up-PIFU-for-thyroid-cancer-3672-PIL.pdf

Finance and Performance Reports 2023-24 Month 10 - January 2024

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Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose: Finance Report 2023-24 Month 10 10.3 Ian Howard – Chief Financial Offi
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/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Finance-and-Performance-Reports-2023-24-Month-10-January-2024.pdf

Papers Trust Board 28 March 2019

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Agenda Group Name: Date of Meeting: Venue: Time: Apologies to: Trust Board – Open Session 28 March 2019 Conference Room, H
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/Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2019/Papers-Trust-Board-28-March-2019.pdf

Aria ePrescribing v13.6 MR1.2 user training guide

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Aria E-Prescribing v13.6 MR1.2 User Training Guide Every effort has been made to ensure that the material in this manual was correct
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/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/User-guides/Aria-ePrescribing-v13.6-MR1.2-user-training-guide.pdf

University Hospital Southampton NHS Foundation Trust Constitution

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Read our constitution here.
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Papers Trust Board 27 May 2021

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Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1
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Papers Trust Board 6 June 2024

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Date Time Location Chair Apologies Agenda Trust Board – Open Session 06/06/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles, Tim Peachey (from 12:00) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 28 March 2024 9:15 Approve the minutes of the previous meeting held on 28 March 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee (Oral) Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 1 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 1 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:45 5.9 People Report for Month 1 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Infection Prevention and Control 2023-24 Annual Report 11:10 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Sue Dailly, Infection Prevention Matron 5.11 Learning from Deaths 2023-24 Quarter 4 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Freedom to Speak Up Report 11:30 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.13 Fuller Inquiry Report 11:45 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gavin Hawkins, Divisional Director of Operations, Division B 6 STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report 11:55 Receive and note the annual report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 6.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 1 May 2024 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 25 July 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 28/03/2024 9:00 – 13:00 Location Chair Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Ceri Connor, Director of OD and Inclusion (CC) (item 4.12) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 4.14) Sophie Limb, HR Project Manager (SL) (item 4.12) 1 member of the public (item 5) 6 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since February 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 30 January 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 30 January 2024, subject to amending a reference to ‘radiology’ on page four to ‘radiotherapy’. 3. Matters Arising and Summary of Agreed Actions It was noted that all actions had been completed or were not yet due. Page 1 In terms of action 1102, the service was provided by NHS Blood and Transfusion, and funding had been removed. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee had reviewed the losses and special payments report and noted that although the individual size of each occurrence was not material, these instances nonetheless did have a significant impact on individual patients. • The committee reviewed the Board Assurance Framework (item 6.1). • The committee reviewed an internal audit report on data quality and noted that there were only some minor matters to address. In addition, there were no outstanding actions from previous reports. • The committee reviewed the internal audit plan for 2024/25, which would include examination of long waiters, the discharge process and rostering. • The external audit plan for the 2023/24 financial year was agreed. 4.2 Briefing from the Chair of the Charitable Funds Committee Steve Harris was invited to provide an overview of the meeting held on 27 March 2024. It was noted that: • The charity was in a position to transfer to the new charitable company. • Gail Byrne would be appointed as a director of the new charitable company on a temporary basis to represent the Trust. • The annual report and accounts for 2023/24 would be the final item of business requiring Board approval. 4.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 25 March 2024. It was noted that: • The committee reviewed the Finance Report for Month 11 (item 4.10) and the planning for 2024/25, noting that the underlying position presented a challenge for 2024/25. • The committee reviewed the Trust’s productivity assessed against that in 2018/19. The NHS England formula showed a 18% decline in the Trust’s performance. However, the basis of the formula was open to debate and the perception in the organisation was different given the demands on the Trust’s capacity. The Trust’s modified formula showed a lower decline in productivity and work was ongoing with the central team. • The committee reviewed the maintenance requirements in the Trust’s estate, which were significant owing to its age. • The committee reviewed the proposed capital prioritisation for 2024/25 and 2025/26. 