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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
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/quality-account-24-25-final1.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Welcome from our Chair 7 A word from the chief executive 8 Overview of the Trust Statement of purpose and activities 9 History of UHS 9 Our executive team structure 10 Structure of our services 11 Our vision and values 12 Our priorities, key issues and risks 13 Performance report Going concern disclosure 16 Reporting structure 16 Key performance indicators 17 How we monitor performance 18 Detailed analysis and explanation of the development and performance of UHS 18 Regulatory body ratings 23 Environmental matters 24 Social, community, anti-bribery and human rights issues 25 Accountability report Members of the Trust Board 27 Trust Board purpose and structure 31 Board meeting attendance record 2018/19 32 Well-led framework 33 Strategy and finance committee 34 Quality committee 34 Audit and risk committee 35 External auditors 36 Governance code 36 Performance evaluation of Trust Board and its committees 36 Remuneration 36 Countering fraud and corruption 36 Independence of external auditor 37 Internal audit service 37 Better payment practice code 37 Statement as to the disclosures to auditors 37 Disclosures 37 Income disclosures 38 Governance disclosures 38 Approach to quality governance 38 Council of Governors 40 Annual remuneration statement 49 Remuneration and appointments committee 52 Governors’ nomination committee 54 Staffing report 58 Staff survey results 62 Trade union facility time 66 Statement of chief executive’s responsibilities as the accounting officer 69 Annual governance statement 70 Voluntary disclosures Equality, diversity and inclusion 78 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Developments in informatics 85 Leading research into better care 85 Investing for the future 86 Quality account and quality report 2018/19 Chief executive’s welcome 88 Our approach to quality assurance 90 Our commitment to safety 90 Duty of candour 91 Our commitment to staff 91 Freedom to speak up 94 Our commitment to education and training 95 Our commitment to staffing rota gaps 96 Our commitment to technology to support quality 97 Our commitment to the Care Quality Commission 98 Our commitment to improving the environment for our patients 100 Review of quality performance 101 Clinical research 101 Review of services 102 CQUIN payment framework 103 Data quality 103 Participation in national clinical audits and confidential enquiries 104 How we are implementing the priority clinical standards for seven day hospital services 105 Learning from deaths 106 Progress against 2018/19 priorities 109 Priorities for improvement 2019/20 128 Conclusion 132 Responses to our quality account 133 Statement of directors’ responsibilities 138 Independent auditor’s report 139 Quality account appendix Appendix 1: Our quality priorities 2019/20 143 Appendix 2: Quality performance data 144 Appendix 3: CQUIN data 151 Appendix 4: Clinical audit and confidential enquiries data 154 Appendix 5: British Society of Urogynaecology 156 Appendix 6: National clinical audit: actions to improve quality 157 Appendix 7: Local clinical audit: actions to improve quality 161 Appendix 8: Shared decision making 173 Appendix 9: Registration with the Care Quality Commission 174 Annual accounts Statement from the chief financial officer 177 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay. These are by no means the entirety of our achievements this year and I would like to take the opportunity to thank every single member of staff at the Trust who continues to make UHS one of the leading trust’s in the UK. Paula Head Chief executive officer 8 OVERVIEW AND PERFORMANCE REPORT Overview of the Trust Statement of purpose and activities UHS is a large teaching hospital located on the south coast of England. We have a tripartite mission to provide clinical care, educate current and future healthcare professionals, and undertake research to improve healthcare for the future. Our clinical care encompasses local acute and elective care for 680,000 people who live in Southampton, the New Forest, Eastleigh and Test Valley. We also provide care for the residents of the Isle of Wight for many services. As the major university hospital on the south coast, UHS provides the full range of tertiary medical and surgical specialities (with the exception of transplantation, renal services and burns) to over 3.7 million people in central southern England and the Channel Islands. UHS is a centre of excellence for training the doctors, nurses and other healthcare professionals of the future. We work with the University of Southampton and Solent University to educate and develop staff at all levels, including a large apprenticeship programme, undergraduate and post-graduate education. Our role in research, developed in active partnership with the University of Southampton, is to contribute to the development of treatments for tomorrow’s patients. This work distinguishes us as a hospital that works at the leading edge of healthcare developments in the NHS and internationally. In particular we have nationally-leading research into cancer, respiratory disease, nutrition, cardiovascular disease, bone and joint conditions and complex immune system problems. We are one of the largest recruiters of patients into clinical trials in the country. Over 11,900 people work at the Trust, making it one of the area’s biggest employers. We also benefit from the contributions of over 1,000 volunteers. Our turnover in 2018/19 was more than £878m. History of UHS The Trust has its origins in the 1900s when the Shirley Warren Poor Law Infirmary was built on the site of what is now Southampton General Hospital. In the early half of the century, the site began to expand, including the opening of the school of nursing and the creation of the Wessex Neurological Unit. In 1971 a new medical school was opened in Southampton and the 1970s and 1980s saw a significant building programme encompassing the current footprint of Southampton General Hospital, Princess Anne Hospital and Countess Mountbatten House. During the 1990s, services were increasingly centralised at the general hospital, with the eye hospital and cancer services being relocated from elsewhere in the city. The Wellcome Trust funded a clinical research facility at the hospital in 2001 and this unit remains the foundation for much of the Trust’s groundbreaking medical research. In the last decade, development has continued with the opening of the North Wing Cardiac Centre in 2006, the creation of a major trauma centre with on-site helipad and the opening in 2014 of Ronald McDonald House for the relatives of sick children. Organisationally, Southampton University Hospitals Trust was formed in 1993, creating a single management board for acute services in Southampton. Eighteen years later, University Hospital Southampton NHS Foundation Trust (UHS) was formed (1 October 2011) when Southampton University Hospitals NHS Trust was licensed as a foundation trust by the then regulator, Monitor (now known as NHS Improvement (NHSI)). 9 OVERVIEW AND PERFORMANCE REPORT Our executive team structure Associate director of corporate affairs (interim) Charlie Helps Constitution; Council of governors; legal services; insurance; risk management; policy management; freedom of information (FOI) general data protection regulations (GDPR) Chief executive Paula Head Director of HR Steven Harris Employee relations; pay and reward; resourcing and temporary staffing; staff engagement; staff performance and appraisal; occupational health and wellbeing; childcare services; communications Medical director Dr Derek Sandeman MD for research & development; clinical effectiveness; clinical practices and outcomes; professional regulation & standards; GP relationships Director of nursing & organisational development Gail Byrne Chief financial officer & deputy chief executive David French Clinical governance & patient safety; education; patient experience; clinical practice & outcomes; professional regulation & standards; complaints/PALS; HR/workforce; voluntary services; fundraising Caldicott Guardian Financial management; financial strategy; investment & ROI; audit; procurement; capital programme management; estates; Commercial development Division A Surgery Cancer care Critical care & theatres Chief operating officer Caroline Marshall Major incident planning; security Division B Division C Emergency medicine Women & newborn Specialist medicine/ ophthalmology Pathology Child health Support services Director of transformation & improvement Jane Hayward Division D Cardiovascular & thoracic Neurosciences Trauma & orthopaedics Cost improvement & transformation; information technology; information governance; core platform systems; informatics development; strategy; commissioning; business & capacity planning Senior Information Risk Owner (SIRO) Radiology 10 OVERVIEW AND PERFORMANCE REPORT Structure of our services Our organisation is split into five areas, with our clinical services grouped into four divisions. Within each division there are care groups. Each division, with the exception of Trust headquarters, is led by a divisional management team consisting of: • divisional clinical director (DCD) • divisional director of operations (DDO) • divisional head of nursing/professions (DHN) • divisional research and development lead • divisional finance manager • divisional planning and business development (or strategy) manager • divisional education lead • division HR business partner • divisional governance manager (DGM) The diagram below outlines the five divisions and care groups/services within each. Each care group has a clinical lead, care group manager and matron/s for specific services as a minimum. Division A Surgery Cancer care Critical care Theatres Division B Emergency medicine Medicine for older people Pathology Specialist medicine and ophthalmology Genetics Division C Child health Women and newborn Support services Division D Cardiovascular and thoracic Neurosciences Trauma and orthopaedics Major trauma centre Radiology TRUST HQ Corporate affairs Communications Finance Human resources Informatics Patient support services Claims and litigation Cost improvement and transformation Estates and capital developments Research and development 11 OVERVIEW AND PERFORMANCE REPORT Our vision and values Our Forward vision outlines who we are and what we stand for, as well as describing the current challenges we face and our priorities for the future. It also provides an in-depth review of our three Trust values, which are summarised below: putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien putting patien king together king together king together king together king together king together king together king together king together ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor ts first ts firwsotr ts firwsotr wor always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving always imparlwovaiynsg imparlwovaiynsg improving ts first ts first ts first wor wor wor putting patien putting patien putting patien king together king together king together always imparlwovaiynsg imparlwovaiynsg improving Patients and families will be at Our clinical teams will