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Hospital trust announces three new board appointments

Description: University Hospital Southampton NHS Foundation Trust has announced three new non-executive appointments to its board of directors.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2018/March-2018/Hospital-trust-announces-three-new-board-appointments.aspx

Epcoritamab -Cycle 2 (Onwards)

Description: Chemotherapy Protocol LYMPHOMA EPCORITAMAB – Cycle 2 Onwards - (28 day) Regimen • Lymphoma-Epcoritamab – C
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Lymphoma/Epcoritamab-Cycle-2-Onwards-Ver1.pdf

Epcoritamab -Cycle 1 (Priming)

Description: Chemotherapy Protocol LYMPHOMA EPCORITAMAB -Cycle 1 - (28 Day -Priming) Regimen • Lymphoma-Epcoritamab – Cycle 1- (28 day -Priming) Indication • Treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), after two or more lines of systemic therapy • This protocol is to be used for dose titration of epcoritamab to 48mg (full dose). Once this dose is reached the Cycle 2 onwards regimen protocol should be used. • Blueteq form must be completed for funding -NICE TA954 Toxicity Drug Epcoritamab Adverse Effect Cytokine release syndrome (CRS), immune effector-cell associated neurotoxicity syndrome (ICANS), serious infection, tumour flare, tumour lysis syndrome, cytopenia, thrombocytopenia, neutropenia, hypophosphatemia, hypokalemia, hypomagnesemia, headache, abdominal pain, nausea and vomiting, diarrhoea, elevated ALT, AST & ALP. The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Symptoms of CRS can occur weeks after administration and therefore the patient must be issued with an alert card to carry with them at all times. See Trust Protocol for management and grading of CRS and ICANS following bispecific antibody treatment. Monitoring Regimen • FBC, LFTs, U&Es, bone profile, CRP and LDH prior to day one of treatment • Documented viral screen – CMV, HSV, EBV, VZV, HIV • Check hepatitis B status before starting. Patients with positive hepatitis B serology should consult a liver disease expert before the start of treatment and should be monitored and managed following local medical standards to prevent hepatitis re-activation Version 1 (June 2024) 1 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) CRS: Symptoms: pyrexia, tiredness, cardiac failure, tachycardia, cardiac arrythmias, dyspnoea, hypoxia, capillary leak syndrome, chills, renal impairment, headache, malaise, transaminitis, nausea, diarrhoea, hypotension. • Temperature, blood pressure and oxygen saturation monitored 4-hourly after epcoritamab administration on cycle 1 day 15 and then twice daily as directed in accordance with local procedures. • This must be documented, and CRS graded on the CRS Assessment Form in the patient’s notes, as per local policy. See Trust Protocol following bispecific antibody treatment for CRS guidelines for monitoring requirement and grading. The prescriber must inform the patient of the risk of CRS and signs and symptoms of CRS. Patients must be instructed to seek immediate medical attention if they experience signs and symptoms of CRS. Patients should be provided with an alert card and instructed to carry the card at all times. This card states their treatment regimen and emergency contact details in case of reaction or CRS. ICANS Symptoms: seizures, somnolence, headaches, confusion, agitation, speech disorders, tremor, encephalopathy, ataxia, memory impairment, mental status changes, hallucinations, depressed level of consciousness, delirium, dysmetria. No formal ICANS assessment is required following epcoritamab administration. However, the prescriber, clinical team and patient must be aware of the risk of ICANS and the signs and symptoms of ICANS. Patients must be instructed to seek immediate medical attention if they experience signs and symptoms of ICANS. See Trust Protocol following bispecific antibody treatment for ICANS grading and management. Patient monitoring • All patients must be hospitalised on Cycle 1 Day 15 (i.e. first dose of 48mg) for 24 hours after administration of epcoritamab to monitor for the signs and symptoms of CRS and ICANS. • At least 1 dose of tocilizumab for use in the event of CRS must be available on the ward, or pre-specified location, prior to epcoritamab administration, during dosing of Cycles 1 and 2. Access to an additional dose of tocilizumab within 8 hours of use of the previous tocilizumab dose must be ensured. • Patients who experienced Grade ≥ 2 CRS or received tocilizumab with their most recent infusion should be hospitalised for their next scheduled infusion. Tumour Lysis Syndrome • Tumour lysis syndrome (TLS) has been reported with epcoritamab. Patients should be assessed for risk of tumour lysis prior to each administration. Ensure patients are well hydrated. • In patients who are considered to be at risk of TLS (e.g. patients with a high tumour burden and/or a high circulating lymphocyte count (greater than 25x109/L) and/or renal impairment (CrCl less than 70 ml/min) should receive prophylaxis. Version 1 (June 2024) 2 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) • Prophylaxis should consist of adequate hydration and administration of allopurinol or a suitable alternative such as rasburicase prior to the infusion. • All patients considered at risk should be carefully monitored during the initial days of treatment with a special focus on renal function, potassium, and uric acid values. Any additional guidelines according to standard practice should be followed. Dose Modifications No dose reductions of epcoritamab are recommended. Adverse events should be managed with dose interruption or treatment discontinuation. Please discuss all dose delays with the relevant consultant before prescribing. The approach may be different depending on the clinical circumstances. Patients should permanently discontinue epcoritamab after a Grade 4 CRS or ICANS event. Haematological toxicities Dose modifications for haematological toxicity in the table below are for general guidance only. Any haematological abnormalities will be evaluated with clinical judgement. Always refer to the responsible consultant as any dose delays will be dependent on clinical circumstances and treatment intent. The patient may require blood products and/or growth factor support. Neutrophils (x109/L) ULN, or total bilirubin 1 to 1.5 times ULN and any AST). There is limited data in moderate hepatic impairment (total bilirubin > 1.5 to 3 times ULN and any AST). Therefore, the effects of epcoritamab are unknown. The safety and efficacy of epcoritamab has not been established in patients with severe hepatic impairment (total bilirubin > 3 times ULN and any AST). Renal Impairment Dose adjustment is not considered necessary in patients with mild or moderate renal impairment (CrCL 30 to 8 days between the priming dose (0.16 mg) and intermediate dose (0.8 mg), or • > 14 days between the intermediate dose (0.8 mg) and first full dose (48 mg), or • > 6 weeks between full doses (48 mg) After the re-priming cycle, the patient should resume treatment with Day 1 of the next planned treatment cycle (subsequent to the cycle during which the dose was delayed). Version 1 (June 2024) 4 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) Administration Information Pre-medications Epcoritamab should be administered to well-hydrated patients. Premedication to reduce the risk of CRS as outlined. Pre-medication (30 minutes prior to epcoritamab) Cycle 1 All Patients Dexamethasone 15mg oral 1 √ Chlorphenamine 10mg oral √ Paracetamol 1000mg oral √ 1On these days, the steroid prophylaxis is to continue for 3 consecutive days following each weekly administration of epcoritamab. Epcoritamab should be administered by subcutaneous injection, preferably in the lower part of the abdomen or the thigh. Change of injection site from left to right side or vice versa is recommended especially during the weekly administration schedule (i.e., Cycles 1-3). Supportive Treatments • Tocilizumab must be prescribed as when required in advance of epcoritamab infusion, in the event of CRS.Tocilizumab (8 mg/kg, maximum dose 800 mg) intravenously 8-hourly if required. See CRS management in Trust Bi-specific Antibody Protocol. - One dose of tocilizumab must be available on the ward or pre-specified location prior to infusion of epcoritamab. - Follow local procedures for administration. • Corticosteroids may be indicated (See CRS management in Trust Bi-Specific Antibody Protocol) can be either: ▪ 10 mg intravenous dexamethasone, 100 mg intravenous prednisolone, 1-2 mg/kg intravenous methylprednisolone per day, or equivalent • Tumour lysis syndrome (TLS) prophylaxis should be prescribed according to the individual patient TLS risk and at consultant review: - In high risk patients, consider 3 mg rasburicase intravenous once prior to first dose epcoritamab followed by 300 mg once daily oral allopurinol starting the day after rasburicase. - For low to moderate risk patients, start allopurinol 300 mg oral (100 mg if renal impairment) Version 1 (June 2024) 5 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) - This must be assessed prior to epcoritamab treatment and at each dose increment. • Administration related reactions on a required basis: - salbutamol 2.5mg nebulised - chlorphenamine 10mg intravenous - hydrocortisone sodium succinate 100mg intravenous - paracetamol 1000mg oral - oxygen as required - sodium chloride 0.9% 500ml intravenous - consider pethidine 25-50mg intravenous for infusion related rigors that fail to respond to steroids. • Anti-infective prophylaxis - Aciclovir 400mg oral twice a day - Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday oral • Gastric protection with a proton pump inhibitor or a H2 antagonist according to local formulary choice; - esomeprazole 20mg once a day oral - omeprazole 20mg once a day oral - lansoprazole 15mg once a day oral - pantoprazole 20mg once a day oral - rabeprazole 20mg once a day oral - cimetidine 400mg twice a day oral - famotidine 20mg once a day oral - nizatidine 150mg twice a day oral • Growth factors (GCSF) may be considered to support during neutropenia. To be discussed with consultant. Extravasation • Epcoritamab -neutral References 1. Summary of Product Characteristics for Tepkinyl 48mg solution for injection (AbbVie Limited) -Last updated 28 November 2023. 2. Summary of Product Characteristics for Tepkinyl 4mg/0.8ml concentrate for solution for injection (AbbVie Limited) -Last updated 28 November 2023. 3. Lee D, et al. ASTCT Consensus Grading for Cytokine Release Syndrome and Neurologic Toxicity Associated with Immune Effector Cells. Biology of Blood Version 1 (June 2024) 6 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) Cycle 1 Day ONE REGIMEN SUMMARY Epcoritamab - Cycle 1 - (28 day -Priming) 1. Warning – Ensure TLS assessment completed. - TLS prophylaxis allopurinol supplied as pick-up internal on day 1. - Rasburicase if required will need prescribing on Aria internal prescription. 2. Warning - Ensure patient has been issued with treatment alert card. 3. Chlorphenamine 10mg oral Administration Instructions Administer 30 minutes prior to epcoritamab 4. Dexamethasone 15mg oral Administration Instructions Administer 30 minutes prior to epcoritamab 5. Paracetamol 1000mg oral Administration Instructions Please check if the patient takes regular paracetamol for pain control and take dose into account. Administer 30 minutes prior to epcoritamab 6. Epcoritamab 0.16mg subcutaneous injection Administration Instructions Epcoritamab should be administered by subcutaneous injection, preferably in the lower part of abdomen or the thigh. Change of injection site from left to right side or vice versa is recommended especially during the weekly administration schedule (i.e., Cycles 1-3) 7. Chlorphenamine 10mg when required for infusion related reactions Administration Instructions For the relief of infusion related reactions 8. Hydrocortisone sodium succinate 100mg intravenous when required for the relief of infusion related reactions Administration Instructions For the relief of infusion related reactions 9. Paracetamol 1000mg oral when required for pyrexia Administration Instructions For the relief of pyrexia. Please check if the patient takes regular paracetamol for pain control and take dose into account 10. Salbutamol 2.5mg nebule once only when required for the relief of infusion related bronchospasm 11. Tocilizumab 8mg/kg (maximum 800mg) intravenous 8-hourly if required in the event of CRS. Maximum 3 doses. Administration Instructions See Trust Protocol for CRS management post epcoritamab. One dose of tocilizumab must be available on the ward or pre-specified location prior to infusion of epcoritamab. Follow local procedures for administration. Take home medicines (Day 1) Version 1 (June 2024) 7 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) 12. Dexamethasone 15mg once a day oral on the morning of epcoritamab treatment and then for 3 days after. Administration Instructions Please supply 15 doses for days 2, 3, 4, 8, 9, 10, 11, 15, 16, 17, 18, 22, 23, 24 and 25. Please dispense all days on day 1 of the cycle. ** Take with or after food. 13. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday oral Administration Instructions This may be administered as 480mg twice a day according to local practice. Please supply 28 days or the nearest original pack size. 14. Aciclovir 400mg twice a day oral for 28 days 15. Gastric Protection Administration Instructions: The choice of gastric protection is dependent on local formulary choice and may include; - esomeprazole 20mg once a day oral - omeprazole 20mg once a day oral - lansoprazole 15mg once a day oral - pantoprazole 20mg once a day oral - rabeprazole 20mg once a day oral - cimetidine 400mg twice a day oral - famotidine 20mg once a day oral - nizatidine 150mg twice a day oral Please supply 28 days or the nearest original pack size. 16. Allopurinol 300mg oral once a day for 28 days. In accordance with patient assessment. Cycle 1 Day EIGHT 17. Warning – Ensure TLS assessment completed. - TLS prophylaxis allopurinol supplied as pick-up internal on day 1. - Rasburicase if required will need prescribing on Aria internal prescription 18. Warning - Ensure patient has been issued with treatment alert card 19. Chlorphenamine 10mg oral Administration Instructions Administer 30 minutes prior to epcoritamab 20. Warning – Check patient has taken the dexamethasone dose* 21. Paracetamol 1000mg oral Administration Instructions Please check if the patient takes regular paracetamol for pain control and take dose into account. Administer 30 minutes prior to epcoritamab 22. Epcoritamab 0.8mg subcutaneous injection Administration Instructions Epcoritamab should be administered by subcutaneous injection, preferably in the lower part of abdomen or the thigh. Change of injection site from left to right side or vice versa is recommended especially during the weekly administration schedule (i.e., Cycles 1-3) 23. Chlorphenamine 10mg when required for infusion related reactions Administration Instructions For the relief of infusion related reactions Version 1 (June 2024) 8 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) 24. Hydrocortisone sodium succinate 100mg intravenous when required for the relief of infusion related reactions Administration Instructions For the relief of infusion related reactions 25. Paracetamol 1000mg oral when required for pyrexia Administration Instructions For the relief of pyrexia. Please check if the patient takes regular paracetamol for pain control and take dose into account 26. Salbutamol 2.5mg nebule once only when required for the relief of infusion related bronchospasm 27. Tocilizumab 8mg/kg (maximum 800mg) intravenous 8-hourly if required in the event of CRS. Maximum 3 doses. Administration Instructions See Trust Protocol for CRS management post epcoritamab. One dose of tocilizumab must be available on the ward or pre-specified location prior to infusion of epcoritamab. Follow local procedures for administration. Cycle 1 Day FIFTEEN 28. Warning – Ensure TLS assessment completed. - TLS prophylaxis allopurinol supplied as pick-up internal from Day 1. - Rasburicase if required will need prescribing on in-patient prescribing system 29. Warning - Ensure patient has been issued with treatment alert card 30. Warning – Check supportive medication prescribed Administration instructions 1. Dexamethasone 15mg once a day in the morning days 16 to 18 oral 2. TLS prophylaxis as per TLS assessment. 3. Chlorphenamine 10mg when required for infusion related reactions. 4. Hydrocortisone sodium succinate 100mg when required for infusion related reactions. 5. Paracetamol 1000mg oral when required for pyrexia. 6. Salbutamol 2.5mg nebulised when required for the relief of infusion related bronchospasm. 7. Tocilizumab 8mg/kg (maximum 800mg) intravenous 8-hourly if required in the event of CRS. Maximum 3 doses. See Trust protocol for CRS Management post epcoritamab. One dose of tocilizumab must be available on the ward or pre-specified location prior to infusion of epcoritamab. Follow local procedures for administration. 31. Chlorphenamine 10mg oral Administration Instructions Administer 30 minutes prior to epcoritamab 32. Warning – Check patient has taken the dexamethasone dose* 33. Paracetamol 1000mg oral Administration Instructions Please check if the patient takes regular paracetamol for pain control and take dose into account. Administer 30 minutes prior to epcoritamab 34. Epcoritamab 48mg subcutaneous injection Administration Instructions Epcoritamab should be administered by subcutaneous injection, preferably in the lower part of abdomen or the thigh. Change of injection site from left to right side or vice versa is recommended especially during the weekly administration schedule (i.e., Cycles 1-3) Cycle 1 Day TWENTY TWO Version 1 (June 2024) 9 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) 35. Warning – Ensure TLS assessment completed. - TLS prophylaxis allopurinol supplied as pick-up internal on day 1. - Rasburicase if required will need prescribing on Aria internal prescription. 36. Warning - Ensure patient has been issued with treatment alert card. 37. Chlorphenamine 10mg oral Administration Instructions Administer 30 minutes prior to epcoritamab 38. Warning – Check patient has taken the dexamethasone dose* 39. Paracetamol 1000mg oral Administration Instructions Please check if the patient takes regular paracetamol for pain control and take dose into account. Administer 30 minutes prior to epcoritamab 40. Epcoritamab 48mg subcutaneous injection Administration Instructions Epcoritamab should be administered by subcutaneous injection, preferably in the lower part of abdomen or the thigh. Change of injection site from left to right side or vice versa is recommended especially during the weekly administration schedule (i.e., Cycles 1-3) 41. Chlorphenamine 10mg when required for infusion related reactions Administration Instructions For the relief of infusion related reactions 42. Hydrocortisone sodium succinate 100mg intravenous when required for the relief of infusion related reactions Administration Instructions For the relief of infusion related reactions 43. Paracetamol 1000mg oral when required for pyrexia Administration Instructions For the relief of pyrexia. Please check if the patient takes regular paracetamol for pain control and take dose into account 44. Salbutamol 2.5mg nebule once only when required for the relief of infusion related bronchospasm 45. Tocilizumab 8mg/kg (maximum 800mg) intravenous 8-hourly if required in the event of CRS. Maximum 3 doses. Administration Instructions See Trust Protocol for CRS management post epcoritamab. One dose of tocilizumab must be available on the ward or pre-specified location prior to infusion of epcoritamab. Follow local procedures for administration. Administration information * Please check the patient has taken dexamethasone 15mg oral on the morning of epcoritamab administration. On occasions where individuals attend for treatment and have forgotten to take the dexamethasone dose please administer dexamethasone 15mg oral 30 minutes prior to epcoritamab administration. **The dexamethasone may be dispensed as a single supply in one container or as two containers depending on local preference. All doses for cycle one will be supplied on day 1. Version 1 (June 2024) 10 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming) DOCUMENT CONTROL Version Date Amendment Written By Approved By 1 January 2025 New Document Madeleine Norbury Pharmacist Hwai Jing Hiew Consultant This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors which occur because of following these guidelines. Version 1 (June 2024) 11 Lymphoma – Epcoritamab - Cycle 1 - (28 day -Priming)
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Lymphoma/Epcoritamab-Cycle-1-Priming-Ver1.pdf