4.4 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 20 March 2024. It was noted that: • The committee reviewed the People Report for Month 11 (item 4.11) and noted that the additional recruitment controls were having an impact. Page 2 • The committee reviewed the Staff Survey results (item 4.12), noting that key themes were staff burnout and morale. 4.5 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee reviewed the patient safety and experience reports for the third quarter and noted some concerns regarding infection prevention control and pressure ulcers. In addition, there was some concern about overcrowding in the resuscitation area. • The committee had carried out a thematic review of never events, especially in Dermatology. • The committee reviewed the Trust’s performance in terms of its quality priorities for 2023/24. The Trust had achieved all its objectives, except one, which had been partially achieved. It was intended that there would be eight quality priorities in 2024/25. • It had been confirmed that the Integrated Care Board would fund the tobacco dependency programme in 2024/25. • Work was also taking place to provide additional capacity in the Paediatric Intensive Care Unit. 4.6 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) had launched a consultation on how it will re-shape itself for the future. The ICB had been required to reduce its running costs by 20% during 2024/25 and by a further 10% during 2025/26. • Junior doctors had voted to continue industrial action for a further six months. • In the Spring Budget, the Chancellor announced additional funding for the NHS, although, once inflation had been taken into account, the NHS budget would remain broadly flat. • The NHS England Workforce Race Equality Standard data report showed some improvements, but further work was required. • Steve Brine, the Member of Parliament for Winchester and Chandler’s Ford had been hosted by the Trust on a visit the week before. This afforded an opportunity to discuss the Hampshire County Council consultation, social care and non-criteria to reside. • The latest NHS patient survey showed a reduction in satisfaction, but this was largely due to waiting to get into the system. • There was significant pressure from NHS England for trusts to achieve the targets set. The Trust has demonstrated strong performance during 2023/24 across the six targets. • A nurse from the Trust has received a national recognition award based on their work on the ‘Diabasics’ initiative and the first episode of ‘Surgeons at the Edge of Life’, filmed at Southampton General Hospital, had been broadcast on BBC2. • Thanks were expressed to all staff for their performance during the year. 4.7 Performance KPI Report for Month 11 Joe Teape was invited to present the Performance KPI Report for Month 11, the content of which was noted. It was further noted that: • In terms of the Trust’s performance compared with comparators, the Trust was top quartile for the majority of indicators and top half for others. Page 3 • There were 19 patients who would breach the 78-week wait target at year end, 18 of which were corneal patients where materials were unavailable. It was noted that there was a national shortage of materials. • There were expected to be about 50 breaches of the 65-week wait target, of which around 30 were corneal patients. • The Trust had achieved diagnostic performance of 92% achieving the sixweek target. • There had been high volumes of patients in the Emergency Department during February and March 2024. However, the Trust had achieved 70.6% for type 1 performance and expected to achieve the 76% target by the end of March 2024. • The Trust’s Referral To Treatment metric was beginning to improve and there were some examples of very good waiting list management in Trauma and Orthopaedics and in Women and New Born. • The key point to emphasise was that, although it might not seem so at times, the Trust was out-performing most other comparable organisations. It was considered appropriate that staff communications should be worked on to reinforce this message. In terms of the Trust’s Key Performance Indicators: • The Quality Committee had seen significant improvements in diagnostic performance. • The two-week wait cancer target performance had also improved since April 2023. • Unfortunately, due to significant challenges with flow, overnight ward move performance had dropped significantly during the month, leading to poor patient experience. • In addition, the rate of pressure ulcers appeared to be increasing. 4.8 Non-Criteria to Reside Spotlight Report Joe Teape was invited to present the Non-Criteria to Reside Spotlight Report, the content of which was noted. It was further noted that: • Management of non-criteria to reside patients was one of the Trust’s biggest risks in terms of its operational and financial performance and achievement of its targets. • The Trust has seen 20%+ of beds occupied by patients without criteria to reside, which significantly impacted patient flow in the Emergency Department and has led to ambulance handover delays. • In addition, stays in hospital of longer duration were known to lead to worse patient outcomes. • The Trust was unable to have a significant impact on this issue, as the main driver was insufficient funding availability in local authorities. • In terms of what the Trust could do, work was ongoing to improve the discharge process by having conversations about care needs early on as part of the Trust’s flow transformation programme. 