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Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and w
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

UHS AR 22-23-6

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

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2023/24 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Looking after your child's adrenaline auto injector - patient information

Description: This factsheet will give you more information on the care of your child's adrenaline auto injector.
Url: /Media/UHS-website-2019/Patientinformation/Childhealth/Looking-after-your-childs-adrenaline-auto-injector-2429-PIL.pdf

Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Jenni
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.04.2025-v2.pdf

Annual report 2021-2022

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

Papers Trust Board 28 March 2019

Description: Agenda Group Name: Date of Meeting: Venue: Time: Apologies to: Trust Board – Open Session 28 March 2019 Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH 9.00am Sue Diduch, Corporate Affairs Administrator 9.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 28 February 2019 3. Matters Arising/Summary of Agreed Actions 9.15 9.30 9.35 9.40 9.45 10.30 10.40 10.50 4. Quality, Performance and Finance 4.1 Patient Story (Derek Sandeman, Medical Director) 4.2 Briefing from Chair of Audit & Risk Committee for review (Simon Porter, Chair, A&RC) 4.3 Briefing from Chair of Quality Committee for review (Mike Sadler, Chair, QC) 4.4 Briefing from Chair of Strategy & Finance Committee for review (Jane Bailey, Chair, S&FC) 4.5 Integrated Performance Report for Month 11 including Quarterly Patient Experience Report (QIF) for review 4.6 Informatics Update for review (Jane Hayward, Director of Transformation & Improvement/ Adrian Byrne, Director of Informatics) 4.7 2018 NHS National Staff Survey Results for review (Paula Head, Chief Executive/Steve Harris, Director of Human Resources) 4.8 Finance Report for Month 11 for review (David French, Chief Financial Officer) Oral Oral Oral Oral 11.00 5. Chair’s and Chief Executive’s Reports 5.1 Chief Executive’s Report for review and Chair’s Actions for ratification (Paula Head, Chief Executive/Peter Hollins, Trust Chair) 11.05 6. Corporate Governance, Risk and Internal Control 6.1 Feedback from Council of Governors’ Meeting 12 March Oral 2019 to note (Peter Hollins, Trust Chair) 11.15 7. Any other business 8. To note the date of the next meeting: Tuesday, 30 April 2019 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH In Attendance: Adrian Byrne, Director of Informatics Steve Harris, Director of Human Resources Vicki Havercroft-Dixon, Head of Patient Relations (shadowing Gail Byrne) 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” 11.30-11.45 Follow-up discussion with governors Items Circulated: The following items have been circulated to the Board since the last meeting. Executive directors are happy to take questions from individual members, before the meeting, by e-mail or telephone, or to meet separately to discuss in more detail. 25 February 2019 Press Release: Hospital first to offer all patients chance to manage healthcare online 7 March 2019 Press Release: Eight-week breastfeeding supplement prevents weight loss in premature babies after discharge 12 March 2019 Press Release: Leading doctor warns use of blood test to diagnose heart attacks is “flawed” 15 March 2019 Press Release: Healthcare scientists “hamstrung” by lack of awareness and investment Trust Board Minutes – Open Session Minutes of the Open Trust Board meeting held on Thursday 28 February 2019, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1100. Present: Mr P Hollins, Trust Chair Mrs P Head, Chief Executive Mr D French, Chief Financial Officer & Deputy Chief Executive Mrs G Byrne, Director of Nursing & Organisational Development Ms J Hayward, Director of Transformation & Improvement Dr C Marshall, Chief Operating Officer Dr D Sandeman, Medical Director Mr S Porter, Senior Independent Director/Deputy Chair Ms J Bailey, Non-Executive Director Prof C Cooper, Non-Executive Director Ms J Douglas-Todd, Non-Executive Director Ms C Mason, Non-Executive Director Dr M Sadler, Non-Executive Director PTH PHe DAF GB JH CM DS SP JB CC JD-T CMa MS In Attendance: Mr C Helps, Interim Associate Director Corporate Affairs CH Mr N Pearce, Associate Medical Director for Patient Safety NP Mr M Green, Head of Bereavement Care MG Ms V Boland, Corporate Affairs Manager (minutes) VB Ms S Herbert, DHN/P, Division A (shadowing Mrs G Byrne) SH 1 member of staff 2 governors 19/19 20/19 Apologies Apologies were received from Jenni Douglas-Todd, Non-Executive Director. Chair’s Welcome, Opening Comments and Declarations of Interest The Chair welcomed everyone to the meeting, specifically welcoming back VB. The chair congratulated CMa for her successful appointment as Chair at Solent NHS Trust. Action By There were no declarations of a conflict of interest with any items on the agenda. 21/19 Minutes of Previous Meeting (Agenda item 2) The minutes of the meeting held on 31 January 2019 were AGREED as an accurate record subject to amendments to: 6/19c) the last sentence of the second paragraph was deemed inaccurate and should state that the key performance indicator (KPI) for emergency readmissions be reviewed for next year. 6/19g) date of the major incident that occurred on 30th November 2018 to be provided in full. 22/19 22/19 a) Matters Arising/Summary of Agreed Actions (Agenda item 3) Minute Ref 143/18a) Complexity of Employee Relations Cases and Minute Ref 159/18a) Integrated Performance Report (specifically relating to Diabetes) – It was agreed that the Trust Board Study Session forward plan would be discussed during the closed Board session, to include these items. Page 1 of 6 22/19 b) Minute Ref 6/19j) Staffing – GB confirmed that a more detailed update in relation to the appraisal target would be included in the next Human Resources Report. 22/19 c) The Board noted the latest position on the actions in summary of actions. 23/19 Quality, Performance and Finance Patient Story (agenda item 4.1) DS introduced the patient to the Board. The Board heard a first-hand account of their experience of the Trust’s services. It was noted that the patient felt their experience fell short of their expectations and provided specific examples where the standard of care was disappointing. The patient reported a high standard of care from medical staff. The importance of listening to patients and responding appropriately, and ensuring patients basic needs as well as medical needs were met was emphasised. The Board thanked the patient for attending and providing an overview of their experience noting the value of this. It was confirmed that this information would be used to improve the care provided by UHS. 24/19 Integrated Performance Report for Month 10 including Quarterly Infection Prevention & Control Report (Agenda item 4.2) a) Safe GB advised that there was nothing specific to highlight from the report. There were no further comments or questions. 24/19 b) Caring GB provided an update noting the initiatives being introduced to improve the quality of response to patient complaints and concerns. A patient panel has now been introduced to assist in collecting and understanding patient feedback. It was confirmed that this would be discussed in more detail at the March Quality Committee. The decrease in the percentage of patients with a nutrition care plan was noted. GB will be working with the matrons and ward leaders for areas that are not achieving the expected standard. 24/19 c) Effective DS advised that there was nothing specific to highlight from the report. MS sought additional detail in relation to the four national reports with areas of concern within section E1.2. DS gave a brief overview of these reports noting that diabetes will be scheduled for discussion at a future Trust Board Study Session. 24/19 d) Activity CM highlighted the increase in Emergency Department (ED) attendances compared to the previous January, the significant reduction in non-elective length of stay and the reduction in the percentage of elective operations cancelled as a result of this. The increase in ED attendances was attributed to the opening of the Paediatric ED. An increase had been anticipated however data was being reviewed to confirm the cause as increased paediatric attendances. PHe emphasised the importance of ensuring that the increased attendances do not adversely affect the patient experience. MS congratulated those involved in reducing non-elective length of stay. Page 2 of 6 24/19 e) Emergency Access CM provided an overview noting that ED performance was the average of our local peer group despite the significant increase in attendances. The time to initial assessment metric is currently under development following the introduction of a new triage process within ED. JB drew attention to the continued reduction in eye casualty performance noting the difficulties already within Ophthalmology. CM confirmed that this was being addressed and more detail could be provided if required. PHe introduced the “Best March Ever” concept. CM provided an overview of the steps being taken to achieve this including working with community providers to reduce delayed transfers of care and patients referred to ED, for example, by GPs. PHe added that ED targets were being reviewed and new targets were expected. 24/19 f) Referral to Treatment Time (RTT) CM summarised RTT performance noting improvements in the number of patients waiting over 18 weeks and the number of patients on an incomplete pathway. Patients waiting longer than 52 weeks had been reviewed; patient choice was the reason for delay and there were no clinical concerns due to delayed treatment. 