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Managing pain after surgery

Description: pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 1 Managing pain after your surgery This leaflet explains what you can do to prepare for going home after surgery and to help your recovery. It describes the medicines used to reduce pain, and how to use them safely while you recover. pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 2 Why have I been prescribed pain medicines? Some pain after an operation or surgery is normal. The amount of pain will be different for everybody. It’s known as acute pain and it can be lessened with pain medicines. You will usually be offered pain medicines straight after your operation. Your healthcare team will develop a plan that includes pain medicines you may already be taking. These reduce the pain. This makes it easier to cough, move, walk about and become steadily more active. These activities are vital to your recovery. It is normal to feel anxious about moving again after surgery. As you recover and gradually increase your activity level, you may notice that your confidence grows as well. It is important to have a plan to help you get there. Perhaps you might want to try something new or do things in a different way. Pain medicines also make it easier to follow the exercise plan from your physio team, so you recover more quickly. Being active reduces the risk of complications such as chest infection or clots in the legs or lungs. As you feel better, stronger and are more active, you should reduce and then stop your pain medicines. If pain persists, contact your healthcare team. 2 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 3 Opioid medicines: the basics Opioid medicines such as morphine are useful to help reduce higher levels of pain experienced after an operation or injuries like a fractured bone. They are usually prescribed when other pain medicines have not reduced the level of pain enough to allow you to comfortably increase what you are able to do e.g. physiotherapy, getting up and moving about. There are different types of opioid pain medicines and they might be used at different times in your recovery or vary depending on other medicines that you are also taking. You may only need opioid medicines for a short time after surgery. Most people stop them after a couple of days. If you need to take them for longer, it is important to reduce and stop them in a planned way. You may be advised to take other pain medicines as you recover. Your healthcare team will advise you on the type of opioid medicine to use. They can guide you to use pain medicines safely to reduce the chance of side effects or other problems. Your healthcare team will also recommend how you can best reduce and stop taking pain medicines as soon as you feel able to. 3 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 4 Before your surgery What can I do before my operation to improve my recovery afterwards? Be as active and fit as you can be Being as active and fit as you can be helps recovery to be quicker and the pain will reduce and stop sooner. Sometimes staying active can be tricky if you have pain or problems with joints or other areas of the body. So ask for advice about how to increase your body and heart fitness. Regular gentle walking several times a day, water-based exercise and exercises done in your chair can all help build fitness. Pace these activities so as not to cause pain or symptom flare ups. Steady and gentle approaches everyday are the most helpful. Eat healthily Healthy eating helps wounds to heal. So explore ways to eat more healthy foods, like fruit and vegetables. Losing extra weight helps reduce many complications, like wound infections. Even small weight loss helps better healing. 4 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 5 Reduce or stop smoking and vaping This helps lessen the risk of a chest infection, clots in the legs and lungs and other health issues that make your recovery tougher and longer. Reduce or stop alcohol This can help the body recover faster after your operation. Use enjoyable distraction and relaxation • Bring enjoyable and easy-to-read books into hospital • Listen to music or podcasts you enjoy • If you find relaxation or mindfulness techniques helpful, use them through the day, and at night if sleep is difficult • Audio versions of books, relaxation and mindfulness recordings are worth bringing into hospital too What if I’m already taking opioids? If you are already taking opioids, please talk to your healthcare team. Depending on timing of your surgery, you may benefit from reducing your opioids beforehand in a safe manner. This may help with recovery after surgery, particularly in terms of your pain management, wound healing or reducing the risks of infections in body areas like the skin, chest or mouth. 5 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 6 How medicines reduce pain Paracetamol is thought to relieve pain by blocking chemical messengers in the brain and spinal cord. Non-steroidal anti-inflammatory drugs (also known as NSAIDs) such as Ibuprofen block the production of certain body chemicals that cause inflammation and pain. Opioids (for example codeine, tramadol and morphine) provide pain relief by acting on areas in the spinal cord and brain to block the transmission of pain signals. Opioids are considered to be some of the strongest pain medicines. You should reduce and then stop taking opioids as soon as you can, or by the date on your pain management plan. This is because of the risk of becoming dependent or addicted to them. If you find it difficult to stop taking opioids by the time agreed in the plan, talk to your healthcare team to find other ways of stopping opioids and lessening your pain. For further information on all pain medicines, read the patient information leaflet provided with the medicine. 6 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 7 Using a pain management plan One thing you can do to help your recovery after surgery is to use a pain management plan. There’s a plan printed on the following pages for you to use. A member of your healthcare team will work with you on your plan to fill it in. This will then become your personal Pain Management Plan. It will show you which medicines to take, when to take them and when to reduce and stop them safely. Take the plan home with you and use it to remind you how to use your medicines safely and when you should be reducing and stopping them. 7 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 8 My Pain Management Plan My name Filled in by (healthcare team member) Date filled in 1. The pain medicines I have been given Opioids Tick the ones prescribed Tramadol Morphine Oxycodone Tapentadol Other? Codeine Dihydrocodeine Other? NSAIDs Ibuprofen Naproxen Diclofenac Other? Paracetamol Paracetamol The dose How often I should take them 8 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 9 NOTE: Paracetamol (shown below in green), the NSAIDs (shown in yellow) and the opioids shown in orange should be taken at regular times during the day. The opioids shown in red should only be taken when you need them. 2. When I should be reducing and stopping them The date I started Day 1 The date I should reduce and stop taking them 9 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 10 After your surgery Going for gentle, regular walks is a great way of staying active When you leave hospital, you will receive a pain management plan and a prescription for pain medicines. The pain medicines will help manage your pain levels so you can be as active and independent as possible. The pain levels will lessen as your body heals and you steadily increase your daily physical activities in your home and outside. If you are still struggling with high levels of pain even with pain medicines, you should ask for a review with your healthcare team. 10 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 11 What can I do after my operation to reduce pain and recover well? Manage your medicines safely Follow the advice on the best way to use your pain medicines so you make a good recovery. Remember to take pain medicines (such as paracetamol and ibuprofen) regularly, as written in your pain managment plan on page 8. Learn to pace your activity Try not to overdo things just because you’re having a ‘good day.’ This is sometimes called a “boom or bust cycle” and is unhelpful for a steady recovery. It can make you overtired so that you can’t do anything the next day. Steady pacing of activities is better. Choose activities that help build fitness and do them at regular intervals through the day. You’ll be more likely to keep it up if you choose activities that you find are fun or rewarding. Always stop before you get overtired and remember to build in rest breaks. Stay active Build up your physical activity and do enjoyable daily activities. Activity will help you distract yourself from the pain. For example you can: • go for gentle, regular walks • do enjoyable hobbies or crafts, indoor or garden activities (remember to do these within your recovery limits) Distraction and other techniques • use techniques such as watching fun or gripping films or TV programmes • practise mindfulness, use crosswords and mindfulness colouring books, and try relaxation and breathing techniques 11 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 12 More about opioids... Using opioid pain medicines to prevent pain levels increasing Using opioid pain medicines only when you need them will help you recover better. You’ll be able do more daily activities and keep to the exercise plan from your physio team. Think about which activities are likely to increase your pain levels (for example, a longer walk or an outing with friends). You can then plan for these expected increases in pain by taking your strong opioid pain medicines before the activity. This helps keep pain levels controlled. It is the most helpful way to take strong opioids. As your pain lessens, you can reduce pain medicines. Remember: you should aim to stop taking opioids sooner than other pain medicines like paracetamol. 12 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 13 Constipation: a common side effect of opioids Constipation is the most common side-effect of opioids and can really upset bowel movements. The most helpful way to reduce constipation is to take action before you are severely constipated. Three useful things to manage constipation well: 1. Drinking fluid helps. You should aim to drink plenty of fluids. 2. Eat foods that you know reduce constipation in you. For some people it can be figs, prunes, breakfast cereals, oranges, beans or pulses. Everyone is different. 3. Take a laxative medicine every day, to soften your ‘poo’ or stools and keep your bowels moving most days of the week. Get advice from a pharmacist or GP on the most useful type of laxatives. There are two types of laxatives: those that soften the stool and those that help move it through and out of the bowel. You might need to take both. Nearly everyone should take laxatives until they stop their opioids. 13 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 14 Stay safe while taking opioids after your surgery You should not drive if your ability to do so is impaired. Always lock opioids safely away. Keep them away from children at all times. Start reducing opioids as your pain level improves and interferes less with the things you are trying to do. Never keep leftover opioids at home. Do not throw them in the bin. Always take unused opioids to your local pharmacy for disposal. Tell your carers to call 999 if they can’t wake you up or if your breathing is very slow. Tell them to tell doctors or paramedics you take opioids for pain. 14 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 15 For further information: painconcern.org.uk my.livewellwithpain.co.uk flippinpain.co.uk versusarthritis.org My questions If you have any questions about your pain management plan or recovering from your surgery please make a note of them here, to help you remember to ask a member of your healthcare team. 15 pain management after surgery v2.qxp_Layout 1 09/06/2022 12:21 Page 16 Faculty of Pain Medicine College of Anaesthesiologists of Ireland Thanks to Louise Trewern of the British Pain Society’s Patient Voice Committee, for her valuable input to the development of this booklet. Booklet design: Andrassy Media. Version 1, June 2022
Url: /Media/UHS-website-2019/Docs/Services/Pain/Managing-pain-after-surgery.pdf

Quality account 24-25 final

Description: QUALITY ACCOUNT 2024/25 QUALITY ACCOUNT Contents Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome 3 Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction 5 2.1 Priorities for improvement 6 2.1.1 Progress against 2024/25 priorities 6 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports 8 2.2 Priorities for improvement for 2025/26 28 2.3 Statements of assurance from the Board 47 2.3.1 Review of services 47 2.3.2 Participation in national clinical audits and confidential enquiries 47 2.3.3 Recruiting to research 52 2.3.4 Commissioning for Quality and Innovation (CQUIN) payment framework 52 2.3.5 Statements from the Care Quality Commission (CQC) 52 2.3.6 Payment by results 53 2.3.7 Data quality 54 2.3.8 Data Security and Protection Toolkit (DSPT) 54 2.4 Overview of Quality Performance 55 2.4.1 Single Oversight Framework 55 2.4.2 Reporting against core indicators for 2024/25 55 2.4.3 Learning from deaths 67 2.4.4 Seven-day hospital services 70 2.4.5 Freedom to Speak Up 72 2.4.6 Rota gaps 74 2.4.7 Duty of Candour 76 Part 3: Other information 3.1 Our commitment to safety 77 3.2 Our commitment to improving the experience of the people who use our services 81 3.3 Our commitment to improve the quality of our patients’ environment 83 3.4 Our commitment to sustainability and the environment 85 3.5 Our commitment to staff 89 3.6 Our commitment to education and training 91 3.7 Our commitment to clinical research 98 3.8 Our commitment to technology 102 3.9 Conclusion 103 Part 4: Appendices 104 2 QUALITY ACCOUNT Part 1: Statement on quality from the Chief Executive 1.1 Chief Executive’s statement and welcome I am pleased to present this year’s quality account, which reflects our ongoing commitment to delivering safe, effective and compassionate care for our patients. 2024/25 has been a challenging year for UHS and the wider NHS and social care system. We have navigated operational pressures, with increasing numbers of patients who are medically fit but do not have an onward care package in place to be discharged, alongside a rise in winter infections and a record number of attendances to our emergency department. In the face of these challenges, our teams have worked tirelessly to enhance patient outcomes, improve service accessibility and ensure that the care patients receive meets the highest standards. I want to recognise the hard work of our staff in ensuring safety, driving innovation, and adapting to changes. This report highlights successful initiatives that have improved patient care over the past year. It also provides an overview of our quality priorities for 2024/25 and sets out our quality improvement priorities for 2025/26. We are proud to have maintained our focus on quality and achieved most of our objectives, enhancing the experience for those who use our services. Patient experience is an important priority for UHS. In 2024/25 we have successfully recruited approximately 2,000 ‘involved patients’, which will ensure that we co-design our services with those who use them, keeping our focus on our Trust values of patients first, working together and always improving. 2025/26 promises to be an exciting year for patient experience, with the development of the Patient and Family Support Hub, which will integrate voluntary services and ensure equitable access to support services for all. Our long-standing commitment to delivering safe, high-quality care is underpinned by the Fundamentals of Care programme - eight care commitments that patients, families and carers can expect from their care at UHS and these statements have been written in conjunction with patients, relatives and staff. In 2024/25 the programme has made significant progress in embedding Fundamentals of Care into our organisational culture. This has been achieved through developing understanding with newly registered professionals in our preceptorship programme, support worker development opportunities and the ongoing empowerment of staff through leadership development. In 2024/25, we have continued to strengthen our internal quality assurance programmes by aligning the clinical accreditation scheme with the CQC single assessment methodology. We are collaborating with other internal programmes - such as infection control, Patient-Led Assessments of the Care 3 QUALITY ACCOUNT Environment (PLACE) and friends and family feedback - to triangulate data and enhance oversight of key quality metrics, including patient safety, effectiveness, patient experience, and outcomes. This approach provides us with valuable intelligence to help us uphold our Trust values. 2024/25 marked one year of Patient Safety Incident Response Framework (PSIRF) implementation at UHS which has helped develop ‘just and learning’ culture across the organisation. Safety awareness has increased through our education programmes that have achieved good attendance and feedback. This coming year we will continue to build on the work that has been undertaken as part of implementation of the national safety standards for invasive procedures (NATSSIPS) 2. We continue to collaborate with our partners and develop our work as an integral organisation in the integrated health and social care system, building on trusted relationships across organisational boundaries are essential in improving health outcomes for our whole population. I want to recognise the amazing dedication of our staff in maintaining the safety of both colleagues and patients, fostering innovation, and adapting to evolving circumstances. Throughout this year, our teams across all services have strengthened their collaboration with our partners. As we continue to advance towards an integrated health and social care system, these trusted relationships are proving essential in our ability to respond effectively. To the best of my knowledge, the information contained in this document accurately reflects our performance, provides a true account of the quality of the health care services we provide, and where we have succeeded and exceed in delivery on our plans. David French Chief Executive Officer 26 June 2025 4 QUALITY ACCOUNT Part 2: Priorities for improvement and statements of assurance from the Board 2. Introduction Despite it being an extremely challenging year and unprecedented demand in the emergency department during 2024/25, the Trust maintained a strong focus on quality assurance. This was undertaken through established programmes and clinical leadership oversight of key safety and patient experience indicators, including falls, pressure ulcers, and venous thromboembolisms. The Fundamentals of Care initiative continued to be embedded, supported by high-quality peer reviews and weekly matron-led quality walkabouts aligned with CQC domains. The clinical accreditation scheme (CAS) was enhanced with updated documentation reflecting learning from themed walkabouts and aligned with national frameworks. A new governance framework for mortality and morbidity meetings was introduced to improve learning dissemination and escalation. The Trust also opened a Patient and Family Support Hub (P&FSH), advanced volunteer recruitment through a system-wide passporting approach, and began implementing NatSSIPs 2. In response to rising violence against staff, de-escalation training was rolled out, leading to a reduction in physical restraint and violence incidents. The Trust’s commitment to continuous improvement was demonstrated through training over 1,000 staff, outperforming NHS averages in improvement metrics, and achieving measurable service enhancements, including a 5.25% reduction in average length of stay, increased theatre throughput, and expanded use of patient initiated follow up pathways. Every year all NHS hospitals in England must prepare and publish an annual report for the public about the quality of their services. This is called the quality account and makes us at UHS more accountable to our patients and the public which helps drive improvement in the quality of our services. Quality in healthcare is made up of three core dimensions: Patient experience - how patients experience the care they receive Patient safety - keeping patients safe from harm Clinical effectiveness - how successful is the care we provide? 