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Papers Trust Board 27 May 2021

Description: Date Time Location Chair Agenda Trust Board – Open Session 27/05/2021 9:00 - 13:00 Microsoft Teams Peter Hollins 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 To note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Staff Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 30 March 2021 9:15 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Charitable Funds Committee (Oral) 9:25 Dave Bennett, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:30 Dave Bennett, Chair 5.3 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.4 Chief Executive Officer's Update (Oral) 9:40 Sponsor: David French, Chief Executive Officer 5.5 Integrated Performance Report for Month 1 10:00 To review the Trust's performance as reported in the Integrated Performance Report Sponsor: David French, Chief Executive Officer 5.6 Equality and Diversity Update (WRES and WDES) 10:45 Sponsor: Steve Harris, Chief People Officer Attendee: Gemma Genco, Head of Equality, Diversity & Inclusivity 5.7 Gender Pay Gap Reporting 2020 11:05 Sponsor: Steve Harris, Chief People Officer Attendee: Kirsty Durrant, Strategic HR Projects Manager 5.8 Freedom to Speak Up Report 11:25 Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.9 Finance Report for Month 1 11:45 Sponsor: Ian Howard, Interim Chief Financial Officer 6 STRATEGY and BUSINESS PLANNING 6.1 CRN: Wessex 2020/21 Annual Report and 2021/22 Annual Plan 11:55 Sponsor: Paul Grundy, Chief Medical Officer Attendees: Rebecca McKay, Chief Operating Officer, CRN: Wessex/Clare Rook, Deputy COO, CRN: Wessex 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair's Actions 12:15 In compliance with the Trust Standing Orders, Standing Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Peter Hollins, Trust Chair 7.2 Emergency Planning and Business Continuity Annual Report 2020/21 12:20 Sponsor: Joe Teape, Chief Operating Officer 7.3 Charitable Funds Committee Terms of Reference 12:30 Sponsor: Peter Hollins, Trust Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 7.4 Trust Executive Committee Terms of Reference 12:35 Sponsor: David French, Chief Executive Officer Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 8 Any Other Business 12:40 To raise any relevant or urgent matters that are not on the agenda 9 To note the date of the next meeting: 29 July 2021 Page 2 10 Resolution regarding the Press, Public and Others Sponsor: Peter Hollins, Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 3 Minutes of Previous Meeting held on 30 March 2021 1 Minutes TB 30 March 2021 OS Minutes Trust Board – Open Session Date Time Location Chair Present 30/03/2021 9:00 - 12:05 Microsoft Teams Peter Hollins (PH) Dave Bennett (DB), Non-Executive Director (NED) Gail Byrne (GB), Chief Nursing Officer Cyrus Cooper (CC), NED Keith Evans (KE), NED David French (DAF), Interim Chief Executive Officer Paul Grundy (PG), Interim Chief Medical Officer Steve Harris (SH), Chief People Officer Jane Harwood (JH), NED (until item 5.10) Ian Howard (IH), Interim Chief Financial Officer Tim Peachey (TP), NED and Senior Independent Director/Deputy Chair Joe Teape (JT), Chief Operating Officer In attendance Brenda Carter (BC), Assistant Director of People (for item 5.8) Ellen Copson (EC), Associate Professor of Medical Oncology, University of Southampton and Honorary Medical Oncology Consultant (for item 2) Kirsty Durrant (KD), Strategic HR Projects Manager (for item 5.8) Karen Flaherty (KF), Associate Director or Corporate Affairs and Company Secretary Sarah Herbert (SHe), Divisional Head of Nursing and Professions, Division B (for item 5.9) Sandra Hodgkyns (SHo), Head of Emergency Planning Response and Resilience/Security (for item 5.9) Stephanie Ramsey (SR), Director of Quality and Integration (Chief Quality Officer and Chief Nurse), NHS Southampton City CCG (for item 5.6) 3 governors (observing) 3 members of the public (observing) 5 members of staff (observing) 1 member of the public (for item 2) 1 Chair’s Welcome, Apologies and Declarations of Interest The Chairman welcomed all those attending to the meeting. The following declaration of interests for GB were reported to the Board: • Chair of the Directors of Nursing Group, University Hospital Association; • Chair of the Wessex Patient Safety Collaborative; and • Member of the Policy Board, NHS Employers. The Board also noted that DB was no longer a director of Davox Consulting Limited. 2 Patient Story The patient story was told by the husband of a patient who sadly died in early 2020 following treatment for cancer at the Trust. As a result of the treatment she had received at the Trust following a diagnosis in April 2017, her life had been extended by over three years. In terms of areas for improvement, better communication of his wife’s initial diagnosis would have helped her and her family to come to terms with the diagnosis more quickly. Following their arrival at hospital, they were being asked lots of questions and his wife was being sent for tests and scans without being given information about what concerns the clinicians had or potential diagnoses. The diagnosis was also delivered on the ward just prior to a visit from a relative and with better planning this could have been done more sensitively by providing a better environment in which to have the conversation and more time for his wife to absorb the information. Once his wife met the specialist team, including the specialist nurse, she felt more reassured and was given hope by the availability of different treatment options. The Trust’s appointment of a dedicated specialist nurse for his wife’s particular cancer shortly after her diagnosis made a huge difference. The specialist nurse was always present when his wife met the consultants and would check if there was anything he or his wife needed and provided practical advice and support, which meant that he and his wife were able to spend more time together. GB reiterated the importance of specialist nurses across different patient pathways and the Trust continued to invest in more specialist nurses. While acknowledging that there was a shortage of private spaces to speak with patients and their families, through its End of Life Care Steering Group the Trust had identified a number of rooms across the hospitals to enable clinicians to go somewhere private in situations like these. The cancer service also continued to adapt to changes in cancer care and the needs of patients, with patients now living longer. Maggie’s Southampton had recently opened at the Southampton General Hospital site to provide help and support for those living with cancer, although the services it offered were currently reduced as a result of the Covid-19 pandemic. The Board expressed its gratitude for sharing the story with such strength and dignity. 3 Minutes of Previous Meeting held on 28 January 2021 The minutes of the meeting held on 28 January 2021 were approved as an accurate record of that meeting. 4 Matters Arising and Summary of Agreed Actions The updates on the actions were noted. The action relating to cancelled appointments in ophthalmology (reference 354) had been followed up and could be closed, as could the actions relating to patients medically optimised for discharge (reference 351 and 393) and the Ockenden report (reference 395), which were included as items on the agenda later in the meeting. The action relating to patient nutrition (reference 394) would be reviewed at the next meeting of the Quality Committee, which would then report to the Board. The Board agreed that the actions relating to specialty outcomes (reference 350 and reference 326) should be combined, with the paper due to be presented to the Board at its meeting in April 2021. Page 2 5 QUALITY, PERFORMANCE and FINANCE 5.1 Briefing from the Chair of the Audit and Risk Committee KE updated the Board on the meeting of the Audit and Risk Committee held on 15 March 2021: • the external audit work had commenced and there were no issues to report at this early stage; • the internal auditors had reviewed referral to treatment (RTT) data quality and while data inaccuracies had been identified in the sample testing, these had not impacted on patients clinical treatment or on Trust’s the overall performance against the RTT target, and in most instances had resulted in the Trust overreporting on pathways; and • updates had been provided on progress against the recommendations in the board governance review and the ongoing review of the data security and protection toolkit. 5.2 Briefing from the Chair of the Finance and Investment Committee DB provided an overview of the Finance and Investment Committee meeting the previous day, highlighting: • that funding for the loss of other income and additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic had been received; • the update on the planning process for 2021/22 following the publication of new national guidance that sought to achieve a balance between restoring services and reducing backlogs while supporting staff recovery; • the review of the most recent operational productivity dashboard, from which it had been difficult to draw any meaningful conclusions given the impact of the Trust’s response to the most recent wave of the Covid-19 pandemic in the previous months; and • the business case for the expansion of the outpatients area in ophthalmology, which would be considered by the Board later in the meeting. 5.3 Briefing from the Chair of the Quality Committee TP provided an update on the meeting of the Quality Committee held on 15 March 2021 focusing on the following areas: • the increase in waiting times for diagnostics and plans to recover performance, with a review of patient harm to be completed once patients who had waited longer than six weeks had been seen; • the review of a ‘never event’ relating to a retained swab including the recommendations for a number of sensible actions that had already been implemented; • the latest update on experience of care including the Trust’s accreditation as a Veteran Aware NHS trust; • the recommendations for reporting on maternity safety following the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust, which would be considered by the Board later in the meeting; • the urgent investigation of aspergillus infections in the intensive care unit to establish whether there was a link to an earlier leak in a pipe above the ceiling in that area; • the latest report on clinical outcomes, with the Board to receive a full Page 3 report at its meeting in April 2021; and • the review of the committee’s effectiveness. 5.4 Chief Executive Officer’s Update The Trust had taken part in the national day of reflection and one minute’s silence on 23 March 2021 to commemorate the anniversary of the first national lockdown due to the Covid-19 pandemic. This had given staff an opportunity to pause and reflect on the loss of life over the previous year, including patients and staff. There were currently 20 patients in the hospital who had tested positive for Covid-19, three of which were in intensive care. An average of three or four patients with Covid-19 were being admitted daily, which highlighted the importance of continuing to follow the rules as lockdown measures were eased. Staff were being encouraged to take annual leave and wellbeing conversations were taking place with every member of staff. Second doses of the Covid-19 vaccine were being administered to Trust staff and staff at health and social care partners. 92% of frontline staff and 90% of all staff had received at least one dose of the vaccine, including 88% of BAME (Black and Minority Ethnic) staff. Staff who had not yet received the vaccination were being contacted individually to understand the reasons for this and provide additional information where appropriate. As well as planning for the recovery of services in the short term, the Trust was carrying out long-term modelling of future demand and capacity supported by external consultants and architects, which would form the basis of the Trust’s estates masterplan for the main hospital site. In advance of this work, the corporate objectives for 2021/22 would be presented to the Board at its meeting in April 2021. The Trust had performed exceptionally well in its recent external accreditation of endoscopy by the Joint Advisory Group on GI Endoscopy (JAG), providing one of the best submissions reviewed by JAG. Each of the executive directors provided an update in turn, covering the following areas: • reopening of theatres in Southampton General and Princess Anne Hospitals, replacing the current additional capacity in the independent sector from 1 April 2021; • four ‘Always Improving’ quality improvement projects relating to the emergency department (ED), discharge of patients medically optimised for discharge (MOFD), theatres and outpatients; • the launch of the ‘Always Improving’ strategy with staff in June 2021; • the review of patients who had been waiting for surgery, in particular those in priority level 2 (surgery that can be deferred for up to four weeks); • modelling of the potential impact on the waiting list of GP referrals returning to more normal levels and patients potentially presenting with more advanced disease than if they had seen their GP earlier; • the business intelligence programme to improve prospective as well as retrospective reporting; • allowing time for teams to readjust to working together as part of the recovery process with additional support from the Trust for those teams experiencing challenges; • plans to safely reopen the hospitals to visitors, particularly while the Page 4 Trust continued to admit patients with Covid-19; • re-energising the COVID ZERO campaign to ensure that the infection control measures continued to be followed rigorously even as the number of cases reduced, with a nosocomial infection the previous week acting as a timely reminder of the risk; • the successful renegotiation of the limit on expenditure (CDEL) for 2020/21 through which the Trust had been able to access additional capital and the negotiation of the allocation of CDEL across the integrated care system (ICS) for 2021/22; and • the current projects in development including theatres, the private patient unit, ophthalmology and the pathology laboratory information system. The Board noted that that the Trust would need to establish how it would balance the needs of those patients who had been waiting longest for treatment with the clinical prioritisation process already in place as it planned for the recovery of activity. 5.5 Integrated Performance Report for Month 11 The integrated performance report (IPR) for month 11 was noted. During February 2021 the direct impact of Covid-19 infections upon the Trust continued to be significant. There were 263 patients in the hospital with Covid19 at the start of February and 129 at the end of the month. The number of patients in intensive care reduced from 67 at the beginning of the month to 39 by the end of February. This compared to the first wave of Covid-19 pandemic, when the number of patients with Covid-19 in the hospital peaked at 173 and 38 in intensive care. This also had an impact on elective activity within the Trust, which was 42% of the level in February 2020. The Board discussed the following areas: Responsive • while the Trust’s ED was performing well comparatively, it was not meeting the performance target on the length of time patients spent in ED, despite attendances at 71% of the normal level; • this was principally due to patients presenting with mental health conditions and surges of high acuity patients, however, new junior doctors had also joined ED in February who were not used to the level of attendances; • leadership in ED was central to managing the department in these situations particularly the effective operation of the consultant of the day model to ensure that decisions regarding patients were made in a timely manner; • performance in ED had improved overall as 87% of patients were currently seen within four hours with an average daily attendance of 345 patients compared to 78% of patients two years ago when the average daily attendance was 350 patients; • to continue to improve performance and the flow of patients through ED the Trust was ensuring that specialties adhered to the one hour standard for referrals; • infection control measures remained in place, including respiratory assessment and rapid testing in ED and the acute medical unit, although it was difficult to establish whether this had a material impact on performance as ED had performed consistently well during the Page 5 period of the pandemic; • activity in ED had increased in March 2021 as lockdown restrictions had eased; • while the number of non-face-to-face outpatient appointments had increased following the first wave of the pandemic, some of these had not been full appointments but rather an opportunity to check in with patients; • the use of non-face-to face outpatient appointments varied by condition and specialty and was more appropriate for some of these than others, however, the Trust was seeking to learn from those clinicians who had used these types of appointment successfully as part of its quality improvement work in outpatients; • feedback from patients non-face-to face appointments had been positive on the basis that their care was continuing, however, limited work had been done to assess effectiveness in terms of the experience and outcome of these appointments; and • although cancer performance measures remained stable, both the Trust and the Wessex Cancer Alliance had performed well comparatively and ranked as second highest performing in their respective peer groups. Safe • • the unusually high number of medication incidents reported with moderate or severe harm in February and the actions taken in response to these; and ensuring that staff continued to report incidents, particularly as they returned to their normal areas of work following the pandemic. Caring • the number of overnight ward moves for non-clinical reasons given that most patient moves during this period would be related to patients admitted with Covid-19; • the percentage of patients with a disability or additional needs reporting that those needs were met had reduced and there were resource challenges in this area currently with a vacancy in one of the two adult learning disabilities nursing roles, although the recruitment process was underway; and • increasing the number of vulnerable women on a continuity of carer pathway given the benefit to all these women in terms of the quality of oversight in maternity. ACTIONS: (1) GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. (2) The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Well-led • the impact of research activity on outcomes, more detail of which would be provided in the report on clinical outcomes at the meeting of the Board in April 2021. The Board’s review of the IPR, led by TP, would report to the Board in May 2021 with a candidate IPR. Page 6 5.6 Inpatient Flow - Medically Optimised for Discharge Update SR joined the meeting for this item. The Board noted the current performance against the process improvement trajectories and key performance indicators agreed by the system, system plans in the light of current performance and the Trust’s internal work programme for MOFD. The Board was interested to learn what the Trust could be doing differently or better in order to help improve performance as a system. The work to date had made a significant impact as the system responded to discharge an increased number of patients with more complex needs such as stroke patients, patients with challenging behaviours, patients requiring more intensive therapy and homeless patients. There was a specific issue with discharging to care homes at weekends and providing the necessary clinical support to these care homes to enable discharge. The main areas of focus for the Trust were to speed up processes and ensure patients MOFD were ready to be discharged earlier in the day as this would make it easier for services in the community to respond. While there was a target to get to 40-60 patients MOFD in hospital, no specific timescales had been set. ACTION: JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Funding was also likely to be an issue in the future as additional national funding provided during the Covid-19 pandemic to support the discharge of patients would be withdrawn at the end of June 2021. The Board recognised that system partners were aligned in their aim to address the delays in discharging patients MOFD and prevent potential patient harm as a result. However, the Board suggested a more holistic view of the issue would be beneficial when reviewing future resourcing, taking into account the revenue and capital implications and the consequences in terms of hospital capacity and addressing the current backlog of patients waiting for treatment. This analysis may identify where investment was needed to support discharge, including additional capacity, albeit that the ambition remained ‘home first’ when discharging patients in order to assess ongoing needs more accurately and reduce dependency. The meeting was adjourned briefly to allow for a break. 