provide the heart of what we do and services to patients and are their experience within the crucial to our success. hospital, and their perception We have launched a leadership ofmtheeasTurruensgtop,aftwiesnuitlslcfbcnigreesptsaosti.euntrs fnigrsptatients first clsintrrikacintageltgomgyetahtnherkraianggtteoegmnetsehuernkrrintegstteoogaeumthresr are engaged in the day-to-day management and governance of the Trust. alw alw alw Our growing reputation in research and development and our approach to education and training will continue ays improtvoinagiyns icmoprropvionagrysaitmeprnoveinwg ideas, technologies and greater efficiencies in the services we provide tients first tients first tients first together together together mproving mproving mproving putti putting pa putti putting pa putti putting pa wo working wo working wo working always i always i always i 12 OVERVIEW AND PERFORMANCE REPORT Our priorities, key issues and risks Our top eight priorities 1 Promote and live our values. We will: • be clearer about the behaviours we expect from our staff • recruit, train and promote people who demonstrably share our values in everything they do 2 Improve safety, quality and productivity. We will: • Sign up to safety and deliver on our promises to patients as part of this campaign • Focus on improving outcomes by measuring and publishing clinical outcomes for all specialties • Focus on improving the whole patient experience, so that patients feel treated with compassion by all staff in every contact • Develop the concept of excellent administrative care, organising our services well so that the patient journey runs smoothly • Commit to productivity improvement across all areas • Develop innovative solutions that allow us to deliver services more efficiently while making better use of our capacity 3 Our staff and education mission. We will: • Attract the best staff by offering them a better deal and the best place to work • Continue to invest in education and training opportunities for our staff including leadership development • Ensure that our leaders and staff understand and deliver our equality and diversity agenda • Prioritise excellent communication that allows the voice of our staff to be heard and acted on • Focus on the staff of the future by developing our education and training capability for clinical and non-clinical staff • Work with our local education providers to offer excellent education opportunities and bring high calibre people into healthcare roles in our hospitals 4 Become a hospital without walls. We will: • Increase the number of patients we care for who are not inpatients within the hospital. Some of these will be cared for in another residential location or at home in partnership between ourselves and other organisations • Be clear about services where we wish to provide end-to-end integrated care, and those where we wish to work with partners to integrate care across organisations • Work with health and social care partners (public, private and third sector), where necessary using new organisational models, to ensure that patients are always cared for in the right setting • Work more closely with general practices and support innovation being led by primary care 13 OVERVIEW AND PERFORMANCE REPORT 5 Specialised services. We will: • Engage with commissioners to plan changes in service models according to national service specifications • Continue to plan and manage the ongoing drift of sub-specialist work particularly in paediatrics and complex surgical services • Maintain and develop the critical mass that is increasingly required to care for complex and specialist patients • Work with Salisbury NHS Foundation Trust, the University of Southampton and other partners to play our part in the genomic revolution, building on the Genomic Medicine Centre and seeking to become a Genomics Central Laboratory Hub for the region • Develop our clinical informatics ability to ensure that we can take advantage of new information available for the benefit of patients 6 Preventative care. We will: • Continue to expand our screening programmes as national policy and commissioning intentions develop • Take every opportunity to further support and improve the health of our staff • Ensure that our clinical translational research programme, much of which is directly relevant to health promotion, accelerates translation of research into benefit for the local population 7 Discovery. We will: • Develop a detailed plan to continue increasing the number of UHS patients who are offered access to clinical trials and maximise the impact of the research we undertake • Work with the University of Southampton to submit a strong bid for the next round of Biomedical Research Centre / Biomedical Research Unit funding opportunities • Support the University of Southampton to create an international centre for cancer immunology to accelerate the development of new immune therapies to treat cancer 8 All stages of life. We will: • Continue to expand our paediatric services in partnership with community and local acute paediatrics and develop the physical infrastructure of a modern children’s hospital as quickly as finances allow • Continue to improve transition and the care of teenagers and young adults • Develop elderly care services that are integrated across the acute and community sectors • Continue to develop our end of life care 14 OVERVIEW AND PERFORMANCE REPORT Key issues and risks 1 Failure to deliver national access targets, which impacts patient experience and patient safety. Whilst we are meeting some of the national constitutional standards in waiting times, we are not meeting them all. A number of actions have been taken in relation to improving responsiveness and working with local health and social care partners to reduce delayed transfers of care. The Trust will continue to work to reduce delayed transfers of care, as well as reviewing the efficiency of discharge processes during 2019/20. 2 Capacity and occupancy, which impacts on patient flow and the quality and timeliness of care. Operational risks have been identified across a number of services/specialties linking to issues around increasing referrals, system capacity and delayed transfers of care. We have mitigated this by implementing daily reviews to assess system capacity and escalation requirements aligning capacity plans with the wider system, developing plans to reduce length of stay with strong clinical leadership and oversight and working with local health and social care partners to reduce delayed transfers of care. 3 Staffing, both in terms of recruitment and retention. To mitigate this risk we will continue to focus on making UHS an attractive employer by: • developing band four posts and apprentices • leveraging the ‘Think UHS’ recruitment brand • continuing to recruit within Europe and further afield • working with universities to increase student nurses • enhancing medical overseas fellows posts • reviewing all junior doctor rotas in light of the new contract • using flexible and temporary staff when needed • creating different roles linked to our research agenda • reviewing training and education to enhance retention. 15 OVERVIEW AND PERFORMANCE REPORT Performance report Going concern disclosure After making enquiries, the directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Reporting structure As a large NHS university hospital foundation trust, UHS monitors performance within individual teams throughout the year with feedback processes in place to escalate issues to more senior management teams. At a corporate level we have an established executive reporting structure. Monthly Trust Board Public meeting where executive directors present high level summary to chairman and non-executive directors. For further information see page 31. Audit and risk committee Strategy and finance committee Quality committee Trust executive committee (TEC) Review performance/issues/risks in greater depth For further detail on role of these committees please refer to the annual governance statement section on page 70. Trust Board study sessions Trust Board members meet to focus on a specific issue. Performance meetings Operational management team (led by chief operating officer) and division and care group management teams focus on individual patient and service pathways to develop improvement plans. 16 OVERVIEW AND PERFORMANCE REPORT Key performance indicators (KPIs) The Trust publishes a monthly integrated KPI Board report on our website which provides both the Board and the public with an overview of our performance. This report is constantly evolving as new areas of monitoring are developed and new areas of national focus become apparent. For 2018/19 the format of the monthly report followed the five key Care Quality Commission (CQC) questions: • Are we safe? • Are we effective? • Are we caring? • Are we responsive? • Are we well-led? The monthly report features the following sections: • Overview – Aggregation of commentary supporting all sections of the report • Safe • Effective • Caring • Activity • Emergency access • Referral to treatment and diagnostics • Cancer waiting times • Flow • Staffing • Research and development • Estates • Digital This report also includes summary versions of quarterly reports submitted to the Trust executive committee, which go into greater detail about patient experience, patient safety, clinical effectiveness outcomes, and infection prevention. In addition, a separate finance Board report is submitted to Trust Board on a monthly basis. The Emergency Access, Activity and Flow section have several KPI’s that are relevant to the key risk of delivering the national access target. Some of the KPI’s are: • Number of attendances • Time to initial assessment • Hospital red/black alerts • Delayed transfers of care • Non-elective length of stay The Activity and Flow section have several KPI’s that are relevant to the key risk of capacity and occupancy. Some of the KPI’s are: • Length of stay • New referrals • Number of attendances • Bed occupancy • Hospital red/black alerts The Staffing (HR) section has several KPI’s that are relevant to the key risk of Staffing. Some of the KPI’s are: • Staff turnover • Nursing vacancies • Friends and Family Test – percentage of staff who recommend UHS as a place to work You can see full copies of the monthly report by visiting www.uhs.nhs.uk 17 OVERVIEW AND PERFORMANCE REPORT How we monitor performance In addition to reviewing the data submitted to the Trust Board in these papers, we have a suite of tools available to compare UHS performance to that of comparable trusts around the country. Depending on the measures being monitored, UHS has a number of peer groups to benchmark against including other local providers, major trauma centres and university hospital teaching trusts. Each NHS trust will service a different size and type of population and will offer a slightly different range of services so it is important to understand that this benchmarking provides an initial indication of performance rather than an absolute guide to our position nationally. In 2018/19 we continue to review the National Model Hospital data as it is published from NHS Improvement. The data and ability to compare our performance has helped to highlight areas of excellent practice and areas where there is potential to improve. The Trust is engaging