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Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.pdf

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

Description: ANNUAL REPORT AND ACCOUNTS 2019/20 Incorporating the quality account 2019/20 Page 2 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2019/20 incorporating the quality account 2019/20 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 Page 4 ©2020 University Hospital Southampton NHS Foundation Trust Page 5 TABLE OF CONTENTS Overview and performance report Welcome from our chair A word from the chief executive Overview of the Trust Statement of purpose and activities History of UHS Our executive team structure Structure of our services Our vision and values Our priorities, key issues and risks Voluntary disclosures Equality, diversity and inclusion 92 8 9 Environmental sustainability and climate chan ge 95 Quality account 10 Chief executive welcome 101 10 11 Annual accounts 12 Statement from the Chief financial officer 183 13 Independent Auditors report 185 14 Foreword to accounts 192 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 18 How we monitor performance 19 Overview of performance of UHS 18 Regulatory body ratings 19 Environmental matters 23 Social, community, anti-bribery and human rights issues 23 Accountability report Members of the Trust Board 25 Trust Board purpose and structure 30 Board meeting attendance record 2018/19 31 Well-led framework 32 Finance and investment committee 34 Quality committee 33 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 37 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 38 Disclosures 38 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 41 Annual remuneration statement 51 Remuneration and appointments committee 54 Governors’ nomination committee 57 Staffing report 61 Staff survey results 65 Trade union facility time 68 Statement of chief executive’s responsibilities as the accounting officer 72 Annual governance statement 73 Page 6 OVERVIEW AND PERFORMANCE REPORT Page 7 OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2019/20 was another challenging year for University Hospital Southampton NHS Foundation Trust (UHS). Demand for our services continued to rise rapidly, partly because of the ageing of the population we are here to serve and partly because of challenges in the external environment, but also because of our ability to offer exciting innovations for a range of conditions. As a result, we were not always able to offer treatment as rapidly as we wished. A major challenge towards the end of the year was the need to prepare the Trust for the COVID-19 pandemic, resulting in the need to re-engineer services on an unprecedented scale. The response of UHS staff to these challenges has, from start to finish, been magnificent. We saw major innovation in improved patient pathways to accommodate rising demand, and the creativity of colleagues in readying the Trust for COVID-19 was truly breath-taking in its scope and energy. UHS has had a long record of effective financial management. By constantly seeking operational innovation and better value for money in procurement, the Trust has been able to generate the funds necessary to make a number of capital investments which will provide huge patient benefit in future. There has been rapid progress in our major project to refurbish and extend our general intensive care unit. Our £2.2m investment in our new urology unit was completed this year; it will transform our patients’ experiences. We have continued wherever possible to work with partners and we are delighted that work on the £5m Maggie’s Centre has started. Quite apart from the need to navigate our way through the COVID-19 crisis and into the world beyond it, the Trust needs to prepare to play its full role in the Hampshire and Isle of Wight healthcare system as it develops in a way consistent with the NHS Long Term Plan. The responsibility for this falls of course to the Trust Board and I believe that even after having had more change on the Board this year than for some time, we continue to have a strong and committed leadership team. Following the retirement of Caroline Marshall, our long-serving chief operating officer, in September 2019 we welcomed Joe Teape into the position. Joe had not been at the Trust long before we were thrust into the COVID-19 pandemic and got to grips with it impressively rapidly. During the year we said farewell to three non-executive directors (NEDs); Catherine Mason who left us to become chair of Solent Healthcare, Mike Sadler our clinical NED and Simon Porter. After a series of rigorous selection processes, we were delighted to welcome Dave Bennett, Dr Tim Peachey and Keith Evans as replacements. Simon had been both deputy chair and senior independent director (SID) and on his departure Jenni Douglas-Todd succeeded him in both roles. The work of the Board is supported, stimulated and, quite correctly, challenged by the Council of Governors (COG) whose enthusiasm is of huge value to the proper governance of UHS. All of the elections to the COG were competitive, in some cases by a multiplicity of candidates. Unfortunately, one of those vacancies resulted from the death of Edward Osmond. Although Edward had only recently been elected as a governor, he had shown huge commitment to the role and I am sure would have gone on to make a major contribution to UHS. We welcomed nine new governors and one new young governor. I look forward to working with them and all the other governors as we move through and beyond the COVID-19 world. Peter Hollins Chair Page 8 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive My first full year as chief executive officer of UHS has been exciting, inspiring, and extremely rewarding but not, as you would expect, without a considerable degree of challenge! The pressures on the NHS have been well publicised as we strive to provide the highest possible standard of care at a time when demand for our services escalates rapidly. At the same time, at UHS we need to play our full part in working out how we shape and deliver the health and care provision for our community into the future. During the year we have done a great deal of work on how we turn our vision for the Trust, world-class care for everyone, into what happens on the front line every day. While the vision may be new it is built firmly on our long-standing values; patients first, working together, and always improving, which together describe who we are as an organisation. These values were central to the development of our new clinical and corporate strategy which sets out an exciting future for UHS over the coming decade. It includes how we will deliver the safest care, delivering the best outcomes, as well as how we will focus on improving the health of our population, supporting both health and wellbeing. The values also provided the basis for our CQC rating of ‘Good’ awarded during the year as were some other fantastic accolades. These included a prestigious British Medical Journal award for improving care for older patients with the development of our frailty unit and activity hub. Our women’s and maternity care at the Princess Anne Hospital was named as being among the best in the world. In addition, we adopted prehabilitation for cancer patients, a pioneering service. There are countless other examples of innovation which have sprung from the creativity and innovative spirit at UHS. Some of these have involved better outcomes for patients, some an improved patient experience and others simply lower the cost of doing things, liberating money which we can then invest in improving other services. I’d like to thank every one of our staff for creating the spirit of UHS which means that the extraordinary happens every day. The world of health and social care is changing dramatically and we continue to be integral to the Hampshire and Isle of Wight Sustainability and Transformation Partnership (STP). UHS will have a leading part to play in ensuring that, with our partners, we forge a pattern for the provision of healthcare across the local system and beyond, delivering the highest possible standards of care on an enduring basis. As we entered 2020, we began preparing to face COVID-19, the largest pandemic we have seen. Some areas of the hospital are truly unrecognisable as we have adapted to the fight against this virus. The loss of life as a result of COVID-19 has been utterly devastating and it has, I am sure, touched us all personally. It has also challenged the health and wellbeing of all our staff, but particularly our frontline staff, in a unique way. I am not sure whether I am prouder of the spirit with which our staff have responded to the challenge or of the fact that they made us by common consent one of the best prepared trusts in the country. Finally, I’d like to recognise the acts of kindness I see throughout the Trust on a daily basis. It is one of the things that has struck me the most as I have got to know this organisation and the people within it. I watch how they support one another through challenging times, how they support patients and visitors in their own time and in work time, and how they go above and beyond every day for the people they’re caring for. Every day they make me hugely privileged to lead this amazing organisation. Paula Head Chief executive officer Page 9 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and postgraduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 12,000 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2019/20 was £912m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). Page 10 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Executive team structure as at 31/03/2020 Page 11 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Page 12 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: Patients first Patients and families will be at the heart of what we do and their experience within the hospital, and their perception of the Trust, will be our measure of success. Working together Our clinical teams will provide services to patients and are crucial to our success. We have launched a leadership strategy that ensures our clinical management teams are engaged in the day-today management and governance of the Trust. Always improving Our growing reputation in research and development and our approach to education and training will continue to incorporate new ideas, technologies and greater efficiencies in the services we provide Page 13 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our goals 1. Improving patient journeys (system focus, integration) We will: • Write a strategic plan for integrated ‘front door; services to address capacity and demand mismatch and enable flow • Secure influence in primary care by establishing the hospital’s role in supporting primary care networks • Promote value-based healthcare, particularly: Introduce ‘advanced decision making’ • Redesign services to provide timely safe care and meet constitutional access trajectories • Deliver priorities relevant to UHS in the first year of the long-term plan including commissioning and long-term changes 2. Delivering value-based health and care We will: • Deliver the Trust financial plan and maximise any national funding • Prepare UHS for the new NHS financial regime • Deliver the Trust Quality Improvement plan to improve safety/experience and outcomes • Build capability for change by embedding quality improvement, innovation and transformation at a leadership level • Deliver the Cost Improvement Plan (CIP) without compromising on quality 3. Supporting health lives (prevention, wellbeing inequalities, outcomes and experience) We will: • Improve staff health and wellbeing • Improve population health, maximising the impact of UHS touch points • Develop an early warning tool to identify any deterioration in quality 4. Building an expert and inclusive workforce (diversity, engagement, leadership) We will: • Close the staffing supply gap in priority groups/services to provide high quality and timely care • Manage overall workforce cost to meet CIP challenge • Measure improvement in staff engagement by increasing participation in staff survey • Increase representation of diverse groups in leadership and decision making • Improve the staff engagement score 5. Being agile in meeting people’s needs (organisational elegance/design/flexibility) We will: • Reset organisational structure as necessary, responding to changes outlined in the NHS long-term plan • Leverage digital capability to support patient empowerment and self-care • Measure staff user satisfaction with the Trust IT systems and use this to support the digital strategy • Be agile in flexing resources, responding to fluctuating demand • Secure strategic influence by establishing UHS role in the transition from STP to ICS 6. Leading edge research, education and innovation (research and outcomes) We will: • Identify the capacity constraints to expand research and plan to address • Identify priority areas without a research base and set strategy • Improve quality and breadth of education and training programme Page 14 OVERVIEW AND PERFORMANCE REPORT The novel coronavirus (COVID-19) will continue to have a significant impact on public health, morbidity and mortality if adequate prevention and control is not in place. The Trust put rapid and robust arrangements in place early on to prepare for the potential surge in COVID-19 patients. As the government now announces the easing of the lockdown restrictions, the COVID-19 challenge continues to unfold and still represents a very significant future risk to the organization. Our response and mitigations will continue to evolve through 2020/21. Further details on our response to the COVID-19 challenge are in included in the Annual Governance Statement on page 73.. Key issues and risks 1. Inability to develop partnerships and redesign services innovatively renders the Trust unable to meet the expectations of the NHS long-term plan, our strategic plan, and sustainable elective and non-elective pathways. UHS continues to actively develop partnerships across the region and work within the Integrated Care System whilst promoting value-based healthcare and delivering priorities relevant to UHS in the first year of the longterm plan. 2. Failure to deliver regulatory requirements results in license breach and loss of local control with an enforced change in leadership, impacting on Goals 1 to 6. UHS continues to monitor progress against NHSI Performance framework at committee and Board level and build capability for change by embedding quality improvement, innovation and transformation at a leadership level. 3. Failure to achieve financial targets results in a shortfall in cash required to deliver the capital programme. A robust cost improvement programme is in place, continuously monitored through governance processes with a focus on delivery of the Trust’s financial plan. 4. Reduced access to resources compromises the quality of services. We will implement the Trust Quality Improvement plan to improve safety/ experience and outcomes. 5. Capacity and capability gaps in the workforce lead to an inability to provide safe and timely care. To mitigate this risk, we will continue to develop initiatives to improve staff health and wellbeing with proactive recruitment and retention initiatives in place. Staff engagement is monitored through staff survey and leadership and development training in place. 