5.7 Ockenden Review of Maternity Services The Board noted the update on progress on the emerging findings and recommendations of the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust released on 10 December 2020. The Trust had rated its progress against two of the recommendations as red, with no actions currently in place, and nine of the recommendations as amber, where actions were still in progress. Completion of these recommendations was dependent the Trust’s submission to NHS Resolution’s maternity incentive scheme which would be made by mid-July 2021 and therefore other trusts would be in a similar position. The Trust had received feedback on the information submitted to NHS England and NHS Improvement, which had been positive overall. A template had been designed to report to the Board and the local maternity Page 7 service (LMS) on maternity safety, which would incorporate a summary of serious incidents (SIs) and moderate harm incidents. This report would be submitted to the Board maternity safety champions and LMS on a monthly basis. The Board maternity safety champions would also meet with complainants before the referral of a complaint to the Parliamentary and Health Service Ombudsman. It was proposed that reporting to the Board on maternity safety issues including SIs and moderate harm incidents, the perinatal mortality report tool, early notification scheme, red flag incidents, staff concerns and evidence of listening to families including complaints would take place quarterly following review of the information by the Quality Committee. The frequency of reporting to the Board was in line with the recommendations in the Ockenden review although not with the guidance issued subsequently. The Board was keen to ensure it maintained a good understanding of the culture and patient experience in the maternity service given the impact of each on the quality of the service. Proposals to regularly survey staff would be considered later in the meeting. In addition the Board requested that the regular patient story should include maternity at least once annually. ACTION: KF to arrange a patient story from a patient using the maternity service at least once annually. DECISION: The Board agreed: • to receive a quarterly report on maternity safety issues; and • that all SIs and moderate harm incidents would be provided to the Board maternity safety champions and LMS. 5.8 UHS Staff Survey Results 2020 Report BC and KD joined the meeting for this item. The results of the NHS staff survey 2020 were noted by the Board. The survey had been completed by staff between September and November 2020. Overall the Trust’s results were at or above the acute trust average in nine out of ten themes. 77% of staff would recommend the Trust as a place to work and 87% of staff agreed that care of patients was the top priority for the Trust. Performance on health and wellbeing had significantly increased compared to 2019. However, the survey had also identified some areas for improvement. The areas with statistically significant decreases in performance compared to the 2019 staff survey results were: • Equality, diversity and inclusion; • Immediate managers; • Violence; and • Team working. In response to a question from a NED, it was clarified that only a small number of incidents of violence against staff from managers and colleagues reflected in the staff survey results were reported leading to an investigation. The reporting through the Trust’s Freedom to Speak Up processes had identified incidents involving microaggressions rather than acts of violence. Work was also ongoing to improve leadership skills within the organisation, which would set out expectations regarding values and behaviours. Over 1,000 free text comments had been submitted from staff as part of the survey and a national analysis of themes was being prepared, which would Page 8 provide further insight into how staff were feeling following the first wave of the pandemic. The Board supported more regular surveying of staff, particularly around the areas of improvement identified, recognising that things had changed since the survey was carried out six months ago and would continue to change. 5.9 Plan to Address Violence and Aggression against Staff SHe and SHo joined the meeting for this item. The Board noted the update on the progress made since the previous update in September 2020. This included closer working with Hampshire Constabulary, proposed changes to security arrangements, staff training and staff support. These plans aimed to reduce incidents of violence and aggression against staff and provide support to staff in the management of violence and aggression and following any incidents. The Board recognised that violence and aggression against staff would never be eliminated entirely as the Trust provided care to individuals with mental health issues, brain injuries, dementia and who lacked capacity who may find it difficult to control their behaviour. It was important, however, that violent and aggressive behaviour was challenged consistently when appropriate. The Board supported the approach to exclude violent and aggressive individuals from the Trust when they repeatedly displayed unacceptable behaviour that it was not possible to manage through de-escalation, anticipatory care planning and the challenging behaviour protocol. While not formally approving the funding for the plans set out in the paper, the Board noted the importance of investment in this area in order to support staff. A further update on progress would be provided in December 2021. 5.10 Finance Report for Month 11 The finance report for month 11 was noted. The following areas were highlighted: • the Trust has received the payments for the loss of other income, additional accruals of annual leave that staff had been unable to take due to the Covid-19 pandemic and the elective incentive scheme; • the Trust remained on track to achieve a breakeven position for 2020/21 as did the other trusts in the Hampshire and Isle of Wight ICS; and • the Trust’s balance sheet position remained strong, which placed the Trust in a good position to address likely pressures in 2021/22. 6 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 6.1 Register of Seals and Chair's Actions for ratification DECISION: The Board ratified the application of the Trust seal and the Chair’s actions set out in the report. ACTION: IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. 6.2 Amendment to Constitution for CCG Merger With effect from 1 April 2021, the individual Clinical Commissioning Groups Page 9 (CCGs) within Hampshire and the Isle of Wight were to merge to create a new NHS Hampshire, Southampton and Isle of Wight CCG. The Council of Governors (CoG) included an appointed governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and as a result of the merger these two organisations would cease to exist. It was proposed that the Trust should reflect the merger in the composition of the CoG, by amending the composition of the CoG in Annex 3 of the Trust’s constitution to remove the Appointed Governor from each of NHS Southampton City CCG and NHS West Hampshire CCG and include an Appointed Governor from NHS Hampshire, Southampton and Isle of Wight CCG in their place. A separate review of the composition of the CoG would be undertaken as part of the annual review of the Trust’s constitution to ensure that the overall composition of the CoG remains representative and reflected the changes to NHS governance structures. DECISION: The Board approved the amendment to the Trust’s constitution with effect from 1 April 2021, subject to the approval of the CoG at its meeting on 31 March 2021. 7 Any Other Business There was no other business. 8 To note the date of the next meeting: 27 May 2021 9 Resolution regarding the Press, Public and Others DECISION: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders for the Practice and Procedure of the Board of Directors, representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 10 4 Matters Arising and Summary of Agreed Actions 1 List of Action Items List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 5.5 Integrated Performance Report for Month 11 426. Caring - overnight ward moves Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item GB would review the non-clinical reasons for overnight ward moves and provide an overview to the Quality Committee. 427. Caring - vulnerable women Byrne, Gail Peachey, Tim 27/05/2021 Pending Explanation action item The Quality Committee would review the resourcing required to increase the percentage of vulnerable women on a continuity of carer pathway and update the Board. Trust Board – Open Session 30/03/2021 5.6 Inpatient Flow - Medically Optimised for Discharge Update 428. Trajectory for MOFD patients Teape, Joe 27/05/2021 Pending Explanation action item JT agreed to include a trajectory for MOFD patients in the regular reports to the Finance and Investment Committee. Trust Board – Open Session 30/03/2021 5.7 Ockenden Review of Maternity Services 429. Patient story Flaherty, Karen 31/03/2022 Pending Explanation action item KF to arrange a patient story from a patient using the maternity service at least once annually. Page 1 of 2 Agenda item Assigned to Deadline Status Trust Board – Open Session 30/03/2021 6.1 Register of Seals and Chair's Actions for ratification 430. Follow up Howard, Ian 27/05/2021 Pending Explanation action item IH would follow up on the Wessex Clinical Research Network and the assisted conception service items in the paper as these were not single tender actions required to be reported in accordance with the Trust’s Standing Financial Instructions. Page 2 of 2 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose Issue to be addressed: Integrated Performance Report 2021/22 Month 1 5.5 David French, Chief Executive Officer 27 May 2021 Assurance Approval or reassurance Y Ratification Information This report is intended to support the Trust Board in assuring that: • the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • at the same time we continue our journey toward our vision of World Class Care for Everyone. Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with the Care Quality Commission Key Lines of Enquiry. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying This report is provided for the purpose of assurance. out the change / or not: Summary: Conclusion This report is provided for the purpose of assurance. and/or recommendation Page 1 of 1 Integrated KPI Board Report covering up to April 2021 Sponsor - Andrew Asquith, Director of Planning, Performance and Productivity, andrew.asquith@uhs.nhs.uk Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart 100% 0% 66.8% 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). 66.49% The line shows our performance and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. 2 Report to Trust Board in May 2021 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to: • Provide assurance that the care we provide is safe, caring, effective, responsive and well led in the context of the COVID-19 pandemic • Ensure that at the same time we continue our journey toward our vision of World Class Care for Everyone. We adjust / add to these indicators – informing the Board and keeping a comparative narrative – as the situation changes as we work through these unusual circumstances. The structure of the report is currently being reviewed in order that it can better reflect the ambitions within ‘Our Strategy 2025’, and to support the strategic discussions of the Board. April 2021 Summary During April the direct impact of COVID-19 infections upon the Trust reduced further. Patients with a confirmed COVID-19 diagnosis during their admission: • Started the month at 48 (11 of which were in intensive care / high care) • Finished the month at 24 (5 of which were in intensive care / high care) The phased resumption of the elective admissions continued within NHS facilities, and the additional access to independent sector theatres and beds that had been secured by NHS England during the pandemic terminated at the end March. 3 Report to Trust Board in May 2021 Key aspects of performance for consideration this month include: • The total number of patients on the RTT waiting list increased by over 1,000 patients to 37,613 in April. There are over 3,000 patients waiting over 52 weeks for treatment and over 500 patients waiting over 78 weeks. Our benchmarking confirms that we are continuing to perform well in comparison to our peer group. • The crude mortality rate and Hospital Standardised Mortality Ratio (HSMR) both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). Patient details have been requested in order that the recorded diagnosis can be checked as a first step in investigation. It may be relevant that January saw a peak in COVID-19 occupancy. • UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals in March. 4 Report to Trust Board in May 2021 RESPONSIVE • Emergency Department timeliness deteriorated slightly to 87% (RE 9) whilst remaining 3rd best amongst 8 benchmark trusts. Attendance numbers increased further to the highest levels since the COVID-19 pandemic started (RE 8). • Elective spell volumes (excluding daycases, at SGH/PAH only) (RE 13) recovered further, yet remained below those in Autumn 2020. Two SGH theatres are currently closed due to building works and are due to reopen in June. • The total number of patients on the RTT waiting list increased by over 1,000 patients this month. The cohort of patients who have waited over 52 weeks (RE 16) reduced by over 300 patients, whilst those waiting over 78 weeks (RE 17) increased by over 100 patients. We remain concerned by this situation and are focussed on improving the situation as soon as possible for our patients. Our benchmarking (in a group of 20 Teaching hospitals) confirms that we are continuing to perform well in comparison to our peer group. • Cancer performance measures for March indicate continued improvement in performance: o UHS 62 day performance (RE 23) improved to 86.5% (better than our local target and the national target applying to the majority of 62 day pathways). UHS was the best performing trust amongst our 10 ‘peer’ teaching hospitals again this month. o 31 day performance (RE 24) was maintained above the target at 97.6%. 5 Report to Trust Board in May 2021 RESPONSIVE RE1 Non-elective Spells (discharged, including CDU) Non Elective LOS RE2-L Rolling 12 months (Solid) Monthly (Dashed) Number of inpatients that were RE3 medically optimised for discharge (monthly average) Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target 6,800 6,292 4,000 7.5 6.0 4,128 6.49 - 5.45 - 4.5 250 76 0 122 - Longer LOS Census average RE4-N (Patients with LOS > =21days) 203.38 160.86 118.33 73 145 - RE5-l RE6 RE7 Adult midday bed occupancy Last minute cancelled operations not readmitted within 28 days Last minute cancelled operations 100% 98.2% 84.6% 71.1% 82.6% 40% 55 40 0 150 5 0 79.0% 90-95% - 6 35 - 6 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr QTD 12,000 10663 RE8 Total ED Attendances - 5735 5,000 RE9-N Patients spending less than 4hrs in ED SGH Main ED (Type 1 and UCH) 92% 84% Major Trauma Centres (Type 1) 76% 90.2% 87.2% 81.30% 87.2% Rank of 8-> RE10-N Patients spending less than 4hrs in ED UHS Total (includes SGH all types) - 532533422111233 92.22% 85.5% 78.82% 91.1% 91.1% 88.0% 88.0% Q target - 95% 95% RE11-N Total time Total spent in ED - Percentiles UHS RE12 27,000 Accepted Referrals (excluding -initiated by consultant responsible) 0 RE13 2,000 Elective spells (excluding daycase, onsite SGH/PAH only) 0 90th, 4:00 Mean, 2:45 8,013 446 90th, 4:59 - - Mean, 3:04 19,100 - - 1,438 - - 7 Report to Trust Board in May 2021 RESPONSIVE Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 100% % Patients on an open 18 week pathway 66.8% RE14-N (within 18 weeks ) with teaching hospital min-max range and rank (of 20) 18 12 14 14 7 6 7 7 10 10 10 9 30% 38,000 Total number of patients on a waiting RE15-N list (18 week referral to treatment 33106 pathway) 30,000 Patients on an open 18 week pathway 9,000 RE16-N (waiting 52 weeks+ ) with teaching hospital min-max range and rank (of 20) 0 15 154 13 13 13 11 11 11 10 9 6 6 6 1000 RE17 Patients on an open 18 week pathway (waiting 78 weeks+ ) 500 0 0 65,000 RE18 Face to face outpatient attendances 40,105 Feb Mar Apr 66.5% 9 8 37613 3108 5 4 553 34,415 Target > =92% - 0 65,000 RE19 Non-face to face outpatient attendances 15,703 0 RE19 - Latest month is awaiting approx ~3k outpatient attendances to be reported 18,748 - RE20-N Average weeks waited for first outpatient appointment 12.00 10.47 8.89 10.3 7.00 7.30 8.5 - 8 Report to Trust Board in May 2021 7.00 7.30 RESPONSIVE Target Patients to Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar /Apr recover target QTD 11,000 9563 RE21-N Patients waiting for diagnostics - 4317 4,000 80% % of Patients waiting over 6 weeks for RE22-N diagnostics with teaching hospital min- 45.2% 27.2% 90% N = 7 L= L=> 0 of 197 80% 85% 69.1% UHS Total ………………….Rank(of 10)-> 6 5 3 1 1 1 1 1 5 7 4 2 1 1 0.5 31 day cancer wait performance RE24-N (Latest data held by UHS, Combined measure – First and Subsequent Treatments of Cancer) 97.1% 93.2% 89.4% 92.2% 97.6% N=> 96% N=0 of 948 97.41% RE25-N Snapshot of waits > 104 days (from referral on a 62 day pathway) 36 27 29 25 11 17 9 11 25 24 17 13 16 22 - - - RE26-N 28 Day Faster Diagnosis 100% 70% 82.7% 87.5% => 75 % - 84.16% 9 Report to Trust Board in May 2021 RESPONSIVE RE27 My Medical Record - UHS patient logins Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Monthly target 20,000 18,182 10,000 5,566 - 0 2,500 RE28 Number of Estates Help desk requests 900 and percentage completed on time 100% 85% 997 89.6% 1,592 - 84.7% > 85% 50% Elective inpatient activity - % of same month pre COVID-19 100% RE29 UHS Corporate peer average ------------------------------Rank--> 20% Non-elective inpatient activity - % of same month pre COVID-19 100% RE30 UHS Corporate peer average ------------------------------Rank--> 50% 1st outpatient attendances - % of same month pre COVID-19 100% RE31 UHS Corporate peer average ------------------------------Rank--> 30% Follow up outpatient attendances - 110% % of same month pre COVID-19 RE32 UHS Corporate peer average ------------------------------Rank--> 50% RE29-32 corporate peers group size = 7 90.4% 85.1% 35.23% 3 2 2 2 2 2 1 1 4 4 2 95.0% 66.6% 95.42% 534422232254 96.2% 51.7% 93.77% 47.20%2 2 2 2 2 2 2 2 2 2 2 3 70.3% 108.9% 102.8% - 63.6% 6 3 2 2 1 1 2 2 1 1 4 5 QTD - 86.2% - 10 Report to Trust Board in May 2021 SAFE • Only a single case of probable hospital associated COVID-19 acquisition > 7 days occurred in April (SA 6). • Our measure related to pressure ulcers was amended this month to distinguish between category 2 and 3 ulcers, regardless of level of ‘harm’ (SA 7/8). Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target YTD SA1-N Cumulative Clostridium difficile 2 SA2 MRSA bacteraemia 0 100 SA3 Clinical cleaning scores for very high risk areas 95 100 SA4 Serco cleaning scores for very high risk areas 95 Healthcare-acquired COVID 35 SA5 infection: COVID-positive sample taken > 14days after admission (validated) 0 Probable hospital-associated 80 SA6 COVID infection: COVID-positive sample taken > 7 days and 95% - 93.4% YTD target 95% 12 Report to Trust Board in May 2021 CARING • Inpatient feedback (CA 1) continues to be good and significantly better than target. • Maternity patient negative feedback (CA 2) continues to be worse than target; 6.6% compared to the target of =70% 41.5% 65.6% 14 Report to Trust Board in May 2021 0% CARING Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target Total vulnerable women (living 100% CA8 within 10% most deprived decile) booked onto a continuity of carer 40.0% pathway 0% 100% % Patients reporting being CA9 involved in decisions about care and treatment 50% 86.0% 85.0% > =90% CA10 100% % Patients reporting finding somebody to talk to about worries and fears 50% 97.0% % Patients with a disability/ 100% additional needs reporting those 81.0% CA11 needs/adjustments were met (total number questioned included at chart base) 30 165 39 50% 57 153 215 133 164 174 178 240 77 CA11 - Performance is a scored metric with a "Yes" response scoring 1, "Yes, to some extent" receiving 0.5 score and other responses scoring 0. Overnight ward moves with a 100 CA12 reason marked as non-clinical (excludes moves from admitting 75.58 44.08 10 wards with LOS =90% 89.0% > =90% 63 110 289 29 - 10.8 - 15 Report to Trust Board in May 2021 EFFECTIVE • The crude mortality rate (EF 4) and Hospital Standardised Mortality Ratio (HSMR) (EF 3), both increased significantly in January (though HSMR remained significantly better than would be expected on average in the NHS). More deaths than ‘expected’ are reported in General Medicine, Respiratory Medicine and Medicine for Older People, with a primary diagnosis of ‘viral infection’. Information for 97 patients has been requested in order that the recorded diagnosis can be checked as a first step in investigation. • Measures relating to patients screened for smoking and harmful alcohol consumption (EF 5), with those found to smoke and given brief advice or a medication offer (EF 7), stalled in their recovery following the COVID-19 peak in January and are currently slightly below target. EF1-L Cumulative Specialities with Outcome Measures Developed EF2 Developed Outcomes RAG ratings EF3-N HSMR - UHS HSMR - SGH EF4 HSMR - Crude Mortality Rate Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 53 54 56 56 57 255 260 285 305 332 100% 75% 80% 81% 79% 77% 76% 50% 85 82.2 81.5 75 3.5% 3.0% 2.5% Monthly target +1 - 80% EF6-N % patients screened & found to 100% have either moderate or high alcohol dependence given advice or referral 80% 96.7% 95.7% > 90% 100% % patients screened & found to EF7-N smoke given brief advice or a medication offer 60% 83.6% 88.9% > 90% 17 Report to Trust Board in May 2021 WELL LED • Non-medical appraisal rates (WL 2) have continued their modest rate of recovery to 81%, but still remain significantly below the target of 92%. • Overall sickness absence (WL 6) reduced to 3%, which is within target, whilst COVID-19 related absence (WL 7) reduced to 1% of employed time during the month of April. WL1-L Substantive Staff - Turnover Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Target 13.63% 12.92% 12.22% 13.4% 12.3% 92% 95.0% 3.4% 12.4% =76% WL9-N Response rate of - staff recommend UHS 60% as a place to work: UHS Quarterly staff FFT National NHS Staff Survey 20% 50.0% 30% 11% WL10-L % of Band 7+ staff who are Black and Minority Ethnic 9.2% 10.0% 15% by 2023 7% WL11 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.3% 13.6% - 12% WL12- QI training programme, and reporting, is currently temporarily suspended as team members support urgent change programmes as part of our Covid 19 response and recovery WL12-L Statutory & Mandatory Training Achieving Target 7 7 7 6 6 6 6 6 6 6 6 6 6 6 6 - 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 100 WL13-L Number of Apprenticeship Starts 44 49 59 23 - 0 19 Report to Trust Board in May 2021 0 WELL LED Monthly Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr target WL14-L Comparative CRN Recruitment Performance by clinical specialty 56% 52% 28% 36% 40% > =70.0% WL15-L Comparative CRN Recruitment Performance - weighted WL16-L Comparative CRN Recruitment - contract commercial WL17-L Proportion of studies closing in FY on time and to recruitment target non-commercial WL18 NIHR CRF & BRC cumulative quarterly publications 2 5 13 88% 13 50% 600 137 120 0 2 17 43% 246 261 7 7 45% 424 329 Top 5 8 2 Top 10 42% 452 562 > =80% 20 Report to Trust Board in May 2021 Changes and Corrections Section Responsive Safe Safe Caring Caring KPI KPI Name Type RE29-32 Activity metrics - % of same month pre COVID-19, UHS and corporate peer average change SA7 Pressure ulcers category 2 per 1000 bed days change SA8 Pressure ulcers category 3 and above per 1000 bed days change CA11 % Patients with a disability/ additional needs reporting those needs/adjustments were met correction (total number questioned included at