with the model hospital team and has a member of staff on the ‘model hospital ambassador program’, as well as reviewing areas highlighted as having potential opportunities alongside finance and operational teams. Detailed analysis and explanation of the development and performance of UHS Activity, capacity and occupancy Over the past three years we have seen significant increases in all types of activity. This is linked to demographic growth, new specialist techniques and services transferring from other providers, including vascular services from Portsmouth. In addition, UHS now has responsibility for surgical services at Lymington. The graph and table below demonstrate this increase in activity. UHS growth in activity – 2016/17 to 2018/19 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Inpatient spells (inc. day cases) 2013/14 2016/17 Outpatient appointments 2017/18 2018/19 ED attendances (type one) Referrals (excl March) Inpatient spells (inc. day cases Outpatient appointments ED attendances (type one) Referrals (excl March) 2016/17 160,000 630,045 99,273 189,194 2017/18 157,993 658,147 104,616 197,522 2018/19 168,791 695,343 110,771 207,209 Increase 2016/17 to 2018/19 5.5% 10.4% 11.6% 9.5% 18 OVERVIEW AND PERFORMANCE REPORT Hospital alert status The hospital alert status is decided by the operations centre after assessing the bed and staffing position, and is recorded twice daily at the Trust bed meetings (though the status may change at any time). Black alert is the highest level of alert and is issued when there are no empty beds available across the Trust with no expected discharges, the emergency department is full, and if actions are not taken several ambulances are likely to be delayed for long periods of time, stopping them from responding to 999 calls (this is based on a national definition of escalation). Red alert is when the majority of the hospital is under significant operational pressure and is likely to include a mismatch between supply and demand of beds and/or there are no beds available, with patients waiting more than three hours in the emergency department, and patients with a clinical decision for admission but no bed identified for them to move to. The Trust will undertake a wide range of actions in response to this, including the opening of additional overnight beds (usually within day wards), the redistribution of staff or bed capacity to support areas under most pressure, Trust-wide communication to request a focus on actions which will enable patients to be discharged or the admission avoided and the potential review of less urgent elective operations to maintain bed availability for patients with more urgent needs. In 2015/16 a black alert was recorded seven times at the twice daily bed meetings. In 2016/17 this was increased to eleven, in 2017/18 this increased to twenty, however in 2018/19 there were no black alerts. The chart below shows red alerts logged during 2018/19. Red alerts 2018/19 60 Number of AM and PM alerts 45 30 15 0 4/1/18 6/1/18 8/1/18 10/1/18 12/1/18 2/1/19 Contributing to this change has been an increase in day cases and an increase in length of stay (LoS) for elective patients linked to a more complex case mix. UHS delayed transfers of care 2018/19 The chart below shows the total bed days attributable to delayed transfers of care at UHS in 2018/19. 3,600 Percentage of bed days lost 3,200 2,800 2,400 2,000 April 2018 June 2018 August 2018 October 2018 December 2018 February 2019 19 OVERVIEW AND PERFORMANCE REPORT Referral to treatment (18 weeks) performance National target: 92% of all patients on 18 week pathway and not yet treated should have waited 18 weeks or less at the end of the month (incomplete pathways target). How did we do? UHS did not meet the target this year. Achievement of this target in 2018/19 should be set against a rise in patient referrals, which highlights the increased demands being placed on the Trust. The Trust has finished the financial year with no patients waiting greater than 52 weeks, and a total referral to treatment waiting list lower than in March 2018. Emergency department (ED) performance There are three types of emergency departments: Type Type Type ONE TWO THREE 3 24 hour with full resuscitation facilities 3 Consultant-led 3 Designated accommodation for patients admitted via ED 3 Single specialty emergencies (eye or dental) 3 Consultant-led 3 Designated accommodation 3 Minor injuries/walk-in centres 3 Doctor or nurse-led 3 Can be routinely accessed without appointment 3 May be co-located within an ED or sited in the community We run all three types of departments and all three types are subject to the national target and are therefore reflected in our figures. National target: The constitutional standard states that 95% of patients should be treated and either admitted or discharged within fours of arrival into ED. However, NHS Improvement set local targets for all NHS organisations with an ambition that the NHS would return to meet the 95% target by March 2019. The local targets set by quarter (to allow for seasonal variations) for UHS were: Quarter 1 - 90% Quarter 2 - 91.4% Quarter 3 - 90% Quarter 4 - 90-95% How did we do? 2018/19 was another challenging year for emergency patients for the whole Hampshire and Isle of Wight area. Whilst we had a positive start to the year achieving quarter 1 and 2 targets, we did not meet quarter 3 or 4 targets. We did, however, meet out local delivery system targets. 20 OVERVIEW AND PERFORMANCE REPORT The graph below shows our performance against the four hour target over the last year (including all UHS types and Lymington). National 4 hour access target – UHS performance 100% 95% 90% 87.1% 85% 80% 82.1% 82.3% 87.4% 87.4% 93.0% 90.5% 84.7% 82.9% 85.7% 90.7% 88.9% 84.8% 77.9% 81.1% 75% Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 The graph below shows our local delivery system performance against the four hour target over the last year (including all SGH types, Lymington and Southampton Treatment Centre). National 4 hour access target – Local delivery system 100% 95% 91.0% 90% 91.1% 95.1% 92.8% 88.7% 87.1% 89.2% 91.5% 85% 92.9% 88.4% 83.3% 85.9% 80% 75% Apr 2018 May 2018 June 2018 July 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 21 OVERVIEW AND PERFORMANCE REPORT Cancer waiting times There are nine separate cancer waiting times standards (below), each of which can then be split into tumour site specific performance groups. Measures Urgent GP referrals seen in two weeks Breast symptoms referral seen in two weeks Treatment started within 62 days of urgent GP referral Treatment started within 62 days of referral (breast, cervical and bowel screening) 62 day consultant upgrades Treatment started within 31 days of decision to treat Second or subsequent treatment (surgery) started within 31 days of decision to treat Second or subsequent treatment (anti-cancer drugs) started within 31 days of decision to treat Second or subsequent treatment (radiotherapy) started within 31 days of decision to treat Target > 93% > 93% > 85% > 90% > 86% > 96% > 94% > 98% > 98% 18/19 YTD (up to and including Feb 19) 86% 50% 74% 80% Achieved 8 8 8 8 86% 3 93% 8 85% 8 100% 3 100% 3 The number of patients referred under the two week wait urgent suspected cancer protocol seen within two weeks of their referral, rose by 7.7% in 2018/19. The chart below shows the rise in demand for UHS cancer services over the past three years UHS growth in cancer actvity – 2016/17 to 2018/19 (up to and including month 11) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Two week waits 2016/17 up to and incl Feb 62 day target patients 31 day target patients 2017/18 up to and incl Feb 2018/19 up to and incl Feb For staffing performance, please refer to page 58. For financial performance please see page 177. Paula Head, chief executive officer 28 May 2019 22 OVERVIEW AND PERFORMANCE REPORT Regulatory body ratings Single Oversight Framework NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: 1. Quality of care 2. Finance and use of resources 3. Operational performance 4. Strategic change 5. Leadership and improvement capability (well-led) Based on information from these themes, providers are segmented from one to four where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments three or four where it has been found to be in breach or suspected breach of its licence. Segmentation During 2018/19 the Trust was confirmed as being placed within segment ‘2’. This segmentation information is the Trust’s position as at 31 March 2019. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Area Financial sustainability Financial sustainability Financial sustainability Overall scoring Care Quality Commission ratings: Metric Capital service cover Liquidity Income and expenditure margin Distance from financial plan Agency spend Q1 Q2 Q3 Q4 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? Good Requires improvement Outstanding Good Requires improvement Good 23 OVERVIEW AND PERFORMANCE REPORT In December 2018, the CQC inspected four core services; urgent and emergency care, medicine, maternity and outpatients. It also looked at management and leadership, and effective and efficient use of resources. The CQC report (published on the 17 April 2019) rated the Trust as ‘good’ overall and ‘outstanding’ for providing effective services. “Our inspectors found a strong patient-centred culture with staff committed to keeping their people safe, and encouraging them to be independent. Patients’ needs came first and staff worked hard to deliver the best possible care with compassion and respect. Inspectors saw many areas of outstanding practice, with care delivered by compassionate and knowledgeable staff. Several teams led by example with a continuous focus on quality improvement. The Trust did face some challenges especially with the ageing estates. Some patient environments were showing significant signs of wear and tear – but again staff were doing their utmost to deliver compassionate care”. Dr Nigel Acheson Deputy chief inspector of hospitals (South) Environmental matters We recognise that the Trust’s business has an impact on the environment. As a large hospital we undertake a wide range of activities and use a large amount of resources, for example: • The Trust generates approximately 3,000 tonnes of waste yearly, half of which is clinical waste. If not properly treated this huge amount of waste can cause soil, water and air pollution depending on the disposal route. • Due to the large number of visitors and deliveries we attract every day, traffic congestion is regularly experienced on and around the site, which impacts the air quality around the hospital. We are committed to environmental sustainability and consider it as part of the business culture. We acknowledge that reducing waste and minimising the consumption of scarce resources is consistent with financial sustainability. Our sustainability disclosure section on page 80 provides greater detail on the steps we are taking to reduce our activities’ impact on the environment. 