4.9 Break 4.10 Finance Report for Month 11 Ian Howard was invited to present the Finance Report for Month 11, the content of which was noted. It was further noted that: Page 4 • The Trust had received £24.6m of cash support from NHS England and £5m in funding in relation to the impact of industrial action between December 2023 and February 2024. • A year-end deficit of £1.4m was forecast. • The Trust’s underlying monthly deficit was currently £4m, and the Trust’s underlying deficit had been £4-5m a month during 2023/24. • Cost Improvement Programme delivery was expected to be £62m at year end, an increase of £17m compared to the previous year. 4.11 People Report for Month 11 Steve Harris was invited to present the People Report for Month 11, the content of which was noted. It was further noted that: • Total workforce had reduced by 20 whole-time equivalents (WTE) during the month, although the Trust remained 266 WTE above plan. • Use of bank staff had reduced, although it was expected that more bank staff would be used in March 2024 as substantive staff used leftover annual leave before year end. • Average turnover was 11%, below the target of 13.6%. The Board discussed the report and noted that it was necessary to review training expectations in order to make best use of staff time. In addition, it was noted that funding for internationally recruited nurses was likely to reduce and that apprentice and student nurse numbers had reduced. 4.12 UHS Staff Survey Results 2023 Report Ceri Connor, Sophie Limb and Steve Harris were invited to present the UHS Staff Survey Results 2023 Report, the content of which was noted. It was further noted that: • The Trust scored above average in all of the People Promise areas and there had been an improvement in the areas regarding managers and appraisals. • However, the overall NHS average had increased, thus narrowing the gap. • The participation rate was lower than in the previous year and the overall scores hid pockets of concern. The Board discussed the results of the Staff Survey. It was noted in particular that the Trust had invested significant sums into wellbeing, but that morale was low. It was considered that this demonstrated the importance of local management to staff morale. In addition, the Board discussed the impact of the change in approach from granting significant autonomy during the pandemic to increasing levels of control, which had been received negatively by staff. However, it was noted that, whilst in some areas, such as with regard to patients, there was a general culture of accountability, there appeared to be less of a general culture of accountability with respect to finances and budgets. The possibility of ‘earned’ autonomy was considered as a means of mitigating against those who had acted properly being penalised by the actions of others. Page 5 4.13 Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report The Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report was noted. It was further noted that the additional information in respect of post-partum haemorrhage data (action 1101) was contained within the report and had been discussed at a maternity safety champions’ meeting. 4.14 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There had been seven exception reports constituting a breach and resulting in a financial penalty, which were due to exceeding the maximum 13-hour shift duration. All reports were from General Surgery. • There were also concerns in Gynaecology due to the complicated rotas, inadequate rest provision and facilities. • The position of a junior doctor was a difficult one due to a lack of patient contact during the pandemic, industrial action and changes in the assignment of foundation posts. Action: Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. 5. Patient Story David Livermore was invited to relate his experience of attending an appointment at the Eye Unit in October 2023 and, in particular, the difficulties he encountered as a wheelchair user. It was noted that his treatment had been carried out in a room inappropriate for his needs and that he had been asked personal questions in the waiting room. Following discussion with the Board of his experiences, David Livermore offered his services to the Trust to advise on disability access as an ‘expert patient’. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The Trust’s Risk Management Policy and Strategy had been updated, with the main changes being in relation to the Trust’s risk appetite following the Trust Board Study Session held in December 2023. • Work was being carried out to improve the Board’s visibility of operational risks and to improve links between operational risks and the BAF. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Remuneration and Appointment Committee Terms of Reference It was noted that the Remuneration and Appointment Committee had reviewed its terms of reference at its meeting held on 28 March 2024. It was further noted that some minor changes were proposed, largely to update references to documentation and NHS organisations, and, in terms of the executive pay guidance, to better reflect current practice and the available frameworks. Decision: Having reviewed the Remuneration and Appointment Committee terms of reference tabled to the meeting, it was agreed to approve these terms of reference. 8. Any other business There was no other business. 