24/19 g) Cancer CM provided an overview of Cancer performance noting a number of measures had not been achieved. CM outlined a recent visit to the Imperial group of hospitals to learn about data analysis that enables better forward prediction and therefore providing more insightful information for the organisation/Board. MS noted the 6-8% increase in cancer activity year on year and suggested that the executive team consider a more a transformational change to address this to ensure this does not have an adverse effect on patients. JH emphasised the increased pressure on services due to identification of cancer at an earlier stage and new initiatives such as lung cancer screening. This would provide better outcomes for patients however would increase the number of patients being treated; this therefore needs to be planned for as part of the Trust’s strategy. PHe summarised the work that is ongoing with commissioners and the Cancer alliance to enable providers to achieve the cancer targets with the increased activity. It was agreed that further information be provided to the Board in relation to this. Action: Update in relation to planning for cancer targets to be provided to the PHe Board. GB noted that a process for reviewing harm as a result of patients waiting longer than 104 days for cancer treatment was being agreed with commissioners. CC queried whether there was any data providing a longer term perspective i.e. over the past five years. JH confirmed this could be made available if requested. 24/19 h) Infection Prevention Report GB provided an update noting that there would be a hand hygiene campaign in March/April 2019 which should have a direct impact on infection control. 24/19 i) Staffing GB summarised the challenges currently being experienced with nurse staffing particularly due to vacancy levels and the steps taken to address this on a daily basis. Page 3 of 6 24/19 j) RESOLVED That the Board NOTE the Month 10 Integrated Performance Report including the Quarterly Infection Prevention & Control Report. 25/19 Learning from Deaths Quarter 3 Report (Agenda item 4.3) a) DS and NP introduced the report. MS thanked NP for a clear report and the reassurance provided by the small number of avoidable cases. MS sought clarification of the personnel involved in reviewing cases and whether any audits were undertaken to ensure the process was working effectively. NP described the process in use. A new medical examiner service would commence in April. PTH queried whether the process identified the consequences for patients who had experienced repeated delays in treatment. NP advised that previous admissions were reviewed however a more formal process would be instigated once the medical examiner service was in place. CC asked whether there was potential for external validation and comparison of availability. NP has been working with other Trusts to ensure their processes mirror UHS’ to allow a comparison between organisations. JH informed the Board that the Hospital Standardised Mortality Ratio (HSMR) is expected to change from April once Countess Mountbatten Hospital becomes independent from the Trust. 25/19 b) RESOLVED That the Board NOTE the Learning from Deaths Quarter 3 Report. 26/19 Freedom to Speak Up Report (Agenda item 4.4) a) GB presented the report summarising the work undertaken and cases received to date. CC confirmed that all cases appeared to have been dealt with appropriately and had not required his involvement. CMa queried whether any trends had been identified so far. GB advised that some cases were protracted Human Resource cases where action had previously been slow. Learning points were being shared when possible, given the need for confidentiality, and this was encouraging others to speak out. 26/19 b) RESOLVED That the Board NOTE the Freedom to Speak Up Report. 27/19 CRN: Wessex 2018/19 Quarter 3 Performance Report (Agenda item 4.5) a) DS provided an overview of the report noting the good performance of the network. MS asked when the last review by the National Institute for Health Research (NIHR) had taken place and the outcome of this. DS confirmed that this took place 6 to 8 weeks ago and positive feedback had been received. MS asked that this information be included in future reports. Action: Future reports to include the outcome of NIHR reviews. DS 27/19 b) RESOLVED That the Board Page 4 of 6 28/19 Briefing from Chair of Strategy & Finance Committee (Agenda item 4.6) a) JB provided an overview of items discussed at the February meeting: • Outcome of 2017/18 reference cost index submission. • Review of latest financial position. • Operational plan 2019/20 update. 28/19 b) RESOLVED That the Board NOTE the update. 29/19 Finance Report for Month 10 (Agenda item 4.7) a) DAF presented the month 10 Finance report, noting for January: • The Trust delivered a control total surplus excluding Provider Sustainability Fund (PSF) of £2.8m. Year to date the Trust is on plan. • In month once non-recurrent items were excluded was break-even, against a Plan target of £2.8m surplus. • Under the single oversight framework the Trust delivered a score for Finance and Use of Resource of a ’1’. • Cost Improvement Plan (CIP) delivery in the month was £2.5m against a target of £2.8m. • Pay has increased by £1m since month 9 due to an increase in substantive, bank and agency costs month-on-month. A proportion related to December pay enhancements for bank holidays. PTH highlighted elective income as £2.9m behind plan year to date. This was attributed to gaps in spinal and cardiac surgery; these tend to be high value cases. PHe noted that whilst the Trust performed well against the NHS Improvement temporary staff pay ceiling, the total head count had increased. DAF confirmed that the data will be reviewed to better present the overall position. CMa asked whether the invest-to-save negative variance related to delays in the replacement of Princess Anne Hospital (PAH) windows. DAF advised that this related to delays in some estates projects such as PAH windows and theatre modernisation due to the requirement to close services to enable work to be undertaken. 29/19 b) RESOLVED That the Board NOTE the month 10 Finance Report. Chair’s and Chief Executive’s Reports 30/19 Chief Executive’s Report (Agenda item 5.1) a) PHe provided an overview of the requirement for the Trust to formally report progress with the flu vaccination programme and approve the achievement of 7 day services standards self-assessment. MS drew the Board’s attention to the percentage of staff concerned about possible side effects from the flu vaccine despite the evidence available to support that they are limited and manageable. PHe highlighted the importance of influencing perceptions of the vaccine and the need for the Trust to target its messages. DS plans to target messages by staff group. 30/19 b) RESOLVED That the Board NOTE the Staff Flu Vaccinations Update and APPROVE the Achievement of 7 day Services Standards Self-Assessment. Page 5 of 6 30/19 c) Items for Ratification Actions taken by the Chair as set out in paragraphs 3.1 – 3.2 were ratified. Strategy and Business Planning 31/19 Revised Equality, Diversity and Inclusion (EDI) Strategy (agenda item 6.1) a) GB presented the updated strategy which has been consulted upon and comments considered and included where appropriate. MS supported the amended strategy. CMa identified that the ‘white other’ group was classified differently within different sections of the strategy. Action: Ethnic group classifications to be consistent within the Strategy. GB The Board discussed the difference between reducing equality and reducing inequity and how this can be addressed alongside the wider health system. 31/19 b) RESOLVED That the Board APPROVE the Equality, Diversity and Inclusion Strategy subject to one minor amendment as outlined above. 32/19 32/19 a) Any Other Business MS provided an update on the recent Diabetes screening event held at the Southampton FC v Cardiff FC football match. 103 people were tested and 2 cases of undiagnosed diabetes identified. The event raised awareness as well as highlighted the value of co-operation between the organisations involved. PHe thanked those involved for their hard work in organising this event. 33/19 Date and Time of Next Meeting Thursday, 28 March 2019 commencing at 0900 in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH. Page 6 of 6 UHSFT – Directors’ Actions Summary for 28 March 2019 Trust Board – Open Session ___________________________________________________________________________________________________________________________________________ Action & Minute Reference By whom Target Date Current Status Trust Board 28 February 2019 Integrated Performance Report for Month 10 (Minute Ref 24/19 g) Cancer - Update in relation to planning for cancer targets to be PHe provided to the Board. CRN: Wessex 2018/19 Quarter 3 Performance Report (Minute Ref 27/19 a) Future reports to include the outcome of NIHR reviews. DS Revised Equality, Diversity and Inclusion (EDI) Strategy (Minute Ref 31/19 a) Ethnic group classifications to be consistent within the Strategy. GB as at 18/3/19 Page 1 of 1 Cover sheet for a report to the Trust Board of Directors dated Thursday, 28 March 2019 Title: Integrated Performance Report Month 11 Category Quality, Performance, and Finance Agenda item 4.5 Sponsor Director of Transformation and Improvement Author Trust Performance Manager Provenance Report to the Board provided by the Trust Executive. Purpose The paper is presented for the Board for Review The Board is requested to consider the performance metrics provided, identify any elements, trends or emerging themes it wishes to pursue further. Relevant to Board  Goal 1 – Trusted on  Goal 2 – Delivering for  