Board of Directors - Register of Interests 2025 - 2026

Description: BOARD OF DIRECTORS REGISTER OF INTERESTS 2025-26 Director Jenni Douglas-Todd Chair Description of Interest Date acquired Managing Director, Diversa Consultancy Limited Chair of Dorset Integrated Care Board Chair of Dorset Integrated Care Partnership Non-Executive Director, Hampshire Cricket Board Non-Executive Director, Hampshire Sports & Leisure Holdings Limited Non-Executive Director, Hampshire Cricket Company Limited Non-Executive Director, Southern Vipers Limited Member of the English Cricket Board Regulatory Committee; Member of the Judicial Conduct Investigative Office (public appointment extended to 31 March 2023 and to 30 June 2023) Member of the English Cricket Board Recreational Game Committee (3-year term) Daughter to undertake summer audit vacation programme, in the audit team, with KPMG LLP, for one month. Chair, Isle of Wight NHS Trust (IWT) and Portsmouth Hospitals NHS Trust (PHU) Member of the English Cricket Board Professional Game Committee 24/03/2014 01/07/2022 01/07/2022 02/05/2016 17/05/2021 01/05/2022 01/05/2022 01/01/2018 20/05/2015 01/08/2023 08/07/2024 01/04/2025 01/11/2023 Date declared to Trust 13/07/2022 13/07/2022 13/07/2022 13/07/2022 13/07/2022 Date Register presented to Board 28/07/2022 28/07/2022 28/07/2022 28/07/2022 28/07/2022 13/07/2022 28/07/2022 13/07/2022 13/07/2022 28/07/2022 28/07/2022 13/07/2022 31/08/2022 31/07/2023 28/07/2022 29/09/2022 28/09/2023 30/04/2024 06/06/2024 23/10/2024 15/05/2025 14/05/2025 15/07/2025 Date ceased 31/03/2025 31/03/2023 28/07/2025 17/12/2024 31/03/2023 30/06/2023 07/08/2024 Director Diana Eccles Non-Executive Director Description of Interest Date acquired Company Secretary, Orteccles Management Consultancy Dean, Faculty of Medicine, University of Southampton Associate Non-Executive Director, Southern Health Trust Board Chair, Medical Research Council (MRC) Clinical Academic Research Partnership Board Husband is Chief Executive Officer of Eastleigh Southern Parishes Network Limited (ESPN) Son is Senior Manager in Crisis Management at Deloitte Son is UK Account Manager for Smart Building Systems section of Siemens Deputy Chair of Clinical Medicine Sub-Panel, UK Research and Innovation (UKRI) REF 2029 (secondment) Chair of Regional Account for Clinical Researchers (RACR) Funding Panel, Medical Research Council (MRC) (for 1 year) Member of Health Sciences Review Panel, Chinese Universities of Hong Kong Consortium REF 2026 (expires 1 September 2026) Son is Account Manager at Spacit for UK, Europe and AMER countries 01/07/2000 01/09/2018 01/10/2022 01/10/2020 12/11/2014 2018 2021 08/05/2025 01/08/2025 01/06/2025 01/03/2026 Date declared to Trust 12/01/2023 Date Register presented to Board 31/01/2023 12/01/2023 31/01/2023 12/01/2023 31/01/2023 12/01/2023 31/01/2023 12/01/2023 31/01/2023 12/01/2023 31/01/2023 12/01/2023 08/09/2025 31/01/2023 09/09/2025 08/09/2025 09/09/2025 08/09/2025 09/09/2025 09/03/2026 10/03/2026 Date ceased 18/12/2025 30/09/2023 31/07/2025 28/02/2026 Director David French Chief Executive Officer Paul Grundy Chief Medical Officer Description of Interest Non-Executive Director and Chair of Audit and Risk Committee, Vivid Housing Ltd Director, UHS Estates Limited (UEL), a wholly-owned subsidiary of the Trust Director, Southampton CEDP Project Co. Limited, a wholly-owned subsidiary of Southampton CEDP LLP, a joint venture between the Trust and Partnering Solutions (Southampton) Limited Director, Wessex NHS Procurement Limited (WPL), a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust Member of Hampshire & Isle of Wight Counter Fraud Board Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel Partner Member, Acute Hospital Services on the Hampshire and Isle of Wight Integrated Care Board Director, UHS Pharmacy Limited (UPL), a wholly-owned subsidiary of the Trust Director, Brain Tumour Surgery Ltd Trustee, Smile4Wessex (The Wessex Neurological Centre Trust) Honorary Secretary, Society of British Neurological Surgeons Vice President/President Elect, British Neuro-Oncology Society Vice-Chair and Clinical Member, NHS England and NHS Improvement Adult Neurosciences Clinical Reference Group President, British Neuro-Oncology Society Director, Middle Brook Management Ltd Immediate Past President, British NeuroOncology Society (to 30/06/2024) Date acquired 21/04/2017 17/03/2016 28/01/2016 08/05/2019 03/02/2016 01/05/2018 05/07/2023 01/02/2021 12/01/2010 27/07/2018 24/09/2019 01/09/2019 May 2019 01/09/2021 01/02/2023 01/08/2023 Date declared to Trust 23/05/2017 Date Register presented to Board 23/05/2017 12/04/2016 12/04/2016 26/05/2016 26/05/2016 28/11/2019 28/11/2019 03/02/2016 07/02/2019 23/05/2017 23/05/2019 05/07/2023 09/11/2023 02/02/2021 02/02/2021 02/02/2021 02/02/2021 02/02/2021 02/02/2021 25/02/2021 25/02/2021 25/02/2021 25/02/2021 25/02/2021 25/02/2021 04/01/2022 28/09/2023 28/09/2023 27/01/2022 09/11/2023 09/11/2023 Date ceased 23/07/2020 09/11/2020 01/11/2020 01/11/2020 31/08/2023 31/08/2021 30/04/2023 31/07/2023 30/06/2024 Director Description of Interest Date acquired Paul Grundy Chief Medical Officer Steve Harris Chief People Officer Jane Harwood Non-Executive Director/ Senior Independent Director and Deputy Chair Ian Howard Chief Financial Officer Andy Hyett Chief Operating Officer David Liverseidge, Non-Executive Director Clinical Advisor for Brain Injury Group for up to 1 year (reference Brain Tumour Surgery Ltd interest) Clinical Assessment and support for Imperial College Healthcare NHS Trust neuro-oncology MDT Ongoing Support for Imperial College Healthcare NHS Trust neuro-oncology MDT in UHSFT time and remuneration to UHSFT at 1 PA Wife is Team Leader of the Older Persons Specialist Nurses at the Trust (Division B) Wife is Patient and Family Support Hub Nurse Manager at the Trust Director, Jane Harwood Consulting Ltd Shareholder, Jane Harwood Consulting Ltd Trustee/Director and Vice-Chair, Missing People Limited, a charity Trustee, Wooden Spoon Society Designate Chair, Street Doctors Charity Chair, Street Doctors Charity Director, UHS Pharmacy Limited (UPL), a wholly-owned subsidiary of the Trust Director, Wessex NHS Procurement Limited (WPL), a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust Shareholder, Micro-Precision Instruments Ltd Director, UHS Estates Limited (UEL), a whollyowned subsidiary of the Trust None Independent Consultant, Elysium Healthcare Limited 01/03/2025 28/02/2025 03/03/2025 19/02/2009 01/04/2025 18/05/2020 18/05/2020 06/02/2014 14/09/2020 01/09/2023 01/01/2024 27/09/2018 09/11/2020 2018 01/04/2025 21/07/2025 Date declared to Trust 18/03/2025 Date Register presented to Board 14/05/2025 18/03/2025 14/05/2025 18/03/2025 14/05/2025 28/06/2010 14/05/2025 01/10/2020 01/10/2020 01/10/2020 01/10/2020 29/09/2023 29/09/2023 13/11/2020 13/11/2020 28/11/2019 14/05/2025 29/10/2020 29/10/2020 29/10/2020 29/10/2020 09/11/2023 09/11/2023 07/01/2021 07/01/2021 13/11/2020 11/03/2025 05/08/2025 23/07/2025 07/01/2021 14/05/2025 09/09/2025 09/09/2025 Date ceased 03/03/2025 31/05/2025 31/03/2025 31/05/2023 31/05/2023 31/12/2023 Director Description of Interest Date acquired Dr Tim Peachey Non-Executive Director Director, TP-Medcon Ltd Clinical Safety Officer, Block Solutions Ltd Clinical Advisor, Bolt Partners Ltd Associate - Mediator, Problem Resolution Ltd Non-Executive Director and Chair of Quality Committee, Isle of Wight NHS Trust Health Advisory Board member, Palantir Technologies UK, Ltd Associate Non-Executive Director, Portsmouth Hospital University NHS Trust (PHU) and Isle of Wight NHS Trust (IWT) Trustee, Mountbatten Group 15/08/2018 01/10/2018 01/01/2018 01/10/2018 02/04/2018 01/07/2021 01/04/2024 27/07/2024 Steve Peacock Chief Finance Officer, National Trust Non-Executive Director 03/02/2025 Alison Tattersall Non-Executive Director Natasha Watts Acting Chief Nursing Officer Non-Executive Director and Chair of Remuneration Committee, Stafford Building Society Trustee, The People’s Dispensary for Sick Animals (PDSA) Non-Executive Director and Chair of Remuneration Committee, Recognise Bank Trustee, Southampton Hospitals Charity None 01/02/2022 01/06/2016 25/11/2024 11/12/2025 N/A Date declared to Trust 21/10/2019 21/10/2019 21/10/2019 21/10/2019 Date Register presented to Board 28/11/2019 28/11/2019 28/11/2019 28/11/2019 21/10/2019 28/11/2019 27/07/2021 26/08/2021 11/11/2025 11/11/2025 Date ceased 18/09/2024 31/08/2021 31/12/2021 31/12/2023 31/03/2024 01/05/2024 11/11/2025 24/02/2026 11/11/2025 10/03/2026 22/05/2024 06/06/2024 22/05/2024 25/11/2024 N/A 21/10/2025 06/06/2024 14/05/2025 13/01/2026 11/11/2025
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/board-of-directors-register-of-interests.pdf

Building on award success at innovative lifelong health project based at UHS

Description: The pioneering LifeLab which is based at UHS has been recognised as a Centre of Excellence by the Royal Society for Public Health (RSPH) for its work in supporting young people to become ambassadors for healthy change in their own communities.
Url: /AboutTheTrust/Newsandpublications/Latestnews/2019/October/Building-on-award-success-at-innovative-healthy-living-project-based-at-UHS.aspx