6. Lack of inclusion and diversity results in the failure to get the best from every individual. UHS has an equality, diversity and inclusion strategy, with established Trust networks and inclusive talent management programmes. Page 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Page 16 OVERVIEW AND PERFORMANCE REPORT Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. Audit andrisk committee Finance and Investment committee Quality Committee People & Organisational Development Committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. Page 17 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. The format of the monthly report follows our six strategic goals: • Improve patient journeys • Value-based health and care • Healthy lives • An expert and inclusive workforce • Being agile in meeting people’s needs • Leading edge research, education and innovation The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section has several KPIs that are relevant to the key risk of delivering the national access target. Some of the KPIs are: • Number of attendances • Time to initial assessment • Delayed transfers of care • Non-elective length of stay The Activity and Flow sections have several KPIs that are relevant to the key risk of capacity and occupancy. Some of the KPIs are: • Length of stay • New referrals • Number of attendances • Bed occupancy The Staffing (HR) section has several KPIs that are relevant to the key risk of Staffing. Some of the KPIs are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk Page 18 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against, including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2020/21 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Overview of performance Improving patient journeys 2019/20 was a challenging year in which we made only modest progress against some objectives to ‘Improve Patient Journeys’, and deteriorated in performance against others. • Inpatient length of stay remained stable but didn’t reduce as significantly as we had intended. The percentage of bed days used due to ‘Delayed Transfers of Care’ to other settings increased to nearly twice the national target. This, combined with growth in non-elective admissions (2.8% YTD excluding M12), resulted in occupancy rates which often exceeded our target, and an increase in patients cared for as ‘outliers’ away from their own speciality wards. • Emergency Access Performance (patients spending less than four hours in the emergency department) remained below both the national and local targets, though performance did show modest improvement during the year. There has been a further substantial increase in the volume of emergency department attendances. • The number of ‘elective’ patients waiting for treatment, the percentage of patients waiting within 18 weeks, and also the waiting time for first outpatient appointments, deteriorated significantly during the year. This has, in part, been impacted upon by reduced availability of clinical capacity due to staff concerns about the impact of new pension/tax regulations. There are, however, good indications that service changes are being implemented to increase consultation capacity in an efficient way as we had aimed to. There has been a substantial increase in consultations provided through ‘non-face-to-face’ routes, and a small decrease in the number of more traditional face-to-face consultations. • Urgent GP referrals for suspected cancer seen within two weeks saw a substantial and sustained improvement compared to the previous year, exceeding that target. • Performance against treatment within 62 days measures also demonstrated modest improvement during the year. Significant improvement in cancer performance continues to be required in order for UHS to deliver the national targets for timeliness of treatment. Page 19 OVERVIEW AND PERFORMANCE REPORT Delivering value-based healthcare • Complaints about UHS care have remained low, with the percentage of complaints ‘closed’ within 35 days above target for the first 11 months of 2019/2020. • Pleasingly, the availability of nursing care to our inpatients (expressed as care hours per patient per day) has increased progressively through the year from 8.6 to 8.9. An active overseas nursing recruitment and induction process has supplemented domestic recruitment and training. • The Trust has formed a 50/50 joint venture company with Hampshire Hospitals NHS Foundation Trust called Wessex NHS Procurement Limited (WPL). From 1 December 2019, WPL is providing procurement, supply chain and materials management services to the Trust. The objectives of this innovative partnership include the consolidation of supplies purchases for both Trusts (combined revenue £1.4bn) to leverage better prices from suppliers and increased productivity through the elimination of previously duplicated procurement activity. Supporting healthy lives • There was very good performance on the Hospital Standardised Mortality Ratio. The standard is 100 and we are consistently below this (83 in December, results are reported nationally retrospectively). This measure includes all patients in England with the same condition and compares those who have died with those that have survived. Being below 100 is a strong indicator of good care. • We continue to receive feedback, which is largely positive, through the national ‘Friends and Family’ survey for both our inpatient and maternity care. • The Board monitors a range of quality indicators. Of these, exceeding the target number of patients infected with clostridium difficile by six is of some concern, we are pleased that the number of severe/moderate medication errors has been maintained well below our target level, and following an increase in the number of Serious Incidents Requiring Investigation (SIRI) that were reported to Board in the early part of the year both the number of SIRIs has reduced and the timeliness of investigation has significantly improved. • Staff sickness levels were on target through the summer months, but significantly in excess of this through the winter months. As a whole, this is a cause for some concern. Building an expert and inclusive workforce • Very pleasingly, nursing vacancies were reduced significantly during the year, from 18% to 15%. Though still a challenge, this supports increases in the treatment capacity we can make available in the Trust, in our ability to open additional bed capacity to reduce our inpatient occupancy rates, and increases the care hours provided per patient per day. • Turnover rates have been in excess of our target throughout the year and there has also been a reduction in the percentage of staff who would recommend UHS as a place to work, though we remain above our target of 76%. The percentage of non-medical appraisals taking place within 12 months remains below target and is declining. • We have made steady progress this year towards our target of 15% of staff at Band 7 and above being from Black and Minority Ethnic backgrounds by 2023 (above 9% in March 2020). Being agile in meeting people’s needs • 2019/2020 has seen further progress in the implementation of digital tools that enable patients and clinicians to review and discuss patient specific clinical information in new ways, for example, large increases in usage of ‘My Medical Record’ and ‘digi-rounds’, modest further progress in electronic requesting and acknowledgement of tests, and stable usage of other tools. Page 20 OVERVIEW AND PERFORMANCE REPORT Leading edge research, education and innovation • The majority of recruitment targets have been achieved during 2019/20. • In Q4 UHS ranked 13th for contract commercial study recruitment, which is the same position achieved in the previous year and thus did not achieve our target of Top 10, with a constraint on pharmacy research capacity being a contributing factor. • The proportion of commercial studies closing in the 2019/20 financial year on time and to recruitment target ended the year below the 80% target at 68%, though the year-end target for the proportion of non-commercial studies closing on time and to recruitment target was exceeded at 88% compared to 80% target. Details of UHS performance can be found in the Integrated Performance report which is available in the Trust Board papers section of our website www.uhs.nhs.uk. UHS performance is scrutinised by the Board on a monthly basis. Paula Head, chief executive officer 22 June 2020 Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2019/20 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2020. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. The Trust was on track to deliver a use of resources score of ‘2’. However, as a direct result of COVID-19 our staff were unable to take their full complement of annual leave. The Trust was required Page 21 OVERVIEW AND PERFORMANCE REPORT to allow for this additional cost, which was an unfunded cost pressure allowable by NHS Improvement. This had the impact of moving the distance from financial plan score to a ‘4’ and subsequently the overall use of resources score to a ‘3’. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 Year 3 3 2 2 2 1 1 1 1 1 3 1 1 1 1 1 1 2 4 4 1 1 1 1 1 2 1 2 3 3 Care Quality Commission ratings: Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. All sites and services across the organisation are now rated as ‘good’ in the effective and caring domains, with Southampton General Hospital rated as ‘outstanding’ in these areas. The Well-Led section of this report provides further details of the inspectors’ findings. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Page 22 OVERVIEW AND PERFORMANCE REPORT Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital, we undertake a wide range of activities and use a large amount of resources. We are committed to environmental sustainability and consider it as part of the business culture. We continue to invest in energy saving initiatives and staff awareness campaigns that focus on promoting sustainability. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on pages 86 and 95 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter-fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors, and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud, and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the Foundation Trust. No political donations have been made. The Trust has no overseas branches. Page 23 OVERVIEW AND PERFORMANCE REPORT Page 24 ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Biography Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, in hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. David joined the Trust in February 2016 and served as interim chief executive officer from April to September 2018. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Declarations Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a joint-venture company owned 50/50 by UHSFT and Prime plc; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel; Director of Wessex NHS Procurement Limited (WPL), a joint venture company owned 50/50 by UHSFT and Hampshire Hospitals NHS Foundation Trust (from December 2019) Husband is a consultant surgeon at UHS; Daughter is a midwife at UHS (from March 2019) Dr Derek Sandeman Joe Teape Medical director Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional Director of UHS Pharmacy Limited, endocrine service. Throughout his career he has had a wholly-owned subsidiary of extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Joe joined the Trust as chief operating officer in December Nil 2019. Previously he was deputy chief executive and director of operations of a large health board in Wales which managed integrated services across three counties including four district general hospitals as well as mental health, learning disability and community services. Prior to this, Joe worked in director roles across finance and strategy within provider acute trusts across the south west of England. Joe is passionate about providing leadership and support for all staff, whatever their profession, and contributing to excellent patient care. He is committed to open and ongoing engagement with the general public and often uses social media to engage with colleagues and with those who have an interest in healthcare. Page 25 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Dr Tim Peachey Non-executive director David Bennett Non-executive director Biography Declarations Peter graduated in chemistry from Hertford College, Chair of CLIC Sargent Cancer Care Oxford. Joining Imperial Chemical Industries in 1973, for Children (a company limited by he undertook a series of increasingly senior roles in guarantee) (until December 2019); marketing and then general management. Following Council member of University of three years in the Netherlands as general manager of Southampton ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of British Energy where he remained until 2001. From 2001, he held various chairmanships and non- executive directorships. In 2003, he decided to return to an executive role as chief executive of the British Heart Foundation in which post he remained until retirement in March 2013. He joined Southampton University Hospital Trust as a non- executive director in 2010, became senior independent director and deputy chairman of UHS in 2014, and was appointed chair in April 2016. Tim qualified as a doctor from Kings College Hospital Director, TP Medcon Ltd; Clinical School of Medicine in 1983. For nearly 20 years, he Safety Officer, Block Solutions Ltd; worked as a consultant anaesthetist at the Royal Free Non-executive director and Quality Hospital in London, specialising in pancreatic cancer Committee chair, Isle of Wight NHS surgery, liver surgery and liver transplantation. He also Trust developed an interest in medical leadership and management and has held positions such as clinical director, divisional director and medical director at the Royal Free. In 2012, Tim moved into full-time management as chief executive of Barnet and Chase Farm Hospitals NHS Trust until its acquisition by the Royal Free. He then worked as the London associate medical director at the NHS Trust Development Authority before moving to Barts Health NHS Trust as improvement director and subsequently became deputy chief executive. Tim now holds two NHS non-executive posts. In addition to his role at University Hospital Southampton, Tim also serves on the board for Isle of Wight NHS Trust as deputy chair. He is a practicing mediator specialising in the healthcare sector. He also consults for companies in the medical information technology industry. Dave graduated in chemistry from the University of Director, Davox Consulting Limited; Southampton before entering management consulting, Non-executive director, Faculty of becoming a partner in Accenture’s strategy practice. Leadership and Medical In 2003 he joined Exel Logistics (later bought by DHL), Management (from November managing the company’s healthcare business across 2019); Director Royal College of Europe and the Middle East. During this time, he General Practitioners (RCGP) established NHS Supply Chain, a UK organisation Enterprises Ltd and RGCP responsible for procuring and delivering medical Conferences Ltd (from November consumables for the NHS in England, as well as sourcing 2019) capital equipment. Dave joined the board of Cable & Wireless as sales director in 2008. He later set up his own strategy consulting practice serving the healthcare sector, completing numerous projects in the UK and the US. Dave has also served as a non-executive director at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust between 2009 and 2016. He chaired the Trust’s quality committee. Page 26 ACCOUNTABILITY REPORT Board member Name Title Jenni DouglasTodd Senior independent director/deputy chair (from 01/02/2020) Biography Jenni is a former chief executive of Hampshire Police Authority and the office of the Hampshire police and crime commissioner. After beginning her career in the probation service, she was headhunted into the civil service, at the Home Office, where she spent four years before becoming director of policy and research for the Independent Police Complaints Commission. In the latter role she was responsible for establishing governance of the new police complaints system. She then spent two and a half years as a resident twinning adviser for the UK, based in Turkey to help set up a law enforcement complaints system before taking up the role of chief executive of the county’s police authority. During her three years in the post, she supported the authority in developing effective governance processes to increase accountability and transparency. She also helped the organisation deliver cost-savings whilst still improving performance and developing closer working relations with neighbouring forces. Declarations Independent chair, Dorset Integrated Care System. Managing director, Diversa Consultancy Limited; Member of the Judicial Conduct Investigative Office; Nonexecutive director, Hampshire Cricket Board; Trustee, NACRO; Member of English Cricket Board’s Regulatory Committee. Professor Non-executive Cyrus director Cooper In 2012, she became chief executive and monitoring officer for the Hampshire police and crime commissioner, where she led the development of the office’s vision, mission, values and organisational strategy. She took on the role of investigating committee chair for the General Dental Council in 2014 and, in April that year, founded the Diversa Consultancy, which supports organisations with changes in business, culture and behaviour. She is also a member of the Judicial Conduct Investigating Office, a public appointment. Cyrus Cooper is professor of rheumatology and director of the MRC Lifecourse Epidemiology Unit. He’s also vicedean of the faculty of medicine at the University of Southampton and professor of epidemiology at the Nuffield Department of Orthopaedics (rheumatology and musculoskeletal sciences, University of Oxford). He leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have been: • discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood • demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood • characterisation of the definition and incidence rates of vertebral fractures • leadership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture. Director and professor of rheumatology, Medical Research Council (MRC) Lifecourse Epidemiology Unit; Vice-D
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-and-quality-account-2019-202.pdf

