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Directors portfolios structure updated 2025

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University Hospital Southampton NHS Foundation Trust – Directors’ Portfolios – as at 4 August 2025 Director of Strategy and Partnerships Martin De Sousa UHS corporate strategy and strategic planning Clinical Programme: Integrated network care and collaboration (with CMO) Research and Development Partnerships Chief Executive Officer David French NHS FT Accounting Officer Chief Medical Officer Paul Grundy Professional leadership of medical staff Clinical strategy Outcomes and clinical effectiveness Health promotion Public health Realistic medicine Patient consent Clinical networks Innovation, research and development Responsible officer for revalidation Medical education Chief Nursing Officer Gail Byrne Professional leadership of nurses, AHPs, and wider healthcare professionals Integrated governance Risk management Infection prevention and control Patient safety and experience Culture Quality improvement and Always Improving strategy Safeguarding Voluntary services Freedom to speak up PALS and complaints Corporate affairs Legal services Claims and insurance Policy management Data protection and FOI Caldicott Guardian Health and Safety Maternity Safety Champion Chief Financial Officer Ian Howard Strategic and operational finance Financial strategy, planning and modelling Capital planning and prioritisation Financial reporting and external audit Cash and treasury management Commissioning and contracting Estates, Facilities and Capital Development Procurement Commercial Development Payroll Counter fraud Internal audit Wholly-owned subsidiary oversight CIP management and delivery Productivity improvement National and local insight and intelligence Annual planning Business cases Strategic and annual demand and capacity planning Chief Operating Officer Andy Hyett SIRO Operational management Performance delivery Performance reporting and management Business change/service improvement Business continuity and emergency planning Complex Discharge Team Site management and security Digital including digital strategy and business Intelligence Division A Cardiovascular and Thoracic Critical Care Neurosciences (including Spines) Surgery Theatres and Anaesthetics Trauma and Orthopaedics Division B Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine/ Medicine for Older People Ophthalmology Specialist Medicine Division C Clinical Support Child Health Maternity Pathology Radiology Trust Outpatients Women and Newborn Chief People Officer Steven Harris HR management Recruitment, retention and reward Bank and agency Employee relations Organisational development Staff engagement Education, training and, development People strategy Workforce planning and information Leadership Staff health and wellbeing (inc Occupational Health) Communications Equality, Diversity and Inclusion
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/Media/UHS-website-2019/Docs/About-the-Trust/Structure-charts/Directors-portfolios-structure-updated-2025.pdf

Papers Trust Board 28 March 2019

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

Annual-report-2017-18

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ANNUAL REPORT AND ACCOUNTS 2017/18 incorporating the quality account 2017/18 Presented to Parliament pursuant to
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/Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2017-181.pdf

Grant funding support

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Auto Generated Title UHS grant support is a new team here to help you. We assist and facilitate all research-oriented health p
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/ClinicalResearchinSouthampton/For-researchers/Grant-funding-support/Grant-funding-support.aspx

Press release: Hospital trust launches specialist emergency assessment unit for older patients

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Clinicians at Southampton’s teaching hospitals have launched a specialist emergency assessment unit for older patients.  Around 25 people over 80 present to Southampton General Hospital with medical emergencies every 24 hours and, until now, would have been assessed and treated in the emergency department prior to admission to a ward. They are now moved on arrival to a new frailty unit, based in acute medicine, where they receive rapid assessment by a team led by consultant geriatricians Dr Gayle Strike and Dr Daniel Baylis. The five-bed facility, which has been in development for the past year, currently operates for eight hours a day but is expected to extend to 12 hours a day over the next few months. "We have been working extremely hard to improve the quality of care provided to older people as they are often frail and tended to spend a long time within the emergency department prior to being admitted,” explained Dr Strike. “Patients are identified as soon as they present to hospital and, rather than spending time on a trolley in the emergency department, they are taken to our dedicated unit which is a quieter and less disruptive environment.” Following assessment by a team of experts which includes a consultant geriatrician, patients are given a clear plan with the aim of facilitating a smooth admission and minimising their length of stay. "With the winter months approaching and the additional pressures that will place on frontline services, the completion of this project will further help us to support colleagues in emergency medicine in managing demand.” Dr Strike added: “Through this access to specialist review, we hope to be able to get people back home where appropriate and, when that is not possible, to simplify their admission and minimise their length of stay in hospital.” As part of the initiative, UHS has worked in partnership with clinical commissioning groups, surrounding NHS trusts and councils to ensure the development aids improvements in access to community care. Dr Baylis, who is the clinical lead for acute medicine and medicine for older people at UHS, added: “We are really pleased the unit has been received well by staff, patients and their relatives and we are grateful to our partner organisations for working closely with us to ensure we maximise the benefit of such a positive new project.”
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/AboutTheTrust/Newsandpublications/Latestnews/2018/December/Press-release-Hospital-trust-launches-specialist-emergency-assessment-unit-for-older-patients.aspx