Goal 3 – Excellence in goals Quality Taxpayers Healthcare Board Assurance This report relates to all of the aims and objectives contained in the Board Framework links Assurance Framework. Equality Impact Assessment The Trust aims to ensure that any change in performance does not affect one or more cohorts of people with specific protected characteristics. This equality monitoring is conducted operationally. Other standards affected NHS Provider Licence and Constitutional standards. Integrated KPI Board Report covering up to Feb 2019 Executive Sponsor - Jane Hayward, Director of Transformation Jane.Hayward@uhs.nhs.uk March 2019 Overview Safe Amber Caring Green Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. Effective Green There were four national reports published and reviewed in Feburary, of these reports one raised an area of concern (National prostate Cancer Audit Annual Report 2018). There are now 218 outcomes being reported to TEC from 46 specialities. Of these the majority are green (78%) and only 7% graded red. Emergency readmissions was at 10.8% in December which is just below the average of last 2 years (11%). HSMR remained stable in November well below the national benchmark and crude mortality dropped slightly to 3.7% Activity Red Flow Amber New referrals recieved are following expected seasonal variation but continue to be higher than 18/19 in the month, quarter and year to date. New urgent cancer referrals in January did not decrease as seen last year instead are showing a 16% increase in the month. Main ED attendances remain exceptionally high in February compared to previous years. This is contrary to the normal seasonal trend which sees a reduction in the volume but not complexity of attendances, paediatric attendances have increased the most, but other streams also have increased compared to 17/18. There have been a number of changes year on year in services provided and how services are recorded that make year on year comparison difficult, this includes the Lymington surgical services and outpatients (up from August 17, impacts electives and outpatients), the change in TrehceoardveinrgagCeDnUucmhbaeirrso(df oDwelnayfreodmTrSaenpstfeemrsboefrC1a7r,eiminptahcetsTrounstnoinnFeelbercutiavreys)r,etmheairneecdoradti9n4g.oTfhtehenuremsbpeirraotofrpyacteiennttrsew(Ahporihla1v8e, dbaeyecnaisnehs otospoituatlpfaotriegnrtesa)t.er than or equal to 7 days / 21 days also increased yet remained lower than February 2018 by 2% and 4% respectively. Emergency Access Main ED (Type 1) performance reduced in February to 71.4%, compared to UHS February 2018 77.2%, and were 4.8% below the average of our local peer group. This performance was impacted by ED attendances significantly exceeding volumes in previous years and the onset of winter pressures in the inpatient service. Red RTT & Diagnostics Both RTT and diagnostic performance improved again in February. The trend of patients waiting greater than 52 weeks continues downwards and the patients waiting at the end of February have now been treated. Amber Diagnostic performance also improved and achieved the target in February. Pleasing to see Average weeks waited for first outpatient appointment continues to reduce. Cancer Red Cancer performance is currently rated red as we are not achieving a number of measures. Recovery of the Treatment started within 62 days of urgent GP referral wait, is likely to be slow and significant challenges are being experienced linked to significant growth in referrals and the number of additional cancers being treated (192 year to date). Improving trends in waiting times for initial appointment, waiting times for radiology and patients waiting for treatment are encouraging. Research & Dev Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment Amber projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Digital Green DigiRounds has demonstrated both time saving in reviewing the patient record during ward rounds, but also the quality of the review that is carried out, as clinicians are able to easily see all the significant elements of the record. It saves junior doctors time in preparing information for consultants (transcribing relevant results etc) prior to the ward round. Records accessed using Digirounds increased to 98,573 in February. Also in February the number of alerts sent using Medxnote increased again to 4079. 1 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 March 2019 Safe Safe remains amber this month as UHS has failed some KPI's yet we have seen continued good performance in other areas. There were no never events reported in February. There were no avoidable high harm falls or MRSA infections/contaminants in February. C.Diff performance remains better than year to Amber date target. In 18/19 the Trust planned to reduce pressure ulcers by 20% compared to last year, this trajectory has not be met in 18/19, however to date the number of pressure ulcers is very similar year on year. The themes are being collated and the learning is being shared through Pressure Ulcer Panel. VTE risk assessments remain an area of focus for the Trust with the new IT solution being piloted in AMU, Surgery and T&O in January 2019. A decision will be made in March by the Thrombosis committee to roll out trust wide. MMoonntthhllyy Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target YTD YTD Target S1.1 Never Events 1 1 1 - 3 0 1 S1.2 Avoidable High Harm Falls =95% 98% > =95% S1.12 % Thromboprophylaxis . Patients Assessed 95% 93.3% 92.8% > =95% 93% > =95% S1.12 - The IT solution within e prescribing was piloted from 24th January. This has demonstrated improvements in compliance particularly in AMU. This will be seen in April's report containing Feb data. There will be a discussion at thrombosis committee on 21st march about whether we can roll out the IT solution trust wide to increase compliance further. 100% S1.13 Patients appropriately . screened for sepsis 76% 76% 85% 98% 98% 60% 90% S1.14 Sepsis Patients Treated in a . timely manner 82% 77% 86% 82% 85% 60% 90% - - 90% - - 4 March 2019 Caring Green Complaints were low during November, December and January and increased slightly to levels seen previously in February. The rate of complaints against activity level remains consistent and within target range. Negative ratings through the FFT are under the trust threshold with patients continuing to rate their experience positively. Same Sex Accommodation breaches have fallen to under the trust target. C1.1 FFT response rate - Inpatients Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 27% 15% 9% Monthly Target > =20% 0% 0.9% C1.2 FFT Negative Score - Inpatients 5% 0.9% =20% 2.4% =95% 75% C1.6 Although we are maintaining above 90% we are still not reaching 95%. Therefore some focus work to drive this is being done with the ward areas that are consistently achieving below this requirement, as this is reflective of a small pocket of areas. C1.7 Total Complaints Received . 37 48 40 33 44 37 43 44 44 32 50 28 31 32 42 - C1.8 Complaints per 1000 units . 0.50 0.42 0.00 500 C1.9 Bereavement Survey Response Count 0 15% C1.10 Bereavement Survey Negative Score Core Questions - % 0% C1.9/C1.10 - Figures will be updated quarterly (next month) 0.42 =7days Census average 550 Extended LOS Census average 300 256 RF1.8 (Patients with LOS > =21days) 94 =30% 20.9% 66.2% > =80% 95.5% 90-95% 2 8 4 44 46 44 41 42 19 1 12 15 29 32 8 56 40 3 - 150 77 84 - 0 YTD 23.84% 63.17% - RF1.13 - currently undertaking investigation to understand cancelled operations figures 55 RF1.14 Last minute cancelled operations not 5 . readmitted within 28 days 0 2 - - RF1.15 % elective operations cancelled and not 5% 6.5% . readmitted within 28 days 2.4% 314445224641146 70% 100% 92.3% 94.9% RE1.2 Eye Casualty (Type 2) 90.4% - RE1.3 Lymington MIU (Type 3) 85% 100% 99.7% 99.4% 99.6% - 95% RE1.4 UHS Total 85% . . 70% 97% RE1.5 Local Delivery System . . 80% 82.1% 87.5% 90.0% 81.5% 77.9% > =90% 95.0% 83.3% 85.9% > =95% UHS Total (RE1.4) includes SGH all types and lymington. Local Delivery System (RE1.5) is UHS Total and Southampton Treatment Centre (RSH MIU). 14 March 2019 Emergency Access Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target R-3M RE1.6 % patients who left the department 5% 4.7% . before being seen UHS Total 6.8% =92% 80% 4700 4111 3993 RR1.2 Total patients waiting over 18 weeks (in . backlog) - 1700 7 RR1.3 . Patients waiting > 52 weeks for treatment 2 0 RR1.4 Total number of patients on an . incomplete pathway RR1.5 Patients on a surgical waiting List 36000 26000 6900 5900 7,700 RR1.6 Patients waiting for diagnostics RR1.7 . RR1.8 . 5,500 4% % of Patients waiting over 6 weeks for diagnostics 0% Average weeks waited for first outpatient 9.5 appointment 6.5 30978 6541 6651 3.65% 8.44 30037 31297 6701 - 7700 - 0.71% 93% 41 of 1513 90% RC1.2 . Breast symptoms referral seen in 2 weeks 69.1% 25.9% 50.7% => 93% 32 of 75 51% RC1.1 & RC1.2 - Performance has improved significantly in January and February following commencement of a new Consultant Radiologist in post in January. RC1.3 Treatment started within 62 days of . urgent GP referral 89.4% 79.9% 70.5% => 85% 71.4% 18 of 134.5 71% RC1.4 Treatment started within 62 days of . referral (Breast, Cervical & Bowel . Screening) 87.8% 72.0% RC1.4 - All 5 January breaches related to breast surgery RC1.5 62 Day - Consultant Upgrades 86.00% 54.2% => 90% 3 of 24 79% 79.17% 85.71% => 86% 0 of 3.5 86% 17 March 2019 Cancer Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Target no. patients to recover target QTD RC1.6 Treatment started within 31 days of . decision to treat 98.7% 94.9% 91.1% RC1.6 Half of the 41 breaches in January related to either Urology (mainly Prostate) or Breast Surgery => 96% 27 of 341 88% 87.98% Second or subsequent treatment (surgery) RC1.7 started within 31 days of decision to treat 89.5% 76.0% RC1.7 - Approximately 2/3 of the breached pathways in January were for skin surgery, and the remaining pathways were for prostate surgery => 94% 16 of 118 81% 80.51% Second or subsequent treatment (anti 100% RC1.8 cancer drugs) started within 31 days of decision to treat 95% 100% Second or subsequent treatment RC1.9 (radiotherapy) started within 31 days of decision to treat 95% 100.00% 100.00% 100.00% => 98% 0 of 172 100% 99.05% => 98% 0 of 211 99% RC1.10 104 day waits (treated in month) 16 16 16 11 18 20 17 23 26 17 - - - Principal reasons impacting RC1.10 are prostate surgery (same as RC1.3 & RC1.7), also late referrals of patients referred from other trusts and extended waits due to patient choice. 