24 OVERVIEW AND PERFORMANCE REPORT Social, community, anti-bribery and human rights issues We recognise our responsibilities under the European Convention on Human Rights (included in the Human Rights Act 1998 in the UK), which are relevant to health and social care. These rights include the: • right to life • right not to be subjected to torture, inhuman or degrading treatment or punishment • right to liberty • right to respect for private and family life The Trust is committed to ensuring it fully takes into account all aspects of human rights in our work. At University Hospital Southampton we value our reputation for top quality care and financial probity and conduct our business in an ethical manner. The Bribery Act 2010 was introduced to make it easier to tackle the issue of bribery which is a damaging practice. Bribery can be defined as ‘giving someone a financial or other advantage to encourage them to perform their duties improperly or reward them for having done so’. To limit our exposure to bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Standards of Business Conduct Policy and a Freedom to Speak Up (formerly Raising Concerns) Policy. These apply to all staff and to individuals and organisations who act on behalf of UHS. We also employ a local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption. The success of our anti-bribery approach depends on our staff playing their part in helping to detect and eradicate bribery. Therefore, we encourage staff, service users and others associated with UHS to report any suspicions of bribery and we will rigorously investigate any allegations. In addition, we hold a register of interest for directors, staff, and governors and ask staff not to accept gifts or hospitality that will compromise them or the Trust. The Board of Directors carries out its business in an open and transparent way. We are committed to the prevention of bribery as well as to combating fraud and expect the organisations we work with to do the same. Doing business in this way enables us to reassure our patients, members and stakeholders that public funds are properly safeguarded. There are no important events since the year end affecting the foundation trust. No political donations have been made. The Trust has no overseas branches. 25 FR STAND BODY ACCOUNTABILITY REPORT Members of the Trust Board Board member Name Title Paula Head Chief executive officer David French Deputy chief executive officer and chief financial officer Gail Byrne Director of nursing and organisational development Jane Hayward Director of transformation and improvement Biography Declarations Paula joined the Trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. She began her career as a pharmacist working in the community, hospitals and at health authorities before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS FT. Paula lives in Hampshire and has a daughter studying medicine at the University of Southampton. Daughter is a medical student at University of Southampton; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Executive Delivery Group David joined the Trust in February 2016 and led on finance, procurement, estates and commercial development until March 2018, when he became interim chief executive officer. He read Economics and Social Policy at the University of London before joining ICI plc, where he qualified as a chartered management accountant. David has extensive healthcare experience from the pharmaceutical industry, mostly Eli Lilly and Company where he held many commercial and financial roles in the UK and overseas. He joined the NHS in 2010 as chief financial officer of Hampshire Hospitals NHS Foundation Trust. He also serves as a non-executive director for Vivid Housing Limited, a social housing provider across Hampshire and the Solent. Non-executive director and chair of audit and risk committee, Vivid Housing Limited; Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Director, Southampton Commercial Estates Development Partnership (CEDP) Project Company Limited, a whollyowned subsidiary of UHSFT; Member of Solent Acute Alliance; Member of Hampshire & Isle of Wight Counter Fraud Board; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Capital Planning Panel (from May 2018) Gail joined the Trust in 2010 as deputy director of nursing and head of patient safety. Prior to this, she has worked at the Strategic Health Authority as head of patient safety, and director of clinical services at Portsmouth Hospital. Gail has also worked in Brisbane, Australia as a hospital Macmillan nurse, and as general manager of a special purpose vehicle company for the private finance initiative at South Manchester Hospitals. Husband is a consultant surgeon in the Trust; Daughter is a midwife at UHS (from March 2019) Jane joined the Trust in 2000 as a clinical services manager for the cardiothoracic directorate after spending two years in Hertfordshire as director of performance and 11 years at Barts and the London Hospitals in various roles including planning, finance and commissioning. Jane has led on human resources, information management and technology, improvement and modernisation and has been chief operating officer. Jane joined the Trust Board in February 2008 and became director of transformation and improvement in January 2014. Director, UHS Estates Limited, a wholly-owned subsidiary of UHSFT; Father and mother are UHSFT simulated patients (voluntary position) Dr Derek Medical Sandeman director Dr Caroline Marshall Chief operating officer Derek was appointed to the Trust as a consultant physician in 1993 and went on to develop a regional endocrine service. Throughout his career he has had extensive clinical leadership experience, most recently serving eight years as clinical director. Derek’s leadership roles have also included programme director for postgraduate education and the Wessex Endocrine Royal College representative. He has a strong history of wider system engagement, working collaboratively with partners to improve systems resilience and pathways. Caroline joined the Trust in 1997 as a consultant hepatobiliary and neuroanaesthetist. She has held the posts of college tutor for the Royal College of Anaesthetists and UHS mentoring and coaching lead. In 2008, she became clinical service director for critical care, and then divisional clinical director for division A between 2010 and 2013. Caroline served as interim chief operating officer between January to December 2014, and was then appointed to the substantive post. Her portfolio includes the executive lead for cancer and the executive lead for major trauma. Director of UHS Pharmacy Limited, a wholly-owned subsidiary of UHSFT; Member of Hampshire & Isle of Wight Sustainability and Transformation Partnership Clinical Executive Group Daughter is employed within the emergency department at UHS (from 1 August 2018) 27 ACCOUNTABILITY REPORT Non-executive directors Name Title Peter Hollins Chair Simon Porter Senior independent director and deputy chair Dr Mike Non-executive Sadler director Biography Declarations Peter graduated in chemistry from Hertford College, Oxford. Joining Imperial Chemical Industries in 1973, he undertook a series of increasingly senior roles in marketing and then general management. Following three years in the Netherlands as general manager of ICI Resins BV, he was appointed in 1992 as chief operating officer of EVC in Brussels – a joint venture between ICI and Enichem of Italy. He played a key role in the flotation of the company in 1994, returning in 1998 to the UK as chief executive officer of
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.pdf

Papers Trust Board - 9 September 2025

Description: Date Time Location Chair Apologies Agenda Trust Board – Open Session 09/09/2025 9:00 - 13:00 Conference Room, Heartbeat Education Centre Je
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2025-Trust-documents/Papers-Trust-Board-9-September-2025.pdf

UHS AR 23-24 Final

Description: 2023/24 Incorporating the quality account University Hospital Southampton NHS Foundation Trust Annual Report and Accounts
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/UHS-AR-23-24-Final.pdf

Papers Council of Governors 25 January 2023

Description: Agenda attachments 1 CoG Agenda - 25.01.2023.docx Date Time Location Chair Agenda Council of Governors 25/01/2023 14:00 - 16:10 Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 19 October 2022. 4 Matters Arising/Summary of Agreed Actions 14:05 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:07 Receive and note the report Sponsor: David French, Chief Executive Officer 6 Governance 6.1 Chair and Non-Executive Director Appraisal Process 14:27 Approve the Chair and Non-Executive Director Appraisal Process Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Steve Harris, Chief People Officer 6.2 Annual Business Plan 2023/24 14:37 Approve the Annual Business Plan for 2023/24 Sponsor: Craig Machell, Associate Director of Corporate Affairs and Company Secretary Attendee: Karen Russell, Council of Governors' Business Manager 6.3 Composition of the Council of Governors 14:39 Approve the proposals regarding the representation of young people on the Council of Governors on an associate membership basis Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.4 Vacancy for the Nursing and Midwifery Staff Governor 14:49 Approve the proposal for filling the vacancy for the Nursing and Midwifery Staff Governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendees: Craig Machell, Associate Director of Corporate Affairs and Company Secretary and Karen Russell, Council of Governors' Business Manager 6.5 Confirmation of Chair of the Patient and Staff Experience Working Group 14:54 Confirm the appointment of Sandra Gidley as Chair of the Patient and Staff Experience Working Group Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.6 Appointment of Deputy Lead Governor 14:56 Note the process for the appointment of a Deputy Lead Governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Karen Russell, Council of Governors' Business Manager 6.7 Audit and Risk Committee Terms of Reference 15:04 Provide views on the proposed changes before presentation to the Trust Board Sponsor: Keith Evans, Audit and Risk Committee Chair Attendee: Craig Machell, Associate Director of Corporate Affairs and Company Secretary 7 Break 15:14 8 Membership Engagement and Governor Activity 8.1 Membership Engagement 15:24 Receive the report Sponsor: David French, Chief Executive Officer Attendee: Sam Dolton, Events and Membership Officer 8.2 Feedback from Governors' Nomination Committee 15:39 Chair: Jenni Douglas-Todd, Trust Chair 8.3 Feedback from Strategy and Finance Working Group 15:44 Chair: Mandy Fader 8.4 Feedback from Patient and Staff Experience Working Group 15:49 Chair: TBC 8.5 Feedback from Membership and Engagement Working Group 15:54 Chair: Kelly Lloyd 9 Review of Meeting 15:59 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 10 Any Other Business 16:04 Raise any relevant or urgent matters that are not on the agenda Page 2 11 Date of Next Meeting: 26 April 2023 16:09 Note the date of the next meeting Page 3 3 Minutes of Previous Meeting 1 3 COG Minutes - 19.10.2022 V2 Final.docx Minutes - Council of Governors (CoG) Open Session Date Time Location Chair Present 19 October 2022 14.00-16.00 Microsoft Teams Jenni Douglas-Todd, Trust Chair Jenni Douglas-Todd, Trust Chair Shirley Anderson, Elected, New Forest, Eastleigh and Test Valley Katherine Barbour, Elected, Southampton City Patricia Crates, Elected, New Forest, Eastleigh and Test Valley Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Helen Eggleton, Appointed, Hampshire and Isle of Wight Integrated Care Board Professor Mandy Fader, Appointed, University of Southampton Lesley Gilder, Elected, Southampton City Linda Hebdige, Elected, Southampton City Sandra Gidley, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff and Lead Governor Councillor Alexis McEvoy, Appointed, Hampshire County Council Esther O’Sullivan, Elected, New Forest, Eastleigh and Test Valley Catherine Rushworth, Elected, Isle of Wight Liz Taylor, Elected, Non-clinical and support staff Quintin van Wyk, Elected, Rest of England and Wales JDT SA KB PC ND HE MF LG LH SG KL AM EO CR LT QvW In attendance Tracey Burt, Minutes TB Sam Dolton, Events and Membership Officer SD Helen Potton, Interim Associate Director of Corporate Affairs and HP Company Secretary Karen Russell, Council of Governors’ Business Manager KR Joe Teape, Chief Operating Officer (for Item 5.1) JT Apologies Theresa Airiemiokhale, Elected, Southampton City TA Dr Diane Bray, Appointed, Solent University DB Jenny Lawrie, Elected, Southampton City JL Councillor Cathie McEwing, Appointed, Southampton City Council CM Sathish Harinarayanan, Elected, Medical practitioners and dental SR staff Wendy Marsh, Elected, Nursing and midwifery staff WM Ian Ward, Elected, Rest of England and Wales IW 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and noted that ten new governors had joined since the 1 October 2022 . 