Papers CoG 29.01.2026

Description: Date Time Location Chair Agenda Council of Governors 29/01/2026 14:00 - 15:30 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 28 October 2025 4 Matters Arising/Summary of Agreed Actions 14:05 There are no outstanding actions 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Non-Executive Director Appointment 14:26 Approve the appointment Sponsor: Jenni Douglas-Todd, Trust Chair 6.2 Chair and Non-Executive Director Appraisal Process 14:36 Approve the Chair and Non-Executive Director Appraisal Process Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Steve Harris, Chief People Officer 6.3 Governor Attendance at Council of Governors' Meetings 14:46 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.4 Review Governors' Nomination Committee Terms of Reference 14:51 Approve the proposed changes to the Governors' Nomination Committee Terms of Reference Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.5 Council of Governors’ Annual Business Plan 14:55 Approve the Annual Business Plan for 2026/27 Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.6 Review Audit and Risk Committee Terms of Reference 14:59 Following review by the Audit and Risk Committee no changes are proposed Sponsor: Keith Evans, Audit and Risk Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:04 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:14 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:19 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:24 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 22 April 2026 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 28 October 2025 14.00-15.40 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Tara Cavell, Elected, New Forest, Eastleigh and Test Valley Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Richard Green, Elected, Southampton City Martin Hall, Elected, New Forest, Eastleigh and Test Valley Simon Jacob, Elected, Nursing and Midwifery Staff Councillor Pam Kenny, Appointed, Southampton City Council Professor Sue Latter, Appointed, University of Southampton Jenny Lawrie, Elected, Southampton City Brian Lovell, Elected, Rest of England and Wales Councillor Louise Parker-Jones, Appointed, Hampshire County Council Cat Rushworth, Elected, Isle of Wight Karen Smith-Baker, Elected, Health Professional and Health Scientist Staff Stephanie Stinton, Elected, Southampton City Liz Taylor, Elected, Non-Clinical and Support Staff Mike Williams, Elected, New Forest, Eastleigh and Test Valley JDT SA TC PC LG BG RG MH SJ PK SL JL BL LPJ CR KSB SS LT MW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer (for item 7.1) SD David French, Chief Executive Officer (for item 5.1) DF Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Farhanah Miah, Associate Governor FM Karen Russell, Council of Governors’ Business Manager KR David Watts, Corporate Affairs DW Apologies Professor Cathy Barnes, Appointed, Solent University CB Sathish Harinarayanan, Elected, Medical Practitioners and Dental SH Staff 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting, particularly the new governors. She also congratulated the governors who had been re-elected for a second term. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 16 July 2025 were approved as an accurate record of the meeting. 1 4 Matters Arising/Summary of Agreed Actions It was noted that the two action items had been completed. No. 1277 - the Communications Team was under pressure in terms of resourcing and SD had taken on additional roles within the team. He had, however, agreed to attend future CoG meetings (either in person or via MS Teams) to give the Membership report and to answer any questions. No. 1278 - SD would update the CoG regarding the Gypsy, Roma and Traveller community, when we joined the meeting for item 7.1. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed DAF to the meeting to present his report. He told governors that he would outline where the Trust was, as an organisation and also talk about the wider NHS. He advised that the current intensity and pressure within the wider NHS had filtered down to Trusts very quickly. There were now two forms of league tables, one of which was in the public domain and looked at around twenty metrics regarding hospital performance. It included all acute hospitals (including those that specialised in only one area of medicine, e.g. cancer) and UHS had come 48th out of 134. He also advised that financial over-rides meant that UHS was below other organisations who had a worse gross score but were not in financial difficulty. Each week the Trust received league tables for Emergency Department (ED) four-hour performance and the percentage of patients waiting less than 18 weeks for treatment. During mid to late summer ED performance had been relatively strong but it had deteriorated in the last couple of weeks and the Trust was committed to making improvements. It was, however, in the top quartile for its 12hour performance. DAF advised that the level of demand on services at UHS was greater than its capacity to treat patients and did not match the funding it received. The Trust Board had therefore taken the decision that the hospital should reduce some of its activity so that it was better aligned to the money it received. Consequently, the waiting list for the treatment of some benign conditions had risen. There were still extensive recruitment controls in place and the Trust was aiming to only replace 7 out of 10 clinical staff. Innovative ways of working were being considered and DAF acknowledged that there were pockets of staff unhappiness around the organisation. In recent weeks there had been an increase in the level of violence and aggression towards staff. Flags were being seen in and around the hospital and DAF advised that there was a cohort of society who were prepared to say things that were inconsistent with the values of UHS. Whilst the Trust had a policy of zero tolerance, calling out such behaviour was often seen as a badge of honour. A member of the public had recently been banned from attending UHS, other than for “life and limb” need. It was the first time the hospital had taken such a decision, due to racist behaviour, and both the patient and his GP had been written to. In response to questions from governors, DAF said that these patients were not flagged across the wider NHS but he had raised the matter at a national level. 2 The Trust was empowering UHS staff to take action and the message around zero tolerance had been shared with the local community. The CoG was supportive of the action the Trust had taken and was keen to support the staff and Trust Board in strengthening its message around zero tolerance. DAF said that whilst the situation within the NHS was currently tricky, there were a number of things that gave him hope. The link between activity and money was being re-established and he thought that the financial architecture would improve during 2026. He noted that: • the UHS strategy document he had written 5 years ago was being refreshed to take into account a 10-year plan. • the Trust had been given funding for an urgent treatment centre at UHS. It would be in addition to the one at the Royal South Hants, separate to ED and would have its own staff. • the Trust and the University of Southampton had agreed to swap various buildings. It would enable the university to develop a flagship immunology centre at the hospital, while UHS developed the personalised medicine agenda on the university site at Chilworth. • the Trust was in negotiation with a private sector company regarding the potential provision of a five-theatre estate (from April 2026). PC said that Romsey residents had been dismayed that the phlebotomy service at Romsey hospital had been lost. DAF acknowledged that it had been a difficult decision and it was hoped that local GPs would carry out some of the work, while other residents used the service at UHS. 6 Governance 6.1 Governor Attendance at Council of Governors’ Meetings KR noted that if a governor failed to attend two successive meetings of the CoG, they would be contacted to ensure that their absences were due to reasonable cause and that they would soon be able to attend again. The Chair advised that a governor had been contacted, as they had missed two successive meetings. Their absences had, however, been for good reason. Decision: The CoG agreed that the correct process had been followed to confirm that the failure of a current governor to attend two successive meetings of the CoG had been due to reasonable causes and they would attend future meetings within a reasonable period. 6.2 Review of Council of Governors’ Expenses Reimbursement Protocol CM advised that he and KR had reviewed the Council of Governors’ Expenses Reimbursement Protocol. A few minor changes had been made and could be seen as tracked changes on the document circulated with the meeting papers. Decision: The CoG approved the proposed changes to the Council of Governors’ Expenses Reimbursement Protocol. 6.3 Appointment of Deputy Chair The Chair advised that the current deputy chair, Keith Evans, Non-Executive Director (NED), would come to the end of his second term of office on 31 January 3 2026. A new deputy chair therefore needed to be appointed and the process to enable that had taken place. The Chair recommended to the CoG that Jane Harwood, NED and Senior Independent Director (SID) be appointed to the role with effect from 1 October 2025. Decision: The CoG approved the appointment of Jane Harwood as Deputy Chair with effect from 1 October 2025. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement The Chair welcomed SD, Events and Membership Officer, to the meeting and he introduced himself to the governors. He highlighted the following from the Membership Engagement report: • the autumn edition of the quarterly digital magazine for members would go out shortly. • the Trust’s annual members meeting had been held on 8 October 2025 and several governors had attended. The feedback had been positive and those attending had appreciated the clear insight given into both the successes and challenges within UHS. Suggestions for improvements to future annual meetings had included allowing more time for Q&As and to enjoy the exhibitions. Also, that microphones would make hearing easier. • during the nomination stage for local CoG elections, postal members had been given the option to become email members or to continue as postal members. If they had not responded, they were removed from the membership database. Consequently, there had been a significant reduction in postal members, which had saved the Trust over £2,200 on printing and postage costs during the ballot stage for the CoG elections. • 39 new members had joined the Trust since the last CoG meeting in July 2025. SD thanked the governors who had helped to man the UHS stall at Southampton Pride in the summer, when attendees had been encouraged to become Trust members. With regard to the outstanding action item (1278) where it had been noted that there were currently no members from the Gypsy, Roma and Traveller (GRT) community, SD advised that he had spoken with other Trusts and they had all acknowledged that it was a challenging group to engage with. The following comments were made: • UHS had previously employed a GRT Liaison Lead but there was no longer funding for the post. • much of the work to engage with the GRT community was now being done by the local Integrated Care Board (ICB). • SD advised that reports were available on the work being done at a regional level and he was willing to introduce governors to the appropriate people. • not all GRT communities were mobile and data held by schools may be helpful. • SA suggested that governors needed to consider how they reached out to their constituents, including the GRT community. SD said that social media and attendance at local events was used but he acknowledged that other opportunities could be considered (e.g. the use of QR codes). 7.2 Governors’ Nomination Committee Feedback The Chair advised that: • the Trust had engaged Odgers Berndtson, an executive recruitment company, to help with the search for a new Audit and Risk Committee Chair, as Keith Evans, NED, was due to leave. The Governors’ Nomination Committee (GNC) 4 and others (e.g. UHS executives and NEDs) would be involved in the final interview of candidates. • Tim Peachey, NED and Chair of the Quality Committee, had agreed to extend his term of office for another 12 months, to September 2026. The process to recruit a replacement for him would begin in February/March 2026. • a replacement for Jane Harwood, NED, would also need to be found as her term of office would come to an end in September 2026. • if the Trust’s financial position improved next year, a decision may be made to replace the NED post previously held by Dave Bennett. The CoG would be kept up to date regarding developments. 8 Review of Meeting The following comments were made: • sound quality continued to be an issue. • the governors had appreciated DAF’s open, honest and transparent presentation, which had been easy to understand. They also commended him on his work to make the hospital a safe place for staff. The Chair agreed to pass on the feedback to him. • governors would have appreciated hearing more about the Trust’s Violence and Aggression policy. CM noted that it was currently being reviewed but could be an agenda item for a future CoG meeting. 9 Any Other Business • the Chair thanked JL who had been elected as Deputy Lead Governor and BL who had been appointed to the GNC. • PC encouraged governors to attend the carol service being held at Romsey Abbey on 1 December 2025. Money raised from tickets would go to the Southampton Hospital Charity. • CR advised that the campaign on the Isle of Wight to raise money to buy a minibus to transport its residents with cancer to appointments in Southampton, had been successful and a Daisy Ring Bus was now operational. Local volunteers were being sought to drive it. The Chair thanked governors for their attendance and said that she looked forward to seeing them at the Strategy Day in December. 10 Date of Next Meeting The next meeting of the CoG would be held on 29 January 2026. 5 Item 5.1 Report to the Council of Governors - 29 January 2026 Title: Chief Executive Officer’s Performance Report Sponsor: David French, Chief Executive Officer Author: Sam Dale, Associate Director of Data and Analytics Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information x Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future x x x Executive Summary: Information about Trust performance supports the Council of Governors in their role. This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Contents: The Chief Executive Officer’s Performance Report is attached. Risk(s): N/A Equality Impact Consideration: N/A UHS Council of Governors January 2026 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period September to November 2025, noting that some performance data is reported further in arrears and therefore unavailable. Notable features of the quarter include:• The Trust continues to face a highly challenging financial position, reporting a £41m deficit at Month 8, despite delivering £58m of savings, and has implemented a financial recovery plan to improve the run-rate. • Capital spending is on track, with over £55m to be invested this year, including £6m investment in the emergency department to establish an urgent treatment centre supporting improved patient flow. • Emergency care pressures persisted, with performance dipping in October but improving to 63.0% for four-hour performance in November supported by redesigned urgent care pathways. • The overall waiting list has stabilised across Q3, with focused work reaping benefits through the reduction of long waiting patients as we make progress towards zero 65-week waiters, one percent of patients waiting over 52 weeks and a much improved performance position by the end of the financial year. • Cancer performance remains strong for the 28-day faster diagnosis standard (81.3%), with ongoing efforts to increase capacity and maintain resilience against rising demand. • Safety indicators highlight two never events and a small number of PSIIs under formal review, alongside targeted improvements in infection control and IV cannula practice. • Friends and Family Test results remain positive overall, with 94% positive feedback, and new initiatives introduced such as QR codes at bedsides and a health inequalities dashboard. • Workforce data shows turnover stable at around 10%, sickness slightly above target, and the annual national staff survey in progress during the quarter. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection E. Coli Target 78.0% September 2025 67.6% October November 2025 2025 58.4% 63.01% October performance reflected a significantly challenging month within the emergency department due to attendance volumes and complexity of arrivals resulting in increased admissions. However, in November, 63.0% of patients spent less than four hours in the department reflecting an improvement of 4.6% and above our in year performance plan. The key focus area in November was the redesign of urgent care areas into a same day emergency care service for ambulatory and minors’ pathways. This is part of a series of planned pathway improvements designed to drive improvements towards the national target of 78% by March 2026. Referral to Treatment (RTT) Target % incomplete pathways within 18 weeks in month Total patients on a waiting list => 92% September 2025 61.0% 63,160 October 2025 60.9% 63,960 November 2025 60.7% 63,399 The organisation has been managing an increasing waiting list throughout the first six months of the year as referrals increased in key specialties and outsourced capacity was limited to drive financial stability. Waiting list performance has stabilised in quarter three and significant progress has now been made in reducing the volume of long waiting patients as we target zero patients over 65 weeks and the national target of 1% of the waiting list being above 52 weeks. Aligned with national ambitions, the Trust has increased its focus on pathway validation and patient communication to ensure pathways are well managed. Cancer Target Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment > =77% => 96% => 70% August 2025 80.5% 94.7% 75.9% September 2025 81.2% October 2025 81.3% 93.6% 94.3% 72.2% 73.5% The Trust has maintained strong performance for the 28 day faster diagnosis pathway element achieving 81.3% for the latest validated month (October 2025). Performance for the 31day metric Page 4 of 6 (94.3%) and 62 day metric (73.5%) are both marginally short of the national targets, but all services are committed to maximising capacity, appropriately managing referrals and optimising pathways to achieve the performance ambitions set at the start of the year. Challenges have emerged throughout the financial year, but services have maintained flexibility through insourcing and weekend working to ensure cancer patients are appropriately prioritised. In some areas this has been supported through funding from the Cancer Alliance. 5. Finance The financial environment remains extremely challenging for UHS as we approach the final quarter of the financial year. The Trust’s plan for 2025/26 targeted a financial breakeven position, which was predicated on the achievement of £110m of savings. This level of savings achievement represents 8% of turnover and would be a record for UHS if delivered. The financial architecture in 2025/26 has also meant a greater proportion of the Trust’s income is fixed (or capped) therefore savings are required to be achieved mainly via cost out schemes covering both pay and non pay. All areas were asked to explore workforce reductions (5% for clinical divisions and 10% for corporate areas) and a financial improvement group was established, chaired by the CEO, and supported by the CFO and Director of Financial Improvement, to help drive the pace of efficiency improvement in a mindful way. Despite significant progress with savings achievement (over £58m achieved as at the end of November), at M8 the Trust is reporting a deficit of £41m which is £24m behind plan. The Trust has faced a number of pressures, including: 1. The Trust continues to have significant operational pressures, with the level of demand on the hospital exceeding the level of activity funded by commissioners. 2. Non-criteria to reside numbers have increased to peaks of over 275 from an average of 215 in 2024/25. This is over 20% of the Trust’s bed base and has a significant cost in addition to clinical risks of patient deconditioning and infection. This remains a focus of the inpatient flow programme. 3. Mental health patient demand has grown from previous years with patients often requiring enhanced levels of support at a premium cost to the Trust. UHS continues to work with system providers on improvements for this patient group. 4. The Trust set an extremely challenging savings target, and it has proven challenging to deliver savings to the level and pace required. Due to scale of the variance to plan and deficit trajectory if the prevailing run rate continued, a financial recovery plan has been implemented, supported by the Trust board and other system partners. This targets further improvement over the remainder of 2025/26, which has generated favourable movements in the Trusts’ deficit run rate and will help provide a more sustainable footing for the future. There is however a significant risk to the delivery of the plan, with the Trust estimating unmitigated inyear risks of £55m. We are however striving to deliver further financial improvements. The deficit has put a strain on the cash position of the Trust, and we have therefore required additional cash support from NHS England, which has been received. Further to this the Trust remains on target to spend its full capital allocation for 2025/26 totalling over £55m, for which £29m is externally funded following successful grant/business case applications. This includes further investment in the emergency department of £6m to establish an urgent treatment centre supporting improved patient flow. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. Page 5 of 6 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q1 25/26 47.7% 6.39 Q2 25/26 53.2% 6.60 During quarter three, the national and annual staff survey is live and therefore open for responses to individuals within the organisation. Results from this will be subject to embargo and not openly available until March 2026. Quarterly pulse survey data will be available for next quarter’s reporting. Indicator Target Staff Turnover (internal target; rolling 12 month) Sickness absence 12-month rolling (internal target) <=13.6% <=3.9% September 2025 10.4% 3.8% October 2025 10.9% 4.4% November 2025 10.1% 4.1% Turnover: In November 2025, there was a total of 114.5 WTE leavers, 34.3 WTE more than October 2025 (80.2 WTE). Division C recorded the highest number of leavers (44.8 WTE). Within Division C, the Clinical Services staff group had the highest number of leavers (15.3 WTE). Divisions A and Trust HQ had the second and third highest number of leavers (28.5 and 24.6 WTE respectively); with the largest number of leavers for Division A being the Nursing and Midwifery Registered staff group (10.3 WTE), while in Trust HQ Admin & Clerical staff group accounted for 14.5 WTE leavers. Sickness: The current 12 month rolling sickness rate is 4.1% (as of November 2025), this is 0.2% above the 3.9% target. For November 2025, in-month sickness is at 4.2%, an increase on October 2025 (4.1%) and year-to-date sickness is 3.69%. Page 6 of 6 Item 6.1 Report to the Council of Governors - 29 January 2026 Title: Non-Executive Director Appointment Sponsor: Jenni Douglas-Todd, Trust Chair Author: Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information Y Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: The appointment and reappointment of non-executive directors (NEDs) is one of the statutory responsibilities of the Council of Governors (CoG) role following recommendation by the Governors’ Nomination Committee (GNC). Keith Evans (KE) will reach the end of his second term of office as a NED and Chair of the Audit and Risk Committee on 31 January 2026. There will therefore be a vacancy for an independent NED on the board of directors (Board). At its meeting on 28 October 2025, the CoG was advised that following consultation with the GNC, the Trust had engaged Odgers Berndtson, an executive recruitment company, to help with the search for a replacement for KE. The GNC has undertaken a recruitment and selection process for a new NED and Chair of the Audit and Risk Committee and has identified a suitable candidate for appointment by the CoG. Contents: The attached paper provides details of this process, and the candidate proposed for appointment. Risk(s): N/A Equality Impact Consideration: N/A Non-Executive Director Appointment Background The appointment and reappointment of non-executive directors (NEDs) is one of the statutory responsibilities of the Council of Governors (CoG) role following recommendation by the Governors’ Nomination Committee (GNC). Keith Evans (KE) will reach the end of his second term of office as a NED and Chair of the Audit and Risk Committee on 31 January 2026. There will therefore be a vacancy for an independent NED on the board of directors (Board). At its meeting on 28 October 2025, the CoG was advised that following consultation with the GNC, the Trust had engaged Odgers Berndtson, an executive recruitment company, to help with the search for a replacement for KE. The GNC has undertaken a recruitment and selection process for a new NED and Chair of the Audit and Risk Committee and has identified a suitable candidate for appointment by the CoG. When considering the appointment of a non-executive director, the GNC and the CoG should consider: • the composition of the current Board, including in terms of its skills, knowledge and diversity; • the individual’s other commitments and the time available for the role; and • independence. Recruitment Process External advertisement is a requirement for any full appointment to an NED role. The GNC considered proposals from three executive recruitment companies to identify a replacement NED and Chair of the Audit and Risk Committee and unanimously agreed to engage Odgers Berndtson. The selection process included the following: Longlisting meeting with members of the GNC Shortlisting meeting with members of the GNC Stakeholder panel with representation from the Board, and the Hampshire and Isle of Wight ICB Final interview panel with members of the GNC 13 November 2025 2 December 2025 8/9 December 2025 15 December 2025 Applications received were as follows: Applications longlisted 16 Applications shortlisted 6 Applications invited to stakeholder sessions 6 Applications invited to final interview 4 Recommendation Following completion of the selection process, one candidate, Steven Peacock, is recommended for appointment. His CV is attached as an appendix. Steven is an experienced finance leader with a career spanning senior executive and nonexecutive roles across PLCs, venture capital-backed businesses, charities and the NHS. He combines deep financial expertise with strategic leadership and governance experience and has worked in a range of complex environments. He has chaired audit committees for Dorset Healthcare and Royal Bournemouth and Christchurch Hospitals ensuring effective internal control, risk management and compliance with accounting standards and has experience of offering challenge and support to boards to strengthen governance in highly regulated environments. He has served as a NED for Dorset Healthcare since 2020 and previously for Royal Bournemouth and Christchurch Hospitals for eight years (where he also held the position of Vice Chair) working closely with executives and governors, providing oversight of finance, performance and quality during periods of significant operational and strategic change. This role will come to an end in March 2026 on completion of his second term of office. Steven’s executive career includes senior roles at Estée Lauder, WH Smith Travel and Homebase, where he delivered efficiency improvements and large-scale operational change. He has experience of balancing financial control with commercial acumen and has delivered multimillion-pound cost savings. He has championed equality, diversity and inclusion, serving as Executive Sponsor for the RNLI’s LGBTQ+ network and embedding inclusive practices into organisational culture. Steven has nearly 14 years of NHS non-executive experience, including roles as Audit Committee Chair for two organisations, Senior Independent Director and Vice Chair. He is keen to continue contributing to the NHS and sees this role as a chance to apply his financial and risk expertise to support a successful acute provider in a health system he knows. The recommended candidate will be subject to the ‘fit and proper’ persons checks and declaration processes applicable to directors prior to appointment and annual fit and proper persons checks and declaration processes thereafter. As recommended by the Governors’ Nomination Committee following its meeting on 20 January 2026, the Council of Governors is asked to approve that: • Steven Peacock is appointed as a non-executive director for a three-year term on the standard terms and conditions for non-executive director appointments, including the current annual fee of £14,000 as remuneration for the role. • A supplement of £2000 per annum is also payable for the additional role as Chair of the Audit and Risk Committee. The appointment will be subject to the proper completion of the ‘fit and proper’ persons checks and declarations processes referred to above. Steven Michael Peacock FCA Career Summary: An experienced Chartered Accountant with a proven track record in PLC, Venture Capital, Not for Profit and Charity Organisations both as an Executive and Non-Executive at main board level. I am comfortable in working in complex governance environments and have extensive experience in managing broad stakeholder groups including Trustees at Board level and formal committee settings. I am commercial, strategic and pragmatic in my approach, which coupled with my collaborative style and ability to generate and deliver change has led to portfolios and remits extending beyond finance – including commercial roles, oversight of IT, Procurement and being the SRO for a variety of organisational strategic programmes. As a Non-Executive Director (NED), I have nearly 14 years of experience in the NHS working as a Unitary Board member, and over this time I have experienced first-hand the risks and opportunities of the challenging environment faced by the NHS and the evolving healthcare ecosystem. I have held roles including Audit Committee Chair (for 2 organisations), Finance Committee member, Freedom to Speak Up Non-Exec lead, Senior Independent Director and Vice Chair. This gives me a clear insight into the needs and challenges of Executives and Non-Executives and how I can support, in either capacity. I am a keen advocate for Equality, Diversity and Inclusion and was proud to be the Executive Sponsor at the RNLI for the Harbour Network that supports the developing LGBTQ+ agenda. Current Employment: a. National Trust February 2025 – Current Chief Finance Officer • Accountable for all financial matters of the National Trust, covering England, Wales and Northern Ireland. • Role includes exec responsibility for IT, Procurement, Internal Audit, Risk Management, Pensions & Governance. • Focused on delivering org-wide restructuring to support, longer term strategic need & near term financial imperatives. b. Dorset Healthcare University Foundation Trust March 2020 – Current The Trust is responsible for all mental health services and many physical health services in Dorset, delivering both hospital and community-based care. Serving a population of nearly 800,000 people and employing around 6,000 staff across over 300 sites with a Turnover of c. £250M. My 2nd 3 year term will be coming to an end in the next 5 months Non Executive Director Audit Committee Chair (March 2020 – Current) Senior Independent Director (March 2020 – March 2023) Stepped down in line with NHS Guidance of Audit Chair conflicts. Further Employment History: c. RNLI February 2018 – February 2025 Chief Finance Officer • Accountable for all financial matters of the RNLI both domestically and internationally. • Developing an inclusive mindset to finance as an ‘enabler’, supporting the strategic ambition of the RNLI. Good financial governance is the responsibility of all colleagues in the RNLI. • June 2018 – responsibility broadened to include Strategic & Business Planning, Project Management Office (PMO) & Continuous Improvement (Lean) functions. • September 2020 – appointed Senior Responsible Officer (SRO) for the organisation wide Strategic Programme known as ‘Evolving Regionalisation’ which in summary seeks to: • Design & implement ‘empowerment within a framework’ to support decision-making nearest the point of need. • Engage the whole organisation in cross functional, collaborative working with a customer focused mindset – Making the life of the volunteer on the coast as easy as possible. • December 2023 – appointed lead for financial transformation programme – delivering initial diagnostic review and feasibility assessment aimed at delivering sustainable and strategic right-sizing. • April 2024 – appointed SRO for Finance ERP system implementation and payroll transition. Some key deliverables to date • Led the financial strategy of the RNLI through the Pandemic. • Performed a strategic finance review of the RNLI identifying the financial challenges that face the RNLI and a plan to support the long-term financial sustainability whilst delivering on its key strategic objectives. • This work supported me leading a major ‘right-sizing’ initiative across the RNLI. All delivered pre-pandemic. • A focus on developing the mindset of the organisation to become more financially aware ‘Living within our means’. • Reorganised the Finance function to reduce costs of the function by 15%, with increased accountability and improving decision support. d. Estee Lauder January 2012 – January 2018 Estee Lauder is a worldwide organisation with a turnover of c $9bn. Financial Services Group Director • For the UK Region (Turnover of c$1bn) and UK representative on the ‘Estee Lauder - Global Centre of Excellence for Finance’. • Finance lead on the strategy development for the UK across all of the Estee Lauder brands. • Leading a team to manage financial, trading and operational areas of the organisation. • Improved efficiency through automation and organisation that removed c.10% of costs– including areas such as financial accounting, payroll & accounts payable/receivable. • Improved profitability through areas like: o A focus on removing unnecessary head office and field cost – revised expenses policy (£3M saving pa), a focus on conference and related costs (£2M saving p.a.) – part of the historical working practices that were a challenge to overcome. o A focus on ‘in store’ costs – staff costs were the biggest P&L line outside of ‘Cost of Goods’ – required a dedicated specific project – see below • Improved balance sheet focus & cash-flow productivity (+£10M cash p.a.) through focus on areas including cashflow, stock management, fixed assets control management (new stores and refits as well as larger investment projects) • A focus on ‘if it was my money’ was a catalyst in the change of behaviour that was required in the delivery of the above. • Finance lead on acquisitions integration into core business in the UK. • Previous experience as Finance Director for the ‘On-line’ Business –focus on delivering an on line vs off line focus Programme Director – Selling Effectiveness September 2014 • In addition to my financial responsibilities, I was also appointed the Programme Director for a major multi-million pound investment in the UK. This work stream provided a key deliverable in the Estee Strategic Vision. • A global leading strategic initiative that scoped how Estee Lauder would deliver exceptional customer service in stores whilst delivering a focus on customer and staff engagement, brand loyalty, sales and profitability. • The programme had a remit including the re-development & automation of ‘in-store’ processes including the implementation of a Workforce Management System and the development of improved Omni Channel capabilities in the UK. e. Royal Bournemouth & Christchurch Hospitals Foundation Trust Sept 2009 – Sept 2017 An Acute Hospital in Bournemouth supporting a local population of 550,000. Re-appointed in 2013 and 2016. In September 2017 completed my maximum allowed 8 year tenure as a Non-Exec with an NHS Trust. Non Executive Director & Vice Chairman Appointed Vice Chairman in September 2015. Held positions as Chair of the Audit Committee & Member of the Finance, Remuneration & Charity Committees Trustee of the Royal Bournemouth Hospital Charity. • Challenge and support the Board in strategic direction and operational delivery. • To ensure an effective system of internal control, risk management and corporate governance is in place. • To ensure that financial statements comply with accounting policies and practices. • To challenge and support the transition to a focus on Performance, Quality and Value for Money in a very challenging environment. • Trust now recognised as one of the High Performing Trusts in the UK. f. WH Smiths (Travel) PLC: June 2010 – Dec 2011 Travel had a T/O c£450m with outlets in predominantly travel locations eg Airports, Rail Stations but also Hospitals. Interim Finance Director • Focus of my interim role was to: • Shape the long-term financial strategy for Travel. • Improve the credibility of the finance function. • To reshape the team into a decision support function. g. Homebase Limited: July 99 – Nov 08 UK's 2nd largest home improvement retailer. T/O c£1.6bn from 300 out-of-town stores throughout the UK & Ireland Trading Director – Showroom (Sept 05 – Nov 08) • Promoted into a Commercial role heading up the key strategic growth categories nationally. • Full operational trading ownership and strategic development of the ‘Showroom’ – which includes Kitchens, Bathrooms, Furniture, Conservatories and Fireside. • Responsible for customer order fulfilment (Home Delivery) and customer service management (Call Centre). • Full P&L management and budgeting responsibility for £300m annual turnover with all the associated costs of sale including Home Delivery and Customer Service (call centre) infrastructure. • Responsible for the leadership and development of a team of 50 core personnel and c.100 within the call centre and warehouse functions. • Delivered double digit LFL growth in the showroom areas, • Lead a programme to deliver a ‘test before invest’ programme for implementing new ranges of kitchens & bathrooms in store showrooms saving millions from the cost of poor store implementations, • Set up a national kitchen installation service as a key part of the kitchen service offering. • Lead the set-up of a new warehouse to support the bathrooms business as we changed to a direct sourcing model from the Far East and Eastern Europe delivering significant cost reduction (5% improvement in GP%) from sourcing directly. Head of Commercial Finance (July 99 – Sept 05) • Overall financial responsibility for Buying, Stock Merchandising, Distribution and Marketing for Homebase • I led this function through the challenges of changing corporate ownership from PLC (Sainsbury’s) to VC (Permira) to PLC (GUS – subsequently Home Retail Group). This involved the finance function evolving its approach to support the significant changes in emphasis and priorities as a result of changes in ownership. • I developed the role of the team to a respected commercial function where involvement is actively sought in decision making, from a team historically suppressed to cost control only. Employment History Summary: Company: Arthur Andersen Position Held: Insolvency Specialist Period: October 1990 – October 1995 I worked within Corporate Recovery on a wide range of Insolvencies and Bank Investigations across many different sectors - ranging from large organisations such as The Maxwell Group and Leyland DAF to a Holiday Park on the Isle of Wight. My role involved taking control of the business and assets, quickly assessing the best route to realise value for the lender and lead the negotiations for the onward sale of business and assets. Company: Kingfisher Group (Superdrug) Position Held: Business Analyst – Marketing/Pricing Period: November 1995 – November 1996 Responsible for the reporting and recommendation on ROI for National Marketing and Promotional activity. Also devised and implemented a national competitor price monitoring system to improve business performance. Company: Fosters Brewing Group, Australia Position Held: New Business/Acquisitions Analyst Period: December 1996 – October 1997 Commercial manager focusing on ‘New Business’ opportunities. (1) New Concepts within the existing portfolio of ‘Tied’ Public Houses and (2) the Acquisition of new companies to expand the portfolio – including an AU$300m acquisition. Returning from Australia: October 1997 – December 1997 Travelled around Australia and South East Asia Company: United Biscuits (McVities/KP) Position Held: Commercial and Finance Manager – Vending Division Period: December 1997 – July 1999 New Business Development Manager for ‘Workplace Vending’, tasked with converting the initially complex proposition into a business plan. Achieved Board approval to Regional Test and subsequently took the venture through to national roll-out. Education: Arthur Andersen Higher Education Secondary School Chartered Accountant – Qualified 1994 1st Class Honours – Economics 12 ‘0’ Levels, 3 ‘A’ Levels Other Interests: I am a keen cyclist, runner and sailor to balance out my love of good food! Now our children are less dependent my wife and I are rekindling our enjoyment of long walks and exploration with our dog, Salty. Item 6.2 Report to the Council of Governors - 29 January 2026 Title: Chair and Non-Executive Director Appraisal Process 2025/26 Sponsor: Jenni Douglas-Todd, Trust Chair Author: Steve Harris, Chief People Officer and Karen Russell, Council of Governors’ Business Manager Purpose (type an ‘x’ in the appropriate box(es)) (Re)Assurance Approval Ratification Information Y Strategic Theme (type an ‘x’ in the appropriate box(es)) Outstanding patient Pioneering research World class people outcomes, safety and innovation and experience Integrated networks and collaboration Foundations for the future N/A N/A N/A N/A N/A Executive Summary: The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The appraisal process supports the board of directors (Board) in ensuring its overall effectiveness by making sure that any individual or collective development needs are identified and that the chair and non-executive directors continue to have capacity to meet the time commitment required for the role. The outcome of appraisal will also be relevant to any decision by the CoG to reappoint a non-executive director. NHS England (NHSE) also requires all trusts to undertake a robust board appraisal process. This year UHS will be using the new revised NHSE appraisal process guidance that was published in 2025. Following recommendation by the GNC at its meeting on 20 January 2026, the CoG is asked to approve the Chair and NED appraisal process for 2025/26. Contents: The attached paper sets out the proposed appraisal process for 2025/26. Risk(s): N/A Equality Impact Consideration: N/A Chair and Non-Executive Director (NED) Appraisal Process for 2025/26 1. Introduction and purpose 1.1 The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors (NEDs). The Governors’ Nomination Committee (GNC) advises the CoG on that process. The results of the appraisals are shared with the GNC and the CoG. 1.2 The Trust aims to complete the process by 30 April this year. 1.3 The new NHS England (NHSE) Fit and Proper Person Framework for boards was introduced with effect from 30 September 2023, followed by the new board member appraisal guidance on 1 April 2025. This guidance outlines NHSE’s expectations and recommendations in the completion of board member appraisals. It has been developed in service of board effectiveness and to ensure a consistent and standard approach to appraisal. UHS had completed its appraisal processes prior the implementation of the new guidance last year and therefore this is our first year of using the revised process. 1.4 This paper sets out the proposed process and timescales for the Chair and NED appraisals for 2025/26. 2. Overview of the process 2.1 The Chair of the Trust has responsibility for undertaking the appraisals for NEDs. The Chair’s appraisal process is conducted by the Senior Independent Director (SID). 2.2 Jenni Douglas-Todd, as Trust Chair, will undertake the NED appraisals. Jane Harwood, in her role as SID, will undertake the Chair’s appraisal. 2.3 The process will aim to: • Provide a structured review of performance against personal and organisational objectives set, and the performance of the Trust. • Support the process through seeking multi source feedback from other board members and governors. • Reflect on the NHSE leadership competency framework for board members. • Reflect on the demonstration of the Trust values. • Review attendance at key Trust meetings. • Plan for the future, including objective setting for the next year and the identification of a personal development plan. • Provide a performance rating in line with NHS guidelines. • Provide overall reporting and assurance to the GNC and CoG. 2.4 Feedback forms based on the new NHSE appraisal guidance will be provided to governors for completion. The Trust’s NED appraisal process is in line with guidance published by NHS England (NHSE). 2.5 The Trust will review NEDs against our existing Trust values. The values set out in the NHS framework map with the Trust’s own values and therefore this is deemed a reasonable approach within the framework. 3. NHSE Framework for Chair’s appraisal 3.1 NHSE have a national framework for appraisals of Chairs of provider organisations which was refreshed in 2024. This requests that Trusts ensure a robust multi-source feedback process is conducted. In the refreshed process this is now to be undertaken with consideration given to the NHSE new leadership framework. 3.2 A summary of the Chair’s a
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-29.01.2026.pdf