18 March 2019 Research and Development Amber Research and Development has been rated Amber this month. October recruitment benefitted from activity on a high recruiting meningitis prevention study. Whilst recruitment to this study has ended recruitment projections to year end are satisfactory. Complexity (weighted) performance is also satisfactory with UHS ranked 2nd in the UK for a number of consecutive months. CRN Recruitment WR1.1 Participants Recruited WR1.2 Weighted Recruitment WR1.3 Weighted National Ranking - All Studies WR1.4 Specialties Recruiting Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 3000 YTD YTD Target 1602 500 13,729 7,501 1,273 10842 1 1 1 1 2 2 3 4 4 4 5 6 57 1236 12073 14473 60396 60217 - Top 5 53 - tbc The number of research active UHS specialties has been introduced as a new metric this year in response to implementing the new research strategy and the aim for all specialties to be research active. Having identified whether a specialty is research active or not, we are now trying to understand levels of activity in relation to size of department for this to be more meaningful. BRC 200 WR1.5 Papers published in partnership with UOS 0 94 99 153 120 112 Number of BRC papers published are in line with expectations and more detailed analysis is informing the next BRC bid preparations. Activity/Staffing Balance £8,000 6531 WR1.6 Income per WTE £4,000 385 400 4878 - - 19 March 2019 Staffing Amber Staffing remains amber overall because some key targets have been missed including those for turnover, non-medical appraisal completion, total nursing and registered nurse vacancy rates. However, UHS has seen improvements in the following: sickness absence (which has never been lower), turnover (the lowest rate since November 2017), decreases in total nursing and registered nurse vacancy rates and percentage of BME staff at Band 7+ (the highest rate it has been). CHPPD is within normal range this month as expected, after seasonal effects in January and it reflects high patient numbers. WS1.1 HR - Turnover - Rolling 12-months Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Monthly Target 13.67% 13.17% 13.1% 13.0% 92% WS1.4 . Nursing Vacancies (Total Clinical Wards) 11% 13.04% =76% WS1.7 Statutory & Mandatory Training . Achieving Target - 5 5 7 6 7 7 7 7 7 7 8 9 8 8 8 9.5 7 7 5 6 5 5 5 5 5 5 4 3 4 4 4 WS1.8 Total nursing staff all inpatient areas - 8.4 . Care hours per patient day (CHPPD) 8.0 8.3 - WS1.8 The CHPPD for ward based areas in the Trust has decreased from last month to RN 3.7 (previously 3.8) HCA 3.3 (previously 3.3) overall 7.0 (previously 7.2). 6.0 WS1.9 Registered nursing staff all inpatient . areas - CHPPD 5.1 5.0 3.5 3.3 WS1.10 Unregistered nursing staff all inpatient . areas - CHPPD 2.5 5.1 - 3.2 - 9% WS1.11 Black & Minority Ethnic Band 7+ . Percentage 7.5% 7% WS1.11 UHS has a target of 15% Band 7+ BME staff by 2023. WS1.12 Quality of practice experience for doctors . in training (annual report with quarterly . qualitative updates) Minor Risk Minor Risk Minor Risk Minor Risk 8.3% - Minor Risk No risk 21 March 2019 Estates Green Estates has been rated green this month as we are meeting all targets in February. The target missed on a 3 month rolling average is for percentage of help desk requests completed on time. Reactive Maintenance Monthly Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Target 2500 R-3M PE1.1 Number of defect work orders and 1300 2197 - - 2078 percentage completed on time 86.2% 86.7% > 85% 89.2% Preventative Maintenance 74.42% 200 PE1.2 Number of statutory maintenance jobs planned and percentage 50 69 - - 131 completed on time 98.6% 94.09% > 95% 98.3% 98.5% 600 308 PE1.3 Number of mandatory maintenance jobs planned and 250 percentage completed on time 98.8% 96.13% 419 - - 99.5% > 95% 99.5% PE1.4 Number of routine maintenance jobs planned and percentage completed on time 125 75 97.7% 92.29% 80 98.8% 88 - 100.0% > 85% 99.7% 2500 PE1.5 Number of Help desk requests and 1000 percentage completed on time 100% 85% Unresolved help desk requests PE1.6 Unresolved help desk requests PE1.7 (over 30 days old) 50% 1500 500 600 1000 200 0 1737 82.3% 1007 498 1640 - 86.6% > 85% 84.3% 569 =95% - - SD1.4 acknowledgment > =95% - - through eQUEST - rolling 3M 85% Release 29 of CHARTS goes live on 23rd January 2019. This includes enhancements to histopathology requesting from the Endoscopy Unit and should result in an increase in both requesting and acknowledgment - this will first appear in the April 2019 data extracts. SD1.5 digiRounds patient records accessed 200000 0 98573 eQuest Results Alerts Sent SD1.6 Decision support notifications (email alerts) 20,000 9345 0 5000 SD1.7 Medxnote 4079 0 SD1.8 InfoQlik (Daily) Activity 50 20.1 35.4 0 100 SD1.9 Sap BI (Daily) Activity 40.0 0 500 351 SD1.10 My Medical Record - UHS patient registrations 0 2,000 SD1.11 My Medical Record - UHS patient logins 968 0 23 March 2019 Changes and Corrections Page Staffing KPI WS1.11 KPI Name Type Black & Minority Ethnic Band 7+ Change - Display Percentage Detail Long term target added 24 • Improvements made to the processes for managing complaints have driven significantly better performance in the timeliness of responses. For January and February, the trust closed 82% of complaints within 35 working days, with an average response time of 30 working days. This is a significant improvement from Q3 where the trust closed just 42% of complaints in the timeframe, with an average response time of 38 working days. • The complaints quality improvement work continues to deliver benefits for patients. The trust has slightly increased the % of complaints being managed informally to 44% of the overall number received (compared to 42% this time last year). There is a plan to return to clearly distinguishing between the PALS function and formal complaints process, and this will likely improve this further and offer patients and families greater access to support in getting early resolution to their concerns. • Good progress is being made in improving how the trust supports patients and carers with disabilities through compliance with the Accessible Information Standard. A flag is now available in ECAMIS, which pulls through into other systems, to alert staff that a patient has information and / or communication support needs. There is also a Staffnet resource to guide staff in how to meet needs. The Experience of Care team are currently working on a number of projects to enable needs to be identified and recorded on the system, while project teams on E2 ward and Princess Anne Outpatients work on embedding and testing the processes and resources. • Patient feedback remains generally high, although with more local variation in FFT feedback scores. Response rates have declined generally, with a significant factor being survey fatigue experienced by both patients and staff. While the FFT remains mandatory, it is often too generic to gain a sense of local ownership. With a new survey contract, the FFT will be augmented with more locally-relevant questions to better empower staff to use feedback to identify improvements, and this sense of ownership will drive better staff engagement and improve responses. Low recommend scores in ED are due to extremely low response rates. • A review of the trust’s provision of interpreting services is underway, with the aim of ensuring that patient needs are being met effectively and that the trust is receiving value for money. Part of this work is looking at the variability of interpreting provision across the trust, identifying areas for piloting efficiency improvement projects. There is a lack of data on how the impact of poor provision of interpreters (as well as other communication support) affects attendance rates, involvement in care, and overall experience- and this review will look at capturing some of this information. • The number of people applying to volunteer increased in Q3 to 98 (from 57 in Q2). Overall for the year to date, the trust has had 242 applications with 115 of these starting and a number of applications still being processed. Retention of volunteers continues to be an issue, with too many new volunteers still leaving within the first 6 months. The team is reviewing its support and supervision processes, but with 824 active volunteers, it remains an ongoing challenge. • The trust successfully bid for funding from the Pears Foundation to develop and grow a youth volunteering programme. The funding will be for two years and will pay for a project worker to lead on collaboration with local schools and colleges to provide short to medium term placements for young volunteers (16-18). • The trust welcomed the first cohort of employee volunteers from the local NHS England team in March. NHSE staff are able to take up to five days each year in order to volunteer within their local community and the trust has agreed a pilot with NHSE to test out new volunteer roles with the group to assess feasibility and value. This includes getting qualitative feedback from patients and carers, a new role in AMU, and supporting the pharmacy team. 25 Complaints PALS Friends & Family Test Volunteers Indicator Complaints received Complex concerns received Complaints closed within 35 days Average working day to close PALS contacts Inpatient positive score Outpatient positive score Maternity positive score ED positive score Applications received New starters Target Q1 Q2 Q3 Q4* n/a 124 120 109 74 n/a 88 91 110 42 = > 66% 64% 59% 42% 82% 95% 97% 97% 96% 97% = > 95% 95% 96% 96% 93% = > 95% 99% 97% 90% NA = > 95% 94% 96% 85% 71% n/a 87 57 98 NA n/a 57 28 30 NA * Data is provisional and for the quarter to date. NA denotes data not yet available. Jan 32 24 81% 31 324 Feb 42 19 78% 30 275 26 Nursing and midwifery staffing hours - February 2019 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly. Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers. Enhanced Care (also known as Specialling) Occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If enhanced care is required the ward may show as being over filled. If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed. CHPPD (Care Hours Per Patient Day) is a measure which shows on average how many hours of care time each patient receives on a ward /department during a 24 hour period - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. The maternity workforce consists of teams of midwives who work both within the hospital and in the community offering an integrated service and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. WARD C4 (Solent ward) C4 (Solent ward) C6 C6 C6 (Teenage Cancer Trust unit) C6 (Teenage Cancer Trust unit) D2 D2 D3 D3 Surgical high dependency unit Surgical high dependency unit Registered nurses Total hours planned Registered nurses Total hours worked Unregistered staff Total hours planned Unregistered staff Total hours worked Registered nurses % Filled Day Night Day Night Day Night Day Night Day Night 1303.5 975.5 2572.1 1850.0 645.0 610.8 1196.0 943.0 1507.9 944.8 1230.8 910.8 2267.3 1740.5 661.3 513.0 1184.8 943.8 1325.9 932.4 915.0 644.0 174.5 0.0 332.2 0.0 1055.5 770.5 731.5 641.3 1281.3 829.0 209.5 99.5 166.2 79.0 1136.4 816.5 799.0 798.8 94.4% 93.4% 88.1% 94.1% 102.5% 84.0% 99.1% 100.1% 87.9% 98.7% Day Night 1962.1 1843.2 1865.4 1831.7 312.4 322.0 374.7 321.0 95.1% 99.4% Unregistered staff % Filled t Comments 140.0% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 128.7% Safe staffing levels maintained; Support workers used to maintain staffing numbers. 120.1% Support workers used to maintain staffing numbers. Shift N/A Safe staffing levels maintained. 50.0% Safe staffing levels maintained; Staffing appropriate for number of patients. Shift N/A Staffing appropriate for number of patients; Staff moved to support other wards. 107.7% Safe staffing levels maintained. 106.0% 109.2% Safe staffing levels maintained. Safe staffing levels maintained. 124.6% Safe staffing levels maintained. 119.9% 99.7% Safe staffing levels maintained. Safe staffing levels maintained. Page 1 of 5 Cardiac intensive care unit Cardiac intensive care unit General intensive care unit A General intensive care unit A General intensive care unit B General intensive care unit B Neuro intensive care unit Neuro intensive care unit E5A E5A E5B E5B E8 E8 F11 F11 F6 F6 F5 F5 Acute medical unit Acute medical unit D5 D5 D6 D6 D7 D7 Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night 4911.3 4752.0 4116.4 3848.5 3657.1 3526.0 4334.7 3836.5 1151.2 645.0 1274.0 639.0 1961.3 961.0 1914.6 966.0 2016.5 966.5 1821.0 966.0 3826.1 3202.5 1621.6 972.6 1079.3 667.3 841.7 645.0 4309.8 3986.0 3757.0 3793.5 3438.1 3140.0 4218.1 3649.5 904.2 587.0 1117.0 622.5 1356.9 978.3 1236.9 814.0 1535.9 887.0 1172.9 828.0 3750.9 2871.3 1027.5 794.5 987.0 668.8 816.7 634.0 1123.8 794.3 890.5 644.0 507.8 322.0 694.3 587.0 615.4 322.0 727.5 322.0 1496.0 860.0 726.2 322.0 620.9 644.0 876.4 644.0 3032.7 1808.5 957.0 524.0 1451.7 690.5 949.3 300.0 607.8 472.5 722.9 453.5 373.6 274.5 510.0 545.0 707.0 472.5 724.0 398.2 1592.6 1208.4 629.6 587.5 962.5 736.5 1415.2 1068.0 3772.3 2468.3 1250.1 1077.0 1373.0 777.0 1030.3 323.0 87.8% 83.9% 91.3% 98.6% 94.0% 89.1% 97.3% 95.1% 78.5% 91.0% 87.7% 97.4% 69.2% 101.8% 64.6% 84.3% 76.2% 91.8% 64.4% 85.7% 98.0% 89.7% 63.4% 81.7% 91.5% 100.2% 97.0% 98.3% 54.1% 59.5% 81.2% 70.4% 73.6% 85.2% 73.5% 92.8% 114.9% 146.7% 99.5% 123.7% 106.5% 140.5% 86.7% 182.4% 155.0% 114.4% 161.5% 165.8% 124.4% 136.5% 130.6% 205.5% 94.6% 112.5% 108.5% 107.7% Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Beds flexed to match staffing; Safe staffing levels maintained. Safe staffing levels maintained; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained;Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe staffing levels maintained; Additional staff used for enhanced care - Support workers. Support workers used to maintain staffing numbers; Band 4 staff working to support registered nurse numbers. Safe s
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UHS AR 21-22 Quality Account

Description: QUALITY ACCOUNT 2021/22 Part 1: QStaUteAmeLnItToYn qAuaClitCy fOroUm NtheTchief executive 2021/22 1.1 Chief executive’s statement and welcome
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-21-22-Quality-Account.pdf

Annual-report-24-25-final

Description: 2024/25 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2024/25 Presented to Parliament
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Annual-report-201617

Description: ANNUAL REPORT AND ACCOUNTS 2016/17 incorporating the quality account 2016/17 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 2016/17 incorporating the quality account 2016/17 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2017 University Hospital Southampton NHS Foundation Trust TABLE OF CONTENTS Performance report Statement from the chief executive 7 Statement of purpose and activities 9 History of UHS 9 Key issues and risks 10 Going concern disclosure 10 Performance reporting 11 Regulatory body ratings 15 Environmental matters 16 Social, community and human rights issues 16 Accountability report Directors’ report 18 Introducing the Board of Directors 20 The people 21 Audit and risk committee 25 Disclosures 28 Council of Governors 32 Annual remuneration statement 39 Remuneration and appointments committee 42 Governors’ nomination committee 44 Staffing data 48 Responding to the staff annual attitude survey 50 Statement of chief executive’s responsibilities as the accounting officer 55 Annual governance statement 56 Review of economy, efficiency and effectiveness of the use of resources 62 Equality, diversity and inclusion 66 Southampton Hospital Charity 67 Developments in informatics 68 Leading research into better care 68 Investing for the future 69 Environmental sustainability and climate change 70 Quality account and report Chief executive’s welcome 119 Our approach to quality assurance 121 Our commitment to safety 122 Our commitment to staff 125 Our commitment to education and training 126 Our commitment to technology to support quality 127 Our commitment to the Care Quality Commission 129 Progress against 2016/17 priorities 127 Priorities for improvement 2017/18 141 Review of quality performance 152 Conclusion 155 Responses to our quality account 156 Statement of directors’ responsibilities 163 Independent auditor’s report 164 Appendices Appendix one: Patient Improvement Framework (PIF) priorities 2017/18 168 Appendix two: Definitions of pressure ulcer grading 169 Appendix three: Quality performance data 170 Appendix four: CQUINS data 177 Appendix five: Clinical audit and confidential enquiries data 179 Appendix six: Outcome measures data 190 Appendix seven: Registration with the Care Quality Commission 191 Appendix eight: Pulse KPIs 192 Appendix nine: Glossary of acronyms 195 Annual accounts Statement from the chief financial officer 75 Foreward to the accounts 76 Independent auditor’s report 77 Financial statements 81 5 Statement from the chief executive More patients than ever before were treated at University Hospital Southampton (UHS) during 2016/17. And despite seeing an extra 41,000 patients than the previous year, we have continued to maintain our patient satisfaction scores with more than 95% recommending UHS. This is just one of many outstanding achievements across our hospitals which we are proud to highlight in this annual report. Our ongoing challenge now is tackling the high numbers of patients who could be at home, but who lack support from either health or social care to move out of hospital. There has been some hard work done in this area and we’re already seeing signs of improvement. The latest Friends and Family Test results - the survey which all UHS staff are asked to complete - said that 92% of staff would recommend UHS as a place to be treated, and 77% would recommend it as a place to work. Both these figures are the highest we have ever achieved, and are much better than the national average. We have been able to invest heavily in improved and expanded facilities for patients and for research. For instance, work has started on the radiotherapy bunker which will house the new linear accelerators used to treat cancer patients and the new Cancer Immunology Centre is also progressing well. The ongoing investment into diagnostics – particularly radiology but also more specific schemes such as hysteroscopy – should help patients right across the hospital. We recently received national recognition as a “global digital exemplar”; an award which we anticipate will bring an additional £10 million of national money. Historically, we have spent very little on information technology but, despite this, much has been delivered.This extra national money will make a real difference to patient care through some large-scale informatics projects and will also improve the day to