1 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 20 July 2022 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted. Item 444 was on the agenda for discussion and items 779 and 780 had been completed and closed. The Chair noted that in line with the request made in item 779, a 10-minute break had been scheduled into the agenda. 5 Strategy, Quality and Performance 5.1 Chief Executive Officer’s Performance Report JT introduced himself and advised that he was attending on behalf of David French, CEO. He noted that the performance report related to August data so a number of issues had moved on. There had been a significant increase in Covid-19 numbers in the hospital, with up to around 140 Covid-19 positive patients at any time. There had continued to be an increased emergency demand and record levels of cancer referrals. The Trust had been running at maximum occupancy and had focussed on maintaining patient safety and navigating through each day as best it could. Staff sickness absence, due to Covid-19, had been high with close to 200 staff off at one point in time, so it had been a challenging period. The current week had been difficult with 430 Type 1 attendances on 18.10.22 which was more than the hospital could reasonably cope with at any one time. The Trust, like many others across the NHS, was struggling to meet some of its constitutional standards and whilst UHS compared reasonably well against other large teaching hospitals, it was not providing the standards of care it aspired to and staff were struggling. Nationally there was a strong focus and oversight on long waiters, Emergency Department access standards, diagnostic waits and cancer performance. There were, however, many things that the Trust continued to do well and it was working hard to deal with the things that mattered most to the patients it served. The following questions were raised by governors: • whether care group recovery plans were in place around cancer performance and whether there was confidence in them. JT advised that around 2600 patients were on the cancer pathway and over 300 were breaching 62 days (around 15% of the waiting list, against 8% pre Covid-19). By March the trajectory would reduce from 15% to around 12%, so some improvements would be made but there were capacity/workforce issues. • what the vacancy rate was for health care professionals working within the cancer sector at UHS? JT advised that as so many staff within the Trust interfaced with cancer services and there was not a separate cancer directorate, it would be difficult to provide a figure. • whether the Trust had any plans to reduce the footfall into the hospital by signposting patients to more appropriate services. JT noted that there were 2 actions in the wider winter plan in the healthcare system, outside of UHS, but that system was also facing challenges. The Trust was attempting to give better pathways to primary care so that they did not need to send patients to the Emergency Department. An Urgent Care Village had also been piloted at UHS, which had seen the Trust’s four hour performance improve from 50% to 80% during that week. The Trust was therefore looking to see how much of that pilot could be implemented quickly for the winter. • how confident the Trust was that it would get back on track with the financial plan within the financial year. JT advised that the Trust was predicting a year end deficit. However, whilst that was around 2.4%, nationally the average percentage deficit was higher and within the ICS it was at 3.7%. He noted that many things had changed since the financial plans were made, e.g. the pay awards, energy bills and Covid-19 costs. The Chair thanked JT for attending on behalf of the CEO and for his detailed responses to the questions raised. 5.2 Council of Governors’ Strategy Day – Plans and Discussion The Chair advised that the annual CoG Strategy Day would take place on the 14 December. A full day had been scheduled and it was hoped that it would be in person, depending on the Covid-19 situation at that time. KR informed governors about some of the things that had been done at previous strategy days and governors were asked for their suggestions for the day. The following were suggested: • to get to know the strength of the new governors. • to hear more from Adrian Byrne about digital. • how the Trust was supporting patients with dementia in the hospital. • an update on staff training. • horizon scanning and the involvement of governors at the outset. • inviting speakers from the various staff forums to share their strategic views and plans. • learning disabilities/autism and the revised improvement standards. • to provide staff with an opportunity to meet/get to know the governors. • to consider how the governors best served the people who had elected them. • how the Trust was working with its partners, particularly those in the community. • to hear more about the Trust’s strategy on research and university partnerships. • a presentation from Wessex Health Partners around their plans to mobilise the wider region to help solve system problems. • to look at different aspects of the Trust’s strategy and how it was set out to achieve goals. • how the Trust performed against other, smaller, local hospitals. • how the governors could contribute within the Trust. • whether the Trust was looking to work smarter. • how governors could engage more effectively with different constituencies in the future. 6 Break 3 7 Governance 7.1 Appointment of Deputy Chair The previous Deputy Chair had stood down and a replacement needed to be appointed. The Chair had gone through a process of meetings and discussions with the Non-Executive Directors and had recommended Keith Evans (KE) for the role. His first term as a Non-Executive Director was due to expire in January 2023 and the Trust would seek the governors’ permission to extend it for a second, three year term. KE currently chaired the Trust’s Audit and Risk Committee. Decision: The CoG approved the appointment of Keith Evans as Deputy Chair. 7.2 Appointment of Lead Governor KR advised that Bob Purkiss, the previous Lead Governor, had reached the end of his second term of office on the 30 September 2022. He had therefore stood down and a replacement Lead Governor was needed. The process for appointing a Lead Governor was laid out in the constitution and it was the responsibility of the CoG to make an appointment. Expressions of interest had been requested from the governors and KL had responded. Governors had been asked to consider KL’s statement of candidature and they had given their support by written resolution, as laid out in the constitution. Decision: The CoG noted the appointment of KL as Lead Governor. 7.3 Appointment of Council of Governors’ Working Group Chairs KR advised that the Chairs of the Membership and Engagement Working Group (Bob Purkiss) and the Strategy and Finance Working Group (Tim Waldon) had both stood down and replacements were therefore needed. The process for new appointments was laid out in the Terms of Reference and expressions of interest had been requested. The working groups themselves were responsible for appointing their chairs and the following governors had been chosen: • KL - Chair of the Membership and Engagement Working Group • MF - Chair of the Strategy and Finance Working Group. The Chair thanked all the governors who had been involved in the process. Decision: The CoG confirmed the appointment of KL as Chair of the Membership and Engagement Working Group and MF as Chair of the Strategy and Finance Working Group. 8 Membership Engagement and Governor Activity 8.1 Membership Engagement SD introduced the membership engagement report and noted that with the lifting of Covid-19 restrictions it had been possible to engage with community events, whilst continuing with digital communications. He highlighted the following: • a Connect membership newsletter had been produced in August and the October edition would be sent out shortly. • there had been a pause in engagement following the death of the Queen Elizabeth II, in line with the national period of mourning. Consequently, the annual members’ meeting which had been planned for the 28 September had been postponed as there had been a delay in the Annual Report and Accounts being laid before parliament. It would now take place on the 1 4 November and would a virtual event. Details would be included in the weekly governors’ update. • public members had been invited by the Estates, Facilities and Capital Development Team to participate in a Patient Led Assessment of the Care Environment (PLACE) to consider, from an outside perspective, cleanliness around the Trust, signage, whether the site was dementia friendly and supported those with a disability. There had been a good response and 46 public members had expressed an interest in taking part. • the team had attended several large, in person, events to convey key messages to members of the public and to promote membership. These had included having a stall at Southampton Pride, attending the university Fresher events, the Southampton Jobs and Wellbeing Fair organised by Southampton City Council and a support group on the Isle of Wight ‘Breathe Easy Isle of Wight’ for those living with chronic lung conditions. • the team had been very active on its social channels around public engagement. • earlier in the month infection prevention measures had been reintroduced in the Trust as there had been an increase in Covid-19 cases and the team had used social media to provide information to people. • there had been good engagement with news stories that had been published, e.g. a 12 year old girl who had made an incredible recovery from major spinal surgery at UHS and several Children’s Hospital patients who had taken part in the British Transplant Games in Leeds. • there had been an overall drop in the number of members on the database but 90 new members had joined since the last CoG meeting, which made it the best quarter during the year. • the