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Finance and Performance Reports 2022-23 Month 2 May 2022

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance Report 2022-23 Month 2 9.3 Ian Howard – Chief Financial Officer Philip Bunting – Interim Deputy Director of Finance 30 June 2022 Assurance Approval or reassurance Ratification Information X The finance report provides a monthly summary of the key financial information for the Trust. Response to the issue: Financial Planning / National Context In June 2022, Trust Board approved a revised planning submission for UHS of: • A break-even financial position, noting a phasing of deficit in M16 improving to surplus in M7-M12. • Achievement of 106% elective recovery activity, above the 104% target • Receipt of an additional £7m national funding • A revised CIP target of £45.4m (4%) • A revised phasing of the financial plan This was part of a Hampshire and Isle of Wight submission that achieved break-even overall. UHS submitted the plan on the basis that the financial risks within the plan were noted and that should the Trust exceed Elective Recovery Programme targets, additional funding would flow to cover the additional costs of delivery, as outlined in the planning guidance. Within the M2 finance report the plan has been adjusted to reflect the improvement to breakeven and change in phasing. The revised planning submission highlighted significant financial risks within the plan and indicated a range of financial projections between break-even and £57m deficit, should risks around CIP delivery, activity risks, Covid-19 risks and further inflationary pressures all materialise. The report aims to track performance against plan and risk-based scenarios. M2 Financial Position UHS reported a deficit of £1.3m in May 2022, which when added to a £3.7m in April 2022 means a reported deficit of £5m YTD. This compares to a revised plan deficit of £2.8m, therefore is £2.2m adverse to plan. Page 1 of 16 However, it should be noted that a number of items relate to M1: • 2 months of £7.1m additional national funding have been included in May, £0.6m of which relates to M1 • Clinical supplies costs of £0.9m were underreported in M1 and have been reported in M2, partially off-set by £0.2m of other adjustments. The true reported position is therefore a £3.8m deficit in M1 and a £1.1m deficit in M2. Underlying Position The month 2 position has been supported by additional non recurrent measures of £2.7m meaning that the restated month 2 deficit is £3.8m, aligned to that of month 1. The overall underlying financial position is therefore a deficit of £7.6m YTD. This is £4.8m adverse to the plan for month 1 and 2 (£2.8m planned deficit). Key drivers The key drivers for the underlying deficit to plan are as follows: • Cost Improvement Plans – due to the considerable operational pressures the development of plans from Q4 21/22 have been delayed. Only £1m has been recognised in month 1 and 2 against a plan of £4.3m generating a £3.3m shortfall. • Further analysis on CIP has been provided to F&IC as part of the finance spotlight. • Covid costs continuing in excess of plan by £1.5m YTD – this mainly relates to staff sickness absence backfill costs which have improved in May following a spike in April. • Operational Pressures / Emergency Demand – ED continues to experience volumes in excess of planned levels driving up expenditure especially on premium rate staffing. Elective Recovery Framework UHS achieved 109% in May. This included: • 107% in elective • 118% in outpatients (including procedures but excluding followups) • Capped 85% in follow-ups, with actual activity at 130% April activity has also now been coded in more depth and illustrates achievement of 103%. This activity level is extremely positive for achievement of the 106% target for the year and is despite continuing operational pressures and ED demand. It should be noted that Covid pressures eased during May, although staff absence rates remained above 19/20 levels. A further £1.1m of income has been included in the financial position. Page 2 of 16 However, this has off-set an increase in clinical supplies costs associated with the additional activity. It should be noted that some uncertainty remains over national calculations of performance, with data for April expected in July. Financial Trajectory A run rate continuing at this level of deficit would generate a £46m underlying deficit across 2022/23, which is towards the worst-case scenario outlined in the revised planning submission of £57m. We would however expect CIP delivery and financial recovery plan projects to improve this position throughout the year to mitigate this risk. This would lead to a reduced cash balance, a reduced ability to invest in capital and revenue improvements, and increased local, regional and national scrutiny. It is therefore not sustainable to continue at this rate of underlying deficit. Response to the financial challenge Due to the scale of financial risk, a recovery plan is being developed to drive an improvement trajectory. Progress has been made in the last month, with TEC approving the creation of a Recovery Board, with the first meeting set up in July, and a programme manager recruitment process initiated. The purpose of the Financial Recovery Programme Board will be to: • Improve financial performance • Improve control of income and expenditure • Oversee the achievement of the financial aspects of the 2022/23 annual plan • Deliver an improvement to underlying financial performance which provides a foundation for financial sustainability in 23/24 and beyond • Prepare the organisation for a transition from financial recovery to business as usual whilst continuing to deliver on the trust’s financial and non-financial objectives An update will be incorporated into the finance report for F&IC in July. Capital • Within the revised planning submission, we took the opportunity to revise the profile of the capital plan to align with expenditure plans. Internal capital expenditure totalled £1.5m in May which was on-plan. • The trust has an internal capital plan of £49m for 2022/23. Many of the major projects have yet to commence and are in the planning phases hence an acceleration in spend is expected in future months. Spend, and any emerging risks and opportunities, will be monitored closely in year via Trust Investment Group. • Significant progress has been made with External CDEL opportunities: o A business case for wards (£10m) has been submitted to NHSE Regional Officer for review as part of Elective Page 3 of 16 Targeted Investment Fund plans. o A meeting has been held with Specialised Commissioning regarding confirmed CDEL of £5.1m for Neonates, noting that this does not include cash funding. A business case is expected to be submitted in July. There is added complexity within the case due to the potential loss of bed capacity, with mitigation options currently being explored. o Bids for additional CT scanners for ED and for the Targeted Lung Programme are in the process of being submitted. o Southampton and Southwest Hampshire have submitted a draft bid to NHSE Region for Community Diagnostic Centre expansion at RSH. Review of Finance Report The finance team have reviewed and refreshed the finance report. Due to competing priorities, the outcomes of this refresh are partially complete, with further changes to the reporting format anticipated in July. Other It should be noted that an announcement on Agenda for Change pay awards is anticipated imminently. Trusts have planned for a 2% increase as per national planning guidance, with a further contingency held nationally. The Trust are actively exploring additional capacity in the Independent Sector and through Insourcing companies, subject to IR35 compliance checks. These cases are being considered on a case-by-case basis linked to growth in waiting lists, capacity constraints, length of time on waiting list (104/78/52 week waits), patient safety risk and financial implications. The additional activity is only available at tariff or in some cases above tariff, meaning it is not covered by a 75% marginal rate. This may cause additional in-year cost pressures. Implications: Risks: (Top 3) of carrying out the change / or not: • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. • Financial risk relating to the month 2 underlying run rate and projected potential deficit if the run rate continues. • Investment risk related to the above • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 4 of 16 2022/23 Finance Report - Month 2 Report to: Board of Directors and Finance & Investment Committee May 2022 Title: Finance Report for Period ending 31/05/2022 Author: Philip Bunting, Interim Deputy Director of Finance Sponsoring Director: Ian Howard, Chief Financial Officer Purpose: Standing Item The Board is asked to note the report Executive Summary: In Month and Year to date Highlights: 1. Trust Board approved a revised plan in June, which is reflected within this report: • A revised break-even position, phased with deficit in M1-6 improving to surplus in M7-12. • Achievement of 106% Elective Recovery performance • Delivery of 4% (£45m) of CIP 2. In month 2, UHS reported a deficit position of £1.3m with a £5m deficit YTD. This is £2.2m behind plan. CIP delivery remains lowin month at £0.5m, off-plan by £1.7m. 3. However, there were a number of transactions in month which were non-recurrent, including additional national funding for inflation relating to month 1. The underlying in month deficit was £3.8m which was similar to April. A run rate continuing at this level would generate a £46m deficit across 2022/23, although that is expected to improve as CIP and Recovery Plan actions are implemented. 4. The main income and activity themes seen in M2were: – Despite operational pressures and ED demand, UHS has delivered 109% of Elective Recovery activity in month 2, above target and plan levels. – Additional income of £1.1m has been included within the position, at 75% marginal rate, off-setting the variable costs of the additional activity. National calculations on performance are anticipated to be three months in arrears. 1 Page 5 of 16 2022/23 Finance Report - Month 2 Finance: I&E Summary A deficit of £1.3m position was reported in May 2022 as planned. There are three main drivers for this position: Covid-related absences have continued to reduce during May but we are still seeing c.100 daily absences. The excess cost related to backfill is estimated at c.£1m per month. ED continues to experience volumes in excess of planned levels driving up expenditure especially on premium rate s ta ffi ng. CIP delivery in M2 was £0.5m, compared to our pl an of £2.1m. CIP identification for 2022/23 is now £9.5m, 48% of the £20m di vi sional target. CIP i denti fi ed for 2022/23 increased by 4.4m over the most recent month. Of the identified £9.5m total, £6.2m is planned as recurrent. Existing cost pressures from 2021/22 also continue to drive the underlying deficit related to energy costs and drugs. NHS Income: Other income Total income Costs Total expenditure EBITDA EBITDA % Clinical Pass-through Drugs & Devices Other Income excl. PSF Top Up Income Pay-Substantive Pay-Bank Pay-Agency Drugs Pass-through Drugs & Devices Clinical supplies Other non pay Current Month Cumulative Plan Actua Actua Plan l Variance Plan l Variance Plan Forecast Variance £m £m £m £m £m £m £m £m £m 69.8 70.0 (0.2) 139.5 139.0 0.5 837.0 837.0 0.0 11.2 11.4 (0.2) 22.4 21.9 0.6 134.6 134.6 0.0 10.6 13.7 (3.2) 21.1 28.0 (6.9) 126.6 126.6 0.0 0.9 0.8 0.1 1.7 1.4 0.3 8.3 8.3 0.0 92.4 95.8 (3.5) 184.8 190.3 (5.5) 1,106.6 1,106.6 0.0 48.7 49.0 0.3 97.2 98.2 1.0 591.6 591.6 0.0 3.3 3.9 0.6 6.8 8.0 1.3 33.2 33.2 0.0 1.2 1.5 0.3 2.5 3.0 0.6 12.0 12.0 0.0 5.2 3.8 (1.4) 10.4 8.7 (1.7) 59.7 59.7 0.0 11.2 11.4 0.2 22.4 21.9 (0.6) 134.6 134.6 0.0 7.3 8.7 1.5 14.6 15.2 0.7 74.6 74.6 0.0 15.8 17.8 2.0 31.8 38.6 6.8 189.6 189.6 0.0 92.7 96.2 3.4 185.7 193.7 8.0 1,095.3 1,095.3 0.0 -0.4 -0.3 (0.0) -0.9 -3.4 2.5 11.2 11.2 0.0 Non operating expenditure/income -0.4%-0.3% (0.1%) -0.5%-1.8% 1.3% -0.9 -1.0 (0.1) -1.9 -1.8 0.1 1.0% -11.1 1.0% -11.1 0.0% 0.0 Surplus / (Deficit) Less Donated income Profit on disposals Add Back Donated depreciation Net Surplus / (Deficit) 2 Page 6 of 16 (1.3) (1.3) 0.0 (2.8) (5.2) 2.4 0.1 0.1 0.0 -0.1 -0.1 (0.0) -0.2 -0.1 (0.1) -1.4 -1.4 0.0 - - 0.0 - - 0.0 - - 0.0 0.1 0.2 0.1 0.2 0.4 0.1 1.3 1.3 0.0 (1.3) (1.3) (0.0) (2.8) (5.0) 2.2 0.0 0.0 0.0 2022/23 Finance Report - Month 2 Monthly Underlying Position The graph shows the underlying position for the Trust from April 2021 to present. 3.0 This differs from the reported financial position as it has been 2.0 adjusted for non recurrent items (one offs) and also had any 1.0 necessary costs or income rephased by month to get a true 0.0 picture of the run rate. (1.0) A decline in the underlying position can be observed from the first half of 2021/22 moving (2.0) i nto the l ater hal f of that year. At this point a change in the (3.0) financial regime and increased efficiency targets, together with (4.0) increased energy costs, led to a £2m per month deficit (5.0) preva i l i ng. A further step change has then (6.0) occurred from April 2022 with reductions in covid funding together with efficiency targets resulting in underlying performance reducing to £3.8m per month in April and May. This is £1m per month favourable to the worse case scenario modelled within the planning projections for the year but significantly worse than the plan posi ti on of c£1.4m per month. Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Underlying Financial Position (£'m) Plan Underlying Actuals / Forecast Worst Case Modelling 3 Page 7 of 16 Activity Income 2022/23 Finance Report - Month 2 Clinical Income Elective spells £20 10 £15 8 6 £10 4 £5 2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Outpatients Total £12 80 £10 60 £8 £6 40 £4 20 £2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income Activity Income Non elective spells £21 7 £20 6 5 £19 4 £18 3 2 £17 1 £16 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income A&E - Emergency Medicine £3 14 £2 12 10 £2 8 £1 6 4 £1 2 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income 5 Page 8 of 16 Activity Income 2022/23 Finance Report - Month 2 Clinical Income Adult critical care £5 3 £4 3 3 £3 3 £2 3 3 £1 3 £0 2 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded drugs 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Activity Income Income Neonatal & paediatric critical care £3 3 £3 2 £2 2 £2 £1 1 £1 1 £0 0 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 2021/22 2022/23 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded devices 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2021/22 2022/23 Plan - Activity Plan - Income Actual - Activity Actual - Income Income 6 Page 9 of 16 2022/23 Finance Report - Month 2 Elective Recovery Fund 22/23 The graph shows the ERF performance for 22/23 as well as a trend against plan for 21/22. In 22/23 the Trust has a plan to achieve 106% of 19/20 activity for elective inpatients, outpatient first attendances and outpatient procedures, above the 104% national target. The table highlights overall performance against the 19/20 pre-Covid baseline, highlighting M2 performance of 109%. An ERF payment of £1.1m has been provisionally included within Trust income, off-setting additional variable costs of delivery. However, there remains some uncertainty over the national calculation, with figures expected to be released three months in arrears. Income £m £16.0 £14.0 £12.0 £10.0 £8.0 £6.0 £4.0 £2.0 £0.0 ERF 104% performance 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 2021/22 Actual - Chemotherapy Actual - Follow Up Attendances Plan - Chemotherapy Plan - Follow Up Attendances Actual - Elective Spells Actual - Outpatient Procedures Plan - Elective Spells Plan - Outpatient Procedures 5 6 7 8 9 10 11 12 2022/23 Actual - First Attendances Actual - Radiotherapy Fractions Plan - First Attendances Plan - Radiotherapy Fractions Elective Recovery Framework Performance Elective performance Outpatient first and procedures performance Chemotherapy performance Radiotherapy performance Overall ERF performance Outpatient follow up performance M1 M2 97% 107% 110% 118% 147% 108% 119% 104% 103% 109% 127% 130% 9 Page 10 of 16 2022/23 Finance Report - Month 2 Substantive Pay Costs Total pay expenditure in April was £55.5m, up slightly on April by £1.9m. Most of the 65.0 increase relates to substantive staffwith the payment of the two April 60.0 Bank Holiday enhancements in May payroll. Covid staff costs are estimated at £2.6m 55.0 in month, remaining flat from M1. 50.0 Increases in pay costs over the last 24 months are under 45.0 review as part of challenging where costs can be targeted for reduction in a post 40.0 pandemic environment. 35.0 Total Pay Covid Agency Bank Substantive Plan Total 10 Page 11 of 16 2022/23 Finance Report - Month 2 Temporary Staff Costs Expenditure on bank staff has decreased slightly month on month by £0.2m. The decreases were evenly spread across all staff groups although currently still significantly above plan. The primary driver for this is Covid sickness backfill. Agency spend decreased slightly from April to May by £0.1m. However, within this there were larger movements in staff groups as illustrated in the graph. Medic agency spend increased by £0.3m in May but both nursing (£0.1m) and Admin and Estates (£0.2m) spend fell. Although volatile month to month spend remains at c£1.4m per month and has done since July 2021. Spend £ Spend £ 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 - Bank Total Spend Agency Total Spend Page1112 of 16 Pl a n Nurs i ng Me di cs Sci e nt & Te ch Admi n & Es ta te s Tota l Ba nk Nursing Medics Scient & Tech Admin & Estates Total Agency 2022/23 Finance Report - Month 2 Cash The cash balance decreased in May to £140.9m and is analysed in the movements on the Statement of Financial Position. A gradual reduction in cash is expected over the next two years as capital expenditure plans exceed depreciation. The deficit position is also reducing the cash balance. 