day IT equipment our staff have available to them. Our new main entrance, which opened last summer, now feels like it has been here forever but I think it is still worth remembering what an improvement it is on the old entrance, and that it was rebuilt without spending any NHS money. We have been successful in renewing our NHS research funding, through both our Biomedical Research Centre (BRC) and Clinical Research Facility (CRF). This was a tough competition, as we were competing against every other academic medical centre in the country, and the rules were clear that only “world class research” would be funded. So the Southampton research team (UHS and the University of Southampton), led by Rob Read for the BRC and Saul Faust for the CRF, should be very proud that we were successful, and that Southampton research will continue to help patients receive better care across the world. Children’s services are very important to us and thanks to a combination of NHS funds and very generous donations, we have been able to refurbish and expand Piam Brown (paediatric cancer) ward and our paediatric intensive care unit (PICU). Despite a challenging time for NHS finances, UHS had a successful financial year, ending it with a surplus of £20.4m. This has enabled us to plan increased investment in our estate, particularly for the most vulnerable patients such as refurbishment of high dependency and intensive care facilities for patients of all ages, and theatre and interventional radiology rooms. This means that we will continue to have the facilities to look after the sickest patients in Hampshire and beyond. 7 In 2016/17 we launched our children’s emergency department campaign, alongside the Murray Parish Trust. We’re now well on our way to raising the £2 million needed, which will be fund matched by the Government. We hope to start building this summer. So, while there have been considerable challenges meeting uplifts in demand and managing discharges, there has also been much to celebrate and we look forward to 2017/18. Fiona Dalton Chief executive 23 May 2017 8 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 10,500 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 2016/17 was more than £760m. 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 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 2017/18. 2. Capacity and occupancy, which impacts on patient flow and to 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: • continuing to recruit within Europe and further afield • working with universities to increase student nurses • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • 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 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. 10 Performance reporting Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. This begins with the monthly Trust Board meeting where the executive directors of the Trust will present a high level summary to the chairman and non-executive directors, as well as providing greater detail on key performance changes, risks and issues. Below this are a number of executive sub-committees attended by a subset of executive and non-executive directors. These are the audit and risk committee, the strategy and finance committee, and the quality committee. These committees will review issues in greater depth, feeding back to Trust Board as appropriate. In addition, there are regular Trust Board study sessions which focus on specific individual issues with the entire Board present. The Trust executive committee (TEC) meets monthly and is made up of the executive board members and the divisional management teams. Performance and service issues are discussed in greater detail at this meeting. Finally, there are regular performance meetings between the operational management team (led by the chief operating officer) and the division and care group management teams. These meetings focus on the individual patient and service pathways and developing the detailed plans for improvement. Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For the 2016/17 period the most notable development to the monthly report was a restructuring of the format in order to better align the reported metrics to five key Care Quality Commission questions: • Are we safe • Are we effective • Are we caring • Are we responsive • Are we well-led. The monthly report features the following sections: • Executive digest – a textual update on the previous month’s performance across the Trust written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months (see Appendix eight) • Performance • Activity • Capacity • Emergency department (ED) • Referral to Treatment (RTT/18 weeks) • Cancer waiting times • Finance • Patient experience • Patient safety • Outcomes • Staffing (HR) and estates • Education and training • Research and development 11 This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. 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 2016/17 we have reviewed the National Model Hospital data published by Lord Carter’s team at NHS Improvement, this includes the Getting it Right First Time Reports. This data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. This data is reported regularly to the Transformation Board. Detailed analysis and explanation of the development and performance of UHS Over the past three years we have seen significant increases in all types of activity. Some of this is due to an increase in the range of specialist services we offer, becoming a major trauma centre and the building of the helipad, but much of it is due to the increased and aging population in Southampton and the surrounding area. The graphs below demonstrate this increase in activity. Growth iUnHaSctGivritoyw-t2h01in4/A15cttiovi2ty01-62/10714/15 to 2016/17 700,000 600,000 500,000 400,000 300,000 200,000 2014/15 2015/16 2016/17 100,000 - Inpatient Spells (inc Outpatient day cases) Appointments ED Attendances (type 1) Referrals 2014/15 Inpatient spells (inc day cases) 144,934 Outpatient appointments 536,949 ED attendance (type one and two) 94,376 Referrals 182,407 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 Increase 2014/15 to 2016/17 7.5% 11.1% 5.4% 12.3% 12 The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls. In 2014/15 a black alert was recorded 91 times at the twice daily bed meetings. In 2015/16 this was reduced to seven. However, as result of the increasing demand for Trust services this increased to eleven in 2016/17. Contributing to this change has been the increase in Length of Stay (LoS) for elective patients and bed capacity being impacted upon by the increased number of patients requiring a complex package of care after their discharge. These patients can often have their discharges delayed while beds in community care homes are found and supporting community care packages are arranged. The chart below demonstrates the change in LoS for elective and non-elective (emergency) patients over the past three years. 2016/17 saw an increased focus on discharging patients earlier in the day and at the weekend. This will remain a major focus for the Trust in 2017/18. Each of the above metrics will have an impact on the Trust’s performance against the three primary nationally reported targets for Referral to Treatment (RTT, or 18 Weeks) performance, emergency department performance and cancer waiting times performance. Referral to Treatment (18 Weeks) performance Due to a change introduced by the Government in 2015 trusts are only required to achieve the Incomplete Pathways target: 1. Incomplete Pathways – 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. UHS met the target in quarters one, two, and three of 2016/17. In quarter four the target was met in February and March but performance in January meant that the target was not met for the quarter as a whole. Achievement of this target in 2016/17 should be set against the aforementioned rise in patient referrals, which highlights the increased demands being placed on the Trust. It is only due to the increased efficiency shown by the Trust’s inpatient and outpatient services that it has been possible to meet these targets on an ongoing basis. This is an excellent result and goes against the national trend. 13 Emergency department (ED) performance We did not meet the national target of 95% of all ED attendances being treated and either admitted or discharged within four hours of arrival in any month in 2016/17, but we did achieve our nationally agreed trajectory target. This has been a challenging target nationwide with the winter period being the worst performance the NHS in England has ever recorded. There are three types of ED that can be included in these figures: Type one A consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Type two A consultant led single specialty accident and emergency service (e.g. ophthalmology, dental) with designated accommodation for the reception of patients. Type three Other type of accident and emergency/minor injury unity (MIUs/Walk-in Centres, primarily designed for the receiving of accident and emergency patients. A type three department may be doctor led or nurse led. It may be co-located with a major ED or sited in the community. A defining characteristic of a service qualifying as a type three department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. UHS has type one and type two (ophthalmology) departments. The Trust also had a type three (MIU) department until July 2014. Due to the nature of the activity at the MIU, the transfer of this department to another provider reduced UHS performance against the four hour target by approximately 3%. When comparing performance over the long term, it is important to factor this change in. ED performance improved in quarters one, two, and three of 2016/17 compared to 2014/15 and in quarters one and two over 2015/16, despite the increases in activity. In quarter three performance decreased by 0.6% while activity increased by 1,795 attendances, a 7.5% rise. In quarter four performance was 1.2% better than in 2015/16 and matched 2014/15 performance. The graph below shows UHS performance against the four hour target over the past three years. 