InP-REPOCH-Cyclophosphamide-Doxorubicin-Etoposide-Prednisolone-Rituximab-Vincristine

Description: Chemotherapy Protocol LYMPHOMA REPOCH - CYCLOPHOSPHAMIDE-DOXORUBICIN-ETOPOSIDE-PREDNISOLONERITUXIMAB-VINCRISTINE (In-Patient Dose adjusted regimen) There are multiple versions of this protocol
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Lymphoma/InP-REPOCH.pdf

Procedure for start-up, tuning and shut down of profile 3 SIFT FAMS analyser

Description: NIHR Southampton Biomedical Research Centre The NIHR Southampton Biomedical Research Centre (BRC) has a tight quality assurance system for the writing
Url: /Media/Southampton-Clinical-Research/Procedures/BRCProcedures/Procedure-for-start-up,-tuning-and-shut-down-of-profile-3-SIFT-FAMS-analyser.pdf

Total knee replacement HHFT - patient information

Description: Welcome to your guide to total knee replacement (TKR) surgery.
Url: /Media/UHS-website-2019/Patientinformation/Muscles,jointsandbones/Total-knee-replacement-HHFT-4037-PIL.pdf

Papers CoG 28.10.2025

Description: Date Time Location Chair Agenda - Council of Governors 28/10/2025 14:00 - 15:30 Heartbeat Conference Room/Microsoft Teams Jenni
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-28.10.2025.pdf

Gepants for the prevention of episodic and chronic migraine - patient information

Description: This factsheet contains information about a preventative treatment for episodic and chronic migraine called gepants.
Url: /Media/UHS-website-2019/Patientinformation/Brain-and-spine/Gepants-for-the-prevention-of-episodic-and-chronic-migraine-3895-PIL.pdf

Anti-CGRP monoclonal antibodies (mAbs) for the prevention of episodic and chronic migraine - patient information

Description: This factsheet contains information about a preventative treatment for episodic and chronic migraine called anti-CGRP monoclonal antibodies (mAbs).
Url: /Media/UHS-website-2019/Patientinformation/Brain-and-spine/Anti-CGRP-monoclonal-antibodies-mAbs-for-the-prevention-of-episodic-and-chronic-migraine-3075-PIL.pdf