5 QUALITY ACCOUNT The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. This includes: • How well we did against the quality priorities and goals we set ourselves for 2024/25 (last year). • It sets out the priorities we have agreed for 2025/26 (next year), and how we plan to achieve them. • The information we are required by law to provide so that people can see how the quality of our services compares to those provided by other NHS trusts. Additional information about our progress and achievements in key areas of quality delivery. Stakeholder and external assurance statements, including statements from our Council of Governors, Hampshire and Isle of Wight Integrated Care Board and Southampton County Council’s Health Overview and Scrutiny Committee. 2.1 Priorities for improvement This section reflects on the 2024/25 quality improvement priorities at UHS and outlines our quality improvement priorities for 2025/26. 2.1.1 Progress against 2024/25 priorities Last year, we upheld our commitment to delivering the highest standard of care, influenced by various national, regional, local, and trust-wide factors. Throughout the year, we encountered unprecedented demand on our services, contending with challenges related to operational, capacity, patient flow, infection prevention, and safety. Despite these difficulties, we were confident in our ability to maintain our focus on quality priorities. Our teams worked diligently to achieve their goals under these challenging circumstances. We are proud to present our accomplishments and how our successes have continued to enhance the quality of services we provide to those who rely on us. 6 QUALITY ACCOUNT Overview of success Core dimension Patient experience Patient safety Clinical effectiveness Quality priority Progress Exploring the provision of a support centre for people using our services. Creating a behaviour framework behind our values, bringing them to life to improve our patient and staff experience. Volunteering - a new focus. Achieved On hold Achieved Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm. We will ensure that Fundamentals of Care (FoC) are provided to all our patients in collaboration with our patients, their family, and their carers. Improving our morbidity and mortality (M&M) meetings. Achieved Achieved Achieved Develop the Trust’s approach to reducing the impact of health inequalities (HIs). Help develop a UHS quality management system approach. Achieved Achieved 7 QUALITY ACCOUNT 2.1.2 Quality Improvement Priorities - 2024/25: Final Reports Quality Improvement Priority One: Exploring the provision of a support centre for people using our services (year one) Why was this a priority? UHS is a regional centre for many disease types, but we recognise there is inequality in provision of support facilities in the Trust for all our patients and their friends and families regardless of their clinical conditions. While cancer patients have access to designated centres such as The Maggie’s Centre and Macmillan facilities, other disease types have no comparable options despite often having enhanced needs. Patients who are nearing the end of their life are frequently spending their final days in bays with other patients as side rooms are prioritised for isolation purposes, and there are few areas available that can accommodate a hospital bed for patients to have time with their family away from their clinical setting. Apart from the UHS Patient Support Hub, there are no designated spaces that are accessible for patients, families, or carers, often resulting in staff offices and education rooms being inappropriately repurposed to meet their needs. Growing feedback from complaints and Friends and Family Test (FFT) responses emphasis our inability to provide patients, carers and their families access to spaces for respite and support. In addition, a recent UHS carers survey indicated that while we recognise that being a carer can sometimes be demanding both physically and emotionally, there are no designated areas for them to have their own personal needs met. Creating a bespoke support facility at UHS would help to address these needs and would be the first facility of its kind in an acute trust in England. What have we achieved? Estate has been identified. Work has started to repurpose the underutilised Macmillan Centre into a generic non-disease specific Patient and Family Support Hub. This agreement made through the Trust Investment Group was to end the current agreement with the Macmillan charity and to approach Southampton Hospitals Charity to support a refurbishment and further investment into the hub (for example funding a carers shower provision). Key areas identified for further development • Major grant request submitted to Southampton Hospitals Charity due to go to Charity Trustee Board in March 2025. • Recruitment of a band 7 mnager role (appointed in January 2025 and starting 31 March 2025); • Rebranding and merging (of current Patient Support Hub) started in February 2025. 8 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? Once the Patient and Family Support Hub is launched there will be a constant drive for patient and service user involvement, co-designing the space, there will be surveys on before and after, end of life quality of care will improve Progress metrics • Reduction in adverse event reporting that a patient died in an open bay. • Carers survey improvement. • P&FSH FFT results. Quality Improvement Two: Creating a behavior framework behind our values, bringing them to life to improve our staff and patient experience Creating a behaviour framework behind our Trust Values to bring them to life in our everyday work and interactions is still very much a priority. However, the work has been paused to ensure it aligns to the development of the new Trust strategy, both these pieces of work need to be produced side by side. It is anticipated the work on the behaviour framework will commence alongside the development of the overall Trust strategy and timelines for launch and embedding will move to 2025/26. 9 QUALITY ACCOUNT Quality Improvement Priority Three: Volunteering Why was this a priority? To value the contribution our volunteers make to our organisation, we wanted to improve the onboarding process to provide more guidance and support for our volunteer colleagues, and to work with them more closely to build in flexibility and be more creative in the kind of roles and support they could offer. What have we achieved? • We worked with our systems partners to complete a successful bid through Volunteering for Health (VfH) and have plans to develop a unified and standardised approach of volunteer recruitment using a passporting system. • Our key relationship is with the Hampshire and Isle of Wight Voluntary Community and Social Enterprise (VCSE) sector Health and Care Alliance (HIVCA) and it has allowed us to further explore a more system-wide approach, with a view to sharing resources, ideas, and opportunities both internally and outside the organisation on a regular basis. • We have worked with HIVCA and fostered a collaborative learning environment, aiming to streamline and standardise the volunteer onboarding processes over the coming year. • We have built upon current onboarding and training processes and are particularly developing the enhanced care training for our volunteers to support their awareness of working alongside patients who have mental health issues, dementia, delirium, learning disabilities and autism. • We are working with information governance leads to consider how the Trust’s internal policies can create equitable opportunities for a range of volunteers, to support them in accessing limited patient records, to allow them to document the interactions that they have with patients in support of the provision of collaborative holistic care. • We have begun to develop a new “ABC” approach to offering our volunteering roles, codesigning new roles for volunteers, and providing a flexible ‘responsive volunteering’ process that can support the organisational pressures as they arise and dovetailing the offer from our experience of care teams. • We have started to build relationships with the NHS care responder volunteer’s service looking at how they can enhance our existing offering provided by our responder volunteers. Key areas identified for further development • We have more scope to develop a more robust support process for volunteers during their placements through building better relationships between the volunteers and their clinical teams. • We will grow our volunteering hub space in spring 2025, to offer a more effective space for volunteers to access practical and welfare support from voluntary services, giving them a clear base and point of contact. • Working with HIVCA in the system-wide partnership, we will continue to explore the VfH funding and how it can develop the ‘passporting’ system for the volunteers across the network. • As our new Patient and Family Support Hub becomes established, we will work with the NHS responders and our existing responder volunteers to ensure a more extensive five to seven day/ week service (including evenings). 10 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? The key metrics for measuring these outcomes will come from: • Our responder volunteer statistics through the Patient and Family Support Hub. • Our outcomes associated with the HIVCA partnership and the VfH bid i.e. progress with a passporting system including potential recruitment of a post to develop and establish this new system. Progress metrics • Year one funding from the VfH bid was received by the partnership to develop the partnership with the HIVCA support meetings every six to eight weeks. • The system-wide volunteer onboarding and passporting system has not yet been established but will continue to progress with the partnership. • We will have developed a responsive volunteer network, available five days a week with an established support system in place. • We are an open and inclusive recruiter of volunteers and monitor the equality, diversity and inclusivity of the volunteers we recruit, seeing a more diverse range of volunteers that begins to more accurately represent our local community. What our patients/relatives/carers tell us 11 QUALITY ACCOUNT 12 QUALITY ACCOUNT Quality Improvement Priority Four: Acuity and deteriorating patients: continuing to improve how we keep patients safe from harm ADULTS AND PAEDIATRICS Why was this a priority? The recognition, assessment, and escalation of a deteriorating patient either adult or child are a key element of our trust-wide patient safety and quality strategy with the aim of improving clinical outcomes for acutely ill patients. How rapidly we respond to patient deterioration both in and out of hours is a key determinant of patient and quality outcomes. What have we achieved? Five new starters have successfully completed their supernumerary period. The critical care outreach team (CCOT) resumed its 24/7 service on 16 December 2024. Recruitment for the final vacancies was completed in December 2024, with both new recruits scheduled to commence their roles by 31 March 2025. An education task and finish group has been established, which has conducted a gap analysis with all education leads and reviewed both internal and external training resources. Standards are currently under revision. The medical education and simulation team is testing the Acute Life-threatening Events-Recognition and Treatment (ALERT) course, which includes resident doctors and junior nurses. Initial feedback was presented to the deteriorating patient group on 25 September 2024. The Trust’s acute deterioration education day continues to review feedback and evaluations for study days. The acuity surveillance pilot was successful, and the CCOT is now formally implementing this initiative. Monthly acuity reports are generated at the Trust, division, care group, and ward levels, or through bespoke reporting. These reports incorporate various metrics, including National Early Warning Score 2 (NEWS2) and National Paediatric Early Warning Score (NPEWS) activations, Call 4 Concern activations, a 24-hour overview of NEWS2 activations, cardiac arrest calls, CCOT activations and reasons for referral, and unplanned admissions to the intensive care unit (ICU). Quarterly data on cardiac arrests, Treatment Escalation Plans (TEP), and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) are presented to the resuscitation committee and the deteriorating patient group (DPG). Challenges persist in collecting robust sepsis data. UHS is participating in the national Martha’s Rule pilot programme, with Call 4 Concern implemented in March 2024 and all activations reported on Ulysses. A task and finish group has been established to explore patient wellness questions, which is a fixed agenda item at the DPG. The bi-monthly DPG has been established, with increasing medical engagement, and regular reports are submitted to the patient safety and quality committee (PSSG). Key areas identified for further development • Further roll out of Martha’s rule UHS-wide including Call 4 Concern. • Gain feedback from divisional governance teams regarding incidents to ensure learning is identified and appropriate action plans are devised and implemented. Collaboration with maternity and neonatal services. • Development of acuity dashboard. • Medium- and long-term service development commenced including workforce planning. 13 QUALITY ACCOUNT How will ongoing improvements be measured and monitored? • Bimonthly deteriorating patient group meetings to review current trends and themes, implementation of appropriate actions and evaluation of actions. • Biannual review of deteriorating patient group terms of reference. • Quarterly report to patient safety steering group. • Yearly assurance report – Trust quality committee. Progress metrics • Patient observation compliance data. • NEWS2 and NPEWS activations and data analysis. • Analysis of all unplanned admwissions to ICU from ward areas – adult and paediatric for themes to inform education and practice. • Adult and paediatric ICU stepdown data. • Adult critical care outreach team activity and outcome data. • Adult and paediatric cardiac arrest and outcomes data. • Adult TEP & DNACPR data. • Complaints and adverse event reports related to failure to rescue and failure to escalate. • Percentage of patients diagnosed with sepsis within the emergency department receiving appropriate antibiotics within one hour of sepsis diagnosis. • Analysis of adult and paediatric Call 4 Concern data, action plan developed, implemented, and adjusted in response to themes. • Analysis of patient/service user feedback on Call 4 Concern service. • Analysis of staff feedback on Call 4 Concern service. Volunteers and quality patient safety partners helped to promote the Call 4 Concern work 14 QUALITY ACCOUNT Quality Improvement Priority Five: Fundamentals of Care Why was this a priority? Patient Experience - Fundamentals of Care (FoC) was established as a priority in 2024/25 due to evidence that post COVID we had not yet returned to a less task-focussed and more patientfocussed level of care. The priority was developed to create a foundation and structure to tackle these care standards of care and to challenge practices, in response to patient and relative feedback. What have we achieved? Since commencing in late 2023 the following has been achieved: • We have established the FoC project board and this group continues to meet every three months to provide an overall project view, share successes and opportunities for learning, discuss the workstreams continuing under the eight standards and to escalate challenges through a formal governance structure (through quality committee and QGSG). • We have had one quality patient safety partner (QPSP) on the project board since conception. Subsequent events have involved two other QPSPs and have broadened the ‘patient voice’. • Each of the standards has a lead who oversees a multi-professional working group with clinical team representation. Some groups have chosen to pair due to links in their primary and secondary project drivers and actions. Matron involvement is driving the patient facing team involvement. • The project board is minuted, with an action tracker. The board is attended by the corporate nursing team and is supported by our deputy chief nurse, chaired by our head of patient experience. It is also supported by our chief nursing informatics officer, members of the transformation team and communications. • There is a FoC project manager in place who has worked with the transformation team to create a project plan in collaboration with workstream leads, a communications plan and drive forward key initiatives including business intelligence and the development of a clinical quality dashboard so we can measure the impact of the FoC. • Enhancing leadership and role modelling of the FoC has been a key focus through leadership in practice study days. These sessions, held three times annually, target leaders across the organisation to address and challenge behaviours related to the FoC. Incorporating the patient voice, these study days are grounded in real patient stories and involve the practical application of skills using simulated patients. 