180.0 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 - The latest position on our Better Payment Practice Code road map to compliance project is also outlined. The percentage for May is a slight decrease against April 2022. This is due to staff sickness and leave. However, the total count percentage is greater than the target of 95%. As the new financial year progresses it is expected that the 95% will remain stable and improve further. Sep-20 Oct-20 Nov-20 De c- 20 Jan-21 Feb-21 Ma r- 21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 De c- 21 Jan-22 Feb-22 Ma r- 22 Apr-22 May-22 Cash Position Actual Minimum Cash Holding 12 Page 13 of 16 2022/23 Finance Report - Month 2 Capital Expenditure (Fav Variance) / Adv Variance Expenditure on capital schemes was £1.5m in month 2 and £2.9m year to date. The main areas of expenditure were design fees and initial costs on the wards and theatres schemes, IT and equipment leases. It should be noted that we took the opportunity to rephase the plan as part of our revised submission, including a more realistic phasing of expenditure. This including matching the revised plan to actual expenditure to date. The level of monthly spend is expected to rise significantly from the current low levels as major schemes begin, so the Trust are forecasting to spend our full £49.0m capital allocation. Additional funding awards for wards and the expansion of neonates are anticipated, but not finalised, and shown in the forecast. Month Year to Date Full Year Forecast Scheme Org Internally Funded Schemes Strategic Maintenance UHS Refurbish of neuro theatres 2 & 3 UEL General Refurbishment Fund UHS Refurbishment of Theatres/F level Fit Out UEL Oncology Centre Ward Expansion Levels D&E UEL Fit out of C Level VE (MRI) Capacity UEL Donated Estates Schemes UHS Other Estates Schemes UHS Information Technology (incl Pathology Digitiation) UHS IMRI UHS Medical Equipment panel (MEP) UHS Other Equipment UHS Other UHS Slippage UHS Donated Income UHS Total Trust Funded Capital excl Finance Leases Leases Medical Equipment Panel (MEP) - Leases UHS Equipment leases UHS IISS UHS Fit out of C Level VE (MRI) Capacity UHS Adanac Park Car Park UHS Total Trust Funded Capital Expenditure Disposals UHS Total Including Technical Adjustments Externally Funded Schemes Maternity Care System (Wave 3 STP) UHS Digital Outpatients (Wave 3 STP) UHS Oncology Centre Ward Expansion Levels D&E UEL Neonatal Expansion UHS Total CDEL Expenditure Page 14 of1136 Plan Actual Var Plan Actual Var Plan Actual Var £000's £000's £000's £000's £000's £000's £000's £000's £000's 397 173 224 794 794 0 0 0 0 0 0 0 0 0 0 109 130 (21) 218 218 137 216 (79) 274 274 0 0 0 0 0 67 113 (46) 134 134 5 6 (1) 10 10 286 387 (101) 571 539 52 37 15 104 104 2 2 0 4 4 85 7 78 169 169 266 321 (55) 538 538 0 0 0 0 0 (83) (113) 30 (166) (134) 1,323 1,279 44 2,650 2,650 0 0 0 0 0 0 85 170 (85) 170 170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,408 1,449 (41) 2,820 2,820 0 0 0 0 0 1,408 1,449 (41) 2,820 2,820 0 0 0 0 0 0 18 18 0 37 37 0 0 0 0 0 0 0 0 0 0 1,426 1,467 (41) 2,857 2,857 0 8,255 8,255 0 0 730 730 0 0 1,097 1,097 0 0 5,000 5,000 0 0 8,000 8,000 0 0 6,592 6,592 0 0 5,362 5,362 0 0 2,681 2,681 0 32 5,448 5,448 0 0 1,300 1,300 0 0 2,500 2,500 0 0 1,550 1,550 0 0 691 691 0 0 (6,380) (6,380) 0 (32) (6,760) (6,760) 0 0 36,066 36,066 0 0 700 700 0 0 500 500 0 0 3,115 3,115 0 0 5,619 5,619 0 0 3,000 3,000 0 0 49,000 49,000 0 0 0 0 0 0 49,000 49,000 0 0 0 89 89 0 0 592 592 0 0 0 10,000 (10,000) 0 0 5,130 (5,130) 0 49,681 64,811 (15,130) 2022/23 Finance Report - Month 2 Statement of Fi nanci al Positi on The May statement of financial position illustrates net assets of £467.2m, with the main movements in the position explained below. Receivables and payables both moved by significant amounts as a result of an offsetting technical adjustment involving the coding of NHS England receipts. Cash reduced by £12.1m from M1 to M2 partially reflecting the pressure on the I&E position and some catch up on payment of payables. Statement of Fi nanci al Positi on Fixed Assets I nventori es Recei va bl es Cash Pa ya bl es Current Loan Current PFI and Leases Net Assets Non Current Liabilities Non Current Loan Non Current PFI and Leases Total Assets Employed Public Dividend Capital Retained Earnings Revaluation Reserve Other Reserves Total Taxpayers' Equity 14 Page 15 of 16 2021/22 YE Actuals £m 471.9 17.0 53.1 148.1 (204.2) (1.7) (9.1) 475.0 (23.0) (6.8) (33.6) 411.6 261.9 115.6 34.1 411.6 (Fav Variance) / Adv Variance M1 Act £m 464.7 17.4 100.8 153.0 (255.4) (2.5) (9.1) 468.8 (21.3) (6.8) (33.0) 407.7 261.9 105.3 40.5 2022/23 M2 Act £m 470.6 17.4 46.8 140.9 (197.4) (2.5) (8.5) 467.2 (21.2) (6.8) (32.8) 406.4 261.9 104.0 40.5 MoM Movement £m 6.0 0.1 (54.1) (12.1) 58.0 0.0 0.6 (1.6) 0.1 0.0 0.2 (1.3) 0.0 (1.3) 0.0 407.7 406.4 (1.3) 2022/23 Finance Report - Month 2 Efficiency and Cost Improvement Programme 22/23 – M2 Cost Improvement Programme (CIP) Delivery in Month 2 • This month, the Trust increased the efficiency improvement required in 2022/23 from £33.0m to £45.4m, reflecting a national request for NHS systems to re-submit their annual operating plans, and to take further actions to balance their income and expenditure within the year. • The plan is to be delivered by: • £20m CIP through Divisional and Directorate budgets • £25.4m efficiency from central schemes / budgets • CIP delivery YTD at M2 was £992k, compared to our plan of £4.3m. • CIP identification for 2022/23 is now £9.5m, 48% of the £20m di vi sional target. CIP i denti fi ed for 2022/23 i ncreased by 4.4m over the most recent month. Of the identified £9.5m total, £6.2m is planned as recurrent. • Targets for identification have been set - 75% (£15m) by the end of Q1 and 100% identification by the end of Q2. • Central schemes are not anticipated to deliver value within Q1, and much of the (increased) savings target of £25.4m is not yet supported by robust schemes. There are a number of areas of potential opportunity which are being investigated further to support delivery however: • Theatre supply chain management • Additional income by exceeding 104% of the 19/20 activity l evel • Reductions in agency spend, costs related to Covid-19, and additional business cases £k £k In-month CIP delivery 22/23 M1-2 2500 2000 1500 1000 500 0 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 1 2 690 1900 458 534 2134 2134 Month Cumulative delivery 22/23 M1-2 5000 4000 3000 2000 1000 0 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 1 2 690 2587 458 992 2134 4268 Month 19/20 CIP Delivery 22/23 CIP Delivery 22/23 CIP Plan 15 Page 16 of 16 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Integrated Performance Report 2022/23 Month 2 9.2 David French, Chief Executive Jason Teoh, Director of Data and Analytics 30 June 2022 Assurance or Approval reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust services and activities. It is (Clinical, intended to assist the Board in assuring that the Trust meets Organisational, regulatory requirements and corporate objectives. Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of assurance. Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. Page 1 of 26 Report to Trust Board in June 2022 Integrated KPI Board Report Covering up to May 2022 Sponsor – David French, Chief Executive Officer Reviewed – Jason Teoh, Director of Data and Analytics Page 2 of 26 Report to Trust Board in June 2022 Report guide Chart type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they: Go outside control limits; Have 6 points in a row above or below the mean; Trend for 6 points; Have 2 out of 3 points past 2/3 of the control limit; Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 26 Report to Trust Board in June 2022 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board; • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix’, with indicators presented monthly, aligned with the five themes within our strategy. Our indicators and this report structure will continue to be regularly reviewed, and feedback would be welcome. This month there have been no material changes in the format of the report. Some minor changes have been made to the report this month: • Workforce Numbers (WR3-L) graph has been split out the 2021/22 and 2022/23 workforce plans for clarity. • Year to Date (YTD) figures, where available, have been added to the report. • Targets have been agreed for a number of the metrics. Where available these have now been added to the report. Page 4 of 26 Report to Trust Board in June 2022 Summary This month the ‘Spotlight’ section features a Patient Experience section reviewing our patients’ feedback on involvement in decisions, and the experience of patients with disability. • The Trust conducts a number of Friends and Family Test (FFT) surveys each year to provide an insight to patient experience at UHS. • Although there is some variation between divisions, and between months, the results indicate that patients feel involved in their care, with 87% of adults and 92% of paediatric patients reporting this. • On average, 90% of patients who identify as having a disability reported back that they feel their needs were met. • Overall, we are pleased with the results of the survey as it demonstrates strongly that we continue to ensure that we meet the specific needs of patients in our care. Areas of note in the appendix include: 1. May 2022 saw a reduction in the number of healthcare acquired (23) and probable hospital associated (12) COVID-19infections as the rates of COVID-19infection in the community reduced. 2. There has been an increase in pressure ulcers this month, with category 2 ulcers increasing to 0.46 per 1,000 bed days, and category 3 ulcers increasing to 0.67 per 1,000 bed days (compared to target of 0.3 per 1000 bed days). The primary reasons for category 2 ulcers have been around the lack of correct preventative methods (such as correct mattresses or pillows). In category 3, the primary reasons were staffing pressures meaning that two hourly turning targets were not consistently achieved, alongside a lack of knowledge amongst workforce due to reduced training and overall staff pressures. The patient safety teams are working with the divisions to address these. 3. Ongoing high volumes of attendances to Emergency Department (ED) continue to apply downward pressure to the ED four-hour standard, which was reported at 64.7%. However, UHS remains in the upper quartile of teaching hospitals for Emergency Department performance, demonstrating that this remains a wider national problem, rather than being localised to UHS. 4. Higher GP referrals means the number of patients on the waiting list continues to grow to just over 49,000 patients reported at the end of May 2022. 5. High demand for diagnostic procedures, combined with the impact of Easter, bank holidays, and school holiday periods through April and May 2022, have caused the diagnostic waiting list to increase to around 11,100 patients. However, the proportion of breaches have remained steady as UHS has increased diagnostic activity. 6. Our cancer standards remain under pressure due to high referral volumes, with pressures seen within the skin, head & neck, and urology tumour sites. On 62D we continue our upper quartile performance when compared against teaching hospitals. However, we are mid-range for 31 day Page 5 of 26 Report to Trust Board in June 2022 performance, and in May 2022 have also seen a drop to third quartile in 31 day subsequent treatment linked to the urology and skin modalities. We are working with the Wessex Cancer Alliance to review potential improvements to the urology pathway, and in skin are looking to ensure that we have the right clinic capacity in line with the recent referral volumes. Ambulance response time performance The following is the latest Category 1 to 4 information published by South Coast Ambulance Service (SCAS) published within its May 2022 board papers, relating to the Southampton, Hampshire, Isle of Wight, and Portsmouth area. The SCAS Integrated Performance Reviewto their Board states that “increased task time, both on scene and at hospital alongside high levels of sickness impacted on performance”. Southampton, Hampshire, Isle of Wight, and Portsmouth SCAS response time by category Performance measure April 22 Actual April 22 Plan Category 1 Mean 00:09:21 00:07:00 Category 1 90th percentile 00:17:04 00:15:00 Category 2 Mean 00:38:25 00:18:00 Category 2 90th percentile 01:23:53 00:40:00 Category 3 90th percentile 04:37:16 02:00:00 Category 4 90th percentile 05:29:57 03:00:00 UHS continues to ensure that it does not significantly contribute to ambulance handover delays. In the week commencing 13 June 2022, our average handover time was 16 minutes across 657 emergency handovers, and 16 minutes across 32 urgent handovers, just missing the 15-minute hand over target. Page 6 of 26 Report to Trust Board in June 2022 Spotlight Spotlight: Patient experience This month the ‘Spotlight’ section reviews patients’ feedback on involvement in decisions, and the experience of patients with disability. Data is sourced through our Friends and Family Test (FFT) surveys from the following questions: A. Were you involved in decisions about your care and treatment? B. Do you regard yourself as having a disability, impairment, or other condition that requires extra support or reasonable adjustments? o If yes, did the hospital staff do everything they could to provide this support or adjustments? Question A is included on both adults, and children and young people, surveys, while Question B is included on adult surveys only due to many parents, guardians, and carers providing this support for their child. In preparation for the implementation of the updated FFT guidance and launch of new Trust survey system early 2020, the Patient Experience team conducted engagement sessions with clinical teams and patients to undertake a review of the FFT survey forms. Following these sessions several questions from the National CQC surveys were added to collect continuous data on specific areas including the two questions above. Survey forms were launched in February 2020 and following a pause of FFT surveys due to COVID-19, the surveys were relaunched early 2021. This report reviews the data from April 2021 until March 2022. Were you involved in decisions about your care and treatment? • For the year (Apr 21 – March 22), the average number of patients reporting they felt involved is 87%, with children and young people at 92%. • The Trust average response rate for FFT surveys is 8%, with over 12,000 patients responding to this question in 2021-2022. • Quarter one saw the highest response rate, while December 2021 received the highest scores at 89%. • Over 3,000 children and young people responded to this question, and December and February saw our highest engagement with 96% involvement. Page 7 of 26 Report to Trust Board in June 2022 Spotlight Breakdown by division The Patient Experience team produce an experience of care report which is shared with divisions, and the team also attend divisional governance meetings to provide and discuss results. In additiona, all relevant divisional staff have access to the survey system so that they can monitor and review their own results, and some produce their own governance FFT reports where required. The Patient Experience team also receives notifications of all negative comments, so these can be followed up with senior leads where required, or where wider trends can be identified. The number of patients reporting they felt involved has fluctuated throughout the year but has generally remained above 80%. In October 2021 and January 2022, Division A saw their scores drop to 78% and 79% respectively. Division C is the only area that received scores above 90% consistently. Divisions C and D have seen the highest number of responses of Friends and Family Test surveys. Division B has the lowest response rate, but with a significant increase in responses at the end of quarter four. Metric Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 Felt involved (Patient Experience) Div A - Score 83 82 85 86 83 80 78 86 80 79 82 90 Response rate 7.3 7.9 11 22.8 7.2 4.7 5.6 6.3 4.7 3 3.2 10.6 Felt involved (Patient Experience) Div B - Score 86 87 92 89 86 91 86 88 87 87 86 89 Response rate 1.3 3.5 2.7 2.6 1.9 1.3 1.6 2.1 1.7 1.6 1.4 5.1 Felt involved (Patient Experience) Div C - Score 92 92 91 93 93 93 92 93 95 93 95 91 Response rate 27.1 45.2 44.4 121.9 40.6 26.7 23.4 23.2 20.8 26.5 15.6 42 Felt involved (Patient Experience) Div D - Score 83 86 83 81 84 82 85 81 85 85 84 83 Response rate 43.2 33.5 35 66.9 27.7 24.7 28.3 19.9 17.1 13 14.9 36.2 Page 8 of 26 Report to Trust Board in June 2022 Spotlight Experience of patients with a disability There are two questions included on the surveys around disability: 1. Do you regard yourself as having a disability, impairment, or other condition that requires extra support or reasonable adjustments? 2. If yes, did the hospital staff do everything they could to provide this support or adjustment? This report will focus on the supplementary question, question 2. These were introduced to review the support patients with disabilities receive whilst in our care. UHS launched the sunflower scheme trust wide in June 2020, which provide lanyards to identify staff, patients and carers who need additional support and prompt staff and colleagues to ask: “how can I help you today?”. % patients responding 100 90 80 70 60 50 40 30 20 10 0 Apr 21 Experience of patients with a disability % patients reporting needs met or that they had a disability or support need May 21 Jun 21 Jul 21 Aug 21 Do you regard yourself as having a disability? Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Adjustments made for patient with disability (Patient Experience) - Score Feb 22 Mar 22 Page 9 of 26 Report to Trust Board in June 2022 Spotlight Divisional graphs The purple line is the percentage of patients reporting they had their support needs met and the blue line shows the percentage of patients who reported they had a disability or support need. Division A 100 Division B 100 80 80 60 60 40 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 40 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 Division C 100 Division D 100 80 80 60 60 40 40 20 20 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 0 Apr 21 May 21 Jun 21 Jul 21 Aug 21 Sep 21 Oct 21 Nov 21 Dec 21 Jan 22 Feb 22 Mar 22 A total of 18,557 FFT survey responses were received to this question in 2021 – 2022, with just under a quarter of patients who completed the survey reported as having a disability (hidden or physical) or additional need. The first quarter saw the highest number of responses. The number of patients who identified as having a disability and reporting their needs were met was an average of 90% for the year. Quarter three saw this figure reduce to 82% and 87% in November and December. Page 10 of 26 Report to Trust Board in June 2022 NHS Constitution NHS Constitution - Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible • Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions • Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution • All patients should receive high-quality care without any unnecessary delay • Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists 11 of the government pledges on waiting times that are relevant to UHS services, such pledges are monitored within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england Page 11 of 26 Report to Trust Board in May 2022 NHS Constitution Monthly Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May target % Patients on an open 18 week pathway 75% (within 18 weeks ) UT28-N UHSFT 8 69.5% 9 8 7 9 9 10 10 10 9 8 6 5 68.1% 5 ≥92% Teaching hospital average (& rank of 20) South East average (& rank of 17) 8 7 8 8 8 7 9 9 8 8 8 8 7 7 55% % Patients following a GP referral for 100% suspected cancer seen by a specialist within 2 weeks (Most recently externally reported 12 13 16 90.1% 15 16 16 17 17 14 16 12 13 13 13 CN1-N data, unless stated otherwise below) 9 UHSFT Teaching hospital average (& rank of 20) South East average (& rank of 17) 65% 5 13 11 13 14 14 14 9 10 7 5 86.9% 4 4 ≥93% Cancer waiting times 62 day standard - 100% 89.9% Urgent referral to first definitive treatment (Most recently externally reported data, 5 3 11 13 15 16 13 12 15 13 13 11 12 7 UT34-N unless stated otherwise below) 74.4% UHSFT 1 Teaching hospital average (& rank of 19) South East average (& rank of 17) 40% 1 4 6 7 7 2 4 5 3 4 4 2 3 Patients spending less than 4hrs in ED - 95% (Type 1) 8 UT25-N UHSFT Teaching hospital average (& rank of 16) 4 South East average (& rank of 16) 45% 84.0% 6 8 4 4 4 4 5 4 4 4 4 2 6 4 4 3 5 3 8 10 6 4 4 4 64.7% 4 8 4 4 ≥85% ≥95% 50% % of Patients waiting over 6 weeks for diagnostics UT33-N UHSFT 12 9 10 10 10 9 7 6 7 7 7 7 6 7 23.3% ≤1% Teaching Hospital average (& rank of 20) 21.5% South East Average (& rank of 18) 17 0% 16 16 17 16 15 14 12 13 14 14 13 12 13 YTD 67.3% 86.9% 74.4% 66.0% 23.7% 1 Page 12 of 26 Report to Trust Board in May 2022 Outstanding Patient Outcomes,Safety and Experience Appendix Outcomes UT1-N HSMR - UHS HSMR - SGH UT2 HSMR - Crude Mortality Rate Monthly Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May target YTD 83 82.8 78.3 81.7 ≤100 77.9 73 3.1% 2.9% 2.7% 14days 42 36 - after admission (validated) 05 0 0 0 3 0 7 6 11 22 20 14 23 Probable hospital-associated COVID 80 UT8 infection: COVID-positive sample taken > 7 days and = 92.0% 529 325 70.3% - Q1 22-23 Quarterly target - - Apr May 10.5% Monthly target 19% by 2026 WR10 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.4% 13.5% - WR11 WR12 12% 8.0 Staff recommending UHS as a place to work: White British staff compared with all other ethnic groups combined -White British -All other ethnic groups combined 6.0 Staff recommending UHS as a place to 8.0 work: Non disabled /prefer not to answer compared with Disabled -Non disabled /prefer not to answer -Disabled Q4 1921 Q1 21-22 7.36 7.18 7.25 7.03 Q2 21-22 7.36 7.14 7.30 6.90 Q3 21-22 7.44 7.12 7.02 7.18 Q4 21-22 7.30 7.02 Q1 22-23 Quarterly target - 7.09 6.90 - 6.0 Staff recommending UHS as a place to 8.0 work: Sexuality = Heterosexual WR13 compared with all other groups combined 7.25 6.90 7.00 7.20 7.19 6.87 7.08 6.81 - -Sexuality = Heterosexual -All other groups combined 6.0 WR11, WR12,WR13: Average recommendation score of 10 = Highly recommend to 0 = Strongly not recommended, results from National Quarterly Pulse Survey Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Monthly target 54.0% FN6 Percentage of staff living locally (inside the Southampton City boundaries) 52.5% 53.9% - 51.0% Percentage of staff residing in deprived50.0% FN7 areas (lowest 30% - national Index of Multiple Deprivation) 0.0% 23.2% 24.3% - YTD YTD target YTD YTD target YTD YTD target Page 18 of 26 Appendix 7 Report to Trust Board in May 2022 Integrated Networks and Collaboration Appendix Local Integration Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Monthly target Number of inpatients that were 200 NT1 medically optimised for discharge (monthly average) 0 Emergency Department NT2 activity - type 1 This year vs. last year Percentage of virtual appointments as a NT3 proportion of all outpatient consultations This year vs. last year 114 12,500 11,435 7,548 2,500 70% 56.1% 34.5% 0% 195 ≤80 11,981 10,985 - 35.2% 23.3% ≥25% YTD 22,745 25.3% YTD target - - ≥25% 8 Page 19 of 26 Report to Trust Board in May 2022 Foundations for the Future Appendix Digital Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May My Medical Record - UHS patient 110,000 FN1 accounts (cumulative number of accounts in place at the end of each month) 0 71,921 117,686 Monthly target - My Medical Record - UHS patient 25,000 FN2 logins (number of logins made within each month) 15,000 Patients choosing digital correspondence 15% - Total choosing paperless in the month FN3 - Total offered but not yet choosing paperless in the month - % of total My Medical Record service users who have chosen paperless 0% (cumulative) 19,927 1886 1941 2.0% 24,286 - 10,000 958 7.4% 5,000 - 4,309 0 Reduction in transcription through FN4 implementation of voice recognition In development - software YTD 47,301 YTD target 9 Page 20 of 26 Report notes - Nursing and midwifery staffing hours - May 2022 Our staffing levels are continuously monitored through our staffing hub and we will risk assess and manage our available staff 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) This 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 from registered nurses and support staff - this will vary across wards and departments based on the specialty, interventions, acuity and dependency levels of the patients being cared for. In acute assessment units, where patients are admitted , assessed and moved to wards or theatre very swiftly, the CHPPD figures are not appropriate to compare. 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. For the first time we have i