Papers CoG 16.07.2025

Description: Date Time Location Chair Agenda Council of Governors 16/07/2025 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 29 April 2025 4 Matters Arising/Summary of Agreed Actions 14:05 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:10 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Steve Harris, Chief People Officer 5.2 Operating Plan 14:30 Receive and note the report Sponsor: Ian Howard, Chief Financial Officer Attendees: Ian Howard, Chief Financial Officer and Andrew Asquith, Director of Planning and Productivity 5.3 Break 14:50 6 Governance 6.1 Review Terms of Reference - Council of Governors 15:00 Approve the proposed changes to the 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 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:05 Receive the report Sponsor: Jenni Douglas-Todd, Trust Chair 7.2 Governors' Nomination Committee Feedback 15:09 Chair: Jenni Douglas-Todd, Trust Chair 8 Review of Meeting 15:14 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 15:19 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 28 October 2025 15:29 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 29 April 2025 14.00-15:50 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 Professor Cathy Barnes, Appointed, Solent University Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Lesley Gilder, Elected, Southampton City Ben Grassby, Elected, Rest of England and Wales Sathish Harinarayanan, Elected, Medical Practitioners and Dental Staff Professor Sue Latter, Appointed, University of Southampton 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 Jake Smokcum, Elected, Nursing and Midwifery Staff Liz Taylor, Elected, Non-Clinical and Support Staff Mike Williams, Elected, New Forest, Eastleigh and Test Valley JDT SA CB PC SG LG BG SH SL BL LPJ CR KSB JS LT MW In attendance Pete Baker, Commercial and Enterprise Director (for item 5.5) PB Helena Blake, Head of Clinical Quality Assurance (for item 5.3) HB Gail Byrne, Chief Nursing Officer (for item 5.1 and 5.3) GB Sam Dolton, Events and Membership Officer SD Kelly Kent, Head of Strategy and Partnerships (for item 5.4) KK Karen Russell, Council of Governors’ Business Manager KR Apologies Theresa Airiemiokhale, Elected, Southampton City TA Katherine Barbour, Elected, Southampton City KB Linda Hebdige, Elected, Southampton City LH Councillor Pam Kenny, Appointed, Southampton City Council PK Jenny Lawrie, Elected, Southampton City JL Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO 1 Chair’s Welcome and Opening Comments JDT welcomed everyone to the meeting, in particular CB who was attending for the first time. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 1 3 Minutes of Previous Meeting The minutes of the meeting held on 29 January 2025 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions There was one item arising from the previous meeting on 29 January 2025 which had been completed. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed GB who joined the meeting to present the performance report on behalf of David French. GB highlighted the following: • Despite the economic challenges, the Trust continued to benchmark well for productivity measures including theatre utilisation and length of stay whilst recognising there remains an opportunity to go further. • For Quarter 4 the overall Friends and Family Test Trust average was 94% for patients rating their care as “Good” or “Very Good”. • The volume of patients with no criteria to reside remained above 200 per day which continued to place a barrier on the Trust’s bed availability. • The financial environment remained extremely challenging and a Financial Improvement Group had been set up as a sub-group of the Board of Directors (the Board) to consider cost saving initiatives. • Divisions had been asked to identify savings of 5% in clinical areas and 10% in non-clinical areas and Trust Headquarters. • GB and Paul Grundy (Chief Medical Officer) were also setting up a panel to review the Equality Impact Assessment and consider the impact on patient safety and staff. In response to questions raised by the CoG, GB advised: • With regard to Saturday waiting lists in urology, she understood they would be continuing. Agency usage was very low and there had been a £6m reduction. • In addition to bed availability being impacted by no criteria to reside, this was also affected by the number of patients with mental health issues. There was also a discussion about the use of virtual wards and how complex it can be. • With regard to the statistics regarding the proportion of patients attending ED when they should be seeking assistance elsewhere and the number which converted into inpatients, this information was not shown in the Performance Report. 5.2 Annual Report and Quality Accounts Timetable 2024/25 NHS England had published the timetable for the 2024/25 annual report and accounts and associated guidance. The Trust was required to produce an annual report and accounts as well as a Quality Account. The Trust had decided to align the timetables of both the Quality Account and the annual report and accounts, and to incorporate these into the same document. The Quality Account was required to be published by 30 June 2025, whereas the annual report and accounts could not be published until after they had been laid before Parliament. Parliament’s summer recess was to commence on 21 July 2025. 2 The Trust had taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document. However, the quality account was to be published as a separate document by 30 June 2025. Once the annual report and accounts had been published, it would be presented at the next CoG meeting which would be prior to the Trust’s Annual General Meeting. 5.3 Draft Quality Account 2024/25 The chair welcomed HB to the meeting. GB provided the background to the quality account. HB advised that the quality account contained a number of mandated sections which were laid down by NHS England. There was to be a 30 day consultation period and any feedback would be taken into account in the final document. Governors were invited to provide feedback directly to HB by 13 May 2025. The following questions were raised: • It was not clear how quality management linked to the strategic objectives. HB agreed to add into the introduction to the quality account. • The narrative provided details of progress during the year, but year on year improvements were not included. • Were there set quality aspects which were measured and how did objectives map on to bigger quality metrics? GB advised that some aspects were always measured, these would be done vertically if one ward had issues and horizontally to look across wards, for example, in the case of pressure ulcers. HB agreed there may need to be a section regarding quality assurance processes and how it all links together. • Sue Latter questioned that not all the quality measures appeared to be measuring quality. GB answered and referred to the KPI report which goes to TB and JDT commented that it was interesting and wondered if Quality Committee could explore and work with her. GB then mentioned one of the things she was most proud of was leadership development but didn’t know how that could be quantified as a quality measure. JDT thanked GB and HB for attending. 5.4 Corporate Objectives The chair welcomed KK to the meeting. KK advised that this was the final year of the Trust’s current strategic plan which covered 2021-2025, and the future strategy was in the process of being developed. In view of the current financial challenges and growing demands on the Trust’s services, 12 corporate objectives had been created which were fewer than in previous years, to ensure they were fully focussed on the achievements required. In response to a question regarding achieving the previous year’s objectives, KK advised that progress reports were provided quarterly throughout the year. This year the plan was to publish ahead of the first quarter the anticipated milestones against each of the objectives. It was noted that it would be useful to see the planned achievements on one page, possibly with risk ratings and order of priority. 3 KK confirmed that with regard to the future strategy, there had been a period of engagement with staff and the public which would feed into it. JDT thanked KK for attending. 5.5 Non-NHS Activity One of the responsibilities of the CoG was to determine whether the Trust’s nonNHS activity would significantly interfere with its principal purpose, which was to provide goods and services for the health service in England, or the performance of its other functions. There was a clear legal requirement that the Trust must derive greater levels of income from its principal purpose, rather than its non-NHS income. It also enabled the CoG to monitor when it may need to specifically approve an increase in non-NHS income under other provisions of the National Health Service Act 2006. This would apply to proposals to increase by 5% or more the proportion of total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England (including private work). In summary, the contribution arising from non-NHS activity in 2024-25 as a percentage of Trust income (baseline £1.47bn) equated to 2.1%, as per the UHS 2024/25 unaudited accounts. This was a slight increase from 1.8% as reported in 2023-24. In response to questions from governors, PB confirmed that: • He considered that staff having the opportunity (outside their NHS employment) to choose to earn additional income working in a private environment should be seen as beneficial to staff, and something that tended to be attractive to new staff considering joining an NHS Trust. This question was always one of the most important considerations as the Trust did not want to destabilise its workforce. Private healthcare providers typically had non-compete or no-poaching clauses and would invariably have different recruitment mechanisms to a local trust, for example, they would have their own national and international recruitment functions distributing staff to their sites around England. • It was uncommon for NHS Trusts to have the capability to create spin-out companies and he noted that this was far more routine in the University sector. For this reason, the Trust had worked very closely with the university spin-out team and emulated much of their guidance and processes. PB also noted that the Trust differed slightly in the allocation of equity (shares) in the new company than would typically be seen in the university sector. • There had been almost £7m worth of private patient activity performed at UHS over the previous 12 months. • The current income from private work was generated from within the existing SGH operational footprint and that NHS staff were not obliged to work in private healthcare provision. • With regard to the sheer size of the potential Southside A building, this had been informed by a formal Feasibility Study, conducted by an external architect/surveyor, and the area that the Trust had looked at was aligned with the UHS Estates Master Plan, which was the document that looked at how the SGH (and PAH) site could continue to develop. JDT thanked PB for attending. 4 6 Governance 6.1 Governor Attendance at Council of Governors’ Meetings Under the Trust’s constitution (paragraph 2.1 of Annex 5) if a governor failed to attend two successive meetings of the council of governors, his or her tenure of office was to be immediately terminated by the council of governors (CoG) unless the CoG was satisfied that: • the absences were due to reasonable cause; and • he/she would be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Following the recent review, there was one governor who had failed to attend two successive ordinary meetings of the CoG. Reasons for non-attendance were provided and were due to reasonable causes. In order to ensure that the CoG considered the situation when a governor fails to attend two successive ordinary meetings of the CoG, the process was for the Chair or Company Secretary to contact the governor to understand the reasons for this if these had not already been provided. The Chair or Company Secretary would then provide confirmation to the CoG as to whether this was due to reasonable causes and of the governor’s ability to attend future meetings. This would also help to identify any steps that the Trust could take to facilitate attendance. Decision: The CoG confirmed that it was satisfied that the process had been followed correctly to confirm that the failure of one current governor to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period. 6.2 Council of Governors’ Elections 2025 KR advised that a number of vacancies would arise within the council of governors on 1 October 2025 as current governors reached the end of their term of office: • Southampton City public constituency - five vacancies • New Forest, Eastleigh and Test Valley public constituency - three vacancies • Isle of Wight public constituency - one vacancy • Non-clinical and support staff class - one vacancy • Nursing and midwifery staff class - one vacancy The Trust’s constitution required vacancies arising on the council of governors due to the expiry of a term of office to be filled by an election conducted in accordance with the model election rules, as published by NHS Providers in August 2014. The elections were to be conducted by Civica Election Services on behalf of the Trust. Governors reaching the end of their first term of office were eligible to stand for reelection. However, two of the Southampton City governors, KB and TA, were reaching the end of their second term of office (a total of six years) which was the maximum allowed under the Trust’s constitution. The proposed timetable and arrangements for the elections to the CoG in 2025 were noted. 5 6.3 Appointment to the Governors’ Nomination Committee A vacancy had arisen on the Governors’ Nomination Committee (GNC) as Helen Eggleton had stood down on leaving her employment with HIOW ICB on 30 November 2024. Governors had been asked to express an interest if they were willing to join the GNC. Esther O’Sullivan had expressed an interest in taking on this additional role. The CoG was responsible for appointing the members of the GNC and had decided by a unanimous vote to approve her appointment. The CoG was asked to formally note the appointment of Esther O’Sullivan to the GNC. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the Membership Engagement report. He advised that the communications team, in common with other teams within the Trust, were looking to identify cost savings. A colleague in the communications team had recently left the Trust under the Mutually Agreed Resignation Scheme which had placed a further strain on resources and therefore additional key priorities had been distributed across the team. SD had taken on an additional responsibility to assist the children’s hospital with social media. In addition, the publication of the Trust’s annual report and accounts which had previously been outsourced would now be produced in house by SD. In view of this, the communications team would not be able to lead any community events during 2025 but would advise governors if any other departments at UHS or other trusts would be having any involvement so they could provide support. Membership engagement in the previous quarter had been light and this would continue. A Community Care Engagement Event was to be held on Thursday, 1 May which had been communicated to governors and members, and all were welcome to attend. SD would continue to work with KR to promote the CoG elections for 2025. MW asked if the weekly update was only provided to governors and whether this could this be reduced to fortnightly to save resource. SD confirmed that this was the case, but he was happy to continue to prepare this on a weekly basis as it was not very time consuming. There was a discussion regarding how governors could provide support to promote membership of the Trust on day-to-day basis, and the benefits of becoming a member. It was confirmed that there was a statutory requirement for foundation trusts to have a trust membership in place. 