membership was becoming more representative of the population it served in terms of ethnicity and age. The priorities for the next three months included: • the Annual Members’ Meeting on the 1 November, when David French would talk about the Trust’s strategic plan. HE, as Deputy Lead Governor, would also give an update on membership. • the newsletter would continue to be published bi-monthly and there would be an addition in December. • a series of virtual events, exclusively for members, would be launched over the winter months. • a series of library talks, in local communities, was being planned (Covid-19 permitting) with the Trust’s Experience of Care Team. The Chair thanked SD for his detailed report and said that it was encouraging to see the increase in activities. The following questions were asked by governors: • whether new governors, as part of their induction, were given information or a prompt sheet on what being a member of UHS involved, so that consistent messages were shared with the public. SD agreed to distribute an appropriate sheet to governors. • whether a written report from the Events and Membership Officer would suffice, to save time for that staff member and to avoid them having to give the same presentation at several meetings. It would also allow more time for discussion at meetings. The Chair noted that a written report had been included with the meeting papers. • whether impressions (the number of times a post had been displayed on social media or appeared on a person’s social account) and engagements 5 were increasing over time. SD advised that the team were pleased with the interactions on social media and intended to try reaching a younger audience by using Instagram. • whether any communication had been sent out regarding the results of the governor elections. KR agreed to circulate the appropriate link to governors. • ACTION: KR • whether it would be possible to allow members access to the talks being given by the key note speakers at the Championing Individuality and Belonging virtual workshop for staff on the 17 November. SD agreed to check whether that would be possible. • ACTION: SD • how engagement with people of colour, the Asian community could be improved. SD was keen for governors to let him know of any community events that the Trust could attend. • whether the Meet the Governors information on the UHS website could be updated. KR advised that it was in hand. The Chair noted that whilst the membership had gone down, the number of 18 to 60 year old members was the largest it had been since 2021, which was positive. The Chair thanked SD for his report. 8.2 Governors’ Nomination Committee (GNC) Feedback The Chair advised that, in part, the GNC had not met as it had several vacancies. The committee consisted of the Chair, the Lead Governor and three governors, one of which must be a public governor and at least one, a staff governor. There were currently vacancies for a public governor and a staff governor. The Chair invited governors who were interested in joining the committee to let her know as soon as possible. The first duty of the GNC was likely to be the extension of KE’s appointment as a NED, as mentioned earlier in the meeting. Action: Public and staff governors who were interested in joining the GNC were asked to advise the Chair. 8.3 Feedback from Strategy and Finance Working Group MF advised that she had, for the first time, chaired the Strategy and Finance Working Group on 18.10.22. There had been two, previously arranged, agenda items: • a presentation on the PLACE project from Paul Chamberlain, Associate Director of Estates, Facilities and Capital Development. The project had indicated that areas requiring service, e.g. cleanliness and food, had been good. However, those around estate type issues, e.g. disability access and maintaining privacy and dignity, had been poor and recommendations would be made. • a presentation from Jason Light, Head of Sustainability and Energy Support Services, on aspects of the Trust’s Sustainability Plan, including various emission targets, e.g. heating and recycling. MF advised that there had been good challenge from governors on the above and follow ups had been requested. MF had also met with Christine McGrath, Director of Strategy and Partnerships and had discussed how the skills and 6 strengths of the governors on the working group could best be used to support the Trust in terms of strategy and finance. 8.4 Feedback from Patient and Staff Experience Working Group The Chair advised that a governor was needed to chair the Patient and Staff Experience Working Group. KR advised that she would be asking for expressions of interest, together with supporting statements, in case more than one governor stepped forward. The Patient and Staff Experience Working Group had met on 13.10.22. Two topics had been discussed and KR had circulated both presentations to all governors. • Rosemary Chable, Head of Nursing for Education, Practice and Staffing and Alison Trenerry, Lead for Education Quality, Learning and Environment had attended with a trainee nurse. They had talked about the training process for nurses. • Natasha Citeroni, a junior doctor, had attended and there had been discussion linked to her presentation. Action: KR to request expressions of interest and supporting statements from governors interested in becoming Chair of the Patient and Staff Experience Working Group. 8.5 Feedback from Membership and Engagement Working Group KL noted the earlier report from SD. She updated governors on volunteer numbers in the Trust and advised that prior to Covid-19 there had been 800 volunteers. Currently, however, there were around 200 and there were efforts to increase that number. Governors were asked to consider a proposal to appoint a young associate governor to the CoG aged between 16 and 18, for a one year term but with no voting rights. At the end of their term, an endorsement would be given by the Trust, to say that they had performed the role. The Chair noted that in previous years there had been two young governors on the CoG. KR noted that the proposal had arisen as part of a composition review that had commenced in 2021. As part of that review a decision had been made to increase the number of public governors in the New Forest and Test constituency by one and to reduce the Rest of England and Wales constituency by one, keeping the overall number of public governors to 13. There had also been consideration to broadening the range of governors and making it less restricted. There had been further discussion at the Membership and Engagement Working Group meeting on 17.10.22 regarding the appointment of a young governor and proposals regarding the selection process would need to be confirmed. A constituency for that age group would also need to be set up. There had been a suggestion that the young governor become a full member of the CoG and SD was checking what had been done in other large Trusts. Formal proposals would be taken to CoG in January 2023. 9 Any Other Business The Chair advised that the Annual Report had been laid before parliament on the 11.10.22. 7 10 Review of Meeting The Chair asked for feedback from governors regarding the meeting, which would help to shape future sessions. The following comments were made: • the comfort break had been appreciated. • to consider smart and effective ways of working, to save time and repetition. • written reports often contained greater detail than could be given in verbal reports. • whether a sustainability working group was needed (or regular updates). • whether there was a long-term plan for what each working group would be doing. • achieving the right balance between presentations given in the working groups and what was discussed at CoG. • whether there should be a separate staff experience working group to consider many of the challenges being faced. The Chair thanked governors for attending and contributing to the meeting. 11 Date of Next Meeting - 25 January 2023 The next CoG meeting would be held on 25 January 2023. 8 4 Matters Arising/Summary of Agreed Actions 1 4 Action items as at 19 January 2023.docx Agenda item Assigned to Deadline Status Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Craig Machell Karen Russell 25/01/2023 Explanation action item A review of the Council of Governors' (CoG) composition is to be carried out to check that it still remains appropriate. Pending Following discussions by the Membership and Engagement Working Group, proposals for a change to the composition of the CoG, it was agreed to reduce the number of governors representing the Rest of England by one governor; and to increase the number of governors representing New Forest, Eastleigh and Test Valley by one governor. Suggestions regarding young governor representatives were considered further at a sub-group on 24 August 2022 and these will be discussed at the Membership and Engagement Working Group at its meeting on 17 October 2022. Proposals were further discussed at the Membership and Engagement Working Group Meeting on 19 January 2023 and these will be presented to the CoG at its meeting on 25 January 2023. Council of Governors 19/10/2022 8.1 Membership Engagement 866. Publication of Election Results 2022 Karen Russell 25/01/2023 Closed Explanation action item LT had been asked whether the full election results were available which showed the number of votes received for each candidate. KR had circulated the results but would ask the election services provider for this additional information. KR circulated the full results to governors on 2 November 2022. 17 January 2023 16:11 867. Link to talks at the Individuality and Belonging Conference Sam Dolton 25/01/2023 Closed Explanation action item KL asked whether it would be possible to allow members access to the talks being given by the key note speakers at the Championing Individuality and Belonging virtual workshop for staff on the 17 November. SD agreed to check whether that would be possible. SD provided the link to this in the Connect Members' Newsletter in December 2022. Council of Governors 19/10/2022 8.2 Governors' Nomination Committee Feedback 868. Public and Staff Governor Vacancies on the Governors' Nomination Committee (GNC) Karen Russell 25/01/2023 Closed Explanation action item There were two vacancies on the GNC. Governors who were interested in joining the GNC were invited to submit an expression of interest to the Chair. KR circulated an email to governors inviting expressions of interest on 24 October 2022. Shirley Anderson submitted an application and the CoG approved her membership of the GNC by written resolution in November 2022. A further email to invite expressions of interest for the remaining vacancy was sent to governors on 18 January 2023. Council of Governors 19/10/2022 8.4 Feedback from Patient and Staff Experience Working Group 869. Vacancy for the Chair of the Patient and Staff Experience Working Group Karen Russell 25/01/2023 Closed Explanation action item Following the resignation of Wendy Marsh there was a vacancy for the chair of the Patient and Staff Experience Working Group. KR was to invite expressions of interest for the role. An email inviting expressions of interest was circulated to governors on 24 October 2022. Sandra Gidley submitted an application and the Patient and Staff Experience Working Group agreed unanimously to appoint her as their chair. The CoG will be asked to confirm the appointment at its meeting on 25 January 2023. Page 2 5.1 Chief Executive Officer's Performance Report 1 5.1i CEO's Performance Report Cover Sheet.