9. Note the date of the next meeting: 6 June 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 27/06/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 6 June 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Infected Blood Inquiry • General Election • Industrial Action • HEFMA Award • Capital Funding • 2024/25 Planning The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 Infected Blood Inquiry On 20 May 2024, the Infected Blood Inquiry published its report into more than 30,000 people becoming infected with HIV and hepatitis C after being given contaminated blood products in the 1970s and 1980s. The report said that: • Too little was done to stop importing blood products from abroad, which used blood from high- risk donors such as prisoners and drug addicts; • In the UK, blood donations were accepted from high-risk groups until 1986; • Blood products were not heat treated to eliminate HIV until the end of 1985, although the risks were known in 1982; and • There was too little testing to reduce the risk of hepatitis from the 1970s onwards. The UK Government has established a compensation scheme for those impacted. The report can be read at: http://www.infectedbloodinquiry.org.uk/reports NHS England’s formal response to the report is attached as Appendix 1. During the Inquiry, the Trust was made aware of patient cases which would be cited in the report and was offered an opportunity to comment. We chose not to comment in detail on individual cases, primarily due to the time elapsed since they happened. NHS England has commissioned an ongoing patient support service for those affected and it is likely that UHS will be one of two providers in the region offering this service. Funding for a fiveyear period has been confirmed. General Election The Prime Minister has announced that a general election will be held on 4 July 2024. There are a number of practical implications for the Trust as a public body to maintain political impartiality and to ensure that public resources are not used for the purposes of political parties or campaign groups during the pre-election period which commenced on 25 May 2024 and will continue until the day after the election. During this period, the following key principles should apply: • No activity should be undertaken which could be considered politically controversial or influential. • NHS trusts have discretion in their approach, but must be able to demonstrate the same approach for every political party, official candidate and designated campaign group. • The NHS may be under media spotlight, locally and nationally, so it is advisable to have a plan in place for how the organisation will manage the pre-election period and the potential for the organisation to be singled out in the media. Normal business and regulation needs to continue during the pre-election period. However, where a board meeting needs to take place, the agenda should be confined to those matters requiring a board decision or oversight. Matters of future strategy or future deployment of resources may be construed as favouring one party over another and should be avoided. Use of the confidential part of the agenda to discuss matters which may be politically controversial is not recommended. Care should be taken not to comment on the policies of political parties or campaign groups. Page 2 of 9 Organisations should not start long-term initiatives or undertake major publicity campaigns unless time critical (such as a public health emergency). Public consultations should not be launched during the pre-election period, and it is advisable to extend the period for those already running to take into account the pre-election period. The timing of the election means that formal Secretary of State approval for the Solent / Southern transaction is unlikely to happen before the election and therefore the formation of the new Trust, previously scheduled for 1 June, is likely to be delayed. Industrial Action On 29 May 2024, it was announced that junior doctors would stage a five-day strike, commencing on 27 June 2024 and ending on 2 July 2024. This will be the eleventh walkout by junior doctors since March 2023. As during previous periods of industrial action, the Trust will seek to minimise any impact on patient care by organising consultant cover wherever possible. HEFMA Award Paula Melhuish, Deputy Director of Estates and Capital Development, received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. Paula has been a long-serving and esteemed colleague at UHS and has recently announced her retirement. Capital Funding Due to its Emergency Department performance at the end of 2023/24, the Trust was awarded an additional £2m in capital departmental expenditure limit (CDEL) as part of a scheme to reward high-performing trusts. There were several categories where the top-10 performing trusts received additional CDEL, including absolute ED 4-hour % performance and most improved ED 4-hour performance. NHS England agreed that the type 3 Urgent Treatment Centre attendances at RSH and Lymington should be included in the overall UHS performance and that, combined with significantly improved 4-hour performance at SGH, this meant that UHS was in the national top-10 for absolute ED 4-hour performance. terms of using the CDEL allowance, plans are being developed to increase the department’s same day emergency care (SDEC) capacity. The additional CDEL is not cash-backed so we are in discussions with NHSE regarding the cash funding. 2024/25 Planning The CFO and I will update the Board on the status of the 2024/25 planning round which is not yet finalised. At a meeting in London with NHS England executives, the ICS was asked to improve its position further in return for some financial incentives. This challenge was accepted, although the allocation of this further stretch to individual providers has not yet been agreed. The structure and leadership of the ICS-wide transformation programmes has been reviewed and changed. The structure of the programmes was considered by CEO, Chairs and ICB colleagues and it was agreed there should be six programmes for 2024/25, as set out below. The Board should note that I requested to retain the leadership role on the Planned Care programme, mostly because we have an agreed way forward, have good traction and can now see improvement happening. In addition, I was asked to take on leadership of the Workforce programme which, following discussion with the Chair, I have agreed to do. Page 3 of 9 Programme Mental Health Discharge Urgent and Emergency Care Local Care Planned