DH IVIg approved indications summary_May 2012

Description
Demand Management Poster Red Priority - High Short Term Long Term Blue Priority - Medium Short Term Grey Priority - Low Long Term Black Condition Alloimmune thrombocytopenia (foeto-maternal/neonatal)* Chronic inflammatory demyelinating polyradiculoneuropathy Guillain-Barr? syndrome Haemolytic disease of the newborn HSCT in primary immunodeficiencies Immune thrombocytopenic purpura (acute and persistent, excluding chronic*) Condition Acquired red cell aplasia Autoimmune congenital heart block Autoimmune haemolytic anaemia Autoimmune uveitis Coagulation factor inhibitors (alloantibodies and autoantibodies) Haemophagocytic syndrome Immunobullous diseases Inflammatory myopathies Multifocal motor neuropathy Immune-mediated disorders with limited evidence of immunoglobulin efficacy Acute disseminated encephalomyelitis (if high-dose steroids have failed) Autoimmune encephalitis (including NMDA and VGKC antibodies, among others) Catastrophic antiphospholipid syndrome Cerebral infarction with antiphospholipid antibodies Chronic ITP CNS vasculitis Complex regional pain syndrome Neuromyotonia Intractable childhood epilepsy Neuromyotonia Opsoclonus Myoclonus Post-exposure prophylaxis for viral or pathogenic infection if intramuscular injection is contraindicated, or treatment when hyper-immune immunoglobulins are unavailable Pyoderma gangrenosum Systemic juvenile idiopathic arthritis Systemic vasculitides and ANCA disorders Urticaria (severe, intractable) Presumed immune-mediated disorders with little or no evidence of efficacy Acquired red cell aplasia NOT due to parvovirus B19 Acute idiopathic dysautonomia Aplastic anaemia/pancytopenia Atopic dermatitis/eczema Autoimmune neutropenia Chronic facial pain Diabetic proximal neuropathy Haemolytic uraemic syndrome PANDAS Paraneoplastic disorders that are known not to be B- or T-cell mediated POEMS SLE without secondary immunocytopenias (including juvenile) Immunodeficiency secondary to paediatric HIV infection Autologous BMT Adrenoleukodystrophy Alzheimer's disease Amyotrophic lateral sclerosis Chronic fatigue syndrome Critical illness neuropathy Multiple sclerosis Rheumatoid arthritis Neonatal sepsis (prevention or treatment) Sepsis in the intensive care unit not related to specific toxins or C. difficile Asthma Graves' ophthalmopathy IVF failure Recurrent spontaneous pregnancy loss Kawasaki disease Paraprotein-associated demyelinating neuropathy (IgM, IgG or IgA) Primary immunodeficiencies Specific antibody deficiency Thymoma with immunodeficiency Toxic epidermal necrolysis, Stevens Johnson syndrome Myasthenia gravis (including Lambert-Eaton myasthenic syndrome) Necrotising (PVL-associated) staphylococcal sepsis Post-transfusion purpura Rasmussen syndrome Secondary antibody deficiency (any cause) Severe or recurrent Clostridium difficile colitis Staphylococcal or streptococcal toxic shock syndrome Stiff person syndrome Transplantation (solid organ) * Updated May 2012
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/Media/SUHTExtranet/TrustMedicinesFormulary/Forms/DH-IVIg-approved-indications-Summary-Poster-Feb-2106.pdf

Public given exclusive insight into making of hospital documentary

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Members of the public will be given an exclusive insight into the making of a landmark medical ethics documentary on Southampton Children's Hospital at an event later this month.
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/AboutTheTrust/Newsandpublications/Latestnews/2018/April-2018/Public-given-exclusive-insight-into-making-of-hospital-documentaryd.aspx

Alternative methods of feeding your baby - patient information

Description
This factsheet explains alternative ways to feed your baby until breastfeeding is established.
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/Media/UHS-website-2019/Patientinformation/Pregnancyandbirth/Alternative-methods-of-feeding-your-baby-3008-PIL.pdf