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% 82.00% 80.00% 78.00% 76.00% Year-On-Year ED Performance by Quarter Q1 Q2 Q3 Q4 2014/15 2015/16 2016/17 14 Cancer waiting times There are ten separate cancer waiting times measures that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2016/17 the Trust met all but one of these measures. The performance against the targets should be set against the significant rise in activity seen on the cancer pathways. The number of patients referred under the ‘two week wait urgent suspected cancer protocol’ that were seen within two weeks of their referral, rose by 1,058 (6.9%) in 2016/17. The chart below shows the rise in demand for UHS services over the past three years. 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - UHS Growth in Cancer Activity - 2014/15 to 2016/17 2014/15 2015/16 2016/17 Two Week Waits 62-Day Target Patients 31-Day Target Patients 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. The Single Oversight Framework applied from quarter three of 2016/17. Prior to this, Monitor’s Risk Assessment Framework (RAF) was in place. Information for the prior year and first two quarters relating to the RAF has not been presented as the basis of accountability was different. This is in line with NHS Improvement’s guidance for annual reports. Segmentation During quarter four of 2016/17 the Trust was placed within segment ‘2’ This segmentation information is the Trust’s position as at 31 March 2017. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. 15 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 efficiency Financial controls Overall scoring Metric Capital service capacity Liquidity Income and expenditure margin Distance from financial plan Agency spend 2016/17 Q3 score 2 2 1 1 1 1 2016/17 Q4 score 2 2 1 1 1 1 The Care Quality Commission (CQC) gave us an overall rating of ‘requires improvement’ as at December 2014. You can see further details on page 128 of the quality account or in full by visiting www.uhs.nhs.uk or www.cqc.org.uk. The CQC returned in January 2017 to conduct a follow up inspection. We are currently awaiting their full report. Environmental matters A number of projects were undertaken in 2016/17 to reduce our impact on the environment. We have replaced a significant proportion of our external lighting and much of our internal lighting with LED technology. A number of ventilation systems have been upgraded to enable heat recovery and we have launched an awareness programme to help staff work in more environmentally sustainable ways. In addition to these developments we have implemented a range of measures to ensure that we are using energy more efficiently. For example, we now review and ensure the efficiency of high energy consumption equipment. More information can be found within the environmental sustainability and climate change section of this report. Social, community and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. 16 Directors’ report Composition of the Board The Board is currently comprised as follows: Non-executive directors: Peter Hollins chair Simon Porter senior independent director/deputy chair Professor Iain Cameron Lynne Lockyer Dr David Price Dr Mike Sadler Jenni Douglas Todd Executive directors: Fiona Dalton Gail Byrne Jane Hayward Dr Derek Sandeman Dr Caroline Marshall David French chief executive director of nursing and organisational development director of transformation and improvement medical director chief operating officer chief financial officer Each director confirms that at the time the annual report and accounts is approved: • so far as the director is aware, there is no relevant audit information of which the NHS foundation trust’s auditor is unaware • the director has taken all the steps they ought to have taken as director in order to make themselves aware of any relevant audit information and to establish that the NHS foundation trust’s auditor is aware of that information. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. Trust Board declarations of interest Peter Hollins Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council Member of University of Southampton. Iain Cameron Dean, Faculty of Medicine and Member, University Executive Board, University of Southampton; Board Member, Wessex Academic Health Sciences Network; Director (Chair), Medical Schools Council (until 1 July 2016); Director, Medical Schools Council Assessment (until 1 July 2016); Director, UK CAT (Clinical Aptitude Test) (until 1 July 2016); Trustee, Wessex Medical Trust; Joint Chair, University Hospital Southampton/University of Southampton Joint Research Strategy Board; Joint Chair, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) Southampton Executive Board. Simon Porter Former Partner in Ernst & Young LLP; Non-executive Director and Chair of Audit Committee, Radian Group; Non-executive Director and Chair of Audit Committee, Octavia Housing. 18 Lynne Lockyer Board member/trustee of the Brendoncare Foundation. David Price Chair of RTL Materials Ltd; Chair of Telesoft Technologies Ltd; Chair of Optitune Plc; Chair of Symetrica Ltd; Member of Advisory Board, Silverstream Technologies BV; Treasurer, University of Southampton; Chair of Lontra Ltd (from 1 May 2016). Michael Sadler GP Specialist Advisor for the Care Quality Commission (until 31 May 2016); External Clinical Associate for PricewaterhouseCoopers. Jenni Douglas-Todd Managing Director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Non-Executive Director, Hampshire Cricket Board (from 2 May 2016). Fiona Dalton NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT. Gail Byrne Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice. Caroline Marshall Nil. Jane Hayward Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is Mental Health Act Manager, Southern Health Foundation Trust (voluntary position), member of Assessment Committee for Clinical Excellence Awards South and Public Health England (lay member), a UHSFT Simulated Patient (voluntary position); Mother is a UHSFT Simulated Patient (voluntary position). Derek Sandeman Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT. David French Non-executive director and chair of audit and risk committee, Sentinel Housing Association (renamed Vivid Housing Limited on 23 April 2017); Governor and chair of Audit Committee, South Wilts Grammar School for Girls (until 8 December 2016); Chair of Hampshire and Isle of Wight NHS Counter Fraud Board; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint venture between UHS and Interserve Prime. Approved by the Trust Board 23 May 2017. Chief executive 23 May 2017 19 Introducing the Board of Directors Trust Board The Board is made up of the chair, six non-executive directors and six executive directors including the chief executive. Together they bring a wide range of skills and experience to the Trust, such that the board achieves balance and completeness at the highest level. The non-executive directors, including the chair, are people who live or work in the local area and have shown a genuine interest in helping to improve the health of local people. The non-executive directors are determined by the Board to be independent in both character and judgement. The chair, executive directors and non-executive directors have declared any business interests that they have. The Board is satisfied that no conflicts of interest are indicated in any external involvement. The register of Board members’ interests is updated at least annually and is maintained by the company secretary and associate director of corporate affairs. It is available for public inspection from the company secretary and associate director of corporate affairs. The ‘reservation of powers to the Board and delegation of powers policy’ sets out the business to be conducted by the Board, or by one of its committees. Any enquiries should be made to: company secretary and associate director of corporate affairs, Trust Headquarters, Mailpoint 18, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD or telephone 023 8120 6829. Senior independent director The senior independent director role provides a channel through which foundation trust members and governors are able to express concerns, other than the normal route of the chair or chief executive. Appointments Non-executive directors are appointed via open advertisement in accordance with the ‘Appointment of a foundation trust non-executive director good practice guide’ procedure adopted by the Trust. The process is managed through the governors’ nomination committee, a sub-committee of the Council of Governors. This committee also determines the remuneration and terms and conditions of the non-executive directors. For further details on the appointment of non-executive directors please see page 42-43. Development of the Board The Board held monthly study sessions during 2016/17 where strategic issues, along with emerging issues, were discussed. Meetings of the Board The Board meets once a month in public. Additional private meetings with only the Board, and associated employees of the Trust making presentations to the Board in attendance, are held as required. Other committees of the Board include: remuneration and appointment committee; audit and risk committee, strategy and finance committee; quality committee and charitable funds committee. Generally the other committees of the Board meet monthly with the exception of the audit and risk committee, which meets five times a year and the appointments and remuneration committee which meets every other month. The frequency of the meetings is set out in each committee’s terms of reference. These terms of reference are reviewed at least annually. The performance of individual Board members is reviewed as set out on page 24 of this report. 