15 QUALITY ACCOUNT • As part of the patient hygiene working group, we have undertaken surveys using volunteer support, of patients and staff in the clinical decision unit (CDU), acute medical unit (AMU3), trauma assessment unit (TAU) and Macmillan acute oncology service (MAOS) in relation to their experiences of patient hygiene care and the impact of the trial patient hygiene packs. • Existing surveys, PALS interactions, complaints, adverse event reports (AER), Friends and Family Test (FFT) are followed up and reviewed by senior managers accordingly. These inform the FoC workstream through the head of patient experience. • Since conception, sharing the patient perspective and reflecting what patients would like to hear from us has been key. The posters around the organisation on our care commitments and resources on staffnet and the virtual learning environment (VLE) for staff, support this. These resources include: o Resources developed by each group to share during the monthly focussed trolley dashes. o Videos developed by staff for staff, to improve awareness of some key facts about each of the eight standards. Staff on Bassett ward engaging patients with dementia in crafting activities • Strong presence of the FoC throughout education as it has been mapped to the health care support worker (HCSW) induction, is included on preceptorship for all staff groups, has been presented to some university students at the University of Portsmouth and is embedded in lots of local training and development initiatives. The head of patient experience delivers many sessions across the organisation and beyond. Head of patient experience engaging with clinical staff in cardiovascular and thoracics on how to assess the FoC in their area 16 QUALITY ACCOUNT • The What Matters To Me (WMTM) project was trialled in some clinical areas from October 2024 (F7 and G7). Due to challenges in engaging the volunteer support to maintain this project it has temporarily been halted. The boards have an agreed template, agreed by a QPSP, and based upon feedback from staff and patients. The values of this project are echoed in local projects we have seen. • The FoC is being reviewed in conjunction with matron walkabout and the clinical accreditation scheme (CAS). Starting in February 2025, a new monthly focus is being established, with five core questions associated with a FoC standard and five specialist questions associated with that topic. This is forming past of ward benchmarking with a new self-assessment tool being implemented. Key areas identified for further development • Clinical representation in these working groups is to be re-established/built upon to support further engagement in the clinical areas/teams. • Continuing to establish links and support in child health, maternity and outpatients to ensure a bespoke but collaborative roll out of FoC. • To continue strong patient engagement and involvement, linking with involved patients where required with the support of our existing FFT results, the national inpatient and urgent and emergency (U&E) care surveys. • Resources to continue to grow to create a repository of information for staff and develop their knowledge around the FoC and to support each other in challenging behaviours and practices. • Employ interim project manager to maintain the project and support new ones whilst the current project manager is on maternity leave, focusing on establishing the dataset to evidence the FoC. • Strengthen the recruitment of volunteers for WMTM through the successful bid to Volunteering for Health (VfH) through the recruitment and investment in a volunteer coordinator, as part of a partnership with other organisations in Hampshire and Isle Of Wight (HIOW), including the charity sectors. • Successful implementation and evaluation of WMTM boards across key areas in organisation, with full volunteer support for the obtaining of photographs of the patients from themselves/ families to maintain that person-centred focus. How will ongoing improvements be measured and monitored? Improvements will be measured and monitored through FFT feedback, feedback from selfassessment tools and ongoing surveillance of the clinical quality dashboard. Progress metrics Reduction in clinical Iincidents: We’ve seen a decrease in the number and severity of incidents related to the FoC across inpatient settings. A key theme in early 2024 involved patients reporting being asked to urinate in incontinence pads. Six adverse event reports (AERs) were recorded in Q1, with none reported in Q3, indicating improvement. Reduction in complaints: While we don’t yet tag complaints specifically to FoC, we’ve observed a decline in ‘patient care’ complaints - from 14.67% in Q1 to 13.91% in Q3. We’re also exploring refinements in complaint categorisation to better align with FoC themes. 17 QUALITY ACCOUNT Increase in compliments: Patient and family feedback is gathered through various channels. For example, our urgent and emergency care survey showed an overall satisfaction score of 7.68/10. Improved oerformance against metrics: Throughout 2024, we’ve redesigned our improvement metrics in collaboration with clinical teams. These are now reflected in the clinical quality dashboard, supported by a comprehensive data dictionary developed by our project manager. 18 QUALITY ACCOUNT Quality Improvement Priority Six: Improving our morbidity and mortality (M&M) meetings Why was this a priority? The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents. It supports our processes for learning and improving patient safety and clinical effectiveness and replaces the old serious incident framework. An important element of the PSIRF is the focus on strengthening the processes for local learning through M&M meetings. M&M meetings (or clinical review meetings) have a central function in supporting our services to achieve and maintain high standards of care. They allow us to review the quality of the care that is being provided to our patients and learn lessons from outcomes. They are multi-disciplinary meetings which provide a safe place for learning, for supporting comprehensive conversations and ensuring governance standards are met. They allow us to identify any opportunities for improvement and are an important opportunity for education. They also provide opportunities for senior staff to model appropriate professional behaviour and engage the significant expertise of clinicians at the point of care. There is also a growing trend in M&M meetings to identify how resilience within complex systems enables good outcomes in the face of the kind of challenges and uncertainties which we are experiencing, and which are inherent within healthcare delivery. What have we achieved? The medical advisor for patient safety is leading efforts on morbidity and mortality (M&M) meetings. A comprehensive framework for M&M meetings at UHS has been developed, establishing expectations for a safe learning environment that is multiprofessional and multi-disciplinary, with a systematic meeting structure and agenda focused on learning, governance integration, and patient-centred care. This framework is supported by a handbook, resources, and education for M&M leads. A dedicated Teams channel has been created to provide resources for M&M leads. An M&M workshop was held as part of the WHO Patient Safety Day on 12 September 2024, focusing on creating strong learning environments, maintaining patient centrality, and learning from palliative care. The workshop was attended by 20 M&M leads and governance representatives. Additionally, 20 M&M leads attended a study day on 23 January 2025, covering topics such as human factors and systems thinking, PSIRF, keeping the patient central, appreciative inquiry in M&M, creating strong learning environments, managing difficult behaviour, and expanding the scope of M&M beyond mortality. The study day was well received, and another is planned for early April. Regular meetings are held with M&M leads and the medical patient safety advisor to provide support and identify areas needing assistance. An electronic M&M recording system was developed and trialed to capture and evidence outcomes, but it is no longer supported by the Trust, prompting the investigation of alternatives. A clear escalation process from M&M meetings to the existing governance structure has been established, with actions recorded. M&M meeting outcomes are now a standing agenda item in governance meetings. 19 QUALITY ACCOUNT UHS - 6 key principles of M&M Safety A safe space for learning. A meeting atmosphere that is conductive to open discussion with a focus on ‘Just and Learning Culture’ and an emphasis on understanding the systems factors, not focusing on individuals. Multiprofessional and Multi-disciplinary Ensuring active participation across staff groups and different disciplines. Meeting Framework Systematic agenda selection process, structured meeting format and objective analysis of data, including consideration of systems factors, and human factors and ergonomics. Learning Focus Comprehesive discussions to generate actionable learning and system improvement. Using an appreciative inquiry approach to emphasise and learn from the every day, as well as where things can go wrong. Governance Hospital-wide system to record outcomes, lessons learned, and dissemination of recommendations to ensure action and learning. Supporting our integrated approach to quality across the organisation. Folow up to ensure actions are completed. Clear pathways for central reporting and escalation of concerns. Patient Centred Keeping the patient and the family central to the learning. Ensuring that the patient voice is heard when learning from events. Completing feedback and duty of candour to help build trust. Training as part of the WHO World Patient Safety Day: Discussing how to create psychological safety in meetings 20 QUALITY ACCOUNT Key areas identified for further development • Development of electronic recording process that can be used for all M&M meetings. • Need to develop stronger links and greater support from local governance. How will ongoing improvements be measured and monitored? Regular review of M&M meetings with the M&M leads to ensure that: • M&M meetings are represented by the multi-disciplinary. • Terms of reference are in place. • Incorporating mortality data. • Using a recording app (when available). • Outcomes are linked to actions and governance processes. Progress metrics The electronic recording system is not currently supported so we cannot measure this (and it makes it hard to audit actions and escalations as these would be audited via this). Survey of clinical staff (163 replies) and their view on M&M. Key findings: • 73% staff feel UHS views the meetings as important. • 75% that their department views these as important. • 60% that they are fit for purpose. • 75% that they make a difference to patient safety. • 80% agree that systems factors are considered. • 35% felt they were well supported by local governance. 21 QUALITY ACCOUNT Quality Improvement Priority Seven: Develop the Trust’s approach to reducing the impact of health inequalities (HIs) (year one) Why was this a priority? The causes of health inequalities are complex, but research has shown that the main drivers of health inequalities are social determinants; the environments people live in, access to employment and the kind of start they had in life. Inequalities are also driven by the ways in which health services are designed and delivered, and by the quality of clinical care received. The NHS plays an important role in both mitigating against the wider determinants and in reducing healthcare-based inequalities. As well as a moral and social responsibility, NHS trusts have a legal duty to consider health inequalities. A new requirement from NHS England asks that trusts describe the extent to which they have exercised its functions consistently with NHS England’s views set out in the statement on information on inequalities. Addressing health and care inequalities is a core focus of the CQC’s 2021 strategy. To reinforce this commitment, the CQC has outlined five equality objectives aimed at tackling disparities in health outcomes. They have made it clear that action will be taken where care falls short for particular groups. Providers are expected to proactively identify, engage with, and respond to individuals who face barriers to accessing care or experience poorer outcomes. These efforts will be reflected in the CQC’s assessment frameworks. Failure to address health inequalities also carries a significant financial burden for NHS trusts. Estimates suggest these disparities cost the NHS around £5.5 billion each year. Eliminating health inequalities could potentially reduce the volume of treatments provided by the NHS by up to 15%, easing pressure on services and resources. What have we achieved? Governance A health inequalities board has been convened, chaired by the chief medical officer and attended by representation across UHS, patient partners, public health teams from the local councils and the population health team within the integrated care board. The board has set some initial objectives. These will be delivered through five areas of focus, each with a dedicated sponsoring director and a detailed delivery plan. These areas of focus are: • Clinical priorities. • Data and measurement. • Enabling the organisation. • Communications and engagement. • Strategy and approach. Clinical priorities Three clinical priorities have been set, based on national guidance on services where there is greatest health inequalities impact. The public health leadership from the local councils and integrated care board were involved in this prioritisation to ensure that we chose areas with high prevalence locally, and where it was felt an acute trust can have greatest impact. Priorities set are tobacco dependency, hypertension and obesity. 22 QUALITY ACCOUNT Tobacco dependency In Southampton, smoking rates are higher than the national average. It is estimated that one in six Southampton deaths are attributable to smoking (JSNA, 2021). 70% of our lung cancer patients and 86% of our COPD patient deaths are directly attributable to smoking. People who smoke are 36% more likely to be admitted to hospital than non-smokers and have poorer treatment outcomes including reduced response to treatments, prolonged recovery and increased risk of complications, across many areas including surgery, cancer and cardiovascular disease (Royal College of Physicians, 2020). This leads to increased length of stay, higher rates of emergency department attendance and greater pressure upon outpatient clinics due to smoking-related comorbidities. We have been focusing on improving identification of those who have been admitted who smoke, increasing the delivery of very brief advice to all patients who smoke and increasing referral to tobacco dependency services on the ward for those who do not opt out. We’ve been reviewing our data to understand how we are supporting those most at risk of being impacted by health inequalities. Obesity In 2022 to 2023, 29.5% of adults in Southampton were estimated to be living with obesity, above the national average. Southampton has one of the highest childhood obesity rates in the county. There are a large number of conditions linked with obesity, including cardiovascular disease, hypertension and liver disease. There is a multi-disciplinary service provided at UHS for children which provides excellent outcomes, reversing clinical impacts such as hypertension and type two diabetes. This programme seeks to identify opportunities to collaborate with our system to prevent the increasing levels of childhood obesity, reflecting the national focus on left shift and prevention. Adult obesity services are in review across our system. Hypertension Hypertension is amongst the leading causes of death in Southampton and Hampshire. High blood pressure causes threat to life expectancy linked with stroke, vision loss, heart failure, heart attack, kidney disease/failure. Hypertension identification and control have both been a challenge across Hampshire and Isle of Wight. Although hypertension treatment is delivered in primary care, there are actions we are taking as a trust to support this important priority. This includes: • As the largest employer in the city we have the opportunity to improve health by supporting our staff. We are developing materials to support our staff to understand the importance of blood pressure monitoring and approach to accessing help with high blood pressure. We hope this knowledge will extend to families, communities and how we support our patients. • Support people to ‘wait well’ whilst on our waiting list, with improved guidance on controlling and monitoring blood pressure while waiting for surgery, reducing the number of cancelled procedures due to high blood pressure. • Consider how improved data sharing on blood pressure readings between UHS and GPs can support onward support for hypertension. 23 QUALITY ACCOUNT w Data and measurement Several positive steps have been taken in measuring and understanding health inequalities within our services. These have been: • Building new dashboard that enables us to assess whether access to our services in equitable related to IMD decile, age, gender and ethnicity. • Assessment of equitable delivery of smoking cessation services. • Assessing the acute impact of hypertension control. • Collaborating with the Integrated care board on producing the data required for national reporting guidelines. Enabling the organisation We wish to support staff across our organisation to understand health inequalities, to recognise them within services, to access to tools to enable service change and to have routes to escalate issues. We have appointed a health inequalities officer who will be a key link to support services to achieve this. We have begun developing training that will be available across the organisation. We have also established escalation routes for raising concerns related to health inequalities. Communications and engagement There have been a number of excellent case studies communicated during this year through existing communications channels such as the Connect magazine. HELIXR, a pioneering programme that supports vulnerable patients with chronic liver disease through the introduction of peer support workers, attracted news coverage and was featured on the BBC and ITV Meridian in March. We have been attending events across Southampton including Pride and the Black Business and Arts Festival to show our support and to connect with our communities. We’ve been reaching out to grow the number and diversity of our involved patients, aiming to reflect the diversity of our population in our feedback and helping us to better serve the needs of our community. Strategy and approach We have worked on establishing this approach to delivering health inequalities over the year, which is now seeing results in progress in all prioritised areas for improvement. We have taken discussions to our Trust Board to establish how we will move this important work forward in years to come. We have also reflected on how population health, prevention and health inequalities will feature in our developing updates to our trust and clinical strategies. Key areas identified for further development There are detailed delivery plans for all of our priority areas over the next year, which will enable us to keep driving towards our aims. Highlights from these plans include: • Designing and publishing health inequalities training for all staff. • Creating an internal staff campaign, recognising the impact of health inequalities within our people and providing advice. • Establishing a health inequalities operational group who receive escalations of health inequalities issues and assess trust-wide implications and support improvements. • Delivery of planned improvements within our three prioritised clinical specialties. • Connecting with our communities and engagement leads across our city, improving our insights into the local drivers of health inequalities and identifying improvement opportunities. • Reviewing our use of QEIAs for change and decision making. 24 QUALITY ACCOUNT • Development of Trust and clinical strategies with making impact on health inequalities included. • Making use of the data sets we have built to drive change within our services and measure our impact. How will ongoing improvements be measured and monitored? We have clear objectives against all priorities with delivery timelines. We will continue to assess our progress in delivering against these. The dashboards that have been built will enable us to measure change over time, demonstrating where we have been able to impact on the equality of access to services. We will continue to work with our patients to gain feedback on how well we have met their needs while under our care. Progress metrics During 2024/25, we significantly advanced data capabilities to measure health inequalities across UHS services. We now track outpatient and inpatient waiting lists, discharges, and emergency department performance by age, gender, ethnicity, and Index of Multiple Deprivation - enabling long-term impact assessment. Staff access to this data will also be monitored. While some planned measures were successfully implemented, others remain in progress and will continue into year two (2025/26) of this quality priority. As part of our hypertension programme, we aimed to reduce theatre cancellations and non-elective admissions. Pathway improvements are underway and will be implemented in 2025/26, supported by expanded data sources. Combined with the Hampshire and Isle of Wight Intergrated Care Board’s (HIOW ICB) cardiovascular disease (CVD)-focused ‘signature move’ in primary care, these efforts are expected to reduce non-elective admissions. HIOW ICB data for 2024/25 shows: • ~95 CVD-related ED attendances/month • ~420 non-elective admitted episodes of care/month • ~2,340 bed days/month Our tobacoo quit rates continue to be better than expected nationally. Throughout the year, the health inequalities board reviewed case studies from eight services, showcasing impactful improvement work. These have been documented to support organisational learning. 25 QUALITY ACCOUNT Quality Improvement Priority Eight: Develop a UHS quality management system approach (year one) Why was this a priority? In April 2023, NHS Improving Patient Care Together (IMPACT) was launched to support all NHS organisations, systems, and providers at every level (including NHS England) to have the skills and techniques to deliver continuous improvement. NHS IMPACT’s five components form the basis of all evidence-based improvement methods and underpin a systematic approach to continuous improvement: • Building a shared purpose and vision. • Investing in people and culture. • Developing leadership behaviours. • Building improvement capability and capacity. • Embedding improvement into management systems and processes. Taking a more integrated quality approach is also a key component of our ‘always improving’, clinical effectiveness and Trust strategies in support of our ‘outstanding patient outcomes, safety and experience’ strategic pillar. To establish our current position, the Trust undertook a self-assessment to gauge its organisational maturity against the IMPACT framework and identified ‘embedding improvement into management systems and processes’ as an area of opportunity to improve and employ best practice. It was also a recommendation from the Thirlwall Inquiry that organisations focus on their ability to triangulate different quality indicators to build