Papers Council of Governors - 27 April 2022

Description
Date Time Location Chair Agenda Council of Governors 27/04/2022 14:00 - 16:00 Microsoft Teams Jane Bailey 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:01 3 Minutes of Previous Meeting 14:02 To approve the minutes of the previous meeting held on 26 January 2022 4 Matters Arising/Summary of Agreed Actions 14:03 5 Strategy, Quality and Performance 5.1 Operational Plan 2022/23 14:05 Sponsor: Ian Howard, Chief Financial Officer 5.2 Non-NHS Activity 14:20 Sponsor: Ian Howard, Chief Financial Officer Attendees: Na'el Clarke, Commercial Director 5.3 Chief Executive Officer's Performance Report 14:35 Sponsor: David French, Chief Executive Officer 5.4 Draft Quality Report and Annual Report Timetable 14:55 Sponsor: David French, Chief Executive Officer Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6 Governance 6.1 Non-Executive Director Reappointment 15:00 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.2 Review Terms of Reference - Council of Governors and Working Groups 15:10 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.3 Council of Governors' Election 2022 15:15 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.4 Council of Governors' Expenses Reimbursement Protocol 15:19 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 6.5 Consultation Regarding Timings of Council of Governors' Meetings 15:24 Sponsor: Jane Bailey, Interim Chair Attendee: Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:29 Sponsor: David French, Chief Executive Officer Attendee: Sam Dolton, Events and Membership Officer 7.2 Governors' Nomination Committee Feedback 15:39 Chair: Jane Bailey 7.3 Feedback from Strategy and Finance Working Group 15:43 Chair: Tim Waldron 7.4 Feedback from Patient and Staff Experience Working Group 15:47 Chair: Forkanul Quader 7.5 Feedback from Membership and Engagement Working Group 15:51 Chair: Bob Purkiss 8 Any other business 15:55 To raise any relevant or urgent matters that are not on the agenda 9 Date of next meeting: 19 July 2022 15:59 To note the date of the next meeting Page 2 Minutes - Council of Governors (CoG) Date Time Location Chair Present In attendance Apologies 26 January 2022 14.00-15.40 Microsoft Teams Peter Hollins Peter Hollins, Chair Theresa Airiemiokhale, Elected, Southampton City (until item 7.1) Katherine Barbour, Elected, Southampton City (until item 7.1) Colin Bulpett, Elected, Rest of England and Wales Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Professor Mandy Fader, Appointed, University of Southampton (for items 6.2 to 6.4) Harry Hellier, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff Councillor Alexis McEvoy, Appointed, Hampshire County Council Robert Purkiss, Elected, Rest of England and Wales (until item 6.4) Forkanul Quader, Elected, Southampton City Catherine Rushworth, Elected, Isle of Wight Quintin van Wyk, Elected, Rest of England and Wales Tim Waldron, Elected, Southampton City (until item 7.1) Jane Bailey, Non-Executive Director (NED), Deputy Chair and Senior Independent Director Sam Dolton, Events and Membership Officer Karen Flaherty, Associate Director of Corporate Affairs David French, Chief Executive Officer (for item 5.1) Steve Harris, Chief People Officer (for item 6.2) Femi Macaulay, Associate NED Karen Russell, Council of Governors’ Business Manager James Woodward, Student Governor Representative (until item 4) Dr Diane Bray, Appointed, Solent University Helen Eggleton, Appointed, NHS Hampshire, Southampton and Isle of Wight CCG Rebecca Reynolds, Elected, Nursing and Midwifery Staff Councillor Rob Stead, Appointed, Southampton City Council Amanda Turner, Elected, Non-Clinical and Support Staff PTH TA KBa CB ND MF HH KL AM RP FQ CR QvW TW JB SD KF DAF SH FM KR JW DB HE RR RS AT 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and in particular CR and FM who were attending a meeting of the CoG for the first time. DB and RR, who had recently joined the CoG, were also welcomed to the CoG, although they had sent apologies for the meeting. 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 27 October 2021 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted and further updates were provided on the following actions: • Review of the Council of Governors’ Composition This had been considered by the CoG Membership and Engagement Working Group and a progress update with proposals would be presented to the CoG later in the meeting. • Governor Forum The guidance had been shared with governors on 17 November 2021 and the Governor Forum was available for use. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report PTH welcomed DAF, who was attending to present the performance report. The report was noted and DAF provided an update since the period of September to November 2021 covered by the report. He highlighted that: • although the COVID-19 Omicron variant had proved to be much more transmissible than the Delta variant, its symptoms appeared to be less severe; • there were approximately 50 patients in the hospitals who had tested positive for COVID-19, two of whom were in critical care being treated for other medical conditions; • the number of patients with COVID-19 had been relatively stable over the previous two weeks and it was anticipated that numbers would steadily decline over the next few months; • there were 220 patients in the hospitals who were medically optimised for discharge (MOFD), however, levels of staff sickness absence in community care, domiciliary care and care homes were leading to delays in discharge where patients needed further support following discharge or had longerterm care needs; • the number of patients MOFD in hospital was impacting on the Trust’s capacity, particularly elective capacity as beds in surgical wards were being used to accommodate these patients; • sickness absence in the Trust, normally in the region of 3% of staff, had increased to 6% as staff were absent due to COVID-19; • University Hospitals Sussex NHS Foundation Trust and Oxford University Hospitals NHS Foundation Trust were assisting the Trust to reduce the number of patients awaiting cardiac surgery, which had arisen due to a shortage of specialist critical care capacity as the Trust had provided additional surge capacity in previous waves of the COVID-19 pandemic; • the Trust was continuing work to reinstate its full programme of elective activity as the number of patients with COVID-19 in the hospitals reduced; • the Trust was working to increase theatre and bed capacity for elective activity and submitting bids for external funding to support this, including a joint bid with the other acute trusts in Hampshire and the Isle of Wight for an elective hub at Winchester Hospital; • the number of staff at the Trust who were fully vaccinated against COVID-19 was more than 96%, one of the highest levels in the country; • the Trust was continuing to prioritise recruitment and retention of staff, including recruitment in areas where there were staff shortages such as critical care; 2 • Saul Faust, a consultant at the Trust, had led the COV-BOOST vaccine trial, which had been instrumental in informing national policy through identifying the level of protection offered by the booster vaccination; • work was commencing on the rooftop garden at the Princess Anne Hospital for use by staff, which was funded by Southampton Hospital Charity from the proceeds of the auction of the ‘Game Changer’ artwork by Banksy, and there were also plans for a wellbeing centre for staff and to upgrade staff rooms and changing areas across the Trust reflecting the donor’s wishes for a lasting legacy to support the wellbeing of staff; • the implementation of changes to the structure of integrated care systems, which were being introduced to improve coordination of health and social care services at a local level, had been delayed until 1 July 2022; • the Trust was expected to