Annual-report-2017-18

Description: ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2018 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Statement from the chairman and chief executive 7 Statement of purpose and activities 8 History of UHS 8 Structure of executive team 9 Structure of our services 10 Our vision and values 11 Priorities, key issues and risks 12 Going concern disclosure 15 Performance report 15 Regulatory body ratings 22 Environmental matters 23 Social, community and human rights issues 24 Accountability report Directors’ report – the Trust Board 26 Well-led framework 32 Audit and risk committee 32 Disclosures 35 Council of Governors 43 Annual remuneration statement 52 Remuneration and appointments committee 55 Governors’ nomination committee 57 Staffing report 61 Responding to the staff annual attitude survey 66 Statement of chief executive’s responsibilities as the accounting officer 71 Annual governance statement 72 Review of economy, efficiency and effectiveness of the use of resources 79 Equality, diversity and inclusion 83 Environmental sustainability and climate change 85 Southampton Hospital Charity 89 Developments in informatics 90 Leading research into better care 90 Investing for the future 91 Quality account and report Chief executive’s welcome 139 Our approach to quality assurance 141 Our commitment to safety 142 Our commitment to staff 143 Our commitment to education and training 145 Our commitment to technology to support quality 146 Our commitment to the Care Quality Commission 147 Review of quality performance 149 Progress against 2017/18 priorities 157 Clinical research 149 Review of services 150 CQUIN payment framework 150 Data quality 151 Clinical audits and confidential enquiries 152 Seven day hospital services 153 Learning from deaths 154 Priorities for improvement 2018/19 175 Conclusion 191 Responses to our quality account 192 Statement of directors’ responsibilities 198 Independent auditor’s report 199 Appendix Appendix one Quality improvement framework 2018/19 203 Appendix two Quality performance data 204 Appendix three CQUIN data 211 Appendix four Clinical audit and confidential enquiries data 214 Appendix five Registration with the Care Quality Commission 216 Appendix six Glossary of acronyms 217 Annual accounts Statement from the chief financial officer 93 Foreward to the accounts 94 Independent auditor’s report 95 Financial statements 101 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT A word from the chairman and chief executive Staff at UHS achieved some amazing things in 2017/18, a year in which the Trust faced the huge challenge of continuing to deal with rapidly rising demand for our services at a time when, like many hospitals, we were already under great pressure. Perhaps the most obvious achievement was that the Care Quality Commission (CQC) rated UHS as good for the quality of care which it provides overall and outstanding for leadership. It is no coincidence that the results from our latest NHS staff survey were so positive. We were particularly pleased that our response rate had increased and that UHS staff rated us the fourth best nationally for staff recommending the hospital as a place to work or receive care. We are also the seventh best nationally for staff engagement and results show that our staff feel able to contribute fully towards improvements. However, it’s truly in times of adversity, such as that we experienced over the winter period, that you see teamwork and commitment shine through. On several occasions we supported our neighbouring hospitals by providing care to their patients. We were also immensely proud of the way our staff pulled together during the days of thick snow with many staying on site overnight to ensure we had enough staff to care for our patients. Others stayed to look after stranded patients who were unable to get home. Staff with 4x4 vehicles collected colleagues for work and drove patients home. It was a monumental and incredibly uplifting effort from all. Our staff have indeed continued to strive tirelessly to provide both the quality of care and the speed of access to treatment to which we aspire. We are confident that we have done the former but the rapid increase in patient numbers has at times made it difficult to achieve the latter. We are determined to improve our performance to achieve the standards our patients expect. We are encouraged by the terrific results we achieve in the NHS Friends and Family test, with patients overwhelmingly recommending UHS as a place to have their hospital care. As the result of achieving our financial target for 2016/17 we became eligible for additional national cash incentive payments, which meant that in 2017/18 we were able to commit to the biggest capital investment programme the Trust has ever seen. As part of this programme we were able to address some of the areas of our estate that were highlighted as requiring improvement in a previous CQC report. We are delighted to say that we have again delivered our financial target for 2017/18 and will as a result be able to sustain a high rate of investment in upgrading our hospitals. We have also recently been able to start work on a £5m project to build a new Children’s Emergency Department as the result of generous support from the public for Southampton Hospital Charity and our partnership with the Murray Parish Trust without which the project would have been impossible. It will transform the environment in which our young patients are treated. Sadly at the end of the year we waved goodbye to Fiona Dalton, our chief executive for the last four years, who took the opportunity of a lifetime to live and work in Vancouver where she will lead a major Canadian healthcare group. Fiona was a remarkable chief executive, both immensely liked and admired throughout UHS and she left with the goodwill and best wishes of everyone. Peter Hollins David French Chairman Interim chief executive officer 7 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,454 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 2017/18 was more than £810m. 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)). 8 OVERVIEW AND PERFORMANCE REPORT The way we’re structured Structure of the executive team Associate director of corporate affairs Amanda Lowe Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive (interim) David French Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer (interim) Paul Goddard Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security; communications Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 9 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our services are split into five divisions and within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 10 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 11 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 12 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 13 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2018/19. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 14 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 30. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 72. 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. 15 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly Integrated KPI Board Report on its website which provides both the Board and the public with an overview of performance within the Trust. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2017/18 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Executive digest – update on the previous month’s performance written by the director of transformation and improvement. • Trust overview – the top KPIs identified by Trust Board, RAG-rates for the previous 13 months • Safe • Effective • Caring • Activity • Emergency department (ED) • Referral to treatment (RTT/18 weeks) • Cancer waiting times • Flow • Staffing (HR) • Education and training • Research and development • Estates This report also includes summary versions of quarterly reports submitted to TEC which go into greater detail about patient experience, patient safety, clinical effectiveness and outcomes, and infection prevention. In addition, a separate Finance Board Report is submitted to Trust Board on a monthly basis. The emergency department, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 16 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 2017/18 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 now has a model hospital steering group which identifies potential improvement projects from the data and reports to transformation board. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2015/16 to 2017/18 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases Outpatient appointments 2015/16 2016/17 2017/18 ED attendances (type one) Referrals Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals 2015/16 146,066 562,972 95,217 191,888 2016/17 155,780 596,621 99,493 204,840 2017/18 154,224 624,083 102,547 208,872 Increase 15/16 to 17/18 5.6% 10.9% 7.7% 8.9% 17 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven and in 2017/18 this increased again to twenty. The chart below shows red and black alerts logged during 2017/18. 50 Number of AM and PM alerts 40 30 20 10 0 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Red alerts Black alerts Contributing to this change has been an increase in length of stay (LoS) for elective patients linked to a more complex case mix and an increase in day cases. The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2017/18. UHS delayed transfers of care 2017/18 Percentage of bed days lost 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 Mar 2017 April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 18 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS met the target in quarter one of 2017/18 but did not meet the target for the rest of the year. Achievement of this target in 2017/18 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. We have identified a reporting issue at our satellite outpatient clinics in Salisbury and are investigating the impact on referral to treatment reporting. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and, in August 2017 we also took over the operation of Lymington Minor Injuries Unit and opened the Urgent Care Hub at Southampton General in October 2017. All three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard remains at 95% but a national recovery trajectory was agreed as: Patients should be treated and either admitted or discharged within four hours of arrival 85% achievement target set for April 17 90% achievement target in or before September 2017 95% achievement target by March 2018. How did we do? December 2017 was an extremely challenging month for emergency patients for the whole Hampshire and Isle of Wight area. UHS saw an increase in patients admitted to the Trust with influenza and, alongside our own bed pressures, we took ambulance diverts from other hospitals in order to maintain patient safety across Hampshire. Our Trust received formal letters of thanks from local commissioners and providers for the part we played during this difficult period. 19 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year. National 4 hour access target – UHS performance 100% 95% 89.4% 90% 85% 80% 87.4% 86.7% 91.4% 89.5% 93.3% 91.9% 90.5% 87.1% 83.2% 82.1% 82.5% 75% April 2017 May 2017 June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Cancer waiting times There are ten separate cancer waiting times measures (below) that the Trust reports to the Department of Health on a monthly basis, each of which can then be split into tumour site specific performance groups. In 2017/18 the Trust met six of these measures. Number Measures Achieved 1 a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive 8 treatment for all cancers 2 a maximum 31-day wait for subsequent treatment where the treatment is surgery 8 3 a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 3 4 a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen 3 5 a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive 8 treatment for all cancers 6 a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment 3 for cancer 7 a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the 3 priority of the patient (all cancers) 8 a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms 3 9 a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, 8 even if cancer is not initially suspected 10 A maximum 31-day wait (urgent GP referral to treatment) for first treatment for rarer cancers 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 5.2% in 2017/18. The chart overleaf shows the rise in demand for UHS cancer services over the past three years. 20 OVERVIEW AND PERFORMANCE REPORT UHS growth in cancer actvity – 2015/16 to 2017/18 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 62 day target patients 2015/16 2016/17 2017/18 31 day target patients For staffing performance, please refer to page 61. For financial performance please see page 93. David French Interim chief executive officer 24 May 2018 21 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2017/18 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2018. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 2 1 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Good Outstanding Requires improvement Outstanding 22 OVERVIEW AND PERFORMANCE REPORT The CQC inspected all key questions in four of the eight core services of surgery, critical care, end of life care and outpatient and diagnostic imaging and noted the Trust had a stable leadership team in place since their last inspection. The previous inspection in 2015 had found safety of medicine and maternity services, along with responsiveness of urgent and emergency care and children’s services ‘required improvement’. At the 2017 inspection the following observation was made: ‘At this inspection we saw significant improvement across the areas we inspected. There were improvements in surgery, critical care, end of life care and outpatients. Critical care is rated overall as ‘Outstanding’, with surgery, end of life care, and outpatients and diagnostic imaging as ‘Good’ overall. These services had been rated requires improvement in 2015. The improvements were in line with the trust’s improvement plan and had been assisted by the trust board and executive leadership team’ Professor Sir Mike Richards Chief Inspector of Hospitals Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 85 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 23 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 24 FR STAND BODY ACCOUNTABILITY REPORT Directors’ report – the Trust Board Board member Name Title Fiona Dalton Chief executive (until March 2018) David French Interim chief executive (chief financial officer until March 2018) Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Fiona was appointed as chief executive in 2013. Prior to re-joining the Trust she held the combined position of deputy chief executive and chief operating officer at Great Ormond Street Hospital for Children. Fiona joined the NHS management training scheme after graduating from Oxford University with a degree in human sciences and began her career in hospital management at Oxford Radcliffe Hospitals NHS Trust in 1996. She then spent four years at UHS as director of strategy and business development before moving to Great Ormond Street Hospital. NHS representative on Office for the Strategic Co-ordination of Health Research (OSCHR) Board; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT. David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a wholly-owned subsidiary of UHSFT; Member of Solent Acute Alliance Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Trustee of Naomi House Children’s Hospice (until 10 February Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father is mental health act manager, Southern Foundation Trust (voluntary position) (until 31 August 2017), member of assessment committee for Clinical Excellence Awards South and Public Health England (lay member) (until January 2018), a UHSFT simulated patient (voluntary position); Mother is a UHSFT simulated patient (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Daughter-in-law employed at UHSFT as medical support to department of innovation (from January 2017 – December 2017) Daughter is in an administration role at UHS (from July 2017) 26 ACCOUNTABILITY REPORT Board member Name Title Biography Declarations Paul Goddard Interim chief financial officer (from April 2018) Paul joined the Trust in June 2007 as assistant director of finance and become the deputy director in December 2012. Paul has spent over 25 years in NHS finance having worked in many different organisations. A fellow of the Association of Chartered Certified Accountants, Paul became interim chief financial officer at UHS from April 2018. Serves as a director of the Trust’s wholly owned subsidiary company, UHS Pharmacy Limited. Sits on the Southampton Hospital Charity committee. Non-executive directors Peter Hollins Simon Porter Chair Senior independent director and deputy chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a nonexecutive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Partner in the Jubilee Film Partnership; Chair of CLIC Sargent Cancer Care for Children (a company limited by guarantee); Council member of University of Southampton Simon was born and educated in Southampton and then Oxford, graduating with a degree in modern languages (Italian and French). He is a qualified chartered accountant, having spent most of his career with the London office of Ernst & Young, where he specialised first in audit, then in transactions and finally risk management. He was a partner with Ernst & Young from 1994 to 2010. He joined the Trust Board on 1 January 2011 as a designate non-executive director and became non-executive director from 1 June 2011. He is chair of the audit and risk committee and a member of the strategy and finance committee. He also holds non-executive board positions in the social housing sector. Former partner in Ernst & Young LLP; Non-executive director and chair of audit committee, Radian Group; Non-executive director and chair of audit committee, Octavia Housing Dr Mike Sadler Non-executive director Mike joined UHS as a clinical non-executive director in September 2014, from a similar position at an NHS foundation trust providing mental health, learning disability and community services. He has chaired our quality committee since June 2016. He works as an advisor and consultant on health and social care services, recently advising on health reform in the Middle East, and in Ireland. He has been chair and technical adviser to the Diabetes Professional Care Conference since 2015, and also worked for the CQC as a specialist adviser in primary care. External clinical associate for PricewaterhouseCoopers; Member of the Advisory Board for xim (from 1 May) Mike graduated from Nottingham University, and was a GP principal in Hampshire before moving into public health medicine. Having achieved an MSc with distinction at the London School of Hygiene and Tropical Medicine, he joined Portsmouth and South East Hampshire Health Authority, holding the joint posts of deputy director of public health and medical adviser. He has since held a series of senior clinical leadership roles in national organisations in both the public and private sector, including as a chief operating officer at NHS Direct and Serco’s health division. His last full time role, up until July 2013 when he commenced his portfolio career, was as director of health and social care at West Sussex County Council. 27 ACCOUNTABILITY REPORT Board member Name Title Jenni Non-executive Douglas- director Todd Biography