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Jason Teoh, Director of Data and Analytics 25 January 2023 Assurance Approval or reassurance Ratification Information Y Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: This report provides performance information relating to a broad range of Trust services and activities. There are no specific implications. Risks: This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. 1 5.1ii Chief Executive's Performance Report Jan 2023 FINAL.docx UHS Council of Governors 25th January 2023 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. Where available, this report covers data from the period September to November 2022, noting that some performance data in relation to some of the targets is reported further in arrears. This has been a particularly challenging period for the Trust – which is reflected within the statistics. Notable features of the period included: • Challenges with infection control due to an increase in Clostridium Difficile cases, and fluctuations in COVID-19 infections – both trends replicated nationally. • Ongoing high volume of attendances to the Emergency Department (averaging 379 patients per day, and 19 days with over 400 attendances), reflecting an ongoing national trend and significantly impacting four-hour performance. • A significant number of patients not meeting the criteria to reside, usually at between 190 – 210 patients, continuing to occupy hospital beds, restricting flexibility in our elective programmes, and impacting flow through the hospital (including patients awaiting admission from the Emergency Department onto wards). These patients are typically waiting for care to be provided in the community to continue their recoveries or meet long term needs in their home setting. • Continued growth in the RTT waiting list due to higher post-pandemic referral volumes causing the waiting list to rise to over 54,000 patients. However, good progress has been made in reducing the longest waiting patients at both 104+ and 78+ weeks. • Challenges within our cancer services due to higher referral volumes. 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 95.0% ≥ 90.0% Sep 2022 62.3% 76.1% Oct 2022 57.3% 61.5% Nov 2022 59.9% 73.5% Attendances to the Emergency Department (ED) have remained high through this period, averaging 379 per day (including 19 days in the three months with over 400 arrivals). This, alongside with ongoing flow challenges due to the number of patients no longer meeting the Criteria to Reside, means that UHS has seen a deterioration in our four-hour performance. Although lower than target, we continue to benchmark well against other trusts which demonstrates that this is a national challenge. In the period of September to November 2022, UHS ranked in the top quartile of the 16 teaching hospitals that we benchmark against (Type 1 attendances). NHS England has recently made ambulance handover data more readily available. Across the South East and South West regions UHS is in the top three trusts with the lowest ambulance handover delays at 30+ and 60+ minutes, despite the challenges within our own department Page 3 of 5 Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Sep 2022 65.09% 53,106 Oct 2022 64.97% 53,913 Nov 2022 65.24% 54,198 The number of patients on the RTT waiting list continues to increase as higher referrals continue above prepandemic levels. The proportion of patients that we have being treated within 18 weeks is in line with other teaching hospitals, with UHS within the top third. UHS continues to make good progress in reducing the longest waiting patients. UHS has no patients waiting over two years for treatment and are continuing to see a good reduction in the number of patients who have waited over 78 weeks for treatment. Cancer Urgent GP referrals seen in 2 weeks Diagnosis within 28 days Treatment started within 62 days of urgent GP referral Target => 93% > =75% => 85% Sep 2022 80.6% 75.0% 55.2% Oct 2022 76.2% 80.1% 55.1% Nov 2022 73.1% 79.4% 58.0% As a specialist teaching hospital, our cancer services are under pressures not seen in other Wessex region hospitals, but replicated with other national, acute, teaching hospitals. Cancer referrals remain high compared to pre-COVID levels, and this has created challenge on our service. This has been particularly prevalent within Breast, where high demand and some staffing issues have impacted performance between September to November. Other areas seeing higher demand have been Head and Neck and Urology. As a result of referral volumes, our 62-day cancer treatment performance has been adversely impacted. Late tertiary referrals have also impacted our ability to treat patients within 62 days. However, our performance to the 28 Day Faster Diagnosis standard remains above target – ensuring that we are providing patients with an outcome from their referral within a timely manner. 5. Finance The financial position for the trust is particularly challenging with a year-to-date deficit of £17.7m reported at the end of November 2022 (month 8). This compares to a deficit plan of £4.7m so is £13m behind plan. The key drivers for this are: • COVID-19 related cost pressures – patient numbers have remained significant and staff sickness absence has also remained above pre-COVID levels. This has generated a significant cost pressure compared to plan assumptions. • Inflationary pressures especially related to energy costs – these are emerging to a greater extent as the year progresses with energy costs particularly set to increase over the winter period despite the government price cap offering some protection. Energy costs are more than three times greater than they were in 2019/20. • An increase in the volume of patients not meeting the criteria to reside who are medically optimised for discharge – this is causing particularly acute operational challenges and limiting the Trust's ability to deliver additional elective activity supressing Elective Recovery Funding (ERF). These drivers are forecast to continue over the winter period and in the example of increasing energy costs may cause a greater pressure on the financial position. Despite these challenges the cost improvement programme for the Trust continues to deliver savings with £27m achieved against a plan of £25m so £2m ahead of plan. The annual plan of £45m is over 90% identified with the intention of identifying and delivering additional savings in Q4 to bridge the remaining gap. Page 4 of 5 A range of forecast scenarios exist which are currently being risk assessed by the Trust’s Finance and Investment Committee. The trust continues to focus on financial and productivity improvement despite the operational challenges. The Trust Savings Group has now been running six months and a rust financial improvement away day has generated significant ideas for onward development. Capital expenditure year-to-date totals £14m with key programmes of work now starting to take hold such as the new wards project and theatres refurbishments. The Trust remains on target to spend its full capital budget of £49m for 2022/23. Additional to this the Trust has been successfully awarded external capital of c£23m for spend in 2022/23 which will further support investment in capacity, infrastructure and digital. It is hoped the Trust will be successful in achieving more external capital funding in future months with several bids in final stages of the national approval process. 6. Human Resources Indicator Staff recommend UHS as a place to work Staff survey engagement score Target - Q2 22/23 6.96 7.03 The Pulse Survey results show a declining score across both metrics, although we remain slightly better than national averages. Feedback from staff indicates that the scores reflect the ongoing challenging environment that they are working in. Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing Vacancies (Registered Nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Sep 2022 14.7% 4.9% 11.6% Oct 2022 14.6% 4.8% 11.0% Nov 2022 14.4% 4.8% 11.3% Primarily reasons for sickness continue to be: Covid-related sickness (including long Covid); work-related stress; and musculo-skeletal (MSK) problems. Page 5 of 5 6.1 Chair and Non-Executive Director Appraisal Process 1 6.2i 03012023-Non Exec appraisal 2223 cover sheet.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chair and Non-Executive Director (NED) Appraisal Process 6.1 Jenni Douglas-Todd, Trust Chair Steve Harris, Chief People Officer 25 January 2023 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: The NHS Foundation Trust Code of Governance requires that the Council of Governors (CoG) should take the lead on agreeing a process for the evaluation of the chair and the non-executive directors with the chair and non-executive directors. The Governors’ Nomination Committee (GNC) advises the CoG on that process. Response to the issue: The attached paper sets out the proposed appraisal process for 202223. Implications: (Clinical, Organisational, Governance, Legal?) The appraisal process supports the board of directors (Board) in ensuring its overall effectiveness by making sure that any individual or collective development needs are identified and that the chair and nonexecutive directors continue to have capacity to meet the time commitment required for the role. The outcome of appraisal will also be relevant to any decision by the CoG to reappoint a non-executive director. Risks: (Top 3) of carrying out the change / or not: 1. Non-compliance with The NHS Foundation Trust Code of Governance. 2. The Board may not function as effectively without an effective appraisal process in place for the chair and non-executive directors. Summary: Conclusion The CoG is asked to approve the appraisal process as recommended and/or recommendation by the GNC, following its meeting on 11 January 2023. Page 1 of 1 1 6.2ii 03012023-Non Exec appraisal 2223.docx To: From: Date: Subject: Council of Governors Steve Harris - Chief People Officer 25 January 2023 Non-Executive Director (NED) Appraisal Process for Year 2022/23 1. Introduction and purpose 1.1 Each year Non-Executive Directors (NEDs) and the Trust Chair are required to participate in an annual appraisal process. The results of this are shared with the Governors Nomination Committee (GNC) and the Council of Governors (COG). 1.2 The Trust normally aims to complete the process by 31 March each year. The appraisal process will be undertaken by Jenni Douglass-Todd this year, as the new Chair for UHS. 1.3 This paper sets out the proposed process and timescales for the NED appraisals for 2022/23. 2. Overview of the process 2.1 The Chair of the Trust has responsibility for undertaking the appraisals for NEDs. The Chair appraisal process is conducted by the Senior Independent Director (SID). 2.2 Jane Harwood, in her new position as SID, will undertake the Chair’s appraisal. 