deliver its financial forecast and breakeven in 2021/22 due to additional elective recovery fund income, however, the position for 2022/23 was still uncertain as guidance continued to be released and a reduction in funding was expected; and • the Trust was also on track to deliver its capital programme for 2021/22, having spent £33.2 million up to the end of November 2021, including investment in four new theatres within the vertical extension building and an expanded ophthalmology outpatient facility. In response to a query raised by RP, DAF explained that where a complainant was not satisfied with the Trust’s response (identified as complaints returned dissatisfied in the report), the complaint would be reopened and issues that remain unresolved for the complainant would be investigated again. If the complainant remained dissatisfied following this they could contact the Parliamentary and Health Service Ombudsman. Following a question from FQ about whether other hospitals could assist in reducing waiting lists for elective activity in other areas, DAF explained that capacity and the length of waiting lists were a challenge throughout the NHS due to the COVID-19 pandemic and the Trust was focusing on increasing its capacity. AM queried whether the incidence of COVID-19 transmission within the hospital related to more vulnerable patients and if those who had antibodies due to previously contracting COVID-19 could still transmit the infection to others despite having some degree of protection themselves. DAF advised that the mortality rate for patients who contracted COVID-19 in hospital earlier in the pandemic had been approximately 40-50%, however, strict infection control procedures in place at the Trust had kept the rates of transmission in hospital (nosocomial transmission) low. Currently transmission to patients was tending to occur when patients were visiting non-clinical areas within the hospitals and from visitors. Actions: • DAF would provide a response to a query regarding one of the cookers in the Trust’s Feast restaurant which was reported to have been out of order for some time. • PTH would provide a more detailed response about the ability of those who had previously been infected with COVID-19 to transmit the virus. 6 Governance 6.1 Annual Business Plan 2022/23 KF presented the annual business plan for CoG for 2022/23, which would be reviewed and updated during the year as required. Action: It was requested that the annual CoG strategy event was added to the plan 3 for information. Decision: The CoG approved the Annual Business Plan for 2022/23. 6.2 Chair and Non-Executive Director Appraisal Process PTH advised that the contribution of the CoG to the NED appraisal process was critical as one of the key roles of governors was to hold the NEDs to account for the performance of the board of directors (Board). The NHS Foundation Trust Code of Governance required that the CoG should take the lead on agreeing the process for appraisal. The timeline for the appraisal process would ensure its completion before the tenure of the current Chair ended on 31 March 2022. The GNC had reviewed the proposed process at its meeting on 7 January 2022 and recommended that it should be approved by the CoG. Governors were encouraged to participate in the appraisal process by providing feedback to the Lead Governor by 4 February 2022. Although there had been fewer opportunities for governors to interact in person with NEDs due to restrictions on visiting the hospitals and meeting in person as a result of the COVID-19 pandemic, governors were invited to observe the NEDs at Board meetings and Board committee meetings, which were chaired and attended by NEDs, and to participate in the question and answer sessions with NEDs prior to the CoG meetings and in the discussions with governors following the open session of the Board meeting. Decision: The CoG approved the appraisal process as recommended by the GNC. 6.3 Governor attendance at Council of Governors’ Meetings Under the Trust’s constitution if a governor failed to attend two successive meetings of the CoG, his or her tenure of office was to be immediately terminated by the 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. Whilst it was recognised that governors may not be able to attend every meeting the expectation was that they would make every effort to attend meetings regularly. There were five governors who had failed to attend two successive meetings of the CoG, however, for three of these governors this had included the extraordinary meeting of the CoG held in December 2021. There were two governors who had failed to attend two consecutive ordinary meetings of the CoG, both of whom were clinical NHS staff who had not been able to attend due to work commitments. While the CoG was likely to consider that their absence was due to reasonable causes, the two governors concerned had subsequently resigned as they did not feel that they would be able to attend meetings regularly in the future due to work commitments and the timing of CoG meetings. Decision: The CoG confirmed that it was satisfied that the failure of the remaining three governors 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. 4 6.4 Composition of the Council of Governors At its meeting in July 2021 the CoG reviewed its current composition. The consideration of the composition of the CoG had subsequently been referred to the CoG Membership and Engagement Working Group for further review. The CoG Membership and Engagement Working Group commenced this review at its meeting in November 2021 and considered updated proposals at its meeting in January 2022. Following its review, the CoG Membership and Engagement Working Group recommended the following proposals: • to reduce the number of governors in the Rest of England and Wales public constituency by one governor and increase the number of governors in the New Forest, Eastleigh and Test Valley public constituency by one governor to ensure that the number of governors representing the public constituencies was more representative of the number of patients seen by the Trust from those areas; and • to include a student representative as a full member of the CoG as an appointed governor. The Trust’s constitution would need to be amended to reflect these changes and would require approval by the CoG and the Board. Decision: The CoG noted the progress of the review to date and supported the proposals recommended by the CoG Membership and Engagement Working Group. 6.5 Audit and Risk Committee Terms of Reference The terms of reference for all Board committees should be reviewed regularly, and at least once annually, to ensure that they reflected the purpose and activities of each committee. The NHS Foundation Trust Code of Governance required that the CoG was consulted on changes to the terms of reference for any audit committee given the CoG’s role in appointing, reappointing and removing external auditors, prior to their submission to the Board for approval. Only minor changes of a typographical nature were proposed to the terms of reference following a comprehensive review and update in 2021. Decision: The CoG agreed the proposed changes to the Audit and Risk Committee terms of reference. 6.6 Non-Executive Directors’ Additional Commitments The NHS Foundation Trust Code of Governance required that the CoG was informed of any changes to the significant commitments of NEDs following their appointment by the CoG. The Chair would discuss changes to their commitments with NEDs during their appraisals. There was no potential conflict of interest relating to the new commitments that had been declared. Decision: The CoG noted the additional commitments of the NEDs. 6.7 Decisions in Response to Recent Vacancies on the Council of Governors The CoG had been asked to consider a number of proposals to fill governor vacancies that had arisen in the public and staff constituencies in recent months. In addition, there had been a number of new appointed governors who had joined the CoG during that period. 