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2017-181.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2021 University Hospital Southampton NHS Foundation Trust Table of contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 29 Directors’ report 30 Remuneration report 53 Staff report 65 NHS Foundation Trust Code of Governance 81 NHS Oversight Framework 81 Annual governance statement 84 Quality report 95 Statement on quality from the chief executive 96 Priorities for improvement and statements of assurance from the board 99 Other information 153 Annual accounts 180 Statement from the chief financial officer 181 Auditor’s report 182 Foreword to the accounts 188 Statement of Comprehensive Income 189 Statement of Financial Position 190 Statement of Changes in Taxpayers’ Equity 191 Statement of Cash Flows 192 Notes to the accounts 193 5 Welcome from our chair and chief executive 2020/21 was undoubtedly the most challenging year in the history of the NHS, and we have felt the impact of the COVID-19 pandemic here at University Hospital Southampton NHS Foundation Trust (UHS) in full. Responding to this has meant there isn’t a single part of our organisation that hasn’t changed in some way over the last year and we have all had to adapt to a rapidly changing environment. Our staff have been unwavering in their dedication, hard work and commitment to keeping our hospitals running, our patients cared for, and their colleagues supported. Every single member of the UHS family has played their part. The loss of life from COVID-19 has been devastating, and at UHS we stand shoulder-to-shoulder with everyone affected by this tragedy, including the families of staff members whom we lost. We must recognise the incredible work of Southampton Hospital Charity, which has funded boost boxes, wellness rooms, a helpline and so much more to support staff at a time when their wellbeing is more important than ever. As the nationwide vaccination programme continues to offer hope of life more like pre-pandemic times, we are proud to have been at the forefront of these efforts - from being part of early research for the Oxford-AstraZeneca vaccine, to the opening of one of the largest vaccination hubs in the region on our site in December 2020. We will continue to play a key role in vaccination development by leading the world’s first clinical trial into the effectiveness of COVID-19 booster vaccines, as well as taking part in a study involving pregnant people. Our response to COVID-19 has prompted innovation and new ways of working across the Trust, to the benefit of patient experience. At the start of the pandemic we faced real challenges of capacity and increases in waiting times, which led to us working with Spire Southampton so cancer treatment and surgery could continue for patients at highest risk. We also increased the number of outpatient attendances which took place by telephone or video call, and our patient support hub was set up to provide a single point of support for patients who had been advised to shield. We are immensely proud of the record of the Trust during the pandemic, exemplified by the number of patients we were able to take into our care from well outside the local area. The Trust is in a strong financial position as a result of careful spending and efficiencies, which has allowed us to invest significantly in upgrading our estate. These improvements have seen the opening of the general intensive care unit, and the new cancer ward, which was built in just six months. These formed part of overall capital expenditure of £80 million during the year. The last year has seen us say goodbye to two members of our executive leadership team. Paula Head left the chief executive officer role in November to join the national response to COVID-19, before becoming a senior fellow at The King’s Fund. Derek Sandeman moved on from being our chief medical officer to take the same position at the Hampshire and Isle of Wight Integrated Care System. We are grateful to both for their efforts on the Trust leadership team during the most challenging of years. One of our non-executive directors, Jenni Douglas-Todd, also left the Trust to take on the important role of director of equality and inclusion with NHS England and NHS Improvement. 6 Looking ahead to the future, UHS will play a key role in the Hampshire and Isle of Wight Integrated Care System. Our commitment is to deliver services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries for seamless patient care. We as a Trust board are looking forward to implementing our own five year strategy, which sets out ambitions for what we want the hospital to be in 2025, for both patients and staff. Our focus will always be on enabling world class people to deliver world class care. Peter Hollins David French Chair Chief Executive Officer 7 OVERVIEW AND PERFORMANCE Performance report Introduction from our chief executive Over the last year, the way in which the Trust has worked and performance it has achieved, has been transformed by the COVID-19 pandemic. • UHS saw a number of large surges in demand for inpatient care, and for intensive respiratory support in particular, due to COVID-19 infection rates. Our capacity to deliver intensive care had to be increased, and many of our staff moved from other services such as our elective theatres in order to meet this need for care. • We have introduced and continue to maintain a number of changes to reduce the risk of COVID-19 being transmitted, or adversely affecting patient outcomes, within the Trust. Changes have included the wearing of additional personal protective equipment by our staff (especially when caring for patients who might have COVID-19 or undertaking higher risk procedures), reducing the number of patients coming to our outpatient departments and increasing the number of telephone and video consultations, separating elective and emergency patients within our departments and regular testing of our staff and all patients on or prior to their admission to hospital for treatment. • Public concerns about safety, government restrictions and the efforts of community services actually contributed to reductions in the total number of patients who sought hospital care this year. • Treatment plans have been modified by a number of services, in partnership with patients, to reduce the risk posed by COVID-19 to those patients. This was often appropriate in those circumstances in which the normal treatment would significantly reduce the patient’s own resistance to infections. Our performance has, in many cases, been strongly influenced by these profound changes. We have responded well to the need to provide the most urgent care, and the adverse impacts on elective care have been slightly less than the average across the NHS. However, we remain very concerned by the significant increase in the numbers of patients waiting longer than they should for elective care. It will take concerted and sustained action within both the Trust and the wider NHS in order to return elective performance to levels achieved before the pandemic whilst also continuing to meet urgent care needs as the restrictions that have been implemented within our society are progressively relaxed. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2020/21. It is based on the coast in south east England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health Research (NIHR), Wellcome Trust and Cancer Research UK. UHS is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and in the top ten nationally for research study volume as ranked by the NIHR Clinical Research Network. 12,000 Every year over staff at UHS: treat around 160,000 inpatients and day patients, including about 75,000 emergency admissions see over 650,000 people at outpatient appointments deal with around 150,000 cases in our emergency department deliver more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it offers a safe, ‘home away from home’ environment for women having a healthy pregnancy and expecting a straightforward birth. The services provided by the Trust are commissioned and paid for by local clinical commissioning groups (CCGs) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Over 50% of UHS services are paid for by CCGs and approximately 48% by NHS England. We provide these under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by Monitor (the independent regulator, now part of NHS England and NHS Improvement) and the healthcare services we provide are regulated by the Care Quality Commission. Being a foundation trust has enabled greater local accountability and greater financial freedom and has supported the delivery of the Trust’s mission and strategy over a number of years. The diagram below provides an overview of the overall organisational structure of the Trust. Public and foundation trust members Council of Governors Board of Directors Executive Directors Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Division B Division C Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Division D Trust Headquarters Division Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Corporate Affairs Communications Estates, Facilities and Capital Development Finance Human Resources Informatics Patient Support Services Procurement and Supply Transformation and Improvement (‘Always Improving’) Research and Development Strategy and Business Development 11 The Trust is also part of an integrated care system in Hampshire and the Isle of Wight, which is a partnership of NHS and local government organisations working together to improve the health and wellbeing of the population across Hampshire and the Isle of Wight. Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/2021 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to continue on its journey to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these describes a number ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care. Pioneering research • We will recruit and enable people to deliver pioneering research and innovation in Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the tax payer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust will set out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2020/21 these objectives included: • Recovery, restoration and improvement of clinical services • Implementing the ‘Always Improving’ strategy • Restoring a full research portfolio • Continuing our focus on staff wellbeing including the long-term effects of coronavirus (long COVID) • Working in partnership with the newly established integrated care system • Creating a sustainable financial infrastructure • Making our corporate infrastructure (digital, estate) fit for the future to support a leading university teaching hospital in the 21st century, including an estates masterplan. Performance against these objectives will be monitored and reported to the Trust’s board of directors on a quarterly basis. Principal risks to our strategy and objectives The board of directors has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2020/21 were that: • it would be unable to form effective partnerships that achieve networked care for patients; • it could not develop the estate in line with the ambitions set out in the strategy; • it would fail to restore and increase capacity following the COVID-19 pandemic to meet waiting times for elective care and cancer care needs; • it would fail to introduce and implement new technology for the transformation of care; • it would be unable to retain, recruit, develop and train a diverse and inclusive workforce necessary to meet the strategic goals; • it could not develop a sustainable model within the new financial regime that preserves quality care; • it would fail to provide vulnerable service users with timely and high quality and appropriate care; • it would not reach the ambition of outstanding compliance and quality standards; • it could not sufficiently engage with key stakeholders and system partners to support effective interventions and maintain the health of the local population; • it would be unable to respond to the needs of the NHS in order to deliver our strategy; • it would fail to capitalise on its relationship with the universities in Southampton and other health education providers in line with our strategy; • it would not develop innovative education and training approaches. 14 While the COVID-19 pandemic presented the Trust with new risks as it introduced more stringent infection control processes, stopped certain types of activity and responded quickly to care for large numbers of seriously ill patients who had tested positive for COVID-19, it also prompted innovation across a wide range of areas. However the ongoing impact of the pandemic on both our staff, patients who have had COVID-19 and patients who have waited longer than expected for treatment as a result, added to the risks facing the Trust. National targets for performance have not been amended as a result of the pandemic, although the national plan has focussed on the recovery of activity levels as the first stage in a restoration of elective services. Capacity – The initial and subsequent waves of the COVID-19 pandemic have led to increases in the waiting times for patients and the number of patients waiting more than 52 and 78 weeks has increased significantly. While the Trust was able to recover capacity quickly between waves of the pandemic, its ability to reduce the overall waiting list and the length of time patients are waiting for treatment remains one of the key risks for the Trust. This may be compounded by the reduction in the number of referrals from GPs during the pandemic, leading to a potential future increase in the number of patients being referred as people visit their GPs for the first time with more advanced disease. During the pandemic the Trust utilised the support available from the independent sector to continue cancer treatment and surgery for those patients at highest risk. It also increased the number of outpatient attendances which took place by telephone or video call. The Trust developed a clinical assurance framework during the year to better assess the risk of harm to patients as a result of delays in treatment and this has been utilised in decision-making around the allocation of resources to those areas where there is the greatest risk of potential harm to patients. In addition to opening additional capacity during 2020/21 (described in the Estates section below), the Trust also committed expenditure and commenced construction works in 2020/21 in order to be in a position to open an additional endoscopy room and four further operating theatres during 2021/22 and prepared plans for a significant expansion in ophthalmology outpatient capacity. These initiatives will contribute to improvements in elective waiting times that needed following the pandemic. Quality and compliance – The Trust continued to monitor the quality of care delivered throughout 2020/21. During the COVID-19 pandemic the primary focus became infection prevention and control, with the launch of a successful COVID ZERO campaign that saw the Trust reduce the transmission of the virus in hospital (nosocomial transmission). The Trust also achieved its annual target for reduction in Clostridium Difficile infections, however, there was one MRSA Bacteraemia during March 2021, the only such event in 2020/21. The Trust continued to develop its proactive patient safety culture during 2020/21 with changes to the way in which patient safety incidents are investigated and the approval of its Always Improving strategy, which will be launched in 2021. Reporting and investigation of incidents continued during 2020/21. Partnerships – During 2020/21, the Trust and its partners worked together very effectively to discharge patients safely and provide ongoing support to patients who had tested positive for COVID-19, to ensure patients requiring urgent cancer treatment and surgery were able to continue their treatment in the independent sector and to develop a COVID-19 saliva testing pilot with the University of Southampton and local authorities. Work to respond to the COVID-19 pandemic, however, meant that as a system we were unable to progress the Hampshire and Isle of Wight strategic plan delivery at the pace we would have wanted or had set out to achieve, particularly the development of networks. Nonetheless the application for Hampshire and Isle of Wight to become an integrated care system was approved with effect from 1 April 2021. 15 Existing networks continued to develop and improve. The Trust also became the Wessex Cancer Surgical Hub during 2020 as a result of a national initiative with the aim of maximising the number of patients receiving curative surgery. Both the Wessex Cancer Alliance and the Trust ended the year as the second highest performing among their respective peers for cancer treatment. Workforce – While additional staff were recruited to specifically assist the Trust during the pandemic, the Trust continued to recruit nurses from overseas during 2020/21 meaning that the number of vacancies has reduced compared to the position prior to the pandemic. Changes to recruitment processes were approved in 2020/21 to improve the fairness, transparency and quality of these. The Trust also continued to work with its staff networks and specific focus groups to increase diversity in leadership roles. While workforce capacity continues to be one of the biggest challenges faced by the Trust, during 2020/21 our main focus has been on supporting our staff to respond to the COVID-19 pandemic and providing both the tools and time to help staff recovery. We are incredibly proud of the way that staff responded to the pandemic and continue to recognise this in whatever ways we can, however, we also want to ensure that staff continue to be able to contribute to patient care at their best and want to stay and develop with the Trust. Technology was also used at levels not previously achieved to continue to deliver training to staff and enable staff to work from home where possible, ensuring a safer environment for patients and staff in the hospitals. Estate – The Trust continued to invest in and develop its estate during 2020/21 including the opening a new general intensive care unit (GICU), a new operating theatre and a new cancer care ward, built in just six months. These were part of £80 million of capital expenditure in 2020/21. The Trust has also established a programme to reduce backlog maintenance in addition to continuing to add to and improve the environment in which services are provided to patients and the working environment for staff. Innovation and technology – There have been exceptional levels of achievement in relation to COVID-19 related research activity, including in partnership with the universities. You can read more about these from page 167 of the quality report. The board of directors also supported the funding of an expansion of research and innovation activity to allow the continued delivery of the Trust’s ambitions to innovate and improve and transform its services. Sustainable financial model – The Trust achieved its forecast breakeven position in 2020/21. Income was more predictable in 2020/21 as block contract arrangements were put in place in response to the COVID-19 pandemic and ensured that costs were covered. The Trust continues to maintain a strong cash position and to implement improvements and efficiency savings, allowing it to continue to invest in its services. 16 Summary of performance COVID-19 bed occupancy UHS has experienced two distinct peaks in inpatient care for patients with COVID-19 infection, with smaller numbers of patients continuing to receive care outside these peak times. Bed occupancy reached a maximum of 173 in the first peak in April 2020, and 322 in the second peak in January 2021. All bed types Intensive care/higher care beds 17 Emergency access through our emergency and eye casualty departments Public concerns about safety, government restrictions on the activities people were able to do, and the efforts of community services contributed to significant reductions in the total number of patients who presented to our departments. All patients presenting to the emergency department Many changes were introduced within our departments in the course of the year to ensure that emergency assessment and treatment could be provided safely, including wearing of protective equipment by staff and patients, providing care in separate areas for patients suspected or known to have COVID-19, and using rapid laboratory tests to identify infection and confirm/exclude COVID-19 as a cause. Emergency access performance (measured as the percentage of patients discharged from emergency department care or admitted to a hospital bed within four hours of arrival to the department) improved significantly in 2020/21 compared to previous years. The national target of 95% was not achieved, however, the performance of our departments compared favourably with the average for acute trusts in England. 