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UHS AR 22-23-6

Description: 2022/23 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2022/23 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006 © 2023 University Hospital Southampton NHS Foundation Trust Contents Welcome from our chair and chief executive 6 Overview and performance 8 Performance report 9 Overview 10 Accountability report 33 Directors’ report 34 Remuneration report 57 Staff report 71 Annual governance statement 91 Quality account 106 Statement on quality from the chief executive 107 Priorities for improvement and statements of assurance from the board 110 Other information 188 Annual accounts 222 Statement from the chief financial officer 223 Auditor’s report 224 Foreword to the accounts 230 Statement of Comprehensive Income 231 Statement of Financial Position 232 Statement of Changes in Taxpayers’ Equity 233 Statement of Cash Flows 234 Notes to the accounts 235 5 Welcome from the Chair and Chief Executive Officer University Hospital Southampton NHS Foundation Trust (‘UHS’ or the ‘Trust’) experienced another challenging year during 2022/23. Nonetheless, the Trust and its staff have continued to deliver for patients and the wider system in which it operates. Trust highlights from 2022/23 include: • Delivering an 8% increase in activity (compared to 2019/20) under the elective recovery programme, which places us as one of the top performing trusts in England. • Being recognised in the NHS staff survey as the seventh highest trust for recommendation as a place to work nationally and the best performing trust in opportunities for career development. • Celebrating 50 years as a medical school with the University of Southampton and continuing to pioneer UK and world-first research studies. • Enhancing the reputation of our specialist care – for example our bone marrow transplant team at UHS have the best patient outcomes in Europe. However, as was the picture across the country, UHS had an extremely challenging winter with attendances at our emergency department often in excess of 400 a day. This was driven in part by high prevalence of streptococcus A (strep A) in the community along with other seasonal illnesses such as influenza and high incidences of COVID-19 at times. Moreover, the lack of availability of care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore we have been operating at or near to capacity throughout the year. At the time of writing, there continues to be operational pressures due to industrial action by the Royal College of Nursing and British Medical Association. Throughout the disputes, we have attempted to balance the right of our staff to strike with the need to minimise the impact on the Trust’s operations and patients and ensure that safety was not compromised. Our leadership team has engaged proactively with the unions to agree, where possible, derogations (i.e. services that will continue to be staffed during strikes) to ensure that the running of our hospitals can continue and that patients remain safe. We would like to express our thanks to all staff who have gone over and above during these periods of industrial action by being willing to do different work to usual, often at anti-social times of the day. While we cannot influence national negotiations, we are focusing on what we can control within UHS. Our people strategy published last year sets out how we will grow and deploy our workforce of today and the future as part of a thriving community to deliver world-class patient care. Building on this, we have recently launched our inclusion and belonging strategy so that as a leadership team we can deliver what is required for all our workforce to feel they can belong and thrive at UHS. The Trust achieved its Cost Improvement Plan (CIP) target of £45.6m for 2022/23, the highest in our history but despite this, ended the year with a deficit of £11m. The deficit was driven by a combination of factors including a substantial increase in energy prices, higher costs of medicines and equipment and temporary staffing costs as well as changes in recent years in respect of the NHS funding infrastructure, which adversely impacted the Trust relative to others during the year. In terms of the broader context, the Hampshire and Isle of Wight Integrated Care System, in which the Trust operates, reported an overall deficit for 2022/23 driven in part by a significant increase in staffing numbers when compared to 2019/20 as well as structural factors. 6 We have continued to make progress on our estates strategy, building new theatres and carrying out improvements to existing facilities, as well as opening a new park and ride for staff at Adanac Park and progressing plans for a new innovation campus there. During 2022/23 we invested over £88m of capital expenditure to meet our ambition of increasing capacity and improving services in order to manage the increasing demand. All development is underpinned by our green plan, which sets out areas of focus for decarbonising UHS and achieving the net zero target set by the NHS. The Trust has continued to support the Hampshire and Isle of Wight Integrated Care System, which was formed on 1 July 2022 to facilitate integration and collaboration across health and social care partners in the region. In particular, UHS has worked closely with the Integrated Care Board and other providers in the development of the operating plan for 2023/24. We have also continued to work with other partners in the region, including local authorities and the University of Southampton. The 13,000 staff of UHS are our greatest asset and we would like to express our gratitude to them for continuing to go above and beyond to put patients first under very challenging circumstances. Without our staff, we would be unable to fulfil our ambition to be a world-class organisation with world-class people delivering world-class care. Jenni Douglas-Todd Chair 26 June 2023 David French Chief Executive Officer 26 June 2023 7 PERFORMANCE REPORT Performance report Introduction from the Chief Executive Officer The Trust experienced another challenging year with the need to balance the delivery of quality patient care with a significant increase in demand for the Trust’s resources and the need to do so whilst maintaining a sustainable financial position. The Trust saw the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. Despite this, however, the Trust was successful in reducing the number of patients waiting more than 104 weeks to nil and in reducing the number of patients waiting more than 78 weeks to 14 by the end of the year. In addition, the Trust’s performance under the elective recovery programme placed it as one of the topperforming trusts in the country. Demand for non-elective care also significantly increased during the year with the emergency department seeing more than 400 attendances per day at some points, especially during the winter months. The industrial action seen in the latter part of 2022/23 placed further pressure on the Trust and resulted in a need to cancel elective procedures and outpatients appointments. However, on balance, the Trust was able to manage these events through effective planning and the engagement and support of its staff. Although the Trust was successful in recruiting to substantive roles, especially in terms of reducing the number of Health Care Assistant vacancies, the anticipated reduction in use of bank and agency staff was not seen. This, among other factors, such as the substantial increase in energy costs and the rate of inflation, posed a significant challenge in terms of the Trust’s financial position. Despite achieving savings of £45.6m, the Trust reported a deficit of £11m for 2022/23. 9 Overview About the Trust Our services University Hospital Southampton NHS Foundation Trust is one of the largest acute teaching trusts in England with a turnover of more than £1 billion in 2022/23. It is based on the coast in southeast England and provides services to over 1.9 million people living in Southampton and south Hampshire and specialist services, including neurosciences, respiratory medicine, cancer care, cardiovascular, obstetrics and specialist children’s services, to more than 3.7 million people in central southern England and the Channel Islands. The Trust is also a designated major trauma centre, one of only two places in the south of England to offer adults and children full major trauma care provision. As a leading centre for teaching and research, the Trust has close working relationships with the University of Southampton, the Medical Research Council, National Institute for Health and Care Research (NIHR), Wellcome Trust and Cancer Research UK. The Trust is consistently one of the UK’s highest recruiting trusts of patients to clinical trials and one of the top nationally for research study volumes as ranked by the NIHR Clinical Research Network. Every year the Trust: treats around 160,000 inpatients and day patients, including about 75,000 emergency admissions sees over 650,000 people at outpatient appointments deals with around 150,000 cases in our emergency department delivers more than 100 outpatient clinics across the south of England, keeping services local for patients The Trust provides most of its services from the following locations: • Southampton General Hospital – the Trust’s largest location, where a great number of specialist services are based alongside emergency and critical care and which includes Southampton Children’s Hospital. • Princess Anne Hospital – located across the road from Southampton General Hospital and providing maternity care and specialist care for women with medical problems during pregnancy and babies who need extra care around birth across the region. • Royal South Hants Hospital – although the Trust does not operate this site near the centre of Southampton it provides a smaller number of services from this location. • New Forest Birth Centre – located at Ashurst on the edge of the New Forest and run by experienced midwives and support staff it acts as a community midwifery hub. The services provided by the Trust are commissioned and paid for by the Hampshire and Isle of Wight Integrated Care System (ICS) and, in the case of more specialised services (such as treatments for rare conditions), by NHS England. Trust services are supported by clinical income, of which 55% is paid for by NHS England and 43% by the Hampshire and Isle of Wight Integrated Care Board. These are provided under a standard NHS contract, which incorporates ongoing monitoring of the Trust and the quality of the services provided. 10 Our structure UHS gained foundation trust status on 1 October 2011. A foundation trust is a public benefit corporation providing NHS services in line with the core NHS principles: that care should be universal, comprehensive and free at the point of need. The Trust is licensed as a foundation trust to provide these services by NHS England and the healthcare services we provide are regulated by the Care Quality Commission. Since 1 July 2022, the Trust has been part of the Hampshire and Isle of Wight Integrated Care System (ICS) when this was established through the Health and Social Care Act 2022. Each ICS has two statutory elements: an integrated care partnership (ICP) and an integrated care board (ICB). The ICP is a statutory committee jointly formed between the NHS integrated care board and all uppertier local authorities that fall within the ICS area. The ICP will bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population, with membership determined locally. The ICP is responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population in the ICS area. The ICB is a statutory NHS organisation responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in the ICS area. The establishment of ICBs resulted in clinical commissioning groups (CCGs) being closed down. The Trust has been a university teaching hospital since 1971. The diagram below provides an overview of the overall organisational structure of the Trust. Division A Surgery Critical Care Opthalmology Theatres and Anaesthetics Public and foundation trust members Council of Governors Board of Directors Executive Directors Division B Division C Division D Cancer Care Emergency Medicine Helicopter Emergency Medical Services Medicine and Medicine for Older People Pathology Specialist Medicine Women and Newborn Maternity Child Health Clinical Support Cardiovascular and Thoracic Neurosciences Trauma and Orthopaedics Radiology Trust Headquarters Division 11 Our values Our values describe how we do things at UHS and act as a guide to all staff working with colleagues to deliver high quality patient care and a great patient experience every day. Our values are: Patients, their families and carers are at the heart of what we do. Their experience of our services will be our measure of success. Partnership between clinicians, patients and carers is critical to achieving our vision, both within hospital teams and extending across organisational boundaries in the NHS, social care and the third sector. We will ensure we are always improving services for patients through research, education, clinical effectiveness and quality improvement. We will continue to incorporate new ideas, technologies and create greater efficiencies in the services we provide. 12 Our strategy 2021-25 The Trust’s strategy was updated during 2020/21 to take account of everything our staff had experienced during the COVID-19 pandemic and what we had learnt from this. The vision for UHS is to become an organisation of world class people delivering world class care. Our strategy is organised around five themes and for each of these it describes a number of ambitions we aim to achieve by 2025. Theme Ambitions Outstanding patient outcomes, • We will monitor clinical outcomes, safety and experience of our experience and safety patients regularly to ensure they are amongst the best in the UK By 2025 we will strengthen our and the world. national reputation for outstanding • We will reduce harm, learning from all incidents through our patient outcomes, experience and proactive patient safety culture. safety, providing high quality care • We will ensure all patients and relatives have a positive experience and treatment across an extensive of our care, as a result of the environment created by our people range of services from foetal and our facilities. medicine, through all life stages and conditions, to end-of-life care Pioneering research • We will recruit and enable people to deliver pioneering research in and innovation Southampton. We will continue to be a leading teaching hospital with a growing, reputable and innovative research and development portfolio • We will optimise access to clinical research studies for our patients. • We will enable innovation in everything we do, and ensure that ‘cutting edge’ investigations and treatments are delivered in Southampton. that attracts the best staff and efficiently delivers the best possible treatments and care for our patients. World class people • We will recruit and develop enough people with the right Supporting and nurturing our knowledge and skills to meet the needs of our patients. people through a culture that values • We will provide satisfying and fulfilling roles, growing our talent diversity and builds knowledge and through development and opportunity for progression. skills to ensure everyone reaches • We will empower our people, embracing diversity and embedding their full potential. We must provide compassion, inclusion and equity of opportunity. rewarding career paths within empowered, compassionate, and motivated teams. Integrated networks and collaboration We will deliver our services with partners through clinical networks, collaboration and integration across geographical and organisational boundaries. • We will work in partnership with key stakeholders across the Hampshire and Isle of Wight integrated care system. • We will strengthen our acute clinical networks across the region, centralising when necessary and supporting local care when appropriate. • We will foster local integration with primary and community care as well as mental health and social care services for seamless delivery across boundaries. • We will build on our successful partnership with University of Southampton (UoS), growing our reputation as a national leading university teaching hospital. 13 Theme Foundations for the future Making our enabling infrastructure (finance, digital, estate) fit for the future to support a leading university teaching hospital in the 21st century and recognising our responsibility as a major employer in the community of Southampton and our role in broader environmental sustainability. Ambitions • We will deliver best value to the taxpayer as a financially efficient and sustainable organisation. • We will support patient self-management and seamless care across organisational boundaries through our ambitious digital programme, including real time data reporting, to inform our care. • We will expand and improve our estate, increasing capacity where needed and providing modern facilities for our patients and our people. • We will strengthen our role in the community as an employer of choice, a partner in delivery of services to our population and by leading the Greener NHS agenda locally. During each year of the strategy the Trust sets out a more detailed series of objectives to achieve and progress towards the delivery of its ambitions. In 2022/23 these objectives included: Outstanding patient outcomes, experience and safety Pioneering research and innovation World class people Integrated networks and collaboration Foundations for the future • Recovery, restoration and improvement of clinical services • Introducing a robust and proactive safety culture • Empowering and developing staff to improve services for patients • Always Improving strategy • Delivering a high-quality experience of care for all • Delivery of year two of the research and innovation investment plan • Strategy and partnership working • Growing, developing and innovating our workforce • A great place to work, develop and achieve • Compassionate and inclusive workplace for all • We Work in partnership with Integrated Care System and Primary Care Networks • Integrated Networks and Collaborations • Establishing Southern Counties Pathology Network • Establishing the Wessex Imaging Network • Develop Collaborations strategy • Creating a sustainable financial infrastructure • Making our corporate infrastructure fit for the future to support a leading university teaching hospital in the 21st century • Recognising our responsibility as a major employer in the community of Southampton and our role in delivering a greener NHS Performance against these objectives will be monitored and reported to the Trust’s Board on a quarterly basis. 