5 Governors had previously been asked to approve each of the proposals in response to governor vacancies by written resolution. Decision: The CoG ratified and confirmed the decisions taken in response to vacancies on the CoG. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report highlighting that: • engagement with the Trust’s members had continued and included the rebranding of the membership newsletter as Connect, making it more interactive in a page turner format rather than a standard PDF format; • targeted tailored emails had been issued to members including surveys relating to Patient Initiated Follow Up and the UHS discharge process; • in November 2021 members who had stated that they had a disability or were carers were invited to attend a virtual event to launch new access guides for the Trust; • the rescheduled annual members’ meeting took place in November 2021 and included highlights from the annual report and accounts for 2020/21 and the Trust’s five year strategic plan, an update on the membership strategy and an operational update on priorities for managing the surgical waiting list; • a virtual event was held in December 2021, which focused on the next steps for COVID-19 vaccination and included key findings from the Trust led COV-BOOST trial, latest updates on vaccine safety in pregnancy and the vaccination situation in the community from Southampton City Council; • social media activity included an emphasis on encouraging the public to have their COVID-19 booster vaccinations and a message to the community regarding pressures faced by the Trust’s emergency department; • in November 2021 the Trust attended a Health and Home Fair at the University of Southampton, which KBa had kindly supported; • the Trust’s COVID ZERO campaign had been shortlisted in PRWeek’s awards for best crisis communications and results would be announced in February 2022; • governors were thanked for their feedback prior to the issue of a survey to the Trust’s members regarding the membership programme; and • planned future activities included an event about the Trust’s new Green Plan and engagement with students, young people and underrepresented ethnic groups. 7.2 Governors’ Nomination Committee Feedback The GNC had concluded the appointment process for the associate NED role by appointing FM and had reviewed the appraisal process for the Chair and NEDs, approved earlier in the meeting. An update on the recruitment process for a new chair would be provided in the closed session of the meeting. 7.3 Feedback from Strategy and Finance Working Group Due to the operational pressures as a result of COVID-19 in January 2022, it had been agreed with the TW, the chair of the CoG Strategy and Finance Working Group, that the meeting due to have taken place would be rescheduled. 6 7.4 Feedback from Patient and Staff Experience Working Group (including confirmation of election of the Patient and Staff Experience Working Group Chair) A vacancy had arisen for the chair of the CoG Patient and Staff Experience Working Group following the death of Tony Havlin at the end of 2021. FQ had very kindly volunteered to take on the role and was elected as chair at the CoG Patient and Staff Experience Working Group meeting on 24 January 2022. The CoG was asked to confirm the appointment. Decision: The CoG confirmed the appointment of FQ as Chair of the CoG Patient and Staff Experience Working Group. FQ advised that Laura White, the Head of Involvement and Participation, had provided an update on the results of three patient surveys: Adult Inpatients, Children and Young People and Urgent and Emergency Care at the most recent meeting. Following the meeting KR had circulated the full survey results to governors. A question was raised at the meeting relating to the pain scores in the Children and Young People’s survey and the scoring/assessments used and this information would be provided to governors as soon as it was received. Emma Jane Squires had also attended the meeting to provide an update on the Patient Support Hub which had been very informative and well received. FQ was considering including feedback from junior doctors and trainee nurse at a future meeting of the working group. 7.5 Feedback from Membership and Engagement Working Group At the meeting of the CoG Membership and Engagement Working Group on 20 January 2022, the composition of the CoG had been considered followed by an update from SD relating to the membership strategy, feedback on previous events and plans for future events. 8 Any other business Following the discussion with staff governors who had been unable to attend meetings of the CoG, PTH suggested that a consultation exercise was undertaken to ask for governors’ views on varying the timing of CoG meetings to accommodate work schedules of staff and other governors. Action: KR would carry out a consultation to consider the timing of CoG meetings. PTH informed the CoG that this would be his last full meeting as Chair prior to the end of his tenure on 31 March 2022, and thanked governors for their help and support. 9 Date of Next Meeting - 23 February 2022 To note the date of the next meeting. 10 Resolution regarding the press, public and others Decision: The CoG resolved that, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders for the Practice and Procedure of the CoG, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted. 7 List of action items Agenda item Assigned to 14 April 2022 16:00 Deadline Status Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Flaherty, Karen Russell, Karen 27/04/2022 Explanation action item A review of the Council of Governors' composition is to be carried out to check that it still remains appropriate. Pending The review was presented to the CoG at the meeting on 21 July 2021. The CoG agreed that volunteers for a task and finish group would be sought to consider the composition of the CoG in more detail. If no volunteers were forthcoming it would be referred to the Membership and Engagement Working Group for further review. Explanation Russell, Karen Following the discussion at the CoG meeting on 26 January 2022, feedback will be provided to the Membership and Engagement Working Group at its meeting on 26 April 2022. Council of Governors 26/01/2022 5.1 Chief Executive’s Performance Report 633. Query regarding a cooker in the Trust's Feast restaurant French, David 27/04/2022 Completed Explanation action item RP raised a concern regarding one of the cookers in the Trust’s Feast restaurant which was reported to have been out of order for some time. DF agreed to investigate. It was confirmed that the cooker had been replaced and was in operation. Governors were advised by email on 2 February 2022. 14 April 2022 16:00 634. COVID-19 transmission Hollins, Peter 27/04/2022 Completed Explanation action item AM queried whether the incidents of COVID-19 transmission within the hospital related to more vulnerable patients and if those who had antibodies due to previously having COVID-19 could still transmit to others despite having some degree of protection themselves. KR consulted Dr Eleri Dr Eleri Wilson-Davies who is the principal investigator for the Sarscov2 Immunity and Reinfection Evaluation (SIREN) study at the Trust. It was confirmed that transmission could still take place. A full explanation was provided to governors on 2 February 2022. Council of Governors 26/01/2022 6.1 Annual Business Plan 2022/23 635. Strategy Day to be added to the Annual Business Plan Flaherty, Karen Russell, Karen 27/04/2022 Completed Explanation action item PTH queried whether the CoG Strategy Day could be added to the Annual Business Plan. KF agreed this could be added. Explanation Russell, Karen Strategy Day has now been added to the Annual Business Plan Council of Governors 26/01/2022 8 Any other business 636. Consultation regarding timings of CoG meetings Russell, Karen 27/04/2022 Completed Explanation action item Two governors had resigned recently and had found difficulty attending CoG meetings due to work commitments. Governors would be consulted as to the most appropriate timings for CoG meetings. Explanation Russell, Karen The consultation has been held and feedback will be provided to the CoG at its meeting on 27 April 2022. Page 2 5.1 Operational Plan 2022/23 1 5.1i Report template UHS COG April 2022 Operating Plan.