Care Workforce CEO lead Ron Shields, SHFT Penny Emerit, PHU David Eltringham, SCAS Alex Whitfield, HHFT David French, UHS David French, UHS Each programme has been asked to set out its objectives and deliverables for the year ahead by 18 June 2024. I will share the results of this exercise with the Board in due course. Page 4 of 9 Appendix 1 Classification: Official To: • All integrated care boards and NHS trusts: - chairs - chief executives - medical directors - chief nurses - chief operating officers - chief people officers - heads of primary care - directors of medical education • Primary care networks: - clinical directors cc. • NHS England regions: - directors - chief nurses - medical directors - directors of primary care and community services - directors of commissioning - workforce leads - regional heads of nursing - regional heads of communications NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 20 May 2024 Dear colleagues, Publication of the Infected Blood Inquiry final report Earlier today, the Infected Blood Inquiry published its final report at: www.infectedbloodinquiry.org.uk/reports. The Prime Minister has subsequently issued an apology on behalf of successive Governments and the entire British state. On behalf of the NHS in England, now and over previous decades, Amanda Pritchard issued a public apology, saying: Publication reference: PRN01368 Page 5 of 9 “Today’s report brings to an end a long fight for answers and understanding that those people who were infected and their families, should never have had to face. “We owe it to all those affected by this scandal, and to the thorough work of the Inquiry team and those who have contributed, to take the necessary time now to fully understand the report’s conclusions and recommendations. “However, what is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down. “I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected. “In particular, I want to say sorry not just for the actions which led to life-altering and lifelimiting illness, but also for the failures to clearly communicate, investigate and mitigate risks to patients from transfusions and treatments; for a collective lack of openness and willingness to listen, that denied patients and families the answers and support they needed; and for the stigma that many experienced in the health service when they most needed support. “I also want to recognise the pain that some of our staff will have experienced when it became clear that the blood products many of them used in good faith may have harmed people they cared for. “I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.” The report is sobering reading, documenting failings over multiple decades, and making recommendations across a wide range of areas, including recognition, support and compensation; education and training; monitoring of and testing for Hepatitis C; the safety of blood transfusions; preventing future harm, via duty of candour and regulation; as well as giving patients a voice. We write now to set out the initial steps we are taking in response. Support for those affected The Department of Health and Social Care is providing £19 million over five years to provide a bespoke Infected Blood Psychological Support Service which is expected to be rolled out later this summer. We have listened to the experiences of those involved, including patients, their families and staff, and are working with them to design and develop this service, which will provide dedicated support for those affected, located around the country. Copyright © NHS England 2024 2 Page 6 of 9 This service will include talking therapies, peer support, and psychosocial support, as well as access to other treatments or support for physical or mental health needs where appropriate. In the interim, the existing England Infected Blood Support Service remains available here: www.nhsbsa.nhs.uk/england-infected-blood-support-scheme. Further information about existing testing and support services, including those commissioned by the Government, can be found at: www.nhs.uk/infected-blood-support. Supporting affected staff It is important to also recognise that some of our colleagues may be affected by the publication of today’s report in some way, whether through personal or professional connection to the issue. Employers may therefore wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline Shout and NHS Practitioner Health, can be found at NHS England - Support available for our NHS People. Continuing to find and treat people with blood-borne viruses Although it is likely that the majority of those who were directly affected have now been identified and started appropriate treatment given the time that has elapsed since the last use of infected blood products, there may be people who have not yet been identified, particularly where they are living with asymptomatic Hepatitis C. We ask that systems continue to work with partners, including community groups and charities, as well as Hepatitis C Operational Delivery Networks, to promote local testing options for anyone at risk, or anyone who is concerned. This should include promotion of the new national service for at-home Hepatitis C self-testing kits, available via hepctest.nhs.uk. For those who are concerned about the risk of HIV infection, further information can be found here: information on HIV diagnosis and the HIV testing services search tool. Hepatitis B, another infection that can be linked to infected blood, usually clears up on its own without treatment; however, people concerned about Hepatitis B infection should be directed towards relevant hepatitis B information or their local sexual health clinic or GP practice. Today's report highlights that in some cases those affected by infected blood products were told of their diagnosis in ways which were insensitive and inappropriate. We would therefore