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Finance-and-Performance-Reports-2022-23-Month-2-May-2022.pdf

Gift of Life tribute at UHS to mark organ donation awareness week

Description: Gift of Life tribute at UHS to mark organ donation awareness week
Url: /AboutTheTrust/Newsandpublications/Latestnews/2020/September/Gift-of-Life-tribute-at-UHS-to-mark-organ-donation-awareness-week.aspx

Deceiving patients

Description: Can deception ever be justified?
Url: /HealthProfessionals/Clinical-law-updates/Deceiving-patients.aspx

Papers Trust Board 6 June 2024

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 06/06/2024 9:00 - 13:00 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd Diana Eccles, Tim Peachey (from 12:00) 1 Chair’s Welcome, Apologies and Declarations of Interest 9:00 Note apologies for absence, and to hear any declarations of interest relating to any item on the Agenda. 2 Patient Story The patient or staff story provides an opportunity for the Board to reflect on the experiences of patients and staff within the Trust and understand what the Trust could do better. 3 Minutes of Previous Meeting held on 28 March 2024 9:15 Approve the minutes of the previous meeting held on 28 March 2024 4 Matters Arising and Summary of Agreed Actions To discuss any matters arising from the minutes, and to agree on the status of any actions assigned at the previous meeting. 5 QUALITY, PERFORMANCE and FINANCE Quality includes: clinical effectiveness, patient safety, and patient experience 5.1 Briefing from the Chair of the Audit and Risk Committee (Oral) 9:20 Keith Evans, Chair 5.2 Briefing from the Chair of the Finance and Investment Committee (Oral) 9:25 Dave Bennett, Chair 5.3 Briefing from the Chair of the People and Organisational Development 9:30 Committee (Oral) Jane Harwood, Chair 5.4 Briefing from the Chair of the Quality Committee (Oral) 9:35 Tim Peachey, Chair 5.5 Chief Executive Officer's Report 9:40 Receive and note the report Sponsor: David French, Chief Executive Officer 5.6 Performance KPI Report for Month 1 10:00 Review and discuss the report Sponsor: David French, Chief Executive Officer 5.7 Finance Report for Month 1 10:30 Review and discuss the report Sponsor: Ian Howard, Chief Financial Officer 5.8 Break 10:45 5.9 People Report for Month 1 10:55 Review and discuss the report Sponsor: Steve Harris, Chief People Officer 5.10 Infection Prevention and Control 2023-24 Annual Report 11:10 Receive and discuss Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Julian Sutton, Interim Lead Infection Control Director/Sue Dailly, Infection Prevention Matron 5.11 Learning from Deaths 2023-24 Quarter 4 Report 11:20 Review and discuss the report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Jenny Milner, Associate Director of Patient Experience 5.12 Freedom to Speak Up Report 11:30 Review and discuss the report Sponsor: Gail Byrne, Chief Nursing Officer Attendee: Christine Mbabazi, Equality & Inclusion Adviser/Freedom to Speak Up Guardian 5.13 Fuller Inquiry Report 11:45 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gavin Hawkins, Divisional Director of Operations, Division B 6 STRATEGY and BUSINESS PLANNING 6.1 CRN Wessex 2023-24 Annual Performance Report 11:55 Receive and note the annual report Sponsor: Paul Grundy, Chief Medical Officer Attendee: Clare Rook, Chief Operating Officer, CRN: Wessex 6.2 Board Assurance Framework (BAF) Update 12:10 Review and discuss the update Sponsor: Gail Byrne, Chief Nursing Officer Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary/Lauren Anderson, Corporate Governance and Risk Manager Page 2 7 CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Feedback from the Council of Governors' (CoG) Meeting 1 May 2024 12:25 (Oral) Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Register of Seals and Chair's Actions Report 12:30 Receive and ratify In compliance with the Trust Standing Orders, Financial Instructions, and the Scheme of Reservation and Delegation. Sponsor: Jenni Douglas-Todd, Trust Chair 8 Any other business 12:35 Raise any relevant or urgent matters that are not on the agenda 9 Note the date of the next meeting: 25 July 2024 10 Resolution regarding the Press, Public and Others Sponsor: Jenni Douglas-Todd, Trust Chair To agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Board of Directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 11 Follow-up discussion with governors 12:45 Page 3 Minutes Trust Board – Open Session Date Time 28/03/2024 9:00 – 13:00 Location Chair Microsoft Teams Jenni Douglas-Todd (JD-T) Present Dave Bennett, NED (DB) Gail Byrne, Chief Nursing Officer (GB) Jenni Douglas-Todd, Chair (JD-T) Keith Evans, Deputy Chair and NED (KE) David French, Chief Executive Officer (DAF) Paul Grundy, Chief Medical Officer (PG) Steve Harris, Chief People Officer (SH) Jane Harwood, NED/Senior Independent Director (JH) Ian Howard, Chief Financial Officer (IH) Tim Peachey, NED (TP) Joe Teape, Chief Operating Officer (JT) In attendance Martin De Sousa, Director of Strategy and Partnerships (MDeS) Craig Machell, Associate Director of Corporate Affairs and Company Secretary (CM) Lauren Anderson, Corporate Governance and Risk Manager (LA) (item 6.1) Ceri Connor, Director of OD and Inclusion (CC) (item 4.12) Diana Hulbert, Guardian of Safe Working Hours and Emergency Department Consultant (DH) (item 4.14) Sophie Limb, HR Project Manager (SL) (item 4.12) 1 member of the public (item 5) 6 governors (observing) 5 members of staff (observing) 1 members of the public (observing) Apologies Diana Eccles, NED (DE) 1. Chair’s Welcome, Apologies and Declarations of Interest The Chair welcomed attendees to the meeting. There were no interests to declare in the business to be transacted at the meeting. It was noted that apologies had been received from Diana Eccles. The Chair provided an overview of her activities since February 2024, including visits to hospital departments, meetings with peers and other key stakeholders. 2. Minutes of the Previous Meeting held on 30 January 2024 The draft minutes tabled to the meeting were agreed to be an accurate record of the meeting held on 30 January 2024, subject to amending a reference to ‘radiology’ on page four to ‘radiotherapy’. 3. Matters Arising and Summary of Agreed Actions It was noted that all actions had been completed or were not yet due. Page 1 In terms of action 1102, the service was provided by NHS Blood and Transfusion, and funding had been removed. 4. QUALITY, PERFORMANCE and FINANCE 4.1 Briefing from the Chair of the Audit and Risk Committee The chair of the Audit and Risk Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee had reviewed the losses and special payments report and noted that although the individual size of each occurrence was not material, these instances nonetheless did have a significant impact on individual patients. • The committee reviewed the Board Assurance Framework (item 6.1). • The committee reviewed an internal audit report on data quality and noted that there were only some minor matters to address. In addition, there were no outstanding actions from previous reports. • The committee reviewed the internal audit plan for 2024/25, which would include examination of long waiters, the discharge process and rostering. • The external audit plan for the 2023/24 financial year was agreed. 4.2 Briefing from the Chair of the Charitable Funds Committee Steve Harris was invited to provide an overview of the meeting held on 27 March 2024. It was noted that: • The charity was in a position to transfer to the new charitable company. • Gail Byrne would be appointed as a director of the new charitable company on a temporary basis to represent the Trust. • The annual report and accounts for 2023/24 would be the final item of business requiring Board approval. 4.3 Briefing from the Chair of the Finance and Investment Committee The chair of the Finance and Investment Committee was invited to provide an overview of the meeting held on 25 March 2024. It was noted that: • The committee reviewed the Finance Report for Month 11 (item 4.10) and the planning for 2024/25, noting that the underlying position presented a challenge for 2024/25. • The committee reviewed the Trust’s productivity assessed against that in 2018/19. The NHS England formula showed a 18% decline in the Trust’s performance. However, the basis of the formula was open to debate and the perception in the organisation was different given the demands on the Trust’s capacity. The Trust’s modified formula showed a lower decline in productivity and work was ongoing with the central team. • The committee reviewed the maintenance requirements in the Trust’s estate, which were significant owing to its age. • The committee reviewed the proposed capital prioritisation for 2024/25 and 2025/26. 4.4 Briefing from the Chair of the People and Organisational Development Committee The chair of the People and Organisational Development Committee was invited to provide an overview of the meeting held on 20 March 2024. It was noted that: • The committee reviewed the People Report for Month 11 (item 4.11) and noted that the additional recruitment controls were having an impact. Page 2 • The committee reviewed the Staff Survey results (item 4.12), noting that key themes were staff burnout and morale. 4.5 Briefing from the Chair of the Quality Committee The chair of the Quality Committee was invited to provide an overview of the meeting held on 18 March 2024. It was noted that: • The committee reviewed the patient safety and experience reports for the third quarter and noted some concerns regarding infection prevention control and pressure ulcers. In addition, there was some concern about overcrowding in the resuscitation area. • The committee had carried out a thematic review of never events, especially in Dermatology. • The committee reviewed the Trust’s performance in terms of its quality priorities for 2023/24. The Trust had achieved all its objectives, except one, which had been partially achieved. It was intended that there would be eight quality priorities in 2024/25. • It had been confirmed that the Integrated Care Board would fund the tobacco dependency programme in 2024/25. • Work was also taking place to provide additional capacity in the Paediatric Intensive Care Unit. 4.6 Chief Executive Officer’s Report David French was invited to present the Chief Executive Officer’s Report, the content of which was noted. It was further noted that: • The Hampshire and Isle of Wight Integrated Care Board (HIOW ICB) had launched a consultation on how it will re-shape itself for the future. The ICB had been required to reduce its running costs by 20% during 2024/25 and by a further 10% during 2025/26. • Junior doctors had voted to continue industrial action for a further six months. • In the Spring Budget, the Chancellor announced additional funding for the NHS, although, once inflation had been taken into account, the NHS budget would remain broadly flat. • The NHS England Workforce Race Equality Standard data report showed some improvements, but further work was required. • Steve Brine, the Member of Parliament for Winchester and Chandler’s Ford had been hosted by the Trust on a visit the week before. This afforded an opportunity to discuss the Hampshire County Council consultation, social care and non-criteria to reside. • The latest NHS patient survey showed a reduction in satisfaction, but this was largely due to waiting to get into the system. • There was significant pressure from NHS England for trusts to achieve the targets set. The Trust has demonstrated strong performance during 2023/24 across the six targets. • A nurse from the Trust has received a national recognition award based on their work on the ‘Diabasics’ initiative and the first episode of ‘Surgeons at the Edge of Life’, filmed at Southampton General Hospital, had been broadcast on BBC2. • Thanks were expressed to all staff for their performance during the year. 4.7 Performance KPI Report for Month 11 Joe Teape was invited to present the Performance KPI Report for Month 11, the content of which was noted. It was further noted that: • In terms of the Trust’s performance compared with comparators, the Trust was top quartile for the majority of indicators and top half for others. Page 3 • There were 19 patients who would breach the 78-week wait target at year end, 18 of which were corneal patients where materials were unavailable. It was noted that there was a national shortage of materials. • There were expected to be about 50 breaches of the 65-week wait target, of which around 30 were corneal patients. • The Trust had achieved diagnostic performance of 92% achieving the sixweek target. • There had been high volumes of patients in the Emergency Department during February and March 2024. However, the Trust had achieved 70.6% for type 1 performance and expected to achieve the 76% target by the end of March 2024. • The Trust’s Referral To Treatment metric was beginning to improve and there were some examples of very good waiting list management in Trauma and Orthopaedics and in Women and New Born. • The key point to emphasise was that, although it might not seem so at times, the Trust was out-performing most other comparable organisations. It was considered appropriate that staff communications should be worked on to reinforce this message. In terms of the Trust’s Key Performance Indicators: • The Quality Committee had seen significant improvements in diagnostic performance. • The two-week wait cancer target performance had also improved since April 2023. • Unfortunately, due to significant challenges with flow, overnight ward move performance had dropped significantly during the month, leading to poor patient experience. • In addition, the rate of pressure ulcers appeared to be increasing. 4.8 Non-Criteria to Reside Spotlight Report Joe Teape was invited to present the Non-Criteria to Reside Spotlight Report, the content of which was noted. It was further noted that: • Management of non-criteria to reside patients was one of the Trust’s biggest risks in terms of its operational and financial performance and achievement of its targets. • The Trust has seen 20%+ of beds occupied by patients without criteria to reside, which significantly impacted patient flow in the Emergency Department and has led to ambulance handover delays. • In addition, stays in hospital of longer duration were known to lead to worse patient outcomes. • The Trust was unable to have a significant impact on this issue, as the main driver was insufficient funding availability in local authorities. • In terms of what the Trust could do, work was ongoing to improve the discharge process by having conversations about care needs early on as part of the Trust’s flow transformation programme. 4.9 Break 4.10 Finance Report for Month 11 Ian Howard was invited to present the Finance Report for Month 11, the content of which was noted. It was further noted that: Page 4 • The Trust had received £24.6m of cash support from NHS England and £5m in funding in relation to the impact of industrial action between December 2023 and February 2024. • A year-end deficit of £1.4m was forecast. • The Trust’s underlying monthly deficit was currently £4m, and the Trust’s underlying deficit had been £4-5m a month during 2023/24. • Cost Improvement Programme delivery was expected to be £62m at year end, an increase of £17m compared to the previous year. 4.11 People Report for Month 11 Steve Harris was invited to present the People Report for Month 11, the content of which was noted. It was further noted that: • Total workforce had reduced by 20 whole-time equivalents (WTE) during the month, although the Trust remained 266 WTE above plan. • Use of bank staff had reduced, although it was expected that more bank staff would be used in March 2024 as substantive staff used leftover annual leave before year end. • Average turnover was 11%, below the target of 13.6%. The Board discussed the report and noted that it was necessary to review training expectations in order to make best use of staff time. In addition, it was noted that funding for internationally recruited nurses was likely to reduce and that apprentice and student nurse numbers had reduced. 4.12 UHS Staff Survey Results 2023 Report Ceri Connor, Sophie Limb and Steve Harris were invited to present the UHS Staff Survey Results 2023 Report, the content of which was noted. It was further noted that: • The Trust scored above average in all of the People Promise areas and there had been an improvement in the areas regarding managers and appraisals. • However, the overall NHS average had increased, thus narrowing the gap. • The participation rate was lower than in the previous year and the overall scores hid pockets of concern. The Board discussed the results of the Staff Survey. It was noted in particular that the Trust had invested significant sums into wellbeing, but that morale was low. It was considered that this demonstrated the importance of local management to staff morale. In addition, the Board discussed the impact of the change in approach from granting significant autonomy during the pandemic to increasing levels of control, which had been received negatively by staff. However, it was noted that, whilst in some areas, such as with regard to patients, there was a general culture of accountability, there appeared to be less of a general culture of accountability with respect to finances and budgets. The possibility of ‘earned’ autonomy was considered as a means of mitigating against those who had acted properly being penalised by the actions of others. Page 5 4.13 Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report The Maternity and Neonatal Perinatal Quality Surveillance Dashboard Report was noted. It was further noted that the additional information in respect of post-partum haemorrhage data (action 1101) was contained within the report and had been discussed at a maternity safety champions’ meeting. 4.14 Guardian of Safe Working Hours Quarterly Report Diana Hulbert was invited to present the Guardian of Safe Working Hours Quarterly Report, the content of which was noted. It was further noted that: • There had been seven exception reports constituting a breach and resulting in a financial penalty, which were due to exceeding the maximum 13-hour shift duration. All reports were from General Surgery. • There were also concerns in Gynaecology due to the complicated rotas, inadequate rest provision and facilities. • The position of a junior doctor was a difficult one due to a lack of patient contact during the pandemic, industrial action and changes in the assignment of foundation posts. Action: Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. 5. Patient Story David Livermore was invited to relate his experience of attending an appointment at the Eye Unit in October 2023 and, in particular, the difficulties he encountered as a wheelchair user. It was noted that his treatment had been carried out in a room inappropriate for his needs and that he had been asked personal questions in the waiting room. Following discussion with the Board of his experiences, David Livermore offered his services to the Trust to advise on disability access as an ‘expert patient’. 6. STRATEGY and BUSINESS PLANNING 6.1 Board Assurance Framework (BAF) Update Lauren Anderson was invited to present the Board Assurance Framework (BAF) update, the content of which was noted. It was further noted that: • The Trust’s Risk Management Policy and Strategy had been updated, with the main changes being in relation to the Trust’s risk appetite following the Trust Board Study Session held in December 2023. • Work was being carried out to improve the Board’s visibility of operational risks and to improve links between operational risks and the BAF. Page 6 7. CORPORATE GOVERNANCE, RISK and INTERNAL CONTROL 7.1 Register of Seals and Chair’s Actions Report The paper ‘Register of Seals and Chair’s Actions Report’ was presented to the meeting, the content of which was noted. Decision: The Board agreed to ratify the application of the Trust Seal to the documents listed in the ‘Register of Seals and Chair’s Actions Report’. 