7.2 Governors’ Nomination Committee Feedback Governors had received feedback from the Chair and NED appraisals, and an update regarding NED recruitment. 6 8 Review of Meeting Governors felt it had been an interesting meeting with a good mix of presenters. The walkabouts of the hospital earlier in the day had also been informative and worthwhile. 9 Any Other Business LT commented that sound in the conference room was quite poor. JDT noted that all meeting attendees could take responsibility for projecting their voices during discussions but agreed to investigate whether anything could be done to improve the situation. 10 Date of Next Meeting The next meeting of the CoG would be held on 16 July 2025. 7 Agenda item Council of Governors 29/04/2025 9 Any Other Business 1250 Sound in the Heartbeat Conference Room Assigned to Jenni Douglas-Todd Deadline Status 16/07/2025 Pending Explanation action item LT commented that sound in the conference room was quite poor. JDT noted that all meeting attendees could take responsibility for projecting their voices during discussions but agreed to investigate whether anything could be done to improve the situation. An update will be provided at the meeting on 16 July 2025. Item 5.1 Report to the Council of Governors - 16 July 2025 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 July 2025 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. This report covers data from the period March to May 2025. The period reflects the transition out of winter pressures and into a new financial year with its associated targets, bother operationally and financially. Whilst both present significant challenges for the organisation, UHS is focussed on maintaining strong performance across all areas whilst committing to the national requirement to maintain financial balance. Notable features of the period include: • As at May 25, the trust is in line with the financial plan, reporting a deficit of £8m and delivery of £12.5m of savings. • Significant increases in referrals beyond seasonality trends across several key specialties has resulted in further growth in the hospital’s waiting list which closed at 62,949 for May 2025. • The percentage of patients waiting less than 18 weeks increased to 64.4% which reflects the increase in referrals in the last 18 weeks, but also success in bringing waiting times down for several services. • Managing emergency department attendances and the subsequent flow of patients in and out of the hospital continue to be a highest priority. ED performance in May 2025 was 59% for the percentage of attendances who spent less than four hours in the department. • The trust reported an improvement in staff sickness rates. The 12-month rolling turnover rate remained steady at around 10.1% despite recent fluctuations linked to the introduction of a mutually agreed resignation scheme to support a pay expenditure reduction. • The hospital recognised a lower staff survey response rate linked to a change in survey provider. This will be remedied through wider staff communications in the next quarter • The hospital mortality rate continues to reflect better than expected survival. The organisation reported one never event across the three months and two PSIIs. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection E.coli Target 78.0% March 2025 60.1% April 2025 63.6% May 2025 59.3% Attendances to the Emergency Department (ED) have remained high through this period, averaging 433 attendances per day across March, April and May. This, alongside ongoing flow challenges due to the number of patients no longer meeting the Criteria to Reside, means that UHS is facing a number of challenges in moving towards the national target. An external review completed by regional clinical leads for ED and AMU (acute medical unit) was undertaken at the end of June. Initial feedback gave some helpful areas for improvement. Full report is expected in July and will form the basis for our ongoing improvement work. One of the challenges we face is not having an on site urgent treatment centre, but that now has capital funding with plans to open in 2026. Page 3 of 6 Referral to Treatment (RTT) Target % incomplete pathways within 18 weeks in month => 92% Total patients on a waiting list March 2025 62.5% 61,686 April 2025 63.0% 62,310 May 2025 64.4% 62,949 The number of patients on the RTT waiting list continued to increase over the last three months despite signs of an overall NHS waiting list reduction reported nationally. The trust recognises the seasonal trend behind certain services each year, however there are also notable increases in Dermatology due to cessation of Tier 2 services in the community and a continual demand increase seen within Cardiology, Oral Surgery and Clinical Genetics. The trust is focussed on a series of interventions to reduce the waiting list which includes reductions to DNAs, improved theatre utilisation, management of referrals through expanded advice and guidance services and expansion of patient initiated follow-up services. Alongside this, the organisation constantly validates the waiting list to ensure patients’ conditions and pathway changes are well managed and appropriately reported. 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% February 2025 84.4% 92.8% 72.1% March 2025 83.0% 93.8% 81.2% April 2025 81.8% 95.2% 75.4% The hospital continues to appropriately prioritise cancer patients and as a specialist teaching hospital accepts complex patients transferred from other providers during their cancer pathway. Cancer referrals remain high but we have maintained compliant performance on two of the three cancer standards, both also placing the Trust in the top quartile compared to peer teaching hospitals across the NHS. 5. Finance The financial environment remains extremely challenging for UHS. Our plan submission for 2025/26 targets breakeven delivery which is predicated on the achievement of £110m of savings. This represents 8% of turnover. The shape of the financial plan is one that requires month of month improvement with a deficit plan of £17m in the first half of the year offset by an equivalent surplus plan of £17m in the second half of the year. The financial architecture in 2025/26 means a greater majority 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 have been asked to explore workforce reductions and a newly formed financial improvement group has been established, chaired by the CEO, to help drive the pace of efficiency improvement in a mindful way. As at May the trust is on plan, reporting a deficit of £8m and delivery of £12.5m of savings. Some of this has however been underpinned by non-recurrent benefits that will therefore not reoccur in future months meaning the underlying challenge has been assessed at a c£14m deficit over April and May. A run rate at this trajectory would be unsustainable for the trust and therefore further energy is being Page 4 of 6 put into savings achievements. A MARS (mutually agreed resignation scheme) has been launched which should help support the delivery of sustainable workforce savings and detailed workforce trajectories have been developed. Continued efforts are being put into procurement, medicines optimisation, digital efficiencies and estates efficiencies to ensure maximum value for money for patients. Deficit drivers do however remain making the financial climate for sustainable improvement challenging. These are as follows: 1. Urgent and Emergency activity is in excess of block funding levels. This has meant surge capacity continues to be required and bed closure plans where length of stay reductions are achieved are often difficult to embed. 2. Non-criteria to reside numbers have increased to peaks of 270 from an average of 220. This is c20% of the trusts 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 demands continue at consistent levels from previous years with patients often requiring enhanced levels of support often at a significant cost premium to the trust. UHS continues to work with system providers on improvements for this patient group. Despite these pressures however the trust has continued to ensure value for money remains an organisational priority and is focused on transforming services under the three workstreams of theatre optimisation, outpatients and inpatient flow. Further to this the trust remains on target to spend its full capital allocation for 2025/26 totalling over £66m for which £36m is externally funded following successful business case applications. This includes further investment in the emergency department of £8m. This continued investment in capacity, digital and infrastructure helps support continued ongoing financial sustainability and efficiency improvements. 6. Human Resources Indicator Staff recommend UHS as a place to work % Staff survey engagement score (out of 10) Q4 24/25 66.4% 6.8 Q1 25/26 47.7% 6.39 We have changed provider for the quarterly pulse surveys and they are now provided by NHS England through the People Pulse. With the new provider, staff no longer receive a direct email inviting them to take part in the survey. With this change we only heard from 440 of our staff, in comparison to our usual 2000-4000 responses for the quarterly surveys. For quarter 2 we plan on sending out an all-staff email so staff are still receiving that direct communication about the survey. The People Pulse do a correlational analysis for us to show which core questions have the strongest relationship to employee engagement. In this survey, managers seeking to address the work challenges of staff had the highest correlation with engagement. Closely followed by managers seeking to understand work challenges and organisation proactively supporting health and wellbeing. This tells us what our biggest drivers of engagement have been and improving these will continue to increase the engagement of our staff. Page 5 of 6 Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12-month rolling (internal target) Target 106 WTE reduction for UHS. • reduce bank use by 20% and agency use by 30%. Risks: • Delivering a net reduction in workforce will be challenging for UHS, especially in the context of (funded) clinical service expansions. It relies on length of stay and other productivity improvements, capacity closures, and implementation of organisational change processes. 10 Workforce Plan Note: Includes Employed, Bank and Agency Whole Time Equivalents worked 11 Transformation Programme Our plan includes further improvements within our existing Transformation programmes. • In 25/26, we expect to translate the productivity benefits into capacity, staffing and expenditure reductions, whilst maintaining the numbers of appointments / treatments. • Increases in activity numbers and income are not appropriate due to NHS funding limits. • Our improvement programmes also seek to improve patient experience, reduce waiting times, and ensure that patients see the right service for their needs. Programme Urgent & Emergency Care Target cash-releasing financial benefit £6.2m Rationale The value of reducing average length of stay by 5% against our 24/25 baseline and using the released capacity to close escalation beds and ward beds. Elective Care: Optimising Operating Services Elective Care: Outpatients £1.5m £1.5m Filling 30% of the case gaps on elective operating lists with an additional patient by reducing cancellations, better scheduling and improved start times. This will require fewer theatre sessions to run to treat the same number of patients. Improvements in booking practices and digitisation will reduce outpatient administration, postage and paper costs. Patients will be more efficiently treated by seeing additional patients per clinic and providing more advice & guidance allow us to reduce the cost of delivering the funded level of outpatient activity. Note: The above Transformation programmes are enablers for divisional CIP delivery. 12 Transformation Programme: Patient Flow The patient flow programme is targeting a 5% reduction in length of stay in 25/26 having delivered a 5.4% reduction in 24/25. The 20,769 bed days released are expected to be realised by closing inpatient capacity with a cost benefit of £6.2m. Admission numbers are expected to remain consistent with 24/25. 13 Transformation Programme: Theatres UHS increased its average theatre utilisation performance by 1% in 24/25 to 78.2%. Consistent performance at 85% utilisation enabled by improvements in scheduling practices and late starts would enable a further 500 patients to be treated on our existing lists. Reducing the number of lists to keep activity consistent with the funded level is planned to yield a cost reduction of £1.5m. 14 Transformation Programme: Outpatients Improving our Did Not Attend (DNA) rate to upper quartile levels will enable us to see more patients within our outpatient clinics. This will enable us to save money by reducing the number of clinics provided whilst maintaining the same number of appointments. In addition, administration, postage and paper costs will be reduced through centralisation of admin staff, partial booking approaches and digital patient communication. A total cost benefit of £1.5m is anticipated. 15 NCTR Patients (‘non-Criteria to Reside’ in an acute hospital) The number of patients waiting in an acute hospital bed when they are fit to leave (but typically require care in the community arranged by other organisations) continues to be a concern. Our ICS does not currently have an agreed plan or target for improvement in 25/26. UHS colleagues are working with local health and social care partners to explore how improvements could be achieved. Those improvements that can be achieved within the hospital are being driven through our Urgent and Emergency Care Transformation Programme. 16 Mental Health Patients The numbers of patients receiving care for their mental health in acute hospital continues to be a concern, particularly as the acuity of these patients has increased as well as their enhanced need requirements. Whilst some patients have mental health together with physical health needs, many do not require the acute hospital and will receive more appropriate care when a mental health inpatient or outpatient service can be accessed. In addition to the impact on each patient, staffing for mental health needs / safety results in significant additional costs at UHS. Our ICS does not currently have an agreed plan or target for improvement in 25/26. UHS colleagues are working with local partners to explore how improvements could be achieved. 