18 Emergency access four hour performance 19 Elective Waiting times Demand We saw a significant reduction in the number of elective referrals to hospital in the early part 2020/21, though they had returned close to pre-pandemic levels by the end of the year. It is likely that this pattern relates to a range of factors including reluctance from members of the public to attend healthcare facilities at that time, changes to the ways in which primary care was accessed, and efforts made within primary and community to avoid hospital referrals needing to be made. Accepted referrals The number of patients referred to hospital with suspected cancer also reduced during 2020/21; 7% fewer patients were seen across the year as a whole, though referrals returned to pre-pandemic levels or higher from July 2020 onwards. Patients seen following ‘Two week wait’ urgent referral for suspected cancer 20 Activity UHS hospital appointments, diagnostic tests and elective admissions were all significantly reduced during 2020/21 due to the impact of COVID-19. • During periods of higher bed occupancy with COVID-19 it was necessary to significantly reduce the number of elective admissions undertaken in order that additional staff could work in intensive care. Less clinically urgent and therefore longer waiting patients were primarily those affected. • Throughout the year, additional infection prevention measures have reduced the number of patients that can be seen in each session, particularly when higher risk ‘aerosol generating’ procedures are planned, but also as a result of additional PPE being worn or to enable greater distancing of patients attending outpatient departments. UHS was offered additional capacity at local independent sector hospitals and used this effectively to minimise these adverse impacts. Approximately 30% of outpatient appointments are now undertaken by telephone or video, helping to maintain the capacity for patient care whilst reducing the infection risk for those patients and helping to maintain distancing measures for those patients still attending our outpatient departments. The graphs below show 2020/21 activity levels as a percentage of those achieved in the previous year. Elective admissions (including daycase) 21 Outpatient attendances Performance The average waiting time for first outpatient appointments has remained close to nine weeks for the majority of the year. UHS has however experienced very significant deteriorations in the waiting times our patients experience for diagnostic tests to be undertaken and elective treatment to be provided. The reduced number of new patients referred to hospital early in 2020/21 has moderated the extent of the growth in the total numbers of patients waiting, and the greatest rate of growth has unfortunately been amongst those groups of patients already waiting longest. 22 Diagnostics Our performance measures for diagnostics report on a total of 15 different frequently used tests. The waiting list is approximately 50% bigger than it was before the pandemic and stable through the second half of the year. At the end of the year 28% of patients were waiting more than six weeks to receive their investigation compared to the national target of 1%. The tests with the largest numbers of longer waiting patients include non-obstetric ultrasound, MRI and endoscopies, and further recovery will be driven through a combination of recruitment, independent sector capacity and an additional endoscopy room which opened at the start of April 2021. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) Percentage of patients waiting over 6 weeks for a diagnostic test to be performed 23 Referral to Treatment Our waiting list from referral to treatment increased in size by 6% (2,220 patients) during 2020/21, rising when the recovery in referral numbers exceeded the recovery in clinical activity, the total increase in waiting list size would have been significantly higher had it not been for the significant reduction in the referrals received by the hospital especially during the early months of the pandemic. Looking forward, we anticipate referrals numbers returning to pre-pandemic levels, and being able to maintain the total size of our waiting list by delivering an equivalent number of treatments each month. Number of patients waiting between referral and commencement of a treatment for their condition The national target is that at least 92% of patients should be waiting for treatment no more than 18 weeks from their referral to hospital. Our performance against this measure is now 12% worse than one year ago, at 66%. Our performance continues to be typical of the major teaching hospital trusts that we benchmark with and the trend has been similar to that experienced across trusts in England. Percentage of patients waiting up to 18 weeks between referral and treatment 24 Unfortunately, the number of patients waiting significantly longer than the 18 week target has increased at a faster rate than the size of the waiting list as a whole. The graph below shows how the percentage of patients who have waited more 52 weeks increased. The number of patients who have waited more 52 weeks increased from 40 in March 2020 to 3,419 by March 2021 (of these 445 patients had waited more than 78 weeks). Such patients often require surgical treatment, particularly in the orthopaedic, ear nose and throat and oral surgery specialities. The impact on surgical care has been greater than that in outpatients during the pandemic, and it is also more challenging to increase capacity due to the need for additional operating theatres and a combination of different healthcare professionals to work within them. UHS opened an additional operating theatre in 2020/21, and has a further four theatres scheduled to open during 2021/22, which will make a significant contribution to our capacity to treat more patients. Unfortunately, the number of patients waiting significantly longer than the 18 week target is likely to continue to grow further in the short term, due to diagnostic investigations having been progressed less quickly than usual during the pandemic, the need to prioritise our increased treatment capacity according to the clinical urgency of conditions and because our scheduled capacity increases will not be completed before the autumn of 2021. Percentage of patients waiting more than 52 weeks, between referral and commencement of a treatment for their condition 25 Cancer Waiting Times UHS has been mostly successful in maintaining the timeliness of urgent services for patients with suspected cancer through the pandemic, and our performance has been amongst the best in both the south-east and nationally. UHS prioritised the theatre and intensive care capacity we were able to provide during the pandemic in order to meet the needs of those patients with the greatest clinical urgency, used capacity offered by independent sector hospitals to supplement that available within NHS, and operated a hub through which hospitals in Wessex were able to collaborate to continue critical cancer surgery during periods of peak COVID-19 demand. The national target is to provide the first definitive treatment to at least 85% of patients with cancer with 62 days of referral to hospital. Whilst UHS performance remained below this level in the majority of months, our performance has been significantly better than the national average, and has improved relative to other trusts. Treatment for Cancer within 62 days of an urgent GP referral to hospital 26 The national target is to provide the first definitive treatment to at least 96% of patients within 31 days of a decision to treat being made and agreed with the patients; both for the first and any subsequent treatments for cancer. UHS achieved this level on average across the year, and in the majority of months. The treatments provided are typically by means of surgery, chemotherapy/immunotherapy or radiotherapy. The most significant performance challenge this year has been in radiotherapy, where more sophisticated treatment plans improve patient outcomes but take longer to prepare, and there was also reduced treatment capacity whilst we replaced one of our ‘Linear Accelerator’ treatment machines with a new model. First definitive treatment for cancer within 31 days of a decision to treat Equality in service delivery Identifying and addressing health inequalities have been the central part of the Trust’s approach to improving the experience of care for our patients, families and carers. Over the past year, new initiatives have augmented progress on existing work to ensure there is appropriate support, due regard and recognition of those patients and their families and carers who are most at risk of poor experiences, outcomes and access to services. In 2020 we added two questions to our patient surveys, asking first if patients felt themselves to have a disability or require a reasonable adjustment, and, if yes, whether the Trust met this need. In 2020/21, the results were: TOTAL Had a disability / required a reasonable adjustment 27% Had this need met by the Trust (positive response) 95% This question was added to our major Friends and Family Test surveys as well as our local service-specific patient surveys. In June 2020 the Trust launched the sunflower lanyard scheme for hidden disabilities, participating in the national initiative to ensure that people whose disabilities are not visible are able to access further support and reasonable adjustments by means of a nationally recognised indicator (the sunflower). In 2020/21, 618 lanyards were issued with those needs recorded to ensure future reasonable adjustments are made for those individuals. 27 Carers have always been essential partners in the care that we provide, and having introduced a new post at the end of 2019 to focus solely on carer experience, this work has culminated in a Trust strategy for improving the involvement, support and experience carers have of our services. We have, over the past year, introduced carers cards, virtual peer support and carer-specific information about services while actively participating in local and regional work on carers. In January 2021 we realised our ambition of becoming an accredited ‘Veterans Aware’ hospital, with our submission of evidence being recognised as ‘strong’ and indicative of an organisation that has made great progress in helping to provide enhanced support for the armed forces community. Towards the end of 2019 we worked with the disability organisation AccessAble to produce accessibility guides for all of our services and estate. These online guides allow patients and visitors with disabilities to plan their journey and identify potential challenges to the environment. In 2020/21 our guides had 5,000 unique visits per month. One of our COVID-19 initiatives, a patient support hub, was set up in May 2020 to provide a single point of support for our patients who had been advised to shield. The service has grown and now offers support to patients and carers who are vulnerable, disabled or with additional needs. This includes coordinating community transport, arranging companions to assist with attending appointments, hosting a technology library to support those who are digitally excluded in accessing virtual appointments and information, and most recently receiving funding to pilot volunteer-led support for diabetes patients. Across the Trust, we continue to actively promote the importance of asking patients and carers about disabilities and reasonable adjustments, flagging needs on our patient administrative system to prompt our services to take proactive steps to ensure that any needs or adjustments are met on each and every visit. This has been of vital importance for meeting accessible information and communication needs. We are currently one of first trusts to pilot a new translation app that provides immediate interpretation into different languages, and we have worked closely with our communication support partners to ensure that where virtual appointments are needed, people with communication needs (BSL, foreign language) are supported to access care virtually. Our specialist nursing liaison teams continued to support access to services throughout the pandemic, ensuring that patients with dementia, with learning disabilities and autism, were supported to attend hospital where necessary. Further information about the Trust’s work in relation to equality, diversity and inclusion can be found on page 69 and pages 106 and 160 in the quality report. Going concern After making enquiries, the directors have a reasonable expectation that the services provided by the Trust will continue to be provided by the public sector for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual. David French Chief Executive Officer 28 June 2021 28 Accountability report Directors’ report Board of directors The board of directors is usually made up of six executive directors and seven non-executive directors, including the chair. Since 1 January 2021 the number of non-executive directors has been reduced by one as Jane Bailey’s reappointment as a non-executive director was deferred to allow her to lead the Hampshire and Isle of Wight saliva mass testing programme. Jane is expected to return to the board of directors in her non-executive director role by 1 July 2021. Paragraph B.1.2 of the NHS foundation trust code of governance provides that at least half the board of directors, excluding the chair, should comprise non-executive directors determined by the board to be independent. Pending the reappointment of Jane Bailey as a non-executive director, the Trust has been operating with one fewer non-executive directors than is required by the Trust’s constitution and the Trust has been non-compliant with this paragraph of the code. During this period the provisions of the Trust’s constitution that a quorum for meetings of the board of directors requires at least one non-executive director and one executive director to be present and for the chair to have a second and casting vote in the case of an equal vote continued to apply. The board of directors has given careful consideration to the range of skills and experience it requires to run the Trust. Together the members of the board of directors bring a wide range of skills and experience to the Trust, such that the Board achieves balance and completeness at the highest level. The chair was determined to be independent on his appointment and the other non-executive directors have been determined to be independent in both character and judgement. This included specific consideration of Jane Bailey’s continued independence following her role leading the Hampshire and Isle of Wight saliva mass testing programme. The chair, executive directors and non-executive directors have declared any business interests that they have. Each director has declared their interests at public meetings of the board of directors. The register of interests is available on the Trust’s website. 30 The current members of the board of directors are: Non-executive directors Peter Hollins Chair Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, in 1992 he was appointed as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, before returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non-executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non-executive director in 2010, became senior independent director and deputy chairman of UHS in 2014 and was appointed chair in April 2016. Trust roles: • Chair of remuneration and appointment committee • Chair of governors’ nomination committee Jane Bailey Non-executive director In 1985, Jane joined the pharmaceutical company Glaxo as a management trainee, having graduated from London University with a degree in environmental science and pharmacology. Here she rose to senior commercial vice-president, gaining experience of a broad range of disease areas across different regions of the world. She specialised in leading global research and development teams in the formation of strategies to bring new medicines to patients. She also worked to ensure that the medicines developed were supported by robust evidence demonstrating their clinical and cost-effectiveness. In delivering this she gained extensive experience of leading large diverse teams across a complex global organisation. For five years, Jane ran her own strategy development consultancy, working across a breadth of healthcare organisations. In 2017 Jane gained an MSc in public health, with distinction, at King’s College, London University. Her studies focused on how to ensure the public are engaged in development of healthcare services and how social theories can help inform effective disease prevention and management. Jane is a director of Wessex NHS Procurement Limited, a joint venture between the Trust and Hampshire Hospitals NHS Foundation Trust and a director of Healthwatch Portsmouth. Trust roles: • Deputy chair and senior independent director • Chair of finance and investment committee • Audit and risk committee member • Charitable funds committee member • People and organisational development committee member • Remuneration and appointment committee member • Wellbeing Guardian 31 Non-executive directors Dave Bennett Non-executive director Dave graduated in chemistry from the University of Southampton before entering management consulting, becoming a partner in Accenture’s strategy practice. In 2003 he joined Exel Logistics (later acquired by DHL), managing the company’s healthcare business across Europe and the Middle East. During this time, he established NHS Supply Chain, a UK organisation responsible for procuring and delivering medical consumables for the NHS in England, as well as sourcing capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016, where he chaired the Trust’s quality committee. Dave is a non-executive director at the Faculty of Leadership and Medical Management and a director of Royal College of General Practitioners (RCGP) Enterprises Ltd and RCGP Conferences Ltd. Trust roles: • Chair of charitable funds committee • Chair of finance and investment committee (from 1 January 2021) • Audit and risk committee member (from 9 February 2021) • Quality committee member • Remuneration and appointment committee member • Chair of Trust’s organ donation committee 32 Non-executive directors Cyrus Cooper Non-executive director Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He is also vice-dean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. He is president of the International Osteoporosis Foundation, chair of the BHF Project Grants Committee, an emeritus NIHR senior investigator, a director of The Rank Prize Funds and associate editor of Osteoporosis International. He has previously served as chairman of the Scientific Advisors Committee (International Osteoporosis Foundation), the MRC Population Health Sciences Research Network and the National Osteoporosis Society of Great Britain. He has also been president of the Bone Research Society of Great Britain and has worked on numerous Department of Health, European Community and World Health Organisation committees and working groups. Cyrus has published extensively on osteoporosis and rheumatic disorders and pioneered clinical studies on the developmental origins of peak bone mass. In 2015, he was awarded an OBE for services to medical research. Trust roles: • Quality committee member • Remunerati
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Annual report 2021-2022