7.2 Remuneration and Appointment Committee Terms of Reference It was noted that the Remuneration and Appointment Committee had reviewed its terms of reference at its meeting held on 28 March 2024. It was further noted that some minor changes were proposed, largely to update references to documentation and NHS organisations, and, in terms of the executive pay guidance, to better reflect current practice and the available frameworks. Decision: Having reviewed the Remuneration and Appointment Committee terms of reference tabled to the meeting, it was agreed to approve these terms of reference. 8. Any other business There was no other business. 9. Note the date of the next meeting: 6 June 2024 10. Resolution regarding the Press, Public and Others Decision: The Board resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust’s Constitution and the Standing Orders of the board of directors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. The meeting was adjourned. Page 7 List of action items Agenda item Assigned to Deadline Status Trust Board – Open Session 28/03/2024 4.14 Guardian of Safe Working Hours Quarterly Report 1127. Junior Doctors Grundy, Paul Hulbert, Diana 27/06/2024 Pending Explanation action item Paul Grundy and Diana Hulbert agreed to include an item regarding junior doctors on a future Trust Board Study Session agenda. Page 1 of 1 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose: Issue to be addressed: Response to the issue: Chief Executive Officer’s Report 5.5 David French, Chief Executive Officer 6 June 2024 Assurance Approval or reassurance Ratification Information X My report this month covers updates on the following items: • Infected Blood Inquiry • General Election • Industrial Action • HEFMA Award • Capital Funding • 2024/25 Planning The response to each of these issues is covered in the report. Implications: Any implications of these issues are covered in the report. (Clinical, Organisational, Governance, Legal?) Summary: Conclusion The Board is asked to note the report. and/or recommendation Page 1 of 9 Infected Blood Inquiry On 20 May 2024, the Infected Blood Inquiry published its report into more than 30,000 people becoming infected with HIV and hepatitis C after being given contaminated blood products in the 1970s and 1980s. The report said that: • Too little was done to stop importing blood products from abroad, which used blood from high- risk donors such as prisoners and drug addicts; • In the UK, blood donations were accepted from high-risk groups until 1986; • Blood products were not heat treated to eliminate HIV until the end of 1985, although the risks were known in 1982; and • There was too little testing to reduce the risk of hepatitis from the 1970s onwards. The UK Government has established a compensation scheme for those impacted. The report can be read at: http://www.infectedbloodinquiry.org.uk/reports NHS England’s formal response to the report is attached as Appendix 1. During the Inquiry, the Trust was made aware of patient cases which would be cited in the report and was offered an opportunity to comment. We chose not to comment in detail on individual cases, primarily due to the time elapsed since they happened. NHS England has commissioned an ongoing patient support service for those affected and it is likely that UHS will be one of two providers in the region offering this service. Funding for a fiveyear period has been confirmed. General Election The Prime Minister has announced that a general election will be held on 4 July 2024. There are a number of practical implications for the Trust as a public body to maintain political impartiality and to ensure that public resources are not used for the purposes of political parties or campaign groups during the pre-election period which commenced on 25 May 2024 and will continue until the day after the election. During this period, the following key principles should apply: • No activity should be undertaken which could be considered politically controversial or influential. • NHS trusts have discretion in their approach, but must be able to demonstrate the same approach for every political party, official candidate and designated campaign group. • The NHS may be under media spotlight, locally and nationally, so it is advisable to have a plan in place for how the organisation will manage the pre-election period and the potential for the organisation to be singled out in the media. Normal business and regulation needs to continue during the pre-election period. However, where a board meeting needs to take place, the agenda should be confined to those matters requiring a board decision or oversight. Matters of future strategy or future deployment of resources may be construed as favouring one party over another and should be avoided. Use of the confidential part of the agenda to discuss matters which may be politically controversial is not recommended. Care should be taken not to comment on the policies of political parties or campaign groups. Page 2 of 9 Organisations should not start long-term initiatives or undertake major publicity campaigns unless time critical (such as a public health emergency). Public consultations should not be launched during the pre-election period, and it is advisable to extend the period for those already running to take into account the pre-election period. The timing of the election means that formal Secretary of State approval for the Solent / Southern transaction is unlikely to happen before the election and therefore the formation of the new Trust, previously scheduled for 1 June, is likely to be delayed. Industrial Action On 29 May 2024, it was announced that junior doctors would stage a five-day strike, commencing on 27 June 2024 and ending on 2 July 2024. This will be the eleventh walkout by junior doctors since March 2023. As during previous periods of industrial action, the Trust will seek to minimise any impact on patient care by organising consultant cover wherever possible. HEFMA Award Paula Melhuish, Deputy Director of Estates and Capital Development, received the Outstanding Service Award from the Health Estates and Facilities Management Association on 13 May 2024. Paula has been a long-serving and esteemed colleague at UHS and has recently announced her retirement. Capital Funding Due to its Emergency Department performance at the end of 2023/24, the Trust was awarded an additional £2m in capital departmental expenditure limit (CDEL) as part of a scheme to reward high-performing trusts. There were several categories where the top-10 performing trusts received additional CDEL, including absolute ED 4-hour % performance and most improved ED 4-hour performance. NHS England agreed that the type 3 Urgent Treatment Centre attendances at RSH and Lymington should be included in the overall UHS performance and that, combined with significantly improved 4-hour performance at SGH, this meant that UHS was in the national top-10 for absolute ED 4-hour performance. terms of using the CDEL allowance, plans are being developed to increase the department’s same day emergency care (SDEC) capacity. The additional CDEL is not cash-backed so we are in discussions with NHSE regarding the cash funding. 2024/25 Planning The CFO and I will update the Board on the status of the 2024/25 planning round which is not yet finalised. At a meeting in London with NHS England executives, the ICS was asked to improve its position further in return for some financial incentives. This challenge was accepted, although the allocation of this further stretch to individual providers has not yet been agreed. The structure and leadership of the ICS-wide transformation programmes has been reviewed and changed. The structure of the programmes was considered by CEO, Chairs and ICB colleagues and it was agreed there should be six programmes for 2024/25, as set out below. The Board should note that I requested to retain the leadership role on the Planned Care programme, mostly because we have an agreed way forward, have good traction and can now see improvement happening. In addition, I was asked to take on leadership of the Workforce programme which, following discussion with the Chair, I have agreed to do. Page 3 of 9 Programme Mental Health Discharge Urgent and Emergency Care Local Care Planned Care Workforce CEO lead Ron Shields, SHFT Penny Emerit, PHU David Eltringham, SCAS Alex Whitfield, HHFT David French, UHS David French, UHS Each programme has been asked to set out its objectives and deliverables for the year ahead by 18 June 2024. I will share the results of this exercise with the Board in due course. Page 4 of 9 Appendix 1 Classification: Official To: • All integrated care boards and NHS trusts: - chairs - chief executives - medical directors - chief nurses - chief operating officers - chief people officers - heads of primary care - directors of medical education • Primary care networks: - clinical directors cc. • NHS England regions: - directors - chief nurses - medical directors - directors of primary care and community services - directors of commissioning - workforce leads - regional heads of nursing - regional heads of communications NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 20 May 2024 Dear colleagues, Publication of the Infected Blood Inquiry final report Earlier today, the Infected Blood Inquiry published its final report at: www.infectedbloodinquiry.org.uk/reports. The Prime Minister has subsequently issued an apology on behalf of successive Governments and the entire British state. On behalf of the NHS in England, now and over previous decades, Amanda Pritchard issued a public apology, saying: Publication reference: PRN01368 Page 5 of 9 “Today’s report brings to an end a long fight for answers and understanding that those people who were infected and their families, should never have had to face. “We owe it to all those affected by this scandal, and to the thorough work of the Inquiry team and those who have contributed, to take the necessary time now to fully understand the report’s conclusions and recommendations. “However, what is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down. “I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected. “In particular, I want to say sorry not just for the actions which led to life-altering and lifelimiting illness, but also for the failures to clearly communicate, investigate and mitigate risks to patients from transfusions and treatments; for a collective lack of openness and willingness to listen, that denied patients and families the answers and support they needed; and for the stigma that many experienced in the health service when they most needed support. “I also want to recognise the pain that some of our staff will have experienced when it became clear that the blood products many of them used in good faith may have harmed people they cared for. “I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.” The report is sobering reading, documenting failings over multiple decades, and making recommendations across a wide range of areas, including recognition, support and compensation; education and training; monitoring of and testing for Hepatitis C; the safety of blood transfusions; preventing future harm, via duty of candour and regulation; as well as giving patients a voice. We write now to set out the initial steps we are taking in response. Support for those affected The Department of Health and Social Care is providing £19 million over five years to provide a bespoke Infected Blood Psychological Support Service which is expected to be rolled out later this summer. We have listened to the experiences of those involved, including patients, their families and staff, and are working with them to design and develop this service, which will provide dedicated support for those affected, located around the country. Copyright © NHS England 2024 2 Page 6 of 9 This service will include talking therapies, peer support, and psychosocial support, as well as access to other treatments or support for physical or mental health needs where appropriate. In the interim, the existing England Infected Blood Support Service remains available here: www.nhsbsa.nhs.uk/england-infected-blood-support-scheme. Further information about existing testing and support services, including those commissioned by the Government, can be found at: www.nhs.uk/infected-blood-support. Supporting affected staff It is important to also recognise that some of our colleagues may be affected by the publication of today’s report in some way, whether through personal or professional connection to the issue. Employers may therefore wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline Shout and NHS Practitioner Health, can be found at NHS England - Support available for our NHS People. Continuing to find and treat people with blood-borne viruses Although it is likely that the majority of those who were directly affected have now been identified and started appropriate treatment given the time that has elapsed since the last use of infected blood products, there may be people who have not yet been identified, particularly where they are living with asymptomatic Hepatitis C. We ask that systems continue to work with partners, including community groups and charities, as well as Hepatitis C Operational Delivery Networks, to promote local testing options for anyone at risk, or anyone who is concerned. This should include promotion of the new national service for at-home Hepatitis C self-testing kits, available via hepctest.nhs.uk. For those who are concerned about the risk of HIV infection, further information can be found here: information on HIV diagnosis and the HIV testing services search tool. Hepatitis B, another infection that can be linked to infected blood, usually clears up on its own without treatment; however, people concerned about Hepatitis B infection should be directed towards relevant hepatitis B information or their local sexual health clinic or GP practice. Today's report highlights that in some cases those affected by infected blood products were told of their diagnosis in ways which were insensitive and inappropriate. We would therefore ask you to ensure that patients and their families are supported through the process of receiving test results – of whatever kind - in a compassionate and considerate way. Copyright © NHS England 2024 3 Page 7 of 9 Ensuring patients can access the right information. We recognise following the publication of this report, some patients may raise questions directly with their primary and/or secondary care teams, or through other points of contact with the NHS. We will be sharing materials with relevant service providers to ensure frontline clinicians and other colleagues in patient-facing roles are able to provide appropriate information or signposting. We expect that this will be particularly relevant to: • Providers of NHS 111 services • GP practices and community pharmacies • Trusts providing services where blood products are used • Mental health providers Maintaining confidence in current blood and blood products and related treatment The infected blood and blood products that have been the subject of this Inquiry were withdrawn in 1991. In the intervening decades, comprehensive systems have been put in place to ensure the safety of both donors and recipients of blood and blood-derived products. Today, blood and blood products are distributed to NHS hospitals by NHS Blood and Transplant (NHSBT), which was established in 2005 to provide a national blood and transplantation service to the NHS. NHSBT’s services follow strict guidelines and testing to protect both donors and patients. NHS Blood and Transplant has published clear information about these processes here: Infected Blood Inquiry - NHS Blood and Transplant (nhsbt.nhs.uk). Nationally, NHS England will work with NHS Blood and Transplant and others to communicate the safety of current blood products. Assessing further recommendations and next steps As set out above, the final Inquiry report includes a number of important recommendations for the NHS. NHS England will be considering these in detail alongside the Department for Health and Social Care and other relevant bodies. In addition, an Extraordinary Clinical Reference Group is being convened to inform any immediate actions which should be taken. The next steps from this work will be shared as soon as possible, including through relevant clinical networks. Copyright © NHS England 2024 4 Page 8 of 9 Yours sincerely, Amanda Pritchard NHS Chief Executive NHS England Professor Sir Stephen Powis National Medical Director NHS England Dame Ruth May Chief Nursing Officer England Dr Emily Lawson DBE Chief Operating Officer NHS England Copyright © NHS England 2024 5 Page 9 of 9 Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author Date: Purpose Issue to be addressed: Performance KPI Report 2024-25 Month 1 5.6 David French, Chief Executive Sam Dale, Associate Director of Data and Analytics 6 June 2024 Assurance or reassurance Y Approval Ratification Information The report aims to provide assurance: • Regarding the successful implementation of our strategy. • That the care we provide is safe, caring, effective, responsive, and well led. Response to the issue: The Performance KPI Report reflects the current operating environment and is aligned with our strategy. Implications: (Clinical, Organisational, Governance, Legal?) Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report covers a broad range of trust performance metrics. It is intended to assist the Board in assuring that the Trust meets regulatory requirements and corporate objectives. This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 24 Report to Trust Board in June 2024 Performance KPI Board Report Covering up to April 2024 Sponsor – David French, Chief Executive Officer Author – Sam Dale, Associate Director of Data and Analytics Page 2 of 24 Report to Trust Board in June 2024 Report guide Chart type Example Cumulative Column Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart Variance from Target Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). The line shows our performance, and the bar underneath represents the range of performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts is used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. Page 3 of 24 Report to Trust Board in June 2024 Introduction The Performance KPI Report is presented to the Trust Board each month to provide assurance: • regarding the successful implementation of our strategy; and • that the care we provide is safe, caring, effective, responsive, and well led. The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board. • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times; and • An ‘Appendix,’ with indicators presented monthly, aligned with the five themes within our strategy. Due to the timing of the April 2024 Board meeting, the following referral to treatment data points were not included in the March KPI report. They have now been updated for March 2024 and April 2024: - • 31 - Patients on an open 18 week pathway (within 18 weeks) • 33 - Patients on an open 18 week pathway (within 52 weeks) • 34 - Patients on an open 18 week pathway (within 65 weeks) • 35 - Patients on an open 18 week pathway (within 78 weeks) • 35a - Patients on an open 18 week pathway (within 104 weeks) • 32 - Total number of patients on a waiting list (18 week referral to treatment pathway) Changes of note within the report itself: • 53 – The digital metric monitoring page loading time for the CHARTS system has been tightened from under five seconds to under three seconds • 55 – The metric monitoring the rollout of inpatient noting for nurses has been removed as this is now considered complete. This will be revisited when the noting solution is rolled out for doctors • 39 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 40 - The 2024/25 national cancer target changes will be reflected next month when April 2024 data is made available • 37 - The metric now reflects the published 2024/25 national year-end target of 5% of patients waiting over 6 weeks for diagnostics Page 4 of 24 Report to Trust Board in June 2024 Summary This month’s spotlight report covers diagnostic performance. It highlights that UHS consistently increased the volume of elective diagnostic tests delivered throughout the 2023/24 financial year and into the start of the 2024/25 financial year. The diagnostic waiting list reduced by 12% in 2023/24 and in April 2024, 89.6% of patients received their diagnostics within six weeks. The national performance target has been set at 95% by March 2025 and the organisation is working with all services to ensure we maintain waiting times for services that are compliant and address any demand and capacity barriers preventing achievement. The paper describes the activity and performance trends for the hospital and explores modality sites in more detail. Areas of note in the appendix of performance metrics include: 1. The Emergency Department (ED) four hour performance position reduced to 66.0% (April 2024) from 71.7% (March 2024) for type 1 attendances, however UHS remain in the top quartile when compared to peer teaching hospitals across the country. 2. In April, the overall RTT waiting list increased by 2.4% to 59,485. 