14 Principal risks to our strategy and objectives The Board has identified and manages the principal risks to the delivery of its strategy and objectives through its board assurance framework. The principal risks to the delivery of its strategy and objectives identified by the Trust during 2022/23 were that: • There would be a lack of capacity to appropriately respond to emergency demand, manage the increasing waiting lists for elective demand, and provide timely diagnostics, that results in avoidable harm to patients. • Due to the current challenges, the Trust fails to provide patients and their families with a high-quality experience of care and positive patient outcomes. • The Trust would not effectively plan for and implement infection prevention and control measures that reduce the number of hospital-acquired infections and limit the number of nosocomial outbreaks of infection. • The Trust is unable to meet current and planned service requirements due to unavailability of qualified staff to fulfil key roles. • The Trust fails to develop a diverse, compassionate and inclusive workforce, providing a more positive experience for all staff. • The Trust fails to create a sustainable and innovative education and development response to meet the current and future workforce needs identified in the Trust’s longer-term workforce plan. • The Trust does not implement effective models to deliver integrated and networked care, resulting in sub-optimal patient experience and outcomes, increased numbers of admissions and increases in patients’ length of stay. • The Trust is unable to deliver a financial breakeven position and support prioritised investment as identified in the Trust’s capital plan within locally available limits (capital departmental expenditure limit (CDEL)). • The Trust does not adequately maintain, improve and develop its estate to deliver its clinical services and increase capacity. • The Trust fails to introduce and implement new technology and expand the use of existing technology to transform its delivery of care through the funding and delivery of the digital strategy. • The Trust fails to prioritise green initiatives to deliver a trajectory that will reduce its direct and indirect carbon footprint by 80% by 2028-2032 (compared with a 1990 baseline) and reach net zero direct carbon emissions by 2040 and net zero indirect carbon emissions by 2045. During 2022/23, the Trust continued to experience the impact of the COVID-19 pandemic. The need to ensure a safe environment for patients through stringent infection control processes impacted the Trust’s capacity due to the need to isolate patients with COVID-19 in separate areas of the hospital. In addition, outbreaks of norovirus during the winter months placed further pressure on hospital capacity. The impact of the pandemic continued to be felt in terms of staff absence due to becoming infected with COVID-19 as well as the significant impact on staff mental health. The higher than normal (i.e. pre-COVID) levels of staff absence placed additional strain on the Trust’s operations and led to increased expenditure due to the requirement to enlist bank and/or agency staff to maintain safe staffing levels. 15 Performance overview The Trust monitors a broad range of key performance indicators within its departments, divisions, directorates and through Trust executive committees. On a monthly basis, the Board and executive committee receives a performance report containing a variety of indicators intended to provide assurance in respect of the Trust’s strategy and that the care provided is safe, caring, effective, responsive and well-led. This report also includes the Trust’s performance against the national targets set by NHS England. The performance reports include a ‘spotlight’ section, which provides more detailed analysis of a particular area. Typically, this is one of either the national targets or the Trust’s performance against the expectations set out in the NHS Constitution. The monthly performance report is also published on the Trust’s website. The Chief Executive Officer provides a regular report on performance to the Council of Governors, which includes a range of non-financial and financial performance information. Capacity The pressures of the COVID-19 pandemic led to increases in the waiting times for patients and the number of patients waiting for more than a year increased significantly. During the year, the Trust achieved its goal of no patients waiting more than 104 weeks by July 2022 and finished the year with only 14 patients waiting for more than 78 weeks. However, the length of time patients are waiting for treatment remains one of the key risks for the Trust. This situation was compounded by the sustained demand for non-elective activity, which saw attendances at the emergency department rise to over 400 patients per day during some periods of 2022/23 and was consistently higher than previously was the case. The significant increase in referrals, often requiring more complex treatment, has seen the number of patients on a waiting list under the 18-week referral to treatment pathway increase to just over 55,000 patients at the end of the year. In addition, the industrial action during the year placed further strain on the Trust’s ability to both provide urgent care and manage its elective recovery programme. Quality and compliance Furthermore, difficulties in obtaining care home beds and other care packages in the community has resulted in challenges in discharging patients who are ready to leave hospital and therefore the Trust has been operating at or near to capacity throughout the year. The Trust continued to monitor the quality of care delivered throughout 2022/23. The Trust continued its focus on infection prevention and control, which had proven successful during the COVID-19 pandemic. The Trust progressed its Always Improving strategy and successfully supported the identification and implementation of 84 quality improvement projects. In addition, the Trust continued to implement the patient safety incident response framework as well as taking other steps to drive a safety culture within the organisation. Furthermore, the Trust conducted further trials of shared decision making between clinicians and patients and is a leading site nationally for shared decision-making principles. Further information can be found in the Quality Account. 16 Partnerships The new arrangements for integrated care systems were implemented in July 2022 with the Trust becoming part of the Hampshire and Isle of Wight Integrated Care System. As such, the Trust’s senior management frequently meets with peers from across the system to consider and agree matters of wider concern across the system. In addition, the Trust worked with the Integrated Care Board in order to develop its financial and capital plans for 2023/24 and beyond. The Trust also attends the Southampton Health and Wellbeing Board at Southampton City Council and in the Hampshire and Isle of Wight Acute Provider Partnership Board. During 2022/23, the Trust continued to progress research activities and opportunities with the University of Southampton and Wessex Health Partners. Workforce In addition, work continued in the development of an elective hub at Winchester with Hampshire Hospitals NHS Foundation Trust, which will provide the Trust with additional capacity to carry out its elective programme. The Trust’s key areas of focus during 2022/23 were in respect of increasing the substantive workforce and reducing staff turnover. Although the Trust was successful in recruiting to substantive posts, the expected reduction in reliance on bank and agency staff did not materialise, which meant that the Trust was 1,068 whole-time equivalents above its plan for 2022/23. Included in this figure is the TUPE transfer of genomics staff from Salisbury. A particular area of focus was the recruitment of Health Care Assistants where the Trust was successful in reducing the number of vacancies from 27% to 18%. Whilst the Trust was successful in reducing staff turnover from 14.9% in 2021/22 to 13.5%, it remained above the 12% target. However, the Trust did experience a reduction in staff absence from 4.7% in April 2022 to 4.3% in March 2023, and initiatives to improve staff wellbeing were an area of focus during the year. Estate Innovation and technology The industrial action in late 2022 and early 2023 posed significant challenges for the Trust, including in terms of the need to engage additional temporary staff to ensure patient safety. The Trust continued to invest in and develop its estate during 2022/23 including successful completion of the Paediatric Intensive Care Unit project, which delivered single rooms and specialist accent lighting alongside delivery of a ‘twin care’ room. There were a number of other significant projects during the year, including refurbishments of wards and work on creating new theatres as well as projects to improve staff wellbeing. These were part of over £88m of capital expenditure in 2022/23 that also included equipment, digital and the backlog maintenance programme. The Trust continued to promote research and development during 2022/23, including through partnerships with the University of Southampton and Wessex Health Partners. Furthermore, the Trust continued to examine ways to make use of technology to improve its service delivery. In particular, the Trust has promoted the use of MyMedicalRecord, which gives patients the ability to co-manage their healthcare online and through an app. 17 Sustainable financial model The Trust did not achieve breakeven status at the end of 2022/23 and reported a deficit of £11.037m at year-end. This was due to a number of factors, including the Trust’s underlying deficit as well as the increase in energy prices. The Trust was more exposed than most to fluctuations in the wholesale price of gas due to its reliance on a gas-powered energy supply. In addition, the Trust’s 8% uplift in elective activity when compared to 2019/20 was not fullyfunded, which placed further pressure on the Trust’s existing financial resources, which had been used to ensure a breakeven position in 2021/22. The continued use of bank and agency staff as well as the costs of industrial action in late 2022 and early 2023 further eroded the Trust’s financial position. Notwithstanding the above, the Trust did succeed in obtaining a number of sources of nonrecurrent funding during the year, including a successful bid for £29.4m of funding through the Public Sector De-Carbonisation Fund, which will be used to fund green initiatives as part of the Trust’s capital programme. The financial outlook across the NHS continues to appear very challenging during 2023/24 and the Hampshire and Isle of Wight Integrated Care System is forecasting one of the highest deficits in England. 18 Performance analysis COVID-19 Impacts Although the pandemic has ended and serious cases of COVID-19 have reduced significantly, the Trust continued to be impacted by COVID-19 during 2022/23. Heightened infection prevention control measures in respect of patients with COVID-19 placed additional stress on the Trust’s capacity due to the need to isolate those patients and there was a consequential reduction in the Trust’s ability to make most efficient use of its available spaces. Furthermore, the ongoing impact on the Trust’s staff has led to higher staff absence than was the case prior to the pandemic, particularly due anxiety, infectious diseases and colds and flu. • The Trust experienced an average number of 98.7 patients per day who tested positive for COVID-19. During the winter months, this number increased substantially to nearly 200. • During the year, an average of 3.6 intensive care/high-dependency beds per day were occupied by COVID-19 patients. However, at times this increased to as much as ten. • Although staff sickness rates remained higher than pre-pandemic, the Trust saw a decrease in the absence rate from 4.7% at the beginning of 2022/23 to 4.3% by the end of the period. COVID-19 Cases UHS average number of confirmed COVID-19 patients in bed (08:00 census) 250 200 150 100 50 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 Intensive care/higher care beds UHS average number of confirmed COVID-19 patients in an ICU/HDU bed (08:00 census) 12 10 8 6 4 2 0 4/1/20225/1/2022 6/1/20227/1/2022 8/1/2022 9/1/202210/1/202211/1/202212/1/2022 1/1/2023 2/1/20233/1/2023 19 Number of patients Emergency access through the emergency department The Trust continued to experience high demand from patients presenting to receive care in the emergency department throughout the year above that seen prior to the COVID-19 pandemic. In particular, during the period between January and March 2023, the Trust averaged 352 attendances per day compared to 301 during the same period in 2019/20, an increase of 17%. The Trust also saw a significant increase in attendances during December due to both seasonal illnesses, but also due to the prevalence of streptococcus A in the community with attendances sometimes over 400 per day. Furthermore, the industrial action during the latter part of 2022 and early 2023 placed further pressure on the Trust’s ability to deliver services. In addition, the difficulties in discharging patients in need of care either at home or in another setting resulted in reduced flow from the emergency department to the relevant ward(s), which placed further strain on the Trust’s performance. During the year, in order to reduce emergency department attendances, the Trust trialled using General Practitioners to triage and see more straightforward patients who would otherwise have presented to the emergency department. Although this trial did result in a slight reduction in terms of number of patients and waiting times in ambulatory majors and majors, the affordability and value for money of this scheme is under review. Number of patients presenting to the emergency department 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 As a result of the increase in demand upon the emergency department, there continued to be a significant adverse impact on timeliness of care. The Trust failed to meet the national target of 95% of main emergency department/type 1 attendances seen within four hours, achieving 64.5% in March 2023, although this performance was above average in England. 20 % standard met Emergency access 4hr standard UHS vs NHSE average Type 1 performance 70% 0 10 60% 20 50% 30 40 40% 50 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Ambulance handovers are an area of focus for NHS England, with a target of all handovers having to take place within 15 minutes and none waiting more than 30 minutes. The Trust performed well in this area with an average handover time of 17 minutes, having made the conscious decision to ensure that patients did not queue in ambulances at the expense of patients being queued within emergency department majors – thus impacting the Trust’s four-hour target, but meaning that ambulances were not queued outside the hospital as was seen in other areas of the country. Elective Waiting times Demand The year saw a continuation of the trend of increasing elective referrals experienced in 2021/22 following the pandemic, and referral rates continued to be above those seen prior to the pandemic. UHS Accepted Referrals 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Number of accepted referrals 21 Activity The Trust experienced significant increases in terms of the number of hospital appointments, diagnostic tests and elective admissions during the year, exceeding levels in previous years. The Trust was one of the top performing trusts in terms of its elective recovery programme, achieving an 8% increase in its elective activity during the year when compared to 2019/20. However, performance in this area and in terms of outpatients appointments was negatively affected by the industrial action by nurses, junior doctors and other members of staff, which took place in late 2022 and early 2023 due to the need to cancel non-urgent procedures and appointments in favour of maintaining safe staffing levels in areas such as the emergency department. In addition, the continued presence of COVID-19 as well as other illnesses such as influenza and norovirus placed significant pressure at times on the Trust’s capacity due to the need to implement appropriate infection prevention control measures. Furthermore, difficulties in discharging patients fit to be discharged, but in need of a care package, placed additional strain on the Trust’s capacity. Elective admissions (including day case) Post-COVID-19 pandemic Elective (including day case) recovery (% of same month compared between March 2019 – February 2020) 105% 100% 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 % recovery Outpatient attendances Post-COVID-19 pandemic outpatient seen recovery (% of same month compared between March 2019 – February 2020) 140% 0 90% 10 20 40% 30 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 UH S UHS rank amongst NHSE trusts % recovery Rank 22 Diagnostics The Trust measures performance on a total of 15 frequently used diagnostic tests. In March 2023, 22% of patients were waiting more than six weeks for diagnostics compared with the national target of less than 1%. Patients waiting for a diagnostic test to be performed (sum of 15 different frequently used tests) UHS diagnostic waiting list volume 12,000 11,500 11,000 10,500 10,000 9,500 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-2 2 Oct-22 Nov-22 Dec-22 Jan-23 Feb-2 3 Mar-23 Diagnostic waiting list volume Percentage of patients waiting over 6 weeks for a diagnostic test to be performed Diagnostic 6 week wait performance UHS vs. NHSE average 35% 30% 25% 20% 15% 10% 5% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 23 Referral to Treatment The Trust continued to see an increase in the number of patients being referred for treatment during 2022/23 with just over 55,000 patients on a waiting list under the 18-week referral to treatment pathway at the end of the year. Averaged across the year, the volume of referrals exceeded the Trust’s theoretical capacity by around 3.5%. Due to this significant demand, the Trust only achieved 63.2% of patients being treated within 18 weeks of referral in March 2023 compared with the monthly target of more than 92%. However, despite this, the Trust remained in the top quartile when compared to other teaching hospitals, reflecting that this growth in demand continues to be a national challenge. During 2022/23, the national target was to ensure that there were no patients waiting over two years for treatment by July 2022, and that there were no patients waiting more than 78 weeks by the end of March 2023. Long-waiting patients were an area of particular focus for the Trust during the year with no reported two-year waits since November 2022 and only two between the period June-November due to patients choosing to delay their treatment. This was a significant improvement compared to the peak of 171 patients reported in December 2021. Similarly, the Trust made progress in reducing the number of patients waiting over 78 weeks for treatment. In February 2023, the Trust reported 84 patients in this category compared to the peak of over 900 patients in September 2021. By the end of March 2023, the Trust had managed to further reduce this number of patients