17 Quality and Performance Targets Measure National Target for 2025-26 A&E waits: ED patients waiting under 4 At least 78% in March 2026 hours A&E waits: ED patients waiting over 12 hours Elective waits: Incomplete Referral to Treatment pathways of 52 weeks or more Elective waits: Patients waiting no longer than 18 weeks for a first appointment Elective waits: Incomplete RTT pathways of less than 18 weeks Elective waits: 62-day cancer standard Reduce compared to 2024/25 Less than 1% At least 72%, with every trust delivering a minimum 5% improvement by March 2026 At least 65%, with every trust delivering a minimum 5% improvement by March 2026 75% by March 2026 UHS Plan for 2025-26 Complies with national priorities 70% for ED then 78% UHS alone Yes in March 2026 (assumes new UTC at SGH opens) 2% Yes 0.9% Yes 72% Yes 67% Yes 77% Yes Elective waits: 28-day cancer Faster 80% by March 2026 83% Yes Diagnosis Standard Quality: safety in maternity and Delivering the 12 key actions of the Continue planned delivery Yes neonatal services ‘Three year delivery plan’ 18 Service Developments / Investments 2025/26 Our annual plan includes a significant number of service developments / expansions, and investments in buildings / technology, that will deliver improvements for patients and staff alike. These include: Development / Investment Description Aseptic Pharmacy Mechanical Thrombectomy Community Diagnostic Centre HIOW Elective Hub – Winchester Urgent Treatment Centre Audiology Booths Salix Energy Works New building at Adanac Park, an improved and significantly expanded service for the aseptic production of medicines for intravenous infusion Further expansions to the capacity and hours covered by this specialist emergency treatment for suitable patients who have suffered a Stroke (Update – now impacted by changes to NHS Commissioner funding) Expansion of CDC at RSH to include an additional NHS CT and an MRI scanner by 2026, new Phlebotomy service in 2025 New UHS service jointly with HHFT, at Winchester, to undertake Orthopaedic Hip and Knee replacement procedures in two new operating theatres (from summer 2025) Construction will take place during 2025/26 with the aim of service commencement in March 2026 at SGH, adjacent to the existing ED Two replacement Audiology booths at the RSH, that will be suitable for children and patients with disabilities Improve energy efficiency and reduce carbon emissions in healthcare facilities, via the NHS Public Sector Decarbonisation Scheme funding 19 Item 6.1 Report to the Council of Governors - 16 July 2025 Title: Review Terms of Reference - Council of Governors 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 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 Executive Summary: The terms of reference for the Council of Governors should be reviewed regularly, and at least once annually, to ensure that these reflect the purpose and activities of the Council of Governors. Following review, a few small changes are proposed to the Council of Governors’ terms of reference to reflect the current compliance arrangements, and one very minor grammatical change. The proposed changes are highlighted on the terms of reference document. The Council of Governors is asked to approve the revised terms of reference. Contents: Draft Council of Governors’ Terms of Reference Risk(s): N/A Equality Impact Consideration: N/A Council of Governors Terms of Reference Date Issued: 1 May 2024 16 July 2025 Review Date: April 20252026 Document Type: Terms of Reference Version: 78 Contents Paragraph 1 2 3 4 5 6 7 8 9 10 Role and Purpose Constitution Membership Attendance and Quorum Frequency of Meetings Conduct and Administration of Meetings Duties and Responsibilities Accountability and Reporting Review of Terms of Reference and Performance and Effectiveness References Appendices Appendix A Working Group and Reporting Structure Page 2 2 2 3 3 3 4 5 5 5 Page 6 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Page 1 of 7 1. Role and Purpose 1.1 The general duties of the council of governors (CoG) of University Hospital Southampton NHS Foundation Trust (UHS or the Trust) are: 1.1.1 to hold the non-executive directors (NEDs) individually and collectively to account for the performance of the board of directors (the Trust Board); and 1.1.2 to represent the interests of the members of the Trust as a whole, and the interests of the public. 1.2 The duties and responsibilities of the CoG are more fully described in paragraph 7 below. 2. Constitution 2.1 The establishment and role of the CoG is derived from the National Health Service Act 2006 (as amended). The CoG is accountable to the members of the Trust and the public. 2.2 It is supported in its work by other committees and groups established by the CoG as shown in Appendix A. 2.3 The CoG is authorised to investigate any activity within its terms of reference. In carrying out its role the CoG is also authorised to seek reports and assurance from executive directors and managers. 2.4 The CoG is authorised to obtain external legal or other independent professional advice if it considers this necessary, taking into consideration any issues of confidentiality and the Trust’s standing financial instructions and supported by the Company Secretary. 3. Membership 3.1 The CoG comprises: 3.1.1 Public elected governors from the following areas: 3.1.1.1 Five from Southampton City 3.1.1.2 Five from New Forest Eastleigh and Test Valley 3.1.1.3 One from The Isle of Wight 3.1.1.4 Two from the Rest of England and Wales. 3.1.2 Staff elected governors, one from each of the following staff classes: 3.1.2.1 Medical practitioners and dental staff 3.1.2.2 Nursing and midwifery staff 3.1.2.3 Health professional and health scientist staff 3.1.2.4 Non clinical and support staff. 3.1.3 Appointed governors, one from each of: 3.1.3.1 Hampshire and Isle of Wight Integrated Care Board 3.1.3.2 Southampton City Council 3.1.3.3 Hampshire County Council 3.1.3.4 University of Southampton 3.1.3.5 Solent University. Page 2 of 7 3.2 The chair of the Trust (the Trust Chair) is the chair of the CoG. In the absence of the Trust Chair, the deputy chair appointed by the CoG (the Deputy Chair) will chair the meeting, or in their absence, another non-executive director. If there is no nonexecutive director present or available, the governors present will elect one of themselves to chair the meeting. 3.3 Only members of the CoG have the right to attend and vote at CoG meetings. However, the two Associate Governors will be invited to attend all meetings of the CoG. The Company Secretary and the Council of Governors’ Business Manager will also attend all meetings of the CoG. 3.4 Other individuals may be invited to attend for all or part of any meeting, as and when appropriate and necessary, particularly when the CoG is considering areas of risk or operation that are the responsibility of a particular executive director or manager. 4. Attendance and Quorum 4.1 Governors should aim to attend every meeting. Where a governor is unable to attend a meeting they should notify the Trust Chair or Council of Governors’ Business Manager in advance, providing a reason for their absence. 4.2 The quorum for a meeting will be one-third of the governors. A duly convened meeting of the CoG at which a quorum is present will be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the CoG. 4.3 When an executive director or manager is unable to attend a meeting they should appoint a deputy to attend on their behalf. 5. Frequency of Meetings 5.1 The CoG will meet at least four times each year. 6. Conduct and Administration of Meetings 6.1 Meetings of the CoG will be convened by the Company Secretary at the request of the Trust Chair, or the Deputy Chair in their absence. 6.2 If the Trust Chair refuses to call a meeting after a requisition for that purpose, at least one-third of the governors may request the Trust Chair to convene a meeting in writing specifying the business to be transacted at the meeting. If the Trust Chair does not call a meeting within seven clear days after the receipt of the signed request, one-third or more of the governors may call a meeting for the purpose of conducting that business. 6.3 The agenda of items to be discussed at the meeting will be agreed by the Trust Chair with support from the Company Secretary and the Council of Governors’ Business Manager. The agenda and supporting papers will be distributed to each member of the CoG and the regular attendees, no later than five days before the date of the meeting. Distribution of any papers after this deadline will require the agreement of the Trust Chair. 6.4 The Council of Governors’ Business Manager will minute the proceedings of all meetings of the CoG, including recording the names of those present and in attendance and any declarations of interest. 6.5 Draft minutes of CoG meetings and a separate record of the actions to be taken forward will be circulated promptly to all members of the CoG. Page 3 of 7 7. Duties and Responsibilities The CoG will have the following duties and responsibilities. 7.1 Holding the Non-Executive Directors to Account 7.1.1 hold the NEDs individually and collectively to account for the performance of the Trust Board; 7.2 Appointment of Chair, Non-Executive Directors, Chief Executive and External Auditor 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.2.6 7.2.7 7.2.8 7.2.9 approve the policies and procedures for the appointment and, where necessary, for the removal of the Trust Chair and NEDs; approve the appointment (or removal) of the Trust Chair; approve the appointment (or removal) of a non-executive director; approve the policies and procedures for the appraisal of the Trust Chair and NEDs; approve the policy for the composition of the NEDs; approve changes to the remuneration, allowances and other terms of office for the Trust Chair and NEDs; consider and, if appropriate, approve the appointment of the chief executive officer of the Trust as recommended by the Trust Chair and the NEDs; approve the criteria for appointing, re-appointing or removing the external auditor; approve the appointment or reappointment and the terms of engagement of the external auditor; 7.3 Constitution and Compliance 7.3.1 7.3.2 7.3.3 7.3.4 7.3.5 7.3.6 approve amendments to the constitution, recognising that any changes in respect of the powers, duties or role of the CoG will need to be approved at the next general meeting of members; approve the policy for the composition of the CoG; notify NHS England if the CoG is concerned that the Trust has breached, or is at risk of breaching, its licence conditions in the event that these concerns cannot be resolved through engagement with the Trust Board; receive the Trust’s annual report and accounts (including the quality accounts/report) and any report of the external auditor on them; decide whether a member is disqualified from membership or no longer eligible to be a member in the event of a dispute referred by the Company Secretary; consider any appeal by a member about entitlement to membership following a decision by the Company Secretary; 7.4 Governors 7.4.1 7.4.2 7.4.3 7.4.4 7.4.5 7.4.6 7.4.7 decide whether to appoint committees of the CoG to assist in the performance of its functions; approve the appointment of governors to any committees or working groups of the CoG or joint working groups with the Trust Board; approve the process for appointment or election to the role of lead governor and, as necessary, deputy lead governor; receive reports from the chairs of each committee or working group of the CoG on the discharge of the committee’s or working group’s duties; approve the removal from office of any governor in accordance with procedure set out in the constitution; approve jointly with the Trust Board the procedure for the resolution of disputes and concerns between the Trust Board and the CoG; decide whether or not to terminate the tenure of office of a governor for failure to attend meetings or to terminate a governor’s tenure of office for other reasons; Page 4 of 7 7.4.8 decide what action to take when a vacancy arises among the elected governors; 7.5 Strategy, Planning and Reorganisations 7.5.1 7.5.2 7.5.3 7.5.4 7.5.5 7.5.6 in response to requests from the Trust Board, provide feedback on the development of the annual operating plan and the strategic direction of the Trust; contribute to the development of stakeholder strategies, including membership engagement strategies; where the Trust’s forward plan contains a proposal that the Trust will carry on an activity other than the provision of goods and services for the purposes of the NHS in England, determine whether the CoG is satisfied that such activity will not interfere with this and notify the Trust Board of its determination; consider and, if appropriate, approve proposed increases to the amount of income derived from the provision of goods and services other than for the purpose of the NHS in England where such an increase is greater than 5% of the total income of the Trust in the relevant financial year; consider and, if appropriate, approve proposals from the Trust Board for mergers, acquisitions, separations and dissolutions (which will require the approval of more than half of the total number of governors); consider and, if appropriate, approve proposals for significant transactions in accordance with the constitution or such other transactions as the Trust Board may submit for the approval of the CoG from time to time (which will require the approval of more than half of governors voting at a quorate meeting of the CoG); 7.6 Representing Members and the Public 7.6.1 7.6.2 7.6.3 7.6.4 7.6.5 7.6.6 represent the interests of the members of the Trust as a whole and of the public; consider and, if appropriate, approve the membership engagement strategy; contribute to members’ and other stakeholders’ understanding of the work of the Trust in line with engagement strategies; seek the views of stakeholders, including members and the public and feed back relevant information to the Trust Board or to individual executive directors as appropriate; promote membership of the Trust and contribute to opportunities to recruit members in accordance with the membership engagement strategy; and report to members each year on the performance of the CoG. 8. Accountability and Reporting 8.1 The CoG will report to the membership at the Annual Members’ Meeting and on such other occasions as are arranged. 9. Review of Terms of Reference and Performance and Effectiveness 9.1 At least once a year the CoG will review its collective performance and effectiveness and its terms of reference. Any proposed changes to the terms of reference will be approved by the CoG. 10. References 10.1National Health Service Act 2006 10.2NHS Foundation Trust Code of GovernanceCode of Governance for NHS Provider Trusts 10.3Trust Constitution 10.4Standing Orders for the Practice and Procedure of the Council of Governors Page 5 of 7 Appendix A Council of Governors Governors' Nomination Committee Membership and Engagement Working Group Patient and Staff Experience Working Group Strategy and Finance Working Group Required by National Health Service Act 2006 or NHS Foundation Trust Code of Governance Code of Governance for NHS Provider Trusts Discretionary committee/group . Page 6 of 7 Council of Governors Terms of Reference Document Monitoring Information Approval Committee: Date of Approval: Responsible Committee: Council of Governors 1 May 202416 July 2025 Not applicable Version: 78 Monitoring (Se
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Papers CoG 23.10.2024