3. The trust continues to report zero patients waiting over 104 weeks and reported 15 patients waiting over 78 weeks for April 2024. All 15 patients are within ophthalmology and impacted by the ongoing national shortage of corneal graft tissue which is being overseen by NHS Blood and Transplant service. The longest waiting patients will be booked for surgery as soon tissue has been confirmed. 4. The trust reported 66 patients waiting over 65 weeks which predominantly reflects corneal transplant patients again and low volumes within gynaecology and several surgical specialties. The trust is committed to achieving the national target of zero patients waiting over 65 weeks by September 2024 and the ambition to achieve zero patients waiting over 52 weeks by March 2025. 5. The volume of patients not meeting the Criteria to Reside in hospital decreased in April averaging 216 which is a 10% reduction compared to March 2024, yet this remains a significant impact on patient flow through the organisation. 6. There were zero never events reported for April 2024. 7. The volume of medication errors reduced to two in April 2024 which is now below the monthly target following the increase seen in March 2023. 8. The number of Gram-negative bloodstream infections continues to be marginally above the monthly target of 19. The increased incidence in cases continues to be reported both nationally and locally across the Hampshire and Isle of Wight integrated care system. 9. The digital metric to monitor page loading times on CHARTS system has successfully remained at 99% despite increasing the time target by 40%. Ambulance response time performance The latest unvalidated weekly data is provided by the South Coast Ambulance Service (SCAS). In the week commencing 13th May 2024, our average handover time was 16 minutes 56 seconds across 725 emergency handovers and 22 minutes across 52 urgent handovers. There were 44handovers over 30 minutes, and six handovers taking over 60 minutes within the unvalidated data. The volume of weekly handovers over 60 minutes increased by 73% from March 2024 (averaging 7.5 per week) to April 2024 (averaging 13 per week). Page 5 of 24 Report to Trust Board in June 2024 Spotlight Report Spotlight: Diagnostic Performance The following report is based on the validated April 2024 submission. Introduction Diagnostics are a critical component of a patient’s pathway, facilitating an accurate and complete diagnosis, personalised treatment plans and the appropriate monitoring of a patient’s condition. Timely access to diagnostic tests is essential for ensuring that patients re ceive an early diagnosis whilst improving patient experience and delivering an efficient use of NHS resources. The 2024/24 NHS priorities and operational planning guidance confirmed that “systems are asked to continue to work towards the elective care recovery plan target of 95% of patients receiving their tests within 6 weeks”. The national ambitions acknowledged that the NHS delivered record diagnostic activity in 2023, but also highlighted that additional capacity in community diagnostic centres had been partly offset by an unprecedented increase in unscheduled diagnostic activity in acute trusts. This national diagnostic target applies to 15 different diagnostic tests, although performance is measured at a Trust level. These tests are broadly divided into three categories: • endoscopy (e.g. gastroscopy, cystoscopy); • imaging (e.g. CT, MRI, barium enema); • physiological measurement (e.g. echocardiogram, sleep studies). Our teams prioritise diagnostic procedures based on clinical urgency (for example patients with cancer) but aligned to this is a continual review of the longest waiting diagnostic patients. This spotlight paper highlights the current diagnostic performance position for UHS against the national targets and other hospitals. It also describes the current volumes of activity being delivered and the impact on the waiting list. We explore any performance concerns across the different modalities, outlining the challenges that services are facing and the steps being taken to achieve the 2024/25 target. In summary, there was an overall reduction in the diagnostic waiting list across the 2023/24 financial year as UHS successfully increased the delivery of diagnostic activity to manage current levels of demand. The diagnostic waiting list currently stands at 8,849 patients (April 2024) which is a reduction of 12% since April 2023 (10,033 patients) and 24% since the peak levels seen in June 2022 (11,671 patients). The April 2024 performance position is 89.6% for the percentage of patients receiving diagnostic tests within six weeks. The latest comparison data available (March 2024) placed the hospital 5th when ranked against peer teaching hospitals across the country. All organisations are facing challenges due to high demand, workforce shortages and equipment limitations and funding, but the organisation is striving to achieve the 95% target set for 2024/25. Page 6 of 24 Report to Trust Board in June 2024 Spotlight Report Activity and Waiting List Elective diagnostic activity being delivered at UHS consistently increased throughout 2023/24 and into 2024/25 helping to manage the waiting list despite high referral volumes and the complications caused by industrial action throughout the previous year. Graph 1 illustrates that diagnostic activity levels delivered in 2023/24 were 6% higher than 2022/23 and 17% higher than pre-pandemic levels. Overall there was a 12% reduction in the diagnostic waiting list across the 2023/24 financial year (graph 2) despite some levelling off in winter months and a small recent increase which is being closely monitored. The waiting list stands at 8849 patients for April 2024 which breaks down into
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-6-June-2024.pdf

UHS AR 22-23-6

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

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

Description: This factsheet explains what an ultrasound-guided tunnelled drain insertion is, what the procedure involves and how to prepare for it.
Url: /Media/UHS-website-2019/Patientinformation/Scansandx-rays/Having-an-ultrasound-guided-tunnelled-drain-insertion-3302-PIL.pdf

Keeping your baby safe - patient information

Description: We have written this factsheet to make sure your baby is cared for as safely as possible, outside and at home.
Url: /Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Keeping-your-baby-safe.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 pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2024 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 37 Directors’ report 38 Remuneration report 62 Staff report 75 Annual governance statement 95 Quality account 111 Statement on quality from the chief executive 112 Priorities for improvement and statements of assurance from the board 115 Other information 180 Annual accounts 207 Statement from the chief financial officer 208 Auditor’s report 210 Foreword to the accounts 217 Statement of Comprehensive Income 218 Statement of Financial Position 219 Statement of Changes in Taxpayers’ Equity 220 Statement of Cash Flows 221 Notes to the accounts 222 5 Welcome from the Chair and Chief Executive Officer This has been another busy and undoubtedly challenging year across the NHS and UK health and social care system, and much of what has impacted the national picture has been reflected in the operational focuses and patient and people priorities for University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) over the last year. Meeting and continuing to overcome the challenges we have faced has required an organisation-wide team effort, and looking back at the successes we feel incredibly proud of the achievements of our 13,000 staff. Particular highlights include: • In the top ten in the country (7th) against government targets for elective recovery performance with 118% of activity compared with 2019. • Top-quartile performance against most performance metrics compared to similar sized teaching hospitals, including Emergency Department access, long-waiting patients on Referral to Treatment pathways, Diagnostics and Cancer performance. • Significant investment in new capacity through building new wards and theatres and refurbishing existing areas of the hospital. • Delivery of our highest ever Cost Improvement Programme saving. These achievements place us among the best performing trusts in England in several areas and are even more remarkable against a backdrop of continued periods of industrial action and increasing demand for our services, with many people coming to us with higher levels of acuity than ever before. The Trust’s performance in terms of elective recovery places it as one of the best-performing trusts in England and demonstrates the impact of the Trust’s decision to invest in additional capacity in prior years by building new wards and theatres. The Trust’s Emergency Department performance in respect of its four-hour waiting target at the end of March 2024 has attracted additional capital funding as part of an incentive scheme. Some of this funding will be used to increase the department’s same-day emergency care capacity during 2024/25. From a financial perspective, balancing the complexities of today’s challenges alongside the need to protect and ensure the long-term stability and quality of our service provision, has required the Board to take a number of considered and crucial efficiency improvement actions this year. Whilst challenging, the Trust has seen significant progress in delivering on both its forecasted finance position for 2023/24 and productivity targets. Achieving long-term financial stability is key to us continuing to invest in much needed upgrades and improvements to the parts of our estate that are ageing, and to developing new state-of-the-art facilities and infrastructure that increases our capabilities and capacity into the future. In the last year parts of the hospital have been transformed, with the opening of new wards, theatres and a skybridge to link the estate. Construction of a sterile services and aseptics facility has begun at Adanac Park and the expansion of our neonatal department, where we treat and care for some of our most vulnerable babies and their families, is underway. The development of a new aseptic facility at Adanac Park will have capacity to serve other hospitals within the region and is a significant opportunity for improved system-wide working. 6 We have also worked with our people to design spaces where they can rest, relax and recharge - including a new wellbeing hub and rooftop garden on the Princess Anne Hospital site. In addition, 40 staff rooms across the site have been refurbished thanks to funding from Southampton Hospitals Charity. During the year, the Trust worked to establish the Southampton Hospitals Charity as a separate charitable company to improve its ability to both raise and spend funds. This process completed on 1 April 2024. Work was carried out to refurbish a children’s ward during the year in partnership with the charity. Our people are our greatest asset, and we are pleased to see improvements from the annual staff survey in several areas - such as how people can work more flexibly, access to learning and development and improved satisfaction in support from line managers. We recognise the pressures and demands that come with working in this environment and will continue to ensure everyone working here feels heard, encouraged and supported when raising concerns. At UHS, every opportunity is taken to recognise and celebrate the incredible things our people do here every day, including the return of our in-person annual awards ceremony, monthly staff recognition events and the first ever ‘We Are UHS Week’. These occasions are an important reminder that, even when faced with challenges, there is so much to be proud of and celebrate across the whole Trust. Working together, both within the Trust and across organisational boundaries, remains one of our core values. The partnership between UHS and the University of Southampton is as strong as it has ever been, with more than 250,000 individuals having now taken part in research studies in Southampton. As the lead partner member for Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board, we are proactively working with other trusts and healthcare providers in the region to improve the health of the community we serve. In addition, the Trust has continued to work in partnership with other providers across the system to build a shared elective orthopaedic hub in Winchester. It is anticipated that the health and social care system will continue to be a challenging environment in 2024/25. We recognise that many of the big challenges we face can only be solved in partnership with wider local partners, and we are committed to actively playing our part in delivering system-wide solutions. Equally, we will continue to focus on improving whatever is within our internal control, and to work collaboratively with our people to ensure our patients’ experience, safety and outcomes remain central to our decision-making and the actions of everyone at UHS. Jenni Douglas-Todd Chair 19 July 2024 David French Chief Executive Officer 19 July 2024 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer As with 2022/23, this was another challenging year with continued increasing demand for the Trust’s resources and the need to balance this with the need to deliver quality patient care and at the same time maintain a sustainable financial position. Demand for non-elective care continued to increase with an average of 375 attendances per day to our main Emergency Department. In addition, the number of patients on the 18-week Referral to Treatment pathway rose to 58,000. Patients having no clinical criteria to reside in hospital, but unable to be discharged due to the lack of funded care in a more suitable location, posed and continues to pose a significant challenge for the Trust. The number of patients within this category was as high as 270 at times and was consistently higher throughout the year when compared to 2022/23. Despite this the Trust continued to perform well when compared to other comparable organisations, achieving some of the best Emergency Department and elective recovery fund performance in England. The Trust’s financial position continued to be difficult, which required some difficult decisions in respect of spending controls and controls on recruitment. The Trust focused in particular on controlling spending on temporary and agency staff, but in view of the overall workforce numbers compared to the 2023/24 plan, further controls were implemented in respect of substantive recruitment. Due to the additional controls and the Trust’s best delivery to date on its Cost Improvement Programme (£63.4m), the Trust achieved an end of year deficit of £4.5m, compared to the deficit of £26m anticipated in its 2023/24 plan. 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 £1.3 billion in 2023/24. 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 nearly four million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 155,000 inpatients and day patients, including about 70,000 emergency admissions sees over 750,000 people at outpatient appointments deals with around 150,000 cases in our emergency department The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 54% is paid for by NHS England and 43% by integrated care boards, predominantly the Hampshire and Isle of Wight Integrated Care Board (ICB). These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board. The ICP is a statutory committee jointly formed between the NHS integrated care board and all upper-tier local authorities that fall within the ICS area. The ICP brings together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Division B Division C Division D Surgery Critical Care Opthalmology Theatres and Anaesthetics Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values The Trust’s values describe how things are done at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. These values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything its staff had experienced during the COVID-19 pandemic and what had been learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. The Trust’s strategy is organised around five themes and for each of these it describes a number of ambitions UHS aims to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2023/24 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Increasing the number of reported Shared Decision-Making conversations. • Increasing the number of specialities reporting outcomes that matter to patients. • Rolling out the Patient Safety Incident Reporting Framework across the Trust. • Working with patients as partners to improve patient satisfaction. • Treating patients according to need but aiming for no patient to wait, other than through patient choice, more than 65 weeks for treatment. • Delivering national metrics for site set-up time to target for clinical research studies. • Improving the Trust’s position against peers. • Delivering year three of the Trust’s research and innovation investment plan. • Developing the five-year research and development strategy implementation plan and delivery of the first year. • Strengthening and broadening the partnership between the Trust and the University of Southampton. • Supporting delivery of the Trust’s workforce plan for 2023/24. • Reducing turnover and sickness absence rates. • Increasing overall participation in the NHS staff survey and maintaining overall staff engagement score. • Increasing the proportion of appraisals completed. • Delivering the first year objectives of the Inclusion and Belonging strategy. • Working in partnership with acute trusts to agree and implement the acute services strategy. • Producing and embedding an internal framework for network development. • Working with the local delivery system on vertical integration to reduce the number of patients without criteria to reside. • Working with system partners to open a surgical elective hub. • For the Trust to be seen as an ‘anchor institution’ in the local area. • Delivering the Trust’s financial plan for 2023/24. • Engaging the organisation in the challenge to manage demand so that capacity and demand are in equilibrium. • Delivery of the Always Improving strategy priorities. • Delivering the Trust’s capital programme in full. • Entering into a new energy performance contract and delivering the first year of the Public Sector Decarbonisation Scheme. Performance against these objectives was monitored and reported to the Trust’s Board on a quarterly basis. 14 At the end of 2023/24, the Trust had met the objectives set as follows: Corporate Ambition Outstanding patient outcomes, safety and experience Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future Totals Number of Objectives 5 5 5 5 5 25 Achieved in full 4 3 2 3 2 14 Partially achieved 1 2 2 1 3 9 Not achieved 0 0 1 1 0 2 Particular areas to highlight where the Trust has achieved strong delivery during the year include: • Delivery of quality priorities in Shared Decision-Making and the roll out of the Patient Safety Incident Response Framework. • Achieving the Trust’s 65-week waiter glide path. • Successful delivery of a number of research and development priorities, including work with the University of Southampton. • Maintaining sickness absence and turnover well below the targets set at the beginning of the year, and successfully delivering the first year of the Trust’s Inclusion and Belonging strategy. • Delivery of the Trust’s full available capital budget and completion of the first year of the Trust’s decarbonisation scheme. 15 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2023/24 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families or carers with a highquality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust does not take full advantage of its position as a leading university teaching hospital with a growing, reputable and innovative research and development portfolio, attracting the best staff and efficiently delivering the best possible treatments and care for its patients. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position, resulting in: inability to move out of the NHS England Recovery Support Programme; NHS England imposing additional controls/undertakings; and a reducing cash balance, impacting the Trust’s ability to invest in line with its capital plan, estates and digital strategies and in transformation initiatives. • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2023/24, the Trust saw continued increased demand for its services, particularly in the Emergency Department In addition, the number of patients having no clinical criteria to reside in hospital, but unable to be discharged due to a lack of appropriate care packages was higher than anticipated and spiked during winter, which significantly impacted patient flow through the hospital and required the Trust to engage additional temporary staff. The number of patients in this category peaked at 270 during the winter. There were particular challenges in respect of those patients with a primary mental health care need who would be better cared for in a more suitable alternative setting. 