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: 2022/23 Operational Plan 5.1 Ian Howard, Chief Financial Officer Andrew Asquith, Director of Planning, Performance and Productivity 27 April 2022 Assurance Approval or reassurance Ratification Information Y Information about trust planning and budget setting 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 operating environment and plan for 2022/23. A more detailed report is presented to Trust Board for their consideration and approval. Implications: This report provides information relating to a broad range of trust (Clinical, Organisational, services and activities, there are no specific implications. Governance, Legal?) Risks: (Top 3) of carrying This report is provided for the purpose of information. out the change / or not: Summary: Conclusion This report is provided for the purpose of information. and/or recommendation Page 1 of 1 Council of Governors Meeting April 2022 2022/23 Operational Plan 2022/23 Operational Plan Content of Presentation • Process / Expectations • Summary of plan – finance, workforce, activity and performance • Conclusion • Building on ‘Connect’ (Internal Presentation for Senior Leaders) • Questions Process / Expectations • Final plan submission to NHSE (via ICS) due on 28th April • Trust board briefed on draft submissions and the anticipated final submission • Strong influence from national ‘guidance’ / frameworks, issued between Dec 24th and late February, with subsequent clarifications too… • Planning for a ‘low COVID’ environment Summary of plan (see following slides) Summary of plan - Finance • Income broadly level with 2021/22, additional funding for inflation fully offset by reductions in funding / national efficiency requirements • Expectation that 104% elective activity will be delivered for this level of funding through increased efficiency • Planned UHS operating deficit - £19.5m – Driven by understandable factors where the reality is differing from planning assumptions / factors outside trust control e.g. COVID prevalence, energy prices, general inflation, drug cost increases in block contracts Summary of plan - Finance • Planned efficiency improvement valued at £33m / 2.7% (compared to 2021/22) – 2% / £20m Cost Improvement requirement as part of issued budgets – Further £13m improvement to be delivered centrally including through business cases and management of growth funding – Little opportunity to achieve additional financial contribution through growth in NHS activity due to the financial framework / contractual arrangements (75% of tariff) • Financial challenges in delivering the 22/23 plan are being consistently reported across the country Summary of plan - Workforce • Continued recruitment and retention to increase employed staff by a further 478 wte • Offset by planned reductions in the use of Bank and Agency hours • Minimal net increase in funded posts (establishment) - aligned with funding availability, cost improvements to offset additional investments, and significant increases during COVID-19 to date Summary of plan - Activity and Performance Planning to deliver activity as follows: • 104% of 19/20 levels for elective care • 100% of 19/20 outpatient follow-ups (doesn’t achieve national ambition for reduction, despite good UHS engagement with initiatives) • 100% of 19/20 levels for non-elective admissions • 20/21 numbers of A&E attendances (there are risks here, given the 21/22 growth rate) Summary of plan - Activity and Performance RTT • July 2022 - no patient waiting > 2 years • April 2023 - no patient waiting > 18 months Cancer • March 2023 - patients waiting > 62 days from referral returned to pre-pandemic levels Outpatients • Transform care, greater use of technology, improve both waiting times and experience of waiting Conclusion • Very challenging national expectation, when considering finances, workforce, and patient care in combination • Exacerbated by the current variance between planning assumptions and the real environment e.g. COVID, inflation • UHS is well positioned to respond, and aims to deliver for our patients, and people, operate efficiently, and achieve acceptable financial outcomes relative to the context and to our peers Conclusion – ‘Connect’ Slides Our World with and beyond COVID: •Pause to reflect as we come out of COVID •National messages •Reasons to be proud •Our collective leadership priorities  2025 vision guides us  Unite around the patient  Personal development, wellbeing, inclusion, recruitment  Operational sweet spot  Bringing back the hospital to normal footprint  Maximise elective activity  Transformation projects in theatres, outpatients and flow improvement  Always Improving, pathway/process innovation and squeaking wheels  Confidence in us and in our future Questions / Discussion Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Non-NHS Activity 5.2 Ian Howard, Chief Financial Officer Na’el Clarke, Commercial Director 27 April 2022 Assurance Approval or reassurance Y Ratification Information One of the responsibilities of the Council of Governors is to determine whether the Trust’s non-NHS activity would significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or the performance of its other functions. Response to the issue: The Council of Governors must then notify the directors of its decision. The Trust’s private patient income for 2021-22 is forecast to be approximately £6.4 million. This represents just under 0.7% of the Trust’s overall income. This year has seen a growth in activity due to the more complex patients being treated, whilst maintaining the prioritisation of clinically urgent procedures, noting the unprecedented pressure that core NHS services have faced. There has been growth in services delivered through an outpatient setting, whilst remaining mindful of the needs and constraints faced by our core services. Over the next six months at least, activity for private patient services is expected to remain at the same level as NHS activity is prioritised. Again, it is expected that only a limited number of patients that are deemed an emergency or clinically urgent will be treated privately as inpatients. Private cancer treatment is expected to continue in the Solent suite, which provides a dedicated nurse-led service. The income forecast for 2022-23 will be in line with the forecast total for 2021-22. There is also a growing income stream linked to the commercialisation of Trust-derived intellectual property, although this is forecast at just under £40,000 for 2021-22, we expect a forecast income of at least £140k in 2022-23. Another core area of non-core income is linked to the co-development of innovative medical technology, again income from this workstream is forecast at £150,000 for 2022-23, having been established through a series of strategic partnerships to co-develop products that meet unmet clinical needs during 2021-22. The range of commercial workstreams that deliver non-core income has been expanded. Implications: Risks: Summary: This ensures that the Trust meets its legal requirements that income received from its principal purpose is greater than its non-NHS income. It also enables the Council of Governors 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). 1. Non-compliance with the provisions of the National Health Service Act 2006 and the Trust’s constitution. 