to 14, with those in breach of the target all due to the complexity of the cases. UHS referral to treatment waiting list 56,000 54,000 52,000 50,000 48,000 46,000 44,000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 24 Number on waiting list % standard met Percentage of patients waiting up to 18 weeks between referral and treatment RTT 18 week performance UHS vs. NHSE average 70% 65% 60% 55% 50% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Percentage of patients waiting more than 52 weeks between referral and commencement of a treatment for their condition Number of patients Rank UHS Referral to treatment patients waiting more than 52 weeks 3,000 0 2,500 10 2,000 20 1,500 30 1,000 40 500 50 0 60 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts % of RTT patients RTT % of patients waiting more than 52 weeks UHS vs. NHSE average 5.0% 0 4.5% 20 40 4.0% 60 3.5% 80 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S UHS rank amongst NHSE trusts Rank 25 % standard met Cancer Waiting Times The Trust is one of 12 regional cancer centres in the UK offering treatment for rare and complex cancers as well as cancer in children and brain cancer. The Trust has historically been in the upper quartile, relative to teaching hospital peers. Due to loss of key members of staff and industrial action, the Trust’s performance has slipped over the year with 72.5% of patients seen within two weeks in March 2023 following referral by a General Practitioner for suspected cancer (national target: > 93% per month). Cancer waiting times - 2 week wait performance UHS vs NHSE average 100% 0 80% 50 60% 100 40% 150 Apr-22May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23Mar-23 UH S NHSE average UHS rank amongst NHSE trusts Rank Referrals for January to March 2023 were at the highest for that month for the past five years and overall referral volumes in 2022/23 averaged 2,049 patients per month, 8% higher than in 2021/22 and 28% higher than in 2019/20. The national target was for 96% of patients to commence treatment within 31 days of diagnosis. However, in March 2023, the Trust only achieved 87.9%, but this figure hides considerable variation dependent on the tumour site and type of cancer with a range of 100% for haematology and children’s cancers to 71% for skin. The high rate of referrals led to a significant backlog in terms of patients waiting longer than 62 days for treatment. However, the Trust took steps to reduce this backlog by more than 50% through a dedicated recovery programme. In March 2023, the Trust treated 54.8% of patients within 62 days of referral compared to the target of more than 85%. Treatment for Cancer within 62 days of an urgent GP referral to hospital Cancer waiting times 62 day RTT performance UHS vs. NHSE average 80% 60% 40% 20% 0% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average % standard met 26 First definitive treatment for cancer within 31 days of a decision to treat % standard met Cancer waiting times 31 day RTT performance UHS vs. NHSE average 95% 90% 85% 80% 75% Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 UH S NHSE average Quality priorities The Trust set eight quality priorities in 2022/23, which were aimed at ensuring it continued to deliver the highest quality of care. The quality priorities were shaped by a range of national and regional factors as well as local and Trust‐wide considerations. The Trust recognised the overriding issues of significant operational pressures being felt right across the health and social care system, including those associated with the previous two years of the COVID-19 pandemic. The challenge was to deliver the best quality care in the context of these operational pressures, and the Trust set its quality priorities accordingly. Out of the eight priories set, the Trust achieved five and partially achieved three. Priority One: Enhancing capability in Quality Improvement (QI) through our Always Improving strategy The transformation team has grown to over thirty team members including project support officers, project managers, benefit realisation managers. This has allowed the Trust to develop that systematic organisational approach to guide and support its staff in their QI projects. The Trust originally set a target of delivering fifty quality improvement projects but have successfully supported a total of 84 (55 local and 29 flow improvements). These are local change projects which were identified, proposed, led, and delivered by the people who do the work. To date over 1500 people have been trained in the Trust’s improvement approach, which exceeds the original target of 500. The Trust also developed a QI project register and held an Always Improving conference. Priority Two: Developing a culture of kindness and compassion to drive a safety culture The Trust only partially achieved this priority as plans to fully deliver training were affected by operational pressures. However, during the year a variety of communication platforms were used to make sure staff understood the Trust’s vision and were kept up to date with plans and progress. The Trust worked to develop and embed a ‘just culture’ allowing staff to speak up and ask, “what happened and how do we learn?” and developed ‘stop for safety’ staff huddles. Priority Three: We will improve mental health care across the Trust including support for staff delivering care The Trust only partially achieved this priority as several key quality improvement projects have not yet been delivered, and the mental health strategy not yet been finalised. However, a training needs analysis was completed and significant staff training and an education scheme were introduced in response to the findings of the analysis. Mental health champion training has been delivered to 153 staff and IT systems have been improved to help capture vital data to help shape the Trust’s service. 27 Priority Four: Recognising and responding to deterioration in patients During 2021/22 the Trust successfully introduced national Paediatric Early Warning System (nPEWS) into its Southampton Children’s Hospital and UHS is now part of the national test and trial of nPEWS which is assessing the usability of the scoring system. The Trust has also explored how nPEWS can be adapted for children with complex medical conditions requiring interventions (including non-invasive ventilation) as part of their normal care. A daily heat map of escalation times over a 24-hour period was piloted in 2022 and will be rolled out across all adult’s inpatient areas during 2023. The Trust has also performed well with its cardiac arrest audits, and training and education programmes have consistently been delivered. September 2022 saw the implementation of a 24-hour paediatric outreach service. There is a deteriorating patient group and several successful QI projects have been introduced. Priority Five: Improving how the organisation learns from deaths The Trust only partially achieved this priority as it has been unable to establish a learning from deaths steering group. The Trust has introduced a mortality governance coordinator/analyst and grown its bereavement care service. Priority Six: Shared Decision Making (SDM) The shared decision models started at UHS in 2021/22 and have continued to grow with investment in pilot roles to expand these models, which include several advanced nurse practitioner roles, models in paediatrics bringing Shared Decision Making to patients who are transitioning from paediatric to adult services, while in maternity we have introduced SDM in birth planning. When assessing delivery of SDM against NICE guidelines, UHS performs well, especially in targets related to Trust buy-in, governance and practices of pilot areas. This year the Trust has implemented training through key platforms and expanded patient involvement in the project. As a leading site nationally for SDM principles, UHS have worked with NHS England on creating materials for others to learn from. Priority Seven: Working with our local community to expose and address health inequalities During the year the Trust refocused its efforts on making sure that its involvement and participation activities support the health inequalities agenda, while also working to deliver responsive information and advice to patients, carers, and families. Priority Eight: Ensure patients are involved, supported, and appropriately communicated with on discharge During the year the Trust has focused on improved patient, carer and family involvement, and improved communication during the discharge process as well as prompting a more collaborative working between social and health care staff. Strong partnership working with external agencies has been developed to support a system approach to hospital discharge, develop digital solutions, develop the patient hub to support discharge and delivered education to UHS staff. More information can be found about how the Trust delivered and measured its quality priorities, including feedback from patients and staff and improvement aims and quality priorities for 2023/24, in the Trust’s Quality Account for 2022/23. 28 Financial performance The Trust delivered a deficit of £11 million from a revenue position of over £1.2 billion, once items deemed as “below the line” by NHS England, such as the financial position of the Southampton Hospitals Charity, were removed. The Trust was unable to deliver the planned breakeven position. Several material cost pressures were incurred, including unfunded high-cost drugs costs and energy prices. These were unable to be off set in full by a savings programme, despite delivery of £45.6m of efficiencies (2021/22: £15m). Trust operating income rose by £64m from the previous financial year, most notably funding the NHS pay award, as well as additional elective recovery funding. Income reduced from the prior year in relation to ending a nationally funded project regarding testing for COVID-19. The Trust has however been successful in increasing funding for research and development. Trust operating expenditure rose by £78m, incorporating funded inflationary costs as well as the cost pressures outlined above. The Trust has also continued its reinvestment of surplus cash into infrastructure for the Trust, with capital investmen
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Annual report 2021-2022

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

Description: QUALITY ACCOUNT 2021/22 Part 1: QStaUteAmeLnItToYn qAuaClitCy fOroUm NtheTchief executive 2021/22 1.1 Chief executive’s statement and welcome Welcome to the quality report for University Hospital Southampton NHS Foundation Trust (UHS) for 2020/21, which incorporates the quality accounts. 2020/21 has been a year of unprecedented change for healthcare, and as might be expected this year’s account has a strong focus on our ongoing r QUALITY ACCOUNT 2021/22 Part 1: Statement on quality from the chief executive 1.1 Chief executive’s statement and welcome Welcome to the 2021/22 quality account which I am pleased to present on behalf of University Hospital Southampton NHS Foundation Trust (UHS). 2021/22 has been another year of unprecedented challenge for healthcare, and this year’s quality account continues to have a strong focus on our ongoing response to the COVID-19 pandemic. It also includes information about how we are working to restore services for our patients as we move out of the pandemic. It demonstrates that despite the difficulties, we have supported each other and have never been distracted from our commitment to quality. The challenges of the last year may have been enormous, but there have also been some real positives from the experience. We are working differently and more collaboratively as a health and care system, developing integrated care and rapidly introducing major change across our services, which helps us to focus on and continue to develop the high quality of our services. As we recuperate and recover from the pandemic, we will be a team of people that together is stronger than ever before. The professionalism of the team and all those involved across UHS has been inspiring in the face of significant adversity. I am grateful for the care, compassion and kindness shown by all colleagues to our patients and to each other during the most difficult of years. This is a great platform from which to seize all the opportunities we have before us to continue improving the quality of our services and care. As we begin to move forward, the Trust faces another set of challenges as our services have inevitably been affected over the last couple of years. We remain hugely concerned about the national growth in waiting lists for diagnosis and treatment, and for the people who may not have come forward for vital tests or treatment due to the pandemic. We will continue to do everything possible to maximise the number of patients that we can safely treat, and to ensure that patients on our waiting lists are regularly risk assessed and seen according to clinical priority. We are building capacity as quickly as we can and are recruiting more staff so we can treat the patients who need us. I have no doubt that the staff at UHS will continue to keep their focus on the quality of the services and care we give to ensure everyone who comes to UHS will have the best possible experience as they work tirelessly to put patients first. Quality assurance has remained a cornerstone of our care despite this period of intense pressure. We have consolidated the work we started last year to embed a different approach to governance, reporting and assurance requirements, and our approach as an acute provider has continued to flex and adapt. We are hugely proud to be playing an important role in the national response to COVID-19, not only through the delivery of essential healthcare, but also through the many research programmes that are helping us globally to understand and better treat the virus, and as the lead provider for the delivery of the COVID-19 vaccine programme to our population. We are investing significantly in our research and development infrastructure to secure our future as leading-edge university teaching hospital. Equally, we are investing in other significant areas such as refurbishing the hospital, developing innovative digital solutions. We have also launched a sustainability initiative to make the hospital greener, recognising the influence it has on impacting the environment and population we serve. We aim to achieve carbon net zero, resulting in healthier lives for our community and people. 2 QUALITY ACCOUNT 2021/22 During 2021/22 the Board has been working on our strategy for the next five years, which sets out our ambition for our quality standards and what we want the hospital to be in 2025 for patients and staff. I’m excited to be the person leading UHS to achieve these ambitions, knowing success with be a collective effort. There is so much to do, but I know that working together we will overcome all the challenges because that is what the UHS family does. The pandemic has challenged us, but it has also driven change, and it has shown what we can do together with the people of our city and region. In spite of the immense pressures we continue to face, our patients are hugely appreciative and grateful for the outstanding quality of care and treatment they receive here at UHS. This is testament to the dedication and hard work of everyone in the UHS family. The information contained within this report has been subject to internal review and, to the best of my knowledge presents a true and accurate picture of the performance of the Trust. David French Chief Executive Officer 21 June 2022 3 QUALITY ACCOUNT 2021/22 1.2 Introduction to this report Each year all NHS hospitals in England must prepare and publish an annual report for the public about the quality of their services. This is called the quality account and makes us at UHS more accountable to our patients and the public and helps drive improvement in the quality of our services. Quality in healthcare is made up of three core dimensions: • Patient experience – how patients experience the care they receive. • Patient safety – keeping patients safe from harm. • Clinical effectiveness – how successful is the care we provide? This report tells you how well we did against the quality priorities and goals we set ourselves in each domain for 2021/22 (last year). It sets out the priorities we have agreed for 2022/23 (next year) and how we plan to achieve them. The quality account incorporates all the requirements of The National Health Service (Quality Accounts) Regulations 2010 (as amended) as well as additional reporting requirements. 4 QUALITY ACCOUNT 2021/22 Part 2: Priorities for improvement and statements of assurance from the board 2.1 Priorities for improvement This section provides a look back over the 2021/22 quality priorities at UHS and sets out our quality priorities for 2022/23. 2.1.1 Progress against 2021/22 priorities Last year we set our quality priorities to ensure we delivered the highest quality of care shaped by a range of national and regional factors as well as local and Trust‐wide considerations. We recognised the overriding issues of significant operational pressures being felt right across the health and social care system and the pressures associated with the second year of the COVID-19 pandemic. We acknowledged that many of the aims of our priorities could be disrupted by the ongoing pandemic and that we might need to be flexible in adapting the priorities in changing circumstances. We limited ourselves to four priorities in recognition of these pressures and to allow UHS to focus on responding to them. This year our retrospective review reflects how we addressed the four priorities in the context of our organisational response to the COVID-19 pandemic and the pressing need to work towards restoration of our services. Our challenge was to deliver the highest quality care in the context of these combined pressures. Overview of success Figure 1: Priority 1 PRIORITY 1 Introduction of Midwifery continuity of carer (MCoC) for women at risk of complications in pregnancy. Core Dimension: Patient safety, patient experience and clinical effectiveness Achieved Why was this a priority? We recognise that the relationship between care giver and receiver leads to better safety and outcomes for women and babies in our care. Being cared for and supported through their pregnancy by the same midwifery team helps ensure safer care based on a relationship of mutual trust and respect and offers a more positive and personal experience. Midwifery continuity of carer (MCoC) is a model of care that aims to limit the number of different healthcare professionals a woman sees during her pregnancy. Its aim is for the pregnant woman to receive intrapartum care from a midwife she has met previously during her current pregnancy, thereby providing greater continuity. 5 QUALITY ACCOUNT 2021/22 This approach was the single biggest request of women heard during the NHS England 2015 National Maternity Review ‘Better Births’. The model has proven beneficial clinical outcomes for women including: 16% less likely to lose their baby and 19% less likely to lose their baby before 24 weeks. 24% less likely to experience pre-term birth. 15% less likely to have regional anaesthesia (e.g., an epidural). 