ask you to ensure that patients and their families are supported through the process of receiving test results – of whatever kind - in a compassionate and considerate way. Copyright © NHS England 2024 3 Page 7 of 9 Ensuring patients can access the right information. We recognise following the publication of this report, some patients may raise questions directly with their primary and/or secondary care teams, or through other points of contact with the NHS. We will be sharing materials with relevant service providers to ensure frontline clinicians and other colleagues in patient-facing roles are able to provide appropriate information or signposting. We expect that this will be particularly relevant to: • Providers of NHS 111 services • GP practices and community pharmacies • Trusts providing services where blood products are used • Mental health providers Maintaining confidence in current blood and blood products and related treatment The infected blood and blood products that have been the subject of this Inquiry were withdrawn in 1991. In the intervening decades, comprehensive systems have been put in place to ensure the safety of both donors and recipients of blood and blood-derived products. Today, blood and blood products are distributed to NHS hospitals by NHS Blood and Transplant (NHSBT), which was established in 2005 to provide a national blood and transplantation service to the NHS. NHSBT’s services follow strict guidelines and testing to protect both donors and patients. NHS Blood and Transplant has published clear information about these processes here: Infected Blood Inquiry - NHS Blood and Transplant (nhsbt.nhs.uk). Nationally, NHS England will work with NHS Blood and Transplant and others to communicate the safety of current blood products. Assessing further recommendations and next steps As set out above, the final Inquiry report includes a number of important recommendations for the NHS. NHS England will be considering these in detail alongside the Department for Health and Social Care and other relevant bodies. In addition, an Extraordinary Clinical Reference Group is being convened to inform any immediate actions which should be taken. The next steps from this work will be shared as soon as possible, including through relevant clinical networks. Copyright © NHS England 2024 4 Page 8 of 9 Yours sincerely, Amanda Pritchard NHS Chief Executive NHS England Professor Sir Stephen Powis National Medical Director NHS England Dame Ruth May Chief Nursing Officer England Dr Emily Lawson DBE Chief Operating Officer NHS England Copyright © NHS England 2024 5 Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Issue to be addressed: Performance KPI Report 2024-25 Month 1 5.6 David French, Chief Executive Sam Dale, Associate Director of Data and Analytics 6 June 2024 Assurance or reassurance Y Approval Ratification Information The report aims to provide assurance: • Regarding the successful implementation of our strategy. • That the care we provide is safe, caring, effective, responsive, and well led. Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report covers a broad range of trust performance metrics. It is intended to assist the Board in assuring that the Trust meets regulatory requirements and corporate objectives. This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 24 Report to Trust Board in June 2024 Performance KPI Board Report Covering up to April 2024 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 24 Report to Trust Board in June 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target 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). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its 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 is used to show how far away a variable is from its 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 its target. Page 3 of 24 Report to Trust Board in June 2024 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the timing of the April 2024 Board meeting, the following referral to treatment data points were not included in the March KPI report. They have now been updated for March 2024 and April 2024: - • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) Changes of note within the report itself: • 53 – The digital metric monitoring page loading time for the CHARTS system has been tightened from under five seconds to under three seconds • 55 – The metric monitoring the rollout of inpatient noting for nurses has been removed as this is now considered complete. This will be revisited when the noting solution is rolled out for doctors • 39 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 40 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 37 - The metric now reflects the published 2024/25 national year-end target of 5% of patients waiting over 6 weeks for diagnostics Page 4 of 24 Report to Trust Board in June 2024 Summary This month’s spotlight report covers diagnostic performance. It highlights that UHS consistently increased the volume of elective diagnostic tests delivered throughout the 2023/24 financial year and into the start of the 2024/25 financial year. The diagnostic waiting list reduced by 12% in 2023/24 and in April 2024, 89.6% of patients received their diagnostics within six weeks. The national performance target has been set at 95% by March 2025 and the organisation is working with all services to ensure we maintain waiting times for services that are compliant and address any demand and capacity barriers preventing achievement. The paper describes the activity and performance trends for the hospital and explores modality sites in more detail. Areas of note in the appendix of performance metrics include: 1. The Emergency Department (ED) four hour performance position reduced to 66.0% (April 2024) from 71.7% (March 2024) for type 1 attendances, however UHS remain in the top quartile when compared to peer teaching hospitals across the country. 