2.3 The process will aim to: • Provide a structured review of performance against personal and organisational objectives set, and the performance of the Trust. • Reflect on demonstration of the Trust values. • Review of attendance at key Trust meetings. • Plan for the future, including objective setting for the next year and the identification of a personal development plan. • Provide overall reporting and assurance to the GNC and COG. Self evaluation Monitoring and reporting to GNC Seeking structured feedback from others Appraisal meeting and personal development plan Evaluation against organisational and personal objectives Appraisal of living the Trust values 2.4 This year the Trust will use the guidance forms provided by NHSE for NED appraisal. The Trust NED appraisal process is in line with NHSE guidance published. 3. NHSE Framework for Chair appraisal 3.1 NHSE have a national framework for appraisals of Chairs of provider organisations. This requests that Trusts ensure a robust multi-source feedback process is conducted against key areas of performance and competencies (summary in Appendix A). The full framework can be found here. 3.2 A summary of the Chair’s appraisal is also required to be provided to NHSI Regional Director. 3.3 It is intended that UHS use the templates provided for the Chair appraisal, and also include our own local values. Multi-source feedback will continue to be requested from Trust Board members and the Governors. Feedback will also be sought from the ICS. 4. Scope of Appraisal 4.1 Appraisals will cover all non-executive directors. This includes: • Jenni Douglas-Todd (Trust Chair) • Keith Evans (Deputy Chair) • Jane Harwood (SID) • Jane Bailey • Dr Tim Peachey • Dave Bennett • Femi Macaulay (Associate NED) 4.2 An objective setting session will be set up for Professor Diana Eccles as part of her induction into the role of Non-Executive Director, representing the University of Southampton. 4.3 Professor Cyrus Cooper has become an Associate Non-Executive Director. Due to his ill health, it is proposed that he does not participate in the process. 5. Proposed process 5.1 The following is proposed as the process for the 2022/23 round of appraisals: • Use of the standard NED NHSE appraisal template • Use a system of gaining qualitative feedback on each NED to be appraised from both Governors and from the Board. • The Chair will meet with each NED to conduct the appraisal once feedback has been collated. • The SID will conduct the appraisal for the Chairman 5.2 To ensure meaningful views can be obtained, it is suggested that Governors will be asked to provide positive feedback and areas of development on the NEDs as individuals, and as a group. The lead Governor (Kelly Lloyd) will be asked to seek feedback from the council members. 6. Timetable of events Action Agree process and timescales with GNC Sending out forms Details GNC briefed on process and timescales. Who To be completed by JDT and SH Early Jan 23 All feedback forms to be sent out to SH appraisees and to Governors by close of play on TBC Early Jan 23 Feedback forms to be sent to: • Governors (Via Lead Governor) • All Executives • All NEDs Seeking feedback Feedback to be provided to the chief BP people officer, who will collate it. SH 3 Feb 2023 Booking appraisal Appraisal meetings to be booked by meetings JDT (MDC) MDC By end of Jan 2023 Appraisal meetings held Summary reporting to GNC JDT to hold appraisal meetings with: • TP • KE • JH • DB • JB • FM SH and JDT to draft a summary report to be shared with GNC covering: • Feedback • Areas for development • Objectives going forward JDT JDT and SH End of Feb 2023 End of March 2023 Report to be provided to GNC by JDT an SH. Reporting to COG GNC, supported by Chief People Officer and Chairman, to provide summary report and assurance to COG. JDT and SH Reporting to NHSi Summary report to be provided to SH NHSI in line with framework process. End of March 2023 7. The role of GNC in assurance and scrutiny 7.1 The GNC will be provided with an annual report written by the Chair, supported by the Chief People Officer, which will provide an overview of the appraisals undertaken, including an overall performance summary and objectives. 7.2 The GNC will have a direct role in endorsing the appraisal process for the Chairman. The SID will undertake the appraisal and provide a key summary to the GNC who will be asked to endorse the outcome. 7.3 The COG will receive assurance from the GNC that appropriate performance appraisal of NEDs and Chair has taken place. 8. Recommended next steps 8.1 The CoG is asked to review and approve the proposed process following its recommendation by the GNC. 8.2 Governors are asked to participate in the process by providing feedback to the Lead Governor as requested. Steve Harris Chief People Officer January 2023 Appendix A – Summary of NHSI areas for Chair Appraisal • Leading the Board, both in shaping the agenda and managing relationships internally and externally. • Ensuring the Board sets the Trust’s long-term vision and strategic direction and holding Executive Directors to account for delivering the Trust’s strategy. • Creating the right tone at the top, encouraging change and shaping the organisation’s culture. • Building system partnerships and balancing organisational governance priorities with system collaboration (this is becoming more important as organisations move to integrated care systems, prioritising population health in line with the NHS Long Term Plan). 6.2 Annual Business Plan 2023/24 1 6.1i Annual Business Plan cover sheet.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Council of Governors’ Annual Business Plan 2023/24 6.2 Jenni Douglas-Todd, Trust Chair Karen Russell, Council of Governors’ Business Manager 25 January 2023 Assurance Approval or reassurance Ratification Y Information Issue to be addressed: Response to the issue: The Council of Governors (CoG) is required to review its Business Plan on an annual basis prior to the commencement of the new financial year, to ensure that its’ duties and responsibilities are conducted as required in a timely manner. The Annual Business Plan for 2023/24 is attached for approval. Implications: This will ensure that the council of governors continues to conduct its (Clinical, Organisational, business as required in accordance with current rules and practice. Governance, Legal?) Risks: (Top 3) of carrying 1. Non-compliance with the National Health Service Act 2006 and The out the change / or not: NHS Foundation Trust Code of Governance. 2. Non-compliance with the Trust’s constitution and the Standing Orders for the Practice and Procedure of the Council of Governors. Summary: Conclusion The Council of Governors is requested to approve the Annual Business and/or recommendation Plan for 2023/24. Page 1 of 1 1 6.1ii CoG Annual Business Plan 2023.24.docx Council of Governors' Annual Business Plan - 2023/24 Agenda Item April 2023 July October January 2023 2023 2024 Required Action Reports from Executives/Trust Management Chief Executive Officer’s Report Operational Plan/Trust’s Strategy Quality Priorities Draft Annual Report (including Quality Report) Non-NHS Activity Strategic Objectives Annual Self-Certification of the Trust's licence conditions 2021/22 Annual Report and Accounts (including the Quality Report) External Auditor's Report on the Annual Accounts Performance of the External Auditor Membership Strategy Annual Members' Meeting update     Receive  Review and Feedback  Review and Feedback  Review and Feedback  Approve  Review and Feedback  Review and Feedback  Receive  Receive  Receive  Approve  Receive Council of Governors’ Business Governors’ Nomination Committee Feedback     Receive/Approve Feedback from the CoG Working Groups     Receive Membership Engagement Update     Receive Review of Meeting (before AoB)     Discussion Annual Business Plan  Approve Audit and Risk Committee Terms of Reference  Review and Feedback Governors' Nomination Committee Terms of Reference  Approve Chair and Non-Executive Director Appraisal Process  Approve Review of Trust’s Constitution  Approve Review Terms of Reference - Council of Governors  Approve Review Terms of Reference - Council of Governors' Working Groups  Approve Governors’ Election  Information Outcome of Chair Appraisal  Receive Outcome of Non-Executive Directors' Appraisals  Receive Non-Executive Director Appointment and Reappointment (Jane Harwood-1st term ends 30/09/2023)  Approve Strategy Day Planning  Information As Required Chair’s Appointment and Reappointment Approve Approve Chief Executive Officer Appointment Approve Care Quality Commission Reports and Recommendations Information Appointment of the External Auditors Approve Terms & Conditions - Chair and Non-Executive Directors Approve Non-Executive Directors' Additional Commitments Information Governor Attendance at Council of Governors' Meetings Approve Governor Vacancies Approve Appointment of Deputy Chair/Senior Independent Director Approve/Consult Increase of non-NHS income in any financial year by 5% or more Approve Policy for the composition of the Council of Governors Approve Policy for the composition of the Non-Executive Directors Approve Appointment of Lead Governor/Deputy Lead Governor Approve 6.3 Composition of the Council of Governors 1 6.3 Composition of the CoG.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Council of Governors’ Composition Review 6.3 Jenni Douglas-Todd, Trust Chair Karen Russell, Council of Governors’ Business Manager 25 January 2023 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: As part of a review of the composition of the Council of Governors, (CoG) the Membership and Engagement Working Group has been considering proposals regarding the representation of young people on the CoG. Response to the issue: The attached paper describes the proposals discussed by the CoG’s Membership and Engagement Working Group relating to young governor representatives, following its meeting on 19 January 2023. Implications: (Clinical, Organisational, Governance, Legal?) Any change to the composition of the CoG would require a change to the Trust’s constitution, which would need to be approved by the CoG and the board of directors. However, the CoG could decide to appoint a young governor representative on an associate basis which would not affect the formal composition of the CoG therefore the Trust’s constitution would not require amendment. Risks: (Top 3) of carrying 1. Compliance with the National Health Service Act 2006. out the change / or not: 2. Compliance with the Trust’s constitution. 3. Ensuring that the CoG is sufficiently representative of the public, patients and members. Summary: Conclusion a
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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 Pres
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Papers Council of Governors - 26 January 2022

Description: Agenda attachments 1 CoG Agenda - 26.01.2022.docx Date Time Location Chair Agenda Council of Governors 26/01/2022 14:00 - 15:35 Microsoft Teams Peter Hollin
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Papers CoG - 29.01.2025

Description: Date Time Location Chair Agenda Council of Governors 29/01/2025 14:00 - 15:30 Conference Room, Heartbeat/Microsoft Teams Jenni Douglas
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Papers CoG 29.04.2025 v2

Description: Date Time Location Chair Agenda Council of Governors 29/04/2025 14:00 - 15:45 Conference Room, Heartbeat/Microsoft Teams Je
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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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