16% less likely to have an episiotomy. The model organises midwives into teams of eight or fewer. Each midwife aims to provide antenatal, labour and postnatal midwifery care to approximately 36 women per year (pro rata), with support from the wider team for out-of-hours care. The ‘Better Births’ report published in 2016 set out a clear recommendation that the NHS should work towards a shared ambition for the NHS in England of MCoC being the default model of care available to all pregnant women. To ensure equity in maternity health outcomes the report recommended that roll-out should be prioritised by March 2023 for those most likely to be at greater risk of complications in pregnancy and experience poorer outcomes. NHS England identified this group as woman from Black, Asian and minority ethnic (BAME) backgrounds, those who live in the most deprived decile (IMD-1/Indices of multiple deprivation-1) or those with increased vulnerability (e.g., poor perinatal mental health, history of substance misuse, history of domestic violence). What have we achieved in 2021/22? Our service was quick to adopt the model of MCoC. We used a variety of communication forums to engage our staff and patients, including involvement in national and local public MCoC events, staff team meetings, use of digital platforms, newsletters and dedicated time at midwifery study days for education and discussion. We rapidly established five MCoC teams with each team caring for their own caseload of women in the antenatal, labour and postnatal period. Three are ‘‘caseloading’’ teams meaning they care for their women in labour with an ‘’on call’’ commitment night and day and are based in the east, west and centre of Southampton. The remaining two teams are integrated teams who are available for women in labour when they are on a set shift for labour care and are based in the centre and west of the city. All our teams have a linked consultant obstetrician to ensure continuity of obstetric involvement, and a statement of purpose was agreed to describe the roles and responsibilities required to support the delivery of the model. Before the publication of the ‘Better Births’ report we had already identified the need for a focus on the needs of Black and Asian women and those living in IMD-1 areas. Following publication of the report we accelerated our work, and since July 2020 Black and Asian women and those living in IMD-1 areas have been included for care in our MCoC teams. NHS England Ambition target recommendations 2020/21 Percentage achieved by UHS 2021/22 35% of women will be booked to receive care in a continuity of carer team 41.7% 35% of Black, Asian and minority ethnic women booked to receive care in a 75% continuity of carer team 35% of women living in an IMD-1 area booked to receive continuity of carer 80% 6 QUALITY ACCOUNT 2021/22 How improvements are measured and monitored MCoC compliance is reviewed at monthly service delivery meetings, at bimonthly maternity safety champion peer review meetings and through the local maternity and neonatal system (LMNS) by analysing data on the regional maternity services dashboard. We monitor the data, which tracks our performance using key performance indicators (KPIs), and report performance and strategic plans to our quality committee and Trust Board. Our statement of purpose is reviewed every six months by the programme’s senior matron to ensure it is responsive and continues to be fit for purpose. We actively seek feedback from our patients and their families and from our staff. What our patients told us: ‘‘‘I was under X’s care from around 19 weeks into my pregnancy after moving to Southampton. She came to visit us at home on most occasions and stayed in regular contact throughout my pregnancy; she also came to visit us at home after I’d given birth too. This was invaluable throughout the pandemic and I felt really reassured having a familiar face throughout.’’ ‘’My midwife always instilled confidence in me and I felt able to contact her and other members of the team with any worries or concerns no matter how small. I’m extremely grateful for the care I received, Thank you.’’ ‘‘I had my third baby in August and due to my fear of hospitals and anything medical I opted for my first home birth. X from the homebirth team was incredible right from the moment she happened to appear (out of nowhere like a fairy godmother) into my midwife appointment just as I was saying I wanted a homebirth but was worried about it… she told me she would contact me to arrange a Zoom call where we could chat and she could answer all questions.’’ ‘’My midwife seemed to have this sixth sense where she could tell when I was anxious about something and all of a sudden was telling me it was all going to be okay. She continued my care at my home each time, which was the first time I’d had any pre-natal care at home and it made me so much more relaxed!’’ ‘’Even in the two weeks after birth if I needed anything for me or for the baby, I just had to call my midwife, and it would either go through to her or a homebirth midwife on call day or night.’’ ‘’I would like to say huge thanks to you and your team for the care you have provided. I am so glad that I was under your team. Your advice at each stage of pregnancy helped me to deliver a healthy baby.’’ ‘’You have always gone above and beyond to make me feel comfortable (as you were aware of my past history). Whenever I started panicking, you calmed me by your friendly support. You had clarified things by providing more information and clarity …. as we were not sure about the options we had.’’ ‘’You made sure that I will get full support from my consultant and GP where I needed. I cannot imagine my pregnancy journey without you.’’ ‘’I didn’t know them (the midwife team) earlier but they made me feel like they were my sisters.’’ ‘’I do not think you could have done more than what you did.’’ ‘’My overall experience is so positive with the support I got from your team.’’ 7 QUALITY ACCOUNT 2021/22 What our staff told us: ‘’Working in the team has been the most rewarding thing I have done during my time as a midwife.’’ ‘’The role is so varied day to day and the fluidity it allows encourages you to constantly learn new skills and broadens your outlook on what defines being a midwife.’’ ‘’I have supported families throughout their pregnancy, birth, postnatal period and beyond and because of the relationships you nurture with these families they trust you completely.’’ ‘’My self-confidence at work has grown massively and I now feel happy to facilitate birth at home, in a birth centre or on Labour Ward, wherever my woman wishes.’’ ‘’This has given me exposure to new experiences, which can feel challenging at times, but by having a supportive team around you, advice is never far away. Caseloading has meant I’ve been part of the woman’s wider support network and understand the challenges she may face during her day-to-day life. This enables strong working relationships with other members of the multi-disciplinary team working with the family, such as safeguarding teams/family nurses/health visitors/obstetric team/social workers and more.’’ ‘’You really are at the centre of that family, coordinating their care, to improve their outcomes and their experience whilst accessing maternity care.’’ Key areas identified of opportunities for further improvement Originally our aspirations for 2022/23 were to grow our teams to ensure we had enough resource to offer MCoC to all Black and Asian women and women living in IMD-1 areas. Two new integrated teams came online in January 2022, with plans to develop staff incentives to increase this during the year. We agreed to develop a MCoC team for those in IMD-2 and IMD-3 areas in the west Hampshire area where there are currently no IMD-1 areas. When COVID-19 restrictions relaxed, we had also planned to increase face-to-face engagement with the local maternity workforce and continue to engagement with and sharing good practice across the Southeast region. On 30 March 2022 the final report of the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust (the Ockenden Report 2022) was published. The report recommended: ‘’All trusts must review and suspend, if necessary, the existing provision and further roll out of Midwifery Continuity of Carer (MCoC) unless they can demonstrate staffing meets safe minimum requirements on all shifts. This will preserve the safety of all pregnant women and families, which is currently compromised by the unprecedented pressures that MCoC models place on maternity services already under significant strain. The reinstatement of MCoC should be withheld until robust evidence is available to support its reintroduction.’’ Following this recommendation UHS has taken the decision to maintain current levels of provision but cease any further roll out. 8 QUALITY ACCOUNT 2021/22 Figure 2: Priority 2 PRIORITY 2 To support staff wellbeing and recovery Core Dimension: Patient safety and patient experience Achieved Why was this a priority? The health and wellbeing of our people and promoting a healthy work environment is one of our top priorities. Since the start of the pandemic we have focussed on what really makes a difference in supporting people to stay well and healthy and have continued to build on this work during 2021/22. During year we have actively listened to our staff and responded to their feedback by including more “in the moment” support, more regular morale initiatives and creating easier ways to access wellbeing support every day. We have become more flexible and responsive as the year has progressed, provided a range of support and options tailored to the needs of individuals. We have recognised that wellbeing is very personal, and everyone’s approach to promoting and sustaining their own wellness may be different. We appreciated many people were mentally and physically exhausted after the demands of responding to the pandemic. We recognised they would need time, space and support to develop resilience while the pandemic continued, and to recover as pressures eased. We saw that while the overall health and wellbeing scores in the NHS Staff Survey had improve significantly in 2020, the proportion of staff reporting work-related stress had also increased. What have we achieved in 2021/22? During the year we continued to introduce programmes, interventions and wider support offerings. The goal of our model is to ensure our staff can access the most appropriate support at the time and place that they need it. In 2021 we employed a staff wellbeing lead/programme manager and a wellbeing administrator as part of our organisational development (OD) team and tasked them with leading on the development and delivery of the wellbeing programme and interventions. A key area of growth and strength for staff wellbeing during the pandemic and beyond is the joined up working of the wellbeing, psychology, spiritual care, occupational health services and peer practitioner communities. During the early part of 2021 a series of interventions to support reflection and wellness were introduced aiming to provide safe spaces for people to talk, listen, be heard and give feedback on where things could be improved. The OD team worked alongside our psychologists to introduce a variety of different ways that people could be engaged. We invested in the training of peer practitioners called ‘safe space practitioners’ to be able to provide on-site, in the moment, interventions when people needed them. Strengthening that safe space practitioner peer network means we have trained more staff in safe space coaching and support techniques to enable people to access support when needed. The team are open to any suggestions of other areas where staff would find peer support valuable and to deliver thinking environments. 9 QUALITY ACCOUNT 2021/22 We also trained appreciative inquiry facilitators to work with staff in self-determined change to enable them to take a positive approach to their own wellbeing, appreciate the things that are going well and adopt a mindset of appreciation and hope. After a successful pilot in May 2021, we recruited over 100 wellbeing champions working all over the Trust across a range of professions and seniority. Wellbeing champions have been given training, tools and resources to lead on championing wellbeing in their areas. They offer signposting to support, monthly champion meetings sharing ideas and practice and regular updates on wellbeing. They are important links on the ground for the wellbeing team and have their own workplace champion pages on Staffnet (our intranet) for sharing information and mutual support. They carry out regular wellbeing walkabouts wearing pink scrubs to make them highly visible. They are often accompanied by our executive directors and senior clinical leaders who are also available to listen, support and generally help raise morale. In the latter part of 2021 as the COVID-19 pandemic continued, staff resilience was tested by challenges around increasing staff shortages and the ability for staff to take regular breaks away from clinical areas for rest. We recognised a need for boosting staff morale and devised a wellness and appreciation programme, which took refreshments out to staff including lunch grab bags, fruit boxes, hot drinks and wellbeing treats. To make it quicker and easier for staff to access wellbeing information we launched Windows onto Wellbeing (WoW), a one-stop page on Staffnet consisting of various wellbeing windows each outlining a variety of aspects of wellbeing information and available support, with links and resources. This is being supplemented by wellbeing leaflets with QR codes, posters and video information. A staff Facebook wellbeing page was set up, populated by the wellbeing team and any staff who wish to post. This shows the latest wellbeing information, support and training opportunities updated in real time as well as being a platform for inspirational quotes and for people to share wellbeing practice and thoughts. During 2021/22 we tried to ensure, where possible, that wellbeing was included as an automatic element of all our initiatives and ‘‘business as usual’’. Staff wellbeing was incorporated into many of our educational streams, with wellbeing awareness sessions being included in induction training, team study days and our UHS advocates study day. Team and personal wellbeing action plan templates have been created for use across the organisation, and when our chief nursing officer (CNO) introduced daily ward huddles (‘stop for support’) for our nursing teams, a key element was the opportunity to check on staff wellbeing and offer support. 10 QUALITY ACCOUNT 2021/22 Teaching on stress management and post-traumatic stress is delivered by various groups and individuals including the wellbeing programme manager, the OD team, the psychology team and the wellbeing team. Wellbeing conversation workshops have been offered with good uptake and more are being rolled out in 2022/23. Mindfulness and mindful self-compassion workshops were commissioned in 2021/22 and have proved popular. Other initiatives led by our wellbeing programme manager include our domestic abuse project which works with our partners Standing Together to support staff impacted by domestic abuse, our suicide prevention support advisory group, facilitating reflective practice guidance and a small working group which is supporting the patient safety incident response framework (PSIRF) agenda by exploring the impact of being involved in adverse incidents. We have an embedded peer support service to provide psychological support to our staff in the context of traumatic events at work. The service is modelled on an evidence-based approach using a trauma risk management (TRiM) methodology which helps to identify risks for people who may suffer poor mental health following traumatic experiences. Our TRiM practitioners support those who have experienced traumatic events and we have increased the number of our practitioners during 2021/22. UHS is part of a regional mental health first aid (MHFA) faculty which works in partnership across Hampshire and the Isle of Wight and is currently in the process of training peer practitioners as MHFA champions. Our ambition is that our practitioners will go on to participate in ‘train the trainer’ sessions, sharing training across the integrated care system (ICS). We also looked at ways to demonstrate how much we value our staff. We wanted to celebrate the hard work, commitment and dedication consistently shown in rising to the challenges of the pandemic. We have promoted our long service awards, which recognise continuous service to the Trust, and our retirement gift scheme, which rewards employees after completing 20 years or more service in the NHS. In December 2021, a festive card containing a gift token from the CEO and Chair was given to all substantive UHS staff in recognition and appreciation of every person’s effort and dedication to our patients and families during the year. We have asked our staff for feedback about our initiatives and used their insights to help shape ongoing work. We have developed a UHS Insights document which summarised how staff were feeling and how the feedback they have given will support people to move forward This is illustrated in the infographics below. 11 QUALITY ACCOUNT 2021/22 What our staff tell us: “It all means I can allow myself time, space and kindness to deal with the difficulties during/post [pandemic] knowing that others felt/are feeling the same way I am.’’ ‘’I really appreciate the way the hospital has prioritised staff wellbeing. It has made us feel as though we are a priority and really valued.’’ ‘’I have been impressed with how many different options there have been to help us all get through this and help us look after ourselves.’’ ‘’I’ve never known staff health be so important to the Trust, and it’s made a big difference to how I’ve coped.’’ “I don’t know if you ever get to hear how people you’ve seen through TRiM are getting on or not... so I thought I’d give you a little update. I’m back at work on week 2 of a phased return… I’m delighted to say that so far it seems to have worked wonders!’’ 12 QUALITY ACCOUNT 2021/22 ‘’The main reason for this email is to say thank you. You were pivotal in the whole journey ensuring I got on the right track to restore my head health early. Without you it’s highly likely I’d have probably gone back to work and have ended up in a much worse position and the whole process would have been a lot longer and arduous to get back to where I am today.” “Listening to other staff members’ struggles and realising that we are not on our own, we are part of a big team.” “Hearing the different stories but appreciating we were united in suffering, learning, confusion and hope has been helpful.” ‘’I can see senior leaders are human with the same insecurities as us; they’ve been in our shoes at some point.’’ ‘Listening to the situations that others have faced was a real reminder that we have had a shared experience which makes things feel easier. The honesty and openness of others was both enriching and humbling. I left feeling like my faith in humanity had been restored.’’ “I found that listening to others’ experiences was extremely valuable. Although I was obviously aware that we have ‘all been in this together’ it has at times felt quite lonely and difficult.” How improvements will be measured and monitored The decision-making, measurement, monitoring and governance of the wellbeing programme is managed by the healthy workplace and wellbeing group which reports into the UHS people board, and then into the people and OD committee. Membership includes representation from occupational health, psychology, spiritual care, peer practitioner groups, HR and health and safety teams and works to support the NHS health and wellbeing framework (2021/22). The people and OD committee reports into Trust Board. Key areas identified of opportunities for further improvement It is important to us that we continue to lead compassionately and inclusively, so our people are involved in decision-making, feel hopeful for the future and are confident in bringing their whole selves to work no matter who they are. We want the culture at UHS to reflect our commitment to prioritising the health and wellbeing of all staff so that it is a consideration in every decision we make. We are working to build confidence and trust in the vast array of support we have developed over the last two years, to drive uptake now awareness is high and to help people find effective help. Risk of burnout due to exhaustion remains a concern and efforts will be focussed in this area for 2022/23. We have identified temporary wellbeing hub space for staff while we wait for the new staff wellbeing building, which has been made possible with the funding from the proceeds of the auction of the donated Banksy ‘Game Changer’ artwork. This new building will house a gym, café and space for reflective groups to meet as well as being a base from which the wellbeing team will provide its support. In 2022/23 several UHS staff will taking part in the first regional diploma in health and wellbeing and a regional wellbeing festival is planned for July 2022, in which we will be taking an active lead. Our 2021/22 annual NHS staff survey results are positive with our scores relating to wellbeing being above the benchmark average. Contributing factors to wellbeing such as staff engagement, morale, staff experience in areas such as kindness and respect, feeling valued and trusted to do their job were all above the benchmark average. Our staff experience scored related to violence and aggression at work, bullying, and harassment have also improved and are close to the benchmark average. Our score relating to staff experiencing work-related stress has remained the same at 42%, which has not declined since 2017. We will continue to work towards improving our staff survey results during 2022/23. 