20 Engagement with Council of Governors The Trust Board engages with the Council of Governors through the chair and senior independent director. Non-executive and executive directors engage with sub-groups of the council where these are related to their portfolios. Board members meet regularly with governors and have an open invitation to attend formal Council of Governor meetings. The people Non-executive directors Peter Hollins, chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a Nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. He has also been the chair of CLIC Sargent Cancer Care for Children and Young People, and a Council Member of Southampton University, since 2014 and 2016 respectively. Simon Porter, senior independent director and deputy chair Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Professor Iain Cameron Iain is professor of obstetrics and gynaecology and dean of the Faculty of Medicine at the University of Southampton. After graduating in medicine at the University of Edinburgh, he underwent postgraduate clinical and research training in Edinburgh, Melbourne and Cambridge. He held the regius chair of obstetrics and gynaecology at the University of Glasgow from 1993 and moved to Southampton in 1999. His main clinical and research interests are reproductive endocrinology and investigation of the impact of the maternal environment on early pregnancy. Iain was chair of Medical Schools Council from 2013-16 and is a member of the UK Clinical Research Collaboration board and the Wessex Academic Health Science Network board. He was appointed as a non-executive director of the MDDUS (Medical and Dental Defence Union Scotland) in April 2017. Lynne Lockyer Lynne’s background is in human resource management and strategic management. She became a nonexecutive director for Southampton and South West Hampshire in 1996 and the vice chair in 2000. She was chair of Eastleigh and Test Valley South PCT from its inception in 2002 until its disestablishment in 2006. She has taken many roles in the local health economy including being a member of Hampshire’s Local Area Agreement Board and nationally was a member of the NHS Confederation Council and the National NHS Leaders Steering Group. She was until recently a course director at the University of Portsmouth and is now an organisation development consultant. She is a trustee of the Brendoncare Foundation. 21 Dr David Price David is a former chief executive of a FTSE-250 company with broad experience within the electronics, chemical, aerospace, defence, marine, and nuclear industries. He has a successful track record of developing highly complex companies in international markets. He is currently non-executive chairman of Symetrica Ltd, Telesoft Technologies Ltd, RTL Materials Ltd, Lontra Ltd and Optitune Plc. He is treasurer of the University of Southampton and a member of the advisory board of Silverstream Technologies BV. David is a chartered engineer and chartered scientist. He has a degree in electronic engineering, a PhD from University College London and, in 2001 he was awarded an honorary doctorate by Cranfield University for his services to science and engineering. David was made a Commander of the Order of the British Empire (CBE) for his services to industry. Dr Mike Sadler Mike joined us as a clinical non-executive director in September 2014, from a similar position at an NHS Foundation Trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. Jenni Douglas-Todd Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before being becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two-and-a-half years as a resident twinning adviser for the UK, based in Turkey to help set-up a law enforcement complaints system before taking up the role of chief executive of the county’s Police Authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the general dental council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Executive directors Fiona Dalton, chief executive Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. 22 Gail Byrne, director of nursing and organisational development Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Jane Hayward, director of transformation and improvement Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Dr Derek Sandeman, medical director 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. Dr Caroline Marshall, chief operating officer Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, 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. David French, chief financial officer David joined the Trust in February 2016 and leads on finance, procurement, estates and commercial development. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Board effectiveness On the basis of the expertise and experience described above, the Trust is confident that the necessary range of knowledge and skills exists within the Board of Directors and that its balance, completeness and appropriateness to the requirements of the NHS Foundation Trust constitutes a high performing and effective Board. A register of interests of Board members is outlined within this report and is also available from the associate director of corporate affairs. The effectiveness of the Board of Directors meetings is reviewed at the end of each meeting. Effectiveness of Board sub-committees is monitored through monthly board reports and annual evaluation/review of the terms of reference and work programmes. Schedule of Decisions Reserved to the Board The NHS Foundation Trust Code of Governance requires that there should be a formal schedule of matters specifically reserved for decision by the Board. The Scheme of Delegation shows the ‘top level’ of delegation within the Trust. The Scheme should be read in conjunction with Trust’s Standing Financial Instructions and Standing Orders. A copy of the Schedule of Matters Reserved for the Board can be obtained from the associate director of corporate affairs. 23 Attendance at board meetings in 2016/17 Board member 12 28 24 Apr Apr May Extra Extra CS CS 26 May 20 Jun Extra CS 28 26 27 11 27 29 16 26 28 28 Jun Jul Sep Oct Oct Nov Dec Jan Feb Mar Extra CS CS only Peter Hollins chair 3 33 33 3 3 3 3 3 3 3 33 3 Simon Porter 3 non-executive director 33 3 telecon 3 333 3 telecon 3 3 3 33 3 Iain Cameron 3 non-executive director 35 35 5 3 3 3 3 3 3 33 5 Lynne Lockyer 3 33 55 non-executive director telecon 3 3 3 3 3 3 3 33 3 David Price 5 non-executive director 33 3 telecon 3 333 3 telecon OS only 3 3 5 33 3 Mike Sadler 3 non-executive director 33 3 telecon 3 333 5 telecon 3 3 3 33 5 OS OS only only Jenni Douglas-Todd 3 non-executive director 33 3 telecon 3 3 53 3 telecon OS only 3 3 3 53 3 Fiona Dalton Chief executive 3 33 33 3 3 3 3 3 3 3 33 3 David French 3 Chief financial officer 33 33 3 3 3 3 3 3 3 33 3 Derek Sandeman Medical director 5 33 33 3 3 3 3 3 3 3 33 3 Gail Byrne Director of nursing and organisational development 3 33 35 3 3 3 3 3 3 3 33 3 Caroline Marshall 3 Chief operating officer 33 33 3 3 3 5 5 5 5 33 5 Jane Hayward Director of transformation and improvement 3 35 33 333 3 telecon 3 3 3 33 3 Telecon = telephone conference OS only = open session only 24 Audit and assurance committee (until May 2016) Board member Peter Hollins NED chair Simon Porter non-executive director senior independent director and deputy chair Iain Cameron non-executive director Lynne Lockyer non-executive director David Price non-executive director Mike Sadler non-executive director May 2016 3 5 3 5 3 3 Audit and risk committee (formerly audit and assurance committee) (from June 2016) Board member Simon Porter non-executive director senior independent director and deputy chair David Price non-executive director Mike Sadler non-executive director David French Chief financial officer 18 Jul 3 3 3 3 17 Oct 3 16 Jan 3 20 Mar 3 3 3 5 3 3 3 3 3 3 Audit and risk committee The audit and risk committee (formerly known as the audit and assurance committee) is a non-executive committee of the Trust Board with delegated authority to review the establishment and maintenance of an effective system of integrated governance, risk management and financial and non-financial control, which supports the achievement of the Trust’s objectives. As part of the Trust’s on-going commitment to continuous improvement the role and responsibilities of the audit and risk committee were subject to in-year review and revision. The principle change arising from the review was the transfer of responsibilities with regards to ‘clinical quality assurance’ to the quality committee. Composition and meetings There are three non-executive director members of the committee. The committee is chaired by Simon Porter. Further information on the chair is available on pages 21. Executive directors attend by invitation, and there is a standing invitation to the chief financial officer. Other executive directors and staff with specialist expertise attend by invitation. The audit and risk committee met five times between May 2016 and March 2017 in relation to matters covered in this annual report. 25 Purpose and remit The committee purpose is the remit of a ‘traditional’ audit committee, including an oversight function in relation to financial reporting, systems of internal control, risk management, effective use of resources, appointment and effectiveness of external and internal auditors. Major topics considered by the committee
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