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

Description: Chemotherapy Protocol COLORECTAL CANCER CETUXIMAB-ENCORAFENIB Regimen • Colorectal Cancer – Cetuximab-Encorafenib Indication • Cetuximab and encorafenib can be used where; - the patient has a histologically proven colorectal adenocarcinoma that has been shown to contain a BRAF V600E mutation as well as having been shown to be of RAS wild type - the patient has failed one or two prior regimens for advanced/metastatic disease. Note: if the patient progressed through adjuvant chemotherapy or within 6 months of completing adjuvant chemotherapy, the patient can be classed as having received one line of treatment for metastatic disease. - the patient has not received prior treatment with any BRAF inhibitor or MEK inhibitor unless this was received for this specific indication via interim COVID19 funding - the patient has not received prior treatment with cetuximab or panitumumab or any other EGFR inhibitors unless this was received for this specific indication via interim COVID19 funding for this combination. - that the patient has no active brain metastases or leptomeningeal metastases - that encorafenib with cetuximab is to be continued until disease progression or unacceptable toxicity or patient choice to stop treatment, whichever is the sooner. - that a formal medical review as to how the combination of encorafenib plus cetuximab is being tolerated and whether treatment with the combination of encorafenib plus cetuximab should continue or not will be scheduled to occur at least by the end of the first 8 weeks of treatment. - WHO performance status 0, 1 Toxicity Drug Cetuximab Encorafenib Adverse Effect Infusion related reactions, interstitial lung disease, skin reactions, electrolyte abnormalities, fatigue, abdominal pain, constipation Gastro-intestinal disturbances, fatigue, pyrexia, arthralgia, myalgia, haemorrhage, hypertension QTc prolongation, uveitis, haemorrhage, cutaneous reactions, palmar-plantar syndrome, cardiac dysfunction The adverse effects listed are not exhaustive. Please refer to the relevant Summary of Product Characteristics for full details. Version 1 (July 2021) Page 1 of 9 Colorectal – Cetuximab-Encorafenib Monitoring Drugs • Prior to starting therapy confirm a positive BRAF V600E and RAS wild type • FBC, LFT’s and U&E’s prior to day one of each cycle • LFT and U&Es on day 15 of the cycle Dose Modifications In principle all dose reductions due to adverse drug reactions should not be reescalated in subsequent cycles without consultant approval. It is also a general rule for SACT that if a third dose reduction is necessary treatment should be stopped. The management of adverse reactions may require dose reduction, temporary interruption or treatment discontinuation of encorafenib. If encorafenib is permanently discontinued, cetuximab should be discontinued and vice versa. Please discuss all dose reductions / delays with the relevant consultant before prescribing, if appropriate. The approach may be different depending on the clinical circumstances. The following is a general guide only. Haematological Prior to prescribing on day one of cycle one the following criteria must be met; Criteria Neutrophil Platelets Eligible Level equal to or more than 1.5x109/L equal to or more than 100x109/L Consider blood transfusion if patient symptomatic of anaemia or has a haemoglobin of less than 8g/dL Neither cetuximab nor encorafenib are myelosuppressive and no dose reduction is needed for haematological toxicity. Treatment should be delayed for 7 days if the neutrophil count is equal to or less than 0.9x109/L or the platelets are equal to or less than 75x109/L. Hepatic / Renal Impairment Drug Cetuximab Encorafenib Hepatic Administer only when the transaminases are 5xULN or below and the bilirubin is 1.5xULN or below Reduce dose of encorafenib to 300mg in Renal Administer only where the serum creatinine is 1.5xULN or below There is no data for encorafenib in severe renal Version 1 (July 2021) Page 2 of 9 Colorectal – Cetuximab-Encorafenib patients with mild hepatic impairment, encorafenib impairment (Child-Pugh should be used with caution Class A). Encorafenib is in these patients not recommended in patients with severe hepatic impairment (ChildPugh Class C) Encorafenib can cause liver abnormalities. Doses should be adjusted as follows; NCI-CTC Grade 2 3 (first occurence) 3 (recurrence) 4 (first occurrence) 4 (recurrence) Action Encorafenib should be maintained. If no improvement within 4 weeks, encorafenib should be withheld until improved to grade 0 or 1 or to pretreatment/baseline levels and then resumed at the same dose. Encorafenib should be withheld for up to 4 weeks. If improved to grade 0 or 1 or to baseline levels, it should be resumed at a reduced dose. If not improved, encorafenib should be permanently discontinued Consider discontinuing encorafenib Encorafenib should be withheld for up to 4 weeks. If improved to grade 0 or 1 or to baseline levels, then it should be resumed at a reduced dose level. If not improved, encorafenib should be permanently discontinued or encorafenib should be permanently discontinued. Discontinue Other If the cetuximab is permanently discontinued the encorafenib should also be discontinued and vice versa. Dose Level 1st dose reduction 2nd dose reduction Encorafenib 225mg once a day 150mg once a day Cetuximab 400mg/m2 300mg/m2 Cetuximab Allergy Allergic or hypersensitivity reactions have occurred during the administration of cetuximab. For a NCI-CTC grade 1 reaction reduce the infusion rate by 50% (the total should not exceed 240 minutes). For a NCI-CTC grade 2 reaction, stop the infusion and administer supportive therapies as indicated. Once the reaction has resolved to NCI-CTC grade 1 or below resume the infusion at 50% of the previous rate. For a NCI-CTC grade 3 or 4 toxicity stop the infusion immediately and disconnect the tubing from the patient. Administer appropriate supportive therapies. Once recovered, patients should not receive cetuximab again. Once the rate has been reduced it should not be increased on subsequent infusions. Version 1 (July 2021) Page 3 of 9 Colorectal – Cetuximab-Encorafenib If a second reaction occurs on the slower infusion rate the infusion should be stopped and no further treatment given. Eye Patients presenting with signs and symptoms suggestive of keratitis such as acute or worsening: eye inflammation, lacrimation, light sensitivity, blurred vision, eye pain and/or red eye should be referred promptly to an ophthalmology specialist. If a diagnosis of ulcerative keratitis is confirmed, treatment with cetuximab should be interrupted or discontinued. If keratitis is diagnosed, the benefits and risks of continuing treatment should be carefully considered. Electrolyte Disturbances Progressively decreasing serum magnesium levels occur frequently and may lead to severe hypomagnesaemia. Hypomagnesaemia is reversible following discontinuation of cetuximab. In addition, hypokalaemia may develop as a consequence of diarrhoea. Hypocalcaemia may also occur; in particular in combination with platinumbased chemotherapy the frequency of severe hypocalcaemia may be increased. Serum electrolytes abnormalities, including low magnesium and potassium need to be corrected to reduce risk of QT prolongation Skin An acniform skin rash occurs in over 70% of those receiving cetuximab. The onset is normally within three weeks of starting therapy and often resolves after week twelve. For a NCI-CTC grade 1-2 reaction use symptomatic treatments such as topical or oral antibiotics and continue with the cetuximab. For a NCI-CTC grade 3 toxicity delay treatment until the toxicity resolves to NCI-CTC grade 2 or below. If this occurs within fourteen days resume cetuximab at the same dose. If more than fourteen days is required stop treatment. If the NCI-CTC grade 3 toxicity occurs for a second and third time the cetuximab may again be delayed for up to and including fourteen days with concomitant dose reductions. Cetuximab dose reductions are permanent. The cetuximab must be discontinued if more than two consecutive infusions are withheld or a fourth episode of a NCI-CTC grade 3 skin toxicity develops or a NCI-CTC grade 4 toxicity at any time. UV radiation may worsen skin reactions. Sun safety practices should be followed during and for up to two months after the end of treatment. Lung Stop treatment if there is a confirmed pneumonitis. Encorafenib Eye Uveitis including iritis and iridocyclitis can occur. Patients should be assessed at each visit for symptoms of new or worsening visual disturbance, including; Version 1 (July 2021) Page 4 of 9 Colorectal – Cetuximab-Encorafenib diminished central vision, blurred vision or loss of vision. If any of these symptoms are identified, a prompt ophthalmologic examination is recommended. If NCI-CTC grade 1 or 2 uveitis does not respond to specific (e.g. topical) ocular therapy or for grade 3 uveitis, encorafenib should be withheld and ophthalmic monitoring should be repeated within 2 weeks. If uveitis is grade 1 and it improves to grade 0, then treatment should be resumed at the same dose. If uveitis is grade 2 or 3 and it improves to Grade 0 or 1, then treatment should be resumed at a reduced dose. If not improved within 6 weeks, ophthalmic monitoring should be repeated and encorafenib should be permanently discontinued. Encorafenib should also be permanently discontinued for a NCI-CTC grade 4 uveitis and a follow up with ophthalmologic monitoring should be performed Heart QT Prolongation has been observed in patients treated with BRAF-inhibitors. Recommended that serum electrolytes abnormalities, including magnesium and potassium, are corrected and risk factors for QT prolongation controlled (e.g. congestive heart failure, bradyarrhythmias) before treatment initiation and during treatment. For QTcF greater than 500ms and change less than or equal to 60ms from pretreatment value encorafenib should be withheld. Encorafenib should be resumed at a reduced dose when QTcF less than or equal to 500ms. Encorafenib should be discontinued if more than one recurrence. Haemorrhage Haemorrhagic events were observed in 21% of patients treated with encorafenib. Monitor haemoglobin and for epistaxis and blood in stool or urine. Skin Cutaneous malignancies such as cutaneous squamous cell carcinoma (cuSCC) (including kerathoacanthoma) and new primary melanoma has been observed in patients treated with BRAF inhibitors including encorafenib. Patients should be instructed to immediately inform their physicians if new skin lesions develop. For new primary cutaneous malignancies then no dose modifications are required for encorafenib. For new primary non-cutaneous RAS mutation-positive malignancies consider discontinuing encorafenib permanently. For NCI-CTC grade 2 cutaneous reactions encorafenib treatment should be maintained. If rash worsens or does not improve within 2 weeks with treatment, encorafenib (and binimetinib) should be withheld until NCI-CTC Grade 0 or 1 and then resumed at the same dose. Version 1 (July 2021) Page 5 of 9 Colorectal – Cetuximab-Encorafenib For NCI-CTC grade 3 cutaneous reactions encorafenib should be withheld until improved to NCI-CTC grade 0 or 1 and resumed at the same dose if first occurrence, or resumed at a reduced dose if recurrent NCI-CTC grade 3. For NCI-CTC grade 4 cutaneous reactions encorafenib should be permanently discontinued. For NCI-CTC grade 2 palmar-plantar erythrodysaesthesia syndrome (PPES) encorafenib should be maintained and supportive measures such as topical therapy should be instituted. If not improved despite supportive therapy within 2 weeks, encorafenib should be withheld until improved to NCI-CTC grade 0 or 1 and treatment should be resumed at same dose level or at a reduced dose. For NCI-CTC grade 3 PPES encorafenib should be withheld, supportive measures such as topical therapy should be instituted. Encorafenib should be resumed at same dose level or at a reduced dose level when improved to NCI-CTC grade 0 or 1. Regimen 28 day cycle until intolerance or disease progression develops (6 cycles will be set in Aria) Drug Cetuximab Encorafenib Dose 500mg/m2 300mg Days 1, 15 1-28 incl Route Intravenous infusion over 120 minutes (see administration below) Oral Dose Information • Cetuximab will be dose banded in accordance with the national dose bands (5mg/ml) • Encorafenib is available as 50mg and 75mg capsules Administration Information Extravasation • Cetuximab - neutral Other • Individuals should be monitored for hypersensitivity for sixty minutes after finishing the cetuximab infusion. Do not administer other chemotherapy during this period. • The rate of administration of cetuximab must not exceed 10mg/min. The first infusion is given over 120 minutes. If this infusion rate is well tolerated subsequent infusions may be given over 60 minutes Version 1 (July 2021) Page 6 of 9 Colorectal – Cetuximab-Encorafenib Additional Therapy • 30 minutes prior to cetuximab infusion; - chlorphenamine 10mg intravenous - dexamethasone 8mg oral or intravenous - H2 antagonist according to local formulary choice and availability - paracetamol 1000mg oral • Antiemetics As take home medication - metoclopramide 10mg three times a day when required oral (supply day one cycle one only and then as required) • Prophylaxis with doxycycline 100mg once a day for 28 days • Gastric protection with a proton pump inhibitor or a H2 antagonist may be considered in patients considered at high risk of GI ulceration or bleed References 1. Version 1 (July 2021) Page 7 of 9 Colorectal – Cetuximab-Encorafenib REGIMEN SUMMARY Cetuximab-Encorafenib Day 1, 15 1. Chlorphenamine 10mg intravenous 2. Dexamethasone 8mg oral or intravenous 3. Paracetamol 1000mg oral Administration Instructions Please check if the patient has taken paracetamol. The maximum dose is 4000mg in every 24 hours 4. H2 antagonist according to local formulary choice and availability Administration Instructions: Administer according to local formulary choice and availability one of the following 30 minutes prior to chemotherapy; - Ranitidine 50mg intravenous once only - Famotidine 20mg oral once only - Nizatidine 150mg oral once only - Ranitidine 150mg oral once only If there is no stock of these products due to national shortages treatment may proceed without the H2 antagonist provided there is no instruction in the ARIA journal indication the patient must have H2 antagonist treatment. All infusion related reactions must be recorded in the ARIA journal and reported to the appropriate consultant. Many Trusts do not administer an H2 antagonist from cycle three onwards. They have been left in the ARIA protocols so that decisions can be made on an individual Trust and patient basis. 5. Cetuximab 500mg/m2 over 120 minutes intravenous infusion Administration Instructions The rate of administration of cetuximab must not exceed 10mg/min. The first infusion is given over 120 minutes. If this infusion rate is well tolerated subsequent infusions may be given over 60 minutes Take Home Medicines (day 1 only) 6. Encorafenib 300mg once a day for 28 days oral Administration Instructions Oral SACT 7. Metoclopramide 10mg three times a day when required for the relief of nausea oral* Administration Instructions Please supply 28 tablets or the nearest equivalent pack size *The metoclopramide will only appear on day one cycle one. If further supplies are required they should be added from the support directory of Aria as necessary. 8. Doxycycline 100mg once a day oral Version 1 (July 2021) Page 8 of 9 Colorectal – Cetuximab-Encorafenib DOCUMENT CONTROL Version Date Amendment Written By Approved By 1 July 2021 None Dr Deborah Wright Pharmacist Prof Tim Iveson Consultant Medical Oncologist This chemotherapy protocol has been developed as part of the chemotherapy electronic prescribing project. This was and remains a collaborative project that originated from the former CSCCN. These documents have been approved on behalf of the following Trusts; Hampshire Hospitals NHS Foundation Trust NHS Isle of Wight Portsmouth Hospitals NHS Trust Salisbury Hospital NHS Foundation Trust University Hospital Southampton NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust All actions have been taken to ensure these protocols are correct. However, no responsibility can be taken for errors which occur as a result of following these guidelines. Version 1 (July 2021) Page 9 of 9 Colorectal – Cetuximab-Encorafenib
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Colorectal/Cetuximab-Encorafenib.pdf

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