13 QUALITY ACCOUNT 2021/22 Figure 3: Priority 3 PRIORITY 3 Managing risks to patients delayed for treatment and restoring elective programmes Core Dimension: Clinical effectiveness Partially achieved Why was this a priority? The pandemic had a significant impact on waiting times as elective activity reduced to focus on treating patients with COVID-19. In March 2020 only 29 patients were waiting over 52 weeks for treatment, but by March 2021 this had increased to 3,311 patients. These delays clearly have a significant impact on people’s quality of life and, at times, outcomes. During the first wave of the pandemic elective activity reduced substantially, with only 35% of April 2019 levels of activity taking place in April 2020. By 2021 there was a real imperative to move towards managing the pandemic while continuing to treat as many other patients as possible and making sure we communicated effectively with those waiting to help manage the uncertainty and to reduce the backlog where possible. What have we achieved in 2021/22? During the first year of the pandemic the Trust set up a clinical prioritisation process, led by the chief medical officer (CMO) that focused on prioritising all patients waiting for surgery to ensure we continued to treat people based on need and urgency. The Trust also implemented a clinical assurance framework (CAF), designed to measure and mitigate risks across the specialities as well as ensuring that resources (e.g., theatres) were allocated in line with anticipated levels of potential harm. During 2021/22 our hospitals continued to see significant levels of COVID-19 demand with the end of the first wave lasting into May 2021. From September 2021 the number of COVID-19 patients started to increase again, rising to approximately 100 in December 2021 before gradually decreasing. A further wave followed in March 2022, with over 100 COVID-19 patients being cared for in the Trust. Despite this, the Trust continued to see more elective patients in 2021/22 than in 2020/21: Figure 4: Number of elective patients seen April 2020-March 2022 This was despite more stringent and time-consuming infection control measures than prior to the pandemic and reducing theatre capacity to support intensive care staffing. At times, we had up to seven wards repurposed for caring for patients with COVID-19. 14 QUALITY ACCOUNT 2021/22 Cancer care We are proud to have maintained all our cancer services throughout the pandemic and believe that we continue to offer clinically effective services to patients. Despite the number of patients being treated for cancer increasing throughout 2021/22 due to a rise in referrals that occurred after each COVID-19 wave, we were able to respond to this increase. Figure 5: Cancer care patient tracking list July 2020- March 2022 When COVID-19 restrictions in England were relaxed, both in September 2021 and again in February 2022, we saw higher volumes of referrals and two week waits (2WW) performance for urgent referrals has been affected. This is mainly in the breast service with other tumour site performance being broadly maintained. We have seen a relatively stable level of 31-day performance (the target for at least 96% of patients to start a first treatment for a new primary cancer within 31 days of the decision to treat) and 62-day performance (the target that there is no more than 62 days wait between the date the hospital receives an urgent referral for suspected cancer and the start of treatment). We note that our 62-day performance shows us to be in line with other tertiary teaching hospitals, which illustrates that other hospitals are seeing similar challenges to UHS in relation to cancer. When benchmarking against similar trusts (other large teaching hospitals), we have continued to perform well, and we continue to prioritise cancer services to reduce the number of patients awaiting treatment, including reducing those waiting more than 62 days. Outpatient services At the start of the pandemic in 2020 we saw a seismic shift towards non-face-to-face outpatient appointments. The national aspiration was to maintain 25% of patients seen non-face-to-face in 2021/22. Figure 6: proportion of face to face and non-face to face appointments at UHS 15 QUALITY ACCOUNT 2021/22 Although the proportion of virtual appointments has naturally reduced compared to levels seen during the pandemic (as some clinics have reverted to a face-to-face service), we have continued to offer virtual outpatient appointments through 2021/22. We recognise that in some cases this provides a more convenient service for patients. We have also rolled out a patient texting programme, which provided an additional safety net. For the specialties with the highest number of long waiting patients we text patients to ask whether their symptoms have worsened and whether they need to speak to a clinician. If they confirm that they do need to speak to a clinician, an outpatient appointment is scheduled for them. We have also used technology to continue to offer virtual appointments where appropriate and are conducting approximately 30% of our appointments virtually. The Trust has maintained this as a target, and although we have returned to face-to-face appointments where necessary, virtual appointments continue to be a core part of our strategy with our outpatient clinical activity increased to achieve the target. Figure 7: Proportion of virtual appointments Diagnostics During 2021/22 UHS significantly increased the volume of diagnostic activity as the pandemic eased and services adjusted their ways of working, focussing on reducing the longest diagnostic waits first. Despite an increase in diagnostic referrals, the size of the diagnostic waiting list has been held steady, alongside an improved performance. Alongside community partners in Solent NHS Trust and Southern Health NHS Foundation Trust, the Trust successfully bid for phase one funding to develop a community diagnostic hub. The main hub will be based at the Royal South Hants Hospital (RSH), with other targeted diagnostics being delivered in Lymington New Forest Hospital and Hythe Hospital. These hubs will support a one-stop approach for conditions, delivering tests closer to home and releasing acute diagnostic capacity for the support of inpatients and complex patients. In late 2021 the Trust completed a Trust-wide patient-led waiting list validation of all patients waiting 33 weeks or longer. Discussions as to how best to continue this as part of a rolling programme rather than a standalone exercise are ongoing. The Trust worked with third party supplier partners to survey patients by text message or email linked to a secure portal, backed up by paper letters where patient details for digital contact were not available. This saved administrative time, as well as generating a far higher response than traditional methods of validating waiting lists. The purpose of this initiative was to reassure every patient and confirm if patients were ready to attend (and ask them to indicate a timescale if not), as well as indicate whether COVID-19 concerns were a factor in their wish to delay. We also wanted to know if patients’ circumstances had changed, to offer the opportunity of contact with the Trust about their specific circumstances and offer practical and holistic services from the patient support hub. 16 QUALITY ACCOUNT 2021/22 As well as following up patients whose responses did not match their clinical status, or whose responses flagged concern, all patients requesting contact were followed up by care group administrative and/or clinical teams. Referral to treatment (RTT) During 2021/22 UHS has had to continue to manage the impact of COVID-19 on patients on the elective waiting list. We are conscious that some patients have waited a long time from referral to treatment. As referrals have increased post-lockdown ( peaking in Summer 2021) , the total number of patients waiting has grown. However, we have reduced and held steady the total number of patients waiting over 52 weeks through 2021/22 Figure 8: RTT Patient treatment list Figure 9 : Patients waiting over 52+ weeks for treatment In 2021/22 we noted a small, but growing, cohort of patients who had waited more than 104 weeks for treatment due to pressures and constraints associated with the pandemic. This grew from 13 in March 2021, peaking at 171 in December 2021. Throughout 2021/22, our operational teams developed clear plans to address these longest waiters. At the end of March 2022, besides patients who had requested delay of their treatment, we only had five patients who had waited more than 104 weeks for their treatment. Actions to increase capacity and treat these patients include use of the independent sector for specific cohorts of patients (e.g., in the ear, nose and throat (ENT) service) and additional weekend capacity through waiting list initiatives (e.g., Urology ‘super weekends’). 17 QUALITY ACCOUNT 2021/22 We have continued to make good progress against our target and, when we remove the patients who are choosing to wait, we are ahead of the plan. While patients wait for surgery, we have continued to assess them using the CAF, where patients are clinically reviewed based on their previous clinical priority. We use a rating system where priority is given to patients most likely to deteriorate clinically, with P1 being the highest and P4 the lowest risk. Triage takes account of vital signs, pre-hospital clinical course, mechanism of injury and other medical conditions and is a dynamic process and patients are reassessed frequently (e.g., P2 patients every eight weeks, P3 patients every three months, P4 patients every six months). Based on this clinical review patients may be invited for an outpatient review. What our patients tell us: ‘’I was very worried about not getting my surgery because of the pandemic, but the hospital was good at keeping in touch so I felt I knew what was going on’’ ‘’The news was so bad my dad didn’t want to go to the hospital for his tests because he thought the people with covid should have the beds, but he was phoned and the lady was really good at reassuring him that he was important too so he had his tests’’ ‘’I was going to wait until the pandemic was over to have my operation, but they got in touch and said they could do it and got me in and did it anyway and I was so pleased’’ ‘’Not having to go to the hospital for my outpatient appointment was so much easier. No parking problems, and the doctor was just as good as if I’d been there. I hope this carries on‘’ ‘’I was so scared my cancer treatment was going to be stopped, but they sent me to another hospital to have it. I’ve read in the papers about people not getting their treatment, so I am so relieved my hospital could still do it’’. How improvements will be measured and monitored We have a robust reporting processes monitoring this activity which runs from care group and divisional governance and operational reporting through our Trust executive committee (TEC), quality committee and Trust Board. We work closely with our chief operating officer (COO) and executive team to maintain a constant focus. Key areas identified of opportunities for further improvement We will continue to work to restore elective activity and reduce waits during 2022/23. 18 QUALITY ACCOUNT 2021/22 Figure 11: Priority 4 PRIORITY 4 Reducing healthcare associated infection (HCAI) Core Dimension: Patient safety Achieved Why was this a priority? Healthcare associated infections (HCAIs) are among the most significant causes of morbidity and mortality in healthcare settings. We know prevention of HCAIs is central to providing safe and high- quality healthcare, good patient experience and maintaining safety. It also improves length of stay and helps with our financial and operational management. According to the World Health Organisation (WHO), HCAIs are common with an estimated 1.4 million affected at any given time and prevalence varying in the developed world from 5.1% to 11.6%. The most recent point prevalence survey of HCAIs in acute hospitals in England (2016), reported the prevalence of HCAIs as 6.6%, and a tertiary care hospital like UHS will be at risk from high levels as it treats many vulnerable patients needing complex support and procedures. In addition, antimicrobial resistance (AMR) has also been identified by the WHO as one of the top ten major threats to public health. Indiscriminate use of antibiotics in health and farming has led to significant challenges of multi-drug resistant bacteria in certain parts of the world. No new classes of antibiotics have been discovered since 1980, and we are facing the possibility of a world where antibiotics may no longer be effective. The UK five-year national action plan for tackling antimicrobial resistance (2019-2024) outlines key actions for focusing on infection prevention and control (IPC) and addressing AMR. Consequently, AMR and IPC are important for any healthcare organisation, and a system-wide approach to promoting and monitoring the judicious use of antimicrobials to preserve their future effectiveness is essential. At UHS we have a dedicated infection prevention team (IPT) committed to supporting the organisation in preventing and reducing HCAIs. The team is made up of a diverse set of professionals with significant experience in infection control, with leadership and oversight from the CNO and director of infection prevention and control. The team drives improvements in patient outcomes by supporting reductions in HCAIs. What have we achieved in 2021/22? Unsurprisingly the COVID-19 pandemic has remained a key area of focus for UHS in 2021/22, with a continued emphasis on preventing transmission of infection while supporting the recovery and restoration of services. In-hospital transmission of COVID-19 Throughout 2021/22 our COVID ZERO campaigns promoting safety across the workforce and services throughout the pandemic (wash, walk, wear, test and fresh air), and our follow-up #DontGoViral 2021 campaigns continued to be prioritised. Our COVID ZERO campaign has earned award-winning recognition for ‘Best crisis comms’ at the 2022 PRWeek UK Corporate, City & Public Affairs Awards. 19 QUALITY ACCOUNT 2021/22 What have we achieved in 2021/22? Strategies to prevent and reduce the risk of in-hospital transmission of COVID-19 have remained a priority and have been subject to ongoing review, with actions and improvements taken to reduce the ongoing risk of hospital onset infection and outbreaks. The figure below shows the trend of hospital-onset cases of COVID-19 from April 2021 to March 2022 and follows similar trends as the local and national prevalence of COVID-19. Figure 10: Cases of Hospital onset COVID-19*. *Classified as “hospital onset-definite hospital acquired” (HO. dHA) when the first positive test is at least 15 days following admission and “hospital onset-probable hospital acquired” when a first positive specimen occurred on days eight to 14 (HO. pHA) following admission Where cases of hospital acquired infection have occurred, they have been investigated using a root cause analysis (RCA) investigation process either as individual case reviews or part of a wider outbreak investigation. Hospital outbreaks of COVID-19 are robustly managed by the IPT using a formal incident/ outbreak management process and reported in the national outbreak management system with ongoing monitoring until 28 days following the last confirmed case. Learning from individual case investigations or outbreaks is shared promptly across the Trust and used to inform ongoing IPC actions and strategies. Clostridioides difficile (C. diff) UHS has seen wide fluctuations in the monthly number of C. diff cases with evidence of cases rising a few months after a major wave of COVID-19 infections. Reasons for the increase are not clear, but are likely to be multifactorial, and possibly related to the use of high-risk antibiotics during the first waves of the pandemic. This increase is being reported nationally with increases in rates of both community onset and hospital onset cases according to UK Health Security Agency (UKHSA) surveillance data. 20 QUALITY ACCOUNT 2021/22 Figure 11: Trends in hospital acquired C. diff * *Is classified into community-onset (COHA) and Hospital onset (HOHA) depending on identification of C. diff in community or hospital respectively. MRSA In 2021/22, UHS recorded cases of hospital acquired MRSA bloodstream infection as illustrated in the figure below. Figure 12: Number of patients who acquired MRSA (non-bloodstream infection) during their hospital stay The downward trend is representative of the trend that has been seen over the last few years. 21 QUALITY ACCOUNT 2021/22 Blood stream infections (BSI) All BSI cases are reviewed by the IPT to identify contributing factors or gaps in practice which may have contributed to infection occurring. They are investigated in detail to identify any learning that may drive improvements. Overall our reviews have noted that cases are complex with multiple risk factors for infection. A proportion of cases of BSI are assessed as unavoidable, but where infection is thought to have been preventable (e.g., occurred because of the presence of an invasive device such as an intravenous line or urinary catheter), this is followed up with appropriate investigation to identify emerging trends/themes, organisational learning and targeted improvement actions. The NHS Standard Contract 2021/22 includes quality requirements for NHS trusts and NHS foundation trusts to minimise rates of defined Gram-negative bloodstream infections to threshold levels set by NHS England and NHS Improvement. This includes klebsiella species, pseudomonas and E-coli. Monitoring of MSSA bloodstream infections is also undertaken. Hospital BSIs are defined as those that occur after the first 48 hours of admission (post 48-hour BSI). Figure 13: The number of cases of hospital acquired E coli BSI Figure 14 : The number of cases of hospital acquired klebsiella BSI 22 QUALITY ACCOUNT 2021/22 Figure 15 : The number of cases of hospital acquired pseudomonas BSI Figure 16 : The number of cases of hospital acquired MSSA BSI Vigorous focus and attention to IPC strategies targeted at reducing the risk of hospital transmission of COVID-19 has been central to our ongoing response to the pandemic, whilst at the same time focusing on restoring operational activity. Despite the challenges, UHS has one of the lowest rates of MRSA BSI in the country, and hospital-acquired COVID-19 infection is lower than in comparable hospitals. The health, safety and wellbeing of our patients, communities and staff has remained a priority,
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