16 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The Trust continued to experience high demand for its services, especially in the Emergency Department, with average demand during the year being around 375 patients presenting per day in the main adult and children’s emergency department. In addition, the Trust experienced a significant impact on flow within the hospital due to a high number of patients having no clinical criteria to reside in hospital but unable to be discharged. This number was as high as 270 at times during winter: an increase of around 50 patients when compared to the prior year. The Trust also saw an increase in the number of referrals with the number of patients on a waiting list under the 18-week Referral to Treatment pathway rising from approximately 55,000 to 58,000 by the end of the year. In common with other trusts, the ongoing industrial action also impacted the Trust’s ability to provide urgent care and deliver on its elective recovery programme. Quality and compliance Despite the challenges, the Trust’s Emergency Department performance was one of the highest in England in March 2024, which resulted in additional capital funding being awarded. In addition, the Trust’s elective recovery performance was one of the best in England at 118% compared to 2019. The Trust continued to monitor the quality of care delivered throughout 2023/24 through a number of established quality assurance programmes. Clinical leaders monitored key quality, safety and patient experience indicators such as falls, pressure ulcers and venous thromboembolisms. Quality peer reviews were carried out, most significantly through Matron-led Quality Walkabouts every week in and out of hours focusing on the five key CQC questions – safe, effective, responsive, caring, and well-led. The Trust’s Clinical Accreditation Scheme builds on this intelligence, with clinical areas completing self-assessments of performance and review teams completing onsite visits. Patient representatives were included in these review teams. Learning was shared at the Clinical Leaders’ Group and via quarterly reports. The Trust was an active partner in a South-East accreditation network, offering advice and a steer to providers who are just setting up or looking to develop their own scheme, and extended that advice and support to other providers in England. 17 On 15 May 2023, the CQC inspected the maternity and midwifery service at Princess Anne Hospital as part of their national maternity inspection programme. The inspection report was published 11 August 2023, and the Trust retained its overall rating of ‘good’. This year UHS introduced its Fundamentals of Care (FOC) initiative. Whilst this is not a new concept, there were concerns that missed fundamental care had been amplified during the COVID- 19 pandemic. This initiative aims to empower and educate staff at all levels to ensure fundamental care is at the heart of what the Trust does. The Trust completed its transition to the Patient Safety Incident Response Framework (PSIRF) and collaborated with the ICB to develop a PSIRF plan and policy to underpin the change. The Trust implemented the requirements in respect of ‘Martha’s Rule’ where patients, relatives and carers have a legal right to a rapid review by a critical care outreach team during an acute deterioration episode in and out of hours. The Trust continued its focus on infection prevention and control, responding rapidly to rises in infection over the winter, and successfully flexing initiatives and innovations to achieve successful management in a responsive manner. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of further quality improvement projects. This included improvements across theatres, inpatient flow and outpatient programmes. During the year, average length of stay was reduced by 1.64%, day theatre cancellations were reduced by 200, and 42,350 patients were placed onto Patient Initiated Follow Up (PIFU) pathways. Further information can be found in the Quality Account. Partnerships The Trust works within the Hampshire and Isle of Wight Integrated Care System, and is an active member of a number of partner groups including the Acute Provider Collaborative Board and the Health and Wellbeing Board. The Trust develops and agrees its annual financial plans with the Integrated Care Board. The Trust is a member of a number of specific partnership groups for particular services, including the Central and South Genomics Medicine Service, the Children’s Hospital Alliance and the Southern Counties Pathology Network. The Trust works actively as a partner with other provider organisations around clinical networks, particularly with acute Trusts within the Integrated Care System and others closely located geographically. The Trust also links closely with the University of Southampton on a number of topics including research, commercial development and education and has a developed meeting structure to oversee this. 18 Workforce The Trust’s key areas of focus during 2023/24 were in respect of increasing the substantive workforce whilst also reducing reliance on bank and agency usage, and reducing staff turnover and sickness. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 331 whole-time equivalents above its plan for 2023/24. The Trust was successful in reducing staff turnover from 13.5% in 2022/23 to 11.4%, achieving the local target of . Cancer Waiting Times - 2 Week Wait Performance Cancer Waiting Times - 2 Week Wait Performance 100% 90% 80% 70% 60% 50% 40% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance % standard met The national target was for 96% of patients to commence treatment within 31 days of diagnosis. In March 2024, the Trust achieved 92% and performed in the range of 86%-94% throughout the year. The Trust has continued to make progress against the target for treatment of cancer within 62 days of an urgent GP referral, improving performance from 64% in April 2023 to 76% in March 2024 (NHS average: 69%). First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performanceUHS vs. NHSE average Cancer waiting times 31 day RTT performance UHS vs. NHSE average 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% Apr-23 May-23 Jun-2 3 Jul-2 3 Aug-23 Sep-2 3 Oct-23 Nov-2 3 Dec-23 Jan-24 Feb-2 4 Mar-24 Performance NHS Average 27 Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average Cancer Waiting Times 62 Day RTT Performance UHS vs NHSE Average % standard met 1 00% 80% 60% 40% 20% 0% Apr-23 May-23 Jun-23 Jul-23 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Performance NHS Average 28 Quality priorities Priorities for improvement 2023/24 Last year the Trust continued its ambition to deliver the highest quality care shaped by a range of national, regional, local, and Trust-wide factors. During the year the Trust continued to experience unprecedented demand on its services, with flow, capacity, infection prevention and safety all presenting challenges. However, the Trust was confident in its ability to keep a focus on its quality priorities, and its teams worked hard to achieve their goals even in these difficult circumstances. Priorities are aligned to the three core dimensions of quality: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care provided? Out of the six priories set, the Trust achieved five and partially achieved one. Overview of success Quality Priority One Improving care for people with learning disabilities and autistic (LDA) people across the Trust. Supporting staff delivering this care. Outcome against goals: achieved Key achievements: • LDA working group reestablished. • Development of an improvement plan using the NHS Learning Disability Improvement standards. • The LDA team has moved to the virtual enhanced care group in Division B where operational and governance support, leadership, and peer support/learning opportunities has been strengthened. • Sensory Boxes have been introduced for all clinical areas, funded by the Hampshire and Isle of Wight (HIOW) Integrated care board (ICB). These boxes include noise cancelling headphones, fidget toys, communication books and visual cards to support patients and wards. • Recruited additional Learning Disability Champions. • Established links with the parent carer forum (PCF) for the local area and are now attending regular events. A representative from the PCF sits on the LDA working group. The LDA team are working with the Trust lead for patient experience to develop this aspect of the LDA workplan over the next year. Quality Priority Two Supporting patients, service users and staff to overcome their tobacco dependence via a smoking cessation programme. Outcome against goals: achieved Key achievements: • Package of support available to patients who may be smokers and who need to be supported not to smoke during their treatment. • Fully trained team of tobacco advisors working in the hospital and an advisor working in the outpatient setting supporting the patients once they have returned home. • Devised the IT changes the Trust would like to implement to improve its service and referral process. • Recruited 30 smoke-free champions. • Successfully supported 1,131 patients with a self-confirmed quit rate of 45.6% at 28 days. • Supported 109 outpatients who have successfully achieved a 60% quit rate. • On track to achieve the goal to go smoke-free by April 2024 including the removal of smoking shelters. 29 Quality Priority Three Ensure carers are fully supported, involved, and valued across all our services by developing the carers support service across the Trust in partnership with Southampton Hospitals. Outcome against goals: partially achieved Key achievements: • Carers now have a more comprehensive package of concessions and vouchers to help support their cared-for person (e.g. free parking available onsite for blue badge owners is now available). • Listening events were held to put patients at the centre of transforming the way we deliver care is delivered, enabling their voices to improve the quality of care and outcomes for all. • Developed joint working with local partners (e.g. Children’s Society and No Limits to support young carers). Not yet achieved: • The ‘pathway to support, has not yet been developed. Work is ongoing to develop a new strategy. • A charity-funded carers’ support worker has not yet been appointed. • The carers’ training package has not yet been relaunched. Quality Priority Four Put patients at the centre of transforming the way care is delivered, enabling their voices to improve the quality of care and outcomes for all. Outcome against goals: achieved Key achievements: • Work has continued to work across corporate and divisional services to embed patients and carers into quality and service improvement, creating new patient groups (e.g. Mesh Support Group). • Successfully developed our engagement with various local communities, working to ensure that a range of care experiences are considered ( e.g. there is now a Gypsy, Roma, and Irish Traveller community health liaison officer to ensure that these communities are engaged with and brought into work to improve the inclusivity of our services). • Attending multiple public engagement opportunities (Young Carers’ Festival, Mela, University Freshers’ Fayres, Carers’ Listening Lunch, Hoglands Park Play Day, visits to local temples and ‘Love Where You Live’). • Youth and Young Adult Ambassador involvement has increased, including attendance toat meetings of the Council of Governors, and supporting hospital projects. • A Celebration of Carers Week and Volunteers Week were run. • The Trust has analysed its reported outcome measures to identify health inequalities in its services. This information has been used to set a new quality priority for 2024/25. • An SMS friends and family test text survey has been introduced to improve the response rate on patient feedback from the Emergency Department. In the first three months following the survey launch, responses increased from 24 to 424. 30 Quality Priority Five To develop the Trust’s clinical effectiveness process, connecting to the Trust’s Always Improving approach to measuring, understanding, and using outcomes to improve patient care. Outcome against goals: achieved Key achievements: • The Trust has developed its clinical effectiveness process across the Trust with involvement of informatics, governance and management teams, clinical effectiveness leads as well as reporting committees. • Patient representation onhas been included in the clinical assurance meeting for effectiveness and outcomes (CAMEO) to ensure conversations focus on what matters to patients. • The CAMEO template has been changed to focus discussions on areas the specialty is proud of (strong or improving outcomes), areas for improvement (poorly benchmarked or worsening outcomes) and planned actions. • The Trust encourages the use of run and/or statistical process control charts along with benchmarking where available. • Details of NICE and quality standards and national and regional reviews are included to cover breadth of clinical effectiveness. • How the clinical effectiveness team works has been reorganised, aligning each of them to each division giving a named link which helps to deepen understanding and improve links with governance and improvement activities locally. • Working with informatics to establish a core set of clinical outcome measures which are meaningful to patients, which can be reported centrally (starting with surgical specialities). • Starting to develop an education strategy and platform to support staff with a number of tools used in clinical effectiveness as well as clarity on where and how to record and evidence audit and service improvement. • A revised strategy has been drafted. Quality Priority Six Developing a culture where all clinical staff have a basic knowledge of diabetes. Outcome against goals: achieved Key achievements: • Launch of the ‘Start with the Diabasics’ Initiative, designed to help give diabetes visibility across UHS. • Delivered an extensive education programme to clinical staff across the professions and bands, including the introduction of some e-learning and a Diabasics introductory video has been shown at all trust staff inductions since July 2023. • Supported the development of 45 diabetes link nurses, resulting in all ward areas now having a named diabetes link nurse. • Improved triage for referrals. • Established processes for ‘lessons learned’. • Developed IT solutions to improvingimprove alerts and guidance. • A ‘Ketone Wednesdays’ initiative has been created in response to overuse of blood ketone testing (estimated waste cost of £100,000 per year). • The Trust’s lead diabetes specialist nurse and the Diabasics Initiative were both shortlisted for National Quality in the Care Diabetes Awards (October 2023). • The Diabasics Initiative was mentioned as a case study on the Diabetes UK charity website as an example of good practice that could be reproduced elsewhere. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2024/25, in the Trust’s Quality Account for 2023/24. 31 Financial performance The Trust delivered a deficit of £4.5m from a revenue position of over £1.3bn, following receipt of £24.6m one-off cash support from NHS England. UHS started the year with an underlying deficit as a result of a number of cost pressures, notably demand for services being above block contract levels and the cost of national pay awards being above funded levels. The Trust has also continued to face a number of pressures, including high numbers of patients who no longer meet the criteria to reside in the hospital, and high demand for patients with a primary mental health need. In 2023/24, the Trust delivered a record savings level of £63.4m (5%) across a range of programmes. Trust operating income rose by £107m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Trust operating expenses rose by £89m, incorporating funded inflationary costs as well as costs relating to the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investment of over £75m, including investment in new wards, theatres, decarbonisation, digital infrastructure, neonatal expansion and backlog maintenance. Trust cash and cash equivalents finished the year at £79m, a reduction of £24m from the previous year due to the operating loss and capital investment outlined above. Whilst liquidity remained strong in 2023/24 supported by NHS England cash support, the underlying financial deficit means it is likely to decline further in 2024/25. The Trust is continuing to monitor its cash position closely and is considering whether additional cash support may be required in 2024/25. Sustainability The Trust recognises that everyone has a part to play in responding to the climate crisis. In March 2022, the Trust agreed its own green plan in response to the challenge of the NHS becoming the world’s first health service to reach carbon net zero. Now in its third year, the plan identifies the Trust’s key areas of focus and its ambitions and has seen progress across all areas of the plan. The plan sets out the scale of the challenge, the Trust’s commitment to reducing the impact on the environment and the steps to be taken across the following categories: • Estates and facilities • Clinical and medicines • Digital transformation • Supply chain and procurement • Travel and transport • Waste and resources • Food and nutrition • Adaptation • Biodiversity • Wider sustainability The Trust continues to progress through its green plan and has completed the ‘Greener NHS’ reporting tool for several quarters, which has demonstrated good progress. In addition, the Trust is planning to launch its ‘Our Sustainable UHS’ app for staff, which will give tips on sustainability and create personalised travel plans, including identifying potential contacts for car sharing. In addition, the Trust is considering proposals to implement additional solar power, smart metering and expanding the use of LED lighting. 32 In 2022/23, the Trust was successful in bidding for £29.4m of funding through the Public Sector DeCarbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. During the year the Trust successfully bid for £823k in National Energy Efficiency Funding which has been used to upgrade the lighting at Princess Anne Hospital. Social, community, anti-bribery and human rights issues The Trust recognises its responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK). These rights include: • right to life • right not to be subjected to inhuman or degrading treatment or punishment • right to liberty and freedom • right to respect for privacy and family life. These are reflected in the duty, set out in the NHS Constitution, to each and every individual that the NHS serves, to respect their human rights and the individual’s right to be treated with dignity and respect. The Trust is committed to ensuring it fully takes into account all aspects of human rights in its work. An equality impact assessment is completed for each Trust policy. For patients, the Trust’s safeguarding policies protect and support the right to live in safety, free from abuse and neglect and other policies and standards are designed to optimise privacy and dignity in all aspects of patient care. Feedback from patients and the review of complaints, concerns, claims, incidents and audit help to monitor how the Trust is achieving these objectives. The Trust’s green plan, approved by the board of directors in March 2022, recognises the Trust’s broader role and responsibility to address the issues of climate change, air pollution, waste and environmental decline present to the city of Southampton and the impact that these issues have on the health and wellbeing of the local population served. Although the Modern Slavery Act 2015 does not apply to the Trust, its green plan sets out an ambition to stop modern slavery. The Trust is also committed to maintaining an honest and open culture within the Trust; ensuring all concerns involving potential fraud, bribery and corruption are identified and rigorously investigated. The Trust has a Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Raising Concerns (Whistleblowing) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. Anti-bribery is part of the Trust’s work to counter fraud. This work is overseen by the Audit and Risk Committee, which receives regular reports from the local counter fraud specialist on the effectiveness of these policies through its monitoring and reviews, providing recommendations for improvement, as well as an annual report from the freedom to speak up guardian. You can read more about the work of the Audit and Risk Committee and the Trust’s approach to counter fraud in the Accountability Report. Events since the end of the financial year There have been no important events since the end of the financial year affecting the Trust. Overseas operations The Trust does not have any overseas operations. 33 Equality in service delivery NHS trusts have an essential role in tackling health inequalities, both as part of the services they provide, but also through work with the wider system. By working with those in integrated care systems, local authorities and third sector organisations, the Trust can have a significant impact on the health of the local population. The national focus on health inequalities is growing. This comes with new legal duties around reporting information and expectations to report on improvement programmes. In September 2023, a health inequalities steering group was initiated, under the leadership of the Chief Medical Officer, with representation from clinical, operational, transformation, patient experience, research, organisational development and culture, informatics, public health and the Integrated Care Board. The group focused on scoping future priorities aligned to national guidelines, contractual obligations and priorities, regional priorities, feedback from clinical teams and patients, understanding where action is already being taken, and what the data is showing. Overall, the group
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