2. Monitoring the performance of the Trust against its principal purpose. 3. Ensuring NHS activity is not negatively impacted by non-NHS activity whilst recognising how income from additional activity supports NHS services and the activity itself supports innovation. Given the current and forecast levels of non-NHS income, the Council of Governors is requested to: • confirm that is satisfied that the Trust’s non-NHS activity would not significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or the performance of its other functions; and • authorise the Interim Chair or Associate Director of Corporate Affairs and Company Secretary to inform the directors of its decision. Non-Core Income –UHS HIGHLIGHTS: • Non-Core (Commercial Income) forecast at £8.5m for the 22/23 FY • Core areas of commercial activity are : the provision of private patient services, management of overseas visitors, commercialisation of UHS-derived innovations and strategic working with medical technology suppliers to create technology that addresses unmet clinical needs. • Third party commercial contracting with non-NHS bodies is also an important area of commercial activity that brings in around £1.5m of income per annum and which also has reduced third party contractual costs by at least £90k (21/22 FY) and mitigated commercial risks of > £1m • Miscellaneous schemes such as the commercial use of physical and digital space produce a useful income of around £100k p.a. • This income is re-invested back into development projects and core NHS services as part of our CIP PRIVATE PATIENT SERVICES –Summary • Private Patient Income (£6.4m forecast year end position) (21/22) represents a small % of our overall income ( 95.0% ≥ 90.0% Dec 2021 70.1% 79.7% Jan 2022 69.1% 79.5% Feb 2022 65.8% 77.9% A deterioration in UHS timeliness has continued and performance is now a significant distance from the national target, yet remains relatively good in comparison to many other acute trusts. In the period between December 2021 and February 2022 UHS ranked third best amongst eight major trauma centres that we benchmark with (Type 1 attendances). The Trust Board reviews emergency access performance every month and has reviewed the subject in detail at its meetings in September 2021, November 2021 and February 2022. The Trust has continued to invest in both the physical environment and workforce to respond to rapidly increasing levels of attendances. We are also seeking to progress other contributions to improvement including working with partners to improve discharge from hospital beds, an internal focus on improving treatment and reducing patients’ length of stay in hospital, and working with partners to reduce the numbers of patients attending the emergency department where there are alternative ways of meeting their clinical needs. Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Dec 2021 67.4% 44,737 Jan 2022 67.2% 44,551 Feb 2022 67.4% 45,857 The number of patients on our waiting lists has increased by approximately 30% compared to January 2020, although the size of the waiting list has been stable in recent months. Page 3 of 5 Many of our patients are also waiting very long periods to start their treatment: • There were 2,032 patients who had waited over 52 weeks at the end of February 2022 (down from a peak in 3,149 in March 2021) • We are confident that by July 2022 no patient (other than those who are choosing to wait longer) will have waited over 104 weeks (there were a total of 171 such patients waiting in December 2021). The Trust has increased its physical capacity and workforce, and is engaging with NHS partners to plan further expansions which would respond to both rising need for the types of treatment UHS can provide and the ‘backlog’ due to COVID-19. Reductions in the number of inpatients with COVID-19 infection, and the number of staff absent with COVID-19 infection, will also be critical to our rate of improvement. The Trust Board reviewed Referral to Treatment performance in detail through spotlight reports at its meetings in October 2021, November 2021 and January 2022. Cancer Urgent GP referrals seen in 2 weeks Breast symptomatic patients’ referral seen in 2 weeks Treatment started within 62 days of urgent GP referral Target => 93% => 93% => 85% Dec 2021 74.5% 7.0% 71.0% Jan 2022 80.4% 33.3% 66.8% Feb 2022 89.6% 36.4% 69.2% Our breast service is in the process of increasing capacity and improving performance following the challenges relating to demand and COVID-19 disruption described in the previous report. These difficulties, and the time required to implement solutions, account for the failure to achieve two week waiting time targets for urgent GP referrals (patients suspected of having cancer, including breast patients), and breast symptomatic patients (symptoms not considered suspicious for cancer). Improving performance trajectories can now be observed, and further improvement is expected. As a result of both referral and treatment challenges across the majority of specialities, our 62 day cancer treatment performance has been adversely impacted. Performance has deteriorated compared to the previous three month period when it ranged between 71.8% and 74.7%. Despite this, UHS performance remains very good compared to other hospitals, in February 2022 UHS was fourth best amongst our peer group of 19 teaching hospitals, and matched the average performance of 17 hospital trusts in the south east region despite the majority of these hospitals offering a significantly less complex range of treatments than UHS. Cancer performance was reviewed by the Trust Board in detail at the December 2021 meeting and a further detailed review is planned for the April 2022 meeting. 5. Finance At the end of March 2022, the Trust reported a breakeven position for the year. This was an improvement on a planned £3.4 million deficit position as a result of receipt of additional national elective recovery funding. Operational pressures related to staffing (COVID-19 related sickness absence), increased emergency demand and increased COVID-19 inpatient numbers have led to a challenging operational position; however the financial pressures have been supported by nonrecurrent national funding. The underlying position of the finances is however more challenging, with inflationary pressures in energy and drugs cost growth within block contracts, meaning the outlook for 2022/23 is one of significant financial as well as operational challenge. Page 4 of 5 The Trust also reported on plan with its capital investment programme for 2021/22 with expenditure of internally funded capital (£50 million) and additional national funding (£15 million). This included investment in four new theatres within the ‘vertical extension’ building, a refurbishment and expansion of emergency department ‘majors’, and an expanded ophthalmology outpatients facility, as well as investment in digital, equipment and backlog maintenance. 6. Human Resources Indicator Target 2020/21 UHS Comparison Q3 2021/22 Staff FFT - % of staff likely or extremely likely to recommend UHS as a place to work Staff recommending UHS as a place to receive care/treatment => 75.5% => 85.0% 77% 86.7% 71.9% 83.1% National Average (Acute/Acute + Community Trusts) 58.4% 66.9% The ‘advocacy’ scores above, measured through the NHS Staff Survey, have declined since the previous year but remain well above the benchmark averages which have declined further. UHS had a survey response rate of 56%, which is an increase of 6% from 2020, and the highest level of participation UHS has achieved since the survey began. The median response rate in our benchmark group was 46%. UHS: • • • rated “the best” for career progression opportunities, and for offering a range of challenging work scored above average on 106 of 126 questions and scored below average on only 7 of 127 questions Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing vacancies (registered nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Dec 2021 13.4% 4.1% 15.6% Jan 2022 13.6% 4.1% 14.9% Feb 2022 13.7% 4.2% 15.0% Staff ‘turnover’ continues to be high and is increasing (following a reduction in 2020/21). A wide range of actions are being progressed including to support wellbeing, internal career development, work-life balance, and to focus on specific improvement opportunities such as healthcare assistant roles, recent recruits and staff approaching retirement. Sickness absence has unfortunately increased further, with monthly levels reaching a peak of 5.7% in January 2022 associated with a peak of COVID-19 infection. Page 5 of 5 5.4 Draft Quality Report and Annual Report Timetable 1 5.4a Annual Report and Quality Accounts timetable cover sheet.