Description: Date Time Location Chair Agenda Council of Governors 23/10/2024 14:35 - 16:15 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:35 2 Declarations of Interest 14:39 3 Minutes of Previous Meeting 14:40 Approve the minutes of the previous meeting held on 24 July 2024 4 Matters Arising/Summary of Agreed Actions 14:42 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:44 Receive and note the report Sponsor: David French, Chief Executive Officer 15.04 Break 6 Governance 6.1 Governor Attendance at Council of Governors' Meetings 15:14 Review governor attendance at Council of Governors' meetings Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.2 Appointment to the Governors' Nomination Committee 15:19 Note the appointment of Jenny Lawrie to the Governors' Nomination Committee Sponsor: Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.3 Meeting with the Hampshire and IoW ICB - Chair Appointments (Oral) 15:21 Receive details of the background to this meeting Sponsor: Sponsor: Jenni Douglas-Todd, Trust Chair 6.4 Strategy Session Planning (Oral) 15:31 Discuss plans for the Strategy Session on Wednesday, 11 December 2024 Sponsor: Jenni Douglas-Todd, Trust Chair 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:41 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Sam Dolton, Events and Membership Officer 7.2 Feedback from Strategy and Finance Working Group 15:51 Chair: Mandy Fader 7.3 Feedback from Patient and Staff Experience Working Group 15:56 Chair: Sandra Gidley 7.4 Feedback from Membership and Engagement Working Group 16:01 Chair: Patricia Crates 8 Review of Meeting 16:06 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any Other Business 16:09 Raise any relevant or urgent matters that are not on the agenda 10 Date of Next Meeting: 29 January 2025 16:14 Note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 24 July 2024 14.00-15:45 Conference Room, Heartbeat Education Centre and Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair JDT Theresa Airiemiokhale, Elected, Southampton City TA Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley SA Katherine Barbour, Elected, Southampton City KB Patricia Crates, Elected, New Forest, Eastleigh and Test Valley PC Helen Eggleton, Hampshire and Isle of Wight Integrated Care HE Board (ICB) Professor Mandy Fader, Appointed, University of Southampton MF Lesley Gilder, Elected, Southampton City LG Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley SG Jenny Lawrie, Elected, Southampton City JL Brian Lovell, Elected, Rest of England and Wales BL Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley EO Jake Smokcum, Elected, Nursing and Midwifery Staff JS Liz Taylor, Elected, Non-Clinical and Support Staff LT In attendance Jessica Burnett, Associate Governor JB Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD David French, Chief Executive Officer (for item 5.1) DF Ian Howard, Chief Financial Officer (for item 5.2) IH Craig Machell, Associate Director of Corporate Affairs and CM Company Secretary Neylia Mustafapour, Associate Governor NM Karen Russell, Council of Governors’ Business Manager KR Apologies Sathish Harinarayanan, Elected, Medical Practitioners and Dental Staff Linda Hebdige, Elected, Southampton City Councillor Edward Heron, Appointed, Hampshire County Council Councillor Pam Kenny, Appointed, Southampton City Council Catherine Rushworth, Elected, Isle of Wight Professor Emma Wadsworth, Appointed, Solent University Mike Williams, Elected, New Forest, Eastleigh and Test Valley Quintin van Wyk, Elected, Rest of England and Wales SH LH EH PK CR EW MW QvW 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and congratulated SA on her appointment as the new Lead Governor, following Kelly Lloyd’s move away from UHS. 1 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 1 May 2024 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions All actions had been completed. The Chair noted the following: No. 1116 - During the discussion between governors and NEDs, prior to the CoG meeting, Tim Peachey, NED, had provided an update regarding security at the PAH and had advised that improvements had been made. No. 1128 - Staff had been thanked for their hard work and achievements and a message would be included in the next executive briefing. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report The Chair welcomed DAF, Chief Executive Officer. He noted that his report had been circulated prior to the meeting and said that he would be happy to take any questions from governors. DAF advised that he had met with the new Secretary of State for Health on 19 July 2024 and he had said that government would focus on emergency waiting times and the size of waiting lists. DAF advised governors that at the end of the year UHS had been in the top ten peer teaching hospitals for its ED 4-hour performance and had been awarded £5.5m to improve facilities, which was a testament to the work being done by staff. He also noted that the better the outcomes and reputation of the hospital, the more people wanted to come to UHS, which increased the pressure on waiting lists. The Trust had ranked in the top 5 teaching hospitals nationally for its elective activity and had delivered 123% of 2019/20 levels, which was 10% above its own target. The Chair added that many hospitals were still struggling to achieve 100%. DAF advised that UHS was working hard to reduce its waiting lists and had a particular focus on those who had waited the longest. He advised that the Trust had some patients who had waited18-months for corneal grafts but the availability of donor tissue was controlled nationally. There was also a national target to have no patients waiting over 65 weeks by the end of September 2024. The Secretary of State had appointed Lord Darzi to undertake a 10-year review of the NHS and he had been clear that it would look at a shift into the community, the prevention of sickness and a move from analogue to digital. DAF advised that capital funding may become available for digital transformation and UHS would be ready for that. DAF advised that nationally the NHS was overspent at the end of Month 2 by approximately £1b. UHS was part of that overspend and had reported an £8m deficit after two months, which was £2m worse than plan. The number of patients in the hospital not meeting the criteria to reside (CTR) remained between 200 and 250 each day. Also, whilst UHS was a low spending 2 hospital on agency staff, most of that spend related to caring for patients with mental health issues, who it had less ability to discharge. On a more positive note, DAF advised that the hospital’s transformation programmes for the year around inpatient flow, outpatient pathways and getting more patients through theatres, were proving to be successful. In response to questions from governors, DAF advised that: • the Trust was so overwhelmed with treating sick people, it was struggling to make sufficient progress in relation to the government’s strategy for prevention. However, the LifeLab programmes at SGH were very successful and provided an excellent opportunity for school children to go into the hospital to learn about health, diet, activity and mobility. • general practice was overwhelmed and the demands on health services were increasing faster than the NHS could cope with. 5.2 Operating Plan 2024/25 The Chair welcomed IH, Chief Financial Officer, to the meeting. He advised that there had been significant pressure on NHS finances last year with systems similar to the Hampshire and Isle of Wight (HIOW) ICB, off plan by around £1.5b nationally. UHS had delivered a deficit position of £29m in 2023/24 but had then received cash support of £25m, which meant that it had ended the year with a cash deficit of £4.5m. Driving those pressures had been industrial action, unfunded pay awards and system pressures, e.g. patients no longer meeting the CTR and those with mental health needs. On a more positive front the Trust had delivered 118% of its Elective Recovery Fund (ERF) baseline last year, which placed it within the top seven Trusts in the country. It had a savings programme of £65m and some of its transformation programmes were gaining traction. However, some non-recurrent, one-off support, had been removed but the Trust was committed to maintaining the quality of the services it offered to patients. There was, therefore, a focus on stretch improvements that could be made within UHS and collectively, across the HIOW system. In response to questions from governors, IH advised that: • the stretch improvements were a step up from last year but if UHS was to ask NHSE for cash support, the hospital would be unable to maintain its capital programme/investment. • only a small number of staff were funded by industry but there were some military staff and a few linked to charities. NHSE was keen for UHS to reduce its staffing levels by 2% but the Trust had a long-term workforce plan to increase staffing. • the Trust had ambitious plans to generate income from IP (Intellectual Property) but those would take time. 5.3 Annual Report Update CM advised that due to delays in the Standing Orders process, the Trust had not been able to meet the 28 June submission deadline to NHSE. The Trust had informed NHSE, who had asked for some draft information by that date, with the rest to follow. The annual report and accounts had, however, been submitted to NHSE on 19 July 2024 and would be laid before parliament in September, when they returned from their summer recess. 3 The Trust’s auditors had signed off the hospital’s audit report last week and had raised two points: • the size of the Cost Improvement Programme (CIP), which they considered a risk as a large proportion of it was unidentified. CM advised that they had raised the same concern last year. • governance around the finance process which had required a complete rebuild regarding supporting information and had delayed the provision of information to the auditors. 6 Governance 6.1 Appointment of Lead Governor The Chair noted that two governors had expressed an interest in becoming Lead Governor, following the departure of Kelly Lloyd from the Trust. Their statements had been circulated to governors and SA had been appointed by majority decision. The Chair congratulated SA on her appointment. Decision: The CoG noted the appointment of SA as Lead Governor with effect from 1 July 2024. 6.2 Confirmation of Election of the Membership and Engagement Working Group Chair Following the departure of Kelly Lloyd from the Trust, KR advised that PC had been the only governor who had expressed an interest in becoming Chair of the Membership and Engagement Working Group. The working group had voted unanimously, to appoint her to the role. Decision: The CoG confirmed the appointment of PC as Chair of the Membership and Engagement Working Group. 6.3 Governors’ Nomination Committee Terms of Reference CM advised that the Governors’ Nomination Committee (GNC) had reviewed its Terms of Reference (ToR), in order to provide greater flexibility related to the composition of its membership. The ToR had therefore been amended to state that at least three members of the committee were governors elected by the members of either the public or staff constituencies. Decision: The CoG approved the proposed changes to the GNC Terms of Reference. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report. He advised that membership numbers were down and that the Communications Team had reduced by three, which meant that they had been unable to attend as many events as they would have liked to. They had, however, been looking to see which other teams/organisations they could partner with. Engagement with public members had continued with a monthly newsletter to keep members updated and a quarterly Connect digital magazine. The latest edition of Connect had gone out 23.7.24 and the already been opened by 42% of the membership. In May the Trust had hosted a virtual event ‘Choosing the right healthcare for your child’ together with South Central Ambulance Service and in July it had hosted the 4 second virtual event in the series ‘Transforming lives and healthcare through research’. Both had been well received, with over 130 watching the recording of the latter. There had been good engagement with the staff recognition programme, which included the sending of a High 5 certificate to a colleague, the monthly UHS Stars award (presented by DAF) and the annual award ceremony. Nominations for the latter would close on 26.7.24 and 500 nominations had already been received. SD advised that Trust members had the opportunity to nominate a member of staff for the UHS Champions Award at the annual award ceremony. The Communications Team had also been busy supporting the CoG elections and he thanked SA for her support. She, in turn, thanked him for his work and enthusiasm. He also thanked PC and JL for their support at the Mela events in recent weeks. MF advised that the Trust had, in previous years, been successful in recruiting members from Southampton University and she suggested that SD considered making contact with them. The Chair also suggested that he spoke to EW about the possibility of a campaign at Solent University. Action: SD to look into the possibility of campaigns at Southampton and Solent universities to recruit members. 7.2 Annual Members’ Meeting Update SD advised that for the first time in five years, the annual members’ meeting would be in person, rather than virtual. It would include:• the presentation of the annual report and accounts in the Heartbeat Lecture Theatre (which would be recorded). • an open evening with a chance to show case what was happening and what services the Trust offered outside of the hospital. • support for the preventative agenda. • an opportunity to chat with UHS teams about what they offered. Details were still being worked on but it was hoped that governors would be actively involved in the evening, which would be held on 21 November 2024. 7.3 Governors’ Nomination Committee Feedback KR advised that the Trust would be looking to recruit another public governor to join the GNC. 7.4 Feedback from Strategy and Finance Working Group MF advised that Martin De Sousa, Director of Strategy and Partnerships, had attended the meeting to provide a general update on strategy. He had presented a large slide deck which had been circulated to all governors and she commended it to them. She said that there had been a good discussion and that he had been very open about the achievements that had been made but also the challenges. 7.5 Feedback from Patient and Staff Experience Working Group SG advised that Steve Harris, Chief People Officer, Anita Esser, Head of Education, Training and Development and Ceri Connor, Director of OD and Inclusion had attended the meeting. They had talked about staff turnover (which had decreased), apprenticeships, improving leadership and wellbeing and the staff survey. She had, in particular, been struck by the way in which staff, on apprenticeships, had then been able to progress in the Trust. 5 7.6 Feedback from Membership and Engagement Working Group PC advised that Southampton Mela had been reasonably well attended and the hospital team had been able to engage with the public and hand out leaflets. Southampton Pride was coming up and a couple of governors had already said that they would attend. The team had also held a joint meeting with the Diabetic Association. Governors discussed the importance of having an activity (a hook) to draw people in at events and noted that whilst this was something that UHS did well, some teams struggled. KB noted that Solent University had been taking blood pressures at an event, which had caught people’s attention. The possibility of an occasional slot on Radio Solent had been suggested by governors and also whether it would be possible for them to spend some time on the Reception desk, at the main entrance to the hospital, to talk to visitors and patients. SA asked SD whether there would be an opportunity to fill the staff gaps in his team. He advised that clinical posts were currently the priority but said that it was a good team, who supported one another well and he was exploring opportunities to work alongside the Experience of Care Team. PC thanked SD for his unfailing enthusiasm and said that he and his team provided excellent programmes. 8 Review of Meeting Governors noted the significant financial pressures on the Trust, even though UHS was one of the best performing hospitals nationally and also the challenges due to issues related to social care. The difficulties with the poor sound quality during CoG meetings, both in the conference room and for those joining via Teams was raised. The Chair said that this was a long-standing issue that was being looked into but any solution was likely to be expensive. 9 Any Other Business The Chair noted this was JB’s last CoG meeting as she would be going to Sheffield University. She thanked JB for her work as an Associate Governor and wished her well for the future. She also noted that NM had just completed her A level exams and was awaiting the results. NM advised that she intended to remain in Southampton and that she would, therefore, be keen to continue as an Associate Governor. SA thanked both students for their contributions during meetings and at events, which she said had been invaluable. Two governors were reaching the end of their terms of office. BL advised that he intended to stand again for election but KR advised that QVW would be standing down. It was noted that there had been a lot of interest in the vacancy for a staff governor to replace Kelly Lloyd and nominations were to close on 31 July 2024. The Chair thanked colleagues for their contributions during the meeting and said that she hoped everyone had a good summer. 10 Date of Next Meeting The next meeting of the CoG would be held on 23 October 2024. 6 List of action items Agenda item Assigned to Deadline Status Council of Governors 24/07/2024 7.1 Membership Engagement 1153 SD to look into the possibility of membership campaigns at . Southampton and Solent universities to recruit members. Sam Dolton 23/10/2024 Completed Explanation MF advised that the Trust had, in previous years, been successful in recruiting members from Southampton University and she suggested that SD considered making contact with them. The Chair also suggested that he spoke to EW about the possibility of a campaign at Solent University. SD is arranging a Teams meeting with EW regarding the possibility of a campaign at Solent University. MF is standing down with effect from 25 October 2024 due to her retirement from the University of Southampton, so SD will arrange a meeting with her successor once they are appointed. SD also advised that has had a couple of discussions with UHS teams about freshers fairs, but none of them had the capacity. However, SD has confirmed that the Research and Development team attended the University of Southampton freshers fair on 27 September 2024 to take part in a joint partnership stand with the University. Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Sam Dale, Associate Director of Data and Analytics 23 October 2024 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: This report provides performance information relating to a broad range of Trust services and activities. There are no specific implications. Risks: This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. UHS Council of Governors October 2024 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 July 2024 to September 2024, noting that some quarterly performance data is reported further in arrears. Notable features of the last quarter include: • The financial environment remains extremely challenging. The annual plan for 2024/25 was originally approved as a £14.5m deficit, and as at M5 the Trust was reporting a £20.6m deficit. We are however expecting additional funding in M6, including £11.2m of national support towards our planned deficit. • Despite the financial challenges, the organisation has made significant progress in controlling workforce growth and remains on target to invest its full capital allocation. • The trust has delivered elective activity at 126% of 2019/20 levels and continues to drive incremental improvements in theatre utilisation, outpatient productivity and length of stay reduction. • Improving patient flow throughout the hospital remains one of our highest priorities as the number of patients attending the emergency department increased by 3% compared to quarter two in 2023/24. Whilst the volume of patients in the hospital not meeting the criteria to reside (nCTR) did reduce in July and August, it remains above 200 each day and has since increased. • Despite the operational challenges, the hospital is benchmarking well on performance targets for elective waiting lists, emergency waiting times and cancer pathways despite a recent increase in referrals. UHS is consistently in the top quarter for most key waiting time metrics when compared to peer teaching hospitals across the UK. • The organisation continues to prioritise clinically urgent and long waiting patients and reported just 18 patients waiting over 65 weeks at the end of September with 89% of these caused by a national shortage of transplant tissue. Our ambition and focus for the remainder of the year has already transitioned to treating all patients waiting over 52 weeks. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 78.0% EDs (Types 1 & 2) (Mar’25) Jul 2024 72.8% Aug 2024 Sep 2024 69.9% 67.9% Attendances to the Emergency Department (ED) continue to remain high, averaging 421 per day across July, August and September in 2024. Whilst this does represent a small decrease against the previous quarter, it is a 3% increase against the equivalent summer period last year. There were periods of significant pressure on the service in late September 2024. Whilst this presents flow challenges for the organisation, UHS maintained a four hour performance position of 70% when averaged across quarter two. The hospital’s ED performance continues to rank comparatively - ranking 4th for September 2024 when compared to 20 peer teaching hospitals across the UK (for Type 1 attendances). Page 3 of 7 Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Jul 2024 64.39 60461 Aug 2024 63.23 59649 Sep 2024 TBC TBC The trust’s RTT waiting list saw a month on month increase across quarter 1, however this levelled off in July 2024 and marginally reduced back to below 60,000 in August 2024. The recent pressure on the waiting list remains within the referral element of patient pathways, whereas the volume of patients waiting for a planned admission or diagnostics are stable or have reduced. A significant proportion of the referral growth sits within a small number of specialties as they look to flex existing capacity and staffing levels with the increased referral demand. Overall, the hospital continues to benchmark well for the proportion of patients who have been waiting over 18 weeks for treatment, with UHS ranking in fourth place for August 2024 when compared to 20 peer teaching hospitals. The organisation has made strong progress against the national waiting time cohorts and associated targets. The trust has consistently reported zero patients waiting over two years. The only cohort of patients waiting over 78 weeks (2 in September 2024) remain those impacted by the national shortage of corneal tissue which is managed nationally. Similarly the trust reported 18 patients waiting over 65 weeks for September 2024 and 16 of these were corneal transplants. Further corneal tissue is about to released from the national team which will support the trust’s ambition to have zero patients waiting over 65 weeks as we transition focus on patients waiting over 52 weeks. The organisation ranked in first place for the volume of patients waiting over 65 weeks in August 2024 when compared to peer teaching hospitals. Cancer Faster Diagnosis - within 28 days 31 Day target - decision to treat to first definitive treatment 62 day target - urgent referral to first definitive treatment Target > =77% => 96% => 70% Jun 2024 82.43 88.03 74.12 Jul 2024 80.78 93.37 74.54 Aug 2024 82.00 96.09 77.61 The organisation continues to prioritise cancer patients and their treatments for all tumour sites and cancer types. Pathway efficiencies particularly around pathology and diagnostics are constantly being explored as well as regular dialogue with Wessex Cancer Alliance and the ICB on improvements and innovative techniques to ensure referrals are appropriate and timely. There has been a small decline in Cancer performance for 28 day faster diagnosis (80.78% in August 2024) but a significant improvement in the 31 day standard (93.4%). The Trust ranks in the top half when compared to peer teaching hospitals for all key cancer metrics for the latest available month (August 2024). 5. Finance UHS reported a headline financial position of: • Month 5 - £3.8m deficit (£2.1m adverse to plan) • Year to date - £20.6m deficit (£7.6m adverse to plan) Whilst the position remains extremely challenging, there continues to be an improving month on month trend with the in-month deficit reducing from £3.9m to £3.8m. Underlying financial improvement remains more significant with month-on-month improvement being illustrated over the first five months of 2024/25. Page 4 of 7 Overall Narrative The Trust is continuing to substantively deliver on financial improvements where outcomes are within its direct control. For example: • The Trust has delivered LOS improvements for P0 patients of 5%, supporting surge capacity to remain closed. • We have delivered an increase in First Outpatient appointments of 10% and Advice and Guidance of 10%, supported by a reduction in follow-up appointments of 9%. Our Outpatient First/Procedure to Follow-up ratio has improved to 53%, above the 46% national target. • The Trust has implemented new workforce controls embedded within Divisions, which have been widely supported. We are significantly below our pay expenditure plan. • We are currently utilising agency for 0.6% of our total workforce, significantly below the national target of 3.2%. • Our temporary staffing (bank and agency) is below plan by £4m, and £6m below than the same point in 23/24. • UHS is performing well on ERF activity through transformation programmes and other initiatives, with YTD performance at 126% of baselines, above the overall national target of 107% (although marginally below our plan). • UHS has delivered £25m CIP by M5, which is £4m above the trajectory from 23/24. • Since March 24, our ERF performance has increased by 9%, and at the same time our staffing levels have reduced by 2%. However, a number of issues have presented in year which has created a financial variance, some of which are outside of the organisations full control: • Industrial Action (£1.5m) – the junior doctor strike in late June / early July has dampened the level of ERF income by c£1m and resulted in additional direct costs of c£0.5m. • Consultant pay award (£0.9m YTD) – there is a gap between funding and estimated cost of implementing the consultant pay award. • Increase to the Specialist Commissioning ERF Target (£0.5m YTD) – due to a national imbalance a further increase was applied to the ERF target for UHS that will result in unremunerated activity of £1.2m for 24/25. • System Related CIPs undelivered (£3.9m) – the four system related CIP schemes (reducing NCTR patients / reducing MH patients / Corporate cost reductions / additional service development fund income) are working collaboratively across the system; however, output metrics that support reduction in provider costs have not yet materialised. • UHS have YTD performed circa £13.5m of activity above block contract levels, which is unfunded. Further to this, within the Trust a pay underspend YTD is offsetting non pay pressures and income shortfalls against plan. Additionally, several one-off benefits have helped support the position with a VAT benefit from prior years delivering £0.7m in month. Funding Uncertainty There are a number of items expected to impact the financial position in M6 or future months. These include: • Non-recurrent deficit support funding has recently been confirmed to be received in M6. This will result in a revised financial plan from M6-M12. UHS is anticipating receiving c£11m. • ERF final performance for 2023/24 has yet to be confirmed. We are expecting a reduction to our 24/25 target, which will give an upside to our current reported position. • ERF performance to date in 2024/25 has yet to be shared – it is normally 3 months in arrears. We are estimating performance using local data. For every month that information is delayed we are increasing the level of risk and potential variation within our reported numbers. Page 5 of 7 • Industrial action – we are anticipating a share of national funding, which would improve our current position. • Specialised Commissioning ERF target – as mentioned above, this was increased unexpectedly in 24/25. We have submitted a challenge nationally as part of the contractual process for 24/25 and are awaiting the outcome. • Pay award funding – we are awaiting confirmation of the value of funding to be received in relation to confirmed 24/25 pay awards, including cash to support backdated payments being made in M6. These factors could cause some volatility in reported financial positions in coming months. We will ensure our underlying position takes these movements into account. Cash The Trusts underlying deficit continues to drive a deterioration in the month-on-month cash position. August ended with a cash balance of £23.8m that is marginally higher than the recently reforecast position. As per previous updates the cash recovery plan has been enacted and close working with commissioners has helped ensure cash inflows are timely. Capital Capital expenditure of £14.2m YTD is slightly behind plan (£1.9m variance), however leaves over £44m to be spent across the remainder of 24/25. Changes to the Building Safety Act have created delays and overspends in several key projects notably the Neonatal expansion. Trust Investment Group reviewed the most likely forecast that illustrated a high degree of certainty that the capital expenditure plan for 24/25 would be delivered, however did create challenge for 25/26 with slippage greater than planned. This will be reviewed in the context of capital planning and prioritisation for 25/26 over the coming months. 6. Human Resources Staff Survey Results Indicator Q1 24/25 Staff recommend UHS as a place to work % 63.8% Staff survey engagement score (out of 10) 6.85 Q2 24/25 64.1% 6.84 The recommendation as a place to work measure has increased marginally, as it did in the previous report. This quarterly survey received a response rate of 21% (over 3000 of our staff). The quarterly surveys enable us to track engagement measures throughout the year, as a Trust and in particular teams and departments. This quarter, the Trust’s engagement score fell slightly. We hope to see this increase in the annual staff survey launching end of September. Turnover: Indicator Staff Turnover (internal target; rolling 12 month) Sickness absence 12 month rolling (internal target) Target <=13.6% <=3.9% Jul 2024 11.2% 3.9% Aug 2024 11.1% 3.9% Sep 2024 TBC TBC In August 2024 there were a total of 110 WTE leavers. The highest number of leavers was in Division B, with Page 6 of 7 34 WTE leavers. Within Division B, the Nursing and Midwifery Registered staff group had the highest number of leavers (12 WTE), followed by the Additional Clinical Services staff group at 11 WTE. Division D and C had the second and third highest number of leavers (23 and 22 WTE respectively); with the largest numbers being Nursing and Midwifery Registered staff group in both Divisions (11 WTE leavers in Div D and 7 WTE leavers in Div C). Sickness: The 12-month rolling sickness absence rate has hit the Trust’s target at 3.9% from month 4 to month 5 (July to August 2024), after a consistent downtrend from the January 2024 sickness rate which stood at 4.2%. Page 7 of 7 Item 6.1 Report to the Council of Governors - 23 October 2024 Title: Governor Attendance at Council of Governors’ Meetings 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 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 N/A N/A N/A N/A N/A Executive Summary: Under the Trust’s constitution (paragraph 2.1 of Annex 5) if a governor fails to attend two successive meetings of the council of governors, his or her tenure of office is to be immediately terminated by the council of governors (CoG) unless the CoG is satisfied that: • the absences were due to reasonable cause; and • he/she will be able to attend meetings of the CoG within such a period as the CoG considers reasonable. Following the recent review, there was one governor who had failed to attend two successive ordinary meetings of the CoG. Reasons for non-attendance were provided and were due to reasonable causes. In order to ensure that the CoG considers the situation when a governor fails to attend two successive ordinary meetings of the CoG, the process is for the Chair or Company Secretary contact the governor to understand the reasons for this if these have not already been provided. The Chair or Company Secretary would then provide confirmation to the CoG as to whether this was due to reasonable causes and the governor’s ability to attend future meetings. This would also help to identify any steps that the Trust could take to facilitate attendance. The CoG is asked to confirm that it is satisfied that the failure of one current governor to attend two successive meetings of the CoG was due to reasonable causes and that they would be able to attend future meetings within a reasonable period so that no termination of a current governor’s tenure of office is required or occurs. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Item 6.2 Report to the Council of Governors Title: Appointment to the Governors' Nomination Committee 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: A vacancy arose on the Governors’ Nomination Committee as Kelly Lloyd stood down on leaving her employment at the Trust on 30 June 2024. Governors were asked to express an interest if they were willing to join the Governors’ Nomination Committee. Jenny Lawrie expressed an interest in taking on this additional role. The Council of Governors is responsible for appointing the members of the Governors’ Nomination Committee and has decided by a unanimous vote to approve her appointment. The Council of Governors is asked to note the appointment of Jenny Lawrie to the Governors’ Nomination Committee. Contents: N/A Risk(s): N/A Equality Impact Consideration: N/A Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Membership Engagement 7.1 Jenni Douglas-Todd, Trust Chair Sam Dolton, events and membership officer 23 October 2024 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about engagement with Trust members supports the Council of Governors in their role. Response to the issue: This report aims to update the council on Trust membership and recent and planned engagement activities. Implications: (Clinical, Organisational, Governance, Legal?) This report provides engagement information, there are no specific implications. Risks: (Top 3) of carrying out the change / or not: This report is provided for the purpose of information. Summary: Conclusion This report is provided for the purpose of information. and/or recommendation Page 1 of 5 Overview of engagement Over the last three months we have continued to be proactive in engaging with our members. Membership updates Our routine membership updates have continued to be split into two different formats: • A monthly newsletter to keep public members updated on what’s happening across the Trust and the ways they can get involved in various projects, with September and October editions produced. • A quarterly Connect digital magazine which mainly focuses on patient stories, UHS successes and individual/team achievements, with the Summer 2024 edition going out in July. Update Summer 2024 September 2024 October 2024 Type Quarterly magazine Monthly update Monthly update Date sent 23/07/2024 10/09/2024 02/10/2024 Sent to 2988 2978 2958 Bounces 59 60 64 Opens* 49% 49% 47% Targeted emails We sent three targeted emails to smaller sections of our database. In August all public members who registered to attend February’s Spotlight on dementia research virtual event were invited to take part in a survey to explore public perspectives on the use of AI in dementia diagnosis. The study is led by Dr Sofia Michopoulou, head of nuclear medicine physics at UHS and one of the speakers in the Spotlight on dementia research virtual event. At the end of September we were asked to promote an upcoming winter wellness webinar hosted by Wessex Research Hubs to public members between the ages of 50 and 65. And the topic for University of Southampton’s upcoming Annual Wade Lecture this year is Neuroimaging and its spectacular insights into brain health and disease, with guest speaker Professor Joanna Wardlaw, so all public members who registered to attend February’s Spotlight on dementia research virtual event were invited to attend either online or in person. Email Artificial intelligence in dementia diagnosis survey Wessex Research Hubs Winter wellness webinar Annual Wade Lecture 2024 Date sent 14/08/2024 30/09/2024 01/10/2024 Sent to 146 639 142 Page 2 of 5 Bounces 1 20 2 Opens* 73% 46% 66% Other emails At the start of September we invited public members to attend our annual members’ meeting, which will take place in person along with an open evening on Thursday 21 November. Email Invitation to annual members’ meeting Date sent 02/09/2024 Sent to 2978 Bounces 64 Opens* 45% * All open rates as of 15 October 2024 Public engagement on social Impressions = number of times a post has been displayed Engagement = number of likes, shares, comments We have been active across our social media channels. Content with high engagement included: Emergency department pressure In September we asked people to share that our emergency department (ED) was exceptionally busy, with 700 patients seen in a day and a half. Posts advised people to only attend ED in life-threatening emergencies and consider local urgent treatment centres for less-severe conditions. 75,479 impressions 11,992 engagements Appeal for clothing donations In August we asked our community to donate second hand clothing for patients to go home in. Our clothes bank can be supported by donations of clean, loose-fitting clothes such as jumpers, t-shirts, trousers, shorts, dresses, skirts and jogging bottoms. 40,550 impressions 1,537 engagements UHS finalists for NHS Chef of the Year Our talented UHS chef team of Christoffer Dopico Alles and second chef Alex Cavallaro have progressed to the final of a prestigious cooking competition, NHS Chef 2024, which takes place later in October. 20,653 impressions 3,346 engagements Page 3 of 5 Member analysis Age breakdown (and number of new members since 24 July 2024) 16-21 141 (4) 22-29 232 (3) 30-39 480 (10) 40-49 580 (2) 50-59 820 (2) 60-74 1923 (3) 75+ 3628 (3) Not stated 252 Gender breakdown (and number of new members since 24 July 2024) Unspecified 53 Male 3099 (9) Female 4790 (13) Transgender 6 Non-binary 3 (2) Prefer not to say 104 (3) Prefer to self-describe 1 Ethnicity breakdown (and number of new members since 24 July 2024) White - English, Welsh, Scottish, Northern Irish, British 6874 (15) White - Irish 8 White - Gypsy or Irish Traveller 0 White - Other 93 (5) Mixed - White and Black Caribbean 4 (1) Mixed - White and Black African 9 Mixed - White and Asian 10 (1) Mixed - Other Mixed 47 Asian or Asian British - Indian 105 (2) Asian or Asian British - Pakistani 14 Asian or Asian British - Bangladeshi 11 Asian or Asian British - Chinese 27 Asian or Asian British - Other Asian 203 Black or Black British - African 51 Black or Black British - Caribbean 4 Black or Black British - Other Black 75 Other Ethnic Group - Arab 9 Other Ethnic Group - Any Other Ethnic Group 56 (1) Not stated 456 (2) Member recruitment As of 15 October 2024, there are 8,056 public members. Since the last Council of Governors meeting on 24 July 2024, 27 new members have joined the Trust. Recruitment has been driven by attending the Southampton Pride in August and encouraging attendees to sign up via an iPad. Conclusion Our immediate focus is to: • Produce the Connect quarterly digital magazine for autumn and continue monthly updates. • Plan and deliver the in person annual member’s meeting and open evening on 21 November 2024. • Continue our virtual event research series with an upcoming event on healthy ageing. Page 4 of 5 Our long-term focus remains on implementing the membership engagement strategy 20212025. Recommendation This paper aims to update the Council of Governors on Trust membership and recent and planned engagement activities. Page 5 of 5
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