2. In April, the overall RTT waiting list increased by 2.4% to 59,485. 3. The trust continues to report zero patients waiting over 104 weeks and reported 15 patients waiting over 78 weeks for April 2024. All 15 patients are within ophthalmology and impacted by the ongoing national shortage of corneal graft tissue which is being overseen by NHS Blood and Transplant service. The longest waiting patients will be booked for surgery as soon tissue has been confirmed. 4. The trust reported 66 patients waiting over 65 weeks which predominantly reflects corneal transplant patients again and low volumes within gynaecology and several surgical specialties. The trust is committed to achieving the national target of zero patients waiting over 65 weeks by September 2024 and the ambition to achieve zero patients waiting over 52 weeks by March 2025. 5. The volume of patients not meeting the Criteria to Reside in hospital decreased in April averaging 216 which is a 10% reduction compared to March 2024, yet this remains a significant impact on patient flow through the organisation. 6. There were zero never events reported for April 2024. 7. The volume of medication errors reduced to two in April 2024 which is now below the monthly target following the increase seen in March 2023. 8. The number of Gram-negative bloodstream infections continues to be marginally above the monthly target of 19. The increased incidence in cases continues to be reported both nationally and locally across the Hampshire and Isle of Wight integrated care system. 9. The digital metric to monitor page loading times on CHARTS system has successfully remained at 99% despite increasing the time target by 40%. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). In the week commencing 13th May 2024, our average handover time was 16 minutes 56 seconds across 725 emergency handovers and 22 minutes across 52 urgent handovers. There were 44handovers over 30 minutes, and six handovers taking over 60 minutes within the unvalidated data. The volume of weekly handovers over 60 minutes increased by 73% from March 2024 (averaging 7.5 per week) to April 2024 (averaging 13 per week). Page 5 of 24 Report to Trust Board in June 2024 Spotlight Report Spotlight: Diagnostic Performance The following report is based on the validated April 2024 submission. Introduction Diagnostics are a critical component of a patient’s pathway, facilitating an accurate and complete diagnosis, personalised treatment plans and the appropriate monitoring of a patient’s condition. Timely access to diagnostic tests is essential for ensuring that patients re ceive an early diagnosis whilst improving patient experience and delivering an efficient use of NHS resources. The 2024/24 NHS priorities and operational planning guidance confirmed that “systems are asked to continue to work towards the elective care recovery plan target of 95% of patients receiving their tests within 6 weeks”. The national ambitions acknowledged that the NHS delivered record diagnostic activity in 2023, but also highlighted that additional capacity in community diagnostic centres had been partly offset by an unprecedented increase in unscheduled diagnostic activity in acute trusts. This national diagnostic target applies to 15 different diagnostic tests, although performance is measured at a Trust level. These tests are broadly divided into three categories: • endoscopy (e.g. gastroscopy, cystoscopy); • imaging (e.g. CT, MRI, barium enema); • physiological measurement (e.g. echocardiogram, sleep studies). Our teams prioritise diagnostic procedures based on clinical urgency (for example patients with cancer) but aligned to this is a continual review of the longest waiting diagnostic patients. This spotlight paper highlights the current diagnostic performance position for UHS against the national targets and other hospitals. It also describes the current volumes of activity being delivered and the impact on the waiting list. We explore any performance concerns across the different modalities, outlining the challenges that services are facing and the steps being taken to achieve the 2024/25 target. In summary, there was an overall reduction in the diagnostic waiting list across the 2023/24 financial year as UHS successfully increased the delivery of diagnostic activity to manage current levels of demand. The diagnostic waiting list currently stands at 8,849 patients (April 2024) which is a reduction of 12% since April 2023 (10,033 patients) and 24% since the peak levels seen in June 2022 (11,671 patients). The April 2024 performance position is 89.6% for the percentage of patients receiving diagnostic tests within six weeks. The latest comparison data available (March 2024) placed the hospital 5th when ranked against peer teaching hospitals across the country. All organisations are facing challenges due to high demand, workforce shortages and equipment limitations and funding, but the organisation is striving to achieve the 95% target set for 2024/25. Page 6 of 24 Report to Trust Board in June 2024 Spotlight Report Activity and Waiting List Elective diagnostic activity being delivered at UHS consistently increased throughout 2023/24 and into 2024/25 helping to manage the waiting list despite high referral volumes and the complications caused by industrial action throughout the previous year. Graph 1 illustrates that diagnostic activity levels delivered in 2023/24 were 6% higher than 2022/23 and 17% higher than pre-pandemic levels. Overall there was a 12% reduction in the diagnostic waiting list across the 2023/24 financial year (graph 2) despite some levelling off in winter months and a small recent increase which is being closely monitored. The waiting list stands at 8849 patients for April 2024 which breaks down into
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