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Annual Report and Quality Accounts Timetable 5.4 David French, Chief Executive Officer Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary 27 April 2022 Assurance Approval or reassurance Ratification Information Y NHS England and NHS Improvement (NHSE/I) has published the timetable for the 2021-22 annual report and accounts and associated guidance. This removes the requirements to produce a separate quality report, although the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still apply requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the Council of Governors by the end of April for comment. Some additional quality reporting will be required to be included in the performance report section of the annual report instead. There are also no external audit assurance requirements in respect of the quality accounts as a result of the changes to the NHSE/I guidance. Response to the issue: Implications: The quality accounts are required to be published by 30 June 2022, whereas the annual report and accounts cannot be published until after they have been laid before Parliament. This is expected to occur at the beginning of September 2022 to allow time for the external auditor to complete the value for money external audit work and finalise its audit report and certificate for inclusion in the published version of the annual report and accounts. The external auditor expects to complete this work by the end of July 2022 after Parliament begins its summer recess. The Trust has taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document by the submission deadline of 22 June 2022. However, due the additional work required to complete the value for money external audit, the quality accounts will be published as a separate document by 30 June 2022. The attached timetable sets out the process in greater detail. The Trust meets the requirements of the National Health Service Act 2006, The National Health Service (Quality Accounts) Regulations 2010 and the NHS foundation trust annual reporting manual 2021/22. The timing of the meeting of the Council of Governors at which the final annual report and accounts (including the quality accounts) and the external auditors’ report are presented will be later than usual to allow for these to be laid before Parliament as this would normally take place in July. An update will be provided to the Council of Governors in a closed session of its meeting in July 2022 to mitigate the impact of this Risks: Summary: Conclusion and/or recommendation delay. The date of the annual members’ meeting will be finalised at a later date or delayed slightly to ensure that the annual report and accounts have been laid before Parliament before the annual members’ meeting takes place. 1. Non-compliance with the National Health Service Act 2006, The National Health Service (Quality Accounts) Regulations 2010 and the NHS foundation trust annual reporting manual 2021/22. 2. Ensuring openness, transparency and accountability regarding the performance and activities of the Trust. 3. Pressure on staff to provide information for inclusion in the annual report and accounts and the quality accounts as the Trust emerges from the latest wave of the COVID-19 pandemic, deals with significant emergency pressures and deliver the elective recovery programme. The Council of Governors is asked to note the timetable. Annual Report and Accounts (including the Quality Accounts) 2021-22 Timetable NHS England and NHS Improvement (NHSE/I) has published the timetable for the 2021-22 annual report and accounts and guidance on producing the annual report and accounts. This takes into account the pressures of the latest wave of the COVID-19 pandemic and feedback in earlier years of the COVID-19 pandemic that the process went on too long. NHSE/I have been consulting on changes to the quality reporting requirements over the past year and it is anticipated that changes will be made to the requirements in future years. In 2021-22 the requirements to produce a separate quality report have been removed, although the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still apply requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the Council of Governors by the end of April for comment. Some additional quality reporting will be required to be included in the performance report section of the annual report instead. There are also no external audit assurance requirements in respect of the quality accounts as a result of the changes to the NHSE/I guidance. As a result the deadline for submission of the annual report and accounts to NHSE/I has been extended to 22 June 2022. Additional time has also been allowed for the completion of the external audit of value for money introduced in 2020-21. The main changes to the requirements this year are: • reintroduction of the requirement for a performance analysis, which includes information on sustainability incorporating progress against the Trust’s Green Plan and information about social, community, anti-bribery and human rights; • removal of the quality report requirements and a requirement to include performance against quality priorities and quality indicators in the performance report in the main body of the annual report instead; and • new and expanded ‘fair pay’ disclosure requirements. The proposed timetable is set out below Action Deadline for draft accounts submission to NHSE/NHSI through NHSI Portal Draft quality accounts circulated to governors and Quality Committee members Issue final draft quality accounts to CCG, Local Healthwatch, Overview and Scrutiny Committee and Council of Governors for one month consultation Early May Bank Holiday Circulation of first draft annual report to external auditor, Board of Directors and Council of Governors Draft annual report and accounts reviewed at Audit and Risk Committee meeting Draft annual report and accounts reviewed at Board of Directors meeting Spring Bank Holiday Platinum Jubilee Bank Holiday Final draft quality accounts reviewed at Quality Committee meeting Date Tuesday, 26 April 2022 (noon) Thursday, 21 April 2022 By Friday, 29 April 2022 Monday, 2 May 2022 w/c Monday, 9 May 2022 Monday, 23 May 2022 Thursday, 26 May 2022 Thursday, 2 June 2022 Friday, 3 June 2022 Monday, 13 June 2022 Page 1 of 2 Action Final draft annual report and accounts including quality accounts reviewed at Audit and Risk Committee meeting Final draft annual report and accounts including the quality accounts approved by Board of Directors Deadline for submission of signed annual report and accounts and supporting documentation to NHS England and NHS Improvement Add quality accounts to Trust website and forward th
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Feeding information for infants with congenital heart disease

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PARENT INFO Information on feeding for infants with congenital heart disease Contents 03 Introduction 04 What to expect � in
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